Transcript Beyond Bikini Medicine: A Sex and Gender Approach to Women`s

Osteoarthritis: Impact of Sex and
Gender
Kim Templeton, MD
AMWA Annual Meeting
March 2016
CONFLICT OF INTEREST
I hereby certify that, to the best of my knowledge, no aspect of
my current personal or professional situation might reasonably
be expected to affect significantly my views on the subject on
which I am presenting.
Institute of Medicine Report
2001
• Every cell has a sex
• Sex=genetic
(gonadal)
complement
• Gender=social
interactions, available
resources
Sex and Gender-Based Differences
• Anatomy
• Physiology (especially immune system)
• Effect of sex hormones
local
systemic
• Environmental influences
• Impact on incidence, presentation, response to
treatment, prevention
Musculoskeletal System
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Polymyositis
Myasthenia gravis
Duchenne muscular dystrophy
Becker muscular dystrophy
TMJ (syndrome)
Adhesive capsulitis
Shoulder instability/subluxation
Hallux valgus
Hip dysplasia
Musculoskeletal System
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Scoliosis
(de Quervain) tenosynovitis
Carpal tunnel syndrome
Rheumatoid arthritis
Systemic lupus erythematosus
Psoriatic arthritis
Musculoskeletal System
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Adolescent scoliosis
Anterior knee pain (syndrome)
Hallux valgus
Female athlete triad
Stress fracture
Osteoporosis (primary and
secondary)
• Cervical spondyolosis
Musculoskeletal System
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Trochanteric bursitis
Iliotibial band syndrome
Morton neuroma
Breast carcinoma metastatic to bone
Fibromyalgia
Ehlers Danlos syndrome
ACL injury
Osteoarthritis (especially knee and 1st CMC)
Osteoarthritis Incidence
• Depends on definition
• About 14% of people
over 25 y/o (CDC)
• 34% over the age of
65
• 25% lifetime risk
(about 30% for
women, 20% for men)
• Primary cause of
disability
Sex/Gender Differences
Female/male OA per 100
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Radiographic
hand 9.5/4.8
feet 2.7/1.5
knee 1.2/0.4
hip 1.4/1.4
Symptomatic OA
hand 8.9/6.7
feet 3.6/1.6
knee 13.6/10.0
CDC data
Sex/Gender-Specific Osteoarthritis
Risk Factors
• Acquired
injury
patterns of overuse
• Inherent
impact of estrogen
muscle strength
anatomy
Joint Injury
• Significantly higher
risk of OA in younger
people after knee
injury-even with
reconstruction
• Earlier among women
than men with ACL
injuries
Roos Current Opinion in
Rheumatology 2005
Shoe Wear
• Heel height leads to greater
knee flexion, anterior pelvic tilt,
trunk extension, slower
walking speeds
• As heel height increased,
increased internal knee
abduction (external adduction)
moments
• Increases inherent adduction
moment
• Increased peak joint forces
• Impact on medial compartment
of knee?
Barkema et al 2011
Thumb CMC Arthritis
• Overall prevalence noted
incidentally on
radiographs
• No significant correlation
with physical workload
history
• Effects of decreased
estrogen and increased
laxity?
• Significant impact on
function and
independence
Sohda et al JBJS 2005
Effects of Estrogen
• Estrogen receptors on chondrocytes,
bone, synoviocytes
• Promotes chondrocyte proliferation,
differentiation, matrix formation
• Inhibits production of MMPs
• Differences in response to estrogen of
male and female chondrocytes
Estrogen and OA
• OVX rats noted to have
surface cartilage erosions
at 9 weeks
• Lower incidence of
erosion in rats treated
with estrogen or SERM
• 50% decrease in urinary
excretion of type II
collagen degradation
products at 12 months in
postmenopausal women
treated with SERM
Christgau et al 2004
Effects of Estrogen
• Ovariectomized mice
with model of induced
OA
• Increased cartilage
injury
• Due to loss of bone or
direct effect on
cartilage?
Sniekers et al 2010
Femoroacetabular Impingement
• Acetabular dysplasia
higher in women
• Cam vs pincer
• Pincer more common
in women
• Acetabular
retroversion and/or
overcoverage
• Repetitive impaction
of acetabular rim and
femoral head/neck
PFP-Risk Factors
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Large Q-angle
Foot pronation
Increased femoral anteversion
Genu valgum
External tibial torsion
Tibia vara
Patellar ligamentous
hypermobility
Insufficient VMO vs v. lateralis
Generalized ligamentous laxity
Tight lateral patellar
retinaculum
Tight IT band
Patella alta
Shallower femoral notch
Narrower patella
Muscle Strength
• Quads strength in
women with higher in
those without OA or
fewer radiographic
changes
• Only ½ had OArelated pain
• Impact of strength on
development of OA?
Palmieri-Smith et al 2010
Sex-Based Differences in
Osteoarthritis?
508 patients with hip OA
Women more likely to have
• polyarticular disease
• superolateral migration
of femoral head
• more severe symptoms
• more rapid loss of joint
space
Maillefert et al 2003
Treatment
Non-surgical
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Activity modification
Weight loss
Exercise
Muscle strengthening/exercise
NSAIDs
Glucosamine/chondroitin sulfate
Narcotics
Topical rubs (NSAIDs, capsaicin)
Injections
No sex-based differences in response
No objective indication for TJA
Gender Influences on Total Joint
Arthroplasty
• Performed more often in women
• Estimated three-fold underuse in women
compared to men (Ontario)
• Equivalent willingness to undergo the
procedure
• Women less likely to have spoken to physician
regarding surgery (most important predictor of
having surgery)
Hawker et al 2000
Patient Concerns
• Men reported
willingness TJA when
no longer able to
perform vigorous
outdoor activity
• Women reported
willingness for TJA
when limited in indoor
ambulation
Karlson et al 1997
Total Joint Arthroplasty
• Men more likely to be referred for TJA by
their primary care provider (HR 1.25
overall) after adjusting for medical factors,
even in age group 20-39
• Impact of SES more significant for men
• Bias regarding social expectations,
anticipated results of TJA?
Rahman et al 2010
Pre-operative Function
• Patients with end-stage
OA and waiting for
TKA/THA
• Women with
significantly poorer
health-related QOL
scores, self-efficacy
(confidence in
management of pain,
fatigue, etc), and
function
Ackerman et al 2005
Total Hip Arthroplasty
Pre-op more women than
men reported
• severe pain with walking
• needing assistance with
walking
• needing help with
housework
• 28% could walk across
room or less
• Unrelated to age or comorbidities
Holtzman et al 2002
Results of THA
• Women with worse WOMAC scores
(function, pain, stiff) and SF-36 physical
function, pain , social function preoperatively
• Both genders improved post-operatively
• No significant difference in post-operative
scores, but women with worse scores at
all time points
Lavernia et al 2011
THA Outcome
• Total joint replacement
registry
• 35,140 primary, elective,
unilateral
• Women 57.5% of sample
• 29% higher risk of aseptic
implant failure
• Hazard ratio 1.97 for
metal-on-metal
• Partly explained by
smaller head size
(instability)
Nepple et al JAMA 2013
Metal-on-metal THA Outcome
• Increased risk of failure due to
aseptic loosening and
pseudotumors
• Not related to implant size or
orientation (latter significant for
men)
• Enhanced inflammatory
response? Pre-op sensitization
due to jewelry wear?
• Not recommended for use in
women
Latteier et al 2011
TKA-Results
• Results of TKA rely
on sizes of implants?
• Implants more closely
match the average
male bone size
• Soft tissue
impingement?
Hitt et al 2003
Future Directions
• Injury prevention
• Early identification
• Encouraging/empowering pts
to seek care earlier (e.g.,
OAAA)
• Ask pts earlier about pain and
function
• Identify best practices (e.g.,
COAMI)
• Continued
exploration/discussion of
impact of sex and gender
Thank You!