Is Neighborhood Socioeconomic Deprivation Associated With Outcomes Following Primary THA and TKA? A Systematic Review...

Socioeconomic disadvantage is increasingly recognized as an important factor associated with outcomes after total joint arthroplasty (TJA). The Area Deprivation Index (ADI) has emerged as a validated measure of socioeconomic disadvantage that specifically captures individual neighborhood levels of structural and material deprivation based on income, education, employment, and housing characteristics. Prior research has demonstrated ADI to be associated with surgical outcomes; however, its relationship to postoperative outcomes after THA and TKA, procedures in which outcomes depend highly on institutional and structural support, home environment, and accessible postacute care resources, has not been well synthesized. Prior studies provide a broad overview of heterogeneous measures of socioeconomic disadvantage that are not directly comparable.

(1) Is a higher ADI associated with increased postoperative healthcare utilization after primary THA and TKA? (2) Is a higher ADI associated with differences in patient-reported outcome measures (PROMs)? (3) Is a higher ADI associated with increased postoperative complications? (4) Is ADI associated with differences in implant survivorship after TJA?

A systematic review of four databases-Ovid Medline, Embase, Cochrane Library, and Web of Science Core Collection-was performed from their inception to March 27, 2025. Each database was last searched on March 27, 2025. In all, 128 records were available. Studies were included if they evaluated patients receiving primary THA or TKA and examined ADI in the Results section of the manuscript in terms of any of the following: 90-day outcomes, healthcare utilization, complications, reoperations, revisions, cost, or PROMs. Studies were excluded if they examined revision hip or knee arthroplasty, hemiarthroplasty, or arthroplasty of any other joint; did not evaluate outcomes in association with ADI; or were case reports, systematic reviews, conference abstracts, editorials, or narrative reviews. Sixteen studies were included for final review. Two reviewers independently screened studies, extracted data, and assessed methodological quality using the Newcastle-Ottawa Scale (NOS), which has a maximum quality score of nine stars. Included studies had a median (range) NOS score of 8 stars (7 to 9), suggesting that most were of good quality with a low risk of bias. Results were synthesized qualitatively; meta-analyses were not performed because of the heterogeneity of included studies.

A higher ADI was consistently associated with greater healthcare utilization, including prolonged length of stay, increased likelihood of nonhome discharge, and increased odds of emergency department visits. PROMs demonstrated worse absolute postoperative scores and lower likelihood of achieving patient acceptable symptom states among patients who live in high ADI neighborhoods despite comparable levels of improvement across all groups. Overall, ADI was not associated with reaching the standard minimum clinically important difference (MCID). All groups achieved the MCID on all domains of the Hip Disability and Osteoarthritis Outcome Score, Knee Injury and Osteoarthritis Outcome Score, and Patient-Reported Outcomes Measurement Information System short forms regardless of ADI. A higher ADI was associated with increased odds of medical complications such as infection, venous thromboembolism, cardiopulmonary events, and acute kidney injury. Evidence on implant survivorship was limited but suggested increased odds of reoperation and periprosthetic joint infection within 90 days and increased odds of aseptic revision beyond 90 days in populations with more severe levels of deprivation as measured by the ADI.

Higher neighborhood socioeconomic deprivation was independently associated with worse postoperative outcomes, greater resource utilization, and signals of inferior early implant survivorship after THA and TKA. The ADI provides meaningful insight into neighborhood-level social risk beyond traditional clinical factors and individual patient demographics and may help identify patients who may benefit from interventions such as more intensive preoperative medical management of comorbidities, tailored perioperative support, easily accessible rehabilitation, or closer postoperative follow-up. Incorporating the ADI into risk-adjustment models and care pathways may help clinicians better anticipate possible barriers to recovery and may help ensure that patients from less affluent communities achieve the results they seek after lower extremity arthroplasty.

Level III, therapeutic study.