Key result
Male sex is linked to ~31% higher in-hospital mortality among frail hip replacement patients.
Why the study?
The male-female health-survival paradox has been rarely examined in surgical settings.
Does male sex increase in-hospital mortality in frail patients undergoing hip replacement compared to female sex?
Cohort (n=29,063)
Yes
Does male sex increase in-hospital mortality in frail patients undergoing hip replacement compared to female sex?
Odds Ratio: 1.31 (95% CI 1.15–1.49)
Absolute Event Rate: 5% vs 3%
p-value: p=<0.001
Frail men undergoing hip replacement have higher in-hospital mortality than frail women, despite women being older and having a higher comorbidity burden.
Should not yet inform sex-specific perioperative strategies; leaves open need for confirmatory studies in frail hip replacement patients.
BACKGROUND: The "male-female health-survival paradox" describes women's longer lifespan despite a greater burden of non-fatal chronic conditions-a phenomenon rarely examined in surgical settings. This study investigated whether this paradox exists in a national cohort of frail patients undergoing hip replacement and explored its underlying mechanisms. We hypothesized that in this cohort: (1) female patients would be less healthy, presenting with a higher prevalence of frailty, older age, and a higher Charlson Comorbidity Index (CCI); and (2) frail men would experience higher in-hospital mortality. METHODS: A retrospective cohort study was conducted using the US National Inpatient Sample (2005-2014) A frailty-defining diagnosis cluster was employed to identify frail individuals. Sex-based differences in demographics, comorbidities, and in-hospital outcomes (mortality, complications, length of stay, costs) were analyzed using multivariable logistic regression, including interaction terms and sex-stratified models. RESULT: Among 29,063 frail patients, 64% were female. Despite being significantly older (median age 81 vs. 77 years, p < 0.001) and having a higher CCI burden, frail women had significantly lower in-hospital mortality than men (3% vs. 5%, p < 0.001). Comorbidity patterns differed markedly: women had higher rates of rheumatoid arthritis, depression, and hypothyroidism, while men had more congestive heart failure, diabetes, and renal failure (all p < 0.001). After adjustment, male sex remained an independent predictor of mortality (Adjusted OR 1.31, 95% CI 1.15-1.49, p < 0.001), primarily driven by significant interactions between male sex and life-threatening conditions such as heart failure and renal failure. CONCLUSION: The male-female health-survival paradox is evident in frail patients undergoing hip replacement. These findings highlight the need for sex-tailored preoperative optimization, with particular emphasis on cardiovascular and metabolic risk management in frail male patients.
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Lian et al. (2026) conducted a cohort in Frail patients undergoing hip replacement (n=29,063). Male sex vs. Female sex was evaluated on In-hospital mortality (Adjusted OR 1.31, 95% CI 1.15-1.49, p=<0.001). Among frail patients undergoing hip replacement, male sex was an independent predictor of higher in-hospital mortality compared to female sex (5% vs. 3%, Adjusted OR 1.31).
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