Influence of frailty on postoperative outcomes following primary and revision total hip arthroplasty

Abstract

Total hip arthroplasty (THA) effectively treats advanced hip disorders, yet outcomes vary among patients. Frailty has become a crucial factor influencing these results. Several studies explored multiple preoperative factors affecting THA outcomes, highlighting the significance of age, Western Ontario and McMaster Universities Osteoarthritis Index, Center for Epidemiologic Studies Depression Scale, and central sensitization index scores in predicting post-operative recovery, emphasizing comprehensive preoperative assessments. Subsequent research has shown that frailty, measured by tools like the hospital frailty risk score and frailty deficit index, is significantly associated with adverse outcomes such as higher 30-day readmission rates, longer hospital stays, increased costs, and elevated mortality and complication risks in both primary and revision THA. Additionally, frailty related to short-term adverse events but stressed the need for standardized frailty measurement. Currently, there is no unified standard for assessing frailty before THA, which hinders cross-study comparison and evidence-based guideline development. Future research should focus on establishing a universal frailty assessment standard considering physical function, comorbidities, cognitive and psychological status. Prospective studies are also needed to clarify the causal relationship between frailty and long-term THA outcomes and identify modifiable factors for preoperative interventions. Overall, understanding the impact of frailty on THA outcomes is essential for improving patient care and resource utilization, especially in an aging population with a rising prevalence of hip disorders.

Key Words: Frailty; Disability; Preoperative factors; Quality of life; Total hip arthroplasty

Core Tip: Total hip arthroplasty (THA) is an effective treatment for advanced hip problems, but patient outcomes vary. Frailty is a key factor influencing these results. Preoperative factors are important for predicting post-operative recovery, underlining the need for comprehensive pre-operative assessments. Tools such as hospital frailty risk score and frailty deficit index show frailty is linked to adverse outcomes in THA, including higher readmission, longer stays, more costs, and greater mortality and complication risks. Understanding frailty’s impact on THA outcomes is crucial for better patient care, especially as hip disorders increase in the aging population.

INTRODUCTION

Total hip arthroplasty (THA) is a common and effective surgical procedure for treating advanced hip disorders, significantly improving patients’ quality of life by alleviating pain and restoring joint function[1]. However, the outcomes of THA can vary among patients, and frailty has emerged as a crucial factor influencing these outcomes. Nishiwaki et al[2] published in the recent issue of the World Journal of Orthopedics contributes to our understanding of the factors affecting THA outcomes. This editorial will commend the research findings of their article and expand on the topic of frailty, drawing insights from previously published articles to elucidate the significance of frailty in primary and revision THA.

Nishiwaki et al[2] focused on exploring the impact of various preoperative factors, including age, body mass index, pain severity, functional impairment, psychological status, neuropathic pain, and central sensitization, on the clinical outcomes of THA. This retrospective analysis of 411 patients provided valuable insights into the predictors of postoperative recovery. The findings that age, Western Ontario and McMaster Universities Osteoarthritis Index, Center for Epidemiologic Studies Depression Scale, and central sensitization index scores significantly predicted the modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index outcomes are noteworthy. This research emphasizes the importance of comprehensive preoperative assessments, particularly those incorporating psychological and neurological factors, in optimizing THA outcomes.

FRAILTY AND THA OUTCOMES: CURRENT FINDINGS, CHALLENGES, AND FUTURE DIRECTIONS

In addition to these meaningful findings, frailty has become a topic of increasing interest in the context of THA outcomes. Frailty is a state of increased vulnerability resulting from age-associated decline in physiological reserves and function across multiple organ systems. Its assessment and impact on primary and revision THA outcomes have been investigated in several studies. Tram et al[3] found that frail patients, as measured by the hospital frailty risk score, had higher rates of 30-day readmission, longer lengths of stay, and higher hospitalization costs after revision THA. Similar results were reported in the study by Tram et al[4] for primary THA, where frail patients had increased 30-day readmission rates, longer hospital stays, and higher costs. Johnson et al[5] demonstrated that a higher preoperative frailty index, measured by the frailty deficit index, was associated with increased mortality and peri-operative complications following primary and revision THA. These studies consistently show that frailty is a significant predictor of adverse outcomes and increased healthcare burden in both primary and revision THA. The systematic review and meta-analysis by Wen et al[6] further support the association between frailty and poor outcomes after hip arthroplasty. This study analyzed seven retrospective investigations involving 350971 patients and found that frailty was associated with total complications, reoperation, readmission, and 30-day mortality. This comprehensive analysis provides strong evidence for the importance of considering frailty in preoperative risk assessment for hip arthroplasty patients. A systematic review by Schmucker et al[7] evaluated frailty as a risk factor for short-term adverse events and suboptimal clinical outcomes after total joint arthroplasty, including hip arthroplasty. The review found that frailty was associated with higher rates of short-term adverse events and worse clinical outcomes. However, it also highlighted the need for standardizing frailty measurement to improve the generalizability of research findings and the assessment of intervention efficacy.

Frailty may lead to adverse outcomes after THA through multiple mechanisms. Physiologically, frail patients have reduced organ reserves. For example, their cardiovascular system may be less able to tolerate the stress of surgery, increasing the risk of cardiac complications. Additionally, frailty is often associated with weakened immune function. This makes patients more susceptible to infections, which can prolong hospital stays and increase mortality. Cognitive and psychological issues in frail patients may also lead to non-compliance with postoperative rehabilitation, affecting recovery[8]. To mitigate the impact of frailty, preoperative interventions could be implemented. Physical therapy programs focused on improving muscle strength and mobility can enhance physical function. Multidisciplinary team-based care, including geriatricians, can manage comorbidities better. Cognitive and psychological support, such as counseling, may improve patients’ compliance with treatment. These interventions can potentially reduce the adverse outcomes associated with frailty in THA patients[9].

Despite the growing body of research on frailty and THA outcomes, there is currently no unified standard for assessing frailty before THA. Different studies have used various frailty assessment tools, such as the hospital frailty risk score, frailty deficit index, and modified frailty index, among others. The lack of a standardized approach makes it difficult to compare results across studies and develop evidence-based guidelines for clinical practice. Future research should focus on establishing a universal standard for frailty assessment in the context of THA. This standard should consider the multi-dimensional nature of frailty, incorporating factors such as physical function, comorbidities, cognitive status, and psychological well-being. Additionally, prospective studies are needed to further explore the causal relationship between frailty and long-term outcomes after THA. Identifying modifiable factors related to frailty could also lead to the development of preoperative interventions aimed at reducing the risk of adverse outcomes in frail patients.

CONCLUSION

The research on the impact of frailty on outcomes after primary and revision THA is of great significance. Previous studies on preoperative factors set a good basis and emphasized the role of frailty in predicting adverse outcomes and healthcare costs. The lack of a unified standard for frailty assessment is an area that requires urgent attention. By addressing this issue and conducting more in-depth research, we can better identify high-risk patients, optimize preoperative management, and ultimately improve the outcomes of THA for patients, especially those who are frail. This will not only enhance the quality of care but also contribute to more efficient use of healthcare resources in the context of an aging population with an increasing prevalence of hip disorders.