The elbow is a crucial joint for upper extremity function, enabling complex and essential movements such as lifting, pushing, and fine motor tasks. Impairments in elbow function can significantly affect a patient’s ability to perform daily activities, work-related tasks, and recreational pursuits [1]. Elbow injuries, whether due to trauma or degenerative conditions, often lead to pain, reduced range of motion (ROM), and diminished strength. These limitations can significantly compromise a patient’s quality of life (QoL) and adversely affect their physical and mental well-being. Beyond its functional impact, impaired elbow function often results in chronic pain, which also reduces QoL, highlighting the urgent need for timely and effective treatment.

Given the limited availability of healthcare resources, both public and private organizations are increasingly focused on evaluating the effectiveness and cost-efficiency of medical interventions. Health-related quality of life (HRQoL) in patients with musculoskeletal injuries is commonly assessed using the EuroQol five-dimensional questionnaire (EQ-5D), an instrument for assessing HRQoL that is used in the economic evaluation of clinical interventions and health programs [2-4]. For patients with elbow injuries awaiting surgical intervention, the preoperative period is often marked by persistent pain and loss of function. These issues not only exacerbate physical decline, but also contribute to psychological distress such as anxiety and depression that could potentially affect surgical outcomes and long-term patient satisfaction [5,6].

Severe pain and restricted mobility can limit basic tasks such as eating, dressing, or writing, leading to reduced independence, social withdrawal, and diminished HRQoL. As surgeons, we frequently need to postpone elective procedures due to emergency cases or limited healthcare system capacity. Assessing HRQoL in patients awaiting elbow surgery is particularly important because it addresses a critical but often overlooked aspect of surgical care. Even if surgical waiting times cannot be significantly reduced due to systemic constraints, identifying specific challenges during the preoperative period could enable targeted interventions to enhance patients’ HRQoL. At present, little is known about how different elbow pathologies affect HRQoL or shape patients’ treatment priorities. This gap is particularly relevant in healthcare systems with limited surgical capacity and long waiting lists, where patient stratification by clinical need and HRQoL burden is crucial.

Therefore, in this study, we analyzed EQ-5D scores from patients with different elbow pathologies, specifically elbow osteoarthritis, stiffness, and instability, during the preoperative waiting period to examine how pain, functional limitations, and mental distress affected their HRQoL. To additionally assess objective function and perceived disability, we assessed the Mayo Elbow Performance Score (MEPS) and the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) score. Moreover, patients were asked to indicate whether they prioritized pain relief or functional recovery as their primary treatment goal. Ultimately, we explored the role of mental well-being and overall QoL in individuals awaiting surgery for elbow dysfunction, with a focus on mitigating the negative effects of preoperative delays, reducing long-term healthcare costs, and improving overall outcomes. We hypothesized that longer waiting times would contribute to declines in HRQoL, as reflected by lower EQ-5D scores, through increased pain, functional limitations, and psychological distress.

We conducted this study in compliance with the principles of the Declaration of Helsinki. The study was approved by the Ethics Commission of the Faculty of Medicine at the University of Cologne (No. 21-1290). Written informed consent was obtained from patients.

This prospective, single-center study was conducted at the University Hospital of Cologne (Cologne, Germany) and included all patients scheduled for surgical treatment of elbow pathologies from December 1, 2024 onward. All patients enrolled in this study had already failed conservative treatment and were awaiting elective surgical intervention. Treatment decisions were made following thorough consultation with each patient, and all participants consented to surgery before completing the questionnaires. All patients scheduled for elective elbow surgery at our institution were prospectively identified and screened for eligibility. The inclusion criteria were age ≥18 years and an indication for elective elbow surgery. The exclusion criteria were age <18 years and the presence of an additional surgical indication unrelated to the elbow. Comorbidities were not used as exclusion criteria. All participants were categorized into groups based on their underlying diagnosis: group 1 contained patients with elbow osteoarthritis, group 2 comprised those with elbow stiffness, and group 3 contained patients with elbow instability. Group 1 was further subdivided into group 1a (primary osteoarthritis) and group 1b (secondary post-traumatic osteoarthritis). Waiting time was calculated as the number of days between the initial consultation at which the indication for elective elbow surgery was established and the actual date of surgery.

The EQ-5D-3L (European Quality of Life 5 Dimensions, 3-Level Version) questionnaire is a well-established and widely validated instrument for evaluating overall HRQoL. It is a preference-based tool that assesses five key dimensions of health: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each domain is measured using a single question, enabling patients to self-report the extent of their impairments. Patients rate each of the five dimensions on a three-level scale: 1 for no problems, 2 for moderate problems, and 3 for extreme problems. These responses define a total of 243 possible health states, which can be converted into a single EQ-5D index score. The index ranges from 1.0, indicating optimal health, to 0, representing death, with negative values denoting health states considered worse than death [2,7,8]. The descriptive data obtained from the EQ-5D can be translated into a one-dimensional index using country-specific scoring algorithms derived from general population value sets. These value sets are available for multiple countries, including the United Kingdom, the United States, and Germany. The use of national value sets is essential for generating contextually appropriate EQ-5D preference weights that enhance the accuracy and applicability of the findings in health-economic evaluations [7]. We used those procedures to calculate an individual EQ-5D-index score for each patient.

Functional outcomes were evaluated using the MEPS and qDASH measures. The MEPS is a clinician-rated tool that assesses four domains, pain, ROM, joint stability, and daily function, to yield a total score out of 100. The results are classified as excellent (≥90), good (75–89), fair (60–74), or poor (<60). The qDASH is a validated, patient-reported outcome measure designed to evaluate symptoms and functional limitations in upper limb conditions. It includes 11 items rated on a 5-point Likert scale, and the total scores range from 0 (no disability) to 100 (maximum disability) [9]. All assessments were performed by the same experienced examiner. All preoperative patients were asked about their postoperative priorities, specifically whether pain relief or improved ROM was more important, to provide further insight into their health preferences.

Overall, 143 patients were screened for this study, and 42 of them were excluded based on the predefined criteria. The remaining 102 patients (49 female, 53 male) with elbow pathologies awaiting surgery met the inclusion criteria and were included in final analysis. Group 1 consisted of 31 patients diagnosed with osteoarthritis. The severity of osteoarthritis was classified using the Kellgren-Lawrence grading system: 10 patients were classified as grade IV, 18 as grade III, and 3 as grade II. The patients in this group were scheduled for arthroscopic debridement, arthrolysis, and cartilage-smoothing procedures (n=17); the minced cartilage procedure (n=2); or total elbow arthroplasty (n=12), depending on the severity of degeneration. The mean ROM was as follows: flexion 122.4°±7.8°, extension deficit 24.1°±8.5°, supination 65.6°±3.8°, and pronation 68.1°±2.2° (flexion arc: 98.3°±11.54°, rotation arc: 133.7°± 4.39°).

Group 2 contained 45 patients with elbow stiffness. The mean ROM for flexion was 121.9°±6.2°; the extension deficit was 23.1°±4.3°; supination was 64.8°±5.4°; and pronation was 62.1°±4.4° (flexion arc: 98.8°±7.55°, rotation arc: 126.9°±6.97°). Patients in this group underwent either arthroscopic arthrolysis (n=38) or open arthrolysis (n=7), along with the removal of loose bodies or osteophytes, where indicated.

Group 3 comprised 26 patients with elbow instability. The direction of instability was primarily posterolateral rotatory instability (n=12), followed by valgus instability (n=9) and varus instability (n=5). All patients were scheduled for ligament reconstruction procedures, such as lateral or medial collateral ligament repair or reconstruction. The mean ROM was as follows: flexion 123.8°±3.9°, extension deficit 24.2°±7.3°, supination 69.4°±4.7°, and pronation 71.1°±2.8° (flexion arc: 99.6°±8.28°, rotation arc: 140.5°±5.47°). The preoperative values for flexion (P = 0.771), extension deficit (P=0.796), supination (P=0.455), and pronation (P=0.303) did not differ with statistical significance among the groups.

The average time to the scheduled surgery date was 204 days (±115): 223 ±122 days in group 1, 219 ±118 days in group 2, and 165±89 days in group 3. In 17.6% of cases, the surgery was postponed and rescheduled at least once, with some patients experiencing up to five postponements. The average patient age was 46 years (±15) (Table 1).

The overall EQ-5D score for all patients was 0.67 (±0.06), with no significant difference between female (0.68±0.26) and male (0.67±0.27) patients (P=0.952). Our results revealed that patients with osteoarthritis had the lowest average EQ-5D score (0.60±0.29), compared with the elbow stiffness (0.71±0.24) and elbow instability groups (0.71±0.26) (Fig. 1). Furthermore, patients with osteoarthritis had the highest depression score (1.97±0.75), followed by those in the stiffness group (1.78±0.70) and instability group (1.62±0.80). Patients with osteoarthritis also had a significantly higher mean depression/anxiety score than those with elbow instability (P=0.012), and they reported the highest pain score (2.32±0.48) and greatest difficulty with usual activities and self-care (Table 2, Fig. 2).

A subgroup analysis of the osteoarthritis group classified the patients into primary osteoarthritis (group 1a, n=11) and secondary post-traumatic osteoarthritis (group 1b, n=21). Patients with secondary osteoarthritis had slightly higher pain scores (2.38 ±0.49) than those with primary osteoarthritis (2.27±0.47), but the difference was not statistically significant (P=0.421). Additionally, patients with post-traumatic osteoarthritis had lower EQ-5D scores (0.57±0.31) than those with primary osteoarthritis (0.63±0.29), but that difference was not statistically significant either (P=0.091). All other parameters were comparable between the subgroups.

The median waiting time for surgery was 212 days. As a further analysis, patients were divided into two groups based on that median (≤212 days vs. >212 days). The short waiting time group (≤212 days, n=52) had a mean EQ-5D score of 0.71±0.24, and the long waiting time group (>212 days, n=50) had a mean score of 0.64±0.28; however, that difference between the groups was not statistically significant (P=0.219). Even though it was not significant, the data indicate a numerical trend toward lower EQ-5D scores as the waiting times become longer. The linear regression analysis revealed no statistically significant association between the waiting time and EQ-5D scores (β–0.0001; 95% CI, –0.001 to 0.000; P=0.649, R²=0.002), but the regression line also indicated a numerical trend toward lower EQ-5D scores with increasing wait times.

Multivariable regression analysis showed that the wait time had a small negative coefficient (β=–0.0001; 95% CI, –0.001 to 0.0004; P=0.663), suggesting a numerical but non-significant trend toward lower EQ-5D values with increasing surgical delay. Age was also negatively, but not significantly, associated with the EQ-5D scores (β=–0.002; 95% CI, –0.006 to 0.002; P=0.306). Sex showed no association with EQ-5D (β=–0.0002; 95% CI –0.104 to 0.104; P=0.997). Compared with patients who presented with instability, those with osteoarthritis tended to report lower EQ-5D values (β=–0.090; 95% CI, –0.233 to 0.053, P=0.214), whereas patients with stiffness demonstrated no meaningful difference from either of the other groups (β=0.001; 95% CI, –0.131 to 0.133; P=0.986). The overall explanatory power of the model was low (R²=0.048; adj. R²=–0.002), indicating that these variables accounted for little of the variance in the EQ-5D scores.

The preoperative MEPS was 51.87±8.59 in group 1, 57.84±11.42 in group 2, and 54.23±11.72 in group 3. MEPS was the lowest in group 1 and significantly lower in patients with osteoarthrosis than in those with elbow stiffness (P=0.016). The average preoperative qDASH score was 38.55±7.41 in group 1, 35.64±6.37 in group 2, and 36.54±6.73 in group 3. The qDASH score was the highest in group 1, but this difference was without statistical significance.

When asked about their treatment priorities, patients with osteoarthritis expressed a significantly stronger preference for pain relief than for improved ROM (P=0.022). Conversely, patients with elbow stiffness prioritized improved ROM over pain relief (P=0.035). Patients with elbow instability expressed no significant preference between pain relief and improved ROM, valuing both equally (P=0.588). Additionally, patients with osteoarthritis desired pain relief more than those with elbow stiffness (P=0.026), and patients with elbow stiffness prioritized ROM improvement more than those with osteoarthritis (P=0.021).

Elbow dysfunction can severely affect daily activities, often leading to chronic pain and reduced HRQoL. This study is the first to use the EQ-5D to assess HRQoL in patients awaiting elbow surgery. The average waiting time for surgery was 204 days (±115), with an overall EQ-5D score of 0.67 (±0.06) across all patients. Among the different pathology groups, patients with osteoarthritis had the lowest HRQoL, the highest depression scores and pain scores, and the most significant difficulties with daily activities. Multivariable regression suggested that longer waiting times and older age might contribute to lower HRQoL, even though those associations were not statistically significant. Moreover, patients with osteoarthritis had the lowest MEPS and highest qDASH scores among all groups, and they most frequently identified pain relief as their primary treatment priority.

Upper extremity function depends significantly on elbow movement to ensure proper hand positioning in space. Loss of this movement, whether due to elbow stiffness, pain, osteoarthritis, instability, or other causes, can lead to considerable disability. Even a minor reduction in elbow joint mobility can result in substantial functional limitations, making it challenging to perform daily activities. These limitations can profoundly affect a patient's overall HRQoL [1,10,11].

A previous study assessed EQ-5D scores at baseline and over a 2-year period in 813 patients with rheumatic inflammatory arthritis. Those results showed a mean EQ-5D score of 0.498 (±0.316). Notably, 11% of the patients had a negative EQ-5D score, indicating a health state worse than death (WTD). Almost all patients reported extreme pain or discomfort, and the majority experienced at least moderate issues in the anxiety/depression domain [12]. Harrison et al. [13] conducted a study involving 700 patients with inflammatory arthritis. They had a median EQ-5D score of 0.59 (interquartile range, 0.52–0.69), and 62 of them were classified in states rated as WTD. Pain was also the most significant factor contributing to the WTD EQ-5D profiles in those arthritis patients. Patients with rheumatic arthritis have been shown to demonstrate EQ 5D scores of 0.5–0.6, closely comparable to our cohort’s overall score of 0.67±0.06. Remarkably, even though rheumatic arthritis is a chronic, systemic disease involving multiple joints, its impact on QoL appears to be similar to that observed in our patients, whose pathology was confined to a single joint. It is important to note that in this study, the EQ-5D score specifically reflects the pathology of the elbow. This was intentionally designed to isolate the effect of elbow impairment and the waiting period for definitive treatment on patient QoL. Notably, patients awaiting elective elbow surgery for a single-joint pathology still experienced a remarkable reduction, more than one-third, in their QoL. The reason for this might be that patients are more significantly impacted by the loss of motion in the elbow than in other joints. Sardelli et al. demonstrated that a maximum flexion arc of 130°±7° and a maximum pronation–supination arc of 103°±34° are necessary for sufficient elbow joint function in everyday life [1]. In our study cohort, the mean flexion arc was below 100° in all groups, clearly indicating a marked restriction of mobility that likely contributed significantly to the functional limitations and reduced HRQoL observed in these patients.

In line with the findings of Harrison et al. [13] and Gaujoux-Viala et al. [12], all our patient groups reported the highest scores in the pain/discomfort domain, underscoring pain as the primary determinant of reduced QoL. Persistent pain is known to influence multiple dimensions of HRQoL by contributing to psychological distress, reduced mobility, and progressive functional decline [14]. All patients in our cohort had completed nonoperative management, including analgesic therapy, before being referred for surgery when the conservative options were exhausted. This context is particularly relevant for patients with osteoarthritis, who exhibited the highest pain scores and lowest EQ-5D indices. Additionally, patients with osteoarthritis most frequently identified pain relief as their primary treatment priority. For these individuals, pain is typically accompanied by joint degeneration, restricted ROM, and loss of strength, compounding functional impairment. Consistently, osteoarthritis patients had the lowest MEPS and highest qDASH scores. However, the lack of significant differences between groups suggests that disability perception, as measured by qDASH, might be less sensitive than EQ-5D or MEPS in detecting differences between subgroups in this cohort. Prolonged waiting times could exacerbate this decline, as ongoing disease progression and psychological strain might contribute to further deterioration in functional status and subjective well-being. The finding that osteoarthritis patients reported the lowest HRQoL, greatest pain, and highest depression scores can be explained by the distinct pathophysiological characteristics of this disease. As a progressive and degenerative condition, osteoarthritis develops gradually and is marked by persistent pain, stiffness, and functional decline. Unlike instability or post-traumatic stiffness, which have a more acute onset, osteoarthritis progresses slowly with persistent pain, stiffness, and functional decline. This longstanding symptom burden not only limits mobility but also fosters psychological distress, explaining the higher depression levels and more pronounced reduction in HRQoL found in the osteoarthritis group.

A recent study assessed HRQoL in patients awaiting knee arthroplasty. Clement et al. [15] found that 77.9% of patients experienced chronic knee pain after 12 months, with a mean EQ-5D score of 0.16 (±0.302). In contrast, those who did not develop chronic knee pain had an average EQ-5D score of 0.63 (±0.206) after the same period. That study highlighted that prolonged waiting times for knee arthroplasty led to significant deterioration in HRQoL caused by the development of chronic pain, reduced well-being, and increased opioid use. Similarly, in our study, patients with elbow osteoarthritis had a mean EQ-5D score of 0.60±0.29, reflecting a negative impact of surgical delays on HRQoL comparable to that observed in patients with knee osteoarthritis. It is reasonable to assume that if patients, particularly those with elbow osteoarthritis, were required to wait for a longer period, as in the study by Clement et al. [15], the risk of developing chronic pain and experiencing a substantial further decline in HRQoL would likely increase. Although HRQoL has been studied in patients with other joint disorders, research on the elbow remains scarce. Schreiner et al. conducted one study that addressed HRQoL in elbow stiffness and demonstrated that impaired elbow function substantially lowered EQ-5D scores [10]. To date, however, no other studies have systematically applied the EQ-5D questionnaire in patients awaiting surgery for elbow disorders.

Brune et al. [16] conducted a multicenter study of 973 patients undergoing arthroscopic rotator cuff repair and reported a preoperative mean EQ-5D index of 0.70 (±0.23). Their analysis found that being male was positively associated with a higher EQ-5D index. However, in our study, we did not observe a significant difference in EQ-5D scores based on sex. Instead, we found that patients with osteoarthritis (group 1) had both the lowest EQ-5D scores and highest mean age among the groups. These findings suggest that age and pathology-specific factors in elbow pathologies might exert a greater influence on HRQoL than sex alone. In this context, our multivariable regression analysis confirmed that waiting time, age, sex, and diagnosis together explained only a small proportion of the variability in HRQoL measured by the EQ-5D. Although neither waiting time nor age reached statistical significance, both showed negative coefficients, suggesting a possible tendency for longer delays and older age to be associated with lower HRQoL.

Virk et al. [17] examined patient priorities following arthroscopic rotator cuff repair and reported that most patients valued strength recovery over pain relief, both before and after surgery. However, they found that older patients and retirees tended to prioritize pain relief over strength restoration. Similarly, in our study, treatment preferences varied according to the underlying pathology. Patients with osteoarthritis demonstrated a significantly stronger preference for pain relief than the other groups. Notably, this cohort was also the oldest, with a mean age of 52±13 years. These findings suggested that older patients and those with osteoarthritis might experience higher levels of pain than younger patients and those with other elbow pathologies, making pain control the most influential factor in determining their HRQoL. Our findings on patient preferences highlight the importance of integrating individual goals into preoperative care. Patients who prioritize pain relief might benefit from optimized analgesic strategies and psychological support, whereas those focusing on functional recovery might require counseling about realistic rehabilitation expectations. Incorporating patient preferences into prioritization frameworks could help allocate surgical resources more effectively and improve overall patient-centered care.

To the best of our knowledge, this study is the first to demonstrate the crucial impact of elbow pathology and surgical waiting times on QoL. Specifically, prioritizing pain management and mental health support, particularly for patients with osteoarthritis and prolonged waiting times, might be essential for improving overall well-being and potentially even surgical outcomes. Our findings also have relevant clinical implications. The preoperative waiting period is a vulnerable phase in which patients can experience ongoing pain and psychological distress. Structured multimodal analgesia could help to effectively control pain, and preoperative counseling and psychological support could reduce anxiety and depression. Implementing such measures might not only improve HRQoL during the waiting period but also enhance overall patient satisfaction and preparedness for surgery. Further research is needed to improve HRQoL in these high-risk populations during the preoperative period, reduce healthcare costs, and enhance patient care and management.

This study is not without limitations. First, it was conducted at a single center, which could limit the generalizability of our findings. Moreover, the analysis relied exclusively on the German EQ-5D value set, which might not be fully transferable to other populations. Our subgroup sizes were relatively small, which reduced our statistical power for certain comparisons. Another limitation of this study is that comorbidities were not controlled, even though they can independently affect HRQoL and mental well-being. However, we deliberately chose this inclusive approach to capture the real-world spectrum of patients undergoing elective elbow surgery. Future studies with larger cohorts should stratify outcomes according to comorbidity profiles. Additionally, the observational design precludes causal inference, particularly regarding the relationship between waiting time and HRQoL. Furthermore, in the questionnaire, we focused exclusively on elbow-specific limitations and did not account for other comorbidities or functional impairments because our primary aim was to isolate the impact of elbow pathology and surgical delays. Lastly, response bias cannot be excluded because patients who experienced multiple postponements might have emphasized their symptoms. However, those perceptions still reflect their lived experience and are relevant to HRQoL.

Prolonged waiting times for elective elbow surgery might be associated with declines in HRQoL, although no significant association was observed in this cohort. Patients with osteoarthritis showed the lowest EQ-5D index (0.60) and significantly lower MEPS scores (P=0.016) than those with other elbow pathologies. Addressing pain management and offering psychological support could improve HRQoL while patients await surgery. Future studies should test whether preoperative pain or psychological support can mitigate HRQoL decline.