In the evolving landscape of orthopedic surgery, total hip and knee arthroplasty have emerged as transformative procedures that restore mobility and alleviate chronic pain for millions worldwide. Yet beneath the surface of surgical success lies a critical and often underexplored dimension: the influence of socioeconomic factors on patient-reported outcomes following these interventions. A groundbreaking study led by Bonsel, Reijman, Macri, and their colleagues, recently published in the International Journal for Equity in Health, unpacks the complex relationship between socioeconomic inequality and patient-reported outcome measures (PROMs), shedding new light on disparities that could reshape postoperative care and health policy.
Total hip and knee arthroplasty—collectively referred to as joint replacement surgeries—are among the most common elective orthopedic procedures, especially in aging populations with prevalent osteoarthritis and joint degradation. While clinical outcomes like implant survival and complication rates have traditionally dominated research, the patient’s subjective experience, captured through PROMs, is increasingly recognized as a vital metric. PROMs cover a breadth of domains including pain, physical function, mental health, and overall quality of life. These domains offer a window into how surgery impacts daily living, yet their interpretation is often clouded by underlying socioeconomic disparities.
Bonsel and colleagues embarked on a comprehensive analysis of the instruments used to measure PROMs in total hip and knee arthroplasty patients, meticulously examining both the tool design and the patient population. Their study encompassed diverse socioeconomic strata, revealing that patients’ income, education level, and social determinants of health consistently influenced their self-reported outcomes. These findings suggest that standardized PROM instruments may inadvertently reflect socioeconomic biases, masking the true efficacy of surgical interventions across different patient groups.
The heart of the investigation analyzed multiple validated PROM instruments, dissecting how each domain captures the multifaceted impact of joint replacement surgeries. Pain relief—a primary indication for surgery—often showed robust improvement regardless of socioeconomic status. However, domains related to physical function, mental well-being, and social participation displayed marked variability when stratified by socioeconomic indicators. Lower-income patients reported less pronounced improvements in mobility and lifestyle, suggesting that factors beyond the surgical procedure itself critically influence recovery trajectories.
Mental health domains emerged as particularly sensitive to socioeconomic context. Patients from disadvantaged backgrounds tended to report poorer postoperative mental well-being, implicating social stressors, limited access to supportive rehabilitation services, and potentially unaddressed comorbidities. This complex interplay challenges the healthcare system to move beyond a one-size-fits-all model and toward tailored postoperative care pathways that acknowledge the psychosocial dimensions of recovery.
Notably, the research underscores that socioeconomic inequalities are not merely confounders but intrinsic modifiers of PROM outcomes. This distinction is pivotal: it argues for recalibrating how outcome data are interpreted and applied in clinical decision-making. For instance, surgeons and care teams might need to factor in socioeconomic context when setting patient expectations or designing individualized rehabilitation protocols.
Furthermore, the study’s methodological rigor in dissecting PROM instruments offers valuable insights for future research and clinical practice. Variability in instrument sensitivity and domain specificity can compromise the equitable assessment of surgical outcomes. Bonsel’s team advocates for the development or refinement of PROM tools that are more culturally and socioeconomically inclusive, ensuring that measurement accurately reflects patient experiences across societal subgroups.
This line of research has profound implications for healthcare equity. As joint replacement surgeries become increasingly common and healthcare systems emphasize value-based care, understanding and addressing disparities in outcome reporting is essential to avoid perpetuating systemic inequalities. Policies informed by such nuanced data can allocate resources more effectively, prioritize vulnerable populations, and enhance postoperative support services, ultimately improving long-term functional outcomes.
The findings also prompt a critical reexamination of public health strategies. Socioeconomic determinants that influence PROMs—such as income insecurity, educational disparities, and limited access to community resources—require multisectoral interventions beyond hospital walls. Multi-disciplinary collaborations, incorporating social workers, physiotherapists, mental health professionals, and patient advocates, are necessary to bridge the gap between surgical success and patient-perceived well-being.
Importantly, the study highlights a need for longitudinal PROM data collection to monitor how socioeconomic influences evolve over time. Recovery from hip and knee arthroplasty is not static; social determinants may exert cumulative effects that shape rehabilitation potential, adherence to therapy, and health behaviors. Tracking these trends can inform proactive measures that mitigate adverse outcomes before they become entrenched.
The patient voice, captured through PROMs, serves as a critical compass guiding equitable health improvements. Yet, as this research reveals, the instruments collecting these voices must evolve to confront the realities of inequality. Failing to do so risks misinterpreting data and neglecting those who may benefit most from targeted interventions.
In an era where personalized medicine gains traction, the interplay between socioeconomic context and patient-reported outcomes should occupy a central role. Bonsel et al.’s comprehensive analysis serves as a clarion call to clinicians, researchers, and policymakers alike: achieving true equity in orthopedic care demands a holistic approach that integrates biological, psychological, and social dimensions.
By illuminating the nuanced ways socioeconomic status influences PROMs in joint replacement recipients, the study paves the way for more just and effective healthcare delivery models. Future endeavors inspired by this work could incorporate machine learning to model how complex socioeconomic variables interact with clinical outcomes or develop adaptive instruments that dynamically tailor PROM questions to individual social contexts.
As the healthcare community digests these findings, it becomes clear that improving joint replacement outcomes transcends surgical techniques and implant craftsmanship. It requires a systemic commitment to understanding and dismantling social barriers that hinder full recovery. Only then can the promise of arthroplasty—to restore not just joint function but holistic quality of life—be truly fulfilled for all patients, regardless of socioeconomic standing.
This seminal research urges a paradigm shift, transforming how we measure success and, ultimately, how we define equitable health. By acknowledging and embracing the socioeconomic influences embedded in patient-reported outcomes, the orthopedic field can lead the way toward a more inclusive, responsive, and compassionate healthcare future.
Subject of Research: Socioeconomic inequalities affecting patient-reported outcome measures in total hip and knee arthroplasty patients.
Article Title: Socioeconomic inequalities in patient-reported outcome measures among total hip and knee arthroplasty patients: a comprehensive analysis of instruments and domains.
Article References:
Bonsel, J.M., Reijman, M., Macri, E.M. et al. Socioeconomic inequalities in patient-reported outcome measures among total hip and knee arthroplasty patients: a comprehensive analysis of instruments and domains. Int J Equity Health 24, 147 (2025). https://doi.org/10.1186/s12939-025-02520-4
Image Credits: AI Generated
