Sexual dimorphism and racial diversity render bone–implant mismatch inevitable after off-the-shelf total knee arthroplasty: a systematic review and meta-analysis



The purpose of this systematic review and meta-analysis was to investigate the variability in femoral geometric ratios among knees of different sexes and races, and to appreciate whether the observed variability is accommodated by commonly implanted total knee arthroplasty (TKA) components. The hypothesis was that the anthropometric studies report considerable variability of femoral geometric ratios among sexes and races.


This systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) criteria. Two authors independently conducted an electronic search using MEDLINE® and Embase® on 6 July 2020 for clinical studies reporting on femoral geometric ratios among sexes and races. Femoral geometric ratios were graphically represented as means and 2 standard deviations, and compared to those of 13 commonly implanted femoral components.


A total of 15 studies were identified that reported on a combined total of 2627 knees; all reported the aspect ratio, and 2 also reported the asymmetry ratio and trapezoidicity ratio. Men had wider knees than women, and compared to Caucasian knees, Arabian and Indian knees were wider, while East Asian were narrower. There were no differences in asymmetry ratio between men and women, nor among Caucasian and East Asian knees. Men had more trapezoidal knees than women, and East Asian knees were more trapezoidal than Caucasian knees. The commonly implanted femoral components accommodated less than a quarter of the geometric variability observed among sexes and races.


Anthropometric studies reported considerable sexual dimorphism and racial diversity of femoral geometric ratios. Since a surgeon generally only uses one or a few TKA brands, bone–implant mismatch remains unavoidable in a large proportion of knees. These findings support the drive towards personalized medicine, and accurate bone–implant fit may only be achievable through customisation of implants, though the clinical benefits of custom TKA remain to be confirmed.

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The authors are grateful to Ramsay Santé for funding the statistical analysis and manuscript preparation for this study.

Author information




LB: data screening and extraction, data interpretation, and manuscript writing. JHM: data screening and extraction, manuscript writing, tables, and figures. JD, MS: data interpretation and manuscript writing. TASS and MPB: study design, data interpretation, and manuscript editing.

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Correspondence to Mo Saffarini.

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LB, JHM, JD, and MS declare no conflict of interest. TASS reports personal fees from Symbios and DePuy-Synthes outside the submitted work. MPB reports personal fees from Symbios, Wright Medical, Integra, and DePuy Synthesis outside the submitted work.

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Beckers, L., Müller, J.H., Daxhelet, J. et al. Sexual dimorphism and racial diversity render bone–implant mismatch inevitable after off-the-shelf total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc (2021).

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  • Knee
  • Femur
  • Total knee arthroplasty
  • Total knee replacement
  • Off-the-shelf
  • Morphology
  • Morphometry
  • Geometry