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Response to the letter to the editor: “COVID-19 Infection Risk, Elective Arthroplasty and Surgical Complications and COVID-19 Vaccination: Correspondence”

Open AccessPublished:November 03, 2022DOI:https://doi.org/10.1016/j.artd.2022.10.013
      We would like to thank both Dr. Mungmunpuntipantip for his precise comments on our article (
      • Mirghaderi S.P.
      • Salimi M.
      • Moharrami A.
      • Hosseini-Dolama R.
      • Mirghaderi S.R.
      • Ghaderi M.
      • et al.
      COVID-19 Infection Risk Following Elective Arthroplasty and Surgical Complications in COVID-19 Vaccinated Patients: A Multicenter Comparative Cohort Study.
      ), as well as the Editor-in-Chief of Arthroplasty Today for giving us the opportunity to respond. The comments were read with specific interest and we attempted to respond to our colleague's questions, acknowledging the limitations of the study which could also result in misinterpretation of the results. In the following paragraph, we describe the three consecutive studies we published in 2022 about COVID-19 infection after total joint arthroplasty (TJA).
      We conducted a prospective study in which we followed TJA patients following discharge for symptoms of COVID-19 and then confirmed the diagnosis using reverse transcription polymerase chain reaction (RT-PCR). In three published studies, the rate and risk factors of symptomatic COVID-19 were described. Firstly, we evaluated unvaccinated patients who underwent elective TJA between April 2020 and April 2021 and found that their COVID-19 infection rate was 2.4% (18/755), which was not greater than the general population's (2.2%, P>0.05) (
      • Sheikhbahaei E.
      • Mirghaderi S.P.
      • Moharrami A.
      • Habibi D.
      • Motififard M.
      • Mortazavi S.M.J.
      Incidence of Symptomatic COVID-19 in Unvaccinated Patients Within One Month After Elective Total Joint Arthroplasty: A Multicenter Study.
      ). As a result of our study, we concluded that resuming elective TJA surgery in the pre-vaccine era was not free of risks. Both surgeons and patients should be aware of these risks, and perioperative safety protocols should be adhered to strictly. In the second study, we compared the incidence of COVID-19 infection following urgent versus elective total hip arthroplasty (THA) among unvaccinated individuals between April 2020 and August 2021 (
      • Mirghaderi S.P.
      • Sheikhbahaei E.
      • Salimi M.
      • Mirghaderi S.R.
      • Ahmadi N.
      • Moharrami A.
      • et al.
      COVID-19 infection rate after urgent versus elective total hip replacement among unvaccinated individuals: A multicenter prospective cohort amid the COVID-19 pandemic.
      ). The COVID-19 rate among elective cases (1.4%, 5/340) and traumatic cases (3.3%, 3/91) did not differ statistically (P = 0.24). The hypothesis that urgent traumatic cases are at greater risk due to less severe prevention measures failed, and research found a similar risk of infection during the peri-surgery period in both elective and urgent THA cases. In the third and present study, we repeat the first study among vaccinated patients between October 2021 and March 2022 (
      • Mirghaderi S.P.
      • Salimi M.
      • Moharrami A.
      • Hosseini-Dolama R.
      • Mirghaderi S.R.
      • Ghaderi M.
      • et al.
      COVID-19 Infection Risk Following Elective Arthroplasty and Surgical Complications in COVID-19 Vaccinated Patients: A Multicenter Comparative Cohort Study.
      ). In vaccinated individuals, the rate of symptomatic COVID-19 within one month of elective arthroplasty was 3.9% (38/962), which was not statistically different from the unvaccinated cohort rate (P=0.07). The 90-day surgical complications of TJA were similar between the vaccinated and unvaccinated groups (P>0.05) (
      • Mirghaderi S.P.
      • Salimi M.
      • Moharrami A.
      • Hosseini-Dolama R.
      • Mirghaderi S.R.
      • Ghaderi M.
      • et al.
      COVID-19 Infection Risk Following Elective Arthroplasty and Surgical Complications in COVID-19 Vaccinated Patients: A Multicenter Comparative Cohort Study.
      ). In conclusion, vaccination does not guarantee that a patient will not contract COVID-19 following arthroplasty surgery, and reasonable precautions should be taken peri-operatively to prevent the infection.
      We agree with the author's statement regarding the importance of asymptomatic COVID-19 in these cases. COVID-19 asymptomatic cases carry the virus, can infect other patients on the ward, and can even become symptomatic during the critical recovery period following surgery (
      • Gao Z.
      • Xu Y.
      • Sun C.
      • Wang X.
      • Guo Y.
      • Qiu S.
      • et al.
      A systematic review of asymptomatic infections with COVID-19.
      ). COVID-19-positive cases were found to have inferior surgical outcomes and a higher mortality rate (
      Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study.
      ). Therefore, performing strict testing might be a reasonable approach, and in one of our study cities, Isfahan, we performed preoperative testing. However, due to limitations in our low-income healthcare system, complete laboratory testing was not available in all centers, especially not-for-profit public hospitals. Additionally, we should be aware of the high rate of false negative results associated with the RT-PCR test (up to 54%) and should not rely exclusively upon it for diagnostic purposes (
      • Arevalo-Rodriguez I.
      • Buitrago-Garcia D.
      • Simancas-Racines D.
      • Zambrano-Achig P.
      • Del Campo R.
      • Ciapponi A.
      • et al.
      False-negative results of initial RT-PCR assays for COVID-19: A systematic review.
      ).
      Additionally, we agree with the author's comment that many factors affect patient immunization, including co-morbidity, new virus variants, and the type and manner of vaccine administration. Still, the vaccine was a fantastic idea, which had a significant impact on reducing COVID-19's dire consequences (
      • Tenforde M.W.
      • Self W.H.
      • Adams K.
      • Gaglani M.
      • Ginde A.A.
      • McNeal T.
      • et al.
      Association Between mRNA Vaccination and COVID-19 Hospitalization and Disease Severity.
      ). They recommended that laboratory tests be conducted on vaccinated patients or patients with previous exposures to COVID-19 to ensure that they are immunized. A number of immunological deficiencies may hinder vaccine effectiveness, and preoperative laboratory evaluations are necessary for some high-risk patients in order to prevent further complications. Immunocompromised patients, such as those with hematological malignancies and organ transplants, are at greater risk of developing severe COVID-19 and developing less antibody protection (
      • Noori M.
      • Azizi S.
      • Abbasi Varaki F.
      • Nejadghaderi S.A.
      • Bashash D.
      A systematic review and meta-analysis of immune response against first and second doses of SARS-CoV-2 vaccines in adult patients with hematological malignancies.
      ,
      • Kolb T.
      • Fischer S.
      • Müller L.
      • Lübke N.
      • Hillebrandt J.
      • Andrée M.
      • et al.
      Impaired Immune Response to SARS-CoV-2 Vaccination in Dialysis Patients and in Kidney Transplant Recipients.
      ). It is possible that the vaccines are adequate, but not in cases of immunodeficiency. Nevertheless, we believe that performing immunological testing before TJA surgery on vaccinated patients is not cost-effective in our low-income country with significant healthcare deficiencies, except for patients who are at high risk or suspicious (
      • de Assis T.S.M.
      • Freire M.L.
      • Carvalho J.P.
      • Rabello A.
      • Cota G.
      Cost-effectiveness of anti-SARS-CoV-2 antibody diagnostic tests in Brazil.
      ). Also, FDA recommends against assessing immunity and antibody levels following COVID-19 vaccination (

      Antibody (serology) testing for COVID-19: information for patients and consumers: U.S. Food & Drug Administration (FDA); 2022 [Available from: https://www.fda.gov/medical-devices/coronavirus-covid-19-and-medical-devices/antibody-serology-testing-covid-19-information-patients-and-consumers.

      ). A misinterpretation of antibody results can result in people taking fewer precautions against SARS-CoV-2 exposure. There is no clear correlation between the results of a SARS-CoV-2 antibody test, the need for a COVID-19 vaccine or booster, or the effectiveness of a vaccine. Moreover, some SARS-CoV-2 antibody tests may not detect the type of antibody produced as a result of vaccination.
      Our hope is that this discussion has provided an appropriate response to the comments made by our colleague.

      Conflicts of Interest

      The authors declare there are no conflicts of interest.

      Conflict 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.
      ☐ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

      Acknowledgment and funding sources:*

      *(Please note that you should not include a statement to the effect that there is no acknowledgment or funding, only actual funding details or acknowlegments should be included in this section)

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