Total Joint Arthroplasty in Homeless Patients at an Urban Safety Net Hospital

Introduction: Homelessness is a key social determinant of health, and the patient population has grown to over 580,000. Total joint arthroplasty (TJA) is an effective treatment of symptomatic end-stage osteoarthritis of the hip and knee and has been shown to improve health-related quality of life in the general population. However, the literature on the outcomes of TJA among homeless patients is limited. Methods: We retrospectively reviewed 442 patients who underwent primary, unilateral TJA between June 1, 2016, and August 31, 2017, at an urban, tertiary, academic safety net hospital. Based on self-reported living status, we classified 28 homeless patients and 414 control nonhomeless patients. Fisher exact tests, Student t-tests, and multivariate logistic regression were used to compare the demographics, preoperative conditions, and surgical outcomes between the two groups. Results: The homeless group were younger, more often male, and smokers; had alcohol use disorder; and used illicit drugs. After controlling for age, sex, and preoperative medical and social conditions, homeless patients were 15.83 times more likely to have an emergency department visit (adjusted odds ratio, 15.83; 95% confidence interval, 5.05 to 49.59; P < 0.0001) within 90 days but had similar rates of readmission (P = 0.25), revision surgery (P = 0.38), and prosthetic joint infection (P = 0.25) when compared with nonhomeless patients. Discussion: Although homeless patients did not have higher rates of readmission or revision surgery, homelessness still presents unique challenges for the TJA patients and providers. With careful preoperative optimization and collaborative support, however, the benefits of TJA may outweigh the risk of poor outcomes for these patients.