The "male-female health-survival paradox" in frail patients undergoing hip replacement.

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.