The question: My knee replacement surgery was postponed because of the COVID-19 pandemic. I’m not sure when it will be rescheduled. The pain in my knee is excruciating. What am I supposed to do in the meantime?

The answer: You’re certainly not alone. Many elective – or non-emergency – procedures were put on hold when hospitals cleared the decks to make way for COVID-19 patients during the various waves of the pandemic.

And patients waiting for knee and hip surgery were disproportionately affected by these delays, says Dr. Mohit Bhandari, president of the Canadian Orthopedic Association.

As hospitals grappled with limited operating room time, priority was usually given to patients needing immediate and potentially life-saving surgical care.

Knee and hip replacement cases tended to be deferred because they were “perceived as being lifestyle surgeries, which is the furthest thing from the truth,” says Dr. Bhandari. “They’re restorative surgeries for debilitating conditions.”

“This unfortunate ‘lifestyle’ branding has de-prioritized some of these patients who are truly in agony.”

Before the pandemic, the waiting time for knee and hip operations ranged from six to 12 months. That wait will now be substantially longer until the backlog of cases is cleared, Dr. Bhandari says.

Orthopedic surgeons worry that their patients will continue to deteriorate during the delay.

It’s critically important that patients who need either a knee or hip replacement keep physically active, says Dr. Vickas Khanna, an orthopedic surgeon and assistant professor at McMaster University in Hamilton.

A targeted exercise program strengthens the muscles that support the knee or hip and can actually reduce pain. What’s more, exercise helps maintain a healthy weight so there is less pressure exerted on problem joints.

Doctors usually recommend low-impact activities such as using elliptical machines, swimming, cycling, walking and Tai Chi.

However, Dr. Khanna readily acknowledges, “it’s hard to tell patients to exercise when they can barely move a knee or hip.”

In such cases, doctors might suggest various treatments to ease discomfort.

“Each option has pros and cons,” explains Dr. Khanna, adding that they may provide only “minimal benefit in people with severe degenerative changes in their joints.”

The therapies include:

  • An injection of cortisone into the joint can reduce inflammation and stiffness for four to eight weeks. But cortisone must be used judiciously. Research suggests repeated shots may accelerate the deterioration of cartilage, the shock-absorbing material between the bones.
  • An injection of hyaluronic acid works for about six months. It’s a synthetic material that mimics the natural lubricating fluid found inside healthy joints. Unlike cortisone, hyaluronic acid is not associated with cartilage breakdown. But the cost is not covered by most provincial health systems. Some private insurance plans will pick up the tab. Patients without such coverage will pay about $500 out of pocket for the treatment.
  • Platelet-rich plasma, or PRP, is said to harness the body’s own healing powers and can ease pain and inflammation for six to 12 months. Blood is drawn from the patient and put into a centrifuge. The machine spins the blood, separating it into different parts. Some of the components, such as platelets and growth factors, are used to produce the PRP, which is then injected into the sore joint. Sometimes multiple injections are given over a course of several weeks. Each injection costs between $500 and $700.

Dr. Moin Khan, an orthopedic surgeon and assistant professor at McMaster University, says the effectiveness of the injections, particularly in the case of PRP, can vary from patient to patient. “There are different commercial formulations of PRP on the market,” he says, adding that there’s a lack of high-quality comparative studies showing which one is best.

In addition to injections, doctors might recommend a custom-made brace that redistributes the weight on an unevenly worn joint. But, once again, price may be an issue for certain patients. “A carbon fibre medical-grade brace can cost $1,500,” Dr. Khanna says.

There’s no doubt the expense of some of these specialized therapies will put them out of reach of many individuals.

Even so, “there are lots of things people can do on their own to maintain their muscle strength,” says Dr. Jihad Abouali, an orthopedic surgeon and assistant professor at the University of Toronto.

He notes that the Canadian Arthritis Society website provides information about home-based exercises for knees and hips.

And, for pain control, doctors often suggest topical analgesics because prolonged use of non-steroidal anti-inflammatory pills can cause stomach problems.

Despite their best efforts to stay fit, some patients “are going to get worse while on the waiting list,” Dr. Bhandari says. He feels every effort must be made to provide them with “restorative” surgery. “Patients in pain can’t wait.”

Paul Taylor is a former patient navigation adviser at Sunnybrook Health Sciences Centre and former health editor of The Globe and Mail.

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The Globe And Mail

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