Study Examines Gender-Based Factors in Time to Surgery for Below-Knee Injuries

A study exploring whether gender disparities exist in treatment of below-knee fractures found that women may experience prolonged time to surgical fixation of these injuries. The study, presented at the 2023 AAOS Annual Meeting in Las Vegas, found that women experienced longer wait times between admission and operative fixation and longer total length of stay compared with men for fractures of the foot, ankle, and lower leg. The results also showed that women were less likely to experience a wound complication than men after fixation of such fractures.

Christopher R. Leland, MD, orthopaedic surgery resident at the Harvard Combined Orthopaedic Residency Program and the presenting author of the study, said he and his colleagues undertook the study to explore challenges relating to access to care among various demographics as applied to fractures of the lower extremity. “This issue is of particular importance given that prolonged time to surgical fixation has been demonstrated to increase the likelihood of poorer clinical outcomes in prior investigations,” Dr. Leland told AAOS Now. Disparities in musculoskeletal care have been demonstrated with respect to race following multiple fracture etiologies, he noted, “but little has been reported regarding gender disparities for fracture fixation about the foot, ankle, and lower leg.”

Using the National Surgical Quality Improvement Program (NSQIP) database, the authors analyzed 25,556 adult patients—including 15,751 (62 percent) women—with complete demographic and morphologic data who were undergoing ORIF of a below-knee fracture between 2005 and 2020 at participating hospitals. Using 1:1 propensity score matching, controlling for preoperative characteristics and comorbidities, they identified 9,085 women with equal propensity scores to the men in the cohort. The authors used descriptive statistics and multivariable logistic regression modeling to determine differences in wait times from hospitalization to operative fixation, delayed versus same-day discharges, and 30-day postoperative adverse events between the matched cohorts.

The primary outcome was the time from hospitalization to operative fixation of lower-extremity fracture in days. Secondary outcomes included any, severe, or minor 30-day postoperative adverse events, which were defined based on previous studies in the orthopaedic literature using NSQIP. Severe adverse events included failure to wean off the ventilator within 48 hours postoperatively, cerebrovascular accidents, cardiovascular complications, renal failure, systemic sepsis, reoperation, and death. Minor adverse events included reintubation, wound complications, pneumonia, thromboembolic events, and urinary tract infections. Readmission was any unplanned readmission in the first postoperative 30 days. Any adverse event was defined by pooling severe or minor events with readmissions. The authors defined a discharge delay using the time from fixation to discharge in days and defined a same-day discharge as a length of stay less than 24 hours; they referred to the 30-day postoperative window as the early postoperative period.

In the multivariable analysis, controlling for potentially confounding variables such as age, race and ethnicity, BMI, American Society of Anesthesiologists score, and fracture type, the mean time between admission and operative fixation (P <0.01) and total length of stay (>P <0.01) were longer for women compared with men. women also had increased odds of delayed discharge (>P <0.01) and decreased odds of same-day discharge (>P <0.01) compared with men (table 1).>

In the multivariable analysis controlling for the same variables, women did not have increased overall risk for postoperative adverse events compared with men, severe or minor. Women were less likely to experience a wound complication (P <0.01) but more likely to develop a urinary tract infection (>P <0.01) compared with men (table 1).>

“Although women experienced increased wait times and times to discharge, we found that they were not more likely to experience early postoperative adverse events than men and were less likely to experience a wound complication,” Dr. Leland said. “However, although increased wait times are associated with factors related to patient perception, such as pain and satisfaction, there is a lack of evidence to suggest wait times are associated with adverse postoperative outcomes. While we found it encouraging that women did not experience higher rates of postoperative adverse events in our study, this finding does not exclude the possibility that women may experience disparate care that affects their overall experience.”

Summarizing the clinical takeaways, Dr. Leland said the results indicate that although women may not experience any greater rates of adverse postoperative events, they may receive disparate care in terms of surgical wait times and prolonged hospital stays, which potentially implicates inefficient resource allocation, inadequate patient experience, and poorer clinical outcomes. “These differences in time to surgery and time to discharge represent disparities that must be addressed to advance musculoskeletal care for all patients,” he said.

Dr. Leland shared several actionable takeaways from these findings. “First, providers should be privy to the disparities their patients face, particularly regarding perioperative optimization for lower-extremity fracture fixation. Additionally, the differences in timing, from admission to surgery to discharge, present an opportunity to pilot and standardize an enhanced recovery protocol in fractures of the foot, ankle, and lower leg. Such standardization has the potential to not only minimize the impact of gender disparities but also improve patient satisfaction and pain management. Finally, further research is required, particularly utilizing subgroup and intersectional analyses, to refine our understanding of disparities in patient care in orthopaedic surgery,” he said.

He noted that among the limitations of the study is that NSQIP data do not incorporate parameters describing socioeconomic status or geographic variation.

Dr. Leland also said that the researchers could not assess for selection bias within the NSQIP registry regarding potential inherent differences in patient presentations, such as male patients becoming injured in the setting of high-energy traumatic accidents including dirt bike and sporting accidents, as this information is not routinely collected in NSQIP.

Dr. Leland’s coauthors of “Do Gender Disparities in Time to Surgical Fixation Exist for Open Fixation of Below-Knee Fractures?” are Morgan M. Snow, BA; Suraj A. Dhanjani, BS; Amy L. Xu, BS; Christa L. LiBrizzi, MD; Majd Marrache, MD; and Amiethab A. Aiyer, MD.

Terry Stanton is the senior medical writer for AAOS Now.