Introduction. We compared standard NexGen Cruciate substituting-flex prosthesis with gender-specific NexGen Cruciate substituting flex prosthesis in patients undergoing bilateral total knee arthroplasty with regard to Coverage of the bone by femoral component, Clinical outcome, Radiographic outcome, Survival and complication rates, with special emphasis on patellofemoral complications. Material & Methods. 30 female patients with osteo-arthritis of the knees with similar deformity and preoperative range of motion were randomized to have one knee replaced with a gender non-specific Nexgen Cruciate substituting (Zimmer) prosthesis and the other with Gender Cruciate substituting (Zimmer) prosthesis. Follow-up clinical evaluation was done at 6, and 12 months postoperatively and then at yearly interval using “Knee Society” Recommendations. Clinical assessment of the patellofemoral joint of the replaced knees was done with the help of “Hospital for Special Surgery” patellar scoring system. The overall patient satisfaction after surgery was evaluated with use of the British Orthopaedic Association patient satisfaction score. Results. The mean age was 63.8 years (range 49–76 years). 14 patients had standard NexGen Cruciate substituting-flex gender knee prosthesis on right side and 16 patients had on left side. On the other sides, standard NexGen Cruciate substituting-flex prosthesis implant was used. Preop Clinical findings were similar in both groups. The average Preop range of motion was identical in both the groups. The average follow up was 2.5 years (2–3.8 years). The mean post-operative Knee Society knee scores were 88,90,94, (70 to 100) and 87,92, 93 (70 to 100) points and the function scores were 83,85,88 (60 to 100) and 84.86.88 (60 to 100) points for the standard implants and the gender-specific designs, respectively at 6 months, 1 year and 2 year follow up. Mean improvement in patella score was 65, 71.1 and 73.3 points in Gender group at the end of 6 month, 1 yr and 2 yr respectively as compared to 65.6, 71.1 and 72.2 in Nexgen group. No patient had malpositioning of components or radiolucencies at the end of 2 year follow up. Mean improvement in BOA functional score was 20.6, 22.6 and 24.1 points in Gender group at the end of 6 months, 1 year and 2 year respectively as compared to 20.7, 21.8 and 23.2 in Nexgen group. In those with a standard prosthesis, the femoral component was closely matched in 30 knees, overhung in 17 and undercovered the bone in 13. In those with a gender-specific prosthesis, it was closely matched in 45 knees and undercovered the bone in 15. Conclusion. Although gender specific knee matched the femoral anatomy of Indian female knees better than the standard nexgen Knee, we found no significant differences between the two groups with regard to the clinical and radiological results, patient satisfaction or complication rate

Aims. Global literature suggests that female surgical trainees have lower rates of independent operating (operative autonomy) than their male counterparts. The objective of this study was to identify any association between gender and lead/independent operating in speciality orthopaedic trainees within the UK national training programme. Methods. This was a retrospective case-control study using electronic surgical logbook data from 2009 to 2021 for 274 UK orthopaedic trainees. Total operative numbers and level of supervision were compared between male and female trainees, with correction for less than full-time training (LTFT), prior experience, and time out during training (OOP). The primary outcome was the percentage of cases undertaken as lead surgeon (supervised and unsupervised) by UK orthopaedic trainees by gender. Results. All participants gave permission for their data to be used. In total, 274 UK orthopaedic trainees submitted data (65% men (n = 177) and 33% women (n = 91)), with a total of 285,915 surgical procedures logged over 1,364 trainee-years. Males were lead surgeon (under supervision) on 3% more cases than females (61% (115,948/189,378) to 58% (50,285/86,375), respectively; p < 0.001), and independent operator (unsupervised) on 1% more cases. A similar trend of higher operative numbers in male trainees was seen for senior (ST6 to 8) trainees (+5% and +1%; p < 0.001), those with no time OOP (+6% and +8%; p < 0.001), and those with orthopaedic experience prior to orthopaedic specialty training (+7% and +3% for lead surgeon and independent operator, respectively; p < 0.001). The gender difference was less marked for those on LTFT training, those who took time OOP, and those with no prior orthopaedic experience. Conclusion. This study showed that males perform 3% more cases as the lead surgeon than females during UK orthopaedic training (p < 0.001). This may be due to differences in how cases are recorded, but must engender further research to ensure that all surgeons are treated equitably during their training. Cite this article: Bone Joint J 2023;105-B(7):821–832

For all the research into arthroplasty, provision of total knee arthroplasty (TKR) services based on gender in the Australian context is yet to be explored. International literature points toward a heavily gender biased provision of TKA services, skewed away from female patients. This research has aimed to assess the current experience of Australian female patients and to explore better assessment techniques that could provide more equitable services. A retrospective cohort analysis has been conducted using pre-op PROMs data, where available, from the Australian National Joint Replacement Registry (AOANJRR), between 7 August 2018 and 31 December 2021, including: EQ VAS Health; Oxford Knee Score; joint pain; and KOOS-12. Data was adjusted for age, ASA score, BMI, primary diagnosis, public vs private hospital, surgeon gender and years of practice (as estimated from years of registry data available). Of 1,001,231 procedures performed, 27,431 were able to be analysed (12,300 male and 15,131 female). Gender-based bias against female patients reached statistical significance across all PROM scores, according to the Kruskal-Wallis test of difference (p-value <0.0001). Males were more likely to undergo TKR than females, with odds ratios remaining statistically significant when adjusted for age, ASA score, BMI, primary diagnosis, and hospital type. Numbers were further analysed for surgeon years of recorded practice and surgeon gender with mixed results. This study found that women were less likely to undergo TKR despite worse scores on every pre-op PROM available, thus we demonstrate a statistically significant gender-based bias against female patients. More effort needs to be made to identify the base of this bias and find new ways to assess patients that can provide more equitable provision of healthcare

Abstract. Objectives. Osteoarthritis is a common articular cartilage disorder and causes a significant global disease burden. Articular cartilage has a limited capacity of repair and there is increasing interest in the use of cell-based therapies to facilitate repair including the use of Mesenchymal Stromal Cells (MSCs). There is some evidence in the literature that suggests that advancing age and gender is associated with declining MSC function, including reduced proliferation and differentiation potential, and greater cellular apoptosis. In our study, we first performed a systematic review of the literature to determine the effects of chronological age and gender on the in vitro properties of MSCs, and then performed a laboratory study to investigate these properties. Methods and Results. We initially conducted a PRISMA systematic review of the literature to review the evidence base for the effects of chronological age and gender on the in vitro properties of MSCs including cell numbers, expansion, cell surface characterization and differentiation potential. This was followed by laboratory-based experiments to assess these properties. Compare the extent of the effect of age on MSC cell marker expression, proliferation and pathways. Tissue from patients undergoing total knee replacement surgery was used to isolate MSCs from the synovium, fat pad and bone fragments using a method developed in our laboratory. The growth kinetics was determined by calculating the population doublings per day. Following expansion in culture, MSCs at P2 were characterised for a panel of cell surface markers using flow cytometry. The cells were positive for CD73, CD90 and CD105, and negative for antibody cocktail (eg included CD34, CD45). The differentiation potential of the MSCs was assessed through tri-lineage differentiation assays. At P2 after extracting RNA, we investigate the gene analysis using Bulk seq. Clear differences between the younger and older patients and gender were indicated. Conclusions. Chronological age and gender-related changes in MSC function have important implications on the use of these cells in clinical applications for an ageing population. The results from this study will be used to plan further work looking at the effects of chronological age and gender on cellular senescence and identify pathways that could be targeted to potentially reverse any age and gender-related changes. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

This qualitative study aims to explore and highlight the experiences of trainees in the Orthopaedic Surgical Education Training (SET) program in New Zealand, with a focus on identifying gender-specific biases which may impact professional development. Orthopaedic SET trainees in New Zealand were invited to complete a qualitative, semi-structured questionnaire exploring their experiences in the Orthopaedic SET program. A broad range of topics were covered, addressing culture, belonging, learning styles and role modelling. Recurrent themes were identified using inductive methods. Analysis of questionnaire responses identified several key themes for women in the Orthopaedic SET program, compared to their male counterparts, including (1) role incredulity, (2) confidence vs. competence, (3) adaptation, (4) interdisciplinary relationships and (5) role modelling. Female participants described experiencing gender bias or discrimination by both patients and interdisciplinary colleagues at a higher rate than their male counterparts. The majority of female participants described feeling as competent as their male counterparts at the same SET level, however, identified that they do not typically exhibit the same confidence in their surgical abilities. Whilst similar numbers of female and male participants described experiencing barriers to career progression, female participants described having to adapt both physically and socially to overcome additional gender-specific barriers. Positive influences on training experience included role modelling and supportive relationships amongst trainee groups. This study highlighted gender-specific biases experienced by trainees in the Orthopaedic SET program in New Zealand. Further investigation is warranted to determine how these experiences affect professional development, and how they may be addressed to foster increased gender equity in the surgical profession. This will likely require system-level interventions to create meaningful and sustainable culture change

Abstract. Objectives. The need for gender specific knee arthroplasty is debated. This research aimed to establish whether gender differences in patellar tendon moment arm (PTMA), a composite measure that characterises function of both the patellofemoral and tibiofemoral joints, are a consequence of knee size or other variation. Methods. PTMA about the instantaneous helical axis was calculated from positional data acquired using optical tracking. First, data post-processing was optimised, comparing four smoothing techniques (raw, Butterworth filtered, generalised cross-validation cubic spline interpolated and combined filtered/interpolated) using a fabricated knee. Then PTMA was measured during open-chain extension for N=24 (11 female) fresh-frozen cadaveric knees, with physiologically based loading and extension rates (420°/s) applied. Gender differences in PTMA were assessed before and after accounting for knee size with epicondylar width. Results. Combined smoothing enabled sub-mm accuracy (root-mean-squared (RMS) error 0.16mm, max error 0.47mm), whereas large errors were measured for raw (RMS 3.61mm, max 23.71mm), filtered-only (RMS 1.19mm, max 7.38mm) and interpolated-only (RMS 0.68mm, max 1.80mm) techniques. Before scaling, average PTMA throughout knee flexion was 46mm and mean, maximum, and minimum absolute values of PTMA were larger in males (mean differences >8mm, p<0.001), as were the PTMAs at terminal extension and flexion, and the change in PTMA from peak to terminal extension (differences >4mm, p<0.05). After scaling, the PTMA in deep flexion and the change in PTMA from peak to terminal extension were still larger in male knees (differences >2mm, p<0.05). The flexion angle of peak PTMA, unaffected by scaling, was closer to terminal extension for female knee (female 15°, male 29°, p<0.05). Conclusion. Gender differences in PTMA were identified both before and after accounting for knee size, with implications for gender-specific arthroplasty and musculoskeletal models. The developed measurement framework could also be applied in vivo for accurate measurement of the PTMA. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

There is a growing requirement by governmental and other funders of research, that investigators pay attention to and integrate considerations of sex and gender in their health research studies. Doing so, the argument goes, will reduce data waste, lead to the generation of more complete and accurate evidence to apply to the delivery of health care, and hopefully improve outcomes for both male and female patients. Yet, it is not always clear what sex and gender mean and how best to apply these to the study of diverse health conditions and health service delivery. In this presentation sex, gender and other related factors will be considered in the context of fractures, fracture repair, and post-operative management. Examples of sex and gender bias, sex and gender differences, and the integration of sex and gender in research on fracture and fracture repair will be presented

Global surgical literature suggests that female trainees have less operative autonomy than their male counterparts. This pilot study had the primary objective to identify difference in autonomy by gender, and to power a national study to carry out further quantitative and qualitative research on this. This was a retrospective, cross-sectional study utilising eLogbook data for all orthopaedic trainees (ST2-8) and consultants with CCT date 2016–2021 in a single Scottish deanery. The primary outcome measure was percentage of procedures undertaken as lead surgeon. 15 trainees and four recent consultants participated, of which 12 (63%) were male (mean grade 5.2), and 7 (37%) were female (mean grade 4.3). Trainees were lead surgeon on 64% of procedures (17595/27558), with autonomy rising with grade (37% ST1 to 85% ST8, OR 9.4). Operative autonomy was higher in male vs female trainees (66.5% and 61.4% respectively, p=<0.0001), with female trainees more likely to operate with a supervisor present (STU/S vs P/T, f 48%:13%, m 45%:20%). This pilot study found that there was a significant difference in operative autonomy between male and female trainees, however this may be explained by differences in mean grade of male vs female trainees. Five trainees took time OOT, 4/5 of whom were female. Extension to a national multi-centre study should repeat the quantitative method of this study with additional qualitative analysis including assessing effect of time OOT to explore the reason for any gender discrepancies seen across different deaneries in the UK

We need to shift our focus to integrating sex and gender into research proposals, so we can answer some of the most basic unanswered questions in the field of fracture management. Current evidence in guidelines indicate a near-to-linear increase from the 1990s for inclusion of sex and gender. However, these recommendations remain expressed in absolute terms, with little explanatory power, affecting uptake and implementation in clinical practice. This co-branded session, with members of the Orthopaedic Research Society – International section of fracture repair (ORS-ISFR), will provide participants with guiding principles and tools to assist researchers and grant reviewers understand what it means to include sex and gender in meaningful ways: from formulating research questions, recruitment strategies, to conducting sex-stratified analyses. In this presentation, we will consider diverse approaches, methods and, analyses to elevate sex and gender within trauma. A strong emphasis on the ways and means of including marginalized and vulnerable populations in research will be addressed

Distal radius fractures are the most common upper extremity fracture. The incidence is significantly higher in elderly females with osteoporotic bone. When surgery is indicated, volar locking plates (VLPs) allow for rigid fixation particularly in comminuted fractures with poor bone quality. Although numerous studies have shown the importance of plate placement to avoid soft tissue complications associated with volar plate fixation, there has been little evidence on the anatomic fit of current VLPs. Moreover, the effect of gender differences in distal radius morphology on anatomic fitting of VLPs has not been studied. The aim of this study was to evaluate the gender difference in distal radius morphology and the accuracy of the fit of a current VLP to CT-based distal radius models. Segmented CT models of ten female (mean age, 89 ± 5 years), and ten male (mean age, 86 ± 4 years) cadaveric wrists were obtained. Micro-CT models of the DePuy-Synthes 4-hole extra-articular (EA) and 8-hole volar column (VC) distal radius VLPs were created. A 3D visualization software was used to simulate appropriate plate placement on to the distal radius models by a fellowship-trained hand surgeon. Volar cortical angles (VCA) of the medial, middle and lateral portion of the distal radius were measured and compared between genders. The accuracy of the fit of the two VLP designs were quantified using the percentage of the watershed line (WSL) overlapped by the plate (WSL overlap), the distance between the WSL and the most distal aspect of the posterior plate (prominence distance) and the percentage of contact between the plate and bone. There were statistically significant gender differences in medial, middle and lateral VCAs (p=.003 medial, p=.0001 middle, p=.002 lateral). VCA ranged from 28° to 36° in females and from 38° to 45° in males. The WSL overlap did not show statistically significant gender differences (male: 5.9%, female: 13.6%, p=.174). However, the difference in prominence distance between different genders approached statistical significance (male: 3.5mm, female: 2.6mm, p=.087). Contact mapping between the plate and bone did not demonstrate a perfect contact in any of our specimens. Thus, contact measurements were categorized into 0.1mm, 0.2mm, and 0.3mm threshold contacts. There were no statistically significant gender differences in any of the threshold categories (0.1mm: p=.84, 0.2mm: p=.97, 0.3mm: p=.99). Our results confirm that there are gender differences in distal radius morphology. Current plate designs incorporate a VCA of 25° which does not match the native VCA of the distal radius in males or females. Although the difference in prominence distance approached statistical significance, there were no statistically significant gender differences in the WSL overlap or the contact threshold values. This lack of statistical significance may be related to the small sample size. This study proposes novel methods of assessing the anatomic fit of current VLPs in a 3D CT-based model that may be used in future studies with a larger sample size. Moreover, this study demonstrated the importance of considering gender differences in distal radius morphology in the design of future generations of implants

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.

End-stage ankle arthritis (ESAA) is a debilitating disease that does not affect all individuals equally. Gender differences have been identified in patients with end-stage hip and knee arthritis and have stimulated research to explain these findings. The present study was undertaken to examine if gender has a significant effect on pre-operative disability and post-operative outcomes in patients with ESAA. Patients undergoing ankle arthrodesis (AA) or total ankle replacement (TAR) with minimum 2-year follow-up were identified in the Canadian Orthopaedic Foot and Ankle Society prospective ankle reconstruction database. Demographic data, revision data, patient satisfaction questionnaires, and outcome data using the Ankle Osteoarthritis Scale (AOS) and Short-form 36 (SF-36) health survey were collected. TAR: 384 patients were included, with 198 females and 186 males. Patient BMI, comorbidities, and duration of follow-up were similar between groups. Males were slightly older at the time of surgery (65.1 vs 62.4 years, p=0.01)). The most common etiology was post-traumatic arthritis for both genders, however females had a higher rate of rheumatoid arthritis (17% vs 5%, p=0.001). Implant types included STAR, Hintegra, and Mobility, and were similar between groups. Preoperatively females had higher rates of pain and disability, demonstrated by lower SF-36 physical component scores (PCS) (31.0 vs 34.5, p<0.001), and higher AOS pain (54.7 vs 51.1, p=0.05) and AOS disability scores (66.5 vs 59.6, p<0.001). Postoperatively, both groups had significant improvement in PCS, AOS pain, and AOS disability scores. Females, however, continued to demonstrate lower PCS scores (38.3 vs 41.9, p<0.001) and higher AOS disability (31.0 vs 25.8, p=0.02) than males. Regression analysis found that preoperative PCS, gender, age, and arthritis etiology all had a significant impact on postoperative PCS scores, with preoperative PCS scores having the largest impact. Preoperative AOS pain and disability scores had the largest impact on postoperative AOS pain and disability scores, respectively. Gender had no significant impact on AOS pain and disability scores postoperatively. Patient satisfaction was similar between males and females postoperatively. Secondary surgery was performed in 13.6% of females and 16.1% of males. Five males and five females underwent revision to arthrodesis. In patients with ESAA, females tend to have higher pre-operative levels of pain and disability compared to males, which persists post-operatively. This is consistent with the hip and knee arthroplasty literature. This finding may be due to females undergoing surgery at more advanced disease states, arthritis etiology, referral bias, or treatment bias. Both males and females have significant and similar degrees of improvement in pain and disability scores after TAR, and reoperation rates and patient satisfaction rates are similar despite the apparent disparity in outcomes

Aims. Gender bias and sexual discrimination (GBSD) have been widely recognized across a range of fields and are now part of the wider social consciousness. Such conduct can occur in the medical workplace, with detrimental effects on recipients. The aim of this review was to identify the prevalence and impact of GBSD in orthopaedic surgery, and to investigate interventions countering such behaviours. Methods. A systematic review was conducted by searching Medline, EMCARE, CINAHL, PsycINFO, and the Cochrane Library Database in April 2020, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to which we adhered. Original research papers pertaining to the prevalence and impact of GBSD, or mitigating strategies, within orthopaedics were included for review. Results. Of 570 papers, 27 were eligible for inclusion. These were published between 1998 and 2020. A narrative review was performed in light of the significant heterogeneity displayed by the eligible studies. A total of 13 papers discussed the prevalence of GBSD, while 13 related to the impact of these behaviours, and six discussed mitigating strategies. GBSD was found to be common in the orthopaedic workplace, with all sources showing women to be the subjects. The impact of this includes poor workforce representation, lower salaries, and less career success, including in academia, for women in orthopaedics. Mitigating strategies in the literature are focused on providing female role models, mentors, and educational interventions. Conclusion. GBSD is common in orthopaedic surgery, with a substantial impact on sufferers. A small number of mitigating strategies have been tested but these are limited in their scope. As such, the orthopaedic community is obliged to participate in more thoughtful and proactive strategies that mitigate against GBSD, by improving female recruitment and retention within the specialty. Cite this article: Bone Joint J 2020;102-B(11):1446–1456

For many patients, UKA is a good alternative to total knee arthroplasty (TKA) or high tibial osteotomy (HTO). Strong evidence that gender influences outcomes following UKA could alter UKA selection criteria. No prior series has been specifically designed and matched to compare outcomes based on gender. The purpose of this study was to elucidate the effect of gender on the clinical outcome of UKA while controlling for other variables that may affect outcome. Between 1988 and 2006, 257 UKA's were carried out in our department. We studied two groups of 40 patients of each gender, matched by pre-operative clinical and radiological presentation, and with post-operative follow up of at least 2 years. The mean age at operation was 71 years and the mean follow-up was 5.9 years. In both groups, IKS score improved significantly. When comparing the male and female groups post-operatively, no significant differences were found between IKS knee or function scores, limb alignment, or the incidence of radiolucent lines. No difference was found between groups in terms of range of motion or radiologic progression of arthritis. Both tibial (p<0.001) and femoral (p<0.001) component sizes were significantly larger in the male group than the female group. For males, the size of both the femoral (r2=0.12, p=0.033) and tibial (r2=0.29, p=0.0005) components correlated with patient height. For females, the size of neither the femoral (r2=0.000082, p=0.96) nor tibial (r2=0.0065, p=0.63) components correlated with patient height. The key finding in this study is that when patients are selected for UKA according to specific selection criteria (including avoiding performance of UKA in younger patients and patients over 85 kg), gender is not a predictor of outcome based on IKS scores. When using these selection criteria, gender should not be considered when determining whether to perform a UKA

Introduction. Despite the demonstrated success of total knee arthroplasty (TKA) and higher rates of arthritis and disability from arthritis among minorities, these populations utilize TKA at lower rates than non-Hispanic white patients in the United States. In addition, women present for TKA with more advanced disease prior to TKA than their male counterparts. In order to explore potential reasons for this, we examined the relationship between race, gender, and pre-operative expectations on postoperative outcomes among patients undergoing TKA. Methods. 134 patients scheduled for primary unilateral TKA secondary to moderate to severe osteoarthritis were enrolled in this two-institution prospective study. All patient demographics were collected and recorded in an electronic data registry. In addition, patient reported outcome (PRO) questionnaires, including the Knee Injury and Osteoarthritis Outcome Score (KOOS), HSS Patient Expectation Questionnaire, Social Support Survey, Pain Catastrophizing Scale, Visual Analogue Pain Scale (VAS), Geriatric Depression Scale and European Quality (EQ) of Life 5-Dimensions with EQ VAS were prospectively collected at 4 time points (baseline, 4–8 weeks, 9–14 months, 20–26 months postoperative). Statistical analysis was then conducted among patients of different gender and ethnic background to assess for the effect of these demographic variables on patient expectations and outcomes. Results. Female sex was associated with worse preoperative KOOS scores in symptoms (p=0.021), pain (p=0.019), and activities of daily living (p=0.020). African American race was associated with worse preoperative KOOS scores in pain (p=0.009), activities of daily living (ADLs) (p=0.004), and quality of life (QOL) (p=0.003). However, despite worse pre-operative scores, no statistically significant differences were noted in the aforementioned categories between the groups at any point post-operatively. Conclusion. Our results indicate that female and African American patients undergoing TKA presented with worse pre-operative KOOS scores compared with white male patients. However, outcomes were good among all groups postoperatively, and neither race nor gender was associated with compromised post-operative outcomes in relation to pain, ADLs or QOL. These findings may be valuable in counseling patients and surgeons regarding the value of increase utilization of TKA in these patient populations. Further study is necessary to better understand the lower utilization or later presentation observed in these populations

Management of the pathologic long-head biceps tendon remains controversial. Biceps tenotomy is a simple intervention but may result in visible deformity and subjective cramping. Comparatively, biceps tenodesis is technically challenging, and has increased operative times, and a more prolonged recovery. The purpose of this study was to determine the incidence of popeye deformity following biceps tenotomy versus tenodesis, identify predictors for developing a deformity, and compare subjective and objective outcomes between those that have one and those that do not. Data for this study were collected as part of a randomized clinical trial comparing tenodesis versus tenotomy in the treatment of lesions of the long head of biceps tendon. Patients 18 years of age or older with an arthroscopy confirmed biceps lesion were randomized to one of these two techniques. The primary outcome measure for this sub-study was the rate of a popeye deformity at 24-months post-operative as determined by an evaluator blinded to group allocation. Secondary outcomes were patient reported presence/absence of a popeye deformity, satisfaction with the appearance of their arm, as well as pain and cramping on a VAS. Isometric elbow flexion and supination strength were also measured. Interrater reliability (Cohen's kappa) was calculated between patient and evaluator on the presence of a deformity, and logistic regression was used to identify predictors of its occurrence. Linear regression was performed to identify if age, gender, or BMI were predictive of satisfaction in appearance if a deformity was present. Fifty-six participants were randomly assigned to each group of which 42 in the tenodesis group and 45 in the tenotomy group completed a 24-month follow-up. The incidence of popeye deformity was 9.5% (4/42) in the tenodesis group and 33% (15/45) in the tenotomy group (18 male, 1 female) with a relative risk of 3.5 (p=0.016). There was strong interrater agreement between evaluator and patient perceived deformity (kappa=0.636; p<0.001). Gender tended towards being a significant predictor of having a popeye with males having 6.6 greater odds (p=0.090). BMI also tended towards significance with lower BMI predictive of popeye deformity (OR 1.21; p=0.051). Age was not predictive (p=0.191). Mean (SD) satisfaction score regarding the appearance of their popeye deformity was 7.3 (2.6). Age was a significant predictor, with lower age associated with decreased satisfaction (F=14.951, adjusted r2=0.582, p=0.004), but there was no association with gender (p=0.083) or BMI (p=0.949). There were no differences in pain, cramping, or strength between those who had a popeye deformity and those who did not. The risk of developing a popeye deformity was 3.5 times higher after tenotomy compared to tenodesis. Male gender and lower BMI tended towards being predictive of having a deformity; however, those with a high BMI may have had popeye deformities that were not as visually apparent to an examiner as those with a lower BMI. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger patients with low BMI to mitigate the risk of an unsatisfactory popeye deformity

We report gender differences in the epidemiology and outcome after hip fracture from the Scottish Hip Fracture Audit, with data on admission and at 120 days follow-up from 22 orthopaedic units across the country between 1998 and 2005. Outcome measures included early mortality, length of hospital stay, 120-day residence and mobility. A multivariate logistic regression model compared outcomes between genders. The study comprised 25 649 patients of whom 5674 (22%) were men and 19 975 (78%) were women. The men were in poorer pre-operative health, despite being younger at presentation (mean 77 years (60 to 101) vs 81 years (50 to 106)). Pre-fracture residence and mobility were similar between genders. Multivariate analysis indicated that the men were less likely to return to their home or mobilise independently at the 120-day follow-up. Mortality at 30 and 120 days was higher for men, even after differences in case-mix variables between genders were considered

Introduction: morphological analysis of the general shape of the bones and of their particular variations according to the patient age, gender and pathology is an important step to improve the orthopedic management. We aimed to performed a gender specific analysis of the bi and tridimensional anatomy of the distal femur in vitro and in vivo. Materials and Methods: in vitro data were obtained from CT-scan performed on 92 dry men femurs and 52 dry women femurs. Using a manual contouring method and a segmentation method, tridimensional reconstructions were obtained and according to two different algorithms, the regions of discrepancies between men and women were determined. An automatic calculation of 59 defined measurements was then performed. In vivo data providing from 59 CT-scans of men femur and 73 CT-scan of women femurs were acquired. Standardized bidimensional measurements at the level of the trochlear cut were performed. Results: in vivo, statistically significant differences were observed for the: medio-lateral distance (M-Ld women=7.4±0.4cm vs M-Ld men=8.4±0.5cm; p< 0.0001), anteroposterior distance (A-Pd women=5.9±0,4cm vs A-Pd men= 6.4±0.4cm; p< 0.0001) and for the ratio anterior-posterior distance/medio-lateral distance (p< 0.0001). The trochlear groove angle was comparable in the two groups. In vitro, the tridimensional shape of the distal femur was more trapezoidal in women than in men. Medio-lateral distances were also statistically greater in men than in women (p< 0.01), the ratio anterior-posterior distance/medio-lateral distance was also statistically greater in men than in women (p< 0.01) and the Q angle more open in women than in men (p< 0.01). Discussion: Three types of differences between men and women were observed in this gender specific evaluation of the distal femur anatomy. First, for a same anteroposterior distance, the medio-lateral distance was smaller in women. Second, the global shape of the distal femur was more trapezoidal in women and third the Q angle was more open in women. This gender specific anatomy should be clinically considered when performing total knee arthroplasty in women and gender specific implants may be required

Recently, gender-specific designs of total knee replacement have been developed to accommodate anatomical differences between males and females. We examined a group of male and female distal femora matched for age and height, to determine if there was a difference in the aspect ratio (mediolateral distance versus anteroposterior distance) and the height of the anterior flange between the genders. The Hamann-Todd Collection provided 1207 skeletally mature cadaver femora. The femoral length, the anteroposterior height, height of the lateral and medial flanges and the mediolateral width were measured in all the specimens. The mechanical axis of the femur, the cut articular width and the aspect ratio were assessed. Statistical analysis of the effect of gender upon the aspect ratio and the lateral and medial flanges was undertaken, controlling for age, height and race. The mean aspect ratio of male femora was 1.21 (. sd. 0.07) and of female femora it was 1.16 (. sd. 0.06) (p < 0.001). There was no significant difference between male and female specimens in the mean size of the lateral flange (6.57 mm (. sd. 2.57) and 7.02 mm (. sd. 2.36), respectively; p = 0.099) or of the medial flange (3.03 mm (. sd. 2.47) and 3.56 mm (. sd. 2.32), respectively; p = 0.67). Future work in the design of knee prostheses should take into account the overall variability of the anatomy of the distal femur

Introduction: Hip resurfacing has gained popularity for treating young and active patients with arthritis. Recent literature has reported increase revision rate amongst females as compared to males undergoing resurfacing. The aim of this study is to identify any differences in survival or functional outcome between male and female patients treated with metal-on-metal hip resurfacing. Methods: All procedures performed between July 1997 to July 2003 were extracted from the database and grouped based on gender. 1266 patients (1441 hips, 582 female and 859 male patients) were identified. The preoperative diagnosis, Oxford hip score, component size, post operative complications and revisions were recorded. Failures included revision of either the femoral or acetabular components. Results: The mean follow up was 5.5 years. There were 52 revisions in total (30 in female and 22 in male group). The 8 year survival in the male and female groups were 96.1% and 91.5% respectively which is significantly different (p=0.0006). The size of the femoral component was significantly associated with revision (p=0.0008). Cox proportional hazard modelling including gender, aetiology and femoral component size identified a diagnosis of osteoarthritis reduced the risk of revision of 0.2 times (p=0.0004). However, SUFE was significantly associated 5.57 times increased risk of revision (p=0.0019). With every millimetre increase in head size there was a reduction in risk of revision of 0.89 (p=0.0098). By inclusion of all variables in this model gender was found not to be significantly associated with failure. Conclusion: This study demonstrates that although females may initially appear to have a greater risk of revision this is related to differences in the femoral size and pre-operative diagnosis between the genders. Patient selection for resurfacing is best made on size and diagnosis rather than gender

Aims. The aim of this study was to determine if positive Waddell signs were related to patients’ demographics or to perception of their quality of life. Patients and Methods. This prospective cross-sectional study included 479 adult patients with back pain from a university spine centre. Each completed SF-12 and Oswestry Disability Index (ODI) questionnaires and underwent standard spinal examinations to elicit Waddell signs. The relationship between Waddell signs and age, gender, ODI, Mental Component Score (MCS), and Physical Component Score (PCS) scores was determined. Results. Of the 479 patients, 128 (27%) had at least one positive Waddell sign. There were significantly more women with two or more Waddell signs than men. The proportion of patients with at least one positive Waddell sign increased with age until 55 years, and then declined rapidly; none had a positive sign over the age of 75 years. Functional outcome scores were significantly worse in those with a single Waddell sign (p < 0.01). With one or more Waddell signs, patients’ PCS and ODI scores indicated a perception of severe disability; with three or more Waddell signs, patients’ MCS scores indicated severe disability. With five Waddell signs, ODI scores indicated that patients perceived themselves as crippled. Conclusion. Positive Waddell signs, a potential indicator of central sensitization, indicated a likelihood of having functional limitations and an impaired quality of life, particularly in young women. Cite this article: Bone Joint J 2018;100-B:219–25

Radioprotective gowns are an essential part of operating in orthopaedicse. As we are aware from the evidence, surgeons, and in particular orthopaedic surgeons, are at risk of developing chronic neck and back pain. This is likely a result of the combination of of long operations, heavy equipment, radioprotective gowns and poor ergonomic set up.

Women are a minority in orthopaedics. Amongst trainees there has been an improvement with 20–25% of current trainees are women, however at consultant level this percentage is a lot lower at 5–7%.

Radioprotective gowns worn by trainees are frequently not well fitted and few surgeons have access to bespoke fitted gowns. A questionnaire given to 32 trainees in the region found a significant burden of back pain in trainees and 57% of surgeons felt their gowns were not appropriately fitted. In this study every woman questioned reported back pain as a result of operating and 87% felt the gowns used exacerbated back pain, this figure was 56% in men.

80% of surgeons felt that surgeons would benefit from bespoke fitted gowns, even those that did not themselves have severe back pain. 45% of trainees felt their pain was moderate to severe. In surgery we have the responsibility to protect ourselves and our colleagues from work based injury and illness. Back pain should not be ignored as a symptom and radioprotective gowns is a good place to start.

Overall the majority the gowns exacerbated their back pain during or after procedures, worse in women as described above. We can use this data and do what we can to provide trainees with a range of sizes whilst working in hospitals during their training. Anectodally women sizes were less available in the departments and we can work to improve this and reduce the burden of pain amongst surgeons.

Introduction. Previous anthropometric studies have reported gender differences in distal femoral morphology. After total knee arthroplasty, females have a higher prevalence of medial or lateral femoral component overhang, which could be responsible for postoperative knee pain and decreased range of motion. Consequently, gender-specific knee prostheses were designed to accommodate female morphology. However, to date, very few studies have investigated the knee morphology of Japanese adults and possible gender differences. The purpose of this study was to examine the distal femoral morphology of Japanese patients, to characterize anatomical differences between men and women, and to evaluate the need to create gender-specific knee prostheses. Material and Methods. We evaluated 107 knees in 17 male and 90 female Japanese patients for total knee arthroplasty (TKA)[fig.1]. The medial-lateral (ML) and anteroposterior (AP) dimensions of the knees at different levels evaluated intraoperative measurement, and ML/AP aspect ratios were calculated. Results. On the distal femoral cut surface, the mean ML widths were 74.8 mm for men and 65.5 mm for women. Such values were generally smaller compared to data from European and North American studies. In this study, the mean ML/AP aspect ratios were 1.21 for men and 1.13 for women, higher than those from non-Asian regions. The ML/AP ratios of Japanese patients were negatively correlated with distal femoral AP length. Discussion. The dimensions and sizes of the human femur have been reported in the literature, as measured by dissection of cadaver knees, plain radiographs or CT scans of living subjects, or other means. Compared to data on knees from European and North American populations, femoral ML/AP ratios were smaller for a given AP length in Japanese individuals. In addition, the mean AP and ML distances of the distal femur of Japanese individuals were smaller than those of Western populations, which could be associated with differences in height or other physical and skeletal characteristics. Several studies reported significant gender difference in the ML/AP ratio. Because of the shapes of the distal femur were more trapezoidal for women and more rectangular for men. After TKA, females have a higher prevalence of medial or lateral femoral component overhang, which could be responsible for postoperative knee pain and decreased range of motion. Our results suggest that gender-specific knee prostheses may prevent such postoperative complications. Conclusions. Japanese women had a relatively narrower femoral width for a given AP length than men. Our study suggests the utility of Japanese-specific implants and provides useful insights for manufacturers to design components of appropriate sizes and aspect ratios for Japanese TKA patients

Introduction: Women have gender specific shape of the distal femur. To fit these gender characteristics, gender specific femoral implants were developed for total knee arthroplasty (TKA). We aimed to compare. objective and subjective functional improvement;. patient satisfaction and preference and. cost-utility ratio after gender specific TKA or standard component implanted on the same women. Materials and Methods: 30 women (60 knees) operated on successively (6 months in between) for a bilateral TKA between March 2006 and March 2008 by the same surgeon were included in this prospective study. The same surgical protocol and the same post-operative management protocol were applied for both sides. Mean age was 67±3 and mean BMI 26±4 Kg/m. 2. At a minimum follow-up of one year, evaluation objective and subjective functional improvement, patient satisfaction and preference and cost-utility analysis were performed double blind. Results: Knee Society knee score and Knee Osteoarthritis Outcome Score (KOOS) improvements were comparable in both groups. However, 75% of the women preferred their gender TKA (p< 0.001). 68% of the women described less crepitus or anterior knee bothering after gender TKA (p=0.003) and 64% had faster recovery with the gender implant (p< 0.001). The cost-utility analysis was favorable for the gender knee. Discussion: No objective or subjective superiority in terms of functional improvement was shown with gender specific implants at this short-term follow-up. However significant differences in terms of patient satisfaction and preference and a favorable cost-utility analysis were observed. These results should now be confirmed at longer-follow-up. Despite comparative functional improvement, patient satisfaction and preference were higher for the side implanted with a gender specific TKA in this prospective comparative study

Porcine and fish by-products in particular are rich sources for collagen, which is the main component of the extracellular matrix (ECM). Although there are studies investigating different collagen derived from various tissue sources for the purpose of creating biomaterials, the comparison of biophysical, biochemical and biological properties of type II collagen isolated from cartilaginous tissues has yet to be assessed. In addition, it has been shown from previous studies that sex steroid hormones affect the collagen content in male and female animals, herein, type II collagens from male and female porcine cartilage were assessed in order to investigate gender effects on the property of collagen scaffolds. Moreover, type II collagen has a supportive role in articular cartilage in the knee joint. Therefore, the aim is to assess the properties of type II collagen scaffolds as a function of species, tissue and gender for cartilage regeneration. Type II collagen was extracted from male and female porcine trachea, auricular, articular cartilage and cartilaginous fish through acid-pepsin digestion at 4°C. SDS-PAGE was conducted to confirm the purity of extracted collagen. Collagen sponges were created via freeze-drying. Scaffold structure and pore size were evaluated by scanning electron microscopy (SEM). Thermal stability was assessed by differential scanning calorimetry (DSC). Sponges were seeded with human adipose derived stem cells to assess chondro-inductive potential of collagen sponges after 7, 14 and 21 days of culture. In conclusion, collagen sponges support the proliferation and differentiation of human adipose derived stem cells to different extents

Lumbar disc herniation (LDH) is uncommon in youth and few cases are treated surgically. Very few outcome studies exist for LDH surgery in this age group. Our aim was to explore differences in gender in pre-operative level of disability and outcome of surgery for LDH in patients aged ≤ 20 years using prospectively collected data. From the national Swedish SweSpine register we identified 180 patients with one-year and 108 with two-year follow-up data ≤ 20 years of age, who between the years 2000 and 2010 had a primary operation for LDH. Both male and female patients reported pronounced impairment before the operation in all patient reported outcome measures, with female patients experiencing significantly greater back pain, having greater analgesic requirements and reporting significantly inferior scores in EuroQol (EQ-5D-index), EQ-visual analogue scale, most aspects of Short Form-36 and Oswestry Disabilities Index, when compared with male patients. Surgery conferred a statistically significant improvement in all registered parameters, with few gender discrepancies. Quality of life at one year following surgery normalised in both males and females and only eight patients (4.5%) were dissatisfied with the outcome. Virtually all parameters were stable between the one- and two-year follow-up examination. LDH surgery leads to normal health and a favourable outcome in both male and female patients aged 20 years or younger, who failed to recover after non-operative management. Cite this article: Bone Joint J 2015;97-B:1675–82

To our knowledge in medial unicompartmental knee arthroplasty (UKA) no study has specifically assessed the difference in outcome between matched gender groups. Previous unmatched gender studies have indicated more favourable results for women. Method. 2 groups of 40 of either sex was determined sufficient power for significant difference. These consecutively were matched with both the pre-operative clinical and radiological findings. Minimum follow up of 2 years, mean follow-up 5.9 years. Mean age at operation was 71 years. Results. In both groups, the mean IKS knee and function scores improved significantly (p< 0.001) post operatively. There were no significant differences were between the 2 groups. In both groups mean preoperative flexion was 130 degrees and remained unchanged at final follow-up. No significant differences in preoperative and postoperative axial alignment and in the number of radiolucent lines, between groups. With component size used there was a significant difference (p < 0.001) between the 2 groups. However the size of the femoral or tibial implant used was significantly related (p< 0.001) to patient height for both sexes. Radiolucent lines were more frequent on the tibial component, but were considered stable with none progressing. No revisions for component failure. 1 patient in each group developed lateral compartment degenerative change. Male group; one conversion to TKA for undiagnosed pain, three patients underwent reoperation without changing the implant. Female group; no implants were revised, and two patients required a reoperation. Kaplan-Meier 5-year survival rate of 93.46% (84.8; 100) for men and100% for women. The survival rate difference is not significant (p=0.28). Conclusion. These results suggest that there is no difference in outcome between sexes and that gender should not enter into the selection criteria for UKA. It also suggests that height and not gender is important to predict the appropriate UKA components

The use of Patient Reported Outcome Measures (PROMS) has been critical to the success of total joint arthroplasty (TJA). They have made possible the evaluations of new implants, materials and surgical techniques that have been essential to the development of these technologies. PROMS have had a major impact on the decisions that surgeons make regarding treatment and care of patients. However, there are serious limitations of PROMS. They are useless in the first few weeks after surgery. They provide very little objective functional information to which health care providers can respond in the early, critical post-operative period. PROMS do not objectively measure specific outcome measures (e.g. ROM, distance walked). PROMS are also cumbersome and time consuming to use. Joint specific surface sensors are emerging to allow objective measurements of specific functional outcomes of knee surgery. This allows an examination of the factors that might affect these functional outcomes. The purpose of this study was to examine the relationship of age, gender, BMI and pain following TKA on ROM and activity measured using a joint specific surface sensor. Methods. 40 patients who underwent primary cruciate retaining TKA using the same implant system and patient specific instrumentation (PSI) were followed for 3 weeks with a knee specific surface sensor (TracPatch. tm. ). The device was applied one day following surgery. Standard post-TKA care protocols were used. The ROM and distance walked was measured by the device. The relationship of these outcomes to patients’ age, gender, BMI and pain were examined. Results. All but one patient tolerated the device. This patient had a superficial, transient skin reaction to the adhesive and was not included in the study. Patients under 60 regained more motion and were more active in the first 3 weeks after surgery than patients 60–69 and patients 70+. Gender had no significant impact on ROM or activity for each age group. BMI under 30 had no impact on ROM or activity. BMI over 40 had a significant impact on both ROM and activity. Pain had very little impact on ROM and moderate impact on activity in the first 3 weeks after surgery. Summary. Joint specific sensors are becoming available to provide objective measurements of a joint's function. The knee specific sensors used in this study measured the number of steps taken and ROM in patients who underwent a primary, cruciate retaining TKA. The device was liked and well tolerated by patients. ROM was affected by age and BMI, but not by gender or, to a significant degree, by pain. The device will be useful in focusing therapy on those patients who most need it. Use of the device has the potential of making post-surgical care more effective and cost efficient

Purpose: Medical research has classically been based on the male model, this is no different in the design of arthroplasty implants. Focus has recently shifted to gender-specific implant design but evidence is just developing in the literature as to gender specific outcomes. We hypothesised that outcomes in arthroplasty patients are affected by gender. Methods: Patients were retrospectively identified from a prospectively collected database of total joint arthroplasties performed at one center. Six surgeons performed 1123 primary unilateral cemented TKA’s, and 989 primary unilateral cementless THA’s over a period of seven years. General demographic data was collected along with preoperative and 1-year clinical outcomes including the Harris Hip/Knee Society Score and Oxford Hip/Knee scores. These were compared to determine differences, if any, between males and females using independent samples t-test. Results: The TKA sample was comprised of 540 (55%) females and 449 (45%) males. The THA sample included 744 (66%) females and 379 (34%) males. In the TKA group, females were significantly younger, had higher BMI and had differing rates of comorbidities and complications. Female KSS, Oxford and ROM outcomes were significantly inferior to male scores preoperatively and at 1 year follow up. Significantly more females reported higher pain scores than males from pre-op to 1 year. Interestingly, females showed significantly more improvement from pre-op to 1 year in both scores. In the THR group there were varying rates of complications and comorbidities by gender. Females did significantly worse in the HHS and Oxford hip score from pre-op until one year when results equalized. Similarly pain scores were higher for females preop and at 6 weeks but became equivalent thereafter. Females showed significantly greater improvements from pre-op to 1 year in both outcome scores. Conclusion: As reported in the literature, results of this study indicate that women choose TJR at a later stage of disease than men do, presenting with inferior functional status. The effect of waiting seems most marked in the knee arthroplasty population with inferior outcomes and pain relief persisting out to 1 year. Surgeons must counsel females differently about expectations and recovery in joint arthroplasty

Several studies have suggested that, in TKR, gender specific-prostheses are needed to accommodate anatomic differences between males and females. This study was performed to examine whether gender is a factor contributing to the variability of the size, shape and orientation of the patellofemoral sulcus. 3D computer models of the femur were reconstructed from CT scans of 20 male and 20 female femora. The patellofemoral groove was quantified by measuring landmarks at 10 degree increments around the epicondylar axis. The orientation of the groove was defined by the tracking path generated by a sphere moving from the top of the groove to the intercondylar notch. To assess the influence of gender on the shape of the distal femur, all morphologic parameters were normalized for differences in bone size. Overall, the distal femur was 15% larger in males compared to females. The male condyles were 4% wider than the female for constant AP depth (p=0.13). When normalized for bone size, there was no gender difference in most patello-femoral dimensions, including the length, width, angle or tilt of the sulcus. Female femora had a less prominent medial anterior ridge (p=0.07), and a larger normalized radius of curvature of the tracking path (p=0.03). In addition, the orientation of the sulcus differed by 1–2 degrees in both the coronal and axial planes. Overall, gender explained 4.7% of the anatomic variation of the parameters examined, varying from 0 to 15.9%. The size, shape and orientation of the patello-femoral groove are highly variable. While the patello-femoral morphology of male and female femora are very similar, some of the anatomic variability is related to gender, particularly the prominence of the medial ridge and the sulcus radius of curvature. The biomechanical and clinical significance of these differences after TKA have yet to be determined

The surgical treatment of unicompartmental knee osteoarthritis remains controversial. This study aims to compare the medium-term outcomes of age and gender matched patients treated with unicompartmental knee replacement (UKR) and total knee replacement (TKR). We retrospectively reviewed pain, function and total knee society scores (KSS) for every UKR and age and gender matched TKR in NHS Tayside, with up to 10 years prospective data from Tayside Arthroplasty Audit Group. KSS was compared at 1, 3 and 5 years. Medical complications and joint revision were identified. Kaplan-Meier with revision as end-point was used for implants survival analysis. 602 UKRs were implanted between 2001 and 2013. Preoperative KSS for pain and total scores were not significantly different between UKRs and TKRs whereas preoperative function score was significantly better for UKRs. Function scores remained significantly better in UKRs from preoperative until 3 years follow up. Further analysis revealed no statistically significant difference in the change of function scores in both groups over time. There was a trend for TKRs to perform better than UKRs in pain scores. Total KSS for both groups were not significantly different at any point of the 5-year study. Fewer medical complications were reported in the UKR group. Kaplan-Meier analysis showed a survival rate of 93.7% in UKRs and of 97% in TKRs (Log rank p-value = 0.012). The revision rate for UKR was twice as much as TKR. The theoretical advantages of UKR are not borne out by the findings in this study other than immediate postoperative complications

Introduction: Gender specific total knee prostheses have been developed and one expected outcome of a prosthesis that fit normal anatomy better would be the need for fewer soft-tissue releases at the time of implantation. The purpose of this study was to report any change in the frequency of soft-tissue maneuvers between a standard versus a gender based TKA design. Methods: Using the same surgical technique, 568 consecutive primary cruciate retaining TKAs were performed by the author. Only female patients are reported. 258 received a Standard design and 160 received a Gender TKA design. Both groups were statistically evaluated for diagnosis, height, weight, body mass index (BMI), knee alignment, range of motion (ROM), total Knee Society Score (KSS), and the KSS pain component score. Intra-operative parameters including all soft-tissue releases and component sizes were recorded. Results: There was a significant decrease in lateral retinacular release utilization (p < 0.001) and overall soft-tissue releases (p < 0.002) when using the Gender TKA. There was also a significant shift in the size of femoral components used away from smaller Standard TKA femoral components. (p < 0.001). There was no change in the use of the polyethylene insert thickness (p = 0.368). Discussion: Acceptance of femoral component design limitations may adversely affect the outcome of primary TKA. The use of a prosthesis that better reproduces female anatomy decreased the need for soft tissue ‘adjustments’. Additionally a larger size of femoral components was used. This requires less bone resection and may lead to better knee kinematics with a more normal posterior femoral offset. It is concluded that this design change improves operative technique of total knee replacement by requiring fewer releases in female patients

Introduction. Numerous fluoroscopic studies have been conducted to investigate kinematic variabilities of total knee arthroplasty (TKA). In those studies, subjects having a posterior stabilized (PS) TKA experience greater weightbearing knee flexion and posterior femoral rollback of the lateral condyle. In those same studies, subjects did experience a high incidence of variable medial condyle motion and reverse axial rotation, especially occurring when the cam engaged the post. More recently, a PS TKA was designed to accommodate both gender and ethnicity. Therefore, the objective of this study was to assess in vivo kinematics for subjects having this TKA type to determine if subjects having this PS TKA experienced more optimal knee kinematics. Methods. Twenty-five subjects in this study were asked to perform a deep knee bend to maximum knee flexion and a step-up maneuver while under fluoroscopic surveillance. All subjects were patients of one experienced surgeon and received the same PS TKA. Using a 3D-2D registration technique, the CAD models, supplied by the sponsoring company, were superimposed over x-ray images at specified increments throughout the fluoroscopic footage. The kinematics were then analyzed to evaluate lateral anterior/posterior (LAP) and medial anterior/posterior (MAP) condyle translation as well as axial rotation of the femur with respect to the tibia. Results. During the DKB activity, the average flexion for the PS TKA subjects was 1108°. On average subjects experienced a lateral condyle motion in the posterior direction of 7.3mm, with the maximum amount of posterior rollback being 12.8 mm. These same subjects experienced an average medial condyle motion in the posterior direction of 4.8 mm with the maximum amount of posterior motion being 7.8 mm. Therefore, with the lateral condyle rolling more posterior than the medial condyle, these subjects experienced an average amount of 7.1° of axial rotation, with a maximum of 12.0°. Only one subject in this study experienced a reverse axial rotation from full extension to maximum knee flexion. During the step-up maneuver, subjects consistently experienced a roll forward motion of both their condyles. Discussion. Subjects in this study experienced a high incidence and magnitude of lateral condyle posterior femoral rollback, leading a normal-like axial rotation pattern, although less in magnitude compared to the normal knee. There was variability occurring with the medial condyle as some experience experienced an anterior slide while others rolled in the posterior direction. As seen in previous studies, during mid flexion both condyles experienced a more variable motion pattern. Twenty-five subjects having a posterior cruciate retaining TKA are being added to this study to determine if retention of the PCL in a similarly designed TKA leads to more normal-like kinematic patterns

The aim of this study was to investigate the effects of implant design and gender on the outcome of Total Knee Arthroplasty (TKA) in patients with osteoarthritis (OA). In this double blind randomised controlled trial, patients with OA received either a standard posterior stabilised implant (n=28) or high flex version of this implant (n=28). Walking speed, knee flexion under anaesthesia (‘drop test’), knee flexion in sitting and during functional activities as measured by electrogoniometry, daily number of steps, Quality of Life (SF36), the function component of the Knee Society Score, pain (Visual Analogue Score) and extensor strength were measured before and one year after TKA. Type of implant did not have a significant effect on any of the outcome measures recorded, while gender showed significant effects both before and after surgery. Before surgery, females had a significantly lower knee range of motion, (both passive and functional), lower Knee Score function component, walking speed and strength. After surgery they had a statistically significant lower range of knee motion during functional activities such as walking up and down a slope. Strength was also still significantly lower but post-operative self-reported function were similar for both genders. There was also no difference between male and female participants regarding Quality of life, objective daily physical activity or pain. The results of this study showed that there is a clinically and statistically significant difference between the function of female and male patients both before and after total knee arthroplasty. Although female patients seem to benefit more from TKA than males, on average they do not achieve the same functional knee motion after surgery. Unlike gender, implant design did not influence the knee motion or function in this group of patients. This has important implications for future research and treatment planning in order to maximise the functional outcome after TKA

Summary. From a large 3D Caucasian bone data base, female population had significantly larger acetabular anatomical anteversion angle and combined acetabular-femoral anteversion angle than that of male population. There was no significant difference in femoral neck anteversion angles between the groups. Introduction. Combined Anteversion (CA) angle of acetabular component and femoral neck is an important parameter for a successful Total Hip Arthroplasty (THA). The purpose of this study was to electronically measure the version angles of native acetabulum and femur in matured normal Caucasian population from large 3D CT data base. Our question was if there was any significant difference in CA between male and female population. Methods. 221 anonymous (134 males and 87 females) CT paired pelvic and femoral scans from normal Caucasian population with age range of 30–93 years old were analyzed. CT data was converted to virtual bones using custom CT analytical software. 1. (SOMA. TM. V.3.2). Acetabular Anatomical Anteversion (AA) angle as defined by Murray. 2. was selected. The acetabular rim plane was constructed by selecting 3 bony land marks from pubis, ilium and ischium. The AA was measured against pelvic frontal plane. Femoral neck Anteversion (FA) was measured between neck axis plane and the Coronal plane which was defined by posterior condyles. The neck axis plane was defined as being the plane passing through femoral neck axis and being perpendicular to the transverse plane which is defined by distal femoral condyles. The CA angle in standing position was computed as the summation of AA and FNA angles. All the measurements were performed for total, male and female populations. Student's t tests were performed to compare gender difference with an assumed 95% confidence level. The relationship between AA and FA for each gender was studied by the plot of AA and a function of FA. Results. The mean AA angle for total population was 25.8°, SD=6.52°. (male 24.8°, SD=5.91°, female was 27.3°, SD=7.12°. P=0.006). The mean FA angle for total population was 14.3°, SD=7.95°. (male 13.4°, SD=7.99°, female 15.6°, SD=7.76°. P=0.051). The mean CA angle for total population was 40.1°, SD=10.76°. (male 38.2° SD= 10.38 °, female 42.9° SD= 10.79 °. P=.0002). The plot of AA as a function FA is shown. The frequency distribution of CA angle is plotted for males and females. Discussion/Conclusion. The results showed both AA and CA angles were significantly smaller in the male than that in female. However there was no significant difference in FA between male and female. The plot of AA as a function of FA showed no correlation (R. 2. <.09) between the two angles for both male (R. 2. =.0097) and female (R. 2. =.0029). The FA angle of a femoral stem implant in THA may be smaller than that of natural femur, therefore a higher AA or higher posterior build up may be required for the acetabular component to achieve optimal function of a THA. This may be a more significant issue in female population. The limitations of this study was that this population did not have pathological conditions which could lead to THA. However, it should provide reference guidance comparing normal anatomy between male and female

Given their role in reducing anterior tibial translation, the recruitment patterns and viscoelastic properties of the hamstring muscles have been implicated as neuromuscular factors contributing to the ACL gender bias. Nevertheless, it is uncertain whether patterns of aberration displayed by the female neuromuscular system significantly alters the antagonist moments generated by the hamstrings during maximal effort knee extension. The purpose of the current study was to examine the effect of gender on hamstring antagonist moments in order to explain the higher ACL injury rates in females. Eleven females (age 30.6 ± 10.1 years, mass 62.1± 6.9 kg, height 165.9 ± 4.6) and 11 males (age 29.0 ± 8.2 years, mass 78.6± 14.4 kg, height 178.5± 6.2) were recruited as subjects. Surface electrodes were placed over the semitendinosus (ST) and biceps femoris (BF) muscles of the dominant and non-dominant limbs. Each subject performed two sets of five maximal extension and flexion repetitions at 180-1. EMG, isokinetic torque and knee displacement data were sampled at 1000Hz using an AMLAB data acquisition system. Average hamstring antagonist torque data across the range of knee flexion for female subjects was significantly higher (%Diff=24%) than for the male control subject. Statistical analyses revealed a significant main effect of gender (F = 4.802; p = 0.036). Given that females possess a more compliant ACL and hamstring musculature, compared with their male counterparts, an augmented hamstring antagonist may represent a compensatory neuromuscular strategy to increase knee stiffness to control tibial translation and ACL strain. The results of this project suggest that it is unlikely that gender-related differences in hamstring antagonist torque is one of the predisposing factors contributing to the higher ACL injury rates in females

Introduction:. Recent studies have concluded that gender influences hip morphology at the time of surgery as well as dysplastic development of the hip. This may lead to a particular choice of implant including stem design and/or neck modularity. In this study we hypothesized that not only gender but also morphotype and etiology (primary osteoarthritis versus aseptic osteonecrosis) may be a significant factor to predict the anatomy of the hip at the time of total hip arthroplasty (THA). Methods:. We reviewed 690 patients undergoing THA for primary arthritis (OA) or avascular osteonecrosis (AVN) between April 2000 and June 2005 and stratified each into three groups based on their anatomic constitution: endomorph (EN), ectomorph (ECT), or mesomorph (ME) (determined by the ratio: pelvic width/total leg length measured on full-length X-rays). Two independent observers measured twice four parameters on preoperative CT scan: neck-shaft-angle angle (NSA), femoral offset value (FO), helitorsion (Ht) value and femoral neck anteversion (Av). Results:. No significant difference were observed between men and women for the four parameters with respectively: NSA (129.29° ± 5.6 versus 129.3° ± 5.7), Av (20.3° ± 8.6 versus 20.27° ± 8.6), FO (19.7 mm ± 3.98 versus 19.74 mm ± 3.98) and Ht (19.97° ± 12.2 for men and 19.94° ± 12.3). Significant difference were found for NSA: 130.1° ± 5.8 for ECT, 129.55° ± 6 for MES and 128.2° ± 5,1 for EN with p < 0.01. For Av, the values were: 18.9° ± 8.7 for ECT, 20.74° ± 8.1 for MES and 21.2° ± 8.95 for EN (p < 0.01). For FO the values were 19.1 mm ± 3.9 for ECT, 19.7 ± 4 for MES and and 20.44 mm ± 3.93 for EN (p < 0.01). No difference was found for Ht between the 3 groups. A significant difference was found between patients suffering from OA and AVN: mean NSA was 130.36° ± 8.79 for OA patients versus 127.35° ± 8.38 for those who had an AVN (p < 0.01). A value was 17.06° ± 8.1 for OA and 23.7 ± 7.89 for AVN (p < 0.01). FO value was 18.72 mm ± 3.71 for OA versus 20.75 mm ± 4.15 for AVN (p <0.01). And Ht was 18.94° ± 9.64 for OA and 21.05° ± 14.5 for AVN patients (p < 0.01). Discussion and conclusion:. Patients with short and wide morphotype (endomorph) had, irrespective of gender, lower values of NSA with greater anterversion and offset values, whereas patients with long and narrow morphotype (ectomorph) had higher values of NSA and smaller Av and FO (figure 1). In the same time patients suffering from AVN have lower NSA angle, lower Av, smaller FO and Ht (figure 2). Femoral stem design should allow the consideration of these differences to optimize the reconstruction of the hip at the time of THA including pre-operative and intra-operative modularity

Introduction: Improved biomechanics and stem fit facilitated by gender adepted dual stems and modularity has the potential to make THA easier and thereby decrease the complication rate. Increased fretting wear at the connecting interfaces may be a drawback. 10 year survival exceeding 90% is required to endorse modular necks and dual stem gender technology. Materials and Methods: We followed the first 190 consecutive implantations of an uncemented, straight femoral stem with dual stem technology and modular necks (European Hip System (EHS)/Profemur E, Wright Medical Technology Inc., Arlington, TN, USA) and a grit blasted titanium acetabular cup with a ceramic on polyethylene bearing in 178 patients from 1992 to 1997. Mean time of follow-up evaluation was 10 (8–13) years. Titanium serum ion levels were measured to detect fretting in the metal connection. Results: At follow-up, 21 patients (22 hips, 11.6%) had died, and 13 (14 hips, 7.4%) were lost to follow-up. One hip underwent femoral revision for a periprosthetic fracture. Overall stem survival was 99 (98–100) % at 10 years, survival with femoral revision for aseptic loosening as an end point was 100 (99–100) % at 10 years. Three acetabular components were revised, one for infection and two for aseptic loosening of the titanium shell. There was one fracture of a high offset modular neck at the laser labeling without trauma; the design was changed subsequently. The mean Harris-Hip-Score at follow-up was 88 points. 153 hips were available for radiolographic evaluation. No case of femoral or acetabular osteolysis or loosening was found. Accelerated wear was not detected on radiographs. No dislocation was found during the study period. The results showed no increased titanium serum ion levels compared to an age matched control group. Conclusions: The complication rate with this uncemented modular gender hip system was extremely low with a high patient (and surgeon) satisfaction. The modular neck system as well as the dual stem technology proved to be reliable. The metal ion analysis revealed no elevated serum ion levels. Modular necks and dual gender stems are a reliable and durable option in primary total hip arthroplasty

Differences in femoral anatomy have been partially ascribed to gender differences. Traditionally, femoral stems for THA have been designed across an entire population including both males and females. The purpose of this study was to compare the applicability of two femoral stem systems in male and female populations via preoperative templating. Methods: All patients seen during a single month who presented complaining of knee pain had screening pelvis x-rays. These x-rays formed a consecutive cohort of hips for the templating study. During templating, the acetabular component was placed in a fully medialised position at 45o of abduction. The center of rotation was marked. The femoral neck osteotomy was set at 15 mm proximal to the lesser trochanter. Templates of equal magnification were utilized for both systems. System 1 had a double tapered wedge body design, a fixed 135o neck-shaft angle with two different offsets (6 mm difference) and two different neck lengths (4 mm difference). There were 7 head options with different lengths. System 2 had the same body design with a modular neck offering 20 different offsets/lengths and 7 different neck-shaft angles, with only one head option. Neck length and offset were independent of body size for both systems. Based upon templating, the categories were: No obvious advantage of either system, System 1 preferred, System 2 preferred, Neither system appropriate. Preference was determined based upon providing at least one additional length or offset option, and avoiding the extra extended offset option in System 2 based upon the theoretical risk of disassociation due to extremely high moments. Results: There were 20 female patients contributing 40 hips and 27 males contributing 54 hips. Among the males, there was no obvious advantage in 20/54 hips (37%), System 1 was preferred in 11/54 hips (20.4%), System 2 was preferred in 15/54 hips (27.8%), and neither system was appropriate in 8/54 hips (14.8%). In addition, System 1 could have been used in 33/54 hips (61.1%), while System 2 could have been used in 42/54 hips (77.8%). Overall, 46/54 male hips (85.2 %) could be implanted with this stem. Among the females, there was no obvious advantage in 17/40 hips (42.5%), System 1 was preferred in 1/40 hip (2.5%), System 2 was preferred in 13/40 hips (32.5%), and neither system was appropriate in 9/40 hips (22.5%). In addition, System 1 could have been used in 22/40 hips (55%), while System 2 could have been used in 31/40 hips (77.5%). Overall, 31/40 female hips (77.5 %) could be implanted with this stem. Discussion: Significantly, there are gender differences in applicability of femoral stems. Specifically, more neck length and offset options seem to be required for females. One criticism of this study would be that the neck osteotomy length was fixed. In practical application, surgeons frequently adjust the level of the neck osteotomy to successfully reconstruct the hip. Further study is necessary to determine the role of neck-shaft angle, bone quality and adjustment of neck osteotomy height

Previous in vivo studies have not documented if ethnicity or gender influence knee kinematics for the healthy knee joint. Other measurements, such as hip-knee-ankle alignment have been previously shown to be significantly different between females and males, as well as Japanese and Caucasian populations in the young healthy knee [. 1. ]. Differences in knee kinematics in high flexion positions may relate to both etiology of osteoarthritis and success in knee replacement designs. Although differences in knee anatomy have been identified, their significance in knee function has not yet been clarified. Therefore, the objective of this study was to determine the 3D, in vivo normal knee kinematics for various subjects from different gender and ethnic backgrounds, and to identify significant differences, if any, between populations. The 3D, in vivo, weight bearing normal knee kinematics was determined for 79 healthy subjects, including 48 Caucasians, 24 Japanese, 42 males, and 37 females. Each participant performed deep knee bend activity from a standing (full extension) to squatting to a lunge motion, until maximum knee flexion was reached. The study was approved by the Institutional Review Board and informed consent form was obtained from all subjects. The 3D bone models, created by segmentation from MR images, were used to recreate the 3D knee kinematics using the previously described fluoroscopic and 3D-to-2D registration techniques (Fig. 1) [. 2. ,. 3. ]. Tibiofemoral rotations were described using the ISB recommended Grood and Suntay convention [. 4. ,. 5. ]. Anterior-posterior translations of the centers of the posterior femoral condyles were normalized due to significantly different anthropometry in the subjects. Anterior cruciate ligament (ACL) laxity was also measured using a KT-1000 device for 72 of these subjects. Statistical analysis was performed using the Student’s t-test, set at the 95% confidence interval. Most subjects achieved very high flexion, however substantial variability occurred in all groups. Range of motion (ROM) varied from 117° to 177°, while average external rotation was 31°± 9.9° for all subjects. Japanese and female subjects achieved greater ROM than Caucasian (p=0.048) and male (p=0.014) subjects. From full extension to 140° of flexion (which 87% of subjects achieved), few significant differences between any of the populations were observed. At deeper flexion, the external rotation was higher for female than for male subjects, however not statistically significant (p=0.0564 at 155°). Also at deep flexion, the adduction was significantly higher for female subjects. The translations of the lateral condyle were very similar between respective groups, but at deep flexion, the medial condyle remained significantly more anterior for females, leading to greater axial rotation and ROM. As ACL laxity increased, flexion/extension ROM significantly increased (r2=0.184, p< 0.001). In addition, ACL laxity was also higher for females (6.8 mm) compared to males (5.6 mm, p=0.011), as well as Japanese (7.5 mm) compared to Caucasian (5.6 mm, p=0.0002) subjects. High variability and ROM in knee kinematics were similar to those seen in previous studies of healthy subjects during a deep knee bending activity [. 6. ]. Subjects in this study achieved much greater axial rotation and ROM than previously analyzed TKA patients. A relationship was found between greater axial rotation and increased ROM, and may be related in part to increased ACL laxity in the knee. Significant differences in ROM and laxity were identified between genders and ethnic groups. Also the medial condyle remaining significantly more anterior for females than for males in deep flexion may explain higher external rotation and consequently higher flexion experienced by women. However, understanding the causes for variability within each group may be the key to improved implant design

Pre- and post-operative Knee Society Scores for 2105 Total Knee Replacements (TKRs) with minimum three year follow-up were evaluated. The effect of gender, age at operation and BMI at operation on Knee Society Data at pre-operative review, at one year post-operatively and at three years after TKR was analysed. Total Knee Score pre-operatively, and at both one year and three year review was found to be independent of gender, age and BMI. There was no effect of the three demographic variables on the component scores for pain, range of motion, stability, alignment, extensor lag and flexion contracture. Lower Function Scores were associated with female gender (p< 0.001), age greater than 70 at time of operation (p≤0.004) and obesity (p< 0.001). Median Function Scores were consistently higher in males than females by 5 points pre- and post-operatively (p< 0.001). At three years post-operatively, the median Function Score in the 80 and over age group was lower than all other age groups (p< 0.001), by between 15 and 20 points. Whilst the normal and overweight groups had similar Function Scores the class I obese and class II obese groups consistently had lower median Function Scores by 5 (p< 0.001) and 10 points (p< 0.001) respectively. We conclude that whilst the Knee Score and its component scores are independent of gender, age and BMI, all three of these demographic variables can be associated with significant differences in Function Score

Purpose: Do children from different gender or racial groups receive different analgesic doses for the same acute pain condition? We previously reported on intra-thecal morphine for preemptive analgesia in children undergoing posterior spinal fusion (PSF) and segmental spinal instrumentation (SSI) for idiopathic scoliosis (IS). We determined the optimal dose range to maximize analgesia while minimizing adverse effects. The purpose is to ensure this adopted protocol is equally effective across gender and racial groups. Method: We studied 407 intrathecal morphine patients. Those given a moderate dose of 9–19 mcg/kg (n=293) had the most effective and safe postoperative pain relief. This group consisted of 246 female and 47 male patients. There were 224 Caucasian (CA) and 63 African-American (AA) patients. Other ethnicities were excluded. Factors analyzed included postoperative Wong-Baker visual analog pain scores (VAS), time to first opioid rescue dose, total morphine dose over the first 48 hours, and postoperative complications. Results: For female and male gender, mean VAS pain scores in post-anesthesia care unit (PACU) were 0.48 and 0.56, mean times to first opioid rescue dose were 999.1 and 1003.3 minutes, and total morphine over the first 48 hours were 1.5mg/kg in both groups, respectively. Respiratory depression and PICU admission occurred in 2 (4.2.%) and 4 (1.6%) patients, respectively. For CA and AA patients, mean VAS pain scores in PACU were 0.48 and 0.46, mean times to first opioid rescue dose were 991.7 and 1031.9 minutes, and total morphine over the first 48 hours were 1.5mg/kg and 1.3mg/kg, respectively. Respiratory depression occurred in 5 (2.2.%) and 2 (3.2%) patients and PICU admission occurred in 4 (1.8.%) and 4 (6.3%) patients, respectively. StudentÂ’s t-test and Fisher exact test demonstrated no significant differences between genders for all variables, and no significant differences between races except less total morphine for AA patients over the first 48 hours (p=0.0024). Conclusion: An optimal intrathecal morphine dose range of 9–19 mcg/kg provides effective and safe postoperative pain relief in children undergoing PSF and SSI for IS, regardless of gender or race. Intrathecal morphine can be given with the assurance that it does not discriminate against gender or provide less optimal analgesia to AA patients

Purpose: Gender specific total knee replacement design has been a recently debated controversial topic. The purpose of this study was to investigate the survivor-ship and clinical outcomes of a large primary total knee arthroplasty cohort, specifically assessing any differences between gender groups. Method: A consecutive cohort of 3817 patients with osteoarthritis, having undergone 5289 primary total knee replacements (3100-female, 2179-male) with a minimum of 2 years follow-up were evaluated. All surgeries were performed at the same institution by one of four surgeons. Pre-operative scores, latest scores, and change in clinical outcome scores (KSCRS, SF12, WOMAC) were compared and tested for significance using the students t-test. Kaplan Meier (K-M) survivor-ship was determined and tested for significance and categorical variables were compared using chi-squared. Results: Men were significantly taller and heavier than women, while women had significantly higher BMI’s (p< 0.0001). While men had higher raw scores preoperatively, women demonstrated statistically greater improvement (p< 0.019) in all WOMAC domains including pain (29.87 vs. 27.30), joint stiffness (26.78 vs. 24.26), function (27.21 vs. 23.09) and total scores (28.34 vs. 25.09) There were no gender differences in improvements of the SF12 scores. Men demonstrated statistically greater improvement (p< 0.0001) in Knee Society function (22.10 vs. 18.63) and total scores (70.01 vs. 65.42), but not the Knee Society knee score (47.83 vs. 46.64, p=0.084). K-M cumulative survivorship at 10 years was 87.4±.01 for females and 82.9±.014 for males. K-M survivorship distribution was found to be significantly different between gender groups (p< 0.013, Mantel-Cox, Breslow, Tarone-Ware). Revision rates were 10.2% for males and 8.3% for females which was found to be significant by crosstabs with chi-squared (p=0.006). Conclusion: In this cohort of patients undergoing total knee replacements, women demonstrated statistically greater implant survivorship, statistically greater improvement in WOMAC scores and less improvement in KSCR scores, leading one to question the hypothesis of an inferior clinical outcome in total knee arthroplasty that is gender based

Total Knee Arthroplasty (TKA) has a tendency to change the individual anatomy of the patient within the limits of today used arthroplasty designs. Femoral external rotation will lead to mediolateral overhang by upsizing to avoid lateral notching and downsizing will lead to loss of posterior condylar offset. Posterior slope is usually reduced to avoid problems with posterior stabilized (PS) designs. We compared 50 bicompartimental arthroplasties (Uni + PFJ) with 50 TKA's. Demographics and BMI are compared. We looked specifically at patient type, preoperative deformity, postoperative function and alignment and results on functional scores. Bicompartimental arthroplasty is a resurfacing intervention that allows less correction of frontal deformity. Postop alignment was within 3° of varus. Better active flexion was obtained than in TKA. Better function was observed for stair climbing and single leg stability. Rotational position of foot was more natural in bicompartimental as compared to TKA. Functional scores like WOMAC, KOOS and IKDC showed better results for bicompartimental. Illness perception score showed that the resurfacing patient is another patient than the TKA patient. No overhang of components was observed. No change of posterior condylar offset was necessary. Posterior slope on the medial side was minimally reduced. In conclusion resurfacing by bicompartimental arthroplasty with two individual components (Uni + PFJ) is an excellent solution to gender and ethnic differences. The individual anatomy of the specific patient goes through minimal changes resulting in better functional results

Introduction. The objective of this study was to investigate the incidence of steroid-induced osteonecrosis (ON) among male and female rabbits. Methods. Forty-seven adult rabbits (male, n = 24; female, n = 23) were injected once intramuscularly into the right gluteus medius muscle with 20 mg/kg of methylprednisolone acetate. Hematological examinations were performed just before and at 1 and 2 weeks after the corticosteroid injection. Two weeks after the injection, both femora and humeri were histopathologically examined for the presence of ON, and the bone marrow fat cells were examined morphologically. Results. Sixteen of 24 male rabbits (66.7%) developed ON, with only 5 of 23 female rabbits (21.7%) developing ON. There was a significant difference in the rate of incidence of osteonecrosis between male and female rabbits (p = 0.0032). Hematologically, at 1 week after the corticosteroid injection, both the mean low-density lipoprotein (LDL) and the ratio of LDL cholesterol to high-density lipoprotein (HDL) cholesterol in the male rabbits were significantly higher than those in the female rabbits (p = 0.0001 for both comparisons). The bone marrow fat cells of the male rabbits (61.5 +- 5.6 μm) were significantly larger than those of the female rabbits (58.9 +- 3.7 μm) (p = 0.0102). Conclusion. This study indicates that gender may be an important factor in considering the pathogenesis of corticosteroid-induced ON

Introduction. Opponents of patellar resurfacing during Total Knee Arthroplasty (TKA) note unique complications associated with resurfacing. Problems include over-stuffing (the creation of a composite patellar-prosthesis thickness greater than the native patella) that may contribute to reduced range of motion; and creation of a patellar remnant that is too thin (in order to avoid over-stuffing) that may contribute to post-operative fracture. Factors including surgical technique, prosthesis design and patient anatomy may contribute to these problems. This study was performed to define the native patellar anatomy, and to compare the effect of differences in component thickness between manufacturers. Methods. This retrospective, IRB approved study reviewed 803 knees that underwent primary TKA between 2005 and 2011 with a single surgeon. Patellar resurfacing was performed with a round, polyethylene component from one of two different implant designs using the same surgical technique. Data recorded for each patient included: gender; patellar thickness before and after resurfacing; the dimensions and manufacturer of the prosthesis. The residual patellar bone thickness after resection was calculated. Results. Mean (SD) native patellar thickness was 25.24mm (2.11) in males, versus 22.13mm (1.89) in females (P = <0.001). 47/313 (15%) of males had increases in the composite patellar thickness after resurfacing, versus 120/480 (25%) of females (P < 0.001). 123/480 (26%) of females had a residual patella thickness <= 13mm, versus 12/313 (4%) of males (P <0.001). Finally, 79/265 (30%) of patients with a patellar prosthesis from manufacturer B had increases in the composite thickness, versus 88/522 (17%) of patients with manufacturer A (P < 0.001). Conclusions. Both patient gender (due to smaller native patellae in females) and prosthesis design (thicker components from manufacturer B) are risk factors for over-stuffing of the patella or over-resection of the patella. These findings suggest that patellar component design can be improved for female patients

Over 80% of patients are satisfied following total knee arthroplasty (TKA). Female gender was one of the factors found to be a predictor of poorer satisfaction. The landmarks commonly used to achieve correct rotation of the femoral component are the posterior condylar axis, the transepicondylar axes (TEA) & the anteroposterior axis (Whiteside’s line) of the distal femur. The design features of most conventional jig based TKA instrumentation assumes a constant relationship of 3 degrees external rotation between the posterior condylar axis & the epicondylar axis. However during TKA using computer assisted navigation, we observe that these rotational landmarks do not have a constant relationship & there is wide variation among the arthritic population & between the male & female rotational profile. We hypothesise no consistent relationship between the posterior condylar axis, the TEA & the anteroposterior axis of the distal femur. 125 Computerised Tomography (CT) scans of the knee were performed using a 3D helical CT scanner in subjects who did not have any pre-existing clinical & radiological evidence of knee arthritis. CT slices 3 mm in thickness were obtained over the distal femur from the level of the proximal pole of the patella. Standard protocols were established for identifying the bony landmarks & taking measurements. The posterior condylar axis, the TEA & the anteroposterior axis were constructed. The condylar twist angle (CTA), the posterior condy-lar angle (PCA) & the angles made by the TEA & the line perpendicular to the anteroposterior axis were then measured using the PACSWEB digital measurement tools. The data was analysed to determine the consistency of the angular relationship between the reference axes using the STATA data analysis & statistical software. Linear regression was used to investigate any differences in the angle measurements between genders. 125 CT scans of the knee were performed in 111 patients (60 males [65 knees] & 51 females [60 knees]). The mean age was 45 years (SD, 15 years). The results showed no significant difference between the rotational axes of the distal femur between men & women (CTA male(SD): female(SD): 5.9(1.6): 6.3(2.0) [p=0.317], PCA male(SD): female(SD): 2.3(1.5): 2.5(1.9) [p=0.648]). The results also showed it would be inappropriate to assume a constant relationship of 3 degress external rotation between the posterior condylar axis & the epicondylar axes (PCA mean (SD) 2.39(1.70) [p< 0.001], CTA mean (SD) 6.11(1.81) [p< 0.001]). Our study suggests no significant difference between the rotational reference axes of the distal femur between men & women. Furthermore, most jig-based systems result in 3 degress external rotation of the femoral component. Our results show this is not consistent & may be responsible for the pain in 20% of patients post TKA because of abnormal patellar tracking

Introduction. The use of screws is frequent for additional fixation, however, since some disadvantages have been reported a cup press-fit is desirable, although this can not always be obtained. Cup primary intraoperative fixation in uncemented total hip replacement (THR) depends on sex, acetabular shape, and surgical technique. We analyzed different factors related to primary bone fixation of five different designs in patients only diagnosed with osteoarthritis, excluding severe congenital hip disease and inflammatory arthritis, and their clinical and radiological outcome. Materials y Methods. 791 hips operated in our Institution between 2002 and 2012 were included for the analysis. All cases were operated with the same press-fit technique, and screws were used according to the pull-out test. Two screws were used if there was any movement after the mentioned manoeuvres. Acetabular and femoral radiological shapes were classified according to Dorr et al. We analyzed radiological postoperative cup position for acetabular abduction angle, the horizontal distance and the vertical distance. Cup anteversion was evaluated according to Widmer and the hip rotation centre according to Ranawat. Results. Screws were required in 155 hips (19.6%) and were more frequently used in women and patients with a type A acetabulum (p<0.001, p=0.021, respectively). There were no differences among the different cups evaluated. The need for screws was more frequent in hips with a smaller version of the cup and with a distance greater than 2 mm to the approximate femoral head centre from the centre of the prosthetic femoral head (p=0.022, 0.012, respectively). Adjusted multivariate analysis revealed that female patients (p<0.001, Odds Ratio (OR): 2.063; 95% Confidence Interval (CI) 1.409–3.020), cups with a smaller version (p=0.012, OR: 0.966, 95% CI 0.94–0.992), and a greater distance to the rotation hip center (p<0.005, OR: 1.695; 95% CI 1.173–2.450) had a higher risk for screw use. No hips needed revision for aseptic loosening. Conclusions. Cup press-fit depends on gender and surgical technique in hips without significant acetabular abnormalities or inflammatory arthritis. Contemporary uncemented cups provide similar primary fixation and mid-term outcome