Next Steps: Advocating for Women in Orthopaedic Surgery.

Orthopaedic surgery is the least diverse of all medical specialties, by both sex and race. Diversity among orthopaedic trainees is the lowest in medicine, and growth in percentage representation is the lowest of all surgical subspecialties. Women comprise only 6% of orthopaedic surgeons and 16% of orthopaedic surgery trainees. This extreme lack of diversity in orthopaedics limits creative problem-solving and the potential of our profession. Women in orthopaedics encounter sexual harassment, overt discrimination, and implicit bias, which create barriers to training, career satisfaction, and success. Women are underrepresented in leadership positions, perpetuating the lack of diversity through poor visibility to potential candidates, which impedes recruitment. Correction will require a concerted effort, as acknowledged by the American Academy of Orthopaedic Surgeons leadership who included a goal and plan to increase diversity in the 2019 to 2023 Strategic Plan. Recommended initiatives include support for pipeline programs that increase diversity of the candidate pool; sexual harassment and implicit bias acknowledgement, education, and corrective action; and the active sponsorship of qualified, capable women by organizational leaders. To follow, women will lend insight from their diverse viewpoints to research questions, practice problems, and clinical conundrums of our specialty, augmenting the profession and improving patient outcomes.

Androgen deprivation in veterans with prostate cancer: implications for skeletal health.

BACKGROUND: Common risk factors for osteoporosis in older men include smoking, heavy use of alcohol, propensity to falls, and use of bone-toxic medications such as prednisone. There is also increasing appreciation of the skeletal risk faced by men receiving androgen deprivation therapy (ADT) for prostate cancer. Measures to prevent bone loss in such patients are available. OBJECTIVE: To test the following hypotheses in a population of veterans receiving ADT for prostate cancer: (1) fracture risk factors in addition to androgen deprivation would be found in most patients, (2) bone mass measurements would be assessed in a minority of patients, and (3) a minority of the subjects would receive bisphosphonate therapy or have contraindications for such treatment. METHODS: We conducted a retrospective chart review of male veterans receiving ADT from 1993 through 2001, at the Veterans Affairs Medical Center, Madison, WI. RESULTS: One hundred and seventy-four subjects met study criteria, with a mean age of 76 years and median duration of 21 months of ADT. Eighty-one percent had risk factors in addition to ADT. Only 13% underwent bone density measurement by dual energy X-ray absorptiometry (DXA) and, of those measured, more than half had osteoporosis. Only 19% of the men received both calcium and vitamin D supplements. Antiresorptive therapy was provided to 11% of men, although more than two-thirds had no contraindications to therapy. A total of 24 men sustained a fracture after starting ADT. For men who did undergo bone density measurement, 77% received antiresorptive therapy. Of those who exhibited osteoporosis by DXA scan, 85% received antiresorptive therapy. CONCLUSIONS: Male veterans receiving ADT for prostate cancer received inadequate evaluation and treatment for osteoporosis. Based on our data, a simple and practical strategy to prompt further evaluation and improved care may be to undertake bone density measurements in men prior to or soon after commencing ADT.

Outcomes and secondary prevention strategies for male hip fractures.

OBJECTIVE: To assess clinical outcomes and determine whether osteoporosis assessment and secondary prevention strategies were performed for male veterans hospitalized for hip fractures. DESIGN: Retrospective chart review for male veterans hospitalized for hip fracture from January 1993 through July 1999. SETTING: The Veterans Affairs Medical Center, Madison, WI. RESULTS: Medical charts were available for 46 of 53 male patients admitted for hip fracture during the study period. Three subjects were excluded because hip fracture was associated with high-impact trauma. Mean age of the 43 study patients was 72 years (range 43-91 y), and mean length of hospitalization was 16 days (median 11 d, range 3-108 d). Thirty-two (82%) of 39 veterans whose disposition was documented were discharged to a nursing home. Eleven (26%) of 43 men died within 12 months after fracture. Twelve (28%) had fractured previously. Four (10%) subsequently had another fracture. Three of 9 patients with documented ambulation status were ambulatory at 1 year. Three patients received a bone mass measurement within a prespecified time interval of 6 months subsequent to fracture. No patient's records included a diagnosis of osteoporosis either before or within 6 months after fracture. One-third of the patients had documentation of calcium or multivitamin supplementation at discharge. One patient was receiving calcitonin at the time of fracture and continued to receive it afterward. No other patient was prescribed antiresorptive therapy by the time of hospital discharge. CONCLUSIONS: Male veterans with hip fractures received inadequate evaluation and treatment for osteoporosis, although a substantial portion had documentation of recurrent fractures. Education of clinicians and creation of algorithms for management of established osteoporosis may improve outcomes for these individuals.