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Editorial   |    
Studying and Reporting Sex and Race Differences in Musculoskeletal Health
Michelle A. James, MD1; Vernon T. Tolo, MD2
1 Deputy Editor for the Upper Extremity
2 Editor-in-Chief
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Copyright © 2014 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2014 Jan 15;96(2):89. doi: 10.2106/JBJS.M.01444
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Orthopaedic surgeons care for people of all ages and races, and both sexes. With this privilege comes the obligation to understand differences in musculoskeletal health associated with age, sex, and race.
Although age-based differences are frequently studied across all medical specialties, sex and race-based differences are studied less. In 2001, an Institute of Medicine (IOM) report1 concluded that “…there are striking differences in human disease that are not explained at this time. Being male or female…affects health and illness…sex should be considered when designing and analyzing studies in all areas…of…research.” A report on sex differences in musculoskeletal health in JBJS in 20052 concluded that “sex-based differences in cell biology, tissue function, and disease presentation and management [have] the potential to affect how orthopaedic surgeons manage their patients” and called for the orthopaedic community to monitor sex differences for all diseases that affect both sexes, to analyze results of studies by sex, and to promote research on sex differences. Disparities in health between people of different races have been well documented. Although these are often attributed to socioeconomic inequality, a 2006 JBJS study of people who underwent total knee arthroplasty demonstrated few differences among income groups but significantly lower rates of knee replacements among minority groups3.
In 2012, another IOM report4 noted that underreporting of sex differences persists and recommended better alignment of the policies of funding agencies, researchers, and editors; an assumption that sex differences exist in all topics of study so that adequate power for subgroup analysis is inherent in the study design; and the identification of an inability to identify sex differences or similarities as a limitation of the study. A 2012 IOM update on health disparities noted that “…health disparities have persisted over time…people of color experience an earlier onset and a greater severity of negative health outcomes.”5
Sex and race are important variables in musculoskeletal health and health care. JBJS is an important source of information for orthopaedic surgeons and researchers, and is the gold standard in peer-reviewed scientific information in our field. A search for JBJS articles over the past ten years that mentioned sex in the title yielded nineteen articles. Only three articles mentioned race in the title. Undoubtedly many studies mentioned these in the text, but they were rarely the main topic of the study. Certainly it is challenging to accrue enough subjects to study these variables. Still, it seems that we could do better.
National Institutes of Health (NIH) funding policy mandates the inclusion of women and minority groups in clinical research as appropriate. Some journals have specific policies requiring authors to report sex-specific or race-specific data. Others, including JBJS, follow the recommendations of the International Committee of Medical Journal Editors: “Because the relevance of such variables as age, sex, or ethnicity is not always known at the time of study design, researchers should aim for inclusion of representative populations into all study types and at a minimum provide descriptive data for these and other relevant demographic variables.”6
Certainly in orthopaedic surgery, there remain striking differences in disease that are not explained at this time. It seems likely that some of these differences are related to sex or race. On behalf of our patients, researchers should consider potential sex and race differences when planning, performing, analyzing, and submitting their research to JBJS for publication; reviewers and editors should take this into account when evaluating manuscripts, and our readers should expect articles published in JBJS to include this information.
Institute of Medicine; Committee on Understanding the Biology of Sex and Gender Differences. Exploring the biological contributions to human health: does sex matter? Wizemann TM, Pardue M-L, editors. Washington, DC: National Academies Press; 2001.
 
Tosi  LL;  Boyan  BD;  Boskey  AL. Does sex matter in musculoskeletal health? The influence of sex and gender on musculoskeletal health. J Bone Joint Surg Am.  2005 Jul;87(  7):1631-47.[CrossRef]
 
Skinner  J;  Zhou  W;  Weinstein  J. The influence of income and race on total knee arthroplasty in the United States. J Bone Joint Surg Am.  2006 Oct;88(  10):2159-66.[CrossRef]
 
Wizemann  TM,  rapporteur; Board on Population Health and Public Health Practice; Institute of Medicine. Sex-specific reporting of scientific research: a workshop summary. Washington, DC: National Academies Press; 2012.
 
Anderson  KM,  rapporteur; Board on Population Health and Public Health Practice; Institute of Medicine. How far have we come in reducing health disparities? Progress since 2000: workshop summary. Washington, DC: National Academies Press; 2012.
 
International Committee of Medical Journal Editors. Preparing a manuscript for submission to a medical journal. 2013 Aug.  http://www.icmje.org/manuscript_a.html. Accessed 2013 Nov 20.
 

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References

Institute of Medicine; Committee on Understanding the Biology of Sex and Gender Differences. Exploring the biological contributions to human health: does sex matter? Wizemann TM, Pardue M-L, editors. Washington, DC: National Academies Press; 2001.
 
Tosi  LL;  Boyan  BD;  Boskey  AL. Does sex matter in musculoskeletal health? The influence of sex and gender on musculoskeletal health. J Bone Joint Surg Am.  2005 Jul;87(  7):1631-47.[CrossRef]
 
Skinner  J;  Zhou  W;  Weinstein  J. The influence of income and race on total knee arthroplasty in the United States. J Bone Joint Surg Am.  2006 Oct;88(  10):2159-66.[CrossRef]
 
Wizemann  TM,  rapporteur; Board on Population Health and Public Health Practice; Institute of Medicine. Sex-specific reporting of scientific research: a workshop summary. Washington, DC: National Academies Press; 2012.
 
Anderson  KM,  rapporteur; Board on Population Health and Public Health Practice; Institute of Medicine. How far have we come in reducing health disparities? Progress since 2000: workshop summary. Washington, DC: National Academies Press; 2012.
 
International Committee of Medical Journal Editors. Preparing a manuscript for submission to a medical journal. 2013 Aug.  http://www.icmje.org/manuscript_a.html. Accessed 2013 Nov 20.
 
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Eldin E. Karaikovic, MD, PhD
Posted on February 11, 2014
Body height as a covariate in reporting sex differences in MSK health
Northshore University HealthSystem, Evanston, Chicago, IL, USA

I read this editorial with great interest. Although the differences between the sexes are important in many aspects of musculoskeletal research, I would like to point out possible false positive conclusions when analyzing certain anthropomorphic anatomical differences between sexes if the BODY HEIGHT of a subject is not taken into account.

In our study on morphologic characteristics of human cervical pedicles (1), we found statistically significant differences in the inner pedicle height and width diameters between the males and females. But when the height of the subjects was used as a covariate, those gender differences were not statistically significant. In conclusion that made a lot of sense since the males on average were taller than the females, therefore all other parameters were proportionally larger.

To my knowledge none of the published anatomical studies recorded the height of the subjects, although almost all of them recorded the gender of the subjects and the differences between the sexes.

Naturally it is hard to make a generalized conclusion based on the results of only one study, but I believe it would be important to study the height of subjects as a confounding factor when reporting sex differences. Body height might be a parameter that has been neglected in our research for years. It is to expect that shorter individuals will have proportionally smaller other anatomical parameters within a human body regardless of their gender.

Reference:
1. Karaikovic EE, Daubs MD, Madsen R, Gaines RW Jr: Morphologic characteristics of human cervical pedicles. Spine 1997;22(5):493-500.

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