As of July 24, 2022, even though 22, 509 published hip osteoarthritis articles have been put forth since 1900, in accord with findings of Quicke et al. 9 very few articles relatively speaking (that is, only 150 listings) currently discuss the topic of COVID-19 (with 298, 2913 postings) relative to osteoarthritis, and especially any aspect of hip joint osteoarthritis (42 articles, with 17 published in 2022), even though all forms of study were deemed acceptable and five data bases listed on the WEB OF SCIENCE CONSOLIDATED were reviewed. As well, even when listed as an article focusing on hip osteoarthritis, not all articles were relevant at all in this regard.

Moreover, even though most hip osteoarthritis sufferers may not require surgery, or surgery may be contra indicated, most currently published articles focused almost exclusively on the impact of COVID-19 on hip joint replacement surgical restrictions, a method of alleviating a high degree of dysfunction in the case of severe hip osteoarthritis pathology 16, but not all. Others discussed methods and approaches for triaging the awaiting body of hip osteoarthritis surgical cases, areas of influence where the ramifications of the COVID-19 virus might however have had one or more associations of relevance for considering a more nuanced disability maintenance or prevention approach to both mitigate excess hip osteoarthritis pathology, as well as to ensure more robust surgical results during any protracted post pandemic surgical waiting period.

As such, and according to the multi layered socio-ecological explanatory model often employed to articulate and examine both health as well as behavioral and environmental disease influences, including individual, political, community, health care service, and family associated realms, one or more of these influential levels of influence may warrant more focused or increased attention in this regard 19. At the same time and as per Quicke et al. 9, as well as Lauwers et al. 17, COVID-19, a viral disease that may never be eradicated, clearly remains a topic of immense worldwide importance to those in public health due to its multiple interactive downstream impacts on multiple levels of society, especially the aging society, as well as on the wellbeing, independence, and life quality of the aging individual. Among the most salient issues in this regard is the impact of COVID on both general health and health behaviors (such as physical activity, dietary intake and healthcare consulting behavior), which in turn, potentially impact suffering, physical impairment, functional independence, deficient energy expenditure, and periods of immense stress, and oftentimes intractable pain.

Indeed, emerging reports from several countries point to a multitude of public policy and organizational changes that have clearly aimed at infection control, but may inadvertently have reduced access to osteoarthritis related healthcare services and green spaces important for wellbeing and physical activity maintenance, and minimizing joint stiffness and swelling, while maximizing muscle strength, endurance, balance, postural control, plus stress control and self-care ability and motivation. Social distancing, and its observed impact on social participation and isolation along with a host of technological substitutes that older adults may be challenged to access and employ, plus a reduced ability to work, may further impact the wellbeing of many older adults suffering from osteoarthritis functional disability, anxiety, stress, and depression, whether or not they have sustained a COVID-19 infection or not 12. Those older adults recovering from COVID-19 infections, but who may require steroid drugs, may also be at heightened risk for future hip degeneration due to their negative impact on reducing bone blood supply 18, while those undergoing surgery may yet be at heightened risk for ICU admissions, and preventable post operative complications 19.

As per Lauwer et al. 17 who discussed recent COVID associated trends, while these accommodations and problems have clearly shifted from dealing with the acute effects of this virus towards the management of its long-term morbidity manifestations, it can be deduced that a fair number of older hip osteoarthritis cases may well be expected to enter surgery, if this is desirable, either with a COVID diagnosis, a deterioration in their pre pandemic symptoms, more fatigue and mental health symptoms, and pain, and may yet acquire this illness on returning home, especially if they are in the older age ranges and have one or more chronic illnesses 20. Moreover, even if no such illness prevails, it can be hypothesized that the COVID-19 virus or its emerging vaccine resistant novel variants can still contribute to age-related perturbations in those endothelial and adipose tissue elements known to characterize the early aging process, and that underlies osteoarthritis susceptibility, in addition to its well established adverse respiratory effects, even when due precautions are taken 21. Huzum et al. 22 have proposed that oxidative stress, metabolism, and even antibiotic resistance might be influenced by either orthopedic conditions such as osteoarthritis or COVID-19 with resulting adverse implications for the sufferers wellbeing that has not been duly investigated to any degree. According to Lauwer et al. 17, this would explain the long-lasting symptoms of COVID-19 that now prevail among some, especially as far as adipose tissue and musculoskeletal tissue are concerned and that may clearly underlie some manifestations of osteoarthritis pathology as well as aging, as well as the joint pain, bone attrition, myalgia, and fatigue accompanying long-COVID 23. As well, compounding this is a possible lack of sunlight exposure, as well as vitamin D access leading to a deficient presence of vitamin D that can increase bone fragility, and calcium deficiency, while fostering joint and muscle pain, as well as COVID-19 risk respectively 24. It also appears that neuronal function may undergo similar perturbations at a molecular level along with the onset and perpetuation of dysfunction and inflammation in response to COVID-19 2526.

Battista et al. 27 who examined the experience of the COVID-19 pandemic as lived by adults with hip and knee osteoarthritis in Italy using a qualitative study approach based on semi-structured interviews showed four predominant themes. (1) Being Stressed due to the Limited Social Interactions and for Family Members at High Risk of Infection. (2) The Need for Recurring Strategies to Cope with the Pandemic. (3) Being Limited in the Possibility of Undergoing Complementary Treatments and Other Routine Medical Visits. (4) Being Unaware of the Importance of Physical Activity as First-Line Interventions. As such it was concluded that the COVID-19 pandemic and related restrictions had clearly impacted the quality of life and the care of individuals with hip and knee osteoarthritis quite markedly and significantly, and in the realm of multiple health behavioral and outcome pathways of influence, especially in the social sphere. However, even though the interviewees tended to develop a ‘good’ level of acceptance in the context of dealing with the pandemic associated restrictions and fears of infection, when it came to their care, they not only faced a delay in their routine medical visits, as well as opportunities for complementary treatments for the osteoarthritis (eg, physical therapies), as well as surgery. As such, it was concluded that more carefully construed policy directives and their implementation, if needed in the future appear imperative, as patients themselves may be passive, rather than active, health care seekers. Moreover, results of surgery, even when carried out, may yet be less profound in fostering physical activity recovery in the post COVID period than anticipated 28. At the same time, as discussed by Folenza et al. 29, postoperative COVID-19 infection remains an important surgical consideration in its own right, and is one associated with higher possible rates of cardiopulmonary complications, renal injury, and urinary tract infections in older cases undergoing hip and/or knee joint replacement. COVID-19 infection earlier in the postoperative period is also associated with a higher risk of ensuing health complications.

Endstrasser et al. 30 who sought to evaluate pain, functional impairment, mental health, and daily activity in patients with end-stage hip and knee osteoarthritis during the COVID-19 lockdown concluded that these lockdowns did appear to have had a significant negative impact on pain, joint function, physical function, and physical activity in patients with end-stage hip and knee osteoarthritis. This study, which included 63 hip or knee osteoarthritis cases scheduled for arthroplasty that was postponed because of COVID-19 showed pain and functional impairment scores tended to increase significantly during the lockdown, while physical activity levels decreased significantly. At the final evaluation, the researchers found the persistent presence of pain and limited physical activity, but surprisingly no mental health symptoms, even though many were anxious to undergo surgery as soon as possible.

Yet, as pointed out by Fahy et al. 15, up to 86% of the osteoarthritis cases they interviewed felt that they were at little to no risk of COVID-19 infection, even though they may have been infected or susceptible to hospital based viral infection 5. Indeed, the majority of patients were happy to proceed with surgery at the current level of COVID-19 risk related threats. Patients with higher levels of perceived health were more likely to postpone their operation than those with lower health perceptions in this regard. Unsurprisingly, the researchers found the cohort had low patient reported outcomes, possibly indicating the significant burden of hip osteoarthritis on both physical and mental health, as well as added COVID-19 restrictions and their actual cumulative possible long lasting health impact. For example, as discussed by Largi et al. 31 the COVID-19 emergency not only resulted in a complete suspension and consequent delay of common planned surgery such total hip replacement in older adults affected by osteoarthritis, but the issue of the quarantine imposed changes to the normal lifestyle of these patients was largely negative in other import self-care spheres. As such and after examining 14 osteoarthritis cases it was concluded that the exceptional COVID-19 pandemic had not only profoundly changed the patients’ lifestyle, but had impacted their normal daily activities as well as regular surgical oriented activity. However, interestingly, the authors found the lifestyle changes imposed by the situation led some adults to show improvements of their clinical scores, rather than any deterioration. Thus, even though fewer hip joint replacement surgeries were performed at the height of COVID-19 restrictions, as discussed by Magnussan et al 32 and Dell’Isola et al. 33 in the context of hip joint injuries, perhaps, some who were scheduled perceived they were more able than they had expected or anticipated functionally.

Yet, even if rates of surgery appear to have returned to normal in the post COVID pandemic period 33, another study has shown that of an excess number of hip osteoarthritis cases awaiting joint replacement surgery a third tended to exhibit features ‘deemed worse than death’ or a deterioration in health 34 when compared to what occurred in pre pandemic periods for comparable lesion manifestations. In addition, those suffering markedly exhibited a lower quality of life than desirable 35. According to Farrow et al. 6 this might explain, as well as predict, the potential, as well as the prevailing evidence of an emerging opioid problem associated with the influence of COVID-19 on elective arthroplasty services that needs to be acknowledged. This includes, but is not limited to, moderate decreases in health, plus higher than desirable hospital costs 3, as well as overall decreases in physical activity participation 36 and mental health status, physical fitness, and stiffness 37.

While it is evident that features of aging that impact health, as well as multiple co occurring health issues found in adults with hip osteoarthritis may increase COVID-19 susceptibility and impacts, where they occur, as well as a variety of secondary infections that have been linked to an array of medications commonly used by this group 38, this topic is very poorly addressed at present. In addition, the fact that COVID-19 not only impacts the respiratory system, even when deemed mild to moderate, but also the musculoskeletal system causing excessive signs of fatigue, myalgia, arthralgia, muscle weakness and skeletal muscle damage is not well documented, despite its relevance. Indeed, one or more of these symptoms, which can persist for months, while decreasing the quality of life of numerous individuals 39 are also comparable to those found in the context of osteoarthritis in its own right.

At the same time, COVID disease, as in most cases of osteoarthritis as experienced by the older adult, can be associated with varying degrees of pain, including muscle and joint pain plus pain mechanisms associated with inflammatory pathways also noted in the context of arthritis 4041. Consequently, even though some may feel COVID-19 is not a serious condition, that surgery can proceed with some due precautions at pre pandemic levels and with prepandemic expectations, the serious nature of both COVID-19 infection risk as well as the presence of hip joint osteoarthritis as these arise in the older population more readily than younger groups, must surely warrant careful attention in the context of efforts to avoid excess debility and possible undesirable hospitalizations or institutionalization.

To this end, and even in the absence of related research, in accord with recommended efforts to avert the suffering and excess debility older community dwelling adults with hip joint osteoarthritis that may have duly increased in severity since 2019, as well as exposure to COVID-19 illness and its multiple adverse health impacts 42, strategies to offset any predictable preventable decline in overall health that could have multiple negative impacts among non hospitalized older adults awaiting surgery are clearly indicated 43. These include possible rescheduling of elective surgery based on the patient s symptoms. In addition, a multidisciplinary and patient-centered approach to rescheduling patients is recommended 43, while Jin et al. 44 noted that for patients with currently confirmed or highly suspected COVID-19, the operation should be carried out only if deemed essential.

While further study is needed to validate these predictions and imperatives and others, and to carefully examine the impact of novel COVID-19 variants and vaccination on timeframes for rescheduling surgery 43, efforts to examine how to maximize older adults overall health in the face of the COVID threat and others, whether they are scheduled for surgery or not, or returning home post surgery, may yet prove of high relevance and utility, and drawing on past and present literature might include efforts known to be advantageous in general that could yet be delivered in some format by the use of carefully tailored periodic communications by practitioners and others that encourage their clients, while explaining the importance of:

Sound nutrition practices

Salient joint protection, COVID-19 mitigation and protection strategies

Non addictive pain control approaches

The pursuit of a healthy weight

The pursuit of moderate physical activity practices

Minimization of stress, anxiety, depression, and fears

They can do this by considering the use of periodic telephone/online discussions/check-ins, plus encouraging emails that reinforce favorable self-efficacy beliefs and expectations, while fostering socially supportive health care needs, and counseling provisions 12454647484950.

In this regard, research is showing that intervention is sorely needed here because, COVID-19, which represents an unprecedented health crisis of global proportions, clearly added an additional burden of risk for older adults as regards the extent and progression of any prevailing osteoarthritis pathology due to its negative influence on physical activity and dietary behaviors, along with an increased likelihood of muscle loss, chronic disease exacerbation and risk, plus persistent COVID-19 infection risk 4650. Narici et al. 51 clearly show that legal constraints that place collective limitations on the pursuit of physical activity practices, are clearly crucial to overcome in adults with or prone to osteoarthritis because muscle wasting not only occurs rapidly, being detectable within two days of inactivity, but this loss of muscle mass is associated with fiber denervation, neuromuscular junction damage and upregulation of muscle protein breakdown, with a consequent loss of joint of joint protection.

Inactivity also affects glucose homeostasis, reduces insulin sensitivity, principally in muscle, as well as aerobic capacity than can have a strong bearing on the physiology of the cardiovascular system, including the functions of peripheral circulation, skeletal muscle oxidative function and energy balance associated with fat deposition and systemic inflammation 51.

In addition, even if we dismiss any endemic COVID-19 impact in the future, osteoarthritis of the hip, currently a major public health problem, is estimated to possibly affect 41.1 million Americans alone by 2030, along with a predicted increased need for total hip replacement surgery that exceed current rates, especially if no advancements are made in preventing its likely occurrence and disabling impacts in the face of COVID-19 issues if these remain unabated.At the same time, revision surgery, also expected to double, may be expected to increase if current surgeries remain delayed and candidates remain in poor health 48. As such, Ezzat et al. 52 propose that in the time it will take to address the backlog of total joint arthroplasty surgery procedures in Ontario alone for example, evidence-based nonsurgical care of hip and knee osteoarthritis enacted by physical therapists and others can be expected to markedly reduce pain and improve function and quality of life for those with the disease awaiting surgery and others, rather than exacerbating social, economic, and emotional hardships 53. As argued by Mak et al. 54 the spill-over impact of COVID-19 on patients with non infectious comorbid diseases is just beginning to unravel, and extra efforts must be taken for planning the resumption of efforts to combat this probable post-pandemic unanticipated outcome. In the meantime, to alleviate hip osteoarthritis symptoms, and COVID-19 risk among vulnerable older adults, the approaches cited above and others applied thoughtfully and consistently might yet prove helpful for countering both conditions and any possible cross talk between these whether surgery is scheduled or not.

In particular, because the presence of any SARS-CoV-2 infection could potentiate or accelerate a possible pre-existing systemic inflammatory state among those infected individuals suffering from obesity, special efforts to avoid weight gain and promote weight loss are likely to be more helpful than not 2. In this regard the added value of techniques such as meditation related practices, guided imagery, joining an online support group, mild to moderate activity participation practices, healthy eating, social distancing, hand washing and optimal sleep routines may prove helpful as well 268.

Unfortunately, not only are possible other emergent consequences of COVID-19 unknown, but in light of the failure to eradicate this virus, and its persistent and emerging COVID-19 variants, predicted to be less susceptible to vaccines, but more potent as novel mutations of the virus emerge, what we do know must surely imply a concerted need for ongoing vigilance, as well as insightful efforts by both practitioners as well as their older vulnerable clients to foster and secure optimal health safety and health behaviors for the older adult, as well as their families. In addition, education to engender salient motivational and cognitive attributes, rather than reactive fear-based health beliefs, including erroneous vaccine as well as surgical beliefs, may be more helpful than not. At the same time, political efforts to aid providers and public health organizations to deliver or make available resources that may be needed, such as healthy foods and safe medication, plus exercise opportunities, may not only help minimize the onset or exacerbation of comorbidities such as cardiovascular disease, obesity, bone attrition, chronic inflammation, and muscle weakness, but the immense public and social health costs of failing to do this.

In short, until the backlog of surgery wanes, and the COVID virus is less virulent and prevalent, clinicians can perhaps look towards the provision of understandable actionable science based periodic communications as a powerful means of enabling the older adult with hip osteoarthritis to make more careful health decisions, rather than those current decisions of an apparent sizeable proportion of cases awaiting hip joint surgery who appear willing to basically overlook any COVID threat 55, even though some cases awaiting elective surgery have been found to improve 15, while others have fared less successful than in prepandemic times 51. They can help access resources needed, reduce stresses, and foster confidence and hope, and may find prioritizing those older hip osteoarthritis cases with unremitting pain, those who suffer from obesity and diabetes, and who are increasingly susceptible to substance use disorders including opioids, alcohol, as well as prescription and illegal drugs to quell pain and depression who live alone very important to assist. Those who have already been scheduled for surgery, but placed on a waiting list, or those presenting with active COVID-19 disease might also benefit from priority care efforts 44.

To support clinicians and policy makers and the probable need to continue to alleviate and avert further potentially adverse COVID-19 undesirable outcomes in the future, more carefully designed and focused research to tease out facts from fears or fiction in the context of case studies of representative older adults that can be conducted safely might be helpful, especially in absence of any large scale controlled ventures that may be very challenging to conduct in a post pandemic climate of health care restraint and personnel shortages, plus high transportation costs, among other barriers. Studies on COVID-19 and rheumatoid arthritis that often results in osteoarthritis joint damage at the hip, as well those that examine COVID-19 and its role in aging, immunity and osteoarthritis linkages, including pain, muscle wasting, osteoporosis, and depression and which home based approaches appear best may also prove highly beneficial 56575859.

In the meantime, a concerted effort to currently examine what we know about hip joint osteoarthritis and its linkages to the novel corona virus 19 shows:

Hip joint osteoarthritis clearly remains, and is projected to persist, as one of the foremost chronic health conditions facing aging adults.

The multiple COVID-19 changes in health delivery and resource availability and its diverse downstream impacts on the magnitude of potentially preventable suffering among the older adult in the context of hip joint osteoarthritis is likely to be continue relatively unabated for some time in the absence of comprehensive public health efforts

Continually compounded in this regard will be the presence and persistence of poor health, including the future risk of exposure to the infectious disease known as COVID-19, as well as in the absence of any past or future infection.

In turn, the hip osteoarthritis surgical candidate as well as those who are not scheduled are likely to be impacted directly as well as indirectly if personalized appropriately tailored timely steps are not taken to ameliorate and if possible prevent the immense suffering, fears, stresses, and inaccurate belief perceptions that have emerged since the onset of the global COVID-19 pandemic.