Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty
Few data exist regarding the impact of socioeconomic factors on results of current TKA in young patients. Predictors of TKA outcomes have focused primarily on surgical technique, implant details, and individual patient clinical factors. The relative importance of these factors compared to patient socioeconomic status is not known.
We determined whether (1) socioeconomic factors, (2) demographic factors, or (3) implant factors were associated with satisfaction and functional outcomes after TKA in young patients.
We surveyed 661 patients (average age, 54 years; range, 18–60 years; 61% female) 1 to 4 years after undergoing modern primary TKA for noninflammatory arthritis at five orthopaedic centers. Data were collected by an independent third party with expertise in collecting healthcare data for state and federal agencies. We examined specific questions regarding satisfaction, pain, and function after TKA and socioeconomic (household income, education, employment) and demographic (sex, minority status) factors. Multivariable analysis was conducted to examine the relative importance of these factors for each outcome of interest.
Patients reporting incomes of less than USD 25,000 were less likely to be satisfied with TKA outcomes and more likely to have functional limitations after TKA than patients with higher incomes; no other socioeconomic factors were associated with satisfaction. Women were less likely to be satisfied and more likely to have functional limitations than men, and minority patients were more likely to have functional limitations than nonminority patients. Implants were not associated with outcomes after surgery.
Socioeconomic factors, in particular low income, are more strongly associated with satisfaction and functional outcomes in young patients after TKA than demographic or implant factors. Future studies should be directed to determining the causes of this association, and studies of clinical results after TKA should consider stratifying patients by socioeconomic status.
Level of Evidence
Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
- Ayers DC, Franklin PD, Ploutz-Snyder R, Boisvert CB. Total knee replacement outcome and coexisting physical and emotional illness. Clin Orthop Relat Res. 2005;440:157–161. CrossRef
- Baker PN, van der Meulen JH, Lewsey J, Gregg PJ; National Joint Registry for England and Wales. The role of pain and function in determining patient satisfaction after total knee replacement. Data from the National Joint Registry for England and Wales. J Bone Joint Surg Br. 2007;89:893–900. CrossRef
- Barrack RL, Ruh EL, Berend ME, Della Valle CJ, Engh CA Jr, Parvizi J, Clohisy JC, Nunley RM. Do Young, Active Patients Perceive Advantages After Surface Replacement Compared to Cementless Total Hip Arthroplasty? Clin Orthop Relat Res. 2013 March 19 [Epub ahead of print].
- Blaha JD. The rationale for a total knee implant that confers anteroposterior stability throughout range of motion. J Arthroplasty. 2004;19:22–26. CrossRef
- Bonnin MP, Basiglini L, Archbold HA. What are the factors of residual pain after uncomplicated TKA? Knee Surg Sports Traumatol Arthrosc. 2011;19:1411–1417. CrossRef
- Booth RE Jr. Sex and the total knee: gender-sensitive designs. Orthopedics. 2006;29:836–838.
- Bourne R. A gender-specific prosthesis was similar to a standard prosthesis in women having total knee replacement. J Bone Joint Surg Am. 2011;93:396. CrossRef
- Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res. 2010;468:57–63. CrossRef
- Brander VA, Stulberg SD, Adams AD, Harden RN, Bruehl S, Stanos SP, Houle T. Predicting total knee replacement pain: a prospective, observational study. Clin Orthop Relat Res. 2003;416:27–36. CrossRef
- Butler RA, Rosenzweig S, Myers L, Barrack RL. The Frank Stinchfield Award. The impact of socioeconomic factors on outcome after THA: a prospective, randomized study. Clin Orthop Relat Res. 2011;469:339–347. CrossRef
- Cai X, Cram P, Vaughan-Sarrazin M. Are African American patients more likely to receive a total knee arthroplasty in a low-quality hospital? Clin Orthop Relat Res. 2012;470:1185–1193. CrossRef
- Centers for Disease Control and Prevention. Prevalence of cholesterol screening and high blood cholesterol among adults – United States, 2005, 2007, and 2009. MMWR Morb Mortal Wkly Rep. 2012;61:697–702.
- Centers for Medicare & Medicaid Services. Medicare Contractor Provider Satisfaction Survey (MCPSS) Public Report 2011. Final Report July 29, 2011, Revised December 2011. Available at: http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MCPSS/Downloads/MCPSS_Public_Report.pdf. Accessed October 3, 2012.
- Chandran N, Amirouche F, Gonzalez MH, Hilton KM, Barmada R, Goldstein W. Optimisation of the posterior stabilised tibial post for greater femoral rollback after total knee arthroplasty—a finite element analysis. Int Orthop. 2009;33:687–693. CrossRef
- Chatman AB, Hyams SP, Neel JM, Binkley JM, Stratford PW, Schomberg A, Stabler M. The Patient-Specific Functional Scale: measurement properties in patients with knee dysfunction. Phys Ther. 1997;77:820–829.
- Dennis DA, Komistek RD. Kinematics of mobile-bearing total knee arthroplasty. Instr Course Lect. 2005;54:207–220.
- Dunlop DD, Manheim LM, Song J, Sohn MW, Feinglass JM, Chang HJ, Chang RW. Age and racial/ethnic disparities in arthritis-related hip and knee surgeries. Med Care. 2008;46:200–208. CrossRef
- Endres S. High-flexion versus conventional total knee arthroplasty: a 5-year study. J Orthop Surg (Hong Kong). 2011;19:226–229.
- Epstein AJ, Gray BH, Schlesinger M. Racial and ethnic differences in the use of high-volume hospitals and surgeons. Arch Surg. 2010;145:179–186. CrossRef
- Fisher DA, Dierckman B, Watts MR, Davis K. Looks good but feels bad: factors that contribute to poor results after total knee arthroplasty. J Arthroplasty. 2007;22:39–42. CrossRef
- Franklin PD, Li W, Ayers DC. The Chitranjan Ranawat Award. Functional outcome after total knee replacement varies with patient attributes. Clin Orthop Relat Res. 2008;466:2597–2604. CrossRef
- Freburger JK, Holmes GM, Ku LJ, Cutchin MP, Heatwole-Shank K, Edwards LJ. Disparities in post-acute rehabilitation care for joint replacement. Arthritis Care Res (Hoboken). 2011;63:1020–1030. CrossRef
- Goyal N, McKenzie J, Sharkey PF, Parvizi J, Hozack WJ, Austin MS. The 2012 Chitranjan Ranawat Award. Intraarticular analgesia after TKA reduces pain: a randomized, double-blinded, placebo-controlled, prospective study. Clin Orthop Relat Res. 2013;471:64–75. CrossRef
- Hanchate AD, Zhang Y, Felson DT, Ash AS. Exploring the determinants of racial and ethnic disparities in total knee arthroplasty: health insurance, income, and assets. Med Care. 2008;46:481–488. CrossRef
- Horn KK, Jennings S, Richardson G, Vliet DV, Hefford C, Abbott JH. The Patient-Specific Functional Scale: psychometrics, clinimetrics, and application as a clinical outcome measure. J Orthop Sports Phys Ther. 2012;42:30–42.
- Ibrahim SA, Stone RA, Han X, Cohen P, Fine MJ, Henderson WG, Khuri SF, Kwoh CK. Racial/ethnic differences in surgical outcomes in veterans following knee or hip arthroplasty. Arthritis Rheum. 2005;52:3143–3151. CrossRef
- Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469:1817–1823. CrossRef
- Jacobs W, Anderson P, Limbeek J, Wymenga A. Mobile bearing vs fixed bearing prostheses for total knee arthroplasty for post-operative functional status in patients with osteoarthritis and rheumatoid arthritis. Cochrane Database Syst Rev. 2004;2:CD003130.
- Jacobs WC, Clement DJ, Wymenga AB. Retention versus sacrifice of the posterior cruciate ligament in total knee replacement for treatment of osteoarthritis and rheumatoid arthritis. Cochrane Database Syst Rev. 2005;4:CD004803.
- Jolles BM, Grzesiak A, Eudier A, Dejnabadi H, Voracek C, Pichonnaz C, Aminian K, Martin E. A randomised controlled clinical trial and gait analysis of fixed- and mobile-bearing total knee replacements with a five-year follow-up. J Bone Joint Surg Br. 2012;94:648–655. CrossRef
- Kim YH, Kim JS, Choe JW, Kim HJ. Long-term comparison of fixed-bearing and mobile-bearing total knee replacements in patients younger than fifty-one years of age with osteoarthritis. J Bone Joint Surg Am. 2012;94:866–873. CrossRef
- Kim YH, Kook HK, Kim JS. Comparison of fixed-bearing and mobile-bearing total knee arthroplasties. Clin Orthop Relat Res. 2001;392:101–115. CrossRef
- Kolisek FR, Mont MA, Costa CR, Johnson AJ, Jaggard CE. A comparison study of two cruciate-retaining total knee designs: a preliminary report. Surg Technol Int. 2011;XXI:194–198.
- Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780–785. CrossRef
- Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res. 2009;467:2606–2612. CrossRef
- Lavernia CJ, Alcerro JC, Brooks LG, Rossi MD. Mental health and outcomes in primary total joint arthroplasty. J Arthroplasty. 2012;27:1276–1282. CrossRef
- Lavernia CJ, Alcerro JC, Contreras JS, Rossi MD. Ethnic and racial factors influencing well-being, perceived pain, and physical function after primary total joint arthroplasty. Clin Orthop Relat Res. 2011;469:1838–1845. CrossRef
- Lieberman JR, Dorey F, Shekelle P, Schumacher L, Thomas BJ, Kilgus DJ, Finerman GA. Differences between patients’ and physicians’ evaluations of outcome after total hip arthroplasty. J Bone Joint Surg Am. 1996;78:835–838.
- Likert R. A technique for the measurement of attitudes. Arch Psychol. 1932;22:1–55.
- Long WJ, Scuderi GR. High-flexion total knee arthroplasty. J Arthroplasty. 2008;23:6–10. CrossRef
- Lozano-Calderon SA, Shen J, Doumato DF, Greene DA, Zelicof SB. Cruciate-retaining vs posterior-substituting inserts in total knee arthroplasty: functional outcome comparison. J Arthroplasty. 2013;28:234–242.el.
- MacDonald SJ, Charron KD, Bourne RB, Naudie DD, McCalden RW, Rorabeck CH. The John Insall Award. Gender-specific total knee replacement: prospectively collected clinical outcomes. Clin Orthop Relat Res. 2008;466:2612–2616. CrossRef
- Maloney WJ. National Joint Replacement Registries: has the time come? J Bone Joint Surg Am. 2001;83:1582–1585.
- Meftah M, Wong AC, Nawabi DH, Yun RJ, Ranawat AS, Ranawat CS. Pain management after total knee arthroplasty using a multimodal approach. Orthopedics. 2012;35:e660–e664. CrossRef
- Mont MA, Mayerson JA, Krackow KA, Hungerford DS. Total knee arthroplasty in patients receiving Workers’ Compensation. J Bone Joint Surg Am. 1998;80:1285–1290. CrossRef
- Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall Award. Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res. 2006;452:35–43. CrossRef
- Nunley RM, Ruh EL, Zhang Q, Della Valle CJ, Engh CA Jr, Berend ME, Parvizi J, Clohisy JC, Barrack RL. Do patients return to work after hip arthroplasty surgery? J Arthroplasty. 2011;26(6 suppl):92–98.e1-3.
- Nwachukwu BU, Kenny AD, Losina E, Chibnik LB, Katz JN. Complications for racial and ethnic minority groups after total hip and knee replacement: a review of the literature. J Bone Joint Surg Am. 2010;92:338–345. CrossRef
- Pagnano MW, Trousdale RT, Stuart MJ, Hanssen AD, Jacofsky DJ. Rotating platform knees did not improve patellar tracking: a prospective, randomized study of 240 primary total knee arthroplasties. Clin Orthop Relat Res. 2004;428:221–227. CrossRef
- Price AJ, Longino D, Rees J, Rout R, Pandit H, Javaid K, Arden N, Cooper C, Carr AJ, Dodd CA, Murray DW, Beard DJ. Are pain and function better measures of outcome than revision rates after TKR in the younger patient? Knee. 2010;17:196–199. CrossRef
- Radler BT, Ryff CD. Who participates? Accounting for longitudinal retention in the MIDUS national study of health and well-being. J Aging Health. 2010;22:307–331. CrossRef
- Rahman MM, Kopec JA, Sayre EC, Greidanus NV, Aghajanian J, Anis AH, Cibere J, Jordan JM, Badley EM. Effect of sociodemographic factors on surgical consultations and hip or knee replacements among patients with osteoarthritis in British Columbia, Canada. J Rheumatol. 2011;38:503–509. CrossRef
- Riddle DL, Wade JB, Jiranek WA, Kong X. Preoperative pain catastrophizing predicts pain outcome after knee arthroplasty. Clin Orthop Relat Res. 2010;468:798–806. CrossRef
- Santaguida PL, Hawker GA, Hudak PL, Glazier R, Mahomed NN, Kreder HJ, Coyte PC, Wright JG. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systematic review. Can J Surg. 2008;51:428–436.
- Scuderi GR, Hedden DR, Maltry JA, Traina SM, Sheinkop MB, Hartzband MA. Early clinical results of a high-flexion, posterior-stabilized, mobile-bearing total knee arthroplasty: a US investigational device exemption trial. J Arthroplasty. 2012;27:421–429. CrossRef
- Singh JA, O’Byrne M, Harmsen S, Lewallen D. Predictors of moderate-severe functional limitation after primary total knee arthroplasty (TKA): 4701 TKAs at 2-years and 2935 TKAs at 5-years. Osteoarthritis Cartilage. 2010;18:515–521. CrossRef
- Singh JA, O’Byrne MM, Colligan RC, Lewallen DG. Pessimistic explanatory style: a psychological risk factor for poor pain and functional outcomes two years after knee replacement. J Bone Joint Surg Br. 2010;92:799–806.
- Skinner J, Zhou W, Weinstein J. The influence of income and race on total knee arthroplasty in the United States. J Bone Joint Surg Am. 2006;88:2159–2166. CrossRef
- Song EK, Jung WB, Yoon TR, Park KS, Seo HY, Seon JK. Comparison of outcomes after bilateral simultaneous total knee arthroplasty using gender-specific and unisex knees. J Arthroplasty. 2012;27:226–231. CrossRef
- Stratford P, Gill C, Westaway M, Binkley J. Assessing disability and change on individual patients: a report of a patient specific measure. Physiother Can. 1995;47:258–263. CrossRef
- Thomsen MG, Husted H, Bencke J, Curtis D, Holm G, Troelsen A. Do we need a gender-specific total knee replacement? A randomised controlled trial comparing a high-flex and a gender-specific posterior design. J Bone Joint Surg Br. 2012;94:787–792. CrossRef
- Ulrich SD, Mont MA, Bonutti PM, Seyler TM, Marker DR, Jones LC. Scientific evidence supporting computer-assisted surgery and minimally invasive surgery for total knee arthroplasty. Expert Rev Med Devices. 2007;4:497–505. CrossRef
- Wainwright C, Theis JC, Garneti N, Melloh M. Age at hip or knee joint replacement surgery predicts likelihood of revision surgery. J Bone Joint Surg Br. 2011;93:1411–1415. CrossRef
- Walker PS, Heller Y, Cleary DJ, Yildirim G. Preclinical evaluation method for total knees designed to restore normal knee mechanics. J Arthroplasty. 2011;26:152–160. CrossRef
- Impact of Socioeconomic Factors on Outcome of Total Knee Arthroplasty
Clinical Orthopaedics and Related Research®
- Print ISSN
- Online ISSN
- Additional Links
- Industry Sectors
- Author Affiliations
- 1. Department of Orthopaedic Surgery, Washington University School of Medicine, One Barnes-Jewish Hospital Plaza, 11300 West Pavilion, St Louis, MO, 63110, USA
- 2. Division of Biostatistics, Washington University School of Medicine, St Louis, MO, USA
- 3. Joint Implant Surgeons, Inc, New Albany, OH, USA
- 4. Rothman Institute of Orthopedics, Thomas Jefferson University, Philadelphia, PA, USA
- 5. Midwest Orthopaedics at Rush, Chicago, IL, USA
- 6. Anderson Orthopaedic Clinic, Arlington, VA, USA