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BackgroundThe COVID-19 pandemic has impacted health, economies and the functioning of societies globally. In addition to direct health effects, it has indirectly impacted population health by limiting access to non-COVID treatments, including joint replacements. The pandemic has necessitated re-organisation of healthcare with the private-sector providing support to public hospitals in some areas. The full impact is therefore difficult to ascertain from public data sources alone.MethodsWe used a mandatory prospective national register of private and publicly funded hip, knee, shoulder, elbow and ankle replacements in England, Wales and Northern Ireland. Descriptive analysis of the provision of joint replacement comparing data from 2019 to 2020 and predicted deficit recovery.FindingsThere was a substantial deficit in the provision of joint replacement in 2020 compared to 2019 with 106,922(48.8%) fewer procedures performed; resulting in 45,116 (44%) fewer hip replacements, 57,115(52%) fewer knee replacements, 3,878(50%) fewer shoulder replacements, 280 (33%) fewer elbow replacements and 533(53%) fewer ankle replacements performed. Wales and Northern Ireland were disproportionately affected with an overall reduction of 8,001(67%) and 2,833(64%) respectively compared to 96,088(47%) in England.An immediate 5% expansion in provision from the 2019 baseline will eliminate the deficit over approximately 10 years (by 2031), whilst a 10% expansion will address the deficit by 2026. InterpretationThis large national analysis of both private and publicly funded joint replacements illustrates a substantial accumulated deficit of surgery, equivalent to six-months of normal activity across England, Wales and Northern Ireland, due to the indirect effects of COVID-19. As the pandemic evolves, further waves of infection are likely to restrict surgery and see the deficit increase, therefore projections of time taken to address the deficit must thus be regarded as the best-case scenario. A significant expansion of joint replacement services compared 2019 is urgently required to address this deficit. FundingThis study was supported by the NIHR Biomedical Research Centre at University Hospitals Bristol and Weston National Health Service Foundation Trust and the University of Bristol. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. This study was also supported by funding from the National Joint Registry. Posts of authors of this work are part funded by a grant from the National Joint Registry to conduct statistical analysis for the National Joint Registry. This study was supported by the NIHR Biomedical Research Centre at Oxford University Hospitals NHS Foundation Trust and the University of Oxford. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

Objective To evaluate whether a progressive course of outpatient physiotherapy offers superior outcomes to a single physiotherapy review and home exercise based intervention when targeted at patients with a predicted poor outcome after total knee arthroplasty. Design Parallel group randomised controlled trial. Setting 13 secondary and tertiary care centres in the UK providing postoperative physiotherapy. Participants 334 participants with knee osteoarthritis who were defined as at risk of a poor outcome after total knee arthroplasty, based on the Oxford knee score, at six weeks postoperatively. 163 were allocated to therapist led outpatient rehabilitation and 171 to a home exercise based protocol. Interventions All participants were reviewed by a physiotherapist and commenced 18 sessions of rehabilitation over six weeks, either as therapist led outpatient rehabilitation (progressive goal oriented functional rehabilitation protocol, modified weekly in one-one contact sessions) or as physiotherapy review followed by a home exercise based regimen (without progressive input from a physiotherapist). Main outcome measures Primary outcome was Oxford knee score at 52 weeks, with a 4 point difference between groups considered to be clinically meaningful. Secondary outcomes included additional patient reported outcome measures of pain and function at 14, 26, and 52 weeks post-surgery. Results 334 patients were randomised. Eight were lost to follow-up. Intervention compliance was more than 85%. The between group difference in Oxford knee score at 52 weeks was 1.91 (95% confidence interval −0.18 to 3.99) points, favouring the outpatient rehabilitation arm (P=0.07). When all time point data were analysed, the between group difference in Oxford knee score was a non-clinically meaningful 2.25 points (0.61 to 3.90, P=0.01). No between group differences were found for secondary outcomes of average pain (0.25 points, −0.78 to 0.28, P=0.36) or worst pain (0.22 points, −0.71 to 0.41, P=0.50) at 52 weeks or earlier time points, or of satisfaction with outcome (odds ratio 1.07, 95% confidence interval 0.71 to 1.62, P=0.75) or post-intervention function (4.64 seconds, 95% confidence interval −14.25 to 4.96, P=0.34). Conclusions Outpatient therapist led rehabilitation was not superior to a single physiotherapist review and home exercise based regimen in patients at risk of poor outcomes after total knee arthroplasty. No clinically relevant differences were observed across primary or secondary outcome measures. Trials registration Current Controlled Trials ISRCTN23357609 and ClinicalTrials.gov NCT01849445 .