SYMPOSIUM: AAOS/ORS/ABJS MUSCULOSKELETAL HEALTHCARE DISPARITIES RESEARCH
Do We Need Gender-specific Total Joint Arthroplasty?
Aaron J. Johnson MD, Christopher R. Costa MD,
Michael A. Mont MD
Published online: 25 January 2011
? The Association of Bone and Joint Surgeons1 2011
anatomy have been well documented. Although it has been
accepted these differences exist, there is controversy
regarding if and how these differences should be addressed
with gender-specific implant designs.
(1) What are the anatomic and mor-
phologic differences, if any, in the knee and hip between
men and women? (2) Do gender-specific TKA designs
provide better clinical functioning, survivorship, and
improved fit in women? (3) How have anatomic differ-
ences in the hip been addressed, if at all, by THA?
We conducted a systematic review of the
MEDLINE database to identify all articles reviewing basic
science and clinical outcomes of gender-specific total knee
and total hip implants. From these, we reviewed 253
The anatomic studies elucidated multiple differ-
ences in the anatomy of knees and hips between men and
women. All reviewed studies report similar clinical func-
tion and satisfaction scores between men and women for
gender-specific TKA and no improvement in these scores
when comparing gender-specific TKA to unisex TKA.
Gender-specific differences in knee and hip
Current modularity in THA appears to accommodate any
anatomic differences in the hip.
Based on the available literature, there is no
difference in the outcome of patients with a gender-specific
knee arthroplasty versus a unisex arthroplasty. It does not
appear gender-specific THAs would provide any benefit
over current systems.
With more than 200,000 primary THAs and 400,000 pri-
mary TKAs performed annually, a number expected to
increase up to fivefold by the year 2030, there is a large and
growing population of patients who will have these pro-
cedures performed . Recent studies have attempted to
summarize the causes and epidemiology of revision pro-
cedures [5, 6, 39] and what can be done to minimize
clinical and radiographic failures [34, 35]. One aspect
where surgeons and patients may differ, however, lies in
the difference between a patient’s and surgeon’s definition
of a successful procedure. Two reports have suggested
nearly 40% of patients believe their expectations had not
been fully met by their total joint arthroplasty [8, 44].
Many surgeons have attempted to improve postoperative
function and to provide a more accurate restoration of
preoperative, and even predisease, anatomy. Related to
those attempts, various studies have described anatomic
differences in the hips and knees of men and women,
including altered aspect ratios in the distal femur and
proximal femur [4, 18, 24, 41], differences in Q angles
[1, 19, 50], trochlear groove dimensions , and femoral
neck and head morphology [38, 42, 51]. This work led
to some orthopaedic device manufacturers developing
‘‘gender-specific’’ total knee prostheses in an attempt to
MAM is a consultant for Stryker Orthopaedics (Mahwah, NJ) and
Wright Medical Technologies Inc (Arlington, TN) and receives
royalties from Stryker Orthopaedics. The remaining authors have no
disclosures to make. No external funding was received specifically in
support of this work.
A. J. Johnson, C. R. Costa, M. A. Mont (&)
Center for Joint Preservation and Replacement, Rubin Institute
for Advanced Orthopedics, Sinai Hospital of Baltimore,
2401 West Belvedere Avenue, Baltimore, MD 21215, USA
e-mail: email@example.com; firstname.lastname@example.org
Clin Orthop Relat Res (2011) 469:1852–1858
provide more options for the surgeon and patient (such as
incorporating more sizes, differing aspect ratios, altered
trochlear grooves, and other features). Additionally, as a
greater understanding of the variability of hip and knee
anatomy has been attained [2, 9, 40, 49], implants have been
redesigned with more modularity in their systems.
We performed a systematic review of the literature to
answer the following questions: (1) What are the anatomic
differences, if any, in the knee and hip between men and
women? (2) Do gender-specific TKA designs provide
better functional survivorship, clinical outcomes, and
improved fit in women? (3) How have anatomic differ-
ences in the hip been addressed, if at all, by THA?
Materials and Methods
A query of the PubMed database was performed to find any
relevant studies addressing either gender-specific total joint
arthroplasty (knee or hip) or addressing anatomic differ-
ences between men and women. The following search
string was used to perform this query: ‘‘(((hip[title] or
knee[title]) and (arthroplasty[title] or replacement[title]))
and (gender[title] or female[title] or sex[title])) OR
((hip[title] or knee[title]) and (gender[title] or female[title]
or sex[title])) NOT fracture NOT athlete.’’ This search
yielded 253 studies. Reports were excluded based on the
following criteria: (1) articles not in English; (2) any arti-
cles that did not pertain to the adult hip, knee, or the
arthroplasty of either; and (3) studies pertaining to out-
comes after revision knee or hip arthroplasty. We excluded
169 studies based on these criteria, leaving 96 reports
(Fig. 1). There were 14 additional reports added from the
reference lists of these articles, giving a total of 110
reports. It should be noted, throughout this manuscript, the
term ‘‘gender’’ is used to refer to both ‘‘sex’’ (as deter-
mined by chromosomal type) and ‘‘gender’’ (as determined
by societal and cultural conventions). As such, there may
be overlap in specific outcome based on sex and gender,
and in general, the term ‘‘gender’’ will be used throughout
to refer to both.
The manuscripts were screened to assess the following
information: (1) What are the reported anatomic differ-
ences in knees and hips between men and women? (2) How
does gender affect survivorship and clinical functioning
after undergoing gender-specific TKA? (3) How does
gender affect outcomes in THA that could necessitate the
further allocation of resources to the development of
gender-specific THA? Further, studies were excluded that
limited patient inclusion based on diagnosis (other than
osteoarthritis), focused specifically on physical rehabilita-
tion after total joint arthroplasty, had a minimum followup
of less than 2 years, reported on the same patient cohort as
another study, had duplicate MEDLINE records, reported
on non-gender-specific TKA, or were an opinion or review
article. All manuscripts meeting these criteria were
grouped according to the above questions, and the fol-
lowing data were extracted to a spreadsheet for each: the
type of study, the number of joints and patients studied, the
specific anatomic and morphologic differences noted
between genders (eg, distal femoral aspect ratio, Q angle,
femoral neck morphology, etc), clinical outcomes reported
Fig. 1 A
the results of our search strategy
using our inclusion and exclu-
Volume 469, Number 7, July 2011 Gender-specific Joint Arthroplasty 1853
on (eg, Knee Society scores, Hip Society scores, WOMAC,
etc), implant or radiographic survivorship, any treatment
disparities, and any differences in patients’ predisposition
to undergo arthroplasty or perception of the success of their
arthroplasty. One author (AJJ) reviewed all studies to
determine whether or not they met these criteria. If there
was any question as to the relevance of a study, a consensus
was reached among all three authors (AJJ, CRC, MAM).
Upon reviewing the screened literature, 29 reports met
these criteria. There were 20 reports on the anatomic dif-
ferences in the hip or knee between men and women [4, 7,
11, 12, 14, 15, 17–19, 22–24, 26, 30, 37, 38, 42, 47, 50,
51]. Of these 20 reports, there were 15 focusing on the knee
and five focusing on the hip (Table 1). There were four
reports specifically on clinical outcomes after gender-
specific TKA [10, 31, 32, 45] (two of which had a pro-
spective, randomized design [31, 32]), and one additional
study assessing whether women received benefit from
expanded prosthesis sizes . Four studies reported on the
effect of gender and modularity on clinical outcomes in
THA [25, 33, 36, 46].
The quality of the two Level I studies was assessed by
all authors (AJJ, MAM, CRC), with discrepancies resolved
by discussion and consensus. The following parameters
were evaluated and given a value of done, not done, or
unclear: randomization, allocation,concealment, and
blinding (participants, assessors, analysts). Additional fac-
tors (baseline demographic comparability of groups and
followup period) were evaluated as adequate, inadequate,
or unclear (Table 2). A failure to properly blind partici-
pants, assessors, and analysts was the most common
The reported anatomic differences between the knees of
men and women were found in the following areas: bone
size , distal femoral aspect ratio [4, 24], tibial aspect
ratio , anterior condylar height of the distal femur
[18, 41], patellar dimensions, Q angle [1, 19, 50], rotation
of the trochlear groove , and contact surface area of
the patella  (Table 3). One study  of 60 human
cadaver knees (from 16 male and 25 female donors)
reported no difference in anatomy, including distal fem-
oral aspect ratio. There were also reports suggesting body
type morphology played a role in the anatomic structure of
the knee, and this may be in addition to differences based
solely on gender . Four studies reported increased rates
of cartilage loss in women [13, 15, 17, 21], one study
reported an increasing incidence of osteophytes in women,
compared to men, older than 60 years , and another
study reported increased varus/valgus laxity in women
. There were several anatomic differences found
between hips of men and women in the literature
reviewed, including bone size [7, 30, 38], femoral offset
[38, 51], proximal femoral shape [42, 51], and trabecular
Four studies clinically or radiographically addressed
gender-specific TKA and one study reviewed TKAs that
had an increased number of smaller size options available
that were not specifically marketed as ‘‘gender-specific.’’
Two Level I studies by Kim et al. [31, 32] each reported on
a separate cohort of female patients in Korea who under-
went bilateral TKA. There was a total of 446 TKAs
performed in 223 patients. The patients were randomized to
determine which knee was to receive either a gender-spe-
cific implant or a unisex implant. The authors found no
difference (in either study) in Knee Society, WOMAC,
ROM, or satisfaction scores. They also concluded the
gender-specific implants did not fit better than standard
Table 1. Breakdown of subjects of studies focusing on anatomic
comparisons of the knee between men and women
Q angle3 19, 25, 50
Knee morphology determined by:
Cadaveric measurement44, 11, 12, 39
Radiographic or MRI
6 13, 14, 16, 17, 21, 22
Intraoperative measurement 123, 38
Radiographic observations2 7, 51
Cadaveric observations330, 43, 51
Table 2. Results of Level I study quality analysis
Study Level of
Kim et al. IDone DoneUnclearNot doneUnclear Done40
Kim et al. IDone DoneUnclear Not doneUnclear Done 25
1854Johnson et al. Clinical Orthopaedics and Related Research1
implants (131 standard implants had a fit described as
‘‘good,’’ compared to only 29 gender-specific implants). A
study by Clarke and Hentz  radiographically compared
three cohorts: a group of women (42 knees, 42 women)
who had unisex TKAs, a group of men (41 knees, 41 men)
who had unisex TKAs, and a group of women (39 knees,
39 women) who had gender-specific TKAs. The authors
concluded women in both groups had higher rates of
medial or lateral overhang of the femoral component. The
study by Emerson and Martinez  compared a group of
183 patients (90 women, 93 men) who had four sizing
options available at the time of surgery to a group of 212
patients (106 women, 106 men) who had an additional
three smaller sizes available and found in the group that
had smaller sizes available 56 women and 19 men had
improved implant fit with one of the smaller sizes. Early
Knee Society scores and ROMs (6-month followup visit)
were similar among all groups.
There were five studies that specifically compared THAs
on the basis of gender. Kostamo et al.  reviewed clinical
outcomes in 4114 primary THAs performed in 3461
patients, 1924ofwhomwere women. Atameanfollowupof
greater than 11 years (range, 2–27 years), the Kaplan-Meier
revision rate was similar (p = 0.14) in women and men:
8.3% versus 9.3%, respectively. Another study, by Traina
et al. , reviewed the use of 1050 modular stemmed
THAs in men and 1080 in women. They found no difference
in the 11-year survivorship (96.0% in women compared to
97.6% in men) or dislocation rates (0.9% in women com-
pared to 0.5% in men). A shorter neck was used more
frequently in women than in men (796 and 541 times,
respectively). Lavernia et al.  reported on 532 patients
(658 hips), consisting of 316 women and 216 men. Of note
was a decreasedperceived function (as measured by Quality
scores) inthe women starting at6to7 yearsafter THA.This
was similar to the findings in a group of 1120 patients (432
men, 688 women) reported on by Holtzman et al.  who
underwent THA. Using functional status, pain levels, and
the ability toperform activitiesofdailylivingasmetrics,the
authors concluded women had less functional ability at the
time of THA and did not do as well at 1-year followup when
compared with men.
Despite high clinical survivorship after TKA and THA,
gender-specific TKA provides superior results over unisex
TKA and whether gender-specific arthroplasties are needed
in general. Although there are well-documented anatomic
differences between the genders, it is uncertain whether a
‘‘gender-specific’’ total joint arthroplasty is the appropriate
solution to these differences. Therefore, we evaluated what
has been published regarding differences between the
genders to answer the following questions: (1) What are the
reported anatomic differences in knees between men and
women? (2) How does gender affect survivorship and
clinical outcomes after undergoing gender-specific TKA?
(3) How have anatomic differences in the hip been
addressed, if at all, by THA?
The major limitation of this report was the limited
information in the literature regarding the ability of
Table 3. Reported knee anatomic differences between men and women
Characteristic Reported mean valuesReference
Distal femoral measurement
Aspect ratio 0.770.69 4, 24
Aspect ratios decreased as AP measurements increased in women, whereas
aspect ratios remained more constant as AP measurements increased in men.
Anterior condylar height (mm)5.7 4.618, 41
Q angle (?)
Trochlear groove rotation (?)
Patellar contact area (0? flexion) (mm2)
Patellar contact area (90? flexion) (mm2)
Femoral head diameter (cm)
13.315.71, 19, 50
4.94.3 7, 30, 38
Proximal femoral shape The authors defined a triangle with the vertices being (1) the most medial aspect
of the greater trochanter, (2) the most proximal point of the lesser trochanter,
and (3) the most lateral articular margin of the femoral head. All distances
between these points were shorter in women than in men.
Volume 469, Number 7, July 2011Gender-specific Joint Arthroplasty 1855
gender-specific total joint arthroplasty to correctly restore
female joint anatomy while improving clinical functional-
ity and improving survivorship. While there are a few
studies assessing clinical outcomes of gender-specific TKA
[10, 31, 32, 45], albeit at short followup periods, there are
even fewer reports on the results of gender-specific THA
[33, 46]. This is more of a failure of the surgeons and
manufacturers who advocate the need for gender-specific
knee designs to conduct large-scale prospective trials to
compare these outcomes. A second major limitation is the
absence of long-term followup of any studies relating to
gender-specific implants. Although short-term studies can
adequately assess and compare the initial pain and func-
tional scores, as well as radiographic fit, it is not possible to
provide any quantitative evidence on the durability and
longevity of one type of implant over another. We do
believe conclusions can be drawn from these studies, as
well as the anatomic studies comparing the difference in
knee anatomy between patients of different gender, height,
or body morphology.
Although there are some anatomic differences found
between men and women, upon review of the literature,
these assumptions may not hold true in all patients, as some
men may have femoral or tibial anatomy more closely
resembling that of a woman and vice versa. For example, in
several reports, the Q angle has long been purported to be
different between men and women [1, 20, 26, 27, 50].
However, a recent study by Grelsamer et al.  suggested
this was a misconception propagated through the literature
because some early reports failed to incorporate subject
height into the analysis of Q angle. Upon further compar-
ison, it was found Q angle is more directly associated
with patient height than gender . Another study by
Bellemans et al.  analyzed the distal femoral and tibial
anatomy of 1000 individuals of white European descent
and found, in addition to having anatomy that varied by
gender, body morphology (ie, endomorph, mesomorph,
ectomorph) played a major role in the determination of the
anatomic characteristics of the knee. However, despite
these differences by body morphology, a majority (98%) of
the smallest knees were in women, while 81% of the
largest knees came from men. This indicates, although a
gender-specific knee might be beneficial to some women,
there might still be a percentage of women who are not
appropriately treated with a TKA, as they might have
femoral or tibial anatomy more closely resembling that of
In an attempt to localize where gender-neutral knee
implants may cause problems to the patient resulting in
postoperative pain, Mahoney and Kinsey  intraopera-
tively measured the overhang of the femoral component,
using 10 specific zones, in 437 TKAs. They found nearly
two-thirds of the implants in women had overhang in at
least one zone and calculated an attributable risk percent
implying 39% of postoperative pain was directly related to
this femoral component overhang. Therefore, based on the
results of that study, better results for women might be
achieved by implanting components with more appropriate
aspect ratios. Manufacturing companies might not need to
promote ‘‘gender-specific’’ knee prostheses but rather focus
more on increased modularity to allow the surgeon to select
more custom-sized components to allow for any individ-
ual’s unique anatomy (based on distal femoral and tibial
aspect ratios, patella size, and Q angle).
While there has been a study suggesting women may
have more difficulty returning to a higher functional status
after THA , another study determined, in the Medicare
population, women have greater disability at the time of
surgery than men, which leads to the argument, if women
do, in fact, perform worse after THA, it is because they
have later progression of disease at the time of presentation
than men . Much as with the anatomy of the knee,
several forensic analyses have suggested there are ana-
tomic differences in hips between the genders [38, 42, 43,
48, 51]. These include bone size, femoral offset, proximal
femoral shape, bone mineral content, and trabecular pat-
terns. However, despite these differences, the only study
specifically addressing the question of gender and its effect
on THA reported women had higher survivorship than
men, and there was no difference in the improvement in
clinical outcome scores (Harris hip score, SF-12) between
men and women, despite men having higher functional
scores than women . The study by Traina et al. 
noted women required, on average, shorter necks, possibly
implicating current modular THA systems may already
adequately address the differences in hip anatomy between
men and women. This review did not specifically address
modular hip components and whether smaller component
sizes were typically used in women so it is difficult to draw
this conclusion. However, it would seem logical the ana-
tomic differencescan be
modularity of THA components.
To return to the original question posed by the title of
this report (do we need gender-specific total joint
arthroplasty?), although the scientific evidence suggests
there may be anatomic differences in knees between the
genders, it appears these differences may be more multi-
factorial than just based on gender. Body morphology,
height, gender, and bone size all contribute to an individ-
ual’s unique bone dimensions. Although we acknowledge
there are some anatomic difference in the shape of the knee
between men and women, no benefit from gender-specific
TKAs has been shown in early clinical reports. The pub-
lished experience with hip arthroplasty systems with
increased proximal modularity has not shown a difference
in results between men and women, and we do not believe
1856Johnson et al. Clinical Orthopaedics and Related Research1
gender-specific THAs would provide any new benefit over
these current prostheses. We emphasize long-term, pro-
spective randomized studies will be required for both hips
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