Symptom management for patients awaiting joint replacement surgery

Abstract

Background Joint replacement surgery is a highly effective treatment option for patients with severe osteoarthritis (OA) of the hip and knee when other treatments have failed. Unfortunately, as a result of the COVID-19 pandemic, a temporary suspension of non-urgent elective surgery was implemented. Thousands of patients currently awaiting hip and knee replacements have been affected. Many of these patients will present to their general practitioners for symptom management during this interim period. Objective The purpose of this article is to summarise current recommendations for the non-operative management of patients with symptomatic OA. Discussion Non-operative treatment modalities for OA include education, lifestyle modification and exercise, mass reduction, physiotherapy, orthoses, psychology, pharmaceuticals and injections. Multimodal therapy is required for patients with severe symptoms. A number of useful online resources are presented, as access to public allied health services may be limited because of the COVID-19 pandemic. OSTEOARTHRITIS (OA) of the hip and knee are common orthopaedic conditions, frequently causing pain and disability. The incidence of OA is steadily increasing. 1 Joint replacement surgery has revolutionised the management of OA but should be reserved for patients who have not responded to non-operative therapies. Joint replacement is very cost-effective and provides long-term improvements in pain, mobility and quality of life for most patients. 2,3 In Australia, more than 105,000 primary and revision hip and knee replacements were performed in 2018, and approximately 35% of these operations were performed in the public sector. 4,5 The projected burden of primary total hip and knee replacement in Australia is expected to increase by 208% and 276%, respectively, by the year 2030. 6 Unfortunately, as a result of the COVID-19 pandemic, a nationwide, temporary suspension of non-urgent elective surgery was implemented. Thousands of patients waiting for joint replacement surgery have been affected. Although the restrictions are being eased, patients may still experience delays as health services manage their waiting lists. Many affected patients will present to their general practitioners for symptom management in the interim period. The purpose of this article is to discuss non-operative management options for patients with severe OA. Although prompted by recent elective surgery suspensions, the principles presented are equally applicable to patients who are unfit for surgery, or patients using the public system who may wait 365 days for their joint replacement, according to National Categorisation Guidelines. 7

Management of Outpatient Elective Surgery for Arthroplasty and Sports Medicine During the COVID-19 Pandemic: A Scoping Review

“…The distribution in level of evidence was as follows: 14% (n = 4) of articles were level 3, 8 , 10 , 12 , 30 14% (n = 4) were level 4, 13 , 16 , 18 , 31 and 72% (n = 21) of articles were level 5. 1 - 7 , 14 , 15 , 17 , 19 - 29 The majority of studies were categorized as expert opinion/societal guidelines (55%). The most common theme among articles was general management recommendations on the resumption of elective arthroplasty and sports medicine surgery (n = 11 articles).…”

“… 13 , 16 Uncontrolled pain leads to increased use of analgesics and opioids, placing patients at increased risk of opioid tolerance and addiction. 12 , 13 , 16 , 29 One institution surveyed patients awaiting elective joint replacement during the COVID-19 pandemic and found that 23.4% of patients reported an increase in dose or frequency of pain medication consumption after being told surgery was delayed, with 21.6% of patients surveyed using opioids to manage their arthritis pain. 31 Less mobility and functional limitations can cause lack of independence during a time of increased social isolation and lead to the development of flexion contractures and loss of muscle mass, making postoperative rehabilitation more difficult.…”

“…Nonopioid agents such as acetaminophen, nonselective and cyclooxygenase 2— selective nonsteroidal anti-inflammatory drugs (NSAIDs), and topical NSAIDs and capsaicin can provide pain relief and reduce swelling. 24 , 29 Pain relief after injections of corticosteroids or high molecular weight hyaluronic acid is variable and often temporary, which may manage symptoms successfully until surgery can be scheduled. 24 , 29 The American Academy of Orthopaedic Surgeons has released a statement in regard to the use of corticosteroids for musculoskeletal care in the setting of COVID-19, reporting a lack of evidence demonstrating potential harm or increased risk of COVID-19 with intra-articular injections of corticosteroids.…”

“… 24 , 29 Pain relief after injections of corticosteroids or high molecular weight hyaluronic acid is variable and often temporary, which may manage symptoms successfully until surgery can be scheduled. 24 , 29 The American Academy of Orthopaedic Surgeons has released a statement in regard to the use of corticosteroids for musculoskeletal care in the setting of COVID-19, reporting a lack of evidence demonstrating potential harm or increased risk of COVID-19 with intra-articular injections of corticosteroids. 1 However, caution is recommended, and robust discussion with patients regarding the potential risks and alternative treatments is critical.…”

Osteoarthritis, COVID-19 Social Isolation-Impacts, and Counter Solutions

“…Resources and personnel to monitor and optimize air quality Information on safety issues and use of vitamin D/ other supplements Information on the harm of excess opioid usageBox 2Possible socially supportive protective factors providers can foster in efforts to improve anxiety control, stress, pain control, adherence to selfprotection/management strategies, sleep hygiene, immunity, and depression among isolated older adults with osteoarthritis[32, 44,51,55] …”