Chronic pain in patients where knee joint replacement surgery is delayed due to the impact of COVID-19 on healthcare provision.

COVID-19 has delayed joint replacement surgery (arthroplasty) in many patients suffering from chronic joint pain secondary to osteoarthritis. It remains to be seen how the NHS will address the current situation, but unfortunately, it seems likely that there will be more delays in the months and years to come, as the prospects of a full return to “normality” remain uncertain and the backlog of patients waiting for elective surgery continues to grow. A moderate delay in knee replacement surgery might not be associated with any clinically significant progression in the underlying osteoarthritis. However, the intrusive chronic pain and the associated functional restrictions can have considerable physical and psychological consequences, which have the capacity to impact significantly on the patient’s health.

Firstly, there is the impact of the loss of muscle bulk, particularly in the quadriceps muscles (quads), both before the surgery and, perhaps even more importantly, after the joint replacement surgery where marked quadriceps muscle weakness can impact considerably on the patient’s physical rehabilitation. In addition, chronic knee pain and loss of strength in the quadriceps muscles will commonly cause patients to compensate by changing their body postures and gait (the manner in which they walk), which in turn leads to secondary musculoskeletal problems with soft tissue inflammation, pain and weakness particularly around the hip girdle and the lower back. These additional problems will also impact negatively upon rehabilitation after joint replacement and so it is essential to prevent their onset where possible or minimise the severity of the condition if it has become established.

Secondly, there is the psychological impact of the relentless joint pain associated with advanced osteoarthritis. Chronic joint pain increasingly restricts daily activities and also interferes significantly with the ability to sleep at night resulting in permanent fatigue/tiredness and yet more reduction in the patient’s overall quality of life. Psychological symptoms, such as anxiety and low mood/depression, are commonly reported in such unsatisfactory circumstances, and impact negatively on the patient’s experience of their pain (their pain feels worse) and also their ability to cope with and manage their ongoing symptoms and associated functional limitations. Added to this, there is also an increased risk of substance misuse (alcohol, opiates and other prescribed and illicit drugs), as patients increasingly struggle to manage the intrusive joint pain and the associated losses in their ability to engage in what were once normal daily activities.

Thirdly, there are the social consequences of suffering from the intrusive chronic pain associated with advanced osteoarthritis. These consequences can often be substantial, not only for those of working age who need to get back to work as soon as they can so that they keep their jobs and the bills can be paid, but also those who are retired from work and wish to remain healthy and happy and maintain their socially active roles within society.

Clearly, the solution must be for the patient to access knee replacement surgery at the earliest opportunity. However, for the many patients who will have to wait for many many months, perhaps even years, for their joint replacement, there is an urgent need for the medical profession to help and support them through what will probably be a very difficult time in their lives.

It is also important to ensure that comorbidity due to the unwanted delay is minimised so that when the time comes for the long-awaited procedure, the patient is in the best possible physical and psychological health. Preventing or minimising further loss of muscle bulk; preventing or minimising painful secondary musculoskeletal conditions and associated muscle weakness; and preventing or minimising significant secondary psychological or psychosocial morbidity will each contribute significantly to achieving a speedier recovery and the best possible outcome after the joint replacement surgery.

Patients must therefore be well supported both physically, through good pain management to minimise their pain and skilled physiotherapy to maintain muscle function and prevent the development of those abnormal postures and gaits that lead to the secondary musculoskeletal issues, and psychologically/psychosocially, through education to promote awareness and understanding so that they can develop their own strategies to help themselves through a very difficult period in their lives. It is also recognised that some patients will need and benefit from a higher level of psychological/psychosocial support from their doctors and other healthcare professionals, including their GP and/or Consultant Pain Specialist, as well as clinical psychologists and other mental health practitioners.

In summary, the experience of chronic pain in patients with advanced osteoarthritis is not simply a matter of the physical pathology within the joint. When definitive surgical treatment with joint replacement is delayed, as has all too commonly been the case during the COVID-19 pandemic to date, there is an important need to ensure that patients are helped through this difficult time through the provision of optimal pain management, active maintenance of musculoskeletal function and ongoing psychological/psychosocial support.

Dr Jon Valentine FRCA FFPMRCA FRCP