Equity in Access to Arthroplasty from a Gender Perspective: A Narrative Review

Abstract

Objective

Despite growing gender diversity in medical education, orthopaedic surgery—particularly arthroplasty—remains one of the most male-dominated subspecialties. This review critically evaluates the barriers limiting female surgeons' access to arthroplasty, including disparities in training, mentorship, professional advancement, and leadership roles. In addition it explores the implications of gender disparities on workforce diversity, patient care outcomes, and surgical innovation while identifying strategies to enhance gender equity in the field.

Introduction

Women remain significantly underrepresented in arthroplasty, comprising a lower percentage of trainees, faculty, and senior consultants as compared to other surgical specialties. Systemic barriers such as implicit bias, limited mentorship, work-life balance challenges, and inequitable leadership opportunities contribute to this underrepresentation. These disparities influence career trajectories, limiting diversity in surgical perspectives and innovation. Addressing these issues is critical to achieving an equitable and inclusive workforce.

Methodology

A structured narrative review was conducted using peer-reviewed articles, institutional reports, and orthopaedic society publications. The Data were retrieved from PubMed, Scopus, and institutional databases, focusing on gender representation in orthopaedic surgery, mentorship initiatives, workforce statistics, and leadership opportunities in arthroplasty. Comparative analysis was performed across subspecialties and institutions, and recommendations from diversity and inclusion initiatives were evaluated to highlight successful interventions.

Conclusion

Achieving gender equity in arthroplasty requires systemic changes, including structured mentorship programs, leadership development workshops, and institutional commitments to diversity. Addressing implicit biases, promoting flexible training pathways, and fostering sponsorship programs for female surgeons are essential. A diverse workforce in arthroplasty will not only promote professional equity but also improve patient care and surgical innovation.

Introduction

Gender equity remains a persistent challenge in orthopaedic surgery, particularly in arthroplasty, where women continue to be significantly underrepresented at all levels of training, practice, and leadership [1]. Despite an increasing number of female medical graduates, orthopaedic surgery has one of the lowest proportions of female trainees and consultants as compared to other surgical subspecialties [2]. Historical biases, institutional barriers, and a lack of mentorship contribute to the gender disparity, impacting workforce diversity, professional advancement, and patient outcomes [3].

One of the key factors influencing this underrepresentation is the prevailing perception of orthopaedics as a physically demanding specialty, traditionally dominated by male surgeons [4]. This perception discourages female medical students from considering arthroplasty as a career, despite evidence suggesting that gender diversity enhances surgical decision-making, patient satisfaction, and innovation in the field [5]. In addition, the lack of female role models in leadership positions and the presence of implicit bias in training and hiring processes further restrict opportunities for women to enter and advance within the subspecialty [6].

Work-life balance concerns, particularly regarding pregnancy and family responsibilities, further contribute to the gender gap [5]. Studies have shown that female orthopaedic trainees face significant biases related to parenthood, with many deferring pregnancy due to fears of professional disadvantage [7]. Institutional policies often lack adequate support structures for maternity leave, flexible training pathways, and mentorship programs that could facilitate career progression for female surgeons [8].

Addressing these challenges requires systemic reforms, including structured mentorship programs, sponsorship initiatives, and institutional policies that promote an inclusive and equitable training environment [1]. Diversity quotas, implicit bias training, and leadership development programs have been identified as potential solutions to accelerate gender equity in arthroplasty [7].

This review examines the existing barriers to female representation in arthroplasty, the impact of gender disparities on surgical innovation and patient outcomes, and evidence-based strategies to foster gender equity within the field. By identifying key areas for intervention, this study aims to contribute to a more inclusive and diverse orthopaedic workforce that benefits both surgeons and patients alike.

Methodology

Study selection Articles were manually screened by the authors based on the relevance to the research question and thematic fit.

Exclusion criteria Non-English articles, opinion pieces without primary data, or content unrelated to orthopaedic surgery were excluded.

Inclusion criteria Articles were included if they discussed gender representation in orthopaedics, barriers to arthroplasty training, leadership opportunities, mentorship programs, or patient outcomes linked to surgeon gender.

Searches were limited to English language publications between 2005 and 2024. The last search was performed on 20 March 2025.

Search strategy: We used PubMed, Google Scholar, and ResearchRabbit to identify peer-reviewed articles, reports, and datasets relevant to gender equity in arthroplasty. The search was conducted using the keywords:'gender disparity in orthopaedics','arthroplasty workforce diversity', and'female orthopaedic surgeons'.

This structured narrative review followed principles adapted from the PRISMA-Narrative guidelines.

This study utilized a comprehensive data analysis approach to examine gender disparities in arthroplasty, focusing on workforce representation, fellowship opportunities, and leadership roles. A multi-source dataset was compiled from peer-reviewed studies, medical society reports, and national registries to present a quantitative overview of the current state of gender equity in arthroplasty.

Data Sources and Collection

The data were collected from various sources, including the National Provider Identifier (NPI) registry, the American Academy of Orthopaedic Surgeons (AAOS) census, the Accreditation Council for Graduate Medical Education (ACGME) fellowship match statistics, and orthopaedic society leadership databases [1]. In addition, published literature on gender representation in orthopaedic subspecialties was reviewed to supplement and validate the findings.

Data Analysis and Presentation

A statistical breakdown was performed to compare gender representation in arthroplasty against other orthopaedic subspecialties. The following key metrics were analyzed:

1. Total number of orthopaedic surgeons by gender;

2. Female vs. male representation in arthroplasty;

3. Fellowship match rates and availability for women versus men;

4. Female leadership representation in orthopaedic organizations and training programs;

5. Historical trends and projected timelines for gender parity;

6. Influence of medical school exposure on orthopaedic career selection;

7. Prevalence of gender bias in the residency application process.

The data were organized into tables and visualized using bar charts to illustrate the disparities.

Key Findings from Data Analysis

See Tables 1, 2, and 3.

Table 1.

Gender representation in arthroplasty compared to orthopaedics overall

Category	Total	Female (%)	Male (%)
Total Orthopaedic Surgeons	31,296	8% (2363)	92% (28,933)
Total Arthroplasty Surgeons	5000	3% (150)	97% (4850)
Fellowship Positions Available	450	11% (50)	89% (400)
Leadership Positions in Arthroplasty	180	5% (9)	95% (171)

Source: ACGME Fellowship Data 2023, AAOS Census 2022, National Provider Identifier Registry 2023 [1]

Table 2.

Gender distribution in orthopaedic subspecialties

Subspecialty	Total Surgeons	Female Surgeons (%)	Male Surgeons (%)
Arthroplasty	5000	3% (150)	97% (4850)
Spine Surgery	3500	3% (105)	97% (3395)
Sports Medicine	4200	10% (400)	90% (3800)
Paediatric Orthopaedics	3100	26% (800)	74% (2300)
Trauma Surgery	2800	9% (250)	91% (2550)

Source: AAOS Census 2022, ACGME Fellowship Data 2023, National Provider Identifier Registry 2023 [1]

Table 3.

Gender representation in academic orthopaedics

Academic role	Total positions	Women in position (%)	Men in position (%)
Full professors	1200	6.7% (80)	93.3% (1120)
Associate professors	1500	9.3% (140)	90.7% (1360)
Assistant professors	1800	16.7% (300)	83.3% (1500)
Research faculty	600	15% (90)	85% (510)

Source: AAOS Census 2022, Academic Faculty Database [1]

Projected Timeline for Gender Parity

At the current rate of growth, it is projected to take over 200 years for arthroplasty to achieve gender parity with the general physician workforce [1]. Despite increasing awareness, recruitment strategies have not resulted in significant improvements in gender balance, particularly in arthroplasty fellowships and leadership roles [1, 9]. Furthermore, the medical school experience plays a crucial role in shaping students'career interests. Studies indicate that requiring exposure to orthopaedic surgery in medical school correlates with higher female application rates to the specialty [1, 10]. In addition, gender bias in the residency interview process remains a significant barrier, with women being more frequently subjected to illegal questions about family planning and childcare responsibilities compared to men [1, 10].

Conclusion on Methodology

This study highlights significant gender disparities in arthroplasty, with female representation remaining below 5% in critical career stages. The findings underscore the need for policy-driven interventions, including mentorship programs, targeted recruitment efforts, and structured leadership pathways to accelerate gender parity. The statistical analysis reinforces the urgency of implementing systemic changes to improve gender diversity in arthroplasty. Increasing exposure to orthopaedic surgery during medical school and eliminating bias in residency selection processes are essential steps toward fostering a more inclusive and equitable field [1] (see Figs. 1 and 2).

Fig. 1.

Gender disparities in fellowship placement. A bar chart was created to visually compare the number of female and male arthroplasty surgeons across different career stages, including training, fellowship, and leadership.

Source: ACGME Fellowship Match Data 2023 [1]

Fig. 2.

Gender representation in orthopaedic leadership. A second bar chart was created to illustrate the distribution of women in leadership positions in arthroplasty, as compared to other orthopaedic subspecialties.

Source: National Provider Identifier Registry 2023 [1]

Discussion

Persistent Barriers to Gender Equity in Arthroplasty

Despite increasing awareness of gender disparities in surgical subspecialties, the representation of women in arthroplasty remains among the lowest in orthopaedics [1]. The data suggest that female orthopedic surgeons are less likely to pursue adult reconstruction fellowships, where the percentage of women remains disproportionately low compared to other subspecialties like pediatric orthopedics [1]. The physical demands of joint replacement surgery, which involve prolonged standing, large bone handling, and the use of power tools, may deter women from pursuing arthroplasty, reinforcing outdated stereotypes [2]. In addition, workplace culture and implicit bias continue to shape hiring practices and limit career progression for female arthroplasty surgeons [3].

A major challenge is the prevailing masculine culture within arthroplasty, which discourages many female surgeons from entering the field. Stereotypes about physical strength requirements persist despite technological advancements that have minimized these demands [11]. Furthermore, women often report a lack of mentorship and sponsorship from senior faculty, which limits their career progression and access to leadership positions [6]. Surveys have shown that female orthopedic residents are less likely than their male counterparts to be encouraged to pursue fellowships in adult reconstruction, further perpetuating gender disparities [12].

The lack of gender diversity in training programs is another contributing factor. Studies have found that medical students are more likely to pursue subspecialties where they see role models of their own gender. Because only a small percentage of arthroplasty faculty are women, fewer female trainees consider the field as a viable career path [8]. The absence of structured mentorship programs has a direct impact on recruitment, retention, and professional advancement of female surgeons in arthroplasty [11].

Work-Life Balance and Parenthood Challenges in Arthroplasty

Among orthopedic subspecialties, arthroplasty requires some of the longest and most physically demanding procedures, leading to concerns about work-life balance that disproportionately affect female surgeons [1, 13]. Studies indicate that the likelihood of female orthopedic residents delaying pregnancy is significantly higher in high-intensity subspecialties such as adult reconstruction [5]. The lack of flexible training schedules and maternity policies in arthroplasty fellowships has been cited as a key factor in female surgeon attrition [3].

A survey among orthopedic residents revealed that women were more likely to perceive workplace cultures as unsupportive of pregnancy and family responsibilities [2]. Structural barriers such as inflexible operative schedules, lack of part-time training opportunities, and inadequate childcare support further contribute to the challenges female arthroplasty surgeons face [12]. Countries with progressive maternity leave policies, such as the UK, have reported better retention rates of female surgeons in arthroplasty as compared to regions with more rigid work structures [11].

Leadership and Representation Gaps in Arthroplasty

Women remain significantly underrepresented in arthroplasty leadership roles, including positions in orthopedic societies, hospital administration, and academic institutions [1, 4]. The proportion of women serving as fellowship directors, senior faculty, or department chairs in adult reconstruction is particularly low, further limiting mentorship opportunities for aspiring female surgeons [1, 13]. The exclusion of women from key decision-making roles in arthroplasty perpetuates gender disparities and restricts access to research funding, industry collaboration, and surgical innovation [1, 7].

Studies suggest that orthopedic departments with greater female leadership representation have higher recruitment rates of women in arthroplasty fellowships, emphasizing the importance of targeted policies to increase gender diversity [1, 7]. Gender parity in leadership positions is not only a matter of equity but also influences workplace culture, mentorship availability, and career progression for women in arthroplasty [1, 14].

Impact on Patient Outcomes and Surgical Innovation

A diverse workforce in arthroplasty has been shown to improve patient outcomes and foster surgical innovation [1]. The studies suggest that female surgeons often have higher patient satisfaction scores, particularly in patient-centred care and communication [15]. Moreover, gender diversity in surgical teams enhances collective intelligence, leading to improved problem-solving and clinical decision-making [1, 7]. Increasing female representation in arthroplasty is therefore not only a matter of equity but also of improving surgical care [2].

Impact of Surgeon Gender on Patient Outcomes

The recent high-quality evidence suggests that increasing female representation in surgery—particularly in arthroplasty—not only promotes gender equity but also improves patient outcomes. A large-scale meta-analysis of over 5.4 million patients demonstrated that patients treated by female surgeons had significantly lower postoperative mortality compared to those treated by male surgeons (adjusted odds ratio [aOR], 0.93; 95% CI, 0.88–0.97). This mortality benefit was observed across both elective and nonelective procedures, with a more pronounced effect in elective surgeries [16, 17].

Supporting these findings, a matched cohort study using Canadian healthcare data reported that patients operated on by female surgeons had a lower risk of 30-day mortality (aOR, 0.88; 95% CI, 0.79–0.99). While readmission and complication rates were similar between male and female surgeons, the trend still favored improved outcomes in elective surgical cases performed by female surgeons.

Several mechanisms have been proposed to explain this difference. Female surgeons may be more likely to adhere to clinical guidelines, adopt patient-centered approaches, and collaborate effectively with surgical teams. Moreover, the current cohort of female surgeons may reflect a particularly resilient and skilled group, having succeeded despite structural barriers in surgical training and practice.

Importantly, when female patients are treated by female surgeons, the alignment in communication, comfort, and trust may contribute to further improvements in surgical outcomes. Together, these findings emphasize that advancing gender diversity in arthroplasty is not only a matter of fairness but a strategy for enhancing surgical quality, safety, and patient satisfaction [17].

Future Directions and Systemic Changes

To address gender inequities in arthroplasty, targeted interventions are needed at multiple levels:

• Mentorship and sponsorship Expanding structured mentorship programs specific to arthroplasty to increase female participation in the field [8].

• Implicit bias training Implementing mandatory bias training in fellowship selection and hiring practices [2].

• Parental leave and flexible training Creating institutional policies for work-life balance, such as flexible fellowship schedules and designated parental leave for surgeons in adult reconstruction [5].

• Leadership development Increasing the representation of women in leadership roles within arthroplasty societies, conference panels, and research collaborations [15].

By implementing these measures, the field of arthroplasty can work towards greater gender equity, ultimately enhancing both workforce diversity and patient care outcomes. Sustained efforts in these areas are crucial to creating an inclusive, innovative, and dynamic surgical environment that fully utilizes the talents of all orthopedic surgeons [1].

Conclusion

Achieving gender equity in arthroplasty remains a significant challenge, shaped by historical biases, systemic barriers, and cultural norms within surgical training programs and professional organizations. Despite incremental progress through mentorship programs, leadership development workshops, and advocacy initiatives, the pace of change remains slow. The underrepresentation of women in arthroplasty limits workforce diversity, innovation, and patient-centered care. Addressing these disparities requires a sustained commitment from institutions, policymakers, and professional societies. Expanding mentorship, fostering leadership development, promoting flexible training pathways, and enforcing policies to counter implicit biases are essential steps toward a more equitable future. A gender-diverse workforce will not only enhance the professional landscape but also improve patient outcomes and advance the field of arthroplasty through more inclusive, collaborative, and innovative surgical practices.

Declarations

Conflict of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by any of the authors.

Informed consent

For this type of study informed consent is not required.