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Editorial

My Grandmother’s Knees: A Call for Research on Strategies to Address Racial and Ethnic Disparities in Orthopaedic Surgery

Okike, Kanu MD, MPH

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The Journal of Bone and Joint Surgery: November 3, 2021 - Volume 103 - Issue 21 - p 1961-1962
doi: 10.2106/JBJS.21.01081
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By all accounts, my grandmother could dance. Her hips would sway, her legs would kick, and her arms would wave gracefully as her tall frame performed traditional Igbo dances in her Nigerian homeland. Or at least that’s what I’ve been told. My grandmother immigrated to the United States when she was 60 and I was a young child—but, even back then, I only knew her as a woman with mobility issues who required assistance to walk just a few steps. She lived a long and fulfilling life, eventually passing away in her mid-90s, but the last 2 decades of her life were primarily spent transferring from bed to chair and back again. I recently tracked down her radiographs, which confirmed what I’d long suspected: uncomplicated knee osteoarthritis.

The first reports of disparities in total joint arthroplasty utilization on the basis of race emerged several decades ago. Wilson and colleagues examined Medicare data from 1980 to 1988 and found that White men were 3 to 5 times more likely to be treated with total knee arthroplasty than Black men; among women, the ratio was 1.5 to 2.01. Likewise, Escarce and coauthors examined Medicare data from 1986 to assess the usage of 32 services in a wide variety of medical fields. While disparities in utilization were identified for several of these services, there were few for which the White-to-Black treatment ratios were as great as those for total hip arthroplasty (2.4 times) or total knee arthroplasty (2.0 times)2. Importantly, these differences in utilization occurred despite similar incidences of osteoarthritis for the 2 groups of patients. Further context was provided by analyses of lower-extremity amputation among diabetic patients, which showed that the procedure was performed 2.4 times more frequently among Black patients as compared with their White counterparts3.

Today, several decades later, it is disheartening to observe that racial and ethnic disparities in total joint arthroplasty utilization and outcome remain as prevalent as ever. For example, Zhang and colleagues recently reported on total knee arthroplasty procedures in 8 racially and ethnically diverse states and found utilization to be substantially lower for Black, Hispanic, Asian, Native American, and mixed-race patients as compared with White patients4. Disparities also have been documented in several other subfields of orthopaedics, including trauma5, spine6, oncology7, and pediatrics8, among others.

On May 25, 2020, George P. Floyd Jr. was murdered by Minneapolis police officers during an arrest*. The weeks and months that followed saw an unprecedented response by individuals of all backgrounds, who sought to denounce the injustice by participating in social media campaigns, attending protest marches, and signing online petitions. Companies, institutions, and organizations, including the American Academy of Orthopaedic Surgeons9 and The Journal of Bone & Joint Surgery10, also expressed their solidarity. The idea that African Americans and other individuals in our society face steady headwinds in the form of enduring institutional and interpersonal biases was widely acknowledged, for the first time that I can recall. Could this be our moment to change the narrative when it comes to disparities in our field? Or will an editorial written 30 years from now read like this one, once again documenting disparities in treatment and outcome based on a patient’s race and ethnicity, only citing newer research?

Eliminating the many disparities that currently exist in orthopaedic surgery will not be an easy task as they stem from processes rooted in >400 years of U.S. history. However, orthopaedic surgeons are innovators who have figured out solutions to complex problems in the past11, and they continue to do so today.

What innovations will orthopaedic surgeons devise to allow patients of racial and ethnic minority groups to access total joint arthroplasty and other orthopaedic procedures at the same rate as their White counterparts while also enjoying similar outcomes? Prior research has suggested that orthopaedic surgeons may be less likely to recommend total joint arthroplasty for Black patients as compared with White patients of similar age and disease severity12. Could implicit bias training ameliorate these differences? Given that Black patients tend to express greater fear regarding arthroplasty13 along with a reduced belief that the procedure will be beneficial14, could the widespread adoption of decision aids15 increase utilization? Since some minority patients may respond better to a physician who looks like them16, are there ways to make our field more attractive to non-White medical students, and to be more intentional about addressing the fact that orthopaedic surgery remains the least-diverse specialty in all of medicine17? How can we make my grandmother’s experience a feature of our field’s past, but not its future?

To date, most research on disparities in orthopaedic surgery has centered on documenting the nature, degree, and scope of the problem. Looking toward the future, JBJS is interested in presenting its readers with articles that begin to remedy this stubborn set of problems. JBJS welcomes research on approaches, interventions, and innovations that seek to attenuate racial and ethnic differences in care.

References

1. Wilson MG, May DS, Kelly JJ. Racial differences in the use of total knee arthroplasty for osteoarthritis among older Americans. Ethn Dis. 1994 Winter;4(1):57-67.
2. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly’s use of medical procedures and diagnostic tests. Am J Public Health. 1993 Jul;83(7):948-54.
3. Lavery LA, van Houtum WH, Ashry HR, Armstrong DG, Pugh JA. Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans. South Med J. 1999 Jun;92(6):593-9.
4. Zhang W, Lyman S, Boutin-Foster C, Parks ML, Pan TJ, Lan A, Ma Y. Racial and Ethnic Disparities in Utilization Rate, Hospital Volume, and Perioperative Outcomes After Total Knee Arthroplasty. J Bone Joint Surg Am. 2016 Aug 3;98(15):1243-52.
5. Dy CJ, Lane JM, Pan TJ, Parks ML, Lyman S. Racial and Socioeconomic Disparities in Hip Fracture Care. J Bone Joint Surg Am. 2016 May 18;98(10):858-65.
6. Feng R, Finkelstein M, Bilal K, Oermann EK, Palese M, Caridi J. Trends and Disparities in Cervical Spine Fusion Procedures Utilization in the New York State. Spine (Phila Pa 1976).) 2018 May 15;43(10):E601-6.
7. Raad M, Puvanesarajah V, Wang KY, McDaniel CM, Srikumaran U, Levin AS, Morris CD. Do Disparities in Wait Times to Operative Fixation for Pathologic Fractures of the Long Bones and 30-day Complications Exist Between Black and White Patients? A Study Using the NSQIP Database. Clin Orthop Relat Res. 2021 Aug 6.
8. Dodwell E, Wright J, Widmann R, Edobor-Osula F, Pan TJ, Lyman S. Socioeconomic Factors Are Associated With Trends in Treatment of Pediatric Femoral Shaft Fractures, and Subsequent Implant Removal in New York State. J Pediatr Orthop. 2016 Jul-Aug;36(5):459-64.
9. Bosco JA. We stand with you. AAOS Now. 2020. Accesse d 2021 Sep 7. https://www.aaos.org/aaosnow/2020/jun/diversity/we-stand-with-you/
10. Statement from JBJS. J Bone Joint Surg Am. 2020 Aug 5;102(15):1296.
11. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet. 2007 Oct 27;370(9597):1508-19.
12. Hausmann LR, Mor M, Hanusa BH, Zickmund S, Cohen PZ, Grant R, Kresevic DM, Gordon HS, Ling BS, Kwoh CK, Ibrahim SA. The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting. J Gen Intern Med. 2010 Sep;25(9):982-8.
13. Lavernia CJ, Alcerro JC, Rossi MD. Fear in arthroplasty surgery: the role of race. Clin Orthop Relat Res. 2010 Feb;468(2):547-54.
14. Ang DC, Monahan PO, Cronan TA. Understanding ethnic disparities in the use of total joint arthroplasty: application of the health belief model. Arthritis Rheum. 2008 Jan 15;59(1):102-8.
15. Ibrahim SA, Blum M, Lee GC, Mooar P, Medvedeva E, Collier A, Richardson D. Effect of a Decision Aid on Access to Total Knee Replacement for Black Patients With Osteoarthritis of the Knee: A Randomized Clinical Trial. JAMA Surg. 2017 Jan 18;152(1):e164225.
16. Laveist TA, Nuru-Jeter A. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav. 2002 Sep;43(3):296-306.
17. Okike K, Utuk ME, White AA. Racial and ethnic diversity in orthopaedic surgery residency programs. J Bone Joint Surg Am. 2011 Sep 21;93(18):e107.

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