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©The Author(s) 2026. Published by Baishideng Publishing Group Inc. All rights reserved.
Impact of preoperative frailty on complications, readmissions, and functional recovery following total knee arthroplasty in elderly patients
Muhammad Bilal Yasin, Muhammad Raheel, Muhammad Mustafa Ahmed, Sheharyar Ashfaq, Hamdoon Suharwardy Asim, Mohammed Qasim Rauf, Renad Fahim, Rejina Chhetri
Muhammad Bilal Yasin, Muhammad Raheel, Department of Trauma and Orthopaedics Surgery, Bahawal Victoria Hospital, Bahawalpur 63100, Punjab, Pakistan
Muhammad Mustafa Ahmed, Department of Orthopedics, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust, Worksop S81 0BD, United Kingdom
Sheharyar Ashfaq, Department of Orthopedics, Hull University Teaching Hospital NHS Trust, Cottingham HU16 5JQ, United Kingdom
Hamdoon Suharwardy Asim, Department of Orthopedics, Dartford and Gravesham NHS Trust, DA2 8DA, England, United Kingdom
Mohammed Qasim Rauf, Department of Orthopedic Surgery, Hillingdon Hospital, Uxbridge UB8 3NN, United Kingdom
Renad Fahim, Department of Trauma and Orthopedic, Jinnah Sindh Medical University, Karachi 75510, Sindh, Pakistan
Rejina Chhetri, Department of Surgery, Nepalgunj Medical College, Kohal 21900, Nepal
Co-first authors: Muhammad Bilal Yasin and Muhammad Raheel.
Author contributions: Yasin MB conceptualized the study, curated the data, performed formal analysis, acquired funding, and drafted the original manuscript; Yasin MB and Raheel M have played important and indispensable roles in the manuscript preparation as co-first authors; Raheel M contributed to data curation, investigation, and validation, while also reviewing and editing the manuscript; Ahmed MM and Ashfaq S provided methodological guidance, supervised the project, and critically revised the manuscript for intellectual content; Asim HS and Rauf MQ assisted with data acquisition, visualization, and software implementation; Fahim R supported investigation and resource management; Chhetri R oversaw administration, ensured ethical compliance, led the writing, review, and editing process; all authors approved the final version and agree to be accountable for all aspects of the work in accordance with the credit taxonomy.
Institutional review board statement: This retrospective cohort study was approved by the Institutional Review Board of Bahawal Victoria Hospital, Bahawalpur, Pakistan (No. 2025-ORTH-012). The study adhered to institutional ethical standards, the Declaration of Helsinki, and relevant national regulations for research involving de-identified medical records.
Informed consent statement: Informed consent was waived due to the retrospective nature of the study, which involved analysis of de-identified existing medical records.
Conflict-of-interest statement: The authors declare that they have no conflict of interest related to the publication of this article.
STROBE statement: The authors have read the STROBE Statement – checklist of items, and the manuscript was prepared and revised according to the STROBE Statement – checklist of items.
Data sharing statement: : No additional data are available.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Rejina Chhetri, MD, Department of Surgery, Nepalgunj Medical College, Banke Baijanath 1 Chisapani, Kohal 21900, Nepal.
rejinachhetri01@gmail.com
Received: October 14, 2025
Revised: October 28, 2025
Accepted: November 26, 2025
Published online: February 18, 2026
Processing time: 117 Days and 6.4 Hours
BACKGROUND
Total knee arthroplasty (TKA) is increasingly performed in elderly patients with osteoarthritis, yet preoperative frailty is associated with adverse outcomes. Limited data exist from South Asian regions like Pakistan, where resource constraints and high osteoarthritis prevalence may influence these associations.
AIM
To evaluate the association between preoperative frailty, assessed by the modified Frailty Index, and postoperative complications, hospital length of stay (LOS), 90-day readmission rates, and 1-year functional recovery in elderly Pakistani patients undergoing primary TKA.
METHODS
This retrospective cohort study analyzed de-identified records from Bahawal Victoria Hospital, Bahawalpur, Pakistan (from January 2015 to September 2025). Patients aged ≥ 65 years with primary unilateral TKA for osteoarthritis were included. Frail patients (n = 512) were propensity score-matched 1:4 to non-frail controls (n = 2048) using nearest-neighbor matching with a caliper of 0.1. Propensity score estimation followed established methodological standards. Logistic regression, t-tests, χ2 tests, and Kaplan-Meier analyses were used, with P < 0.05 denoting significance. Sensitivity analyses addressed alternative modified Frailty Index thresholds, matching overlap and missing data.
RESULTS
Post-matching, groups were balanced. Frail patients had higher composite complications [21.1% vs 9.2%; adjusted odds ratio (OR) = 2.61, 95%CI: 2.05-3.32; P < 0.001], including surgical site infection (OR = 3.12, 95%CI: 2.18-4.46; P < 0.001), deep vein thrombosis (OR = 2.85, 95%CI: 1.92-4.23; P < 0.001), and pulmonary embolism (OR = 4.02, 95%CI: 2.45-6.59; P < 0.001). LOS was prolonged (5.6 ± 1.9 days vs 3.9 ± 1.5 days; P < 0.001), readmissions increased (17% vs 4%; OR = 4.74, 95%CI: 3.56-6.31; P < 0.001), and 1-year Knee Society Score was lower (75.5 ± 10.2 vs 85.1 ± 8.1; P < 0.001), with smaller delta Knee Society Score (30.3 ± 11.4 vs 39.0 ± 10.2; P < 0.001), approaching the minimal clinically important difference of approximately 9 points. Sensitivity analyses confirmed robustness.
CONCLUSION
Preoperative frailty is associated with increased complications, extended LOS, higher readmissions, and impaired functional recovery in elderly TKA patients in this Pakistani cohort. These findings are most directly applicable to tertiary care centers in Pakistan with comparable patient complexity and resource availability. Extrapolation to primary care or markedly different healthcare systems requires further validation. Routine frailty screening may aid risk stratification and perioperative management in similar settings, considering regional challenges such as high tuberculosis prevalence.
Core Tip: This retrospective cohort study from Pakistan demonstrates that preoperative frailty, assessed by the modified Frailty Index, significantly increases postoperative complications, hospital length of stay, and 90-day readmissions while impairing 1-year functional recovery in elderly patients undergoing total knee arthroplasty. Findings are most applicable to tertiary referral centers in Pakistan. Routine frailty screening could enhance risk stratification and perioperative management in resource-limited settings, addressing challenges like high tuberculosis prevalence to optimize outcomes and reduce healthcare burdens. A practical pathway includes: (1) The modified Frailty Index ≥ 0.27 to flag high-risk; (2) Initiate low-cost prehabilitation (nutritional screening/supplementation, home-based resistance exercises, medication review); and (3) Multidisciplinary review before surgery.
