Total Joint Arthroplasty Outcomes Comparable for Patients With Osteoarthritis Regardless of Housing Status

Total joint arthroplasty (TJA) may be a safe and effective option for people with osteoarthritis who are experiencing homelessness or housing insecurity, as a study published in Arthroplasty Today found no differences in surgical progression or outcomes compared with housed patients.¹

Osteoarthritis affects more than 500 million people worldwide and is the leading cause of disability among older adults in the US. TJA is a standard treatment for progressive osteoarthritis, typically resulting in significant symptom improvement.² However, physicians often hesitate to perform this procedure on people experiencing homelessness due to concerns about higher postoperative complication rates and poor follow-up adherence.¹

In general, people experiencing homelessness or housing insecurity face worse health outcomes.³ They also appear to be at higher risk for musculoskeletal injuries and diseases, although little research has quantified their prevalence in this population.¹ Similarly, data are limited on the demographics, clinical backgrounds, and surgical outcomes of patients facing housing insecurity with osteoarthritis who are undergoing TJA.

Researchers found no significant differences in surgical outcomes or follow-up between housed and unhoused patients with osteoarthritis undergoing total joint arthroplasty (TJA), suggesting the procedure is safe and effective regardless of housing status. | Image Credit: 2B - stock.adobe.com

To address this gap, the researchers conducted a retrospective study to characterize the population and postoperative outcomes of patients with osteoarthritis experiencing homelessness or housing insecurity who received TJA at Zuckerberg San Francisco General (ZSFG) Hospital. A secondary aim was to examine potential access barriers across the care continuum, including clinic presentation, surgical optimization, and follow-up.

They selected ZSFG because it is San Francisco's only safety net hospital. The city offers the San Francisco Health Plan, an insurance option at little to no cost to residents, making care accessible and inexpensive for those without resources. As a result, most patients experiencing homelessness or housing insecurity were likely to seek care at this location.

To conduct their analysis, the researchers identified all new patient visits to the ZSFG arthroplasty clinic in 2022 and categorized them into 3 cohorts: unhoused, marginally housed, and housed. The marginally housed group included patients living in single-room occupancy units, those who were incarcerated, or those documented as having other forms of unstable housing at the time of presentation.

Of 250 eligible patients, 204 were stably housed, 41 were unstably housed, 4 were unhoused, and 1 was incarcerated. Due to the small sample size of unhoused patients, the researchers combined the unhoused, marginally housed, and incarcerated cohorts into a composite "unstably housed" group for further analysis.

Patients in the unstably housed group were more likely to be male and younger than those in the stably housed group (63.4 vs 60.3 years; P = .0186). The cohorts' racial compositions also varied, with the unstably housed group having an increased proportion of Black and White patients. In contrast, the stably housed group had a higher number of Asian, American Indian, and Alaskan Native patients (P = .0031).

Additionally, substance use was significantly more prevalent in the unstably housed group, including higher rates of active stimulant use (30% vs 3%; P < .0001), opioid use (22% vs 0.5%; P < .0001), alcohol use (18.2% vs 3.9%; P = .0005), and smoking (56% vs 18.6%; P < .0001). They also had higher rates of HIV infection (13% vs 2.9%; P = .011), hepatitis C virus (23.9% vs 5.9%; P = .0004), and mental illness (40% vs 22.2%; P = .022).

Despite these disparities, there were no statistically significant differences between the groups in surgical progression, in-clinic injections, or postoperative outcomes (P > .05). Similarly, follow-up attendance, 90-day emergency department visits, 90-day readmissions, and 1-year revision surgeries were comparable among patients in all housing groups who underwent TJA (all P > .05).

“These results challenge the preconception of [people experiencing homelessness] as poor surgical candidates and are an indicator of successful medical and social management in the arthroplasty setting,” the authors wrote.

However, the study has several limitations, including its single-site design, which may limit generalizability. Consequently, the investigators suggested future research directions.

“While results suggest that patients experiencing homelessness could achieve good outcomes under specific circumstances, the low sample size and follow-up duration require caution and further study,” the authors concluded. “These results represent an important first step toward addressing disparities in musculoskeletal care and identifying opportunities to improve access and equity in surgical treatment for vulnerable populations.”

References

1. Gifford A, Nwachuku K, Bonsignore-Opp L, Toogood P, Ward D. Osteoarthritis and total joint arthroplasty in housing-insecure patients at a safety net hospital in a major urban city. Arthroplast Today. 2025;34:101773. doi:10.1016/j.artd.2025.101773
2. Skou ST, Roos EM, Laursen MB, et al. A randomized, controlled trial of total knee replacement. N Engl J Med. 2015;373(17):1597-1606. doi:10.1056/NEJMoa1505467
3. Maness DL, Khan M. Care of the homeless: an overview. Am Fam Physician. 2014;89(8):634-640.