Thursday, August 6, 2015

Sex and the shoulder

Sex-specific Analysis of Data in High-impact Orthopaedic Journals: How Are We Doing?

These authors sought to determine the degree to which sex was considered in published orthopedic research and whether the trend showed an increase in the proportion of articles with sex-specific reporting over time, however sex-specific analysis was found in less than 1/3 of the studies.

They concluded, "Where evaluating conditions that affect males and females, studies should be designed with sufficient sample size to allow for subgroup analysis by sex to be performed, and they should include sex-specific differences among the a priori research questions."

Comment: We have consistently advocated for the inclusion of patient factors, including sex, in natural history and in therapeutic outcome studies. We have pushed the need for inclusion of the 4 P's in such studies: Patient, Problem, Physician, and Procedure (see here and here, for example).

Over the years, we have pointed out that when the severity of the condition and age are matched, the self-reported shoulder status reported by women using the Simple Shoulder Test is lower than that of males of comparable age as shown again here and here. We have also shown that the sex distribution can vary widely among different practices, so that consideration of sex in the comparison of results is critical. We have pointed out that women tend to have different arthritic pathoanatomy than males. The difference in range of motion between the shoulders of men and women is well recognized. We have shown that sex is a factor predictive of outcome, as shown here. Most recently, we have shown that sex is an important factor affecting the length of stay after shoulder arthroplasty.

Thus the importance of including patient sex as a factor in natural history and outcome studies is inescapable.  Women ≠ men. As the French would say, 'vive la difference!'

However, in our enthusiasm for considering sex, we must also consider the many other important patient factors that may have comparable importance: race, age, insurance, comorbidities, smoking status, and mental health. The need to include these key variables makes large sample size critical in clinical research.

P.s. The difference between sex and gender can be confusing. According to the World Health Organization,
Sex refers to the biological and physiological characteristics that define men and women.
Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women.
In the current era where hormones and surgery can change the characteristics that traditionally define male and female, we will have to sort out whether we should be studying the effect of sex or gender or both.


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