Clinical Orthopaedics and Related Research®

, Volume 469, Issue 7, pp 1824–1828 | Cite as

Examining Sex and Gender Disparities in Total Joint Arthroplasty

Symposium: AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium



Total joint arthroplasty (TJA) is remarkably successful for treating osteoarthritis: most patients see substantial gains in function. However, there are considerable geographic, racial, and gender variations in the utilization of these procedures. The reasons for these differences are complex.


We examined sex and gender disparities in TJA.


Through Medline/PubMed searches, we identified 632 articles and from these selected 61 for our review.

Where are we now?

A number of factors might explain sex and gender disparities in TJA: underrepresentation in clinical trials, differences in willingness to undergo surgery, pain responses to underlying disease and treatment, patient-physician relationships, treatment preferences, provider-level factors such as physician-patient communication style, and system-level factors such as access to specialist care. Since women have a higher prevalence of arthritis and degenerative joint diseases and overall demand for these procedures will continue to grow, the need to understand why there is a gap in utilization based on gender is imperative.

Where do we need to go?

Understanding what exactly is meant by “disparity” is essential because it is possible anatomic factors may have different impacts on utilization from cultural factors. Ideally, information about these factors should be integrated into the decision-making process so that patients and providers can make the most informed choice about whether or not to undergo the procedure.

How do we get there?

To better understand all of the potential reasons for how anatomic and cultural factors related to sex and gender might impact decision-making and overall utilization of TJA, more research focusing on these factors must be designed and carried out.


  1. 1.
    Akhter N, Milford-Beland S, Roe MT, Piana RN, Kao J, Shroff A. Gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the American College of Cardiology-National Cardiovascular Data Registry (ACC-NCDR). Am Heart J. 2009;157:141–148.PubMedCrossRefGoogle Scholar
  2. 2.
    Amaranto DJ, Abbas F, Krantz S, Pearce WH, Wang E, Kibbe MR. An evaluation of gender and racial disparity in the decision to treat surgically arterial disease. J Vasc Surg. 2009;50:1340–1347.PubMedCrossRefGoogle Scholar
  3. 3.
    American Academy of Orthopaedic Surgeons. The Burden of Musculoskeletal Diseases in the United States. Rosemont, IL: AAOS; 2008.Google Scholar
  4. 4.
    Anderson RE, Crespo CJ, Ling SM, Bathon JM, Bartlett SJ. Prevalence of significant knee pain among older Americans: results from the Third National Health and Nutrition Examination Survey. J Am Geriatr Soc. 1999;47:1435–1438.Google Scholar
  5. 5.
    Blagojevic M, Jinks C, Jeffery A, Jordan KP. Risk factors for onset of osteoarthritis of the knee in older adults: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2010;18:24–33.PubMedCrossRefGoogle Scholar
  6. 6.
    Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ. 2008;178:681–687.PubMedGoogle Scholar
  7. 7.
    Boyer KA, Beaupre GS, Andriacchi TP. Gender differences exist in the hip joint moments of healthy older walkers. J Biomech. 2008;41:3360–3365.PubMedCrossRefGoogle Scholar
  8. 8.
    Byrne MM, Souchek J, Richardson M, Suarez-Almazor M. Racial/ethnic differences in preferences for total knee replacement surgery. J Clin Epidemiol. 2006;59:1078–1086.PubMedCrossRefGoogle Scholar
  9. 9.
    Chang HJ, Mehta PS, Rosenberg A, Scrimshaw SC. Concerns of patients actively contemplating total knee replacement: differences by race and gender. Arthritis Rheum. 2004;51:117–123.PubMedCrossRefGoogle Scholar
  10. 10.
    Cho HJ, Chang CB, Yoo JH, Kim SJ, Kim TK. Gender differences in the correlation between symptom and radiographic severity in patients with knee osteoarthritis. Clin Orthop Relat Res. 2010;468:1749–1758.PubMedCrossRefGoogle Scholar
  11. 11.
    Christmas C, Crespo CJ, Franckowiak SC, Bathon JM, Bartlett SJ, Anderson RE. How common is hip pain among older adults? Results from the Third National Health and Nutrition Examination Survey. J Fam Pract. 2002;51:345–348.PubMedGoogle Scholar
  12. 12.
    Debi R, Mor A, Segal O, Segal G, Debbi E, Agar G, Halperin N, Haim A, Elbaz A. Differences in gait patterns, function and quality of life between males and females with knee osteoarthritis: a clinical trial. BMC Musculoskelet Disord. 2009;10:127–137.PubMedCrossRefGoogle Scholar
  13. 13.
    Dunlop DD, Manheim LM, Song J, Sohn MW, Feinglass JM, Chang HJ, Chang RW. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46:200–208.PubMedCrossRefGoogle Scholar
  14. 14.
    Fillingim RB, King CD, Ribero-Dasilva MC, Rahim-Williams B, Riley JL 3rd. Sex, gender, and pain: a review of recent clinical and experimental findings. J Pain. 2009;10:447–485.PubMedCrossRefGoogle Scholar
  15. 15.
    Fortin PR, Clarke AE, Joseph L, Liang MH, Tanzer M, Ferland D, Phillips C, Partridge AJ, Bélisle P, Fossel AH, Mahomed N, Sledge CB, Katz JN. Outcomes of total hip and knee replacement: preoperative functional status predicts outcomes at six months after surgery. Arthritis Rheum. 1999;42:1722–1728.PubMedCrossRefGoogle Scholar
  16. 16.
    Gabriel SE, Wenger DE, Ilstrup DM, Lewallen DG, Melton LJ 3rd. Lack of evidence for gender bias in the utilization of total hip arthroplasty among Olmsted County, Minnesota residents with osteoarthritis. Arthritis Rheum. 1994;37:1171–1176.PubMedCrossRefGoogle Scholar
  17. 17.
    Geller SE, Adams MG, Carnes M. Adherence to federal guidelines for reporting of sex and race/ethnicity in clinical trials. J Women’s Health. 2006;15:1123–1131.CrossRefGoogle Scholar
  18. 18.
    Giacomini MK. Gender and ethnic differences in hospital-based procedure utilization in California. Arch Intern Med. 1996;156:1217–1224.PubMedCrossRefGoogle Scholar
  19. 19.
    Hanna FS, Teichtahl AJ, Wluka AE, Wang Y, Urquhart DM, English DR, Giles GG, Cicuttini FM. Women have increased rates of cartilage loss and progression of cartilage defects at the knee than men: a gender study of adults without clinical knee osteoarthritis. Menopause. 2009;16:16:666–670.PubMedCrossRefGoogle Scholar
  20. 20.
    Harris DJ, Douglas PS. Enrollment of women in cardiovascular clinical trials funded by the National Heart, Lung, and Blood Institute. N Engl J Med. 2000;343:475–480.PubMedCrossRefGoogle Scholar
  21. 21.
    Hawker GA, Guan J, Croxford R, Coyte PC, Glazier RH, Harvey BJ, Wright JG, Williams JI, Badley EM. A prospective population-based study of the predictors of undergoing total joint arthroplasty. Arthritis Rheum. 2006;54:3212–3220.PubMedCrossRefGoogle Scholar
  22. 22.
    Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, Badley EM. Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med. 2000;342:1016–1022.PubMedCrossRefGoogle Scholar
  23. 23.
    Ibrahim SA. Racial and ethnic disparities in hip and knee joint replacement: a review of research in the Veterans Affairs Health Care System. J Am Acad Orthop Surg. 2007;15(Suppl 1):S87–S94.PubMedGoogle Scholar
  24. 24.
    Karlson EW, Daltroy LH, Liang MH, Eaton HE, Katz JN. Gender differences in patient preferences may underlie differential utilization of elective surgery. Am J Med. 1997;102:524–530.PubMedCrossRefGoogle Scholar
  25. 25.
    Katz JN, Wright EA, Guadagnoli E, Liang MH, Karlson EW, Cleary PD. Differences between men and women undergoing major orthopedic surgery for degenerative arthritis. Arthritis Rheum. 1994;37:687–694.PubMedCrossRefGoogle Scholar
  26. 26.
    Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785.PubMedCrossRefGoogle Scholar
  27. 27.
    Mahomed NN, Barrett J, Katz JN, Baron JA, Wright J, Losina E. Epidemiology of total knee replacement in the United States Medicare population. J Bone Joint Surg Am. 2005;87:1222–1228.PubMedCrossRefGoogle Scholar
  28. 28.
    Mogil JS, Chanda ML. The case for the inclusion of female subjects in basic science studies of pain. Pain. 2005;117:1–5.PubMedCrossRefGoogle Scholar
  29. 29.
    Mureebe L, Egorova N, McKinsey JF, Kent KC. Gender trends in the repair of ruptured abdominal aortic aneurysms and outcomes. J Vasc Surg. 2010;51(4 Suppl):9S–13S.PubMedCrossRefGoogle Scholar
  30. 30.
    Murthy VH, Krumholz HM, Gross CP. Participation in cancer clinical trials: race-, sex-, and age-based disparities. JAMA. 2004;291:2720–2726.PubMedCrossRefGoogle Scholar
  31. 31.
    Myers CD, Riley JL 3rd, Robinson ME. Psychosocial contributions to sex-correlated differences in pain. Clin J Pain. 2003;19:225–232.PubMedCrossRefGoogle Scholar
  32. 32.
    Nante N, Messina G, Cecchini M, Bertetto O, Moirano F, McKee M. Sex differences in use of interventional cardiology persist after risk adjustment. J Epidemiol Community Health. 2009;63:203–208.PubMedCrossRefGoogle Scholar
  33. 33.
    National Center for Health Statistics, Centers for Disease Control and Prevention. National Health Interview Survey, Adult Sample, 2005. Available at: Accessed December 13, 2010.
  34. 34.
    National Institutes of Health. NIH guidelines on the inclusion of women and minorities as subjects in clinical research. Fed Regist. 1994;59:14508–14513.Google Scholar
  35. 35.
    National Institutes of Health. NIH consensus statement on total knee replacement. NIH Consens State Sci Statements. 2003;20:1–34.Google Scholar
  36. 36.
    Nguyen JT, Berger AK, Duval S, Luepker RV. Gender disparity in cardiac procedures and medication use for acute myocardial infarction. Am Heart J. 2008;155:862–868.PubMedCrossRefGoogle Scholar
  37. 37.
    O’Connor MI. Osteoarthritis of the hip and knee: sex and gender differences. Orthop Clin North Am. 2006;37:559–568.PubMedCrossRefGoogle Scholar
  38. 38.
    Parsley BS, Bertolusso R, Harrington M, Brekke A, Noble PC. Influence of gender on age of treatment with TKA and functional outcome. Clin Orthop Relat Res. 2010;468:1759–1764.PubMedCrossRefGoogle Scholar
  39. 39.
    Pathak EB, Strom JA. Disparities in use of same-day percutaneous coronary intervention for patients with ST-elevation myocardial infarction in Florida, 2001–2005. Am J Cardiol. 2008;102:802–808.PubMedCrossRefGoogle Scholar
  40. 40.
    Paulson EC, Wirtalla C, Armstrong K, Mahmoud NN. Gender influences treatment and survival in colorectal cancer surgery. Dis Colon Rectum. 2009;52:1982–1991.PubMedCrossRefGoogle Scholar
  41. 41.
    Petterson SC, Raisis L, Bodenstab A, Snyder-Mackler L. Disease-specific gender differences among total knee arthroplasty candidates. J Bone Joint Surg Am. 2007;89:2327–2333.PubMedCrossRefGoogle Scholar
  42. 42.
    Raine RA, Black NA, Bowker TJ, Wood DA. Gender differences in the management and outcome of patients with acute coronary artery disease. J Epidemiol Community Health. 2002;56:791–797.PubMedCrossRefGoogle Scholar
  43. 43.
    Raine RA, Goldfrad C, Rowan K, Black NA. Influence of patient gender on admission to intensive care. J Epidemiol Community Health. 2002;56:418–423.PubMedCrossRefGoogle Scholar
  44. 44.
    Ramasubbu K, Gurm H, Litaker D. Gender bias in clinical trials: do double standards still apply? J Womens Health Gend Based Med. 2001;10:757–764.PubMedCrossRefGoogle Scholar
  45. 45.
    Ritter MA, Wing JT, Berend ME, Davis KE, Meding JB. The clinical effect of gender on outcome of total knee arthroplasty. J Arthroplasty. 2008;23:331–336.PubMedCrossRefGoogle Scholar
  46. 46.
    Rollman GB, Lautenbacher S. Sex differences in musculoskeletal pain. Clin J Pain. 2001;17:20–24.PubMedCrossRefGoogle Scholar
  47. 47.
    Rosseland LA, Solheim N, Stubhaug A. Pain and disability 1 year after knee arthroscopic procedures. Acta Anaesthesiol Scand. 2008;52:332–337.PubMedCrossRefGoogle Scholar
  48. 48.
    Saha S, Stettin GD, Redberg RF. Gender and willingness to undergo invasive cardiac procedures. J Gen Intern Med. 1999;14:122–125.PubMedCrossRefGoogle Scholar
  49. 49.
    Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, Dubé R, Taleghani CK, Burke JE, Williams S, Eisenberg JM, Escarce JJ. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–626.PubMedCrossRefGoogle Scholar
  50. 50.
    Simon V. Wanted: women in clinical trials. Science. 2005;308:1517.PubMedCrossRefGoogle Scholar
  51. 51.
    SooHoo NF, Zingmond DS, Ko CY. Disparities in the utilization of high-volume hospitals for total knee replacement. J Natl Med Assoc. 2008;100:559–564.PubMedGoogle Scholar
  52. 52.
    Srikanth VK, Fryer JL, Zhai G, Winzenbert TM, Hosmer D, Jones G. A meta-analysis of sex differences prevalence, incidence and severity of osteoarthritis. Osteoarthritis Cartilage. 2005;13:769–781.PubMedCrossRefGoogle Scholar
  53. 53.
    Stewart JH, Bertoni AG, Staten JL, Levine EA, Gross CP. Participation in surgical oncology clinical trials: gender-, race/ethnicity-, and age-based disparities. Ann Surg Oncol. 2007;14:3328–3334.PubMedCrossRefGoogle Scholar
  54. 54.
    Suarez-Almazor ME, Souchek J, Kelly PA, O’Malley K, Byrne M, Richardson M, Pak C. Ethnic variation in knee replacement: patient preferences or uninformed disparity? Arch Intern Med. 2005;165:1117–1124.PubMedCrossRefGoogle Scholar
  55. 55.
    Tavris D, Shoaibi A, Chen AY, Uchida T, Roe MT, Chen J. Gender differences in the treatment of non-ST-segment elevation myocardial infarction. Clin Cardiol. 2010;33:99–103.PubMedCrossRefGoogle Scholar
  56. 56.
    Tsang A, Korff MV, Less S, Alonso J, Karam E, Angermeyer MC, Borges GL, Bromet EJ, De GG, De GR, Gureje O, Lepine JP, Haro JM, Levinson D, Browne MA, Posada-Villa J, Seedat S, Watanabe M. Common chronic pain conditions in developed and developing countries: gender and age difference and comorbidity with depression-anxiety disorders. J Pain. 2008;9:883–891.PubMedCrossRefGoogle Scholar
  57. 57.
    Unruh AM, Ritchie J, Merskey H. Does gender affect appraisal of pain and pain coping strategies? Clin J Pain. 1999;15:31–40.PubMedCrossRefGoogle Scholar
  58. 58.
    Vamos EP, Novak M, Mucsi I. Non-medical factors influencing access to renal transplantation. Int Urol Nephrol. 2009;41:607–616.PubMedCrossRefGoogle Scholar
  59. 59.
    Vidaver RM, Lafleur B, Tong C, Bradshaw R, Marts SA. Women subjects in NIH-funded clinical research literature: lack of progress in both representation and analysis by sex. J Womens Health Gend Based Med. 2000;9:495–504.PubMedCrossRefGoogle Scholar
  60. 60.
    Weisz D, Gusmano MK, Rodwin VG. Gender and the treatment of heart disease in older persons in the United States, France, and England: a comparative, population-based view of a clinical phenomenon. Gend Med. 2004;1:29–40.PubMedCrossRefGoogle Scholar
  61. 61.
    Weng HH, Fitzgerald J. Current issues in joint replacement surgery. Curr Opin Rheumatol. 2006;18:163–169.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  1. 1.Departments of Orthopaedic Surgery and Public Health SciencesUniversity of Virginia School of MedicineHSC, CharlottesvilleUSA
  2. 2.Department of SurgerySouthern Illinois University School of MedicineSpringfieldUSA

Personalised recommendations