CORR - 2026-06-11 - Journal Article
Is Neighborhood Socioeconomic Deprivation Associated With Outcomes Following Primary THA and TKA? A Systematic Review Utilizing the Area Deprivation Index.
Furyes AR, Elmenawi KA, Hackett L, Deren ME, Piuzzi NS
Topics
Key Takeaway
Higher ADI neighborhood deprivation is independently associated with increased healthcare utilization, worse absolute PROMs, greater medical complication rates, and early signals of inferior implant survivorship after primary THA and TKA across 16 included studies.
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Summary
This systematic review asked whether ADI-measured neighborhood deprivation predicts postoperative outcomes after primary THA and TKA across four databases searched through March 2025. Higher ADI was consistently associated with prolonged LOS, nonhome discharge, increased ED visits, worse absolute PROM scores, lower patient acceptable symptom state attainment, and increased odds of infection, VTE, cardiopulmonary events, and AKI. Notably, all ADI groups achieved MCID on HOOS, KOOS, and PROMIS domains, but high-ADI patients showed increased odds of 90-day reoperation, PJI, and aseptic revision beyond 90 days.
Key Limitation
Meta-analysis was not performed due to heterogeneity in outcome definitions and ADI cutoffs across studies, preventing quantification of effect sizes or pooled risk estimates.
Original Abstract
BACKGROUND
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.
QUESTIONS/PURPOSES
(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?
METHODS
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.
RESULTS
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.
CONCLUSION
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 OF EVIDENCE
Level III, therapeutic study.