Should men and women be treated differently when it comes to certain orthopaedic conditions? Emerging research is showing the patients sex is something worth considering when it comes to treatment recommendations and healing options.
Mary OConnor, M.D., chair and associate professor of orthopaedic surgery, Mayo Clinic, Florida, explained that women experience a higher burden of disease from knee osteoarthritis than men, specifically after menopause.
“Thats when the incidence of more women having arthritis than men takes off,” she said. This may be influenced by the loss of estrogen which occurs with menopause. MRI studies show that women lose cartilage at a much faster rate than men as they get older, explained Dr. OConnor.
And while studies also show that patients on estrogen replacement therapy develop less arthritis, Dr. OConnor suggests that “we have to stop looking at the patient as a generic patient” and consider how the patients sex (determined by our chromosomes) is going to play a role in the progression of the disease and the possible outcome of treatments.
Numerous clinical studies show that at the time of their knee replacement surgery, women are more symptomatic than men and have poorer function and sometimes more pain. Women have shown to take longer to walk a certain distance or to get out of a chair, explained Dr. OConnor.
But is knee replacement surgery as effective in women as it is in men?
“Many studies show women improve to the same degree, or slightly better, than men,” said Dr. OConnor.
The problem is that they never “catch up” to the same level of recovery as men since they had a lower level of function when they elected to have their knee replacement surgery. In other words, if a womans pre-operation function score is 40 points out of 100 and a man has a score of 50 out of 100, even though they may both gain 40 points after surgery, the woman still has less final function because she started off worse.
The answer is unclear as to why women wait longer to have knee replacement. Personal reasons aside, one study suggested physician recommendation could be a factor. Canadian researchers Borkhoff and Hawker trained a male patient and a female patient with moderate knee arthritis to visit doctors for their recommendations, regarding knee replacement surgery. Both patients described the same level of pain and limitations of their normal activities and had the same degree of arthritis on their x-rays.
Out of 71 doctors, 42 percent recommended knee replacement to male patients but not to female patients. Only eight percent recommended the surgery to females.
Realizing the numbers of this study were relatively small, Dr. OConnor pointed out, “this study suggests that there is some bias, which I believe is unconscious bias, in a physicians recommendation for knee replacement surgery between male and female patients. This may be a factor as why women delay knee replacement surgery as compared to men.”
The last 2 decades have witnessed a tremendous rise in ACL (anterior cruciate ligament) injuries. In fact, some studies show that 1.4 million U.S. women tear their ACL each year. Increased injuries, particularly in women, may be due to a wider pelvis, making thigh bones sharply angled downward and creating more pressure on the knees. Also, women generally have poorer hamstring strength and their muscle tissue is more elastic which may cause the ACL to tear more easily.
Incidence of ACL injuries can be reduced with neuromuscular training, explained Elizabeth Arendt, professor and vice chair, Department of Orthopaedic Surgery, University of Minnesota.
“All patients need to have a strong organized rehabilitation program that incorporates neuromuscular education,” she said. With special attention to jumping activities, pivoting, cutting and controlling the muscles around the knee, the risks of re-injury lessen.
Dr. E. Anne Ouellette, director of Miami International Hand Surgical Services, said procedures and treatments for carpal tunnel are identical for men and women. But all the studies that distinguish conditions between men and women were done in the 1960s and 1970s when the life expectancy for men was much lower.
“Now were seeing men 65 and over with carpal tunnel,” she said. Possibly, that may be due to hormonal changes, she added.
This is further evidence that hormonal changes are associated with the onset of carpal tunnel syndrome and other nerve entrapment conditions.
Presently, procedures for hereditary osteoarthritis remain the same for men and women, explained Dr. Ouellette. The exception is that there is a greater chance a man especially one who does heavy work with his hands – may have implants.
“Were just beginning to define the differences between men and women and what that implies,” she said.
One distinction is with weight control. Obese women have a higher risk of developing HOA than obese men. The risk increases with 9-13% per kg increase in body weight. By suggesting women reduce their weight, they lower the amount of two chemicals, estrogen and leptin, that have an effect on cartilage. We know that women have more estrogen than men. Estrogen, stored in fat, has a direct effect on cartilage defects and volume. Fat also manufactures leptin, a peptide hormone also related to cartilage destruction.
Increased amounts of estrogen and leptin may create a chemical injury to the cartilage which is above and beyond the mechanical injury, explained Dr. Ouellette.
