As health-care systems worldwide scrambled to cope with the first wave of COVID-19, many countries made the necessary decision to cancel all non-emergency surgical procedures to free up personnel and resources to care for patients with COVID-19. Nearly 10 million people in the UK are now waiting for surgical procedures, up from 4 million before the pandemic hit. Among them are nearly 100 000 patients whose joint replacement surgeries were cancelled during the first COVID-19 wave, many of whom are left struggling with daily activities because of severe pain and limited mobility. The UK is not alone in this dilemma; a US report projected a backlog of more than 1 million joint and spinal surgeries by mid-2022. Drastic measures will be required to clear these backlogs.
Although elective surgeries resumed in the UK (and many other countries) in mid-2020, most hospitals are functioning at substantially reduced capacity, which translates to an ever-lengthening waitlist. As of September, 2020, nearly 140 000 patients in England alone had been waiting for more than a year for their surgeries—100 times the number in 2019. And with a new, highly transmissible variant of SARS-CoV-2 circulating in the UK, resulting in a third national lockdown and further cancellations, patients now face even longer waits.
The most common indication for joint replacement surgery is osteoarthritis, a degenerative joint disease that affects an estimated 250 million people worldwide. The disease—ranked by WHO among the top ten most disabling diseases in high-income countries—often causes debilitating pain that disrupts mobility and interferes with daily activities; living with chronic pain is also strongly associated with substance abuse and impaired mental health. Indeed, clinical depression has been reported in up to 90% of patients with axial pain due to orthopaedic conditions and in 60% of those waiting for knee replacement surgery.
Nonetheless, among the millions awaiting surgical procedures, those with chronic pain due to osteoarthritis might seem a lesser priority compared with patients suffering from other conditions, such as cancer. Indeed, nearly 4000 cancer patients are currently waiting beyond the 3-week target to start treatment, which could substantially increase cancer deaths (eg, delayed treatment of patients in England with breast, colorectal, oesophageal, and lung cancers alone is projected to result in more than 3000 additional avoidable deaths within 5 years).
It will undoubtedly take many years to grasp the totality of the consequences of delayed joint replacement surgeries, both with regard to long-term health outcomes for patients and costs to health systems and societies. And although it may not be an immediate life-or-death situation, the suffering of these patients cannot be ignored. Orthopaedists and rheumatologists caution that delaying surgery in patients with the most severe disease can lead to more complicated surgeries, increased use of medications, more difficult recovery, and worse outcomes, including increased rates of revision surgery and reduced quality of life. A recent study projected 50% greater odds of worse outcomes when surgery is delayed by more than 6 months—far less time than thousands of patients have already waited. Another concern is increased use of opioids, which even before the COVID-19 pandemic was reported in up to one fifth of patients awaiting arthroplasty, despite evidence that this leads to poorer outcomes.
The UK charity Versus Arthritis recently launched its ‘Impossible to Ignore’ campaign, demanding that UK governments and policy makers do not ignore the needs of patients with arthritis during the ongoing pandemic. The campaign calls for clear plans to reduce joint replacement waiting lists safely, to ensure that patients get the communication, support, and advice they need to manage their pain, and to involve patients in plans to restart services. Recent recommendations from the European Hip Society and European Knee Associates outline considerations on how to reintroduce elective arthroplasty surgery safely in the wake of COVID-19; they emphasise the need to assess the impact of delaying hip and knee arthroplasty for patients and for society, along with assessing when these procedures can safely resume, and how to prioritise patients.
Extended wait times for elective surgeries is but one of the myriad problems facing health-care systems as they struggle to manage patients with non-COVID illnesses during the ongoing pandemic—problems that do not have simple solutions. But even when the immediate stakes are not life-or-death, the long-term costs to patients, health systems, and society are high. These patients should not, and cannot, be ignored.
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