Education Trumps Poverty in Total Knee Replacement Outcomes


College gives patients a leg up on their less-educated neighbors.

Key points
• Community poverty is associated with more pain and decreased joint function after total knee arthroplasty.

• Having a college education appears to mitigate the effects of living in a poor community on postoperative pain and function in patients who have undergone total knee arthroplasty.

The effects on health and well-being of living in a poor community are well-known. Susan Goodman and colleagues1 at the Hospital for Special Surgery in New York point out that research shows that pain and function after total knee arthroplasty are worse in patients from poor neighborhoods as well as among those in predominantly black communities.

It is also known that patients with higher levels of education typically do better after surgery than those with lower levels. The authors state that it is not known whether the education effect translates to areas with low socioeconomic conditions and sought to describe this relationship in a recent Arthritis Care & Research article.

The study
The authors conducted a retrospective cohort study looking at a total knee arthroplasty registry utilizing the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function scores 2 years after knee replacement to determine any interaction between socioeconomic community characteristics, educational level, and outcomes after surgery.

The results
• Ultimately, 3970 patients were included in the cohort.

• Average WOMAC pain and function scores were 9 points worse for patients without any college (P < .001) and 5 points lower at 2 years (P < .001) when compared with those who had some college or more higher education.

• Patients without college had greater improvement, although not significant, in WOMAC scores over 2 years than those with college (pain: 32.1 ± 19.4 vs 34.9 ± 21.7, P < .001; function: 30 ± 18.9 vs 34.1 ± 20.8, P < .001).

• As census tract poverty levels increased, WOMAC pain and function worsened for all patients; however, the effect was less among patients with college education.

Implications for physicians
• Physicians who serve patients in low-income communities should be especially vigilant as to outcomes following total knee replacement surgery.

• Special care should be taken to assess patients’ pain and function after knee replacement if they have not attended college and live in poor neighborhoods.

• Poor outcomes following knee replacement in poorly educated patients in lower socioeconomic neighborhoods may be a function of other health-related behaviors seen in such settings. Thus, counseling should encourage proper nutrition, smoking cessation, and proper physical therapy postoperatively.

• Patients without any college who live in poor neighborhoods may benefit from earlier arthroplasty, which may lessen postoperative pain and improve function.


No funding disclosures were made.


1. Goodman SM, Mandl LA, Mehta B, et al. Education mitigates the effect of poverty on total knee arthroplasty outcomes.Arthritis Care Res. 2017 Nov 22. doi: 10.1002/acr.23442. [Epub ahead of print]

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