Abstract
Background
The optimal timing of elective arthroplasty following COVID-19 infection remains unclear. While early postoperative risk is recognized, arthroplasty-specific data stratified by recovery interval are limited. We hypothesized that patients undergoing arthroplasty >12 weeks after COVID-19 would experience decreased complication risk.
Methods
A retrospective cohort study evaluated outcomes following primary total hip arthroplasty and total knee arthroplasty (THA/TKA). Patients with documented preoperative COVID-19 infection were stratified by timing relative to surgery (<4 weeks, 4-12 weeks, >12 weeks) and compared to controls without prior infection. Primary outcomes included 1-year prosthetic joint infection, sepsis, revision surgery, deep vein thrombosis, and pulmonary embolism (PE).
Results
A total of 37,272 THA and 57,158 TKA patients were included. Surgery within 4 weeks of infection was associated with increased risks of sepsis (THA relative risk [RR]: 2.36; TKA RR: 2.27) and PE (THA RR: 1.74; TKA RR: 2.39). In THA, deep vein thrombosis risk remained elevated at 4-12 weeks (RR: 1.49), and modest increases in sepsis and PE persisted beyond 12 weeks. In contrast, TKA demonstrated no increased systemic risk beyond 4 weeks. Prosthetic joint infection and revision rates were lower in patients undergoing surgery more than 12 weeks after infection.
Conclusions
Elective THA and TKA performed within 4 weeks of COVID-19 infection are associated with increased systemic postoperative complications. While risk decreases with increasing time from infection, complications may persist beyond 12 weeks following THA. These findings support a timing-based approach to elective arthroplasty after COVID-19 infection.
Level of Evidence
Level III.
Keywords: COVID-19, Postoperative complications, Total joint arthroplasty, Risk stratification, Infection timing
Introduction
The COVID-19 pandemic has profoundly affected the delivery of elective orthopaedic care, including total joint arthroplasty (TJA). Early reports identified elevated perioperative risks in patients with active or recent COVID-19 infection, including sepsis, thromboembolism, and increased mortality [1]. Subsequent studies suggested that these risks may persist beyond the acute phase of infection, likely due to prolonged immune dysregulation, endothelial injury, and hypercoagulability [[2], [3], [4], [5], [6]]. However, much of the existing literature focuses on heterogeneous surgical populations, short-term outcomes, or broadly defined recovery intervals, limiting applicability to elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) [1,[6], [7], [8], [9]].
Within arthroplasty-specific cohorts, recommendations regarding optimal timing after COVID-19 infection remain inconsistent. Some studies advocate delaying surgery for several weeks to mitigate postoperative complications, yet the precise duration of elevated risk and whether it differs between THA and TKA remains unclear [1,[7], [8], [9]]. Furthermore, outcomes beyond 12 weeks after infection have been minimally explored, despite recognition that physiologic recovery may lag behind symptom resolution. With widespread vaccination and the transition of COVID-19 to an endemic disease, the clinical impact of prior infection on elective surgery may be less pronounced than during the early pandemic. Nonetheless, as the volume of patients recovering from COVID-19 continues to grow and multistate outbreaks of COVID-19 continue to occur nearly 6 years after the pandemic despite adequate vaccination, clarifying postoperative risk as a function of infection timing is increasingly important for evidence-based surgical scheduling. The National Institute for Health and Care Excellence defines clinically relevant COVID-19 recovery phases as acute (0-4 weeks), ongoing symptomatic (4-12 weeks), and post–COVID-19 syndrome (>12 weeks), providing a standardized framework for evaluating postoperative risk [10].
To address these gaps, this study evaluated the association between preoperative COVID-19 infection timing and postoperative complications following primary THA and TKA using a large, multi-institutional national database. Outcomes were assessed across 3 recovery intervals (<4 weeks, 4-12 weeks, and >12 weeks) and compared with matched patients without prior infection. This study extends prior work by applying standardized recovery intervals to a large arthroplasty-specific cohort, providing evidence to inform optimal surgical timing in the post-pandemic era. We hypothesized that patients undergoing arthroplasty shortly after COVID-19 would experience higher complication rates, with risk decreasing as time from infection increased.
Material and methods
This retrospective cohort study utilized the TriNetX Research Network (TriNetX, LLC, Cambridge, MA), a platform of deidentified electronic health records drawn from participating U.S. healthcare organizations. The network integrates inpatient and outpatient encounters while standardizing demographics, diagnoses, procedures, medications, laboratory values, and outcomes under Health Insurance Portability and Accountability-compliant deidentification and quality-control protocols. TriNetX has been extensively employed in orthopaedic outcomes research and supports reproducible cohort development and analytic methods [11].
Definition of cohorts
Adults undergoing primary THA or TKA between January 1, 2020, and December 31, 2023, were identified using Current Procedural Terminology and International Classification of Diseases (ICD)-10-Procedure Coding System procedure codes. The date of arthroplasty served as the index date. To establish baseline covariates, patients were required to have at least one healthcare encounter within the 12 months preceding surgery. Exclusion criteria included patients less than 18 years of age, prior arthroplasty of the index joint (revision or conversion), fracture-related arthroplasty, and active prosthetic joint infection. THA and TKA cohorts were constructed and analyzed independently to maintain clinical homogeneity. The exposures of interest were preoperative diagnoses of COVID-19 made within 4 weeks of index surgery, between 4 and 12 weeks prior to surgery, and greater than 12 weeks before surgery. These patients were identified through ICD-10-Clinical Modification (CM) codes. Each exposure cohort was compared to a control group consisting of arthroplasty patients with no recorded diagnosis of COVID-19, and these groups were propensity matched to control for confounders.
Statistical analysis
The primary outcomes were 1-year postoperative prosthetic joint infection, sepsis, revision, deep vein thrombosis (DVT), and pulmonary embolism (PE). All outcomes were defined using ICD-10-CM and procedural codes. To address baseline differences, propensity score matching was performed in TriNetX using 1:1 nearest-neighbor greedy matching without replacement and a caliper of 0.2 standard deviations on the logit of the score, as recommended by Austin et al [12]. Confounders controlled in the propensity model were age, sex, body mass index, smoking status, Charlson Comorbidity Index, perioperative use of anticoagulants, and immunosuppressant prescription. Covariate balance was assessed with standardized mean differences, with values < 0.10 considered successful matching.
Baseline characteristics were summarized descriptively. Exposure vs control risks of 1-year outcomes were compared in the matched cohorts and expressed as relative risks (RRs) with 95% confidence intervals (CIs) and probability values. Log-binomial regression was used when appropriate; otherwise, Poisson regression with robust standard errors was applied. Absolute risks of each outcome were also calculated, and all absolute risk differences (ARDs) and absolute counts are reported. Cohort construction and primary analyses were conducted within TriNetX Analytics, with tables and figures generated in R (version 4.3.1; R Foundation for Statistical Computing, Vienna, Austria). Statistical significance was defined as a 2-sided P value < .05.
Summary of cohorts
A total of 94,430 patients were included for analysis, including 37,272 THA patients and 57,158 TKA patients. Patients with documented COVID-19 were allocated into the <4-week cohort (THA 3468; TKA 4232), the 4-12-week cohort (THA 3150; TKA 5250), and the >12-week cohort (THA 30,654; TKA 47,676). An equal number of matched controls were included in each cohort for comparison. A summary of relevant characteristics is included in Table 1.
Table 1.
Baseline characteristics of propensity score–matched THA and TKA cohorts.
| Total hip arthroplasty (THA) | ||||
|---|---|---|---|---|
| Characteristic | <4 wk | 4-12 wk | >12 wk | SMD |
| Number of patients | 3468 | 3150 | 30,654 | <0.10 |
| Agea | 66.1 (12.0) | 66.2 (10.9) | 66.5 (11.4) | <0.10 |
| Female sexb | 1900 (54.8) | 1745 (55.4) | 18,025 (58.8) | <0.10 |
| Body mass indexa | 29.5 (5.8) | 30.1 (6.1) | 30.4 (6.2) | <0.10 |
| Current smokerb | 479 (13.8) | 476 (15.1) | 5303 (17.3) | <0.10 |
| Anticoagulant useb | 1474 (42.5) | 1553 (49.3) | 16,645 (54.3) | <0.10 |
| Immunosuppressant useb | 2324 (67.0) | 2577 (81.8) | 27,312 (89.1) | <0.10 |
| Total knee arthroplasty (TKA) | ||||
|---|---|---|---|---|
| Characteristic | <4 wk | 4-12 wk | >12 wk | SMD |
| Number of patients | 4232 | 5250 | 47,676 | <0.10 |
| Agea | 67.7 (9.4) | 67.8 (9.3) | 67.7 (9.3) | <0.10 |
| Female sexb | 2577 (60.9) | 3234 (61.6) | 30,179 (63.3) | <0.10 |
| Body mass indexa | 32.6 (6.4) | 32.4 (6.3) | 32.6 (6.2) | <0.10 |
| Current smokerb | 453 (10.7) | 614 (11.7) | 6150 (12.9) | <0.10 |
| Anticoagulant useb | 2010 (47.5) | 2777 (52.9) | 25,697 (53.9) | <0.10 |
| Immunosuppressant useb | 3225 (76.2) | 4530 (86.3) | 43,718 (91.7) | <0.10 |
SD, standard deviation.
Propensity score matching achieved standardized mean differences (SMDs) < 0.10 for all covariates, indicating adequate balance of cases and controls in each cohort.
Mean (SD).
n (%).
Institutional review board approval statement
This study was designated by the Washington University School of Medicine Institutional Review Board/Human Research Protection Office as not human subject research due to the deidentified datasets used through the institution.
Results
Total hip arthroplasty outcomes postinfection
Patients undergoing THA within 4 weeks of COVID-19 infection demonstrated significantly increased risks of sepsis (RR: 2.36; 95% CI: 1.52-3.65; P < .001) and PE (RR: 1.74; 95% CI: 1.13-2.70; P = .012). No significant increases were observed for prosthetic joint infection, revision surgery, or DVT.
Among patients undergoing THA 4-12 weeks after infection, only DVT risk was significantly increased (RR: 1.49; 95% CI: 1.01-2.20; P = .044). Risks of prosthetic joint infection, sepsis, revision, and PE were not significantly different from controls.
In patients undergoing THA more than 12 weeks after infection, risks of sepsis (RR: 1.27; 95% CI: 1.09-1.47; P = .002) and PE (RR: 1.25; 95% CI: 1.08-1.46; P = .004) remained modestly elevated. Conversely, decreased risks were observed for prosthetic joint infection (RR: 0.82; 95% CI: 0.70–0.96; P = .016) and revision surgery (RR: 0.69; 95% CI: 0.58-0.82; P < .001). No significant differences were noted for DVT or surgical site infection. All results for THA patients, including absolute risks and ARDs, are summarized in Table 2.
Table 2.
One-year postoperative outcomes following THA by timing of COVID-19 infection.
| Relative risks and P values across the 3 cohorts compared to propensity-matched controls | ||||||
|---|---|---|---|---|---|---|
| Outcome | <4 wk RR (95% CI) | P value | 4-12 wk RR (95% CI) | P value | >12 wk RR (95% CI) | P value |
| Prosthetic joint infection | 1.12 (0.70-1.78) | .629 | 0.93 (0.54-1.59) | .780 | 0.82 (0.70-0.96) | .016 |
| Sepsis | 2.36 (1.52-3.65) | <.001 | 1.20 (0.74-1.94) | .455 | 1.27 (1.09-1.47) | .002 |
| Revision | 0.68 (0.40-1.14) | .142 | 0.96 (0.57-1.63) | .892 | 0.69 (0.58-0.82) | <.001 |
| Deep vein thrombosis | 1.05 (0.74-1.50) | .780 | 1.49 (1.01-2.20) | .044 | 0.92 (0.82-1.03) | .145 |
| Pulmonary embolism | 1.74 (1.13-2.70) | .012 | 1.42 (0.84-2.38) | .185 | 1.25 (1.08-1.46) | .004 |
| Absolute counts (absolute risk) of primary outcomes in COVID cohorts and absolute risk differences (ARD) between COVID cohorts and matched controls. | ||||||
|---|---|---|---|---|---|---|
| Outcome | <4 wk | ARD | 4-12 wk | ARD | >12 wk | ARD |
| Prosthetic joint infection | 37 (0.02) | 0.002 | 25 (0.02) | −0.001 | 258 (0.02) | −0.004 |
| Sepsis | 66 (0.04) | 0.02 | 36 (0.02) | 0.004 | 367 (0.02) | 0.01 |
| Revision | 23 (0.01) | −0.01 | 27 (0.02) | −0.001 | 210 (0.01) | −0.01 |
| Deep vein thrombosis | 61 (0.04) | 0.002 | 61 (0.04) | 0.01 | 562 (0.04) | −0.003 |
| Pulmonary embolism | 54 (0.03) | 0.01 | 34 (0.02) | 0.01 | 367 (0.02) | 0.005 |
Bold indicates statistical significant values.
Total knee arthroplasty outcomes postinfection
TKA patients undergoing surgery within 4 weeks of COVID-19 infection demonstrated significantly increased risks of sepsis (RR: 2.27; 95% CI: 1.44-3.59; P < .001) and PE (RR: 2.39; 95% CI: 1.48-3.88; P < .001). No significant differences were observed for prosthetic joint infection, revision, or DVT.
Patients undergoing TKA 4-12 weeks after infection did not demonstrate increased risks for any evaluated outcome, including prosthetic joint infection, sepsis, revision, PE, surgical site infection, or DVT.
Among patients undergoing TKA more than 12 weeks after infection, decreased risks were observed for prosthetic joint infection (RR: 0.72; 95% CI: 0.62-0.83; P < .001) and revision surgery (RR: 0.70; 95% CI: 0.59-0.83; P < .001). No significant differences were observed for sepsis, PE, surgical site infection, or DVT. All results for TKA patients, including absolute risks and ARDs, are summarized in Table 3.
Table 3.
One-year postoperative outcomes following TKA by timing of COVID-19 infection.
| Relative risks and P values across the 3 cohorts compared to propensity-matched controls | ||||||
|---|---|---|---|---|---|---|
| Outcome | <4 wk RR (95% CI) | P value | 4-12 wk RR (95% CI) | P value | >12 wk RR (95% CI) | P value |
| Prosthetic joint infection | 1.29 (0.85-1.96) | .233 | 0.96 (0.64-1.43) | .835 | 0.72 (0.62-0.83) | <.001 |
| Sepsis | 2.27 (1.44-3.59) | <.001 | 1.15 (0.78-1.69) | .482 | 1.02 (0.89-1.17) | .781 |
| Revision | 1.11 (0.67-1.84) | .694 | 1.00 (0.61-1.64) | .999 | 0.70 (0.59-0.83) | <.001 |
| Deep vein thrombosis | 0.93 (0.70-1.23) | .595 | 1.18 (0.91-1.53) | .215 | 1.02 (0.93-1.11) | .708 |
| Pulmonary embolism | 2.39 (1.48-3.88) | <.001 | 1.06 (0.73-1.53) | .772 | 1.02 (0.90-1.15) | .793 |
| Absolute counts (absolute risks) of primary outcomes in COVID cohorts and absolute risk differences (ARD) between COVID cohorts and matched controls | ||||||
|---|---|---|---|---|---|---|
| Outcome | <4 wk | ARD | 4-12 wk | ARD | >12 wk | ARD |
| Prosthetic joint infection | 49 (0.02) | 0.005 | 46 (0.02) | −0.001 | 312 (0.01) | −0.01 |
| Sepsis | 59 (0.03) | 0.02 | 54 (0.02) | 0.003 | 424 (0.02) | 0.0003 |
| Revision | 31 (0.02) | 0.001 | 31 (0.01) | 0 | 232 (0.01) | −0.004 |
| Deep vein thrombosis | 87 (0.04) | −0.003 | 119 (0.05) | 0.01 | 957 (0.04) | 0.001 |
| Pulmonary embolism | 55 (0.03) | 0.02 | 56 (0.02) | 0.001 | 478 (0.02) | 0.0003 |
Bold indicates statistical significant values.
Discussion
This study demonstrates that the timing of COVID-19 infection relative to TJA significantly influences postoperative outcomes. Consistent with prior work, surgery performed within 4 weeks of infection was associated with the highest systemic complication risk. In this cohort, THA patients within 4 weeks of infection experienced increased sepsis (RR: 2.36) and PE (RR: 1.74), while TKA patients had similar elevations (sepsis RR: 2.27; PE RR: 2.39). These findings align with Deng et al., who reported higher perioperative morbidity and mortality in patients undergoing major elective surgery shortly after COVID-19 infection [1]. Similarly, COVIDSurg Collaborative demonstrated elevated postoperative pulmonary and thromboembolic complications when surgery was performed within 6 weeks of SARS-CoV-2 infection [7]. Collectively, these studies support early postinfection surgery as a period of heightened systemic vulnerability. While most studies examine outcomes in patients <12 weeks from recovery, no large TJA-specific cohort analyzes outcomes in patients >12 weeks from infection, which is only extrapolated from data [[11], [12], [13], [14]].
A temporal gradient of risk was evident. Between 4 and 12 weeks, THA patients demonstrated only a modest increase in DVT (RR: 1.49), whereas TKA patients showed no significant systemic complications. Beyond 12 weeks, THA patients exhibited modest elevations in sepsis (RR: 1.27) and PE (RR: 1.25), while TKA patients had no residual systemic risk. These results extend prior observations by quantifying arthroplasty-specific risks across standardized recovery intervals, highlighting that risk attenuation is gradual rather than binary [1,[7], [8], [9]]. Fan et al. and Kennedy et al. demonstrated persistent endothelial dysfunction, immune dysregulation, and hypercoagulability for weeks to months after COVID-19, providing mechanistic support for prolonged systemic vulnerability observed in our THA cohort [1,2,5].
Interestingly, patients more than 12 weeks postinfection demonstrated decreased rates of prosthetic joint infection (THA RR: 0.82, TKA RR: 0.72) and revision surgery (THA RR: 0.69, TKA RR: 0.70) compared with matched controls. While residual confounding cannot be fully excluded, this may reflect a true protective effect of prior infection. Ryan et al. and Santopaolo et al. showed that mild COVID-19 can induce prolonged but regulated T-cell activation and immune modulation [3,4], which may enhance postoperative host defense against infection. This “immune preconditioning” effect is consistent with reports of trained immunity following viral infection, where prior exposure primes innate immune responses to subsequent insults [15,16]. Alternatively, patients who achieve sufficient recovery to proceed with elective arthroplasty beyond 12 weeks may represent a clinically fitter cohort, reinforcing the potential benefit of delayed surgery selection.
The differential findings between THA and TKA highlight procedure-specific considerations. Modest residual risk in THA beyond 12 weeks may relate to higher physiologic stress or larger surgical exposure inherent to hip arthroplasty, whereas TKA appears less sensitive to lingering systemic effects. These observations emphasize the importance of individualized risk assessment when planning elective surgery post-COVID-19. El-Boghdadly et al. similarly noted heterogeneity in risk across surgical types and advocated for procedure-specific timing considerations [8].
Our findings provide actionable guidance for clinical practice. Surgery within 4 weeks of COVID-19 infection should generally be avoided, consistent with current National Institute for Health and Care Excellence and COVIDSurg recommendations [7,8,10]. Elective TJA can typically proceed safely at 4-12 weeks postinfection, with targeted monitoring for DVT in THA. Beyond 12 weeks, systemic risk largely normalizes, and the potential protective effects on joint-specific outcomes suggest that deferring surgery to this interval may optimize postoperative results. This evidence-based framework allows surgeons to balance the risk of systemic complications with the benefits of timely arthroplasty.
This study benefits from utilizing the largest sample size of TJA patients studied over longer time points post-COVID-19 infection. Limitations include retrospective design, potential coding inaccuracies, and lack of detailed data on infection severity, vaccination status, viral variant, or functional recovery. Residual confounding remains possible, and causality cannot be inferred. Future prospective studies are needed to confirm the observed protective effects beyond 12 weeks and explore underlying immunologic mechanisms.
Conclusions
Timing of COVID-19 infection prior to THA or TKA is a critical determinant of postoperative outcomes. Surgery within 4 weeks of infection carries the highest risk of systemic complications, particularly sepsis and PE. Delaying surgery beyond this early period reduces risk, with 4-12 weeks generally safe and >12 weeks associated with normalization of systemic risk and potential reductions in prosthetic joint infection and revision. These findings support a cautious, arthroplasty-specific, timing-based approach to elective TJA in patients recovering from COVID-19.
Conflicts of interest
I. Bendich is a paid consultant for DePuy, Biocomposites, and Smith & Nephew and receives research support from DePuy and Stryker as a Principal Investigator. A.M. Schneider receives research support from Stryker and Zimmer Biomet as a Principal Investigator; all other authors declare no potential conflicts of interest.
For full disclosure statements refer to https://doi.org/10.1016/j.artd.2026.102079.
CRediT authorship contribution statement
Lane McCoy: Writing – review & editing, Visualization, Validation, Methodology, Investigation, Formal analysis, Data curation, Conceptualization. Gabrielle Helm: Writing – review & editing, Writing – original draft. Tyler Calkins: Writing – review & editing. Ilya Bendich: Writing – review & editing. Andrew M. Schneider: Writing – review & editing, Visualization, Supervision, Methodology.
Acknowledgments
This is the third paper from Dr. Andrew M. Schneider, who has published 2 papers to this journal in this calendar year.
Appendix A. Supplementary data
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