key: cord-1004538-6dpwr8ds
authors: Sheikhbahaei, Erfan; Mirghaderi, Seyed Peyman; Moharrami, Alireza; Habibi, Danial; Motififard, Mehdi; Javad Mortazavi, Seyed Mohammad
title: Incidence of Symptomatic COVID-19 in Unvaccinated Patients within One Month after Elective Total Joint Arthroplasty: A Multicentre Study
date: 2022-01-24
journal: Arthroplast Today
DOI: 10.1016/j.artd.2022.01.024
sha: d171b47206a5bdc0d55495e3eed1505dc8557873
doc_id: 1004538
cord_uid: 6dpwr8ds

BACKGROUND: The safety of continuing Total Joint Arthroplasty (TJA), as an elective procedure, during the pandemic is controversial. The present study aimed to investigate the incidence of symptomatic COVID-19 and its related risk factors in unvaccinated patients after TJA within one month post-discharge in two large cities of our country. METHODS: The present prospective study included all the patients admitted to three hospitals, located in two high-populated cities of our country from April 1st, 2020, to April 1st, 2021, for elective TJA. Urgent TJA (traumatic fractures) were excluded. The primary outcome was symptomatic COVID-19 within one-month after discharge that was diagnosed using the SARS-CoV-2 RT-PCR test. Afterward, the incidence of the COVID-19 in the study population was compared with the general population to estimate the safety of elective TJA during the pandemic. RESULTS: From the 1007 patients undergoing TJA, 755 patients met the inclusion criteria. None of the patients was vaccinated against COVID-19. Among them, 18 patients (2.4%) developed symptomatic COVID-19 within one-month after discharge. In the same time interval, the incidence of COVID-19 was 2.2% in the general population of these two cities, which was similar to the incidence reported in the study population. Of the patients who were positive for COVID-19, four patients were hospitalized, and 3 of them were ICU-admitted; however, no mortality was reported. CONCLUSION: The TJA will be a safe elective procedure for the patients during the pandemic if the preventive protocols are followed strictly.

The COVID-19 pandemic has adversely influenced global healthcare, rendering hospitals unsafe contact during hospitalization and surgery, hospital admission for many elective surgical 28 procedures, such as arthroplasty, has been reduced or completely suspended for a while (5). 29 Considering the shortage of healthcare-related resources at the beginning of the pandemic and the 30 preventive protocols announced by the healthcare authorities, many surgeons postponed their 31 elective surgeries, such as arthroplasties (5, 6) . 32 However, the continuation of this situation made both hospitals and patients face a dilemma. On 33 the one hand, hospitals developed financial problems due to increased costs and decreased income 34 (7). On the other hand, patients had to tolerate their prolonged articular pain and dysfunction. 35 Therefore, elective surgeries, such as the total joint arthroplasty for the hip and knee, need to be 36 continued (8, 9) and should not be deferred to an unknown time. However, there was no protocol 37 for resuming elective surgeries during the pandemic. Every healthcare facility had its own protocol 38 based on the related management policy and available resources, such as beds (10).

During the past two years, the prevalence and incidence of COVID-19 had several fluctuations 40 and led to different challenges in each country. However, the introduction and implementation of 41 vaccination against COVID-19 were highly effective, remarkably reducing the global incidence, 42 prevalence, and mortality. Therefore, people are gradually getting back to a new routine life (11, 43 12). However, the slow expansion of vaccination coverage in some countries, rapid reopening, and 44 the emergence of the new mutated variants of SARS-CoV-2 (such as delta and omicron variants) 45 led to many new outbreaks with a more extensive spread of the disease, especially in the 46 developing countries (13-17). Therefore, restarting the mass elective practice by the orthopedic surgeons, especially arthroplasty surgeries, is still debating, and the related protocols have been 48 changed several times (18) (19) (20) (21) . Moreover, limited studies have investigated the possibility of 49 COVID-19 contraction and related risks due to hospitalization for the TJA.

The present study aimed to investigate the incidence of symptomatic COVID-19 within one month 51 after elective TJA and its related risk factors in unvaccinated patients in three hospitals of two 52 populated cities in our country.

written consent for participation.

The required data was extracted from their medical records. We prepared our checklists which 67 were filled using the following data of the participants: age, gender, weight, height, type of surgery 68 (THA or TKA), surgery being primary or secondary, TJR indication, surgery cancellation and 69 delay due to the pandemic, any contact with positive COVID-19 patient before the surgery and its The preoperative TJA protocol included two parts. The first part was a comprehensive routine 81 assessment of complete history taking (any recent symptoms suggestive of COVID-19 or any 82 contact with the COVID-19 patients within the last months), body temperature measurement using 83 a digital thermometer, and oxygen saturation measurement using pulse oximetry. These routine 84 J o u r n a l P r e -p r o o f assessments were performed for all the patients in all three hospitals before the TJR surgery. The 85 second part included the laboratory and imaging investigations that were different between the 86 hospitals. The patients hospitalized in city1 were tested for COVID-19 using the RT-PCR twice: 87 48-72 hours pre-operation and the day of the surgery. However, the patients in city2 did not tested 88 for COVID-19 by RT-PCR and they underwent a chest X-ray (CXR) for screening. Then, those 89 suspicious for COVID-19 (i.e. any related symptoms or with airspace opacities in radiography) 90 were referred to the COVID-19 clinic for further investigations. If the COVID-19 was ruled out 91 by the infectious disease service, the patient was listed for the surgery. All the patients were followed up for one-month after surgery. They received weekly phone calls 95 and were asked about recent COVID-19 symptoms, such as fever, fatigue, sore throat, dyspnea, 96 cough, or diarrhea. The patients experiencing any suspicious symptoms underwent RT-PCR for SARS-CoV-2 using nasopharyngeal and oropharyngeal swabs. Those positive for COVID-19 98 were visited by the infectious disease specialist, and the data regarding their disease was recorded, 99 such as the interval between discharge and the onset of COVID-19 symptoms, hospital stay, ICU 100 admission, the need for intubation/mechanical ventilation, and mortality due to COVID-19.

The monthly number of TJA procedures performed in the hospitals before the pandemic was 102 extracted from the Hospital Information Systems (HIS) and was compared with the number of TJA 103 procedures during the pandemic. Moreover, we received the daily number of new COVID-19 cases 104 in these two cities and the whole country in the study duration from the Deputy for Health, 105 Research, and Education of the Ministry of Health and Medical Education of our country in order 106 to compare the incidence of COVID-19 between the study population and the general population. 

Of the patients who were positive for COVID-19, 4 patients (22%) were hospitalized, and 3 (17%) 148 of these 4 were ICU-admitted; however, no mortality was reported. The detailed clinical 149 information of the COVID-positive patients is presented in Table 2 . The patients with COVID-19 150 developed symptoms at a mean time of 10 days after discharge (range=4-22 days). The data 151 regarding the duration between the hospital discharge and onset of symptoms is presented in Figure   152 2. 

The present study investigated the incidence of symptomatic COVID-19 in unvaccinated patients 156 undergoing elective TJA within one month after being discharge in 3 arthroplasty centers of two 157 high-populated cities of our country. According to our results, of the 755 unvaccinated patients 158 meeting the eligibility criteria, 18 patients (2.4%) developed COVID-19 within one month. In the 159 same time interval, the incidence of COVID-19 was 2.2% in the general population of these two 160 cities, which was similar to the incidence reported in this study population. Moreover, pulmonary symptomatic . According to them, preoperative testing for 168 preoperative self-isolation, and operating in those hospitals with no COVID-19 ward could not decrease the risk of contracting COVID-19. Eventually, the authors concluded that elective 170 bariatric surgery was safe during the pandemic and could be resumed while following safety 171 protocols (22). We can also conclude similarly, however, we reported a higher rate of postoperative 172 COVID-19 compared to the mentioned study (2.4% vs. 0.56%), which can be due to higher cases 173 of COVID-19 in our country, smaller sample size, and different study population. reported that all the patients were negative for COVID-19 after the surgery (25). 186 We assumed that all the cases showing COVID-19 symptoms post-operation had been contracting 187 the disease due to hospitalization. However, finding the exact source of infection is not possible.

In order to reduce the risk of postoperative COVID-19, surgeons should recommend to their 189 patients to avoid public places after the discharge. In addition, screening the family and friends 190 visiting the patients can be helpful.

It is very likely that the COVID-19 pandemic continues even with extensive vaccination. J o u r n a l P r e -p r o o f 

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COVID-19 Mortality Rate and Its Incidence in Latin America: 282 Dependence on Demographic and Economic Variables

The politics of COVID-19 vaccination in middle-285 income countries: Lessons from Brazil