Biological sex may influence postoperative outcomes following primary total hip arthroplasty. However, these differences may be closely linked to age, implant selection, fixation strategy, and other clinical factors rather than biological sex alone.
Investigators conducted the review according to PRISMA guidelines and registered the protocol in PROSPERO. They searched PubMed, Scopus, and Web of Science for studies published from December 2015 through December 2025 that compared postoperative outcomes between women and men undergoing primary total hip arthroplasty (THA). Twenty-six studies involving more than 2.3 million patients met the inclusion criteria, most of which were retrospective cohort or registry-based analyses and three of which were prospective observational studies. The investigators assessed outcomes, including revision surgery, periprosthetic femoral fracture, postoperative complications, discharge disposition, patient-reported outcomes, and functional recovery. Because of substantial heterogeneity across the studies, they performed a qualitative synthesis rather than a meta-analysis.
The investigators found that women had a modestly higher risk of revision surgery, particularly among younger patients and older patients receiving uncemented fixation. A national cohort reported a 2-year revision rate of approximately 3% in women compared with 2% in men, with the largest difference observed among patients younger than 55 years. Another population-based study of patients aged 40 to 60 years identified female sex as independently associated with revision during follow-up.
Women also had higher rates of several surgical complications, including periprosthetic femoral fracture, surgical site infection, urinary tract infection, blood transfusion, prolonged hospital stay, and discharge to non-home settings. In a matched cohort, 5-year revision occurred in 2% of women compared with 1% of men, wheres periprosthetic fracture occurred in 1% vs less than 1%, respectively. By contrast, men had higher rates of early medical complications, including cardiac events, acute kidney injury, and mortality following elective and nonelective THA.
Several registry studies included in the review suggested that age and implant fixation modified these associations. Older women undergoing uncemented THA had higher risks of periprosthetic fracture and fracture-related revision compared with women receiving cemented stems. In men, fixation strategy appeared to have less influence on revision risk, with outcomes more closely associated with comorbidity burden. Further, optimal implant selection may have differed by sex and age, with cemented stems associated with lower reoperation rates in older women and cementless collared stems associated with lower reoperation rates in older men.
The investigators identified differences in postsurgical recovery. Women generally reported greater improvements in pain relief and mental quality of life, whereas men experienced faster early functional recovery. However, prospective studies reported similar long-term implant survivorship and overall functional outcomes between women and men, suggesting that most differences were observed during the early postoperative period or within specific outcome domains rather than in long-term function.
Biological sex should not be considered an isolated predictor of postoperative outcomes, the investigators stated. The available evidence suggested that sex may interact with age, implant design, fixation strategy, bone quality, and comorbidity burden to influence postoperative risk and recovery.
The study had several limitations. Almost 90% of the studies were retrospective, and the remainder were prospective observational studies. Most studies had a moderate risk of bias, and outcome definitions, adjustment strategies, implant characteristics, and follow-up periods varied considerably, preventing quantitative pooling. Further, many studies did not account for bone mineral density, hormonal status, activity level, or other biologic factors. The investigators noted that the studies evaluated biological sex rather than gender-related variables.
"Sex significantly modulates postoperative outcomes following THA through complex interactions with age, implant choice, fixation strategy, and biological factors," wrote lead researcher Francesca Salamanna, PhD, of IRCCS Istituto Ortopedico Rizzoli in Italy, and colleagues. They highlighted the need for prospective studies to better define the mechanisms underlying these associations.
The study authors reported no conflicts of interest.
