Frailty across Hip arthroplasty pathways: vulnerability domains, outcomes, and implications for care—a narrative review

Abstract

Background Frailty helps explain why older patients with similar chronological age and comorbidity burdens experience markedly different outcomes after hip arthroplasty. Interpretation is complicated because instruments capture different vulnerabilities and elective primary, revision, and fracture-related arthroplasty impose distinct stresses and intervention windows. Review approach PubMed and Web of Science Core Collection were searched from inception through 27 July 2026, followed by a targeted PubMed search on 29 July 2026. Eligibility, staged title-and-abstract screening, an explicit supplementary-search relevance score, and selection counts were documented. Evidence was synthesized narratively by vulnerability domain, procedure context, outcome, and potential action; no meta-analysis or uniform risk-of-bias appraisal was performed. Main findings Cumulative-deficit indices support rapid risk stratification but may overlook cognition, nutrition, mobility, and social support. Physical frailty and sarcopenia are more closely related to functional recovery, whereas multidimensional assessment can identify interacting and potentially actionable vulnerabilities. Nutritional-inflammatory indices may add modest mortality-prediction information in hip-fracture surgery, but they partly reflect acute illness and remain adjunct markers rather than validated core frailty domains. Evidence is stronger for prognostic association than for the effectiveness of frailty-guided interventions. Conclusions A clinically useful pathway should combine low-burden screening with targeted vulnerability-domain assessment, incorporate procedure context, and repeat assessment during recovery. Frailty should guide proportional monitoring, rehabilitation, discharge planning, and shared decisions rather than serve as an isolated threshold for denying surgery. Research priorities include context-specific validation, standardized patient-centred and resource outcomes, longitudinal assessment, and trials of domain-informed care.