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The Influence of Race and Ethnicity on Complications and Mortality After Orthopedic Surgery: A Systematic Review of the Literature

Schoenfeld, Andrew J. MD*; Tipirneni, Renuka MD; Nelson, James H. MD; Carpenter, James E. MD§; Iwashyna, Theodore J. MD, PhD

doi: 10.1097/MLR.0000000000000177
Original Articles

Background: The decision to perform orthopedic surgery requires substantial discretion and judgment. Similar conditions have been associated with health care disparities in other fields, but the extent of racial and ethnic disparities in orthopedics is unknown.

Objective: To evaluate the quality of extant orthopedic literature on health care disparities.

Research Design: This study is a systematic review.

Subjects: Eligible studies reported complications and/or mortality stratified by minority group after orthopedic surgery in an American population.

Measures: Queries of PubMed, Embase, Scopus, and Web of Science were performed. Included papers were abstracted regarding complication and/or mortality rates for whites and minority populations, statistical findings, and whether a health care disparity was reported. Statistical associations between study characteristics and the identification of disparities were evaluated using the χ2 test.

Results: The literature search returned 2604 studies, of which 33 met inclusion criteria. All but 3 works dealt with spine surgery or joint replacement. Twenty-one publications (64%) documented health care disparities. Forty-four percent of efforts investigating outcomes for Hispanics and 36% of works documenting results for non-whites recorded a disparity. Investigations reporting on African Americans were significantly more likely to identify health care inequalities (77%) as compared with non-white (P=0.02) cohorts.

Conclusions: Patients from racial and ethnic minority populations seem to be at increased risk of complications and/or mortality following spine surgical or joint replacement procedures. There is insufficient evidence to support generalization to the entire orthopedic field. Studies specific to African American patients identify health care disparities at a significantly higher rate than those utilizing non-white cohorts.

Supplemental Digital Content is available in the text.

*Robert Wood Johnson Clinical Scholars Program, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital

Robert Wood Johnson Clinical Scholars Program, Department of Internal Medicine, University of Michigan, Ann Arbor, MI

Department of Orthopaedic Surgery, William Beaumont Army Medical Center, Texas Tech University Health Sciences Center, El Paso, TX

§Department of Orthopaedic Surgery

Robert Wood Johnson Clinical Scholars Program, Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI

Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website,

Some authors are employees of the US Federal Government and the United States Army. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the United States government.

A.J.S. and R.T. are Robert Wood Johnson Foundation Clinical Scholars at the University of Michigan. T.J.I. is supported by the National Institutes of Health. The Robert Wood Johnson Foundation and the Department of Veterans Affairs were not directly involved in study design, data acquisition and interpretation, or manuscript preparation or review. Any opinions expressed herein do not necessarily reflect the opinions of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.

The authors declare no conflict of interest.

Reprints: Andrew J. Schoenfeld, MD, Robert Wood Johnson Clinical Scholars Program, Department of Orthopaedic Surgery, University of Michigan, Ann Arbor Veterans Administration Hospital, 2800 Plymouth Road, Building 10, RM G016, Ann Arbor, MI 48109. E-mail:

© 2014 by Lippincott Williams & Wilkins.