The effect of postponing joint replacement surgery due to COVID-19 on quality of life for patients suffering end-stage osteoarthritis

W. van der Weegen1 T. Sijbesma1 M .Siebelt1 R.W. Poolman2

1 Sports and Orthopedics Research Centre

2: Leiden University Medical Center


Abstract Purpose To analyse the effect of postponing joint replacement surgery due to the coronavirus disease 2019 (COVID-19) pandemic on osteoarthritic (OA) pain, functional limitations and Quality of Life (QoL) in end-stage OA patients. Methods A survey-based cross-sectional study and repeated pre-operative standard Patient Reported Outcomes (PROs) in a general district hospital in the Netherlands. All patients planned for hip of knee replacement surgery which was cancelled after March 16th 2020 due to the COVID-19 pandemic (n=134) were asked to participate. The survey included questions on change of symptoms, analgesic medication use, complications and fear for COVID-19 when returning to the hospital. Patients who already completed their PROs before initial surgery was cancelled due to COVID-19 were asked to complete PROs again, in order to estimate disease burden. Results 96 patients (71%) returned the survey of which 88 (66%) were included in the study. Symptoms improved in one patient (1.1%) 24 patients (27.3%) reported no change, 27 (30.7%) a mild increase and 36 (40.9%) a strong increase in OA symptoms. Mean QoL measured with the EQ5D deteriorated more in hip patients than in knee patients (-.17 versus -.03, p = 0.03). One patient suffered a gastrointestinal bleeding due to NSAID use. 14 Patients (15.9%) expressed fear for COVID-19 contamination if arthroplasty surgery was to be scheduled after the first lockdown. Conclusion OA complaints increased and QoL deteriorated in the vast majority of patients who had their hip or knee replacement surgery cancelled due to the COVID-19 pandemic.

Background In March 2020 the COVID-19 pandemic spread fast throughout the Netherlands. During this pandemic, there was a sudden increase of critically ill patients in need of intensive care treatment. In order to prevent spread of COVID-19, public places like hospitals were closed and almost all medical resources were used for critically ill (COVID-19) patients. Their number almost exceeded the number of available ICU beds and nearly all Dutch hospitals were in danger of being overloaded. Almost all electively scheduled operations were cancelled from March 16th 2020 onwards. One of the most important and successful procedures in orthopedic surgery is artificial joint replacement, most often related to hip or knee osteoarthritis (OA). In the Netherlands, every year approximately 77.000 joint replacement surgeries are performed and in our hospital annually 450 hips and 550 knees.1 Due to COVID-19, this type of surgery was postponed for many thousands of patients. By the end of May 2020 less COVID-19 patients were hospitalized, and usual hospital care was started again. The urge to resume oncologic and cardiologic care is obvious, due to life threatening consequences and great impact on Quality of Life (QoL) of involved pathologies. Pathology within the field of orthopedic surgery mostly concerns quality of life, but is not related to life-threatening or life-lengthening indications for surgery. Therefore, the urge to resume orthopedic care seems less acute and restarting elective OA related arthroplasty after the first lock down progressed slowly. However, information on how profound orthopedic patients are affected when their joint replacement surgery is postponed is scarce. In this study, we present the effect of postponing joint replacement surgery in end-stage OA patients related to symptoms and quality of life during the first COVID-19 hospital lockdown in the first half of 2020. Methods We conducted a cross-sectional study in a single district hospital (St. Anna hospital, Geldrop). The study was reviewed and approved by the hospital Medical Ethical Committee. In our hospital, due to the COVID-19 pandemic all elective surgery was cancelled from March 16th 2020 onwards. A survey was sent (June 2020) to all patients who were planned for joint replacement surgery but who had their surgery postponed due to this first lockdown (n=134). This survey included questions on symptoms during their extended waiting period using a 4 point scale with the options:

1: symptoms improved during lockdown;

2: no change in symptoms;

3: mild increase;

4: strong increase in symptoms.

Any change in the use of analgesic medication and complications due to the extended waiting were also evaluated using open text fields. We also asked patients if they had any fear for COVID-19 if in time, they were allowed to come to the hospital for surgery. Standard Patient Reported Outcomes (PROs) were repeated if patients had completed these before their surgery was postponed. For patients scheduled for total hip replacement this included the Hip disability and Osteoarthritis Outcome Score – Physical function Short form (HOOS-PS, ranging from 0 (no difficulty) to 100 (extreme difficulty) and the Oxford Hip Score (OHS, ranging from 0 (worst) to 48 (best)). Patients scheduled for total knee replacement were asked to complete the Knee disability and Osteoarthritis Outcome Score – Physical function Short form (KOOS-PS, ranging from 0 (no difficulty) to 100 (extreme difficulty)) and the Oxford Knee Score (OKS, ranging from 0 (worst) to 48 (best)). Both hip and knee OA patients were also asked to complete the EuroQol five-dimension (EQ-5D-5L) questionnaire to measure Quality of Life and pain scores at rest and during activity using a Numeric Rating Scale (NRS, ranging from 0 (no pain) to 10 (worst pain)). For the Netherlands, the EQ-5D scores range from -.329 to 1, with a score of 1 representing full health and 0 representing death.2 Negative EQ-5D index scores are possible and are noted as a ‘Worse than Death (WTD) status, as described earlier by Scott et el.3 PRO results were compared to the Smallest Detectable Change (SDC) and the Minimal Important Difference (MID) both on group and individual level if available.4,5 All patients who gave written informed consent, completed the survey and did not yet have their postponed joint replacement surgery at the time of completing the survey were included. No protected health information was collected from any patient. Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research. Descriptive statistics were used to report the outcomes.

Results Response rate The questionnaire was returned by 96 patients (71%). Of these 96, eight already received their joint replacement surgery by the time they received the survey and were excluded from analysis. In the remaining 88 (66%) patients, the average time that their surgery was postponed until they completed the survey was 10 weeks (min-max: 6.7-13.0). Compared to reference data from the Dutch Arthroplasty Register, the proportion of male patients was larger in our study group (51% versus 36%). The mean age was comparable to the reference group males ( 69.5 years versus 69.1 years).6 See table 1 for patient demographics.

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Change in symptoms 24 patients (27.3%) reported no change in symptoms, 27 (30.7%) reported a mild increase in symptoms and 36 (40.9%) reported a strong increase in symptoms. One patient (1.1%) noticed less symptoms. Extra pain medication use was reported by 38 (43.2%) patients and 15 patients (17%) contacted either their GP or our hospital to seek advice related to their increased symptoms. One patient received an intra-articular knee injection due to increased OA symptoms. 19 Patients (22%) developed pain in other joints during this period. Of all 88 included patients, 14 (15.9%) expressed COVID-19 related fear for entering the hospital after the lockdown.

PRO results 38 patients (43%) were initially scheduled for TKP and already completed PROs before their surgery was postponed. Sixteen patients completed PROs again for this study. In our group of patients scheduled for THP, 35 completed their PROs questionnaires before their surgery was postponed, 27 completed these PROs again for purpose of this study. Mean QoL deteriorated during the COVID-19 lockdown, but only for the patients awaiting hip replacement surgery than for patients awaiting knee replacement surgery (change in EQ-5D index score: -0.17 for THA versus +0.02 for TKA, p = 0.03). There were no patients with a WTD status (negative EQ-5D index score) before the COVID-19 lockdown, and one patient (waiting for hip replacement surgery) with a WTD status at the end of the lockdown (EQ-5D score -0.16). Pain at rest improved for the TKA patients, while the OHS score worsened significantly. All other PROs did not show any statistically significant change. See table 2.

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1 measured using a NRS score, with 0 meaning “no pain at all” and 10 meaning “worst imaginable pain”;

2 EQ-5D index score Dutch dataset ranging from -0.329 (worst possible health) to 1 (best possible health);

3 KOOS-PS and KOOS-PS scores range from 0 (no difficulty) to 100 (extreme difficulty);

4 OKS and OHS scores range from 0 (worst) to 48 (best)). SD = Standard deviation.

Discussion QoL deteriorated more for the patients awaiting hip replacement surgery than for patients awaiting knee replacement surgery (EQ-5D index change score: - 0.17 versus -0.03). Almost halve (40.9%) of arthroplasty patients for who surgery was postponed due to COVID-19 reported a strong increase of their symptoms and almost a third (30.7%) experienced a mild worsening of their hip or knee symptoms, although this effect was less apparent in the standard PRO’s. An EQ-5D index score of 1 represents full health and 0 represents death, but negative EQ-5D index scores are possible and reflects a ‘Worse than Death (WTD) status.2 In our study no patient had a WTD status while being scheduled for joint replacement surgery before the COVID-19 lockdown. At the end of the first lockdown, one patient scored a WTD status while waiting for hip replacement surgery. In a recent study 19% of patients awaiting hip replacement and 12% awaiting knee replacement for degenerative joint disease reported to be in a WTD health state, as measured with the EuroQol five-dimension (EQ-5D) questionnaire.3 This result signifies the impact of end stage osteoarthritis (OA) for patients awaiting joint replacement surgery, although this effect is less pronounced in our study population. Our study is limited by the fact that not all patients completed PROs, possibly introducing selection bias. Strong points are a high response rate, and the inclusion of both hip and knee arthroplasty patients. Compared to patients included in the Dutch Arthroplasty Register, the study group included more males but the mean age was similar. [LROI REF] The pre-operative QoL scores for our patients were not as dramatic as found in the study by Scott et al3, who investigated the proportion of the patients with a WTD status while waiting for joint replacement surgery in the United Kingdom. This might be explained by a different EQ-5D syntax for the United Kingdom, since in the United Kingdom value set one-third of the 243 possible health states are negative or WTD, compared to only 15% in the Netherlands. Similar to our results, Scott et al. found that the majority (54%) of electively scheduled hip and knee arthroplasty patients suffered from increased OA pain during the COVID-19 pandemic.3 This U.S. based study provided detailed information on financial and job security anxiety due to COVID-19 but less details on OA pain. In addition, we were also able to add standardised PRO results and complications during the COVID-19 lockdown. Hoogeboom et al. systematically reviewed the effect of waiting lists on joint replacement surgery patients and, in contrast to our findings, reported that patients waiting for hip replacement had no change in pain or functional status and conflicting evidence for patients awaiting knee replacement surgery.7 However, the patients in the study by Hoogeboom et al. faced long waiting times (>180 days), but their surgery was not cancelled and subsequently postponed, as was the case in our study. Patients in our study predominantly showed worse outcome in almost all PROs and EQ5D. This might be caused by the fact that our patients were already at the end of their waiting time when their surgery was cancelled, and nonoperative care (e.g. moderate exercising and physiotherapy) were severely limited during the first COVID-19 lockdown in 2020. During the current (second) COVID-19 lockdown elective surgery is again cancelled for almost all joint replacement surgery patients. This time however, physiotherapy is still available which might mitigate the negative effects of postponing this type of surgery. On the other hand, possibly some patients were not even rescheduled for their surgery when the second lockdown came into effect, or were rescheduled but cancelled again. One can imagine that the negative effects presented in this study are even more pronounced if surgery is postponed multiple times. In conclusion, most patients who had their joint replacement surgery cancelled due to first COVID-19 lockdown experienced a deterioration in their QoL during this lockdown. With a simple questionnaire we were able to identify which patients reported no change, which patients reported mild worsening, and which patients reported severe worsening of their OA symptoms during the COVID-19 lockdown. Funding source Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

References 1. LROI report 2019. https://issuu.com/bladerboek/docs/lroi_magazine_2019. Date last accessed June 30th 2020. 2. Dolan P. Modeling valuations for EuroQol health states. Med Care 1997;35:1095-1108. 3. Scott CEH, MacDonald DJ, Howie CR. 'Worse than death' and waiting for a joint arthroplasty. Bone Joint J. 2019 Aug;101-B:941-50. 4. Beard DJ, Harris K, Dawson J, Doll H, Murray DW, Carr AJ et al. Meaningful changes for the Oxford hip and knee scores after joint replacement surgery. J Clin Epidemiol. 2015; 68(1): 73-9. 5. McClure NS, Al Sayah F, Xie F, Luo N, Johnson JA. Instrument-Defined Estimates of the Minimally Important Difference for EQ-5D-5L Index Scores. Value Health 2017;20:644-50. 6. https://www.lroi-report.nl/hip/total-hip-arthroplasty/demographics/. Date last accessed 26th January 2021 7. Hoogeboom TJ, van den Ende CHM. van der Sluis G, Elings J, Dronkers JJ, Aiken AB et al. The impact of waiting for total joint replacement on pain and functional status: a systematic review. Osteo Cart 2009; 17(11): 1420-7.