Poor Preoperative Nutrition Linked to Higher Complications and Lower Survival After Hip Replacement

Patients heading into total hip replacement surgery who show signs of malnutrition before the operation face substantially higher risks afterward, according to a retrospective cohort study conducted at a single tertiary academic medical center in China. The research, published in Frontiers in Public Health, followed 426 consecutive patients who underwent primary total hip arthroplasty between January 2020 and December 2023 and examined how three nutritional measures taken before surgery related to both short-term complications and longer-term survival.

Patients were divided into three PNI strata: 198 patients with PNI of 45 or above, classified as well-nourished; 142 patients with PNI between 40 and 44.9, classified as mildly malnourished; and 86 patients with PNI below 40, classified as moderately or severely malnourished.

The overall 30-day complication rate across the cohort was 18.3 percent, affecting 78 of the 426 patients. But the distribution of those complications was far from even. Among patients with PNI below 40, the complication rate reached 34.9 percent, compared with 19.0 percent in the mildly malnourished group and 10.6 percent in the well-nourished group, a difference the authors report as statistically significant with a p-value below 0.001.

When the researchers adjusted for other factors in a multivariate logistic regression model, all three nutritional measures remained independently associated with postoperative complications. A PNI below 40 carried an odds ratio of 3.42 (95 percent confidence interval: 2.01 to 5.82), serum albumin below 35 g/L carried an odds ratio of 2.64 (95 percent CI: 1.58 to 4.41), and an NRS-2002 score of 3 or higher carried an odds ratio of 2.21 (95 percent CI: 1.35 to 3.62). In practical terms, patients flagged by any of these measures had roughly two to three times higher odds of experiencing a complication within 30 days of surgery.

Survival differences between the nutritional groups were also pronounced. The estimated three-year overall survival probabilities were 93.4 percent for the well-nourished group, 82.4 percent for the mildly malnourished group, and 68.6 percent for the moderately or severely malnourished group, with a log-rank p-value below 0.001. In a Cox proportional hazards model, PNI below 40 was associated with higher mortality, with a hazard ratio of 2.96 (95 percent CI: 1.78 to 4.92).

The authors conclude that lower preoperative PNI, hypoalbuminemia, and NRS-2002-defined nutritional risk were associated with higher postoperative complication risk and lower estimated long-term survival after total hip arthroplasty.

Importantly, the study is observational and retrospective, drawing on a single center’s experience over four years. It establishes associations between nutritional indicators and outcomes, not a causal effect of nutrition on complications or survival, and it cannot determine whether correcting malnutrition before surgery would change results.

Malnutrition is described in the paper as prevalent among patients undergoing hip arthroplasty and increasingly recognized as a potentially modifiable risk factor for adverse surgical outcomes. The authors argue that routine preoperative nutritional screening and targeted perioperative nutritional optimization should be integrated into the standard care pathway for hip arthroplasty patients, though this recommendation reflects the authors’ interpretation of their associative findings rather than evidence from an intervention trial.

Subject of Research: Associations between preoperative nutritional status and postoperative outcomes in total hip arthroplasty patients

Article Title: Preoperative nutritional status and its association with postoperative complications and survival in patients undergoing total hip arthroplasty: a retrospective cohort analysis

Article References: Lian, Y., Yu, Z., Lu, J., Yan, J., Han, B., & Zhu, Y. (2026). Preoperative nutritional status and its association with postoperative complications and survival in patients undergoing total hip arthroplasty: a retrospective cohort analysis. Frontiers in Public Health, 14, Article 1942939. https://doi.org/10.3389/fpubh.2026.1942939

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1942939

Keywords: total hip arthroplasty, malnutrition, Prognostic Nutritional Index, serum albumin, NRS-2002, postoperative complications, overall survival, nutritional screening, retrospective cohort study, perioperative risk, Preoperative, nutritional