Sex Disparities in Clinical Need, Willingness, and Surgeon Recommendations for Total Knee Arthroplasty

Abstract

Objectives Sex disparities exist in the receipt of total knee arthroplasty (TKA) for osteoarthritis (OA), with females disproportionately less likely to undergo surgery. Understanding the reasons for this gap is critical for equitable health care delivery. Lower willingness to undergo TKA, a strong predictor of future surgery, may explain lower rates of TKA referral among females vs males. However, it is unknown whether surgeons’ recommendations for TKA differ by patient sex among those who express TKA willingness at orthopedic consultation. We examined the inter-relationships of patient sex and TKA willingness on surgeon’s TKA recommendations. Methods This cross-sectional study included individuals with knee OA referred for TKA to 2 centralized hip/knee centers in Alberta, Canada. A pre-consultation questionnaire assessed patients’ TKA need, readiness, willingness, importance of various TKA outcomes, health status and contextual factors. Using multivariable logistic regression, we examined the determinants of TKA “definite willingness” (yes/no) in females and males, separately, and in a combined model, the odds of a female vs a male being “definitely willing”, adjusting for these factors. Using multivariable log Poisson regression adjusting for clustering by surgeon and potential confounders, we examined the adjusted risk ratios (RRs) for receipt of a TKA recommendation associated with patient sex and willingness. Results Of 2,064 participants, 58.6% were female with mean age (SD) 65.7 (9.2) years. Compared with males, females had worse knee symptoms, were more likely to report their symptoms as unacceptable and to have received non-surgical therapies. In both sexes, definite TKA willingness was associated with greater knee pain, unacceptable symptoms, and expectations for TKA regarding pain relief and activities. Adjusting for these factors, females were less likely than males to be “definitely willing” (adjusted OR 0.61, 95% CI 0.46, 0.82). The risk ratio for receiving a TKA recommendation for those “definitely willing” was 1.26 (95% CI 1.14, 1.38) for females and 1.90 (95% CI 1.48, 2.43) for males. Conclusion Among individuals with knee OA referred for TKA consultation with an orthopedic surgeon, females had greater clinical need but were less likely than males to indicate willingness to undergo surgery if offered. Among patients who were “definitely willing” to consider TKA, surgeons were more likely to recommend surgery to males than females, indicating sex disparities in TKA recommendations at the point of surgeon consultation.