key: cord-0742354-tt93sg2d
authors: Jungwirth-Weinberger, Anna; Boettner, Friedrich; Kapadia, Milan; Diane, Alioune; Chiu, Yu-Fen; Lyman, Stephen; Fontana, Mark Alan; Miller, Andy O.
title: History of COVID-19 Was Not Associated with Length of Stay or In-Hospital Complications After Elective Lower Extremity Joint Replacement
date: 2021-12-10
journal: Arthroplast Today
DOI: 10.1016/j.artd.2021.11.021
sha: 9a0ba0529e6887b0e1b33ee7d51e41b9f4395f84
doc_id: 742354
cord_uid: tt93sg2d

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

p=0.001). There was no significant difference in in-hospital complication rates between the two 23 groups (0/340=0.0% versus 22/5,014=0.44%, p=0.221).

Conclusion 25 We do not find differences in LOS or in-hospital complications between the two groups. 26 However, more work is needed to confirm these findings, particularly for patients with a history 27 of more severe COVID-19. after resolution of primary illness. Furthermore, active COVID-19 illness has been shown to be 41 associated with an increased risk for perioperative complications, including sepsis, shock, 42 cardiac arrest, pneumonia, respiratory failure, acute respiratory distress syndrome, acute kidney 43 injury, and mortality in patients undergoing emergency procedures [9] . 44 The impact of prior infection with SARS-CoV-2 on the outcomes of elective surgical procedures 45 is an important, unanswered clinical issue. 46 As rates of COVID-19 illness fell in New York City, elective surgical procedures at our high-47 volume specialty musculoskeletal center resumed. Presurgical screening was adjusted to test for 48 serum antibodies to SARS-CoV-2 [10] . In addition, all patients underwent nasopharyngeal PCR 49 screening within three days prior to admission, and elective surgery on PCR-positive patients 50 was postponed in accordance with regulatory guidance. 51 The impact of previous SARS-CoV-2 infection on the morbidity of patients undergoing elective 52 total joint replacement has not yet been carefully assessed. We hypothesized that morbidity after 53 joint replacement would be increased among those who had a history of COVID-19, even if 54 symptoms were resolved [11] . 

After obtaining institutional review board approval, we queried our institution's data warehouse 60 for patients undergoing elective primary total hip (THA) or knee (TKA) arthroplasty between 61 5/6/2020 and 1/5/2021. Inclusion criteria was based on ICD-10 codes from the Center for arthroplasty; concurrent revision, resurfacing, or implanted device/prosthesis removal procedure; 65 indications for mechanical complication; indications for malignant neoplasms [12] .

Our institution's presurgical screening for elective surgery was modified to account for the 67 ongoing COVID-19 pandemic. These changes included: 

Before our analysis, we conducted power calculations for length of stay and in-hospital 119 complications. For length of stay, this was estimated using a nonparametric Mann-Whitney 120 method We estimated our sample size would achieve 90% power to detect non-inferiority at a 121 5% significance level with the margin of equivalence set to a third of a day and the true 122 difference assumed to be 3 hours. For in-hospital complications, we used an equivalence test for 123 difference between two independent proportions. We estimated our sample size would achieve 124 45% power to detect equivalence at a 5% significance level assuming 0.5% of patients with no 133 We identified 5,354 patients who underwent a primary elective total hip or knee arthroplasty, 134 among whom 3,083 (57.6%) were female, 4,458 (83.3%) were white or Caucasian, 394 (7.4%) 135 were Black or African American, and 301 (5.6%) were Hispanic or Latino. Mean age was 64.8 136 (SD 10.2) years, and mean BMI was 30.5 (SD 6.4) ( Table 1) .

The history of COVID-19 group consisted of 340 (6.3%) patients where 3/340 (0.9%) had a (Table 1) . 159 There was no difference in the percentage of ambulatory (versus inpatient) surgeries (11.8% vs. (Table 4) . 168 The overall in-hospital complication rate was 0.4% with no significant differences between the (Table 3) . pathogen transfer, as well as hygiene measurements and personal protection equipment [29] .

Optimal timing for emergency surgery is still debated, although severe COVID-19 has been 206 described as relative contraindication. and critical COVID-19 as an absolute contraindication for 207 emergency orthopedic surgery [30] . In our study of elective primary joint arthroplasty patients, no significant differences in length of 219 stay or complication rates during hospitalization were detected. COVID-19 patients were 220 somewhat more likely to be discharged to a post-acute care facility. While the current study is 221 not well-powered to detect differences for in-hospital complications (especially for rarer 222 complications like pulmonary emboli), our preliminary findings suggest that, at least with respect 223 to in-hospital complications, elective joint replacement surgery is safe in patients with history of 224 COVID-19. However more research is needed in larger samples to confirm the robustness of this 225 finding, as well as to investigate longer-term outcomes. Future research in broader patient 226 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 228 have self-selected into surgery and thus may not represent the true spectrum of disease among all 229 COVID-19 survivors who need a joint replacement (e.g., some sicker patients likely did not 230 receive medical clearance for elective surgery or may have self-selected not to undergo surgery 231 this year). In addition, the antibody response to COVID-19 in patients with immune issues is 232 likely not be the same as in healthier patients, which may have led us to miscategorize some 233 unknown proportion of previously-infected, anergic patients; (2) we did not assess complications 234 after hospital discharge; (3) despite the fact that this cohort represents the largest group of 235 elective surgical patients in the COVID-19 era, our study is likely underpowered to detect 236 increased risks for relatively rare outcomes like in-hospital complications; and (4) COVID-19 is 237 not randomly assigned, so all analyses, particularly with respect to any differences we found, 238 must be viewed as associations (i.e., are not necessarily causal). 

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