Abstract
Aims
Our primary aim was to establish the proportion of female orthopaedic consultants who perform arthroplasty via cases submitted to the National Joint Registry (NJR), which covers England, Wales, Northern Ireland, the Isle of Man, and Guernsey. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.
Methods
Publicly available data from the NJR was extracted on the types of arthroplasty performed by each surgeon, and the number of procedures of each type undertaken. Each surgeon was cross-referenced with the General Medical Council (GMC) website, using GMC number to extract surgeon demographic data. These included sex, region of practice, and dates of full and specialist registration.
Results
Of 2,895 surgeons contributing to the NJR in 2023, 102 (4%) were female. The highest proportions of female surgeons were among those who performed elbow (n = 25; 5%), shoulder (n = 24; 4%), and ankle (n = 8; 4%) arthroplasty. Hip (n = 66; 3%) and knee arthroplasty (n = 39; 2%) had the lowest female representation. Female surgeons had been practising for a median of 10.4 years since specialist registration compared to 13.7 years for males (p < 0.001). Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (8%). A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple hospitals (74% vs 40%; p < 0.001).
Conclusion
Only 4% of surgeons currently contributing cases to the NJR are female, with the highest proportion performing elbow arthroplasty (5%). Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons, and are less involved in private practice. There is a wide geographical variation in the proportion of female arthroplasty surgeons.
Cite this article: Bone Jt Open 2024;5(8):637–643.
Take home message
There were 102 (4%) female orthopaedic surgeons contributing to the National Joint Registry, out of 2,895 surgeons.
The highest proportion of female surgeons were among those who performed elbow (5%), shoulder (4%), and ankle (4%) arthroplasty.
A greater proportion of male surgeons worked in private practice (63% vs 24%; p < 0.001) and in multiple trusts (74% vs 40%; p < 0.001).
Introduction
Issues of gender bias and sexual discrimination have been brought to the forefront of public discourse owing to increasing coverage in entertainment, politics, and sport.1 Such issues include prejudice towards one gender or discrimination on the grounds of gender,2 with these being highly prevalent in the medical sector.3,4 Those identifying as female surgeons face multiple sources of implicit bias and epistemic injustice,5 including limited access to parental leave and role models, stereotyped expectations pertaining to adopting surgery’s care working roles, and objectification.4
Since 1996, females have comprised 55% of medical students in the UK.6 However, orthopaedic surgery is the surgical speciality with the lowest proportion of female surgeons, with women comprising 19% of registrars and 6% of consultants.7 Organizations in the UK such as the British Orthopaedic Trainees Association and the British Orthopaedic Association have carried out campaigns to help rectify this imbalance.8
Studies pertaining to various surgical specialities have demonstrated that patient-surgeon gender concordance leads to improved surgical outcomes and patient satisfaction.9-11 However, there is a paucity of literature on the effect of surgeon gender on patient outcomes in orthopaedic surgery. A recent register-based cohort study carried out in Sweden explored outcomes following primary total hip arthroplasty according to gender concordance between patients and surgeons.12 A total of 11,993 procedures were included in the study, which were categorized into gender-concordant (n = 5,318) and gender-discordant (n = 6,675) groups. The former had a lower likelihood of developing adverse events (odds ratio (OR) 0.82; 95% CI 0.71 to 0.95) and surgical adverse events (OR 0.86; 95% CI 0.72 to 0.99). However, no association was detected between gender concordance and patient-reported satisfaction.12 Evidence suggests patient-surgeon gender concordance leads to improved outcomes, rather than surgeon gender alone, considering the latter was not found to impact outcomes of arthroplasty.13
The National Joint Registry (NJR) is a publicly available register which records, monitors, and analyses outcomes in arthroplasty in England, Wales, Northern Ireland, the Isle of Man, and Guernsey.14 Information on hip, knee, ankle, elbow, and shoulder arthroplasty surgery is collected, with the aim of improving patient safety and clinical outcomes. It accurately represents orthopaedic workforce, with a total of 3.7 million records, and 250,000 submitted annually.14 The General Medical Council (GMC) register provides a list of doctors in the UK, including their registration and training status.15 Given the importance of patient-surgeon gender concordance and the need to evaluate the gender composition of orthopaedic surgeons, our primary aim was to establish the proportion of female consultants who perform arthroplasty via cases submitted to the NJR. Secondary aims included comparing time since specialist registration, private practice participation, and number of hospitals worked in between male and female surgeons.
Methods
We extracted publicly available data from the NJR14 and GMC websites.15 Ethical approval was therefore not required.
Data extraction
Data were extracted in April 2023. Types of arthroplasty performed by each surgeon, the number of procedures of each type undertaken, patient demographic data, location, and trust were collected from the NJR. We extracted the total number of each procedure that the surgeon performed in the last 12 and 36 months. We categorized hospitals into NHS and independent hospitals. We cross-referenced each surgeon by GMC number with the GMC website in order to extract surgeon gender and dates of full and specialist registration. If a surgeon was recorded in the NJR as working in hospitals in different regions, they were assigned to a single region for the purposes of analysis; this was the site registered as their designated body with the GMC.
Statistical analysis
The percentage of female orthopaedic surgeons in different regions was calculated, as well as the percentage of female surgeons performing knee, hip, ankle, elbow, and shoulder arthroplasty. We calculated time since full and specialist registration, taking 1 January 2023 as reference. The Kolmogorov-Smirnov test and visual assessment of histograms were used to establish whether data were normally distributed. Accordingly, difference in time since registration and time in training between male and female surgeons was compared using the Mann-Whitney U test. The categorical values of female and male surgeons carrying out each procedure more or less than five times in the previous 12 and 36 months, the number of female and male surgeons working in multiple hospitals, and those working in independent or NHS hospitals were compared using the chi-squared test (test statistic denoted by χ²). Degrees of freedom for each test were denoted by df. Significance was set at the 5% level. All statistical analyses were carried out using SPSS v. 29 (SPSS, USA).
Results
Out of 2,895 surgeons in the NJR, there were 2,793 male consultant orthopaedic surgeons (96%), and 102 female consultant orthopaedic surgeons (4%).
Distribution of female surgeons according to joint
The highest proportion of female surgeons were among those who performed elbow arthroplasty (25 (5%) vs 535 (95%) males), followed by ankle (eight (4%) vs 210 (96%) males), shoulder (24 (4%) vs 639 (96%) males), and hip arthroplasty (66 (3%) vs 2,192 (97%) males). The joint with the lowest proportion of female arthroplasty surgeons was the knee (39 (2%) vs 1,947 (98%) males). Of 102 total female surgeons, 52 (50%) had not performed a single hip arthroplasty within 12 months, 26 (26%) had performed fewer than five, and 24 (24%) had performed five or more within 12 months. Conversely, of 2,793 total male surgeons, 1,108 (40%) had not performed a single hip arthroplasty within 12 months, 342 (12%) had performed fewer than five, and 1,343 (48%) had performed five or more within 12 months (p < 0.001) (Table I). Overall, males performed a statistically significant higher volume of operations than females pertaining to primary and revision hip arthroplasty, primary patellofemoral arthroplasty, primary total knee arthroplasty, primary unicompartmental knee arthroplasty, revision knee arthroplasty within 12 and 36 months, and primary elbow arthroplasty within 12 months. This was not the case for the remaining procedures (Table I).
Table I.
Volume of operations performed by male and female orthopaedic surgeons.
| Procedure | Gender | Number of procedures within 12 months, n (%) | Number of procedures within 36 months, n (%) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| None | < 5 | ≥ 5 | χ² | None | < 5 | ≥ 5 | χ² | ||
| Hip primary | Female | 52 (50) | 26 (26) | 24 (24) | p < 0.001 χ² = 29.289 |
37 (36) | 29 (29) | 36 (35) | p < 0.001 χ² = 152.440 |
| Male | 1,108 (40) | 342 (12) | 1,343 (48) | 692 (25) | 510 (18) | 1,591 (57) | |||
| Hip revision | Female | 87 (85) | 10 (10) | 5 (5) | p = 0.002 χ² = 12.434 |
78 (77) | 14 (13) | 10 (10) | p = 0.001 χ² = 13.519 |
| Male | 1,957 (70) | 375 (13) | 461 (17) | 1,665 (60) | 459 (16) | 669 (24) | |||
| Knee primary - patellofemoral | Female | 102 (100) | 0 (0) | 0 (0) | p = 0.006 χ² = 10.212 |
100 (98) | 2 (2) | 0 (0) | p = 0.004 χ² = 11.138 |
| Male | 2,538 (91) | 190 (7) | 65 (2) | 2,430 (87) | 216 (8) | 147 (5) | |||
| Knee primary – medial compartment | Female | 102 (100) | 0 (0) | 0 (0) | p = 0.619 χ² = 0.958 |
102 (100) | 0 (0) | 0 (0) | p = 0.426 χ² = 1.707 |
| Male | 2,767 (99) | 24 (0.9) | 2 (0.1) | 2,748 (98) | 39 (1.4) | 6 (0.2) | |||
| Knee primary – total knee arthroplasty | Female | 75 (74) | 3 (3) | 24 (23) | p < 0.001 χ² = 41.467 |
68 (67) | 3 (3) | 31 (30) | p < 0.001 χ² = 44.701 |
| Male | 1,162 (42) | 133 (5) | 1,498 (53) | 962 (34) | 155 (6) | 1,676 (60) | |||
| Knee primary – unicompartmental knee arthroplasty | Female | 95 (93) | 3 (3) | 4 (4) | p < 0.001 χ² = 18.070 |
92 (90) | 4 (4) | 6 (6) | p < 0.001 χ² = 18.876 |
| Male | 2,089 (75) | 201 (7) | 503 (18) | 1,977 (71) | 180 (6) | 636 (23) | |||
| Knee revision | Female | 88 (86) | 11 (11) | 3 (3) | p < 0.001 χ² = 17.646 |
78 (76) | 16 (16) | 8 (8) | p < 0.001 χ² = 22.120 |
| Male | 1,874 (67) | 530 (19) | 389 (14) | 1,517 (54) | 565 (20) | 711 (26) | |||
| Ankle primary | Female | 96 (94) | 6 (6) | 0 (0) | p = 0.087 χ² = 4.882 |
95 (93) | 4 (4) | 3 (3) | p = 0.739 χ² = 0.605 |
| Male | 2,640 (95) | 86 (3) | 67 (2) | 2,600 (93) | 81 (3) | 112 (4) | |||
| Ankle revision | Female | 99 (97) | 3 (3) | 0 (0) | p = 0.454 χ² = 1.578 |
99 (97) | 3 (3) | 0 (0) | p = 0.665 χ² = 0.815 |
| Male | 2,744 (98) | 42 (1.5) | 7 (0.3) | 2,711 (97) | 64 (2) | 18 (1) | |||
| Elbow primary | Female | 84 (82) | 17 (17) | 1 (1) | p = 0.019 χ² = 7.939 |
79 (77) | 17 (17) | 6 (6) | p = 0.203 χ² = 3.189 |
| Male | 2,492 (89) | 244 (9) | 57 (2) | 2,294 (82) | 307 (11) | 192 (7) | |||
| Elbow revision | Female | 99 (97) | 3 (3) | 0 | p = 0.769 χ² = 0.526 |
96 (94) | 4 (4) | 2 (2) | p = 0.643 χ² = 0.883 |
| Male | 2,712 (97) | 69 (2.5) | 12 (0.4) | 2,653 (95) | 112 (4) | 28 (1) | |||
| Shoulder primary | Female | 81 (79) | 10 (10) | 11 (11) | p = 0.07 χ² = 5.318 |
78 (76) | 7 (7) | 17 (17) | p = 0.715 χ² = 0.670 |
| Male | 2,295 (82) | 135 (5) | 363 (13) | 2183 (78) | 140 (5) | 470 (17) | |||
| Shoulder revision | Female | 97 (95) | 4 (4) | 1 (1) | p = 0.462 χ² = 1.545 |
93 (91) | 7 (7) | 2 (2) | p = 0.424 χ² = 1.716 |
| Male | 2,560 (91) | 188 (7) | 45 (2) | 2,445 (88) | 224 (8) | 124 (4) | |||
-
χ² = chi-squared test statistic.
-
All tests had degrees of freedom (df) of 2.
Distribution of female surgeons according to region
Northern Ireland was the region with the highest proportion of female arthroplasty surgeons (6 (8%) vs 66 (92%) males), followed by the South East (20 (5%) vs 409 (95%)), South West England (13 (4%) vs 282 (96%)), and North West England (17 (4%) vs 376 (96%)). North Wales, the Isle of Man, and the Channel Islands had no female arthroplasty surgeons (Figure 1 and Table II).
Fig. 1
Percentage of female orthopaedic surgeons according to region.
Table II.
Number of male and female orthopaedic surgeons according to region.
| Surgeon gender | Channel Islands, n (%) | East of England, n (%) | Isle of Man, n (%) | London, n (%) | Mid and Central Wales, n (%) | Midlands,n (%) | North East & Yorkshire, n (%) | North Wales, n (%) | North West, n (%) | Northern Ireland, n (%) | South East, n (%) | South East Wales, n (%) | South West, n (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Female | 0 (0) | 10 (4) | 0 (0) | 14 (3) | 2 (4) | 8 (2) | 10 (3) | 0 (0) | 17 (4) | 6 (8) | 20 (5) | 2 (3) | 13 (4) |
| Male | 2 (100) | 251 (96) | 4 (100) | 410 (97) | 48 (96) | 481 (98) | 367 (97) | 31 (100) | 376 (96) | 66 (92) | 409 (95) | 66 (97) | 282 (96) |
Distribution of female surgeons according to hospital
Female orthopaedic surgeons were distributed across 147 NHS hospitals and 26 independent hospitals. Male orthopaedic surgeons were distributed across 283 NHS hospitals and 175 independent hospitals. Of 102 female surgeons, 80 (78%) worked in the NHS exclusively, whereas the remaining 22 (22%) worked in an independent hospital. Of 2,793 male surgeons, 1,031 worked in the NHS exclusively (37%), and 1,762 (63%) worked in an independent hospital. The proportion of arthroplasty consultants working in private practice was significantly greater among males than in females (p < 0.001, χ² = 71.726; df = 1). The proportion of surgeons working in more than one hospital was higher in males than in females (74% vs 40%, p < 0.001, χ² = 56.830; df = 1). Overall, males worked in a greater number of hospitals than females (p < 0.001) (Table III).
Table III.
Distribution of male and female orthopaedic surgeons according to number of hospitals worked in.
| Number of hospitals worked in | Female surgeons, n (%) | Male surgeons, n (%) | Test statistic |
|---|---|---|---|
| 1 | 61 (60) | 726 (26) | p < 0.001 χ² = 61.630 df = 8 |
| 2 | 24 (24) | 762 (27) | |
| 3 | 8 (8) | 642 (23) | |
| 4 | 6 (6) | 396 (14) | |
| 5 | 2 (2) | 171 (6) | |
| 6 | 1 (1) | 59 (2) | |
| 7 | 0 (0) | 24 (1) | |
| 8 | 0 (0) | 7 (0.3) | |
| 9 | 0 (0) | 6 (0.2) |
-
χ²= chi-squared-squared test statistic.
-
All tests had degrees of freedom (df) of 2.
Time since registration
The median time since full registration was 24.4 years (2.9 to 55.8) for males and 32.1 years (range 12.3 to 45.5) for females (p < 0.001). A total of 179 males and one female were not on the specialist register; these could be consultants who retired. Among those on the specialist register, the median time since specialist registration was 13.7 years (11 days to 30 years) for males and 10.4 years (2.0 to 26.6) for females (p < 0.001). There were 43 males and one female who received their full and specialist registration concomitantly. In the remaining, the median time from full to specialist registration was 10.9 years for males (5 days to 36.8 years) and 11.5 years (128 days to 24.6 years) for females (p < 0.001).
Discussion
There is a low proportion of female arthroplasty surgeons within the NJR, with females comprising only 4% of arthroplasty consultants. This is the lowest proportion among all surgical specialties.16 The highest proportion of female surgeons were among those who performed elbow, shoulder, and ankle arthroplasty. Hip and knee arthroplasty had the lowest female representation. The proportion of female surgeons performing arthroplasty varied by geographical region and was highest in Northern Ireland. Males were more likely to be participating in private practice and to be performing arthroplasty surgery at a greater number of hospitals.
Female orthopaedic surgeons had a longer time from full GMC registration to specialist registration than their male counterparts, and were on average earlier in their careers with less time spent on the specialist register. The shorter time from full to specialist registration observed for some surgeons may be explained by consultants carrying out their training abroad, and registering with the GMC directly on the specialist register, yielding a very short gap from full to specialist registration. This also applies to consultants who may have done part of their training abroad. Surgeons may spend a longer time in training due to undertaking fellowships, working in other specialties, taking career breaks or maternity leave, and choosing less than full time training.
The longer time from full to specialist registration among female consultants may be attributed to a greater tendency to have time out of training or working less than full time than their male counterparts. Lachish et al17 found that at ten years post-graduation, there was a six-fold higher proportion of female doctors working less than full-time compared to male doctors. Female doctors working in surgery were less likely to work full-time than those in other specialties.
These imbalances could be attributed to multiple reasons affecting all stages of professional development. Contemporary research consistently shows that medical students perceive orthopaedic surgery to be an unwelcoming career for women, with both physical and social burdens impairing the development of equality between male and female surgeons.18,19 In addition, literature from the USA suggests female residency applicants are more likely to be asked inappropriate questions during interviews than males.2 Women who have completed their training take longer to receive a job offer, and enjoy less success than men in academia.2 This leads to orthopaedics being less popular among females compared to males during training,20 and results in women earning less and being under-represented in leadership positions.21-23 In our study, males were more likely to be participating in private practice than females. This could be a factor contributing to the existing pay gap.24
Effective inclusion campaigns are required to increase the proportion of female orthopaedic surgeons. For instance, Mason et al25 reported on 118 students who completed an orthopaedic summer internship programme. This lasted eight weeks, and consisted of lectures, workshops, presentation of a completed research project, counselling, and ongoing mentoring. Completion of this programme was associated with increased odds of applying to orthopaedic surgery residency (OR 51.3, 95% CI 21.1 to 122.0; p < 0.001). However, it could be argued that those taking part in the programme had an initial interest in orthopaedic surgery, rendering a self-selecting group of a disproportionately high number of orthopaedic surgery residency applicants. Therefore, it is unclear whether this scheme is able to recruit women into orthopaedics who otherwise would have not considered it as a career.
Coffin et al26 presented a survey to 18 high school and 18 medical students before and after the delivery of simulated orthopaedic procedures and speaker sessions. Average interest score before the event was 6 out of 10, with all respondents believing that women faced more barriers than men in orthopaedics. Respondents stated that upholding the expectations and perceptions of orthopaedic surgeons in the view of peers and patients could be an impediment to women seeking a career in orthopaedic surgery. After the simulated procedures and lectures, average interest increased to 7.67 out of 10 (p = 0.003). In addition, participants perceived fewer barriers to entry in terms of balancing a career and family life.26 However, other studies have demonstrated that women in surgery events alone are not enough to alter the perception of sex bias in orthopaedic surgery.27
Publications on inclusion campaigns are dominated by the USA, with the results of many UK initiatives yet to realized or published.8 Many are local initiatives and hence are limited in scope, with their effectiveness at regional or national level remaining unclear.2 Strategies must target all levels of training, from medical school to senior faculties and editorial boards.2 Misconceptions, such as women not being suited for a career in orthopaedics due to physical requirements, must be dispelled, considering that the evidence does not support this.28 Further, equality during job applications must be promoted, and initiatives to improve work-life balance must be instated. Though there are schemes in place in the UK for less than full-time training, participants of such schemes may experience undermining behaviour due to their choice of working flexibly.29 Addressing this is necessary, with current evidence suggesting that concerns regarding family life deter women from choosing a surgical career.30
Such initiatives should be implemented across the UK, with particular emphasis on regions which had the lowest proportion of female orthopaedic surgeons. These were the Midlands, North Wales, the Channel Islands, and the Isle of Man, with the latter three having no female consultant orthopaedic surgeons. The geographical variation in female surgeons may require further investigation to identify and help alleviate any potential barriers to increasing representation in these regions. Okike et al31 found that increased orthopaedic faculty and resident ethnic diversity was associated with a greater orthopaedic application rate among under-represented minority medical students. Similar benefits may be expected with an increased female representation, particularly in hip and knee arthroplasty, which had the lowest proportion of female orthopaedic surgeons among all subspecialties. In order to reflect the population we serve, and to have the possibility of gender concordance between patient and surgeon, active efforts should be made to increase the proportion of female surgeons undertaking hip and knee arthroplasty. The British Hip Society have a very active programme to increase diversity among its members and among hip surgeons within the UK, which has included workshops for school age children, in addition to an actively managed mentorship scheme.32 Such efforts have not yet been replicated across all other adult orthopaedic subspecialty societies.
The limitations of this study must be taken into account when interpreting the findings. The main limitation of our dataset from the NJR is that it only represents those surgeons who perform arthroplasty as part of their practice. Orthopaedic subspecialties performing exclusively non-arthroplasty surgery, such as paediatrics and hand surgery, could not be explored. However, it is increasingly unusual for adult shoulder, foot and ankle, knee, or hip surgeons not to perform any arthroplasty. In addition, arthroplasty is typically employed in oncology, which captures many of the orthopaedic subspecialties. Therefore, although our study cannot provide insights into the proportion of female surgeons among the entire orthopaedic profession with certainty, it may serve as a proxy. The quantitative nature of the data limits the ability to analyze the root causes of gender imbalance in orthopaedic surgery. An understanding of baseline representation and stage of training can help guide future qualitative research exploring the reasons behind the gender disparity, and inform efforts to address it. We evaluated the orthopaedic workforce composition at a single timepoint, rather than carrying out a historical analysis. Further work should explore time trends to garner a better understanding of changes over time and areas for improvement. The NJR does not include Scotland, and therefore cannot be quoted as UK-wide.14 The NJR does not report absolute numbers of procedures when fewer than five are performed, therefore the mean number of procedures performed per surgeon could not be calculated. Moreover, the NJR and GMC do not provide information on changes in job plans that can affect hospital sites represented in the NJR, which may impact the results. Finally, the gender quoted on the GMC website is self-identified, but there are only male and female options presented when searching for doctors, and further gender diversity is absent.
In conclusion, there is a very low proportion of female consultant orthopaedic surgeons performing arthroplasty surgery within the NJR of England, Wales, Northern Ireland, the Isle of Man, and Guernsey. This was lowest among lower limb arthroplasty. Female orthopaedic surgeons in the NJR are earlier in their careers than male surgeons and are less likely to engage with private practice performing arthroplasty. There is a wide variation in the proportion of female arthroplasty surgeons across different geographical regions. The ongoing support of inclusion campaigns is required to increase the proportion of female orthopaedic surgeons in the long term.
References
1. Rihal CS , Baker NA , Bunkers BE , et al. Addressing sexual harassment in the #MeToo era: an institutional approach . Mayo Clin Proc . 2020 ; 95 ( 4 ): 749 – 757 . Crossref PubMed Google Scholar
2. Halim UA , Elbayouk A , Ali AM , Cullen CM , Javed S . The prevalence and impact of gender bias and sexual discrimination in orthopaedics, and mitigating strategies . Bone Joint J . 2020 ; 102-B ( 11 ): 1 – 11 . Crossref PubMed Google Scholar
3. Miller P . #MeToo in surgery: narratives by women surgeons . Narrat Inq Bioeth . 2019 ; 9 ( 3 ): 179 – 183 . Crossref PubMed Google Scholar
4. Hutchison K . Four types of gender bias affecting women surgeons and their cumulative impact . J Med Ethics . 2020 ; 46 ( 4 ): 236 – 241 . Crossref PubMed Google Scholar
5. Claahsen-van der Grinten H , Verhaak C , Steensma T , Middelberg T , Roeffen J , Klink D . Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up . Eur J Pediatr . 2021 ; 180 ( 5 ): 1349 – 1357 . Crossref PubMed Google Scholar
6. Moberly T . Number of women entering medical school rises after decade of decline . BMJ . 2018 ; 360 : k254 . Crossref Google Scholar
7. International Orthopaedic Diversity Alliance . Diversity in orthopaedics and traumatology: a global perspective . EFORT Open Rev . 2020 ; 5 ( 10 ): 743 – 752 . Crossref PubMed Google Scholar
8. Rimmer A . Orthopaedic trainees launch anti-bullying programme . BMJ . 2017 ; 356 : j398 . Crossref PubMed Google Scholar
9. Chekijian S , Kinsman J , Taylor RA , et al. Association between patient-physician gender concordance and patient experience scores. Is there gender bias? Am J Emerg Med . 2021 ; 45 : 476 – 482 . Crossref PubMed Google Scholar
10. Wallis CJD , Jerath A , Coburn N , et al. Association of surgeon-patient sex concordance with postoperative outcomes . JAMA Surg . 2022 ; 157 ( 2 ): 146 – 156 . Crossref PubMed Google Scholar
11. Hassan AM , Ketheeswaran S , Adesoye T , et al. Association between patient-surgeon race and gender concordance and patient-reported outcomes following breast cancer surgery . Breast Cancer Res Treat . 2023 ; 198 ( 1 ): 167 – 175 . Crossref PubMed Google Scholar
12. Jolbäck P , Mukka S , Wetterling K , Mohaddes M , Garland A . Patient-surgeon sex discordance impacts adverse events but does not affect patient-reported satisfaction after primary total hip arthroplasty: a regional register-based cohort study . Acta Orthop . 2022 ; 93 : 922 – 929 . Crossref PubMed Google Scholar
13. Chapman TR , Zmistowski B , Votta K , Abdeen A , Purtill JJ , Chen AF . Patient complications after total joint arthroplasty: does surgeon gender matter? J Am Acad Orthop Surg . 2020 ; 28 ( 22 ): 937 – 944 . Crossref PubMed Google Scholar
14. No authors listed . About the NJR . National Joint Registry . https://www.njrcentre.org.uk/about-the-njr/ ( date last accessed 1 August 2024 ). Google Scholar
15. No authors listed . General Medical Council . https://www.gmc-uk.org/registration-and-licensing/the-medical-register ( date last accessed 1 August 2024 ). Google Scholar
16. Moberly T . A fifth of surgeons in England are female . BMJ . 2018 ; 363 : k4530 . Crossref PubMed Google Scholar
17. Lachish S , Svirko E , Goldacre MJ , Lambert T . Factors associated with less-than-full-time working in medical practice: results of surveys of five cohorts of UK doctors, 10 years after graduation . Hum Resour Health . 2016 ; 14 ( 1 ): 62 . Crossref PubMed Google Scholar
18. Hackney R , Robinson PG , Hall A , Brown G , Duckworth AD , Scott CEH . Medical students’ perceptions of and experiences in trauma and orthopaedic surgery: a cross-sectional study . British Orthopaedic Association . https://www.boa.ac.uk/resource/medical-students-perceptions-of-and-experiences-in-trauma-and-orthopaedic-surgery-a-cross-sectional-study.html ( date last accessed 1 August 2024 ). Google Scholar
19. Pechlivanidou E , Antonopoulos I , Margariti RE . Gender equality challenges in orthopaedic surgery: a systematic review . Int Orthop . 2023 ; 47 ( 9 ): 2143 – 2171 . Crossref PubMed Google Scholar
20. Jain A , Nichols G , Tarabishy S , Scomacao I , Herrera FA . A comparison of applicant and resident physician demographics among surgical subspecialties from 2009 to 2019: trends in gender and underrepresented minorities in medicine . Ann Plast Surg . 2022 ; 88 ( 4 ): 451 – 459 . Crossref PubMed Google Scholar
21. Dossa F , Simpson AN , Sutradhar R , et al. Sex-based disparities in the hourly earnings of surgeons in the fee-for-service system in Ontario, Canada . JAMA Surg . 2019 ; 154 ( 12 ): 1134 – 1142 . Crossref PubMed Google Scholar
22. Peck CJ , Schmidt SJ , Latimore DA , O’Connor MI . Chair versus chairman: does orthopaedics use the gendered term more than other specialties? Clin Orthop Relat Res . 2020 ; 478 ( 7 ): 1583 – 1589 . Crossref PubMed Google Scholar
23. Robin JX , Murali S , Paul KD , et al. Disparities among industry’s highly compensated orthopaedic surgeons . JB JS Open Access . 2021 ; 6 ( 4 ): e21.00015 . Crossref PubMed Google Scholar
24. Halim UA , Qureshi A , Dayaji S , et al. Orthopaedics and the gender pay gap: a systematic review . Surgeon . 2023 ; 21 ( 5 ): 301 – 307 . Crossref PubMed Google Scholar
25. Mason BS , Ross W , Ortega G , Chambers MC , Parks ML . Can a strategic pipeline initiative increase the number of women and underrepresented minorities in orthopaedic surgery? Clin Orthop Relat Res . 2016 ; 474 ( 9 ): 1979 – 1985 . Crossref PubMed Google Scholar
26. Coffin MD , Collins CS , Dib AG , Matzkin EG , Gould SJ . A plausible pipeline to diversifying orthopaedics: premedical programming . J Surg Educ . 2022 ; 79 ( 1 ): 122 – 128 . Crossref PubMed Google Scholar
27. Hull B , Pestrin O , Brennan CM , Hackney R , Scott CEH . Women in surgery events alone do not change medical student perceptions of gender bias and discrimination in orthopaedic surgery . Front Surg . 2022 ; 9 : 905558 . Crossref PubMed Google Scholar
28. Pico K , Gioe TJ , Vanheest A , Tatman PJ . Do men outperform women during orthopaedic residency training? Clin Orthop Relat Res . 2010 ; 468 ( 7 ): 1804 – 1808 . Crossref PubMed Google Scholar
29. Harries RL , Gokani VJ , Smitham P , Fitzgerald JE , Councils of Association of Surgeons in Training and British Orthopaedic Trainees Association . Less than full-time training in surgery: a cross-sectional study evaluating the accessibility and experiences of flexible training in the surgical trainee workforce . BMJ Open . 2016 ; 6 ( 4 ): e010136 . Crossref PubMed Google Scholar
30. Giantini Larsen AM , Pories S , Parangi S , Robertson FC . Barriers to pursuing a career in surgery: an institutional survey of harvard medical school students . Ann Surg . 2021 ; 273 ( 6 ): 1120 – 1126 . Crossref PubMed Google Scholar
31. Okike K , Phillips DP , Johnson WA , O’Connor MI . Orthopaedic faculty and resident racial/ethnic diversity is associated with the orthopaedic application rate among underrepresented minority medical students . J Am Acad Orthop Surg . 2020 ; 28 ( 6 ): 241 – 247 . Crossref PubMed Google Scholar
32. No authors listed . British Hip Society Mentors . British Hip Society . https://britishhipsociety.com/bhs-mentors/ ( date last accessed 1 August 2024 ). Google Scholar
Author contributions
D. Abelleyra Lastoria: Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft
L. Casey: Conceptualization, Formal analysis, Investigation, Writing – review & editing
R. Beni: Visualization
A. V. Papanastasiou: Data curation
A. A. Kamyab: Visualization
K. Devetzis: Visualization
C. E. H. Scott: Conceptualization, Methodology, Writing – review & editing
C. B. Hing: Conceptualization, Methodology, Project administration, Supervision, Writing – review & editing
Funding statement
The authors received no financial or material support for the research, authorship, and/or publication of this article.
ICMJE COI statement
C. B. Hing reports that the editorial stipend for The Knee for Elsevier is unrelated to this work. C. E. H. Scott declares a department grant and payment for education delivery from Stryker; consulting fees from Stryker, Smith & Nephew, and Osstec; being on the data safety monitoring board for the PASHION trial; and being a board member of The Bone & Joint Journal, all of which are also unrelated to this paper.
Data sharing
The data for this study are publicly available at https://www.njrcentre.org.uk/about-the-njr/ and https://www.gmc-uk.org/registration-and-licensing/the-medical-register.
Acknowledgements
We would like to thank C. E. H. Scott and C. B. Hing for their guidance and support throughout the completion of this manuscript.
Open access funding
This paper received funding from the department of orthopaedics at NHS Lothian, UK, to cover the open access and author publication charges.
© 2024 Abelleyra Lastoria et al. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (CC BY-NC-ND 4.0) licence, which permits the copying and redistribution of the work only, and provided the original author and source are credited. See https://creativecommons.org/licenses/by-nc-nd/4.0/
