GENDER ASYMMETRY IN LARGE JOINT ARTHROPLASTY: A SYSTEMATIC REVIEW OF EPIDEMIOLOGICAL, BIOMECHANICAL, AND METABOLIC DETERMINANTS

Abstract

This review presents a systematic analysis of a persistent clinical and epidemiological phenomenon characterized by the predominance of males among patients undergoing total hip arthroplasty and females among those undergoing total knee arthroplasty. Based on retrospective data from national registries of Australia, the United Kingdom, Sweden, the United States, and South Korea spanning the period from 2010 to 2024, this pattern is demonstrated to be reproducible across diverse populations, with the greatest disproportion observed in Asian cohorts, reaching 78% females in knee arthroplasty, and the smallest in the American registry at 66%. Key pathophysiological mechanisms are examined, including morpho-biomechanical differences (Q-angle and gait biomechanics), metabolic dimorphism mediated by adipokinetic activity of visceral adipose tissue, and hormonal suppression of chondrogenesis in the postmenopausal period. A clinically significant finding of this work is the demonstration that male sex serves as an independent predictor of revision due to periprosthetic joint infection, with hazard ratios of 1.60 for hip and 2.06 for knee arthroplasty, necessitating the implementation of sex-specific antibiotic prophylaxis protocols. The proposed conceptual model, integrating biomechanical, metabolic, and behavioral factors, provides a rationale for a differentiated approach to preoperative preparation: weight reduction and anti-osteoporotic therapy for females, and screening for methicillin-resistant Staphylococcus aureus colonization and glycemic control for males. Future research should focus on polymorphisms of estrogen receptor genes ESR1 and ESR2, which may enable prediction of individual osteoarthritis risk long before clinical manifestation.