Resuming elective hip and knee arthroplasty in the COVID-19 era: a unique insight into patient risk aversion and sentiment

Abstract

Introduction

There has been guidance from the government and orthopaedic community on how best to ensure the safety of our patients and colleagues as we recommence elective surgery in the UK. The primary aim was to determine what proportion of patients feel they should proceed with their elective hip and knee arthroplasty surgery during the COVID-19 climate. The secondary aim was to investigate what variables affected this decision.

Methods

Patient information from a single surgeon's waiting list in a district general hospital were recorded. A standardised telephone discussion was had with all the patients noting the severity of pain and the potential reasons for not wanting to proceed with surgery.

Results

A total of 70.6% (96/136) of patients wished to proceed with surgery; 29.4% (40/136) did not wish to proceed. The decision to proceed with surgery was not correlated with sex, American Society of Anesthesiologists grade or COVID-19 risk. Those who wished to proceed with surgery had a mean age of 68.5 years while those who did not had a mean age of 72.4 years (P = 0.03). Within the matched subgroups, patients under the age of 70 years were more willing to proceed with primary hip arthroplasty surgery (87.9%) compared with primary knee arthroplasty surgery (57.1%; P = 0.007); 75% of the patients who did not wish to proceed with surgery expressed concerns about perioperative COVID-19 infection.

Conclusion

There is a significant proportion of arthroplasty patients on waiting lists who would be willing to accept the increased risks associated with COVID-19 to undergo surgery on an urgent basis. The subgroup of younger patients awaiting hip arthroplasty is more willing than those awaiting knee arthroplasty to proceed with surgery.

Introduction

Timely access to joint replacement surgery is crucial for ensuring that people with end-stage degenerative joint disease can enjoy a good quality of life. This forms the basis for national guidelines on the ’18-week’ rule.¹ The COVID-19 pandemic led to a redistribution of services within the NHS and the suspension of all elective surgeries in the UK including hip and knee arthroplasty operations.² A study of elective surgery cancellations due to the pandemic based on predictive modelling estimated that approximately 43,307 elective procedures were cancelled per week in the UK during this period.³

Following the peak and decline in cases relating to COVID 19 in the UK, NHS England has called for a move to the second stage of the response, including a return to elective orthopaedic surgery when capacity and resources are available.⁴ There has been a wealth of guidance within the international orthopaedic community from orthopaedic associations and from Public Health England regarding the restarting of elective surgery.^{5, 6} On the 15 May 2020, the British Orthopaedic Association (BOA) produced a document to help guide clinicians with the elective restart of orthopaedic care.⁷ The establishment of COVID-free (green) and COVID-managed (blue) pathways for patient care suggested in the guidance goes further to ensure the safety of patients undergoing elective procedures, and the BOA has tried to disseminate this information to patients by releasing guidance specifically for patients awaiting arthroplasty surgery on 26 June 2020.^{7, 8}

Public opinion regarding the COVID-19 pandemic is dynamic and is influenced by information from the media, which can have an effect on patients’ perception of risk and decision-making processes when considering proceeding with elective surgery. This study has been intentionally timed to follow the government announcements regarding lifting of lockdown precautions in the UK.

As elective services start to resume across the country, surgical teams are risk stratifying and prioritising the patients on the waiting list. At the time this study was carried out, the literature reports a 30-day mortality rate up to 23.8% and 50% pulmonary complications in patients who contract COVID-19 perioperatively.⁹ Prior to the pandemic, the quoted 30-day mortality in the UK was 1/400 (0.22% total hip replacements and 0.31% total knee replacements).¹⁰

The aim of this study was to identify what proportion of patients still want to proceed with elective hip and knee arthroplasty surgery given the added risks of COVID-19. Secondary outcome measures included identifying the factors that influenced the decision-making process.

Materials and methods

Primary and revision hip or knee arthroplasty cases from a single surgeon's waiting list were included in this prospective study. All patients had been reviewed and clinically assessed by the consultant arthroplasty surgeon in the outpatient clinic. They were confirmed to have bone-on-bone radiographic findings indicative of end-stage osteoarthritis. A discussion was had with the patients who confirmed that they understood the different treatment options and were keen to proceed with arthroplasty surgery. Following an outpatient clinic appointment, patients were added to the elective arthroplasty pathway awaiting surgery. Patients who were listed for non-arthroplasty procedures, were not contactable via telephone and those who were listed after the beginning of the UK lockdown period starting 23 March 2020 were excluded.

Those patients who were awaiting surgery were categorised by operation type into primary total hip replacement (THR), primary total knee replacement (TKR), unicompartmental knee replacement (UKR), complex/revision THR and complex/revision TKR. ‘Complex’ was defined by the need for concurrent metalwork removal or significant deformity correction or an anticipated additional significant surgical time.

Patients were contacted by telephone by the two arthroplasty registrars and senior arthroplasty fellow working in this surgical team. The telephone consultations were all performed within five days commencing on the 23 June, when the UK government announced the plan to relax lockdown measures on the 4 July.¹¹ Those patients who were not contactable after multiple attempts were excluded from the study.

Patient demographics and details of the surgery were gathered using electronic patient records. The information included the operation type, sex, American Society of Anesthesiologists score (ASA) grade. NHS guidance on the risks of serious complications following COVID-19 infection was used to stratify the patients into high risk (clinically extremely vulnerable), moderate risk (clinically vulnerable) and the remaining patients as lower risk.¹²

The telephone consultation was standardised including the creation of a ‘crib sheet’ script of key topics to cover (Box 1). During this consultation with the patients, the risks of the surgical procedure were reiterated. The added risks of COVID-19 were also discussed, including the potential risk of approximately 20% mortality in the event of contracting COVID-19 perioperatively. The new perioperative measures to reduce the risks was explained to the patients including the necessity to self-isolate for two weeks before the operation.

Box 1. Interviewer's crib sheet.

• • Discussion of available alternative treatments.
• • Review severity of current pain on numeric rating scale of 0–10.
• • Check for coronavirus symptoms and testing.
• • Discuss necessity for patient and household to self-isolate for two weeks prior to date of surgery.
• • Discuss requirement for testing and negative results prior to surgery.
• • Discuss possibility of developing coronavirus before, during or after operation while in hospital.
• • Discuss outcomes of perioperative coronavirus infection, with added complications including a death rate of up to 20%.
• • Discuss specifically higher patient risks if in moderate or high COVID risk categories.
• • Discuss ban on visitors to hospital during inpatient stay.
• • Discuss possibility of limited face to face outpatient physiotherapy postoperatively and possibility of family members being less available for support.

Each patient was also asked about the severity of their pain symptoms. They were asked to grade this on a numeric pain rating scale of 0–10, with 0 being described as no pain and 10 being described as the worst pain ever experienced.

Patients were asked whether they wanted to remain on the waiting list to have their operation as soon as possible (outcome 1) or come off the waiting list but be seen in the clinic at a later date, in around six months’ time, to significantly delay the operation but not be discharged from the service (outcome 2). They could also elect to be discharged from the service altogether (outcome 3). If the patient indicated that they would not want to remain on the waiting list, they were asked whether their decision was based on any of the concerns in Box 2. Each patient was asked whether they would consider having their operation at a different, but relatively local, hospital by the same surgical team. Patients were finally asked an open-ended question to discuss any concerns not yet raised and responses were documented as accurately as possible.

Box 2. Patient concern questions.

Q1 Are you concerned that the hospital is not adequately equipped to prevent you from contracting COVID-19 during your inpatient stay?

Q2 Are you concerned about the two-week preoperative self-isolation period?

Q3 Are you concerned about the risk of contracting COVID-19 during your inpatient stay?

Q4 Are you concerned about not having any visitors during your inpatient stay?

Q5 Are you concerned about not having enough people to help you recover postoperatively?

The specific risk of perioperative coronavirus infection and mortality of 20% was confirmed with patients verbally and included in a personalised letter to the patient detailing the entire discussion, with an additional hospital trust approved information letter giving further information on risks and practical considerations.

The results were compiled, and statistical analysis performed using SPSS version 26. Chi-square and Fisher's exact tests were used to compare categorical data. The independent t-test and Mann–Whitney U tests were used to compare continuous results.

Results

A total of 96/136 (70.6%) of patients awaiting arthroplasty wished to proceed with surgery as soon as possible (Table 1). Patients who wished to proceed with surgery were slightly younger (mean age 68.5 years, standard deviation, SD, 10) than patients who did not (mean age 72.4 years, SD 9); P = 0.03) with a higher numerical rating scale (NRS) score (P = 0001). There was no significant correlation with ASA grade (P = 0.7), COVID-19 risk (P = 0.15), sex (P = 0.135) or procedure type when all were grouped together (P = 0.056).

Table 1 .

Patient demographics

	Patients		Patients wishing to proceed with surgery as soon as possible		Patients who did not wish to proceed with surgery
Demographic	(n)	(%)	(n)	(%)	(n)	(%)	P-value
Patients	136		96	70.6	40	29.4
Age:			68.5 (SD 10)		72.4 (SD 9)		0.03
<60 years	17	13.1
60–70 years	41	56.2
>70 years	73	31.5
Male sex				43		30	0.135
American Society of Anesthesiologists grade:							0.7
1	3	2.3
2	66	50.7
3	56	43.1
4	5	3.8
COVID-19 risk:							0.15
High	42	32.3		31.3		35
Moderate	48	36.9		32.3		45
Lower	40	30.7		36.5		20
Numerical rating scale score			8 (SD 1.5)		7 (SD 2.5)		0.0001
Procedure:							0.056
Primary total hip replacement				83		17
Primary total knee replacement				58.9		41.1
Revision/complex total hip replacement				75		25
Revision/complex total knee replacement				80		20
Unicompartmental knee replacement				50		50

SD, standard deviation from the mean.

Some 44/53 (83%) of patients awaiting primary THR wished to proceed with surgery compared with 33/56 (58.9%) awaiting primary TKR (Table 2). Furthermore, aged 70 years and below awaiting primary THR were statistically more likely to proceed with surgery than those awaiting primary TKR in the same age group (87.9% vs 57.1%, P = 0.007). Within this age group, there was no statistical difference between the primary THR and primary TKR group for sex (P = 0.993), ASA (P = 0.41), COVID-19 risk or NRS score (P = 0.62).

Table 2 .

Subgroup analysis (primary total hip replacement vs primary total knee replacement)

	Wished to proceed with surgery (age ≤ 70 years)			Wished to proceed with surgery (age > 70 years)
Demographic	Primary THR (%)	Primary TKR (%)	P-value	Primary THR (%)	Primary TKR (%)	P-value
Wished to proceed with surgery	87.9	57.1	0.007	75	60.7	0.3
Male sex	32	39	0.993	30	32	0.875
ASA grade:			0.41			0.11
1/2	67	68		45	32
3/4	33	32		55	68
Numerical rating scale			0.62			0.68
High COVID-19 risk	21.2	21.4	038	11.3	11.7	0.19

ASA, American Society of Anesthesiologists; THR, total hip replacement; TKR, total knee replacement.

Patients aged over 70 years were more likely to wish to undergo primary THR compared with primary TKR (75% vs 60.7%), but this result was not statistically significant. (P = 0.3) Within this age group, there was no statistical difference between the primary THR and primary TKR group for sex (P = 0.875), ASA P = 0.11), COVID-19 risk or NRS score. (P = 0.68).

Of the patients awaiting complex/revision THR, 12/16 (75%) wished to proceed with surgery, as did 4/5 (80%) of those awaiting complex/revision TKR and 3/6 (50%) of those awaiting UKR. Of the 40/136 (29.4%) who did not wish to proceed, 30/40 wished to be followed up in 6 months and 10 wished to be discharged altogether (Table 3). The majority of these patients (75%) cited concern over perioperative COVID-19 risk as the reason not to have surgery; 10% cited the adequacy of personal protective equipment, while 20% cited the two-week preoperative self-isolation.

Table 3 .

Patient concerns among groups who did not wish to proceed with surgery

	Patients who wished to reassess in 6 months
Primary reason for not wishing to proceed with surgery	(n)	(%)
Are you concerned that the hospital is not adequately equipped with personal protective equipment?	4/30	10
Are you concerned about the two-week preoperative self-isolation period? (total)	8/40	20
Are you concerned about the risk of contracting COVID-19 while having your operation?	30/40	75
Are you concerned about not having any visitors during your inpatient stay?	1/40	5
Are you concerned about there not being enough people to help you recover postoperatively?	0/40	0
Are you concerned about the risks of surgery?	3/40	7.5
Does your pain no longer warrant surgery?	3/40	7.5
Total patients not wishing to proceed	40/136	29.4

Discussion

The results of this study suggest that the majority of patients awaiting hip and knee arthroplasty on an NHS waiting list are willing to proceed with surgery in the current climate. Having been informed that perioperative COVID-19 infection could carry with it a mortality of up to 20%, 70.6% of patients still wished to proceed with surgery as soon as possible. In this context, this is nearly a 100-fold increase in mortality rate if a patient contracts coronavirus perioperatively compared with the pre-COVID-19 era of 1/400 quoted generalised mortality risk.¹⁰

There was no statistical correlation between ASA score, COVID-19 risk and willingness to proceed with surgery. Those who wished to proceed were on average 3.9 years younger, though this is unlikely to be an age gap of clinical significance. Of the 29.4% that did not wish to proceed with surgery, the majority were concerned primarily with the risk of perioperative COVID-19 infection. The need for perioperative self-isolation was also a cause of rejection of surgery.

The significantly higher NRS score in the patient group remaining on the waiting list is an evocative reminder of the degree of pain that patients waiting for arthroplasty undergo. They also suggest that those awaiting THR were more willing to undergo the risks than those awaiting TKR. When stratified by age, patients aged 70 years or younger were significantly more likely to wish to undergo primary THR than TKR. This was independent to ASA, COVID-19 risk or sex. This is in line with previous data suggesting that 19% of THR and 12% of TKR experience ‘worse than death’ pain while awaiting arthroplasty.¹³ However, we are not aware of any study that reveals a distinction between the willingness to undergo the risks of surgery of patients needing THR and TKR. The COVID-19 pandemic has presented a unique opportunity to explore patient's desire for joint replacement surgery under a new set of circumstances, and as such this paper opens a potentially novel discussion regarding the urgency of THR compared with TKR.

It is perhaps surprising that there is no clear correlation between those patients who are in at-risk groups and those who are concerned about proceeding with surgery. Comprehensibly, those with lower NRS scores were more likely to opt to reassess the situation in six months or be discharged altogether.

A similar study, published by another group in London, found that 56.8% of patients on a lower-limb arthroplasty and sports waiting list wished to proceed, while 68.6% of those awaiting primary THR and 43.8% of primary TKR wanted to go ahead with surgery.¹⁴ Of note, this group began their census process on 15 May 2020, on the same day that the UK basic number of reproduction was reported to have risen.¹⁵ We began the process of patient interviews on the 23 June when confirmed coronavirus case were reported by the BBC to have fallen to pre-lockdown levels.¹⁶ Public perception of risk, influenced by a rapidly evolving, media reported situation, is likely to play a major role in willingness to proceed with joint replacement surgery. Many patients will now deem the risk to be acceptable to treat their debilitating pain.

Precisely what this risk is, is of course still uncertain. Patients in this study were informed of perioperative COVID mortality of up to 20%, based on the evidence reporting the highest mortality rates.^{3, 17} A study of arthroplasty cases performed during the peak of the outbreak in Northern Italy demonstrated a 1.2% mortality rate after patients contracted COVID-19 during rehabilitation.¹⁸ Clearly while the situation is evolving, and the literature remains in its infancy, healthcare systems are advised to proceed with caution.

This study has several limitations. Perhaps most importantly, observation bias relating to patient's decisions. Being called by a member of the surgical team may have inadvertently pressured the patient into making a decision on their treatment. Patients may have perceived the default option to be proceeding with their planned surgery. Reverting to default is a recognised pattern of behaviour among patients that could affect this study's outcomes.¹⁹ Despite reassurances, patients may have been worried that postponing their surgery could mean not getting it at all. This is particularly relevant given the building media attention on lengthy post-COVID waiting lists.²⁰ The study is limited to a district general hospital in London, where new cases and transmission of COVID-19 are at present among the lowest in the country. The outcomes therefore may not be directly transferable to other parts of the globe. The NRS, derived from the visual analogue scale, is a well-recognised tool, but such scores are limited to pain severity, do not assess function and are prone to bias.^{21, 22} Notably, the mean NRS scores among patients awaiting primary THR and primary TKR were similar, despite the difference in willingness for surgery. This highlights the limitations of the NRS as a functional scoring tool, but also that it cannot always be used to compare different ‘types’ or sites of pain.

Further research should primarily focus on the perioperative risks of a COVID-19 infection and its long-term sequalae, particularly in major joint arthroplasty. With resurgences and second waves, and in the absence of a widely available vaccine, this will allow surgeons and patients to make informed decisions in an uncertain landscape. As extensive backlog on arthroplasty waiting lists may continue, further study into the effect of delay on patients’ quality of life, mental health and on surgical outcomes will ensure that treating the continuing epidemic of degenerative joint disease remains at the forefront of planning for healthcare systems.

Conclusions

The majority of patients awaiting hip and knee arthroplasty are keen to proceed with surgery as soon as possible in the current peri-COVID-19 climate. Patients awaiting primary THR may be more willing than those needing primary TKR to undertake perceived greater risks from surgery in the hope of a better quality of life. This pilot study opens the door for further research into COVID-19 risk surrounding arthroplasty, the effect of delays on patients and on their willingness to have surgery.