Escolar Documentos
Profissional Documentos
Cultura Documentos
82 Original Article
1 Knee Group of the Orthopedics and Traumatology Discipline of the Address for correspondence José Luiz Colleoni, Centro de Estudos da
Hospital Estadual Mário Covas, Faculdade de Medicina do ABC Disciplina de Ortopedia e Traumatologia da Faculdade de Medicina do
(FMABC), Santo André, SP, Brazil ABC, Rua: Dr. Henrique Calderazzo, 321, Vila Paraíso, Santo André,
SP 09190-615, Brazil (e-mail: jcolleoni@uol.com.br).
Rev Bras Ortop 2020;55(1):82–87.
Abstract Objective To compare the postoperative functional result of total knee arthroplasty
(TKA) with gender-specific prosthesis versus TKA with conventional prosthesis in a 5-
year period.
Methods Retrospective study with functional evaluation of 30 patients (15 patients from
each group) using scores (Knee Injury and Osteoarthritis Outcome Score [KOOS], Western
Ontario and McMaster Universities arthritis index [WOMAC], and The Knee Society Clinical
Rating System [KSS]) and range of motion (ROM) as methods of assessment.
Keywords Results The differences found between the score values and ROM were not statisti-
► knee arthroplasty cally significant.
► female Conclusion The gender-specific prosthesis presents functional results equal to those
► outcome assessment of conventional prosthesis after 5 years postoperatively.
Study developed at Knee Group of the Orthopedics and Traumatology
Discipline of the Hospital Estadual Mário Covas, Faculty of Medicine of
ABC (FMABC), Santo André, SP, Brazil.
Discussion
Methods
There are well-documented anatomical differences between
The present study was approved by the research ethics men and women regarding lower limb alignment and distal
committee of the Faculdade de Medicina do ABC (CAAE femoral anatomy. Women have a valgus and anteroposterior
51201915.1.0000.5484). It was retrospectively performed dimension of distal femur slightly enlarged, while the medio-
from April 2017 to December 2017 with 30 female patients lateral diameter is narrower.4,8 These findings have led some
undergoing TKA for primary gonarthrosis in a public univer- authors to conclude that there is a need to develop implants
sity hospital. that can adapt better to these anatomical variations.9 The
The patients were divided into 2 groups with the same fundamental premise of this approach assumes that
number of individuals. Group A used the gender-specific the results of TKA performed in women are inferior, and
implant, Gender Solutions Natural-Knee System (Zimmer some of the causes of these worse outcomes are related to
Biomet, Warsaw, IN, USA) with a model developed for female these anatomical differences and the need for gender-specif-
patients, and Group B individuals underwent TKA with ic implants.15
conventional implant from Exactech Optetrak Logic Primary Implant models with gender-specific design were devel-
System (Exactech, Gainesville, FL, USA). oped based on existing anatomical differences in the distal
All surgeries were performed between January and end of the femur, when comparing men and women.5,16–21
December 2012. The patients were evaluated 5 years Some studies have been conducted trying to establish the
postoperatively. superiority of gender-specific implants over conventional
Table 1 Data of patients undergoing arthroplasty with Exactech unisex implants when used on women’s knees,22 but it
Optetrak (Exactech) type prosthesis. remains unclear how much the anatomical differences
between men and women can influence TKA results.23,24
EXACTECH In our study, we did not find a statistically significant
Ptts AGE BMI KSS WOMAC KOOS difference in relation to postoperative ROM with the use of
1 73 29.9 74 93.9 91.1 gender-specific implants.12 Song et al12 conducted a
prospective study with 40 female patients undergoing
2 71 33.5 70 93.2 88.7
simultaneous bilateral TKA in which a conventional
3 39 24.4 75 93.9 91.1
implant was used on one knee, and a gender-specific
4 68 31.1 74 93.2 88.7 implant was used in the other one, and, in the ROM
5 74 38 52 92.4 87.5 evaluation after 24 to 36 months postoperative, similar
6 69 37.89 77 81.8 78.5 and statistically nonsignificant results between the groups
were found. These data conflict with the hypothesis that
7 79 25.3 77 86.4 83.9
conventional implants cause overfilling in the patellofe-
8 75 32.6 72 87.9 85.7
moral compartment, since the anteroposterior dimension
9 73 33.7 77 84.1 81.5 of the female condyle is smaller, and it may lead to a
10 80 36.97 62 81.9 78.6 decrease in the postoperative ROM.16,25 Despite the
11 80 34.6 64 83.3 80.4 reduced flange height in the Gender Solutions natural-
12 73 28.7 74 88.6 85.1
knee implant (Zimmer Biomet), postoperative ROM was
similar when comparing the two groups.
13 80 25 75 80.3 76.2
Two Level I studies were conducted in Korea by Kim
14 86 33.3 75 90.9 85.7 et al20,26 with 223 female patients undergoing bilateral
15 78 35 79 88.6 85.1 TKA, totaling 446 TKAs. The patients were randomized to
MEAN 73.2 31.997 71.8 88.026 84.52 determine which knee would receive a gender-specific
33333 66667 implant or a unisex implant. The authors found no difference
in any of the studies regarding ROM, satisfaction, or KSS and
Abbreviations: BMI, body mass index; KOOS, Knee Injury and Osteoarthritis
Outcome Score; KSS, The Knee Society Clinical Rating System; Ptts, patients; WOMAC scores. Johnson et al,11 after a meta-analysis study
WOMAC, Western Ontario and McMaster Universities arthritis index. involving 253 studies, claim that no postoperative difference
Table 2 Data from patients undergoing arthroplasty with the was found between TKA and total hip arthroplasty using
Gender Solutions (Zimmer Biomet) type prosthesis. gender-specific implants in comparison to conventional
implants.
GENDER Song et al,12 in a prospective study in which 50 patients
Ptts AGE BMI KSS WOMAC KOOS
underwent simultaneous bilateral TKA, one knee with a
conventional unisex implant and the other with a gender-
1 83 32.6 70 83.3 81.5
specific implant, state that they did not observe significant
2 79 30.4 74 93.2 78.6 differences when comparing ROM, hospital for special
3 78 30 75 87.9 85.7 surgery (HSS), and WOMAC scores. Clarke and Hentz,27 in
4 73 34.13 77 81.8 80.4 a similar prospective study with 46 patients undergoing
5 64 34.8 74 92.4 88.7 simultaneous bilateral TKA, also concluded that there is no
functional difference by the HSS score between the two types
6 69 29 74 84.1 81.5
of implants in the postoperative period after 2 years of
7 74 39.1 72 92.4 85.1 follow-up.
8 81 33.6 79 93.2 91.1 However, we know that our study has a few limitations.
9 68 34 75 93.9 91.1 The first is that we did not evaluate preoperative condi-
10 75 33.2 72 93.2 87.5 tions, such as ROM and functional scores, which are known
factors influencing the outcomes after TKA, but this was
11 77 28.6 72 88.6 85.7
minimized by excluding patients with ROM below 90 ° and
12 71 31.2 64 83.3 81.5
with severe deformities, or when bone grafting or revision
13 74 29.5 60 86.4 83.6 implants were required. The second is related to the
14 76 33.3 72 93.2 88.7 medium term follow-up, only 5 years, which makes it
15 DEATH (in 04/04/2014) cause: cerebrovascular acci- impossible for us to draw long-term conclusions about
dent (CVA) satisfaction; however, recent studies show that these rates
MEAN 74.428 32.387 72.142 89.064 85.05 reach a plateau after 1 year of surgery and do not change
57143 85714 8571 28571 much after this period.26,28
In summary, we can say that there are few studies in the
Abbreviations: CVA, cerebrovascular accident; BMI, body mass index;
KOOS, Knee Injury and Osteoarthritis Outcome Score; KSS, The Knee
literature that refer to the analysis of postoperative efficacy
Society Clinical Rating System; Ptts, patients, WOMAC, Western Ontario of gender-specific implants and, in our retrospective study of
and McMaster Universities arthritis index. 30 female patients, the apparent superiority of gender-
Table 3 Mann-Whitney test application in order to verify possible differences between both groups for the variables of interest
Variable Group n Mean Standard Min. Max. Percentile Percentile 50 Percentile P-value
deviation 25 (median) 75
AGE Exactech 15 73.20 10.63 39.00 86.00 71.00 74.00 80.00 0.948
Gender 14 74.43 5.21 64.00 83.00 70.50 74.50 78.25
Total 29 73.79 8.34 39.00 86.00 71.00 74.00 79.00
BMI Exactech 15 32.00 4.52 24.40 38.00 28.70 33.30 35.00 0.930
Gender 14 32.39 2.84 28.60 39.10 29.88 32.90 34.03
Total 29 32.19 3.74 24.40 39.10 29.70 33.20 34.37
KSS Exactech 15 71.80 7.22 52.00 79.00 70.00 74.00 77.00 0.522
Gender 14 72.14 4.93 60.00 79.00 71.50 73.00 75.00
Total 29 71.97 6.12 52.00 79.00 71.00 74.00 75.00
WOMAC Exactech 15 88.03 4.83 80.30 93.90 83.30 88.60 93.20 0.629
Gender 14 89.06 4.53 81.80 93.90 83.90 90.50 93.20
Total 29 88.53 4.63 80.30 93.90 83.70 88.60 93.20
KOOS Exactech 15 84.52 4.64 76.20 91.10 80.40 85.10 88.70 0.759
Gender 14 85.05 4.02 78.60 91.10 81.50 85.40 88.70
Total 29 84.78 4.28 76.20 91.10 81.50 85.10 88.70
ROM Exactech 15 103.33 9.00 90.00 120.00 100.00 100.00 110.00 0.982
(degrees)
Gender 14 103.57 8.42 90.00 120.00 100.00 100.00 110.00
Total 29 103.45 8.57 90.00 120.00 100.00 100.00 110.00
Abbreviations: BMI, body mass index; KOOS, Knee Injury and Osteoarthritis Outcome Score; KSS, The Knee Society Clinical Rating System; Min.,
minimum; Max., maximum; ROM, range of motion; WOMAC, Western Ontario and McMaster Universities arthritis index.
Fig. 1 Graphical representation according to the age variable. Fig. 2 Graphical representation according to the body mass index
variable.
25 Mihalko W, Fishkin Z, Krackow K. Patellofemoral overstuff and its 27 Clarke HD, Hentz JG. Restoration of femoral anatomy in TKA with
relationship to flexion after total knee arthroplasty. Clin Orthop unisex and gender-specific components. Clin Orthop Relat Res
Relat Res 2006;449(449):283–287 2008;466(11):2711–2716
26 Kim YH, Sohn KS, Kim JS. Range of motion of standard and high- 28 Ritter MA, Berend ME, Harty LD, Davis KE, Meding JB, Keating EM.
flexion posterior stabilized total knee prostheses. A prospective, Predicting range of motion after revision total knee arthroplasty:
randomized study. J Bone Joint Surg Am 2005;87(07): clustering and log-linear regression analyses. J Arthroplasty
1470–1475 2004;19(03):338–343