Prospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Mar 18, 2021; 12(3): 152-168
Published online Mar 18, 2021. doi: 10.5312/wjo.v12.i3.152
Pain and function deteriorate in patients awaiting total joint arthroplasty that has been postponed due to the COVID-19 pandemic
Jurek Rafal Tomasz Pietrzak, Zia Maharaj, Magdalena Erasmus, Nkhodiseni Sikhauli, Josip Nenad Cakic, Lipalo Mokete
Jurek Rafal Tomasz Pietrzak, Department of Orthopaedics, University of the Witwatersrand, Johannesburg 2193, Gauteng, South Africa
Zia Maharaj, Magdalena Erasmus, Nkhodiseni Sikhauli, Lipalo Mokete, Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg 2193, Gauteng, South Africa
Josip Nenad Cakic, Department of Orthopaedic Surgery, Life Fourways, Johannesburg 2193, Gauteng, South Africa
Author contributions: Pietrzak JRT and Cakic JN designed the manuscript; Pietrzak JRT and Mokete L supervised the study; Pietrzak JRT, Maharaj Z, and Erasmus M drafted the manuscript; Maharaj Z and Mokete L reviewed the manuscript; Maharaj Z and Erasmus M analyzed the data; Sikhauli N collected the data; All authors read and approved the final manuscript.
Institutional review board statement: Medical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee (Medical) registered with the National Health Research Ethics Council (NHREC) of the national Department of Health Clearance Certificate No. M200681.
Conflict-of-interest statement: All authors declare neither financial nor non-financial conflicts of interest that are directly or indirectly related to this study.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author, JRT Pietrzak at jrtpietrzak@yahoo.com.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Zia Maharaj, MBChB, Doctor, Research Fellow, Department of Orthopaedic Surgery, Charlotte Maxeke Johannesburg Academic Hospital, Jubilee Street, Parktown, Johannesburg 2193, Gauteng, South Africa. maharajzia@gmail.com
Received: November 23, 2020
Peer-review started: November 23, 2020
First decision: December 24, 2020
Revised: January 6, 2021
Accepted: February 26, 2021
Article in press: February 26, 2021
Published online: March 18, 2021
Processing time: 108 Days and 23.6 Hours
ARTICLE HIGHLIGHTS
Research background

The postponement of elective surgery in response to the coronavirus disease 2019 (COVID-19) pandemic resulted in a total shutdown of total joint arthroplasty (TJA). The impact of elective surgery postponement has resulted in the cancellation of approximately 92.6% TJAs in Europe. The demand for TJA is already high and waiting lists continue to grow with 150000 procedures per month postponed in the United States.

Research motivation

There is wide variation across countries worldwide; with the average median waiting time of 113 d (range 50-282 d) for total hip arthroplasty and 189 d (range 45-839 d) for total knee arthroplasty respectively. Patients awaiting surgery longer than 6 mo and those with poor pre-operative baseline function have demonstrated increased risks for poor outcomes after TJA. The unprecedented postponement of elective TJA in response to the COVID-19 pandemic may impact patients awaiting surgery.

Research objectives

Our aim was to assess the impact of TJA postponement on the physical and mental health of patients awaiting elective surgery. We secondarily sought to determine the demand for TJA and average waiting time for our South African population. Additionally, we investigated the role of patient insight after providing education and counseling regarding the healthcare system’s response to the COVID-19 pandemic. The effect of TJA postponement on patients should be considered with the re-initiation of elective surgery and waiting lists should be prioritized to optimize outcomes.

Research methods

A prospective cross-sectional telephonic interview-based study of patients awaiting TJA at an academic referral institution in South Africa during the COVID-19 pandemic. We recorded baseline demographic data and length of time awaiting surgery and demand for TJA. A 5-point Likert scale was used to determine the degree to which the patient felt the postponement of surgery had affected various characteristics of their physical and mental health. We assessed patient insight regarding elective surgery cancellation in response to the COVID-19 pandemic and subsequently re-evaluated demand for TJA after providing education and counseling.

Research results

Patients with comorbidities were 8.45-fold less likely to want elective surgery at earliest possibility compared to those with no comorbid conditions (P = 0.013). In our study in South Africa, the mean length of time for patients awaiting total hip arthroplasty was 28.29 mo and total knee arthroplasty was 25.03 mo, respectively. Before and after receiving patient education, the number of patients who demanded elective TJA decreased respectively, from 164 patients (88.65%) to 100 patients (54.05%) (continued demand group). The continued demand group had a higher mean pain score (P < 0.000) and the greatest proportion of patients with increased joint pain (P = 0.035) since the postponement of surgery compared to the other patients.

Research conclusions

The effect of TJA postponement on patients should be assessed on an individualized basis and waiting lists should be prioritized for urgency. Patient consent prior to elective surgery during the COVID-19 pandemic must focus on counseling and education, particularly for high-risk patients, to ensure optimal outcomes. The urgency to proceed with TJA should be based on both the potential harm of delaying surgery and the individual risk profile of performing surgery incurred by each patient, respectively, in the context of the COVID-19 pandemic.

Research perspectives

There is a demonstrated need to postpone elective surgery in response to the COVID-19 pandemic, particularly in high-risk patients. Patients should be reassessed and thoroughly counseled prior to rescheduling their elective procedures, particularly those at increased risk for morbidity and mortality if infected with COVID-19 peri-operatively. In addition to the potential negative impact on patient outcomes, the economic implications of the postponement of elective surgery place an increasing burden of healthcare systems worldwide. The reinstitution of elective surgery must be carefully implemented to ensure patient and staff safety and the responsible management of institutional resources.