Published online Feb 18, 2026. doi: 10.5312/wjo.v17.i2.115188
Revised: October 28, 2025
Accepted: November 26, 2025
Published online: February 18, 2026
Processing time: 117 Days and 9.7 Hours
Total knee arthroplasty (TKA) is increasingly performed in elderly patients with osteoarthritis, yet preoperative frailty is associated with adverse outcomes. Limi
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.
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.
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.
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.