Elective, but not optional: Orthopedic patients eagerly await surgeries delayed by Covid-19

Robin Young wants you to know she thinks her second knee replacement is the least important thing in the world. While hospitals are caught in the grips of a Covid-19 surge that is straining their capacity, she doesn’t compare her pain to the life-and-death struggles that have erased most elective surgery from hospital booking calendars.

“I’d give up a bed for somebody struggling to breathe,” she said. “Gladly.” 

Still, she has endured months of daily bone-on-bone pain that makes every footfall hurt, and takes ibuprofen to get through the day. So the Boston-based host of the NPR and WBUR news program “Here & Now” was excited that an operation canceled in December was rescheduled for February. “If you need an elective surgery,” she said, “there’s a good chance that whatever you need it for isn’t getting better.”

She’s not alone. More than 100 U.S. hospitals have put elective surgeries on hold indefinitely. It’s a decision few would question as ambulances are turned away from emergency departments throughout Los Angeles and small hospitals in Texas have flown their patients to other states to find open beds. Elective doesn’t mean optional; for some people anticipating operations to ease their pain or halt their disease, hospitals’ decisions about what’s elective involves a grim calculus of how long they can wait.

Even some organ transplantation can fall into the elective category. Dialysis, for example, can keep someone alive while waiting for a kidney transplant. That makes the surgery “life-enhancing” versus “lifesaving.”

In orthopedics, the question seems simpler, but isn’t always so clear-cut. Joint replacements and other musculoskeletal repairs understandably take a backseat to traumatic injuries. Hip fractures after a fall raise the risk of dangerous blood clots in older adults, making their prompt treatment lifesaving. At any age, a herniated disc puts a patient’s spinal cord at risk of paralysis, arguing for a speedy resolution.

The wave of Covid-19 patients now deluging hospitals is creating a mounting backlog of elective cases doctors have decided can be put off for weeks or months. It is also dismaying many patients.

Ron Navarro, an orthopedic surgeon and regional chief of orthopedics for Kaiser Permanente’s 13 medical centers across Southern California, has to explain the gravity of the situation to patients whose procedures have been postponed.

“I tell them, sir or ma’am, there are simply no nurses in the operating room area. We cannot do yours.’” he said. “If a nurse is no longer in a unit to help us in the operating room or postoperatively, we just simply can’t do the case.”

There are differences in the current pause compared to last spring’s hiatus in elective surgery, surgeons told STAT. 

As the pandemic overwhelmed hospitals from March through May, shortages of PPE to protect health care workers and ICU equipment to help patients breathe were matched by the thinning ranks of health care workers who weren’t sickened by the virus, said Felix Savoie, chair of orthopedic surgery at Tulane University. Without widespread testing available even to hospitals, patients were assumed to be contagious. That meant full precautions and scarce protective equipment had to be deployed every time, for every patient, exacerbating the shortage.

Meanwhile, patients waited. All kinds of procedures were pushed into the summer and fall. In some states, the governor was the one who ordered elective surgeries to halt to keep hospital beds open for Covid patients. In others, hospital leaders made the call. Surgeons weighed how long each patient could wait — at least eight weeks meant the elective category.

Covid-19 treatments, testing, and PPE supplies have all improved, but crowded hospitals and their exhausted staffs are closer to their limits.

So are patients.

Some people waiting for knee replacements or shoulder surgery don’t want to go anywhere near hospitals or even their doctors’ offices for fear of Covid-19 infection — despite safety measures put in place. Other people disabled by pain wait in near-desperation as they lose the power to travel beyond their homes’ four walls. Almost a year into the pandemic, some patients are moving from one camp to another, flipping from deciding to wait to pressing for a surgery date. Mental fatigue and physical pain are both taking a toll, said Savoie. 

“We’re doing a guy tomorrow that put his surgery off nine months because of the pandemic. And then he called back and said, ‘Look, I hurt. I’m tired of this,’” Savoie, whose hospital is still doing elective procedures, told STAT in early January. “One guy said, ‘I don’t care if I die afterwards. I’ve got to get this.’” 

When stratifying patients for surgery, Javad Parvizi, an orthopedic surgeon at the Rothman Orthopaedic Institute of Jefferson University in Philadelphia, considers more than physical exams or imaging studies. He worries about people who live at home in isolation, without someone to care for them as their mobility diminishes. Other patients can’t return to work because of their joint pain while they wait for a knee or hip replacement.

“It is not seen as lifesaving, but it certainly impacts the lives of our patients,” Parvizi said. “These people have difficulty going up and down stairs. They’re having a difficult time sleeping at night. Patients with hip arthritis are unable to get in and out of a car to drive themselves to the supermarket to buy food.”

Still, if patients have severe comorbidities or lower immune function and their need for surgery is not an emergency, Paravizi and his colleagues are recommending that these patients wait until the pandemic is under better control. 

For patients who are waiting — voluntarily or not — there are some strategies to help relieve their pain. Doctors are reluctant to prescribe opioids for fear of addiction, so they suggest milder analgesics or anti-inflammatory drugs. Steroid injections into a joint can help. So can physical therapy or exercising in a pool, if either one isn’t shut down. 

“Unfortunately, these chronic conditions are really not curable until the patient has the surgery,” Parvizi said. 

Young of “Here & Now” looks forward to the day she can stop relieving her pain with ibuprofen, only half-joking that she’ll be getting a new knee but losing a kidney from the painkiller’s side effects from heavy use.

Tulane’s Savoie looks at another potential price of delay. If someone falls off a ladder and tears the rotator cuff in the shoulder or a knee ligament, those injuries often require surgical repair — eventually. A brace can help, as can crutches, but another slip can do further damage.

Patients waiting for a hip replacement can be so hobbled by their pain that their muscles become deconditioned, making their eventual recovery from surgery longer, Savoie said, stretching three to four months into something like 12 to 24 months.

While Kaiser Permanente’s Navarro isn’t concerned about degeneration if the delay isn’t indefinite, he does acknowledge patients’ pain.

“For the person who’s had arthritis of their knee for many, many years and it’s certainly worse now, it may be harder to walk, I feel bad that we have to put them off,” he said. “By putting them off, we’re not going to change the natural history of the disease or make the operation harder.”

Meanwhile, he’s helping hospital staff do phone triage for patients worried they might have Covid-19 and filling shifts in the emergency department.

“Some patients are unwilling to wait and they’ve become less understanding of Covid because they’ve been put off for six, eight months now,” Navarro said. “We have to deal with them any way we can.” 

Young has been willing to wait, certain that other people have endured delays in getting more serious elective surgery. But a few days after securing the new date for her knee replacement in February, it was called off again, in light of rising Covid cases at the hospital. Now she’s looking — skeptically — at mid-March. Still, she’s anticipating the future. 

“I’m going to be swimming in Walden Pond, I’m going to be hiking in a few months, and I’m going to be dancing and wearing high heels,” Young said. “I don’t have any complaints.”