Commentary As a spotlight has illuminated gender inequality among orthopaedic surgeons worldwide, the article by Jolbäck et al. is well-timed. Although the world has not yet reached gender parity in any single country with respect to orthopaedic surgeons, the number of female trainees has increased in recent years. In the Swedish population, the proportion of female orthopaedic surgeons has increased from 6% to 17% over the past 3 decades, giving Sweden one of the highest female-to-male ratios in the world, second only to Estonia1. This proportion varies greatly between the countries of the world, however, ranging from 0% to 26%1. Several explanations have been offered for the reluctance of women to pursue careers in orthopaedic surgery, including skepticism and bias by colleagues and patients as well as the inaccurate perception of the specialty requiring physical strength. As a current female hip and knee replacement surgeon in Canada with expertise in primary and complex revisions, I can personally attest that my gender, strength, and stature have not limited my ability to perform any surgical procedures within my specialty. As the authors pointed out, ongoing barriers, including a lack of mentorship, female leadership, and role models, further perpetuate this landscape of reduced female orthopaedic surgeon enrollment. Finally, the financial burden of maternity leave and perceived difficulty of a busy surgical practice with young children at home further diminish enrollment. In their Swedish-based registry study, Jolbäck et al. addressed the elephant in the room as to whether adverse events through 90 days postoperatively were associated with the sex of the operating surgeon. Their methodology was carefully thought out to address this question, complete with a direct acyclic graph, an important transparent variable-association metric that is all too often left out of studies such as this. Overall, the authors showed no difference in adverse events between male (7%) and female surgeons (6%). Readers may be quick to conclude that the asymmetry of the study population (male, 82.5%; female, 17.5%) may have impacted the validity of the results as the female cohort was numerically smaller, was earlier in practice (female, 4 years; male, 16 years), and had a smaller annual volume of total hip arthroplasties (female, 19; male, 23). By including annual surgical volume (along with patient age, sex, and comorbidity index) and by performing a subsequent sensitivity analysis that excluded resident surgeons, the authors addressed this potential methodology criticism and increased the robustness of their results. Furthermore, given that the female surgeons tended to operate on older patients in this study, one might expect their adverse events to in fact be higher; however, this was not the result. There will always be concerns regarding the retrospective nature of such a study, as well as concerns regarding the completeness of the data supplied by the registry. Furthermore, adverse event data captured at the hospital level via retrospective chart review have been shown to underestimate the true number of adverse events2; however, one would expect this underestimation to affect male and female surgeons in a non-differential manner. Overall, the authors had a reasonable sample size, utilized a seemingly robust registry, and implemented a strong regression methodology that addressed their question with a good degree of precision, as was reflected in the span of the confidence intervals reported with the odds ratio measures of association. The authors in fact suggested that women had a tendency toward lower adverse events; however, given the lack of significance, a more acceptable conclusion was that female surgeons did not have increased rates of adverse events. Comparison of male and female physician outcomes is not new. In their 2017 article, Tsugawa et al. concluded that female internal medicine specialists had lower rates of mortality and readmissions3. A 2017 Canadian study involving >100,000 patients showed that on review of 25 surgical procedures, female surgeons had a small but significant decrease in 30-day mortality, with similar surgical outcomes, compared with male surgeons4. Finally, Chapman et al., in their U.S. Medicare-based study, found that complications following total joint arthroplasty were not associated with sex5. The study by Jolbäck et al. adds to the current body of literature by being performed in a country with one of the largest proportions of female orthopaedic surgeons, with linkage to an arthroplasty surgical registry—2 aspects lacking in the current literature. The authors should be commended for their work on this critically important topic, which has added an important layer to the growing body of literature. Moving forward, journals must ensure that studies such as this are carefully considered for publication. I look forward to future growth within our global orthopaedic surgical field in which a person of any sex or gender may enter this specialty on the basis of personal choice and can lead a full life balancing family with a successful surgical practice.
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Dec 31, 2022
Gyuhee Yi 
Open Access