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Editor’s Spotlight/Take 5

Does THA Improve Social Status Among Turkish Women with Developmental Dysplasia of the Hip?

Leopold, Seth S., MD

Clinical Orthopaedics and Related Research®: September 2018 - Volume 476 - Issue 9 - p 1692–1695
doi: 10.1097/CORR.0000000000000414

S. S. Leopold, Editor-In-Chief, Clinical Orthopaedics and Related Research®, Philadelphia, PA, USA

S. S. Leopold MD, Clinical Orthopaedics and Related Research®, 1600 Spruce Street, Philadelphia, PA 19013 USA, Email:

A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present “Take Five,” in which the editor goes behind the discovery with a one-on-one interview with an author of the article featured in “Editor’s Spotlight.”

The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request.

The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

This comment refers to the article available at DOI: 10.1097/CORR.0000000000000403.

Received June 29, 2018

Accepted June 29, 2018

While some liberal democracies have taken steps during the past several decades to protect the rights of individuals with physical disabilities [5, 15], it’s also clear that even in those countries, considerable injustices persist [1]. And in more-traditional, patriarchal societies, people with disabilities—especially women—often are marginalized [4, 8]. Only a minority of nations protect persons with disabilities as a matter of law [9], and even in nations that have laws on the books to protect them, women with disabilities in many third-world countries experience grievous hardships [3], including barriers to essential social services [6] and basic education. For example, only about 1% of women with disabilities around the world can read [14].

All true, sad, and important, you may say, but what has any of this to do with orthopaedic surgery? This month’s Clinical Orthopaedics and Related Research® contains a paper that I can only characterize as a bittersweet tale, but one worth the attention of every surgeon who practices our specialty, because it is thought provoking on so many levels. Dr. Tansel Mutlu and colleagues [10], from the Karabük University School of Medicine, found that women with developmental dysplasia of the hip (DDH) in Turkey who underwent THA experienced dramatic improvements in social standing (as measured by mental health and social role functioning subdomains in the SF-36, as well as in terms of the proportion who were married and who were employed) compared to those who did not undergo surgery. The authors characterize their country as patriarchal, and they suggest that women with DDH “may be seen as insufficient in terms of marriage and sexual intercourse because of hip-related limitations,” and so are limited in terms of “the ways women can engage in society.” The authors indicate that those women with DDH who are able to marry at all often are paired via arranged marriages to men with disabilities. Happily, much of this improves after THA. They attribute the changes in social standing after surgery to improvements in the way others perceive these patients, as well as the patients’ improved self esteem related to changes in appearance (leg length, in particular), function, and gait.

These authors’ perceptions about their own society seem likely to be true. More than 12% of people in Turkey have a serious disability, but as one writer observes “it is almost impossible to encounter disabled people on the streets”, in part because of a lack of accessible infrastructure, but more so because of the mindset of many who live there [12]. Although Turkey bridges the east and west both geographically and geopolitically, its treatment of persons with disabilities leaves much to be desired, as is the case over a large part of the developing world [9]. While the Turkish government has turned its attention to the problem and seems more-interested in equity under the law for those with disabilities now than ever before [13], the problem there is anything but solved. And while I am proud that CORR® published the inspiring story of Safak Pavey, the first woman with a disability ever to be elected to the Turkish parliament [11], the election of one official is but a small step in the larger scheme of things.

If the politics of disability are improving in Turkey [11, 13], and the patients got better in the series in this month’s CORR [10], why did I earlier characterize this story as bittersweet rather than happy? Because in a much-more-perfect world, no woman’s self-esteem—indeed, no person’s self-esteem—should be tied to the perceptions of others, and any person who wishes to marry (or not to marry) should be free to do so without constraints imposed by his or her appearance or physical function. The fact that this is not the case in much of the world tells us just how far we remain from a compassionate and fair global community.

Please join me as I discuss these sensitive but critical issues with Dr. Tansel Mutlu, first author of this month’s Editor’s Spotlight article, in the Take 5 interview that follows.

Take Five Interview with Tansel Mutlu MD, first author of “Does THA Improve Social Status Among Turkish Women with Developmental Dysplasia of the Hip?”

Seth S. Leopold MD: Congratulations on your study, which focuses on a seldom-discussed topic: The struggles of women with disabilities, particularly in more-traditional societies. How widespread is this problem in the more-traditional societies outside of Turkey?

Tansel Mutlu MD: Thank you for giving us the chance to explain such an important topic and thanks to the reviewers who were instrumental in the publication of this manuscript.

In traditional societies, most people are in a constant struggle for day-to-day survival, especially those living in rural areas. Those who are active and can contribute to their society have higher self-esteem and a chance to be stronger in social life. Those who cannot contribute to their society inevitably are pushed to narrower and less-fulfilling social surroundings. In patriarchal societies, women generally remain in the background. Therefore, the problem of treating women as second-class citizens is as widespread as patriarchal societies themselves. These societies may be limited to small regions or communities in developed countries; however, this problem is seen in all areas (urban or rural) of countries in which adherence to patriarchal culture norms are still an important part of day-to-day life.

Dr. Leopold: And yet this is not simply a problem of the patriarchy. Considerable inequities remain even in liberal democracies like the United States and the European Union (EU). In what ways do you perceive the problems of persons with disabilities to be similar in places like the United States and the EU to places like Turkey?

Dr. Mutlu: Liberal societies are only as liberal as the least liberal person in their midst. Groups or persons who perceive strength in physical and financial prowess limit the liberal characteristics of their society. While western democracies such as the United States and countries in the EU seem to have solved many problems regarding social equity, these improvements are not universal among their own citizens—let alone among refugees or other people in less-developed countries. As much as we try to classify societies and communities, these are theoretical classifications, and I believe the error margins are much higher than what we see in scientific research. These differences among communities may cause unseen adverse effects to those with disabilities. Until the last century, persons with disabilities were considered limited in all aspects of being a functional human being and this has not changed as much any of us had hoped it would, even with all the technological improvements and political movements in support of people with disabilities. I believe the inequity problem remains and western cultures have yet to achieve social modernization on a grand scale.

Dr. Leopold: Even so, it’s clear enough that people with disabilities are doing somewhat better in the United States than in Turkey, even though Turkey has both signed and ratified the United Nations Convention on the Rights of Persons with Disabilities, while the United States has not ratified this Convention. Why might this be the case, and more importantly, how might the countries that lag behind in terms of fairness improve?

Dr. Mutlu: I do not believe that societies are changed by signing any type of convention. Human-rights issues are not solved with mere words. It is not good enough to simply state: “You should have more equality.” Western civilization should act by contributing more to these regions in terms of solving equality problems while also considering the current limitations of those societies. At the same time, these countries should at least try to adhere to the convention they have signed while also finding their own specific ways to solve the problems of disabled people.

Dr. Leopold: In some parts of the world, patients undergo limb-lengthening surgery as a purely cosmetic intervention to increase their height because of some societies’ biases against individuals of shorter stature [7]. In doing so, they expose themselves to serious risks, and many are harmed by these interventions. THA is a safer intervention by far than is distraction osteogenesis for cosmetic limb lengthening, but THA is major surgery by any definition. What distinctions do you draw between THA as a quasi-social intervention in Turkey and elective limb-lengthening surgery for cosmetic reasons?

Dr. Mutlu: With all due respect to specialists around the globe, I believe surgeries for cosmetic reasons have caused the loss of individual identity. Seeking social acceptance has become so widespread that, even those who do not seek it have come to believe they are missing out on better social surroundings. Therefore, we should accept that any type of correctional surgery (including THA) may be perceived by the masses as a way to increase social standing, regardless of quality of life. However, it is important to understand that disabled women in patriarchal societies are perceived by the majority as second-class citizens (because they are women) with second-class capabilities (because they are considered to be disabled), especially in terms of sexual intercourse and lifestyle [2]. They have less control of their own lifestyle, as witnessed through arranged marriages with persons who also have disabilities. As we considered these factors, we felt that the majority of women with developmental dysplasia of the hip saw the procedure as a means to improve their chance to participate in social life without being labeled as disabled. While we could not confirm this observation scientifically, it is apparent that there is a difference between a person wanting to undergo a procedure to treat a condition that profoundly affects all aspects of his or her life and one who sees it as a way to improve just one aspect of his or her appearance. Therefore, if a line is to be drawn, I would propose that decisions should be based on consideration of a patient's well-being together with the suffering caused by the condition.

Dr. Leopold: How certain are you that the differences you observed were a function of the intervention (THA), rather than baseline differences between your groups? For example, if a patient has depression, she may be less likely to undergo THA, but also less likely to seek employment outside the home or to marry.

Dr. Mutlu: While the groups were similar in respect to depression, it is possible that some patients were affected more than the rest. It is also possible that undergoing treatment may have assured some patients that they were better than before (similar to a placebo effect), leading to an increase in self-esteem, which may have caused the differences we observed. However, we firmly believe that the procedure was effective in ameliorating the physical complaints of patients, which ensured that they could dress as they pleased, walk without substantial problems, and allow them not to be perceived as disabled as soon as they walked into a social environment.

Tansel Mutlu MD

Tansel Mutlu MD

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