Oxford hip and knee scores deteriorate in patients awaiting lower limb arthroplasty during the COVID-19 pandemic and predict a health state ‘worse than death’

Abstract

AimsThe COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD).MethodsIn this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L.ResultsA total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity).ConclusionOHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data.Cite this article: Bone Jt Open 2023;4(3):138–145.

Socioeconomic deprivation is associated with worse health-related quality of life and greater opioid analgesia use while waiting for hip and knee arthroplasty

“…33 Although we found no difference in waiting times between deprivation quintiles, all patients in our region are waiting a long time for TJR (5.5 years in some cases) while enduring chronic pain and impaired mobility; therefore, a detrimental effect on physical and mental health is unsurprising. Overall, 39.2% of patients waiting for TJR were in a state WTD, higher than the figures reported by other authors, 6,8,34 demonstrating the impact of unacceptably long waiting lists. Prior to the COVID-19 pandemic, 19% and 12% of patients waiting for THA and TKA, respectively, had WTD health states.…”

“…8 During the COVID-19 pandemic, this increased to 22% and 35% of patients awaiting TKA and THA, respectively. 6 Similarly, Clark et al 34 in 2023 found that overall, 29% of 174 patients waiting for THA, TKA, and unicompartmental knee arthroplasty during the COVID-19 pandemic were in a state WTD. A significantly smaller proportion of the least deprived patients in our study were living in a state WTD (29.5%) compared to all other deprivation quintiles (41.3%).…”

“…35 Edwards et al 36 in 2018 also reported worse preoperative OKS in TKA in the most deprived patients. 36 Clark et al 34 reported that the overall mean OHS/OKS deteriorated significantly from 15.43 when patients were added to the waiting list, to 11.77 14 months into the COVID-19 pandemic. The median Oxford scores in the current study of 9 or 10 highlight the poor function of patients waiting for surgery in our region.…”