As the global population ages and osteoarthritis become more common, more people are seeking joint replacement to manage pain and regain mobility. With better access to healthcare and evolving implant materials and surgical techniques, the demand for total hip and knee replacement surgeries is growing exponentially.1,2
Hip and knee replacements can reliably ease pain, help restore movement and daily function, and may lead to a better quality of life.3 But like any major surgery, they come with risks. Many of those risks are predictable, and many can be reduced with the right preparation.
Here are some of the risk factors that can raise the chance of complications:
Key risks to be aware of:
- Older age: Age is one of the strongest predictors of complications. Aging brings physiological changes like reduced reserve in the heart, lungs, kidneys, and immune function, that make recovery more challenging.
- Higher body mass index (BMI) and obesity: Excess body weight increases mechanical stress on the new joint and is linked to higher risks of:
- Surgical site and periprosthetic joint infection (PJI)
- Wound healing problems
- Blood clots (Deep Vein Thrombosis/ Pulmonary Embolism)
- Longer operative time and blood loss
- Medical comorbidities: Several chronic conditions are consistently linked to worse outcomes:
- Cardiovascular disease (heart failure, prior MI) – higher risk of cardiac events and death.
- Chronic lung disease – more respiratory complications and infections.
- Liver disease, kidney disease, and metastatic cancer – associated with higher mortality and longer stays.
- Rheumatoid arthritis and other inflammatory/rheumatic diseases – higher infection and revision risk.
- Peripheral vascular disease – impaired healing and infection risk.
- Depression/anxiety – associated with poorer functional recovery and higher complication rates.
The more comorbidities a patient has, the higher the overall risk profile. - Operative time and blood loss
Longer surgeries and greater blood loss are associated with:
- Higher infection risk
- Increased need for transfusion
- More medical complications and longer hospitalization
Factors that prolong surgery include complex deformities, obesity, and revision procedures. - Dislocation: The new joint can slip out of place, especially in the first weeks to months after surgery.
- Fractures around the implant: Falls or stress on the bone can cause breaks near the new joint, sometimes needing further surgery.4,5,6
- Lifestyle and modifiable risks
Some risk factors can be improved before surgery to prevent potential complications:
- Smoking: Increases wound complications, infection, and poor healing.
- Alcohol misuse: Linked to higher infection and medical complication rates.
- Poor nutrition/low albumin: Associated with infections and slower recovery.
- Physical inactivity and frailty: Predict slower rehabilitation and higher complication rates.
If these risk factors lead to complications, patients can face a tougher recovery, additional procedures, and significant financial strain.
What are the potential complications to watch out for?
The most important complications tied to these risk factors include:
- Periprosthetic joint infection (PJI) – the most feared complication; may require multiple surgeries and long-term antibiotics.
- Venous thromboembolism (VTE) – blood clots in legs/lungs; prevented with anticoagulants and early mobilization.
- Cardiopulmonary events – heart attack, stroke, pneumonia, especially in older or medically complex patients.
- Wound problems – delayed healing, dehiscence, especially in obesity, diabetes, smokers.
- Dislocation (hip) and periprosthetic fracture – related to bone quality, implant position, and falls.
- Medical complications – delirium, kidney injury, transfusion reactions, especially with multiple comorbidities.7
Most of these are uncommon, and care teams have strong protocols to prevent and catch them early.
Bottom-line
Hip and knee replacement surgery is highly effective, but not risk-free. The likelihood of complications is shaped by a mix of patient factors, surgical and lifestyle factors. Many of these risks and complications can be reduced with thoughtful preoperative preparation and high-quality perioperative care
References :
- Sadoghi P, Koutp A, Perez Prieto D, Clauss M, Kayaalp ME, Hirschmann MT. The projected economic burden and complications of revision hip and knee arthroplasties: insights from national registry studies. Knee Surg Sports Traumatol Arthrosc. 2025;33(9):3211-3217. doi:10.1002/ksa.12678.
- Zhang H, Cao J, Chen J, Ning X. Risk factors for general complications after hip or knee replacement surgery in elderly patients: a single-center study. BMC Musculoskelet Disord. 2025;26:596. doi:10.1186/s12891-025-08742-5.
- Madry H. Surgical therapy in osteoarthritis. Osteoarthritis Cartilage. 2022;30(8):1019-1034. doi:10.1016/j.joca.2022.01.012.
- Aabedi A, Fraix MP, Agrawal DK. Surgical interventions in severe osteoarthritis: pros and cons. J Orthop Sports Med. 2025;7(1):169-178. doi:10.26502/josm.511500192.
- Goldberg VM, Buckwalter J, Halpin M, Jiranek W, Mihalko W, Pinzur M, et al. Recommendations of the OARSI FDA Osteoarthritis Devices Working Group. Osteoarthritis Cartilage. 2011;19(5):509-514. doi:10.1016/j.joca.2011.02.017.
- Rhee C, Lethbridge L, Richardson G, Dunbar M. Risk factors for infection, revision, death, blood transfusion and longer hospital stay 3 months and 1 year after primary total hip or knee arthroplasty. Can J Surg. 2018;61(3):165-176. doi:10.1503/cjs.007117.
- Desai R, Triplett O, Stickels M, Dossett HG. Perioperative considerations for orthopedic surgery in a geriatric population. Fed Pract. 2026;43(4):e0661. doi:10.12788/fp.0661.
Frequently Asked Questions
Risk factors include older age, obesity, chronic medical conditions, smoking, alcohol misuse, poor nutrition, and physical frailty. Surgical complexity and blood loss may also influence complication risks.
Older adults may face higher risks due to reduced physiological reserves and underlying health conditions. However, overall health and functional status are more important than age alone when assessing surgical suitability.
Heart and lung diseases, diabetes, kidney or liver disease, inflammatory joint conditions, and vascular disease may increase complication risks. Proper management of these conditions before surgery can help improve outcomes.
Complications may include infections, blood clots, wound-healing problems, heart or lung events, and fractures around the implant. Hip replacement may also involve the risk of dislocation.
Patients should attend preoperative assessments, manage existing health conditions, follow nutritional and activity advice, and discuss medications with their surgeon. Following postoperative instructions and rehabilitation plans also supports recovery.
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