Nutritional markers differ in arthroplasty risk

Frailty was linked to 2.35-fold higher odds of 30-day mortality, while malnutrition and sarcopenia were tied to other postoperative risks.

By
Andrea Surnit
November 4, 2026
4 min

MDSpire News

Overview

A systematic review of 58 studies involving 2,076,289 patients found that frailty, malnutrition, and sarcopenia were associated with adverse outcomes after hip and knee arthroplasty, although associations varied by marker, definition, and procedure. Frailty and ESPEN-defined malnutrition were linked to higher mortality and other complications, while low BMI alone was generally not associated with adverse outcomes.

Background

Nutritional disorders may affect mortality, postoperative complications, and length of stay after hip and knee arthroplasty. The review examined primary and revision arthroplasty and surgery following hip fracture, assessing malnutrition, frailty, and sarcopenia using ESPEN-recommended and study-specific definitions. Outcomes included mortality, complications, infection, reoperation and revision, patient-reported outcomes, length of stay, and health care costs. Variation in populations, definitions, and outcome reporting limited comparisons across studies.

Data Highlights

Finding	Reported data
Review population	58 studies; 2,076,289 patients
Frailty and 30-day mortality after primary total knee arthroplasty	0.2% with frailty vs 0.1% without; odds of death were 2.35 times higher among patients with frailty
Delayed wound healing after arthroplasty for hip fracture	28.5% at risk of malnutrition and 25% classified as malnourished vs 7% with normal nutritional status
Low muscle mass among patients undergoing arthroplasty after hip fracture	58.4% among patients who died vs 40% among survivors
Costs after primary total knee arthroplasty in one study	$19,841 with frailty vs $6,104 without frailty
Hospital stay in the same study	4.1 days with frailty vs 2.2 days without frailty

Key Findings

Frailty was associated with poorer clinical outcomes across primary, revision, and hip-fracture arthroplasty populations, including increased complications, infections, and longer hospital stays.
In a study of 179,702 primary total knee arthroplasty patients, 30-day mortality was 0.2% among those with frailty and 0.1% among those without; the reported odds of death were 2.35 times higher with frailty.
Malnutrition identified using ESPEN-recommended criteria was associated with increased mortality, postoperative pain, and longer hospital stays.
After arthroplasty for hip fracture, delayed wound healing was reported in 28.5% of patients at risk of malnutrition and 25% of those classified as malnourished, compared with 7% of patients with normal nutritional status.
Sarcopenia was associated with adverse postoperative outcomes, including more prosthetic joint infections after primary arthroplasty and poorer functional outcomes; low muscle mass was more common among patients who died after hip-fracture arthroplasty than among survivors (58.4% vs 40%).
Malnutrition defined solely as BMI below 18.5 was generally not associated with adverse outcomes after primary hip or knee arthroplasty. Hypoalbuminemia was associated with adverse outcomes in included studies, although ESPEN no longer recommends serum albumin as a standalone malnutrition diagnostic marker.

Clinical Implications

The review reports differing associations according to the nutritional measure used, so its findings do not support treating BMI alone as equivalent to broader nutritional assessment. The authors called for prospective studies to determine whether treating nutritional disorders improves postoperative outcomes and reduces costs; the review's heterogeneous evidence and risk of bias limit quantification of these associations.

Conclusion

The authors concluded that nutritional disorders have detrimental effects on clinical outcomes following hip and knee arthroplasty. They noted that prospective research is needed to assess whether treatment can improve outcomes and reduce health care costs.