The impact of the pandemic on functional outcomes for joint replacement patients: An observational study

Abstract

Elective surgeries, as joint replacement, were resumed after the first COVID-19 pandemic wave in 2020 and a phase of coexistence with the virus began. Surgery was organized in a new way that incorporated procedures aimed at reducing the risk of spreading the virus. The aim of this study is to describe the early functional results for patients undergoing hip and knee replacements at the time healthcare services were being reopened and to compare them with the same outcomes recorded in the prepandemic period. This is a controlled retrospective study. All patients consecutively admitted during 2020 and who underwent hip and knee replacement were enrolled in the study. Patient records from January to March 2020 constituted the prepandemic control group, while patient records from May to December 2020 constituted the study group. Functional recovery was described through the patient’s ability to walk using antebrachial devices and to climb up and down 3 steps. The day after surgery on which these activities were first performed was also recorded. The prepandemic group consisted of 183 patients and the pandemic group of 280 patients. The mean age of patients was 66 years (±13.1), female was 44.9% and hip replacement was 66.5%. The number of patients who climbed stairs and the timing thereof was comparable for the 2 groups (68.5% vs 72.2%, respectively; P = .403). There was no significant difference in the incidence of patients able to walk with antebrachial device and incidence of pressure ulcers and major complications. Multivariate analysis confirmed that the incidence of stair climbing was not associated with the prepandemic or pandemic inclusion. During the reopening of orthopedic surgery activity, the reorganization and treatment pathway did not affect the functional outcome achieved by patients underwent joint replacement. Constant monitoring of the functional outcomes will be required so as to further increase the number of joint replacement surgeries.

1. Introduction

Internationally, the proliferation of COVID-19 has had an unprecedented impact on individual countries’ healthcare systems. The consequences of the spread of the pandemic were seen in terms of health of those affected by the virus and indirectly in terms of a lack of treatments.^[1–3] In many countries, in orthopedic contexts, the decision was to cancel any hip and knee replacements deemed nonessential.^[4,5] The joint replacement for osteoarthritis is a scheduled surgery. Pain, joint stiffness, and significant limitation in activities of daily living including difficult walking are the main symptoms complained by the patients eligible for surgery.^[6,7] In America, implementation of this principle is estimated to have resulted in the cancelation of 33,000 primary hip and knee replacements a week throughout 2020, thus making it necessary to reschedule approximately 130,000 operations.^[8,9] Consequently, the increased waiting times for joint replacement surgery have led to a deterioration in the candidates’ quality of life.^[10,11] In Italy, the state of emergency commenced in March 2020 and resulted in the suspension of all nonessential activities. Hospital care was reorganized, and many wards were closed, with most resources going to care for COVID-19 patients. It was only in May 2020 that the restrictive measures were relaxed. However, the reopening of nonessential activities did not mean a return to normal, and thus a phase of coexistence with the virus began. Elective surgeries were resumed, organization in a new way that incorporated procedures aimed at reducing the risk of spreading the virus. The European Hip Society and European Knee Associates^[12] provided recommendations for performing surgery in coexistence with the spread of the virus and in anticipation of new waves of the pandemic.

While consequently to first pandemic wave, an urgent resumption of orthopedics surgical activity was necessary, on the other hand, it was necessary to understand the capabilities of hospitals to do so without having a worsening of clinical outcomes for patients. There is a lack of data on the clinical results and care outcomes for patients who underwent surgery during this period of reopening, and thus it is unclear what impact the pandemic may have had on non-COVID-19 patients.^[13,14] The study’s hypothesis was that the reorganization and treatment pathway put in place to reopen the surgical services could be associated with worse functional outcomes for patients undergoing joint replacement surgery, particularly in recovering the ability to climb up and down 3 steps. Therefore, the aim of this study is therefore to describe the early functional results and outcomes of care for patients undergoing hip and knee replacements at the time healthcare services were being reopened and comparing them with the same outcomes recorded in the prepandemic period in 2020.

2. Materials and methods

2.1. Study design: retrospective cohort study

2.1.1. Setting and participants

The study was conducted by consulting the computerized medical records of a single-speciality orthopedic hospital in central-northern Italy. All patients consecutively admitted during 2020 and who underwent surgery in the 2-speciality hip and knee joint surgery wards: 26 and 30 beds, respectively: were enrolled in the study. Patient records from January to March 2020 constituted the data for the prepandemic control group (PPG), while patient records from May to December 2020 constituted the study group, also referred to as the pandemic group (PG). During the period from March to May 2020, in line with Italian national restrictions, elective surgeries were suspended.

The criteria for inclusion in the study were age of 18 years and over and elective joint replacement surgery. Patients undergoing prosthetic surgery as a result of cancer, femur fracture and prosthetic revision were excluded from the study. Likewise, patients who, at the time of admission, refused their consent to having their data viewed were also excluded from the study. The study was approved by the hospital’s Ethics Committee under protocol number 352/2021/Oss/IOR. The study was registered at ClinicalTrial.gov under registration number: NCT04883788.

2.2. Reorganization and treatment pathway

From May 2020 on, in-hospital activity was restored for most surgical wards. Only the 11-bed Physical and Rehabilitation Medicine ward had not been reopened. The healthcare staff were once more returned to their assigned departments. In order to cope with the spread of the virus, Occupational Medicine set up surveillance and screening of healthcare personnel, while specific routes were created for patient admission to the wards from the emergency room and elsewhere. A dedicated department was also created for the hospitalization of confirmed/probable/suspected COVID-19 cases. In the management of admissions, procedures were implemented to screen patients who underwent molecular swabbing within 48 hours prior to admission. Inside the hospital, the use of protective equipment was required in compliance with current regional and national regulations; moreover, to limit contacts and crowding inside the hospital, the presence of care givers was not permitted. Relatives of in-patients could receive information on the condition of their loved ones through discussions with the ward doctors, but they were not granted admission to the in-patient ward. With exceptions for the above-mentioned aspects, the pathway care had not changed from the prepandemic period: care protocols related to the preoperative preparation, surgical techniques and surgical wound management had not been changed. As regards the prevention of PU, the ward nurse assessed the patient’s skin daily, checking for any redness requiring the implementation of specific prevention and treatment strategies as outlined in the guidelines.^[15]

Postoperative rehabilitation protocol included 2 sessions of physical therapy per day, Monday through Friday, and an additional session on Saturday morning, and had not been changed. For patients who underwent surgery in the morning, treatment was started on the day of the procedure itself, while it was started on the first day after surgery for patients undergoing surgery in the afternoon. Each physical therapy session lasted 30 minutes and included, bedside active and active-assisted mobilization exercises, ambulation training and recovery of independence. The aim of rehabilitation was to provide the patients with as much independence as possible, helping them recover ambulation with the aid of antebrachial devices and climbing up and down stairs.

Based on patient characteristics and the concept of tissue sparing, the surgical technique for hip replacements was a minimally invasive procedure with an anterior, posterolateral, or anterolateral skin incision. In total knee replacement, a medial longitudinal incision of skin and subcutaneous was made. The prostheses were cemented and the lower surface of the patella was cut off and replaced with a plastic button.

2.3. Outcome measurement.

During the hospital stay, functional recovery was described through the patient’s ability to walk using antebrachial devices and to climb up and down 3 steps. The day after surgery on which these activities were first performed was also recorded. Measurement of the outcome also included the incidence of major cardio-circulatory complications requiring admission to an intensive care unit or other specialist ward, and the incidence of pressure ulcers (PU) of any degree. PUs were defined as damage to the skin and underlying tissues due to pressure, stretching or friction, or a combination thereof.^[15]

2.4. Data collected

Variables related to the basic patient characteristics, type of surgery and the treatment path implemented in the PPG and GP groups were collected.

Baseline characteristics: age, in years, sex, body mass index (BMI), preoperative anesthesia risk (ASA score),^[16] preoperative hemoglobin values were collected.

Characteristics related to the treatment path: the type of anesthesia performed (mixed vs spinal or total); type of surgery (hip replacement or knee replacement); duration of the pre- and postoperative hospital stay; minimum postoperative hemoglobin value and difference between the pre- and postoperative hemoglobin values; time after the day of surgery when physical therapy was started, expressed in days; number of physiotherapy sessions performed; number of treatments requiring 2 operators; incidence and number of days of bladder catheter usage; incidence of episodes of syncope occurring during standing or walking. Pain symptoms were recorded as the number of days on which the patient reported pain exceeding 3 on the Numerical Rating Scale (NRS) for at least one of the daily pain reports entered in the medical record.

In-patient and surgical activities: the number of in-patient admissions and the number of joint replacement operations performed monthly during 2020 were recorded so as to understand the trend in surgical activities.

Using the hospital’s computerized medical records management software, this study was able to identify eligible patients. Patients were enrolled on the basis of the criteria for inclusion and exclusion, and their medical records were opened. In particular, the physical therapy and nursing diaries were reviewed. All data deemed of interest were recorded in an anonymized hard copy and then entered into an electronic database. From each medical record, information was extracted from the day of admission to the ward until the day of discharge. The physiotherapist researcher was responsible for data collection.

2.5. Statistical analysis and sample size

All continuous data were expressed as mean and the standard deviation of the mean, when normally distributed, and as median and interquartile range when non-normally distributed; the categorical data were expressed as frequencies and percentages. The Shapiro-Wilk test was carried out to test the normality of the continuous variables. The Levene test was used to test the homoscedasticity. The ANOVA test was performed to assess the between groups differences of continuous, normally distributed and homoscedastic data, the Mann-Whitney test was used otherwise. The Fisher Chi-square exact test was performed to investigate relationships between dichotomous variables. For all tests, P < .05 was considered significant. The Logistic Regression with backward Wald selection method was used as multivariate analysis to assess the combined influence on the primary endpoint of variables significant (P < .05) at the univariate analysis. All the statistical analyses were carried out using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY:IBM Corp.

3. Results

A search of the computerized system for the year 2020 revealed 643 medical records, 110 of which were excluded from the study on the basis of the inclusion/exclusion criteria. Of the remaining 533 eligible patients, 70 patients refused consent to access their data, thus the resulting patient sample was 463 (Fig. 1). The PPG consisted of 183 patients and the PG of 280 patients. The mean age was 66 years (SD 13.1), and women made up 44.9% of the sample. Table 1 summarizes the results of the group studied and compares the PPG with the PG, revealing no differences in functional outcomes. The number of patients who climbed stairs and the timing thereof was comparable for the 2 groups. There was no significant difference in the other outcome. By contrast, analysis of the baseline characteristics and treatment path-related variables did reveal statistically significant differences. In the pandemic study group, the proportion of patients with an ASA score above 2 was 8.4% higher (P = .026) than in the prepandemic period, the hemoglobin level was 0.4 g/dl lower (P = .01), the length of hospital stay increased on average by 0.7 days (P = .032), the number of hip replacement surgeries increased by 12.4% (P = .007), the percentage of physical therapy treatments requiring the presence of 2 healthcare professionals was 0.4% higher (P = .02), and the reduction in postoperative hemoglobin was 0.2 g/dL lower.

Figure 1.

Flow diagram.

Table 1.

Characteristics and outcome of the enrolled patients.

Characteristics	Prepandemic group (N = 183)	Pandemic group (N = 280)	P	Total (N = 463)
Baseline characteristics
Age, mean (DS)	65.8 (12.6)	66.1 (13.4)	.804	66.0 (13.1)
Female, % (n)	43.2 (79)	46.1 (129)	.567	44.9 (208)
BMI, mean (DS)	27.9 (3.8)	27.2 (4.5)	.071	27.5 (4.2)
ASA score > 2, % (n)	14.8 (27)	23.2 (65)	.026	19.9 (92)
Hb presurgery, mean (DS)	14.2 (1.3)	13.8 (1.6)	.010	13.9 (1.5)
Variables linked to treatment path
Total length of stay, mean (DS)	7.2 (2.9)	7.9 (3.2)	.032	7.4 (3.1)
Presurgery length of stay, mean (DS)	0.4 (0.7)	0.7 (0.8)	.01	0.6 (0.8)
Postsurgery length of stay, mean(DS)	6.8 (2.8)	6.9 (3.1)	.571	6.9 (3.0)
Number of hip replacement, % (n)	59.0 (108)	71.4 (200)	.007	66.5 (308)
Mixed anesthesia, % (n)	91.3 (167)	86.1 (241)	.228	(408) 88.1
Number of days from surgery to the start of physiotherapy, mean (DS)	0.7 (0.5)	0.8 (0.6)	.180	0.8 (0.6)
Number of physiotherapy sessions, mean (DS)	6.9 (1.4)	7.0 (1.3)	.967	6.9 (1.4)
Number of treatments requiring 2 operators, mean (DS)	0.4 (1.2)	0.8 (1.8)	.020	0.6 (1.6)
Number of days with pain > 3, mean (DS)	1.3 (1.8)	1.2 (1.5)	.557	1.2 (1.6)
Postsurgery Hb, mean (DS)	10.4 (1.7)	10.3 (1.6)	.251	10.3 (1.6)
Difference between pre- and postsurgery Hb, mean (DS)	3.7 (1.4)	3.5 (1.4)	.088	3.6 (1.4)
Number of episodes of syncope, % (n)	16.4 (30)	15.0 (72)	.696	15.6 (102)
Incidence of days of bladder catheter, % (n)	26.8 (49)	26.1 (73)	.914	26.3 (122)
Number of days of bladder catheter, mean (DS)	3.0 (2.6)	3.3 (3.2)	.774	3.2 (3.0)
Outcome
Incidence of patients able to climb up and down 3 steps, % (n)	68.5 (124)	72.2 (200)	.403	70.7 (324)
Postsurgery day of stair climbing, mean (DS)	4.7 (1.5)	4.8 (1.6)	.285	4.7 (1.6)
Incidence of patients able to walk using antebrachial devices,% (n)	89.6 (164)	83.9 (235)	.207	86.9 (399)
Postsurgery day of walk with antebrachial, mean (DS)	3.8 (1.8)	3.4 (1.4)	.350	3.6 (1.6)
Incidence of pressure ulcers,% (n)	2.2 (4)	3.2 (9)	.579	2.8 (13)
Incidence of major cardio-circulatory complications, % (n)	2.7 (5)	1.8 (5)	.525	10 (2.2)

DS = standard deviation, Hb = hemoglobin.

The number of admissions remained stable over the 2 periods. The average was 221 in the prepandemic period, compared with 224 in the pandemic period. The percentage of prostheses performed dropped from 37 to 26. The trend in surgical activity for 2020 is summarized in Figure 2.

Figure 2.

Surgical volume.

Multivariate analysis (Table 2) confirmed that, in hip replacement surgery, an ASA score of <3 and a higher preoperative hemoglobin level were protective factors with respect to the incidence of stair climbing. Inclusion in the pandemic or pre-PG was not a significant factor, thus confirming that, regardless of baseline population characteristics, the incidence of stair climbing was not associated with this aspect. Likewise, there was no significant difference in the precocity of stair climbing in the 2 periods (P = .626) (Fig. 3).

Table 2.

Multivariate analysis to assess the combined influence on the patient’s ability to climb 3 steps.

Variables	OR	95% Confidence Interval	P
Hip replacement vs knee replacement	3.507	2.189–5.616	<.001
ASA score > 2	3.809	2.243–6.468	<.001
Hb presurgery	1.251	1.068–1.465	.005
Prepandemic group vs pandemic group	0.749	0.470–1.193	.223

ASA = American Society of Anesthesiologists, Hb = hemoglobin.

Figure 3.

Cumulative recovery of number of patients able to climb stairs.

4. Discussion

The functional and healthcare outcomes achieved by hip and knee replacement patients in the pandemic period were largely unchanged from the prepandemic period during the first year of the proliferation of COVID-19. The ability to climb stairs was 72 and 69% in the sample, respectively, for the P and PP periods, the median performance time being 5 days after surgery. Vukomanic et al^[17] and Gocen et al^[18] reported time to climbing stairs ranging from 3.7 to 7.4 days after hip replacement surgery. Likewise, the incidence of pressure ulcers remained unchanged and extremely limited in the 2 periods under review, in line with the data found in the literature.^[19,20] Undergoing hip replacement surgery, an ASA score less than or equal to 2 and a higher preoperative hemoglobin level were independent predictors associated with the ability to climb up and down 3 steps. The period of hospitalization was not found to be significant predictors, showing no difference between the prepandemic period and the pandemic period. Analyzing the 2 study periods, however, differences in patients’ baseline characteristics emerged. In general, at the time surgery was reopened, the patients undergoing surgery presented worse general clinical conditions than did similar patients in the prepandemic period. An ASA score of more than 2 was recorded for a greater number of patients and lower presurgery hemoglobin in the pandemic period showed this basic difference between the 2 study groups. The increased waiting time for surgery could be a possible cause of the worsening clinical condition of patients. Clement et al^[10] showed that the cancelation of orthopedic procedures during the lockdown period resulted in a 35% and 22% increase in patients with critical quality of life, respectively, among patients on the waiting list for hip and knee replacements. Second, it is likely that, at the time of the reopening of the surgical activity, patients with worse clinical conditions requiring more urgent prosthetic surgery were called first from the waiting list.

In November 2020, the European Hip Society and the Knee Associates Survey of Members presented a paper highlighting the importance of prioritizing orthopedic prosthetic surgical procedures.^[13] After the lockdown period, following the reopening of elective surgery, an increase in demand for surgery was expected. In this study, from the point of view of numbers of surgical procedures, the trend was similar to what was described in the literature for elective surgery,^[3,9] thus showing that such elective surgery was only partially resumed after the first wave of the pandemic with its sharp decline in activity. The total number of hospitalizations did not differ significantly between the 2 periods, the total number of patients admitted during the pandemic period being similar to the prepandemic period. In contrast, the number of elective hip and knee replacements fell significantly from 37% to 26%. There was also a change in the type of patient, with the number of hip replacements increasing significantly. In addition to the surgical volume, the pandemic also had a major impact from an organizational point of view. The total length of the hospital stay increased on average by 0.7 days. This condition was most likely related mainly to a significant increase in the preoperative stay from an average of 0.4 days to an average of 0.7 days. This increase was due to the COVID-related screening activities needed to contain the pandemic.

To the authors’ knowledge, this study is the first paper in which the focus is not only on aspects of surgical volume and organization of orthopedic surgical activity but data on the clinical outcomes of patients are collected. The real impact of the pandemic on hospital management, healthcare professionals and patients are difficult to quantify, but it is crucial to understand and monitor citizens’ health outcomes in the first place. From the orthopedic point of view, it is possible to highlight that in the face of a partial resumption of surgical activity it is possible to ensure standards of care comparable to the prepandemic period. It is therefore important to increase orthopedic surgical activity in order to meet the needs of patients who are in worse clinical conditions, but at the same time it is necessary to monitor the functional outcomes of patients to verify that adequate standards of care are maintained.

4.1. Limits

The study does present some limitations, the first being the small sample size. The size of the sample was set by consecutively enrolling all patients admitted in 2020, the year the pandemic started. Secondly, it was not possible to compare the functional condition of the patients using specific assessment tools to determine what impact the extended presurgical waiting time may have had. There is no mention of this in the literature as a significant prognostic factor for postoperative recovery.

5. Conclusion

In a context of coexistence with the spread of COVID-19, the partial reopening of orthopedic surgical activity is compatible with the achievement of adequate functional outcomes in patients undergoing joint replacement. Therefore, it is possible to increase the surgical activity in order to be able to treat the backlog of patients on the currently long waiting lists. At the same time a constant monitoring of the functional outcomes that patients are able to recover after the surgery, it is necessary.

Acknowledgments

Open access publication of this study has been funded by Fondi 5 × 1000 anno 2018 into the project entitled: “Livelli di assistenza evalutazione degli esiti sensibili al trattamento fisioterapico.”

Author contributions

Conceptualization: Mattia Morri, Antonella Orlandi Magli, Cristiana Forni.

Data curation: Mattia Morri, Riccardo Ruisi, Vincenzo Peccerillo, Natalia Franchini, Antonella Orlandi Magli

Formal analysis: Mattia Morri, Cristiana Forni

Methodology: Cristiana Forni

Project administration: Antonella Orlandi Magli, Cristiana Foirni

Software: Riccardo Ruisi, Vincenzo Peccerillo

Supervision: Cristiana Forni

Validation: Mattia Morri, Riccardo Ruisi, Vincenzo Peccerillo, Natalia Franchini, Antonella Orlandi Magli, Cristiana Forni

Visualization: Mattia Morri, Riccardo Ruisi, Vincenzo Peccerillo, Natalia Franchini, Antonella Orlandi Magli, Cristiana Forni

Writing – original draft: Mattia Morri

Writing – review & editing: Mattia Morri, Cristiana Forni