The study sought to understand the self-management strategies used by patients during the postponement of their total knee arthroplasty (TKA) procedure, as well as the associations between the length of waiting time, pain, and physical frailty and function. The study focused on individuals aged 50 years and above, as they are known to be more vulnerable to the negative impacts of delayed elective surgery and rehabilitation. This study hypothesizes that delayed TKR due to coronavirus disease 2019 (COVID-19) will bear negative effect in self-management, pain, and physical frailty and function in older adults.

To investigate the effects of COVID-19 pandemic on self-management, pain, and physical function in older adults awaiting TKA in Malaysia.

This cross-sectional study has the data of participants, who matched the criteria and scheduled for TKA for the first time, extracted from the TKA registry in the Department of Orthopaedics and Traumatology, Hospital Canselor Tuanku Mukhriz. Data on pain status, and self-management, physical frailty, and instrumental activities daily living were also collected. Multiple linear regression analysis with a significant level of 0.05 was used to identify the association between waiting time and pain on physical frailty and functional performance.

Out of 180 had deferred TKA, 50% of them aged 50 years old and above, 80% were women with ethnic distribution Malay (66%), Chinese (22%), Indian (10%), and others (2%) respectively. Ninety-two percent of the participants took medication to manage their pain during the waiting time, while 10% used herbs and traditional supplements, and 68% did exercises as part of their osteoarthritis (OA) self-management. Thirty-six participants were found to have physical frailty (strength, assistance with walking, rising from a chair, climbing stairs, and falls questionnaire score > 4) which accounted for 72%. Increased pain was associated with physical frailty with odds ratio, odds ratio (95% confidence interval): 1.46 (1.04-2.05). This association remained significant even after the adjustment according to age and self-management.

While deferring TKA during a pandemic is unavoidable, patient monitoring for OA treatment during the waiting period is important in reducing physical frailty, ensuring the older patients’ independence.

Late December 2019, a viral infection, novel coronavirus which is known as coronavirus disease 2019 (COVID-19) was detected with cases emerging from Wuhan, China[1]. According to the World Health Organization, as of 20^th October 2021, there had been more than 241 million confirmed cases around the world, with more than 4 million deaths reported. The first reported COVID-19 case in Malaysia was on 25^th January 2020 with a history of close contact with an infected person in Singapore[2]. Due to the emergence of the pandemic, elective surgery and rehabilitation were interrupted. Hospitals were converted into COVID hospitals, and procedures and outpatients’ appointments were postponed or cancelled. Individuals with chronic conditions such as osteoarthritis (OA) may have been impacted by these circumstances.

The prevalence of OA increases with age, making it one of the most common joint complaints among older adults. OA is characterized with articular cartilage deterioration and persistent pain, the debilitating symptoms may cause reduce physical function, disability, poor quality of life and depression in long run[3]. As a disease of whole joint, there are multiple structural factors associated with OA. Nevertheless, pain generally becomes more intense and frequent as OA worsens[4]. With a global incidence of 203 cases per 10000 and 654.1 million knee OA cases reported worldwide in 2020, it’s an important issue to address[5]. For those with severe knee OA, who have not responded well to non-operative treatments, total knee arthroplasty (TKA) may be the only option available. However, during the COVID-19 pandemic, TKA operations have been postponed and delayed globally, with data from low-middle income countries such as Malaysia not yet well studied[6]. In the United States, 30000 primary and 3000 revision total joint arthroplasty procedures were cancelled weekly and around 92.6% of primary total joint arthroplasty procedures were cancelled in Europe[7].

Our goal is to explore how the COVID-19 pandemic has affected patients in need of TKA by examining the self-management practices they have adopted, as well as how these practices have influenced the relationship between waiting time, pain, physical frailty, and function in individuals over the age of 50 seeking TKA at the Hospital Canselor Tuanku Mukhriz (HCTM), which is a tertiary urban hospital in Kuala Lumpur.

Out of the 180 patients who had deferred TKA, 50% were aged 50 years and older (Figure 1). Of the 50 participants successfully contacted, the mean age was 68.7 (SD 6.97). Half of the participants were waiting for TKA surgery for 12 mo or more. The highest waiting period among participants was 14 mo, with the lowest waiting times being four, seven, nine, and 12 mo (Figure 1).

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Figure 1 Number of patients according to their waiting time for total knee arthroplasty.

Most of the included participants were female, with a total of 40 (80%) and belonged to the Malay ethnicity (66%), Chinese (22%), Indian (10%), and others (2%) respectively. Participants were mostly married, with 86% of them living with their spouses. 30 participants had pursued their studies at the tertiary level (30%) while 44% had finished secondary school, 20% at the primary school level, and 6% had not received any formal education. Most participants were retired, with 86% of them, while 8% were still working. The most common medical conditions presented among the participants were hypertension (70%), followed by hypercholesterolemia (44%), and diabetes (40%). The percentage of the duration of OA was the same for durations below one year and within one to three years, with 42%, while participants who had been diagnosed with OA for more than three years were 16% (Table 1).

Data on self-management showed that 92% of the participants took medication and only a handful of them took alternative medicine such as ointment and herbs (10%). More than half of the participants (68%) did exercise on a daily basis. According to pain severity using VAS as a measurement tool, the median (range) for pain intensity was 7 (6.0-8.0). For the subtype of KOOS, the median (range) for KOOS pain was 14 (9.75-19.25), KOOS symptoms 11 (9-12), KOOS function 19.5 (14-30), and KOOS quality of life 9 (8-10.25) respectively. In activity of daily living, shopping appeared to be the most challenging task with 68% unable to perform, followed by food preparation (38%) and laundry (22%) respectively. In physical frailty, by using SARC-F as a measuring tool, 86% of participants were unable to climb stairs, and 20% of participants were able to walk without assistance or walking aids. Among 50 participants, 72% of them were found to have physical frailty with a SARC-F score of more than 4 (Table 2).

Our study found that among patients who had their TKA surgery deferred during the COVID-19 pandemic, there was a significant association between pain intensity and physical frailty, as measured by the odds ratio of 1.46 (95% confidence interval: 1.04-2.05). This association remained significant even after adjusting for factors such as age and self-management practices. However, we did not find a significant association between waiting time for TKA surgery and poor physical function or frailty (Table 3).

The current study found that, in our setting, the procedure of TKA was delayed due to the pandemic, and our patients undertook self-management to cope with the conditions such as exercise and medication. Despite efforts to manage pain through self-care measures, there was a strong correlation between pain intensity and poor functional status. This suggests that a lack of proper pain management during the waiting period for surgery greatly impacted these patients’ overall function.

Our results align with those of previous studies conducted in developed countries, which have shown that delaying elective surgery during the COVID-19 pandemic can have a detrimental effect on patients’ quality of life, overall health, and independence[12-14]. Specifically, our study observed that the functional status of patients who were waiting for TKA to be rescheduled was poor. This could be due to chronic conditions of OA related symptoms which can greatly affect their daily activities[15]. However, the length of TKR waiting time does not reflect pain intensity, which is in line with previous systematic review[16]. The severity of OA required to be referred to TKR was argued due to underuse of nonoperative treatments beforehand. This might influence the pain intensity reports arose from varied disease progression[17].

Despite the widespread postponing of elective surgeries during the COVID-19 pandemic, a limited number of studies suggest that such surgeries may be safely carried out with appropriate precautions in place. For example, a retrospective study found that elective surgeries could be resumed with additional precautions taken[18]. Furthermore, some research has indicated that elective surgeries can proceed as scheduled if the patient tests if the patient priorly tested positive for COVID-19, with a certain period of time having passed, such as seven weeks or more. In the United Kingdom specifically, one study found that the 30-d mortality rate after elective surgery was lower among patients who had surgery at seven weeks or more post-positive COVID-19 test results compared to those who underwent surgery within six weeks of a positive test result, with a 3.5 to 4 times higher risk of death[19]. Another study supports that waiting seven weeks or more after a COVID-19 infection to undergo surgery may be optimal[20]. Despite the spike in COVID-19 cases, older patients with severe OA may still opt to undergo surgery depending on their level of pain[21].

Exercise, by improving neuromuscular control, joint range of motion and strengthening muscle, helps in managing pain, improving functional status and quality of life of people with knee OA, especially elderlies with multitube of comorbidities[22,23]. Although exercise is the most recommended therapy for TKA postponement during COVID-19, a study suggests that proper nutrition, and the use of corrective and assistive orthotics as additional equipment may help in reducing OA pain[24]. Remote telecommunication consultation to serve patient education was also suggested[25]. There was also a study that found patients who experienced an unexpected surgical delay during the COVID-19 pandemic improved physical function and prevented a decline in patient-reported outcome measures using a psychological intervention delivered via a text messaging robot[26].

This study did not find significant association between waiting time for TKA surgery and poor physical function or frailty, suggesting the postponement was not the main factor that bore negative effect on self-management, pain, and physical function in older patients aged 50 and above. Nevertheless, the significant association between pain and physical frailty highlights the importance of closely monitoring these patients for OA pain management during the waiting period to prevent declines in physical function and frailty, and to maintain their independence. Additionally, this research may aid healthcare providers in creating emergency protocols for future pandemics that may cause further postponements of elective surgeries. Such protocols should prioritize older patients for TKA procedures and emphasize thorough monitoring of OA pain management.