History of COVID-19 Was Not Associated with Length of Stay or In-Hospital Complications After Elective Lower Extremity Joint Replacement

Open AccessPublished:December 09, 2021DOI:https://doi.org/10.1016/j.artd.2021.11.021

      Abstract

      Background

      The impact of previous SARS-CoV-2 infection on the morbidity of elective total joint arthroplasty (TJA) is not fully understood. This study reports on the association between previous COVID-19 disease, hospital length of stay (LOS), and in-hospital complications after elective primary TJA.

      Methods

      Demographics, comorbidities, LOS, and in-hospital complications of consecutive 340 patients with history of COVID-19 were compared to 5,014 patients without history of COVID-19 undergoing TJA. History of COVID-19 was defined as a positive IgG antibody test for SARS-CoV-2 before surgery. All patients were given both antibody and PCR tests prior to surgery.

      Results

      Patients with history of COVID-19 were more likely to be obese (43.8% vs. 32.4%, p<0.001), Black (15.6% vs. 6.8%, p<0.001) or Hispanic (8.5% vs. 5.4%, p=0.028) compared to patients without history of COVID-19. COVID-19 treatment was reported by 6.8% of patients with a history of COVID-19. Patients with history of COVID-19 did not have a significantly longer median LOS after controlling for other factors (for hip replacements, median 2.9h longer, 95% CI -2.0 to 7.8, p=0.240; for knee replacements, median 4.1h longer, 95% CI -2.4 to 10.5, p=0.214) but a higher percentage were discharged to a post-acute care facility (4.7% vs. 1.9%, p=0.001). There was no significant difference in in-hospital complication rates between the two groups (0/340=0.0% versus 22/5,014=0.44%, p=0.221).

      Conclusion

      We do not find differences in LOS or in-hospital complications between the two groups. However, more work is needed to confirm these findings, particularly for patients with a history of more severe COVID-19.

      Level of evidence

      II

      Keywords

      Introduction

      The novel coronavirus, SARS-CoV-2, has caused millions of deaths worldwide as part of a global pandemic; the impact of persistent health effects among survivors of COVID-19 remains under evaluation [
      • Debeaumont D.
      • Boujibar F.
      • Ferrand-Devouge E.
      • Artaud-Macari E.
      • Tamion F.
      • Gravier F.E.
      • et al.
      Cardiopulmonary Exercise Testing to Assess Persistent Symptoms at 6 Months in People With COVID-19 Who Survived Hospitalization - A Pilot Study.
      ,
      • De Biase S.
      • Cook L.
      • Skelton D.A.
      • Witham M.
      • Ten Hove R.
      The COVID-19 rehabilitation pandemic.
      ]. Beyond upper and lower respiratory symptoms commonly reported in COVID-19, systemic effects including thrombophilia [
      • Waleed R.M.
      • Sehar I.
      • Iftikhar W.
      • Khan H.S.
      Hematologic parameters in coronavirus infection (COVID-19) and their clinical implications.
      ], myocarditis [

      Magadum A, Kishore R. Cardiovascular Manifestations of COVID-19 Infection. Cells 9(11), 2020

      ,
      • Nishiga M.
      • Wang D.W.
      • Han Y.
      • Lewis D.B.
      • Wu J.C.
      COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives.
      ], and neuropathy [
      • Ellul M.A.
      • Benjamin L.
      • Singh B.
      • Lant S.
      • Michael B.D.
      • Easton A.
      • et al.
      Neurological associations of COVID-19.
      ,
      • Sharifian-Dorche M.
      • Huot P.
      • Osherov M.
      • Wen D.
      • Saveriano A.
      • Giacomini P.S.
      • et al.
      Neurological complications of coronavirus infection; a comparative review and lessons learned during the COVID-19 pandemic.
      ] have been reported. Other symptoms including fatigue and malaise [
      • Yang W.
      • Cao Q.
      • Qin L.
      • Wang X.
      • Cheng Z.
      • Pan A.
      • et al.
      Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China.
      ] can persist months after resolution of primary illness. Furthermore, active COVID-19 illness has been shown to be associated with an increased risk for perioperative complications, including sepsis, shock, cardiac arrest, pneumonia, respiratory failure, acute respiratory distress syndrome, acute kidney injury, and mortality in patients undergoing emergency procedures [
      • Knisely A.
      • Zhou Z.N.
      • Wu J.
      • Huang Y.
      • Holcomb K.
      • Melamed A.
      • et al.
      Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures.
      ].
      The impact of prior infection with SARS-CoV-2 on the outcomes of elective surgical procedures is an important, unanswered clinical issue.
      As rates of COVID-19 illness fell in New York City, elective surgical procedures at our high-volume specialty musculoskeletal center resumed. Presurgical screening was adjusted to test for serum antibodies to SARS-CoV-2 [
      • Boettner F.
      • Bostrom M.P.
      • Figgie M.
      • Gonzalez Della Valle A.
      • Haas S.
      • Mayman D.
      • et al.
      Timeline and Procedures on Restarting Non-Emergent Arthroplasty Care in the US Epicenter of the COVID-19 Pandemic.
      ]. In addition, all patients underwent nasopharyngeal PCR screening within three days prior to admission, and elective surgery on PCR-positive patients was postponed in accordance with regulatory guidance.
      The impact of previous SARS-CoV-2 infection on the morbidity of patients undergoing elective total joint replacement has not yet been carefully assessed. We hypothesized that morbidity after joint replacement would be increased among those who had a history of COVID-19, even if symptoms were resolved [
      • Lei S.
      • Jiang F.
      • Su W.
      • Chen C.
      • Chen J.
      • Mei W.
      • et al.
      Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection.
      ].
      The current study reports how demographics, comorbidities, hospital course (including length of stay), and in-hospital complications among consecutive elective arthroplasty patients at our large orthopedic hospital differed between patients with and without history of COVID-19.

      Material and Methods

      After obtaining institutional review board approval, we queried our institution’s data warehouse for patients undergoing elective primary total hip (THA) or knee (TKA) arthroplasty between 5/6/2020 and 1/5/2021. Inclusion criteria was based on ICD-10 codes from the Center for Medicare and Medicaid (CMS) Elective Primary THA/TKA Complication Measure. Exclusion criteria included indications for pelvic or lower limb fracture; concurrent partial hip or knee arthroplasty; concurrent revision, resurfacing, or implanted device/prosthesis removal procedure; indications for mechanical complication; indications for malignant neoplasms [

      De Buhr J MK, Grady J. Condition Specific Measures Updates and Specifications Report Hospital-Level 30 Day Risk-Standardized Readmission Measures: elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) - version 9.0. 2020.

      ].
      Our institution’s presurgical screening for elective surgery was modified to account for the ongoing COVID-19 pandemic. These changes included:
      The cohort was then divided into two groups based on evidence of history of COVID-19 at time of presurgical screening. Because this study was fairly early in the COVID-19 pandemic, and because any patient with a positive COVID-19 PCR would not have qualified for elective arthroplasty, patients in the history of COVID-19 group were defined as those with a positive IgG serology test for SARS-CoV-2 prior to surgery. All remaining patients were classified as lacking history of COVID-19. Chart review of the COVID-19 group was done to collect further data on their symptom history and degree of illness (Figure 1) and included questions about presence, start and duration of symptoms, prior COVID-19-related hospitalizations, and pharmacological and respiratory treatments for COVID-19. For the majority of patients in the COVID-19 group, who were never PCR-tested and were pauci-symptomatic, the date of COVID-19 infection and its relationship with the date of surgery was unknown.
      Patient demographics (including age, sex, race, ethnicity, and BMI), the American Society of Anesthesiologists classification (ASA) [
      • Dripps R.D.
      • Lamont A.
      • Eckenhoff J.E.
      The role of anesthesia in surgical mortality.
      ], the Elixhauser Comorbidity Index (ECI) [
      • Elixhauser A.
      • Steiner C.
      • Harris D.R.
      • Coffey R.M.
      Comorbidity measures for use with administrative data.
      ,
      • Quan H.
      • Sundararajan V.
      • Halfon P.
      • Fong A.
      • Burnand B.
      • Luthi J.C.
      • et al.
      Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
      ], and comorbidities were compared between patients with and without history of COVID-19. We also compared information from patients’ pre-surgical screening including vital signs (pulse, respiration rate, SpO2), blood type, antibody test results, PCR test results, self-report of recent travel, self-report of recent COVID-19 exposure, and self-report of recent COVID-19 symptoms, as well as surgery details (hip or knee replacement, inpatient or ambulatory, type of anesthesia), discharge disposition (home or not), length of stay, and in-hospital complication rate (which included eight specific complications from the CMS Elective Primary THA/TKA Complication Measure, but was limited to complications that occurred during the index hospital admission and were not present on admission).
      Continuous variables with normal distribution were presented as mean (standard deviation [SD]) and compared by Student's t test; non-normal variables were reported as median (interquartile range [IQR]) and compared by Wilcoxon Mann-Whitney U test. Categorical variables were presented as frequencies and percentages and compared using the chi-square test or the Fisher exact test, when appropriate. Multivariable quantile regressions were used to analyze the association between median length of stay and history of COVID-19, controlling for age, BMI, sex, race, and ECI (separately for TKA and THA cohorts).
      All tests were 2-sided. Significance was defined as p < 0.05. Statistical analyses were performed using R 4.0.3. (R Foundation for Statistical Computing, Vienna, Austria, https://www.R-project.org/) and SAS 9.4 (SAS Institute Inc., Cary, NC).
      Before our analysis, we conducted power calculations for length of stay and in-hospital complications. For length of stay, this was estimated using a nonparametric Mann-Whitney method We estimated our sample size would achieve 90% power to detect non-inferiority at a 5% significance level with the margin of equivalence set to a third of a day and the true difference assumed to be 3 hours. For in-hospital complications, we used an equivalence test for difference between two independent proportions. We estimated our sample size would achieve 45% power to detect equivalence at a 5% significance level assuming 0.5% of patients with no history of COVID-19 would have an in-hospital complication, the actual difference in in-hospital complication rates between groups is 0.5%, and the margin of equivalence, given in terms of difference, is [-0.5%, 1.5%]. Given low expected power, we view the in-hospital complications analysis as preliminary. We report the results here given the importance of the underlying questions and in the hopes of spurring further work on this topic.

      Results

       Demographics, Comorbidities, and History of COVID-19

      We identified 5,354 patients who underwent a primary elective total hip or knee arthroplasty, among whom 3,083 (57.6%) were female, 4,458 (83.3%) were white or Caucasian, 394 (7.4%) were Black or African American, and 301 (5.6%) were Hispanic or Latino. Mean age was 64.8 (SD 10.2) years, and mean BMI was 30.5 (SD 6.4) (Table 1).
      Table 1Patient characteristics by history of COVID-19
      OverallHistory of COVID-19No History of COVID-19p-value
      Total53543405014
      Age (mean (SD))64.8 (10.2)63.4 (10.22)64.9 (10.19)0.533
      BMI (mean (SD))30.5 (64.2)31 (5.71)30.4 (66.31)0.533
      Female (%)3083 (57.6)180 (52.9)2903 (57.9)0.074
      Race (%)<.0001
       White or Caucasian4458 (83.3)248 (72.9)4210 (84)
       Black or African American394 (7.4)53 (15.6)341 (6.8)
       Other502 (9.4)39 (11.5)463 (9.2)
      Ethnicity (%)0.028
       Hispanic or Latino301 (5.6)29 (8.5)272 (5.4)
       Not Hispanic or Latino4912 (91.7)299 (87.9)4613 (92)
       Other141 (2.6)12 (3.5)129 (2.6)
      ASA (%)0.22
       1197 (3.7)15 (4.4)182 (3.6)
       24304 (80.4)261 (76.8)4043 (80.6)
       3+853 (15.9)64 (18.8)789 (15.7)
      Elixhauser Comorbidity Index (%)0.565
       01839 (34.3)106 (31.2)1733 (34.6)
       11281 (23.9)87 (25.6)1194 (23.8)
       21192 (22.3)75 (22.1)1117 (22.3)
       3+1042 (19.5)72 (21.2)970 (19.3)
      Comorbidities
       Congestive heart failure (%)41 (0.8)3 (0.9)38 (0.8)0.7989
       Valvular disease (%)171 (3.2)9 (2.6)162 (3.2)0.5535
       Pulmonary hypertension (%)3 (0.1)1 (0.3)2 (0)0.0552
       Peripheral vascular disease (%)66 (1.2)3 (0.9)63 (1.3)0.5452
       Hypertension (%)2144 (40)147 (43.2)1997 (39.8)0.2147
       Neurological disease (%)118 (2.2)8 (2.4)110 (2.2)0.8467
       Pulmonary disease (%)539 (10.1)30 (8.8)509 (10.2)0.4309
       Diabetes (%)301 (5.6)24 (7.1)277 (5.5)0.2346
       Diabetes with complications (%)97 (1.8)6 (1.8)91 (1.8)0.9464
       Hypothyroid disease (%)665 (12.4)35 (10.3)630 (12.6)0.2193
       Renal disease (%)186 (3.5)9 (2.6)177 (3.5)0.3895
       Liver disease (%)44 (0.8)2 (0.6)42 (0.8)0.622
       Peptic ulcer disease (%)10 (0.2)0 (0)10 (0.2)0.4098
       HIV (%)2 (0)0 (0)2 (0)0.7126
       Lymphoma (%)13 (0.2)0 (0)13 (0.3)0.3472
       Metastatic cancer (%)3 (0.1)0 (0)3 (0.1)0.6519
       Solid Tumor cancer (%)36 (0.7)4 (1.2)32 (0.6)0.2399
       Rheumatic disease (%)200 (3.7)6 (1.8)194 (3.9)0.0477
       Coagulopathy (%)109 (2)9 (2.6)100 (2)0.4096
       Obesity (%)1772 (33.1)149 (43.8)1623 (32.4)<.0001
       Anemia (%)229 (4.3)26 (7.6)203 (4)0.0015
       Alcohol abuse (%)13 (0.2)0 (0)13 (0.3)0.3472
       Drug or substance abuse (%)5 (0.1)1 (0.3)4 (0.1)0.2105
       Psychoses (%)51 (1)6 (1.8)45 (0.9)0.1111
       Depression (%)481 (9)27 (7.9)454 (9.1)0.4872
      The history of COVID-19 group consisted of 340 (6.3%) patients where 3/340 (0.9%) had a positive RT-PCR for SARS-CoV-2 at time of presurgical screening; surgeries of those three patients were initially postponed for at least four weeks, and these patients were later included in the cohort; 145/340 (42.6%) reported experiencing COVID-19 symptoms, 29/340 (8.5%) reported pneumonia, 23/340 (6.8%) were admitted to a hospital for COVID-19 treatment, and 2/340 (0.6%) were transferred to the ICU for treatment of severe COVID-19 disease. The mean time to surgery from disease onset was 168 (SD 71) days.
      A higher proportion of patients with history of COVID-19 were Black (15.6% vs. 6.8%, p < 0.001) and Hispanic (8.5% vs. 5.4%, p = 0.028). Also, a higher proportion of patients with history of COVID-19 were obese (43.8% vs. 32.4%, p < 0.001), anemic (defined as hemoglobin <12g/deciliters [dL] in female and <13.3g/dL in male patients) (7.6% vs. 4.0%, p=0.002), and a lower proportion had rheumatoid arthritis (1.8% vs. 3.9%, p = 0.048). There were no significant differences with respect to mean age, sex, ASA, or Elixhauser Comorbidity Index (Table 1).

       Presurgical Screening

      During presurgical screening, 22 (6.5%) patients with history of COVID-19 reported recent exposure to a suspected or confirmed case of COVID-19; only 78 (1.6%) in the no history of COVID-19 group reported recent exposure (p < 0.001) (Table 2). There were no differences in patient reported recent symptoms of COVID-19 (p = 0.218) or recent foreign or domestic travel (p = 0.773) between groups. For vitals taken during presurgical screening, there were no differences in mean SpO2, respiration rate, or pulse. The history of COVID-19 group had a higher proportion of A (44.4% vs. 40.3%) and B (17.6% vs. 14.0%) blood types (p = 0.012).
      Table 2Presurgical screening results by history of COVID-19
      OverallHistory of COVID-19No History of COVID-19p-value
      Preoperative vitals (mean (SD))
       Pulse72 (12.2)71 (12.6)72 (12.2)0.614
       Respiration rate16 (2.2)17 (4.7)16 (1.9)0.195
       SpO298 (1.3)98 (1.2)98 (1.3)0.431
      Blood type (count (%))0.012
       A2171 (40.5)151 (44.4)2020 (40.3)
       B764 (14.3)60 (17.6)704 (14)
       N52 (1)0 (0)52 (1)
       O2367 (44.2)129 (37.9)2238 (44.6)
      COVID-19 Screening
       SARS-CoV-2 Antibody Positive (%)340 (6.4)340 (100)0 (0)<.0001
       SARS-CoV-2 RT-PCR Positive (%)3 (0.1)3 (0.9)0 (0)<.0001
       Patient reported recent foreign or domestic travel
      Patients were asked at presurgical screening if they had recently traveled outside of the country or outside of the NY, NJ, CT, PA area within the past two weeks
      (%)
      185 (3.5)11 (3.2)174 (3.5)0.773
       Patient reported recent exposure to COVID-19
      Patients were asked at presurgical screening if they had been exposed to a suspected or confirmed COVID-19 case within the past two weeks
      (%)
      100 (1.9)22 (6.5)78 (1.6)<.0001
       Patient reported recent COVID-19 symptoms
      Patients were asked at presurgical screening if they had experienced any COVID-19 related symptoms within the past two weeks.
      (%)
      299 (5.6)15 (4.4)284 (5.7)0.218
      1 Patients were asked at presurgical screening if they had recently traveled outside of the country or outside of the NY, NJ, CT, PA area within the past two weeks
      2 Patients were asked at presurgical screening if they had been exposed to a suspected or confirmed COVID-19 case within the past two weeks
      3 Patients were asked at presurgical screening if they had experienced any COVID-19 related symptoms within the past two weeks.

       Surgery Details, Discharge Disposition, Length of Stay, and In-Hospital Complications

      There was no difference in the percentage of ambulatory (versus inpatient) surgeries (11.8% vs. 11.3%, p=0.797) or regional anesthesia use (97.1% vs. 97.8%, p=0.136). However, a lower proportion of patients in the history of COVID-19 group were discharged home (95.3% vs. 98.1%, p < 0.001) (Table 3). The median length of inpatient stay was 53 hours (IQR 33-76) among the history of COVID-19 group and 50 hours (IQR 31-60) in the no history of COVID-19 group (p = 0.001). However, our multivariable quantile regression controlling for confounders found that history of COVID-19 was not significantly associated with median inpatient length of stay for hip replacements (2.9 hours longer, 95% CI -2.0 to 7.8, p = 0.240) and knee replacements (4.1 hours longer, 95% CI -2.4 to 10.5, p = 0.214) (Table 4).
      Table 3Surgery details and index admission outcomes by history of COVID-19
      TotalHistory of COVID-19No History of COVID-19p-value
      Joint (%)0.24
       Hip2732 (51)163 (47.9)2569 (51.2)
       Knee2622 (49)177 (52.1)2445 (48.8)
      Admission type (%)0.797
       Ambulatory
      Ambulatory was defined as discharge on same day.
      607 (11.3)40 (11.8)567 (11.3)
       Inpatient4747 (88.7)300 (88.2)4447 (88.7)
      Type of anesthesia (%)0.136
       General110 (2.1)8 (2.4)102 (2)
       Regional5235 (97.8)330 (97.1)4905 (97.8)
       Other9 (0.2)2 (0.6)7 (0.1)
      Discharge Status (%)0.0004
       Home5244 (97.9)324 (95.3)4920 (98.1)
       Not Home110 (2.1)16 (4.7)94 (1.9)
      Length of stay (hours) (median (IQR))
       Ambulatory, hip and knee
      Ambulatory was defined as discharge on same day.
      10 (9, 11)11 (9, 11)10 (9, 11)0.5669
       Ambulatory, hip11 (10, 12)11 (11, 12)11 (10, 12)0.2843
       Ambulatory, knee10 (9, 11)10 (9, 11)10 (8.5, 11)0.7163
       Inpatient, hip and knee50 (31, 61)53 (33, 76)50 (31, 60)0.0005
       Inpatient, hip35 (30, 56)50 (31, 57)35 (30, 56)0.0536
       Inpatient, knee53 (32, 77)55.5 (39, 81)53 (32, 77)0.0051
      Index admission complications (%)
       All complications22 (0.4)0 (0)22 (0.4)0.221
       Acute myocardial infarction0 (0)0 (0)0 (0)--
       Mechanical complications1 (0)0 (0)1 (0)0.7945
       Pulmonary embolism6 (0.1)0 (0)6 (0.1)0.5233
       Prosthetic joint / wound infection0 (0)0 (0)0 (0)--
       Pneumonia8 (0.1)0 (0)8 (0.2)0.4611
       Sepsis0 (0)0 (0)0 (0)--
       Surgical site bleeding7 (0.1)0 (0)7 (0.1)0.4906
      1 Ambulatory was defined as discharge on same day.
      Table 4Quantile regression analysis of inpatient length of stay (in hours)
      Hip (n = 2446)pKnee (n = 2294)p
      Intercept26.08 (19.65 – 32.51)<.000122.47 (15.04 – 29.9)<.0001
      History of COVID-192.93 (-1.96-7.82)0.244.08 (-2.35-10.51)0.214
      Age (year)0.13 (0.04 - 0.22)0.0040.21 (0.1-0.31)0
      BMI (kg/m2)0.06 (-0.08-0.2)0.388-0.005 (-0.12-0.11)0.937
      Male (v Female)-6.23 (-7.95--4.51)<.0001-5.01 (-6.57--3.45)<.0001
      Race
       Black or African American (v White)13.01 (7.13-18.89)<.00017.8 (1.24-14.35)0.02
       Other (v White)2.27 (-1.42-5.95)0.2282.91 (-0.78-6.61)0.122
      Elixhauser Comorbidity Index
       1 (v 0)3.09 (1.21-4.97)0.00117.98 (15.64-20.31)<.0001
       2 (v 0)7.01 (2.91-11.12)0.00119.04 (16.85-21.24)<.0001
       3+ (v 0)19.53 (17.35-21.72)<.000122.22 (19.69-24.74)<.0001
      Point estimates and 95% confidence intervals
      The overall in-hospital complication rate was 0.4% with no significant differences between the history of COVID-19 group and the no history of COVID-19 group. There were zero complications in the history of COVID-19 group (0/340=0.0% versus 22/501= 0.44%, p = 0.221) (Table 3).

      Discussion

      This study reports on the largest known cohort of elective TJA patients operated on during the COVID-19 pandemic and compares 340 patients with evidence of history of COVID-19 to 5,014 contemporaneous patients without evidence of history of COVID-19. Patients in the history of COVID-19 group were more likely to be obese and more likely to be part of an ethnic/racial minority. These findings are consistent with the literature. In a study by Gu et al, obesity was associated with higher risk of having positive COVID-19 test results among African American patients [
      • Gu T.
      • Mack J.A.
      • Salvatore M.
      • Prabhu Sankar S.
      • Valley T.S.
      • Singh K.
      • et al.
      Characteristics Associated With Racial/Ethnic Disparities in COVID-19 Outcomes in an Academic Health Care System.
      ]. Unfortunately, a greater risk of severe COVID-19 disease has been described in African American, Asian, and minority ethnic populations in a study by Raisi-Estabragh et al [
      • Raisi-Estabragh Z.
      • McCracken C.
      • Bethell M.S.
      • Cooper J.
      • Cooper C.
      • Caulfield M.J.
      • et al.
      Greater risk of severe COVID-19 in Black, Asian and Minority Ethnic populations is not explained by cardiometabolic, socioeconomic or behavioural factors, or by 25(OH)-vitamin D status: study of 1326 cases from the UK Biobank.
      ]. In New York City, more cases and deaths of COVID-19 of Black and Latino individuals were recorded compared to white individuals [
      • Grigsby-Toussaint D.S.
      • Shin J.C.
      • Jones A.
      • Grigsby-Toussaint D.S.
      Disparities in the distribution of COVID-19 testing sites in black and Latino areas in new York City.
      ]. Potential reasons underlying why minorities have been more affected are lack of ability to socially distance at work and in multigenerational homes, mistrust of healthcare systems resulting from historical mistreatment, lack of access to quality medical care, and personal experience of discriminatory treatment [
      • Buikema A.R.
      • Buzinec P.
      • Paudel M.L.
      • Andrade K.
      • Johnson J.C.
      • Edmonds Y.M.
      • et al.
      Racial and ethnic disparity in clinical outcomes among patients with confirmed COVID-19 infection in a large US electronic health record database.
      ].
      Published data on the safety of elective surgery in COVID-19-recovered patients has been limited to smaller cohorts and some recent population-level studies. Among smaller cohorts, Lei et al reported a death rate of 20.6% in 34 patients who developed COVID-19 during a hospitalization for an elective procedure [
      • Lei S.
      • Jiang F.
      • Su W.
      • Chen C.
      • Chen J.
      • Mei W.
      • et al.
      Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection.
      ]; Aminian et. al reported a mortality rate of 75% among four patients with active COVID-19 undergoing elective surgery [
      • Aminian A.
      • Safari S.
      • Razeghian-Jahromi A.
      • Ghorbani M.
      • Delaney C.P.
      COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period.
      ]; and in a study by Shrikhande et al, none of six patients undergoing oncologic surgery who tested positive for COVID-19 required intensive care [
      • Shrikhande S.V.
      • Pai P.S.
      • Bhandare M.S.
      • Bakshi G.
      • Chaukar D.A.
      • Chaturvedi P.
      • et al.
      Outcomes of Elective Major Cancer Surgery During COVID 19 at Tata Memorial Centre: Implications for Cancer Care Policy.
      ]. Other specific surgical sub-disciplines have reported that elective surgeries during COVID-19 can be low risk [
      • Shrikhande S.V.
      • Pai P.S.
      • Bhandare M.S.
      • Bakshi G.
      • Chaukar D.A.
      • Chaturvedi P.
      • et al.
      Outcomes of Elective Major Cancer Surgery During COVID 19 at Tata Memorial Centre: Implications for Cancer Care Policy.
      ,
      • Teitelbaum S.
      • Diaz J.
      • Singer R.
      Outpatient Plastic Surgery Is Safe During the Covid-19 Pandemic: Results of a July 2020 Los Angeles Survey and Literature Review.
      ,
      • Hoyos Mejía L.
      • Romero Román A.
      • Gil Barturen M.
      • Córdoba Pelaez M.D.M.
      • Campo-Cañaveral de la Cruz J.L.
      • Naranjo J.M.
      • et al.
      Thoracic surgery during the coronavirus disease 2019 (COVID-19) pandemic in Madrid, Spain: single-centre report.
      ]. Kaye et al assume elective plastic surgery could be safe among COVID-19 negative patients given the relatively short duration of surgery and good underlying health of the plastic surgery patient population. On the other hand, data suggest that surgeries with longer durations and higher severity levels among COVID-19 positive patients may be associated with negative outcomes [

      Kaye K, Paprottka F, Escudero R, Casabona G, Montes J, Fakin R, et al. Elective, Non-urgent Procedures and Aesthetic Surgery in the Wake of SARS-COVID-19: Considerations Regarding Safety, Feasibility and Impact on Clinical Management. Aesthetic Plast Surg: 1, 2020

      ]. In a multidisciplinary ambulatory surgery center setting, 300 elective surgeries in patients without COVID-19 symptoms seven days prior to their surgery were safely performed between March and April 2020 with no noted COVID-19 related illnesses or complications [
      • Couto R.A.
      • Wiener T.C.
      • Adams W.P.
      Evaluating Postoperative Outcomes of Patients Undergoing Elective Procedures in an Ambulatory Surgery Center During the COVID-19 Pandemic.
      ]. The International Consensus Group (ICM) recommends elective orthopedic surgery only among COVID-19 negative patients, preoperative screening for SARS-CoV-2, and minimizing risk of pathogen transfer, as well as hygiene measurements and personal protection equipment [
      • Parvizi J.
      • Gehrke T.
      • Krueger C.A.
      • Chisari E.
      • Citak M.
      • Van Onsem S.
      • et al.
      Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines Developed by the International Consensus Group (ICM).
      ]. Optimal timing for emergency surgery is still debated, although severe COVID-19 has been described as relative contraindication. and critical COVID-19 as an absolute contraindication for emergency orthopedic surgery [
      • Wang Y.
      • Zeng L.
      • Yao S.
      • Zhu F.
      • Liu C.
      • Di Laura A.
      • et al.
      Recommendations of protective measures for orthopedic surgeons during COVID-19 pandemic.
      ].
      On the other hand, among surgical patients with symptomatic COVID-19, risks may abound. An international multicenter cohort of 1,128 patients undergoing surgery with perioperative COVID-19 infection found a mortality rate of 18.9% among patients undergoing elective surgery and 25.6% among patients undergoing emergency surgery [
      Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.
      ]. Because of this risk, preoperative assessment for the presence of SARS-CoV-2 remains important, particularly in populations where the pandemic persists and vaccination is not widespread.
      In a recent and more rigorous epidemiologic analysis, among 140,231 patients undergoing surgery in 116 countries, 3,127 had a history of COVID-19. Mortality in this cohort was significantly lower among patients who had completely resolved symptoms and delayed surgery >seven weeks after COVID-19 was diagnosed [

      Collaborative C, Collaborative G. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia n/a(n/a),

      ].
      In our study of elective primary joint arthroplasty patients, no significant differences in length of stay or complication rates during hospitalization were detected. COVID-19 patients were somewhat more likely to be discharged to a post-acute care facility. While the current study is not well-powered to detect differences for in-hospital complications (especially for rarer complications like pulmonary emboli), our preliminary findings suggest that, at least with respect to in-hospital complications, elective joint replacement surgery is safe in patients with history of COVID-19. However more research is needed in larger samples to confirm the robustness of this finding, as well as to investigate longer-term outcomes. Future research in broader patient samples, including patients recovering from more severe COVID-19 disease, is also important.
      The current study has several limitations: (1) patients with history COVID-19 in our cohort may have self-selected into surgery and thus may not represent the true spectrum of disease among all COVID-19 survivors who need a joint replacement (e.g., some sicker patients likely did not receive medical clearance for elective surgery or may have self-selected not to undergo surgery this year). In addition, the antibody response to COVID-19 in patients with immune issues is likely not be the same as in healthier patients, which may have led us to miscategorize some unknown proportion of previously-infected, anergic patients; (2) we did not assess complications after hospital discharge; (3) despite the fact that this cohort represents the largest group of elective surgical patients in the COVID-19 era, our study is likely underpowered to detect increased risks for relatively rare outcomes like in-hospital complications; and (4) COVID-19 is not randomly assigned, so all analyses, particularly with respect to any differences we found, must be viewed as associations (i.e., are not necessarily causal).

      Conclusion

      While patients undergoing elective joint arthroplasty with history of COVID-19 (compared to patients without history of COVID-19) differed in terms of race, ethnicity, and prevalence of obesity, there were not significant differences in median length of stay (after controlling for measured confounding variables) nor in-hospital complication rates between groups. Our findings suggest that a history of mild or asymptomatic SARS-CoV-2 infection is not a risk factor for perioperative adverse events following elective primary joint replacement. Further surveillance and research are needed to evaluate the impact of COVID-19 on post-hospitalization complications and patients with history of moderate and severe COVID-19.

      Conflict of Interests:

       Declaration of interests

      ☐ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Appendix A. Supplementary data

      References

        • Debeaumont D.
        • Boujibar F.
        • Ferrand-Devouge E.
        • Artaud-Macari E.
        • Tamion F.
        • Gravier F.E.
        • et al.
        Cardiopulmonary Exercise Testing to Assess Persistent Symptoms at 6 Months in People With COVID-19 Who Survived Hospitalization - A Pilot Study.
        Phys Ther. 2021;
        • De Biase S.
        • Cook L.
        • Skelton D.A.
        • Witham M.
        • Ten Hove R.
        The COVID-19 rehabilitation pandemic.
        Age Ageing. 2020; 49: 696
        • Waleed R.M.
        • Sehar I.
        • Iftikhar W.
        • Khan H.S.
        Hematologic parameters in coronavirus infection (COVID-19) and their clinical implications.
        Discoveries (Craiova). 2020; 8: e117
      1. Magadum A, Kishore R. Cardiovascular Manifestations of COVID-19 Infection. Cells 9(11), 2020

        • Nishiga M.
        • Wang D.W.
        • Han Y.
        • Lewis D.B.
        • Wu J.C.
        COVID-19 and cardiovascular disease: from basic mechanisms to clinical perspectives.
        Nat Rev Cardiol. 2020; 17: 543
        • Ellul M.A.
        • Benjamin L.
        • Singh B.
        • Lant S.
        • Michael B.D.
        • Easton A.
        • et al.
        Neurological associations of COVID-19.
        Lancet Neurol. 2020; 19: 767
        • Sharifian-Dorche M.
        • Huot P.
        • Osherov M.
        • Wen D.
        • Saveriano A.
        • Giacomini P.S.
        • et al.
        Neurological complications of coronavirus infection; a comparative review and lessons learned during the COVID-19 pandemic.
        J Neurol Sci. 2020; 417: 117085
        • Yang W.
        • Cao Q.
        • Qin L.
        • Wang X.
        • Cheng Z.
        • Pan A.
        • et al.
        Clinical characteristics and imaging manifestations of the 2019 novel coronavirus disease (COVID-19):A multi-center study in Wenzhou city, Zhejiang, China.
        J Infect. 2020; 80: 388
        • Knisely A.
        • Zhou Z.N.
        • Wu J.
        • Huang Y.
        • Holcomb K.
        • Melamed A.
        • et al.
        Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures.
        Ann Surg. 2020;
        • Boettner F.
        • Bostrom M.P.
        • Figgie M.
        • Gonzalez Della Valle A.
        • Haas S.
        • Mayman D.
        • et al.
        Timeline and Procedures on Restarting Non-Emergent Arthroplasty Care in the US Epicenter of the COVID-19 Pandemic.
        Hss j:. 2020; 1
        • Lei S.
        • Jiang F.
        • Su W.
        • Chen C.
        • Chen J.
        • Mei W.
        • et al.
        Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection.
        EClinicalMedicine. 2020; 21: 100331
      2. De Buhr J MK, Grady J. Condition Specific Measures Updates and Specifications Report Hospital-Level 30 Day Risk-Standardized Readmission Measures: elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) - version 9.0. 2020.

      3. Cepheid. Xpert Xpress SARS-CoV-2/Flu/RSV Instructions for Use [Internet]. 1/ cited 2/1/21]. Available from: https://www.fda.gov/media/142438/download.

      4. Biomerieaux. Biomerieaux Diagnostics Respiratory Panel 2.1 (Technical Details) [Internet]. cited 2/1/21]. Available from: https://www.biomerieux-diagnostics.com/filmarrayr-respiratory-panel.

      5. Abbott Architect SARS-CoV-2 IgG https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/eua-authorized-serology-test-performance.

        • Dripps R.D.
        • Lamont A.
        • Eckenhoff J.E.
        The role of anesthesia in surgical mortality.
        Jama. 1961; 178: 261
        • Elixhauser A.
        • Steiner C.
        • Harris D.R.
        • Coffey R.M.
        Comorbidity measures for use with administrative data.
        Med Care. 1998; 36: 8
        • Quan H.
        • Sundararajan V.
        • Halfon P.
        • Fong A.
        • Burnand B.
        • Luthi J.C.
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130
        • Gu T.
        • Mack J.A.
        • Salvatore M.
        • Prabhu Sankar S.
        • Valley T.S.
        • Singh K.
        • et al.
        Characteristics Associated With Racial/Ethnic Disparities in COVID-19 Outcomes in an Academic Health Care System.
        JAMA Netw Open. 2020; 3e2025197
        • Raisi-Estabragh Z.
        • McCracken C.
        • Bethell M.S.
        • Cooper J.
        • Cooper C.
        • Caulfield M.J.
        • et al.
        Greater risk of severe COVID-19 in Black, Asian and Minority Ethnic populations is not explained by cardiometabolic, socioeconomic or behavioural factors, or by 25(OH)-vitamin D status: study of 1326 cases from the UK Biobank.
        J Public Health (Oxf). 2020; 42: 451
        • Grigsby-Toussaint D.S.
        • Shin J.C.
        • Jones A.
        • Grigsby-Toussaint D.S.
        Disparities in the distribution of COVID-19 testing sites in black and Latino areas in new York City.
        Prev Med. 2021; 106463
        • Buikema A.R.
        • Buzinec P.
        • Paudel M.L.
        • Andrade K.
        • Johnson J.C.
        • Edmonds Y.M.
        • et al.
        Racial and ethnic disparity in clinical outcomes among patients with confirmed COVID-19 infection in a large US electronic health record database.
        EClinicalMedicine. 2021; 39: 101075
        • Aminian A.
        • Safari S.
        • Razeghian-Jahromi A.
        • Ghorbani M.
        • Delaney C.P.
        COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period.
        Ann Surg. 2020; 272: e27
        • Shrikhande S.V.
        • Pai P.S.
        • Bhandare M.S.
        • Bakshi G.
        • Chaukar D.A.
        • Chaturvedi P.
        • et al.
        Outcomes of Elective Major Cancer Surgery During COVID 19 at Tata Memorial Centre: Implications for Cancer Care Policy.
        Ann Surg. 2020; 272: e249
        • Teitelbaum S.
        • Diaz J.
        • Singer R.
        Outpatient Plastic Surgery Is Safe During the Covid-19 Pandemic: Results of a July 2020 Los Angeles Survey and Literature Review.
        Aesthet Surg J. 2020;
        • Hoyos Mejía L.
        • Romero Román A.
        • Gil Barturen M.
        • Córdoba Pelaez M.D.M.
        • Campo-Cañaveral de la Cruz J.L.
        • Naranjo J.M.
        • et al.
        Thoracic surgery during the coronavirus disease 2019 (COVID-19) pandemic in Madrid, Spain: single-centre report.
        Eur J Cardiothorac Surg. 2020; 58: 991
      6. Kaye K, Paprottka F, Escudero R, Casabona G, Montes J, Fakin R, et al. Elective, Non-urgent Procedures and Aesthetic Surgery in the Wake of SARS-COVID-19: Considerations Regarding Safety, Feasibility and Impact on Clinical Management. Aesthetic Plast Surg: 1, 2020

        • Couto R.A.
        • Wiener T.C.
        • Adams W.P.
        Evaluating Postoperative Outcomes of Patients Undergoing Elective Procedures in an Ambulatory Surgery Center During the COVID-19 Pandemic.
        Aesthet Surg J. 2020;
        • Parvizi J.
        • Gehrke T.
        • Krueger C.A.
        • Chisari E.
        • Citak M.
        • Van Onsem S.
        • et al.
        Resuming Elective Orthopaedic Surgery During the COVID-19 Pandemic: Guidelines Developed by the International Consensus Group (ICM).
        J Bone Joint Surg Am. 2020; 102: 1205
        • Wang Y.
        • Zeng L.
        • Yao S.
        • Zhu F.
        • Liu C.
        • Di Laura A.
        • et al.
        Recommendations of protective measures for orthopedic surgeons during COVID-19 pandemic.
        Knee Surg Sports Traumatol Arthrosc. 2020; 28: 2027
      7. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.
        Lancet. 2020; 396: 27
      8. Collaborative C, Collaborative G. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia n/a(n/a),