Thank you and welcome to the Women's Leadership Forum, a recently added tradition to the meeting. And I'd like to thank Casey and Daniel for recognizing the value of this symposium's topic today and including it in the program. This forum also lets us acknowledge and highlight our Women's Leadership Award recipients on the podium. With that, we have a wonderful panel of speakers for you today, and we're going to talk about what the science says or fails to say about caring for female patients. So with that, hopefully everyone will gain something to take home and take care of their patients. We'll start off with Dr. Lauren Gainey to talk about hormones and their impact on the musculoskeletal system. So thank you, everyone. Thank you for inviting me to talk about this. When Daniel and Casey asked me to give a talk, I thought that they had a really interesting take on this. Rather than talk about women in orthopedics, which I think that we're finally maybe making some gain on, they want us to talk about how we treat women and how maybe this is different than how we treat men. And so I realize there's quite a bit that we know about estrogen and about bone, but there's not a lot that we know, or at least I knew, about how it affects tendon and ligament and other parts of the body, and also about what other hormones may have an effect. So I'm going to go into some of that today. These are my disclosures, none having to do with hormones. So in reality, we know women are different, right? And so we have estrogen, and one thing I came across is this idea of relaxin. And I'm going to get into that a little bit, but I think that that has some effect on our patients, particularly those that are pregnant. So if we look at estrogen on bone, this is, I know, going back to many years ago for most of us, but if we talk about the biology of bone, you have osteoblasts, which are the bone creators. You have those that then turn into osteocytes, which help with regulation of the bone, and then you have osteoclasts, which are those that break down the bone. Now estrogen has an effect directly and indirectly on all of this, but what they do essentially is that they encourage osteoblasts and that they indirectly and directly inhibit osteoclasts. So what does that mean? When a patient goes through menopause and they have low estrogen, what happens is that you have decreased osteoblast activation, you have increased osteoclast activation. So this tips everything in favor of losing bone rather than gaining bone. So we know that in menopause, there is a significant decline in bone mineral density. Ten years after the start of menopause, women have 9% decrease in bone mineral density in the femoral neck and 10% in the lumbar spine. And estradiol concentrations lower than 5 actually have an increased rate of fracture. This is really important, not only in patients that are postmenopausal, but in athletes and other women that may have low estrogen levels. So now we know quite a bit, like I said, about bone, but how does it affect other things? So if we look at the skeletal muscle, there's a lot that's very controversial and it's not really clear where the effect is. There's potentially an effect on muscle structure in that it can preserve skeletal mass and maintain the quality of it. So it maintains how much you have as well as how good it's working. How does it do it? It regulates turnover and it can protect skeletal muscle from apoptosis and help with the actual muscle contraction. That's not quite so clear, but what does seem to be very clear is that there is a big influence on muscle damage and repair. And so if you look at creatinine kinase, which is a marker for muscle damage, what we see is that with estrogen, that amount of creatinine kinase is decreased, suggesting that there's less damage to the muscle. Similarly, beta-glucuronidase is the same thing, that that is decreased in people that have normal, or in animal studies, with estrogen. Why does it do this? There's an antioxidant effect, and again, it seems to be infiltration by fewer leukocytes and those leukocytes can cause damage to the muscle. It may also help with satellite cells, which are really important for muscle repair and regeneration. The effect on ligament tendon is even less clear. We know more about this in our sports world. We know that ACL tears are two to eight times higher in women, and what's interesting is that the ACL rates of injury actually may be different depending on the phase of the menstrual cycle. So there certainly is an effect of estrogen on this. Now not a lot has been done in foot and ankle, and this may be an opportunity for all of us to learn more, but this one study was the only one I could find in 2006 that looked at Achilles tendinopathy, and what's interesting is that they found that hormone replacement therapy and oral contraceptives were associated with an increased risk of Achilles tendinopathy, again suggesting that hormones may have an effect and increase the issues with tendon. This is a super crazy slide, and I'm not asking you to look at it, but what's important to recognize is that there is an effect on healing, collagen, failure load, and stiffness with estrogen. And if I put this into a synopsis slide, this is what we see. It seems that there's a decreased collagen type one and fibroblast synthesis. Again, this is a little bit controversial depending on the studies that you read. It decreases stiffness, and there's a lower failure load. But in a protective way, it does improve healing, similar to what we see in muscle, and it may prevent apoptosis of the tendon tissue. So if we make our conclusions on estrogen, what do we know? We know that on bone, it's important in the regulation of bone turnover. This is well established. But if you look at skeletal muscle, perhaps there's an effect on muscle size and contractile properties, but it does seem to have a positive effect on healing and post-injury recovery. In tendon and ligament, again, really contradictory in what we know. There's probably a negative effect on stiffness, but again, in a similar fashion to the skeletal muscle, there may be a protective effect with healing. Now I want to talk about relaxin, and I think this is really an interesting idea, and I'll talk about what they found in other subspecialties in orthopedics, because I think, again, this is an area that we can all learn, and it may be a possible source of research in the future. So relaxin is a hormone that is a necessary hormone when women are giving birth, in that it allows laxity of the pelvic ligaments. It's highest in the third trimester, which makes sense, and it tends to return back to normal level after postpartum. The way that it works is it upregulates matrix metalloproliasis, and also has a direct effect on collagen remodeling. And what's interesting, Dr. Jennifer Wolfe in Chicago has done quite a bit of research on this related to thumb arthritis. She recognized that women had a higher rate of CMC arthritis, and it brought her to wonder why that was. What they found is there's actually relaxin receptors in the anterior oblique ligament of the thumb, and maybe this is where that's coming from. They also know that there's estrogen and relaxin receptors in the ACL, which may be one of the reasons that women are more prone to injury to these. Similarly, with shoulder instability, those people that had shoulder instability had a higher rate of serum relaxin at baseline. So again, does this mean that these patients that we're treating who are pregnant, maybe they come in with ankle ligament instability, maybe they come in with flat feet. Does this mean that this is something in pregnancy and will get better, but certainly something to think about. In the foot, there was a study that was done showing that if you look at women who were postpartum, what's interesting is that they do have a decrease in their arch height and an increased length in their foot following their pregnancy, which again suggests perhaps is relaxin, a contributing factor to this. So if we think about managing women through the life cycle, we think about all these hormones, and of course there are many more, but in 10 minutes, this is what I wanted to focus on. So women that are premenopausal, they have high rates of circulating estrogen. They're going to tend to have increased tendon injury. We saw that in the Achilles, at least in that one study. They may have decreased tendon ligament stiffness and possibly have a difficult to build, decreased collagen synthesis. Once they hit pregnancy, they're going to have increased ligament laxity, and maybe this returns to normal, but maybe not. We see that specifically with flat feet in patients having increased foot length and arch collapse, as well as decreased rigidity after pregnancy. Then when women get older and they become postmenopausal, we know bone mineral density is going to go down, but they're also going to have more difficulty with muscle recovery after injury, as well as potentially decreased muscle mass and contractile properties. So these are the kids that gave me flat feet, but thank you guys for your time. Thanks, Dr. Gainey. Next we have this year's Career Impact Award recipient, Zann Lofgren. We welcome back, and she'll talk to us about AOPS, challenges, successes, and outcomes. Thank you. It's great to be invited back to the AOFAS. I received compensation from the Promise Health Organization, where I serve as its Executive Director, and I have no other disclosures. It's humbling to be the first non-surgeon to receive this Career Impact Award, and I'm grateful for this very special honor. Unlike the rest of you here today, my contributions are not clinical. They're organizational. Association management is a team sport. It's the partnership among leaders, volunteers, and staff, and builds trust and strength in an organization. Success happens when we work together. Together we succeed. Before AOFAS, I spent 21 years with the American Society of Plastic Surgeons in senior staff positions. All of this prepared me for the challenges and opportunity to be the first Executive Director in-house with the AOFAS and the Foundation. During the search committee, I suggested expanding the Vietnam Project. It would increase member engagement, it would reflect well on the society, and the medical mission would change some lives. I learned this as a volunteer on a cleft lip and palate trip to the Philippines long ago. A member of the search committee disputed my enthusiasm. He said orthopedic surgeons could not change lives the way the plastic surgeons had done, and I told him he was wrong. I got the job. Today, the Vietnam Project has an impressive record. It started out in 2001 with Pierce-Scranton. Sixty-three orthopedic surgeons have now volunteered their time and paid their own way to travel to Vietnam. They'd operated on more than 1,500 patients and seen more than 3,500 patients in the clinics. All of this at no cost to patients. They worked alongside the Vietnamese orthopedic surgeons and they presented at Symposia in Hanoi. Among this impressive fact, though, is that 19% of those who volunteered their time and went were women. Naomi Shields was the first, and others followed. Here are pictures from Vietnam of Naomi Shields, Ruth Thomas, Judy Baumhauer, and Holly Johnson in Vietnam, and I know that there are more of you here in the audience who have stepped out of your comfort zone and done this same thing. When I was first hired, my first challenge was to manage the move from a management company in Seattle to Rosemont, Illinois. Jim Brodsky then was the AOFAS president and he expressed the board's strong desire to work with professional staff, to partner. My hiring approach is, and continues to be, look for skills and hire for attitude. I had great staff. Here we are when 200 boxes arrived from the Seattle office. An important challenge that first year was getting reaccreditation from the ACCME. It was not an easy task. AOFAS needed to be able to offer CME credit for their educational programs. Within six months, reaccreditation was approved. We set up a new computer system, clean data, set up membership and a new website. The annual meeting that next summer in La Jolla was a success and I felt we were on our way. The next came growth, and with that came new challenges. Leaders and volunteers bring vision, enthusiasm, and clinical expertise. But let's face it, that's your day job. You all have that day job. It's the staff who partner with you that can help move ideas into results. Projects can include education, finance, tech, communication, and more. I won't read all these things on the slide, but this is what are essential tasks to make an organization move forward. It's our day job and it's what we do and it's what we really love doing. The partnership and accomplishments provide satisfaction and meaning to what we do. Here is a rundown of some of the AOFAS challenges and growth. It's an impressive list. I'm not going to read this slide either, but all of these accomplishments were important and required teamwork. Leaders, volunteers, and staff work together as partners. Ideas move forward, and new initiatives created value for members and for the organization. Important milestones happened with the journal, Foot & Ankle International. In 2008, David Thordeson moved into the editor-in-chief position from Greer Richardson. Then in 2012-13, Charlie Saltzman led the transition of FAI from a small publisher to a large publisher with greater international reach. Elaine Layton was hired as the FAI managing editor and today she is your executive director. That strategic move brought growth for the journal and was a positive financial move for the society. In 2016, FAO was added your online journal, and again, there was growth. To reflect back a bit, the society began in 1969 with a small group of men, but times are changing. Women have taken up the leadership challenge. Judy Baumhauer was the first AOFAS president in 2011-12, but she will tell you that she really was not the first female president. It was really Francesca Thompson who died in 1996 during her vice presidential year. Naomi Shields then served as president of the foundation in 2007, 2005, and 2007. Now just look around the room. The number of female members in AOFAS has increased significantly. Female members are now serving on the board as committee chairmen, committee members, program chairs, fellowship directors, program presenters, foundation donors, Vietnam volunteers, and journal reviewers. If you are serving in any of these capacities, would you kindly stand? applause applause Thank you. I hope that many of you have looked at the AOFAS history book. It starts with the founding in 1969 with 46 members. Fifty years later, in 2019, the AOFAS was thriving with more than 2,300 members around the world. Challenges led to new opportunities that led to growth. I've had the great privilege of partnering with dedicated leaders, volunteers, and staff. Working together, much was accomplished, and we had a lot of fun along the way. I am forever an AOFAS fan and will continue to do so from the sidelines. So what am I doing now? So I retired from the AOFAS in 2016, and then my husband and I traveled a bit. Nevertheless, I think association management is in my blood. Three years ago, I took on a new challenge as Executive Director of the Promise Health Organization. It's a non-profit, a collaborative international organization. The members are researchers, clinicians, and other health care professionals. The members work in universities, health systems, private clinics, and tech and pharma, government, and the businesses that support patient outcomes. And the PHO conducts educational workshops, webinars, and an annual conference. As I hope you all know, PROMISE is the acronym for the Patient Reported Outcome Measurement Information System. It's a big mouthful, I know. Development was funded by NIH through the leadership of Dave Sella at Northwestern. PROMISE measures are included in electronic medical records, in private clinics, in health systems, and in multinational clinical trials. PROMISE is being used in many specialties, but orthopedics is actually leading the way. The American Board of Orthopedic Surgery has been visionary on this. Orthopedic surgeons seeking certification for Part 2 exam must collect PROMISE measures as part of their cases. The measures for physical function and pain interference provide a validated assessment of how the patient is feeling and functioning pre-op and at 6 months and 12 months. PROMISE measures have been translated into dozens of languages and are used around the world. The number of articles published on PROMISE has been increasing rather rapidly. Here you can see that the number of journal articles is projected to top 700 this year. And that's in journals across many different specialties. This is the PHO Board of Directors. It's an international board led this year by one of your own, Judy Baumhauer. Next month, the annual conference that the PHO is holding will be in Prague and we hope that you will join us. We'd love to have you join us. Come and learn about how PROMISE is being used to bring the patient's voice to the forefront of health care. Thank you again for this very special honor. It's a delight to be here. Thank you. applause Thank you, Zan. Next we move on to looking at a specific subgroup of My disclosures will be on a slide coming up. We can go quickly through that. Thank you for inviting me. Female athlete, my disclosures. Pretty much no discussion of the female athlete doesn't start without a discussion of Title IX. This was part of the civil rights legislation that was passed in 1972, which made it required for proportional female sports participation and opportunities like scholarships in any higher institution of learning that received federal funds. This is based on the enrollment numbers in the school. And just for your information, it does not apply to high schools. Moving forward to 2021, NC2A participation is pretty much a half a million college athletes, male and female. And 47%, almost on parity with male, are the females. There are 90 national championships. The majority are female. And co-ed also exists, for example, in skiing, for example. However, with this increased participation, we also see increased differences in injury rates and injury patterns in women versus men. This includes anatomical differences, hormonal, biomechanical, neuromuscular, and even some genetic. That's sort of a newer area of research. No discussion about the female athlete is complete without a discussion of the triad. The triad was first reported in 1993 and was pretty exact. It was eating deficiencies, osteoporosis, and amenorrhea. The IOC felt that this was too narrow of a criteria and came together with a consensus statement in 2014 and renamed the triad Relative Energy Deficiency in Sports. This exists with and without an eating disorder. It's more of a continuum, as you can see in the upper part of the slide, where it goes from normal or optimal energy, optimal menstrual cycles, optimal bone health, and then has a sliding scale down to osteoporosis, low energy, and absence of menstruation. And you can exist anywhere around that sliding scale. The feeling is that includes men and male athletes as well. But if you see a low energy availability athlete, female athlete, and they present with a stress fracture or a suspicion of osteoporosis, the recommendation is that you get a DEXA scan. And also the recommendation is that you look at the Z score, not the T score, the Z score on the DEXA scan, which gives you bone mineral density based on sex, ethnicity, age, and weight. It gives you a better approximation of osteopenia and osteoporosis in the female athlete. Hormonal changes, we've already had a good discussion about that, but this is one slide. Take home message, there are hormone receptors on ligaments, all ligaments. Most of the research is done in the ACL, but Hewitt and Meyer have done a lot of good research on this and have found, if you look at this pretty well publicized graph to the right side of the screen, that as estrogen increases, so does the number of ACL tears. The thought is that as estrogen increases, such as right before ovulation, you have more laxity due to this higher estrogen concentration and possibly more ligament tears. More research is needed, but it is interesting. Stan James made some comments about the female anatomy, female athletes. He called it generally the miserable malalignment syndrome. But if you look at the blue highlighted skeleton there, the basic premise is that females have wider pelvises. They have more anteversion of the femur, more internal rotation of the femur, more valgus at the knee, more external rotation at the tibia, and more eversion of the hind foot, just keeping that plumb line going right through the center of the body. If you use an angle, the Q angle, through the center of the ASIS, through the center of the patella, that's the anterior superior iliac sprine, through the center of the patella, and then another line through the tuberosity and through the center of the patella, you get a Q angle. It pretty much, on the frontal plane, shows you valgus, but it also shows you internal rotation of the femur. And women have about a 6 to 8 degree increase on average than males do. So what does this alignment lead to? On a practical level, the increase in the Q angle really shows you the vector of pull of the quadriceps. Notably, the big ones, the strong ones, the rectus femoris and the vastus lateralis, they attach on the patella and then extend down on the patellar tendon. But as you increase that Q angle, you increase the lateral pull on the patella, so it has more of a lateral displacement in the femoral trochlea. It can increase the stress in that joint by about 45%. And yes, women have more patellar femoral syndrome than men, up to double in incidence in the female athlete. What other injuries do we see? No discussion can go without the ACL. Hey, we have to stay upstream because this is a complex system. John early already mentioned is a trampoline, but you gotta look upstream. You gotta look above the ankle for these instability patterns. But females do have more ACL tears, up to eight times greater than males. I think one of the big concepts is the hamstrings-quadriceps ratio. It's very important when you're thinking about the ACL. The hamstrings protect the ACL. On the upper part of the slide, you have the hamstring working best in flexion, over 30 degrees of flexion. It helps stabilize that tibia underneath the femur so that the tibia doesn't glide anteriorly. The quadriceps works better in extension and has a tendency to stress and stretch the ACL, pulling that tibia anteriorly in relationship to the femur. Females have weaker hamstrings. Increased risk also, not only that HQ ratio. You can measure that ratio, and it has been done doing a single-leg squat. Males have been found to have three to three times, three and a half times greater ratio than females. That means higher hamstring strength. Men also land with their knees more bent than women. You can see it in the upper part of the slide. So you have a few other biomechanical issues as well. But the bending of the knee gives you the optimal position for the hamstrings to fire, which protects the knee. Women tend to land with more of a straight knee position in anything less than 30 degrees of flexion, means you're quadricep dominant. The woman on the bottom, the athlete on the bottom, has been trained, she's pretty good. Also, just looking at female ligament anatomy, studies have shown that the female ACL is smaller in cross-sectional area, but it also has less fibrils per, or fewer collagen fibrils per unit area. In addition to that, they have a more narrow intercondylar notch to accommodate the ACL. Now, there's been criticisms of this study saying, oh, well, females are just shorter. That's why that happens, they're just smaller. But if you take our middle blocker versus our libero here in this picture, actually the studies have shown that, yeah, the ACL gets bigger, but the notch does not get more wide with increase in height. Stress fractures, female athlete has three times the incidence of stress fractures in the lower extremity compared to male athletes. If you have a patient, a female athlete, with stress fracture, you have to be suspicious of osteopenia, osteoporosis, and relative energy deficiency in sports. The most common locations for these stress fractures, well, they're pretty much all foot and ankle areas. Tibia's number one, but some of these fractures such as the more distal second and third metatarsal area, which is the most common metatarsals, to have a stress fracture. They can heal pretty well with conservative care, but fractures such as the navicular, even the tibia, may end up with a critical problem and require surgery. Military medicine gives us good information because it directly compares males and females, about the same age, same training, mention the age, equipment, and gear. Gideon Mann out of Israel, he's looking at the Israeli border patrol there on your right, they look like a good group, but they look at the males and the females, basic training, 16 weeks, and they found that the stress fracture incidence was five times higher in the female recruits. So they wanted to know, how can we prevent this? Because this is not good that they're getting higher injury rates. So in conjunction, actually, with Nike, they have tactical boots that they make, the SBP, SBFs, excuse me, and also inserts. They changed that and they found that that didn't have an effect with the incidence of stress fractures. The one thing that did was changing the weight of the gear and just to give you an idea how much gear is carried, in Afghanistan, our troops carried 60 to 100 pounds. Israeli border police, 45 pounds. If you're dropping weight, you're usually dropping body armor. But women are a little bit smaller, so they can do that, but that's usually where they look. As far as inversion injuries, the NC2A Injury Reporting System and Surveillance System reports that ankle injuries in all comers, males and females, is the number one injury that we see in athletes. 15% in approximately both groups. Men's basketball, 1.3 per 100 athletic events. Women's soccer, 1.3. I have to tell you, spring football is actually higher, but I did not include it, but it's pretty much on parity in general. However, women end up with more chronic ankle instability, up to two times more common in the female athlete. So why do women progress to more chronic ankle instability? Well, the feeling is, and there's a lot of good research that is done. Out of Lenox Hill, I like McHugh's work. Less postural control that's seen. Landing patterns in fitness. We've already looked at the landing patterns. They land in a more unstable position. Your athlete on the right, compared to the athlete on the left, she may look like she's in a fairly stable condition or position because she's athletic looking, but look at the pelvic tilt. That's trunk control. Look at the internal rotation of the hip. that means the glutes aren't working. That's your major stabilizer of your trunk. Internal rotation of the femur, valgus of the knee, and compensatory eversion of the foot. A less accurate passive joint inversion position sense also seen, that would be Tenney Williams, who's done good research on that. All these things are modifiable. So I have this picture of one of our volleyball players on the bottom. I have to tell you, women need to get more serious about conditioning and strength, particularly hitting the weight room. And this girl is doing a hamstring curl. Some of the other good ones are like Russian curls, Nordic curls, that sort of thing, to strengthen the posterior chain. The posterior chain is the low back, the butt, the gluteals, and the hamstrings, to stabilize that trunk and stabilize the trampoline. A word about the female athletic shoe. Even after all this time, female shoes are often just scaled down versions of men's shoes. Women have different shaped feet. They're wider in the forefoot than they are in the heel. They also have a shorter stride, more foot strikes per distance, so they may wear down the midsole slightly faster than the males. More in the 300 mile range than the 500 mile range. With a deep dive into companies by calling them, emailing them, and looking on their websites and specification sheets, the only companies that really call out that they have a female last as of 2021 are Asics, Adidas, Alter, Ryka, and Nike. The others either don't have any information or say they're unisex, like Hoka. And I can't remember the second one, but Hoka was one of the ones that actually called out that they had a unisex last. Thank you. Thank you, Dr. Fry. And next we have Dr. Alistair Younger, who will talk to us about outcome database that can teach us about care of women DJD. Thank you, and thank you for inviting me to talk. I hope I can shine some light on where we stand in this, and I focus this on what we have in access to care and in outcomes in foot and ankle, although there is more information elsewhere. The title was more degenerative joint disease. We could have focused also on hip and knee, but I think in this audience we should focus more on foot and ankle. In particular, I'm going to just summarize one of the papers we recently did, mainly out of Toronto with Ellie Pinsker and with Tim Daniels. I don't have direct conflict. So specifically within gender, there's two potential areas of concern about outcomes of degenerative joint disease, and one is access to care and the other is outcomes, and I think databases can help us with both. So I'm just going to summarize what the ankle arthritis database is in Canada and how we've used it. So it was initiated in 2002, cited in Victoria, Vancouver, Toronto, and Halifax in the provinces of British Columbia, Ontario, and Nova Scotia, and it consists of demographics and outcome scores, and I'm using this because I can't really extrapolate any other information from other databases to answer some of these questions. I did try and look at some of the US national databases and stuff to try and find data, and I couldn't find it. So our database exists in these provinces, and in particular, I'm going to sort of concentrate a bit on the province of British Columbia because I can get data on population demographics and also on overall surgery rates for the entire province, and I can relate it more to what's happening in our center. So if you look at the province of British Columbia, it's five million people, there's a single foot and ankle teaching center, and we have a single payer. So we can see that the number of ankle arthritis operations per population is here. So if we look at the far right, we're doing roughly total ankles to fusions, you know, like roughly double as many fusions, and we're doing about five, roughly five, ankle arthritis procedures per 100,000 population per year. And so of these in our database, so the database only unfortunately covers what comes into our actual institution. It doesn't cover what goes on in the entire province. We'd love it if it did. It doesn't. We've tried to get the Canadian Joint Registry involved in this as well, but so far we've had no luck. There may be more information from other databases. So what does the database tell us about gender? So this is the BC data. This is what comes into our own database, and the first thing is, you know, a woman more likely to be failed to be enrolled. So when we look at all the people that come in, who fails to to be enrolled? And so we lose people, for example, you know, not asked or excluded or, you know, active, withdrawn, lost to follow-up, deceased. And so is there gender difference between those enrolled and not enrolled? And if there is, then that means that it's much harder to, you know, understand the outcomes. And we did look at this, and there was no difference in gender between those enrolled and not enrolled into the database. So first concern about gender is there. Second is access to surgery in British Columbia. So I used the BC database and the billing statistics, again, because we've got one teaching center and one provider. And when we look at this, the chance of a female having an ankle arthritis operation is lower than a man. So I looked at the entire population statistics. We looked at who was enrolled in our local database, and we found that the statistically lower chance of a female with end-stage arthritis, sorry, of a female getting arthritis, we don't know if it's end-stage arthritis or not. And that's where one of the questions then comes up, and I think is a source of potential further research. So I looked at this. I thought, well, maybe it's because, you know, men are surviving less time. But then when you go back to the database, you find the average of age of men getting ankle arthritis surgery is actually older. So it's not a demographic issue. So what do we know about the difference between procedures? Well, we do know that women are more likely to get a replacement than men. So there's a, and this is sort of fairly consistent across the various databases. So there's sort of pretty much a one-to-one ratio of men to women getting ankle joint replacements, but much more men getting ankle joint fusions. So this then comes to this sex differences outcomes paper. So I've looked at the data now on access in our province. I'm going to focus on outcomes, which this paper focused on. The paper's actually called Sex Differences, and this was pooling of data between the Vancouver database, the Toronto database, and the Halifax database. So again, not represented necessarily of the entire country, but a select population of people enrolled in the database. So is this sex or is this gender? If we actually look at the question we asked on our questionnaire, we actually asked people, what's your gender? But when it went to the journal, the journal asked us to change it to sex. I don't think it actually makes a difference when it comes down to what's going on. You know, if somebody, you know, started off and say they were male and they transitioned to female, in this paper, we'd ask them what their gender is. They'd say they're female. You know, I'm not sure in the big picture this makes a huge difference, but anyway, the terminology is something these days we have to be careful and accurate in. So the enrollment was 2001 to 2013, so you know, over many years. Inclusion of total ankles and ankle fusions and excluded were TTC fusions and revisions. So this again goes for our exclusions here, so a bunch were TTCs, and then a fairly limited number lost because they were either fusions to replacements or replacements to fusions or revisions of replacements to other replacements, leaving 872 in the entire data set. When we looked at the actual population, it was 872 patients. As we've just summarized in the BC statistic, there was more men than women in the entire data set. And if we then look at total ankles versus ankle fusions, we see that the almost equivalent amount of women as men getting total ankles and more men getting fusions than women. I don't have details on the breakdown between the different joint replacements or between arthroscopic and open. Statistical analysis was advanced. It was done by Lipinsker, and we looked at things like linear regression to adjust for age, inflammatory arthritis, and other potential confining variables, and P was taken at less than 0.05. In summary, in demographics, men were older than women, and both in total ankles and in ankle fusions. Overall, there was otherwise no demographic differences between men and women, bar the etiology of arthritis. So in etiology, women were more likely to have inflammatory arthritis, men were more likely to have primary arthritis, as summarized in this table. In outcomes, women had higher pain, so they had more disability before they had surgery. They had more disability after surgery. The change in score was the same. So the benefit was the same, but the actual disability before and after was worse. Revision rates were the same, and between ankle fusions and replacements, there was no difference between men and women. So in summary, women had worse pre-operative and post-operative scores, but the actual improvement, i.e. the benefit, was the same. So it raises a lot of questions, and sometimes there's more questions than there are answers. So is this consistent with other joint replacements? Well, the answer is yes. In hip and knee joint replacement, women had worse pre-operative and post-operative outcome scores, and there's various sort of causes being raised. There's been a potential for gender bias with regard to referral to orthopedics by primary care. And bearing in mind also that this database goes back many years, hopefully things are changing, but this still reflects historically what's been going on. Women with arthritis are more likely to live alone and not have support, and also there's a potential for women being less trusting in the medical system. So what's the cause of the difference of access? Is it a difference in rate of onset of arthritis, a woman just getting to surgery later? Is it a reflection on difference in cause of arthritis, or is it a lack of support allowing female patients not to be caregivers, because often they're looking after parents, or looking after children, or they may be looking after their spouse. And certainly, if we start looking at things like withdrawal off wait lists, we then start seeing things like causes, you know, why did somebody come off the wait list? And it often is because they've got somebody dependent on them, but they can't actually then look after their own needs. So we also need to sort of think, you know, and understand this better by looking at other countries and other cultures, and try and understand what are the true gender differences in access to care and outcomes. So to the future, we need more information, we need answers, and we need to try and work out how we make access to care equitable and fair. And I finish up just acknowledging our late queen, a woman who deserves great admiration. Thank you. I just want to start off with a broad comment for the panel. A lot of this seems to be, it doesn't seem to be the specific orthopedic surgeon-related problem. The problem isn't us doing the surgery or figuring out these issues. It's either, as Dr. Younger said, getting the access or getting our colleagues in primary care or other areas. Should we take a more active role in protecting women with all these issues in sports, in primary care, so that they can increase their estrogen level, since we know that this happens, or do a better part in the social part of it to get them access to care? So I think it's a great question. I think it's very similar to the debate, the Own the Bone campaign with osteoporosis. And whose job is it? Is it ours as providers of musculoskeletal care, or is it on the part of the primary care doctors to be looking for that? And I think it's a collaboration. I don't know necessarily the answer to that. I think us being on our side and recognizing that it's a problem. I do reach out to primary care doctors to say, I'm looking into this. And I'll order DEXA scans, but then what am I going to do with it? And we're fortunate to have an osteoporosis center at UConn that we work closely with. But I think if we recognize it, we should at least look for it and then communicate with our colleagues. I can make a comment as well. But I think it's part of being an orthopedic surgeon, not only looking at the entire kinetic chain and looking for weaknesses in it. And as women have evolved and had more opportunities in sports, it really hasn't been that long. But we certainly have seen neuromuscular differences. And one of the things I can just comment on taking care of a lot of high school students is that it is required that the male athletes go to the weight room as part of varsity sports. It's kind of recommended for the females. And when the males go, there's an assistant coach there and ATC. The females are lucky to get an assistant coach in there. And it just doesn't seem to be supervised nearly as much or taken as seriously. And I think a lot of the problems with female athletes getting injured, there's a tendency to blame the triad. Oh, it's their hormones. Oh, it's their diet. I think the problem is training. I think they need to take weightlifting and strength training and conditioning more seriously. They need to get to the weight room. They need to do posterior chain strengthening, such as doing squats and Russian curls and what have you to develop the low back, the gluteals, the hamstrings, also the core. They need to stabilize their trunk. As soon as they're landing, they're in a more unstable position than the male is. But this is modifiable. And this is orthopedic. Thank you. So you're asking about how do we change access to care. And I think it's a really complex problem. Certainly in the Canadian system, we've been struggling to have primary care doctors around in the first place. And that creates a big barrier in itself. And I understand from our British colleagues that that's the same. And it comes down to each country, because the way that people actually access the system varies. We have to continue to educate those that refer to us to refer people and to recognize the barriers to access to care. And we've talked about barriers to access to care for women, but also there's barriers to access to care through language and through skin color and culture. Locally for us, we've got a lot of barriers. For example, we have a large Sikh population. And so each culture has its own barriers. And when we look at Western culture, we've got one barrier. And in other cultures, we may have a much bigger barrier for women to get care. And I think we need to look at it as an international society, as more of a global problem, and to look at solutions locally. Because what might work in our province with a huge deficit in family doctors, I mean, we may come up with a plan to try and educate family doctors. But if they're not there, we're not going to improve access. So it means educating. It means finding local solutions, in my mind, and to continue to drive towards equitable care. Totally agree. And I think forums like this, where we can share ideas. Because in all of our countries, they're still having physicians well-respected, and they're looking. Let's go to mic two, please. Tim Daniels from Toronto. So regarding that paper that we published, Alistair reviewed, first of all, I'd like to acknowledge Dagmar Gross. She really was an important initiator of that project. She's our paper writer and only gets acknowledgement at the end of that paper. I found it interesting that the paper was initially rejected and the reasons were that they thought the differences weren't significant enough. And we successfully argued that no difference is still important because the topic of women and men is quite topical, but also we successfully argued that the differences that we did see were important. And fortunately enough, the journal listened to us. Thank you for that clarification. Mic one, please. Yes, is this on? Yes. Hi, Aaron Geyer from Tallahassee, Florida. First, I wanna say this is a great symposium. I'm glad you all put this together. For the last 12 years, I've been one of the team physicians for a Division I track and field and cross country team. And we see, as you might expect, a lot of stress fractures in runners. First, I'd just like to know, do you have any strategies, Lauren and Carol, do you have any strategies you use for your collegiate athletes as far as vitamin D supplementation, specific shoe inserts, anything like that that you recommend for all of your high-level runners and other endurance athletes? And then second, I just wanted to comment on what Carol said earlier. I 100% agree with you on weight training with female athletes. I saw it myself with my two teenage daughters who are elite athletes. And they, at the school they were at, they had a weight training coach that at first wouldn't even allow the women in the weight room. And until they changed that person, who now, we are lucky that our weight training coach believes that the women should be in the weight room more than the male athletes, and then actually has pushed that. So 100% agree with you, I've seen it myself, and I think it's very important. Lauren, I'll go first. Word about vitamin D, there's some very good research on vitamin D and stress fractures. And when you look at the vitamin D levels, your internal medicine doctors are gonna say, oh, it's 40, help me on this, Alastair, is it nanograms per milliliter? Yeah, that's what it is. I just know it's low, I look for the red. Having said that, the feeling is, is with athletes, you should probably keep it much higher, even close to 100. So that means supplementation, because no athlete, particularly in the Northern Hemisphere, a good research out of the UK on this, is gonna get enough sun exposure to have the right vitamin D levels. And there's higher incidence if they have a vitamin D level around 40 or lower. So you can keep them at least 50, but up to 100, and there's no danger of toxicity. And I think that that's something that's very important, it's certainly been substantiated with good research. I'm sure there's more to come, but good question. Lauren? I mean, I would agree with that. I mean, I think there's a question, do we supplement everyone in that position, understanding that it could prevent them? I mean, I think the data certainly shows that it helps with healing afterwards, and that there is a deficiency amongst, you know, anyone that gets stress fractures, women in particular. I don't know that we've proven supplementation prevents it, but to your point, I mean, I don't know if there's any downside to doing it. But then again, the question becomes, who's prescribing that? I've always thought that we need an education program, you know, with, at the schools. And I'm always surprised by many of the athletes and females, you know, that come in, where they just are totally unaware of vitamin D deficiency, you know, like in the dancing schools. Indoor sports, you know, like soccer and stuff, which is often played indoors. Just, it just surprises me that we don't reach out and hit those particular populations, particularly in the younger female athletes, where it means so much, you know, like for them to be vitamin D deficient in those growing years, it seems such an obvious target population to go around the dance schools and just say, all these kids should be taking vitamin D. They're indoors, they're young, they're growing, they need it. And so when I've measured levels, and you know, like I had one ballet dancer come in, and she was 16, and her vitamin D was right through her boots and she had a scholarship set up and everything. There was so much for her to lose. And we just, it just seems to me to be such a big win if we could somehow target that population, because you can't target everybody, but that particular at-risk population and get them to be taking vitamin D through school programs and stuff. Thank you. Well, similarly along that line, that goes to my next question, and kind of directed towards Dr. Fry, but anybody can answer. What should we, as surgeons, because there's a lot of our colleagues who do take care of high-level athletes from the high school, college, professional level, if you could give them like just one piece of advice on how to change their practice, like what would you want to see us do to try to improve the situation for these athletes, female athletes? Well, with the high school athletes, there's about 3.5 million, at least in the United States, high school athletes. 7% of them make it to the NC2A, most of them Division III, and then professionals, much smaller number. If I was going to give them one piece of advice, I already mentioned it, it's pretty simple, taking weight training seriously. Female athletes, even at a very high professional level, don't do it that seriously. You can watch them weight train. They need to actually really concentrate on stabilizing upstream in the kinetic chain. I think the main problem, because I don't want to get too complicated, is the posterior chain, low back, gluteals, hamstrings. Unfortunately, they don't like doing squats. A back squat is the best way to do that, but if they don't want to do that, they can do hamstring curls, Russian curls, Nordic curls, the ones I showed there with the BOSU ball, goblet squats. There are all sorts of modifications you can do for the female. So they don't have to avoid it because they can't do the deep squats that the football players, male football players are doing. But that's the one piece of advice I would give them. Thank you. To Mike Reed. Hi, I'm Dagmar Gross, and I think this has been a fantastic session, so enlightening, and I think we've got a lot of energy going here for the orthopedic surgeons, especially those who are focusing on athletes in the younger population, and we're talking about two very important elements, vitamin D and weight training, and how can we go about educating and getting that message out. On a very different level, about 20 years ago at St. Michael's Hospital in Toronto, which is now part of the University Health Network, they had a group of, they had, led by Dr. Bogosh, an orthopedic surgeon, and a number of other surgeons got involved, and they developed an osteoporosis exemplary care program to specifically target patients who are coming in with fragility fractures to prevent them from getting, to get them into treatment so that they don't get subsequent fragility fractures. And they had this initial group of people come together with this energy and interest that I'm seeing here today, and I'm wondering if we could, I'm just throwing out ideas here, and I'm wondering if we could somehow learn from that group, and I would be happy to facilitate and work with bringing people together and discussing the ideas, because I've worked with that group extensively, I've worked with the COFAS group, so let me be your conduit and help you to start putting ideas together. I would be happy to do so, and maybe we can explore something. I'm just throwing this out as, we have the potential now to start something here, and explore what do we need to bring the group together. We can learn from the Bogosh group, the St. Michael's Hospital group, who we need to bring together, who the key people need to be to get this going. Just throwing it out as an idea. Thank you so much. I'll grab your name and grab your contact information. We'll find the right people. I just want to close up this and ask Zan. I put her a little bit on the spot, but if you can share with us your greatest memory, your favorite part of being part of AOFAS during your time. I know there's a lot, but just share whatever you can with us. Yeah, there was a lot. I guess one of my favorite parts was the Vietnam project. I had the opportunity and the pleasure to go to Vietnam nine times with various teams, both men and women. I think they all did a wonderful job there, and I think it was a great service. I think it was a wonderful project that was started by Pierce Granton. It was kind of a high point for me, but more than that was the partnership that I found in working with so many different leaders and volunteers in the society. There were so many wonderful programs that moved forward during the 10 years that I was here, and it was due to the enthusiasm and just the go and let's get it done and partnering with the staff. It was a wonderful experience. Thank you all for that.

Women's Leadership Forum

gender-focused discussions

female leaders

hormones

estrogen

bone turnover

muscle structure

ligaments and tendons

access to care