The Impact of COVID-19 in Total Hip Arthroplasty: A Comparison Study in a Center without Elective Surgery Protocols

The Impact of COVID-19 in Total Hip Arthroplasty: A Comparison Study in a Center without Elective Surgery Protocols | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Impact of COVID-19 in Total Hip Arthroplasty: A Comparison Study in a Center without Elective Surgery Protocols Amir Ali Okhovat, Parmida Shahbazi, Mobina Taghva Nakhjiri, Mohammad Javad Boroujerdi, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4978724/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Oct, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 12 You are reading this latest preprint version Abstract Background The COVID-19 pandemic has affected elective surgeries, including Total Hip Arthroplasty (THA). This study compared THA outcomes before and after the COVID-19 outbreak in a center without a specific COVID-19 protocol for elective surgeries. Methods This cross-sectional study included a total of 304 THA surgeries. The study period was divided into pre-COVID-19 outbreak (April 21, 2017 to April 21, 2019) and post-COVID-19 outbreak (April 21, 2020 to April 21, 2022) groups. Demographic characteristics, etiology of operations, anesthesia time, pre-operation length of stay (LOS), post-operation LOS, comorbidities, mortality, complications, and transfusion needs were compared between the two periods. Results Patients during the COVID-19 pandemic were significantly younger (mean = 49.2 ± 16.3 vs. 53.7 ± 17.1 years) (P-value = 0.02). The most common indication for THA in both periods was trauma, but there was a significant difference in the distribution of etiologies between the two periods (P-value = 0.01). Pre-operative LOS was significantly longer during the COVID-19 pandemic (mean = 2.75 ± 1.69 days) compared to the pre-pandemic period (mean = 2.28 ± 1.5 days) (P-value = 0.01). However, there was no significant difference in post-operative LOS or total LOS. There were no significant differences in comorbidities between the two periods. In-hospital mortality was low in both periods, with no significant difference. Complications and transfusion needs did not show any significant differences. Conclusions COVID-19 pandemic led to younger THA patients, changes in etiologies, longer pre-operative LOS, but no difference in mortality, complications, anesthesia time or transfusion needs. Further research is needed to better understand the impact of the pandemic on elective orthopedic surgeries. SARS-CoV-2 Arthroplasty Replacement Hip Hip Prosthesis Elective Surgical Procedures Introduction The emergence of COVID-19 in March 2020 posed major public health challenges globally. The number of patients escalated quickly, and hospitals got filled with COVID-19 cases [ 1 , 2 ]. This situation placed an excessive burden on healthcare systems and providers, who had to allocate more resources to combat the pandemic. As a result, fewer resources were available for elective procedures such as orthopedic surgeries. Therefore, most of the elective orthopedic surgeries were postponed or canceled due to COVID-19 pandemic restrictions [ 3 , 4 ]. Total Hip Arthroplasty (THA) is one of the most common orthopedic surgeries. Most indications of THA are non-emergent operations, so THA was affected by these policies [ 3 , 5 ]. Some of the medical centers established an exclusive protocol for managing elective surgeries and THA surgeries got postponed or canceled [ 6 ]. Delaying surgeries may lead to higher levels of patient dissatisfaction, but it has not been shown to have an impact on mortality or morbidity rates [ 7 , 8 ]. However, there are concerns that during the COVID-19 pandemic, there may be an elevated risk of post-surgery incidents such as superficial surgical site infections (SSIs) and myocardial infarction. One possible reason for the increase in SSIs is reduced follow-up for hip replacement patients during the COVID-19 pandemic, as outpatient visits declined partly due to patients' fear of contracting the virus [ 9 ]. After THA, some patients may require intensive care services, but considering the fact that Intensive Care Units (ICU) were filled with patients at that period, these patients may not receive the necessary care, and this can have serious implications for their recovery and outcome [ 10 , 11 ]. This study aims to compare the post-operative outcomes of THA operations before and after the COVID-19 outbreak in a center that did not have a specific COVID-19 protocol for primary THAs. We hypothesized that the surgeries in these centers would have more post-operative complications due to fewer resources available for primary THAs. This study may provide insights into how to optimize surgical care during future pandemics or other resource-limited situations. Material and methods This cross-sectional study was conducted on patients who underwent THA at a single general university hospital. Data were collected from the Orthopedic subspecialty research center (OSRC) database, and two groups were formed based on the timing of the surgery: the pre-COVID-19 group (from April 21, 2017 to April 21, 2019) and the COVID-19 group (from April 21, 2020 to April 21, 2022). The patients were followed throughout their hospitalization. All participants who underwent THA and were above 18 years of age were included in the study. During the COVID-19 period, all patients underwent outpatient testing for COVID-19 two days prior to surgery. However, due to limitations in our data registry and documentation, we were unable to ascertain the COVID-19 history of these patients. Therefore, we deemed it inappropriate to underestimate their previous COVID-19 exposure during the pandemic. Patient with revision THA were excluded. To assess the outcome of surgeries, we recorded all complications such as Surgical Site Infection (SSI) and dislocation of the prosthesis, periprosthetic infection, extended wound drainage, implant loosening, nerve injury, Myocardial Infarction (MI), Deep Vein Thrombosis (DVT), arrhythmia, Acute Kidney Injury (AKI), gastrointestinal, Loss of Consciousness (LOC), sepsis, and genitourinary. The gathered data included the variables gender, age, past medical history (coronary artery disease (CAD), hypertension (HTN), and diabetes mellitus (DM)), anesthesia time (including the preoperative anesthesia induction, intraoperative period (i.e., surgery duration), and postoperative recovery under anesthesia care), pre-operation length of stay (LOS), post-operation LOS, LOS, in-hospital death, in-hospital complications, the number of pack cells that the patient received (before, during and after the operation), and the indication of surgery. Indications of these surgeries were divided into six groups: 1. Osteoarthritis 2. Rheumatoid and other inflammatory arthritis 3. Avascular necrosis 4. Post-traumatic arthritis 5. Developmental dysplasia of the hip and other congenital disorders 6. Trauma. Statistical analysis Categorical variables were described as frequencies, and continuous variables were described using mean standard deviation (SD), or median. Proportions for categorical variables were compared using the chi-square or Fisher exact test. An Independent t-test was used to compare the numeric variable. We have analyzed our data using SPSS version 23 [International Business Machine (IBM), Armonk, NY, USA)]. In our study, we chose the level of significance as p-value < 0.05. Ethical consideration All patients were identified by a random computer-generated unique code, and no personal data was revealed to any party during data extraction or analysis. This study was approved by the medical ethics committee of TUMS under the code of: IR.TUMS.SINAHOSPITAL.REC.1401.091 Results Out of a total of 372 THA cases, 68 revisions were excluded. Among 304 primary THA operations, 120 were performed before the pandemic, with 59 procedures (49.2%) performed on men. The remaining 184 operations were conducted during the COVID-19 pandemic, with 109 procedures (59.2%) performed on men. The analysis showed no significant difference between the genders during the study period, whether it was before the pandemic or during the COVID-19 period (p-value=0.099). Interestingly, the mean age of participants during the COVID-19 pandemic (mean= 49.2±16.3) was significantly lower than that of the pre-COVID-19 pandemic (mean=53.7±17.1) (p-value=0.022). The most common surgical indications in both study periods were trauma, post-traumatic and degenerative joint disease, and avascular necrosis. However, as Table 1 shows, there is a significant difference between etiologies in two periods. (p-value=0.010). From the Table 2, it can be seen that there is not significant difference between past medical histories (DM, HTN, and CAD) before and during COVID-19 pandemic. There was no significant difference in complication rates during and before COVID-19 pandemic as demonstrated in Table 3 . Additionally, the number of in-hospital deaths was three, with two occurring before the pandemic، and one during it, and the difference was not statistically significant (p-value=0.564). The anesthesia time in pre-COVID-19 and COVID-19 time were 3.56±0.85, and 3.58±0.72 hours respectively without any significant differences between them (p-value=0.813). During the COVID-19 pandemic period, the mean pre-operative LOS was significantly longer at 2.75±1.69 days compared to the pre-COVID-19 period at 2.28±1.5 days (p-value = 0.014). However, no significant differences were observed in the post-operative and total LOS between the two periods (p-values=0.43 and 0.26, respectively). There was no significant difference in the mean of the number of packed cell transfusions, neither before the operation, during the operation, nor after the operation, between the two periods. This is indicated in Table 4 . Discussion The present study was designed to assess and compare the outcomes of THA operations before and during the COVID-19 outbreak in a medical center that did not have a specific COVID-19 protocol for elective surgeries. It is notable that the mean age of participants during the COVID-19 pandemic was significantly lower than that of the pre-COVID-19 pandemic, which is consistent with the findings of another study [12]. However, another study by Gordon et al. did not find any significant differences in age between the two periods [3]. One possible explanation for these discrepant results is that, when not matched, there was no significant difference between the two time periods, but after matching hospitalized patients during the COVID-19 pandemic were significantly younger, as reported by Badin et al. [9]. Another possible explanation for the age difference observed during the pandemic period is that elderly patients were less likely to be admitted by surgeons, especially for elective surgeries, due to the increased risk of exposure to COVID-19 in medical centers. This, combined with the higher prevalence of morbidities in older patients, may have led to their higher anxiety and reluctance to seek medical care during the pandemic. Among THA etiologies osteoarthritis, rheumatoid and other inflammatory arthritis showed a significantly lower number of cases during the COVID-19 pandemic at our center. This observation could be attributed to the fact that these conditions are more prevalent in older individuals [13], who, as established, face a higher risk of morbidity and mortality from COVID-19 transmission [14]. Consequently, it is plausible that older patients with these conditions were less frequently referred to hospitals during the pandemic period. In line with the findings of Gordon et al.'s study, there were no significant differences in patient demographics, including gender and past medical history [3]. However, Abdelaal et al. reported that without matching, there was no significant difference in these factors between the two study periods. Nevertheless, after matching for patient characteristics, gender and hypertension were found to be significantly different between the periods, with a higher proportion of men and lower rates of hypertension during the COVID-19 pandemic [15]. During the COVID-19 pandemic, our pre-operative LOS increased, potentially due to the anesthesiologist’s strict oxygen saturation restrictions. This led to delays as several patients with borderline saturation levels required pulmonary consultations. However, our post-operative and total LOS remained unchanging between the pre-pandemic and pandemic periods. In contrast to earlier studies that reported a decrease in average LOS during pandemics [3,9,12,15], this variation might be due to the lack of COVID-19 precautions, such as early discharge, which were not implemented in our hospital [16]. Another reason that could be indicating the similarity in LOS observed in both periods is the absence of significant differences in medical and surgical complications between the pre-COVID-19 and COVID-19 periods, which is consistent with prior research [3,9,15]. This study's findings are in line with Shah et al. [12], which also reported no significant differences in total operation time and pack cell transfusions between the pre-COVID-19 and COVID-19 periods. However, our results are in contrast to Gordon et al. [3], which observed longer total operation time during the COVID-19 period. The finding that there was no significant difference in mortality rate between the pre-COVID-19 and COVID-19 periods in this study is in contrast to another study that reported a significantly higher 30-day mortality rate during the COVID-19 period [3]. When interpreting the results of this study, it's crucial to consider that there is a limitation inherent in its retrospective design, despite the prospective collection of data, which may expose it to bias and confounding variables. Conclusions In conclusion, while postponing non-emergent surgeries during the COVID-19 pandemic was necessary to prioritize resources, previous studies have shown that the cancellation of elective surgeries during the pandemic had various consequences for patients [ 18 ], particularly younger individuals who experienced greater changes in their symptoms, anxiety, and job security [ 7 , 19 ]. Elective surgeries should be resumed, but with measures in place to minimize pre-operation and total length of stay and ensure that older patients are not overlooked. Despite the absence of significant differences in complications and mortality rate between the pre-COVID-19 and COVID-19 periods, our study did not investigate the specific impact of protocols on patient outcomes. Thus, further research is necessary to evaluate the effectiveness of protocols in improving patient outcomes. Declarations Ethics approval All patients were identified by a random computer-generated unique code, and no personal data was revealed to any party during data extraction or analysis. This study was approved in accordance with the Declaration of Helsinki and by the medical ethics committee of TUMS under the code of: IR.TUMS.SINAHOSPITAL.REC.1401.091 Consent to participate Every human participant in the study declares their informed consent to participate in the study. Consent to publication Every human participant in the study declares their informed consent for the study to be published. Clinical trial number Not applicable Availability of data and materials Data available on request. For access to the raw data analyzed in this study, please contact Dr. Parmida Shahbazi at [email protected] . Competing interests The authors declare that they have no competing of interest. Funding The authors recieved no financial suppport for the research. Author's contributions All authors contributed to the study conception and design. Material preparation and data collection were performed by AAO, MJB and MTN. PS analyzed and interpreted the data and was a major contributor to writing the manuscript. MS and TA reviewed and revised the manuscript. SHS and MG were the main designers of the study. All authors read and approved the final manuscript. Acknowledgements not applicable. Conflict of Interests: Amir Ali Okhovat declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Parmida Shahbazi declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Mobina Taghva Nakhjiri declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Mohammad Javad Boroujerdi declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Mohammad Soleimani declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Tina Azimzadeh declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Seyyed Hossein Shafiei declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Mohammadreza Golbakhsh declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgment not applicable Sources of funding The authors declare that they have received no financial support for the research. References Filip R, Gheorghita Puscaselu R, Anchidin-Norocel L, Dimian M, Savage WK. Global Challenges to Public Health Care Systems during the COVID-19 Pandemic: A Review of Pandemic Measures and Problems. JPM 2022;12:1295. https://doi.org/10.3390/jpm12081295. Birkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States: Study examines trends in US hospital admissions during the COVID-19 pandemic. Health Affairs 2020;39:2010–7. https://doi.org/10.1377/hlthaff.2020.00980. Gordon AM, Magruder ML, Ng MK, Sheth BK, Conway CA, Hang Jason Wong C. The combined effect of policy changes and the covid-19 pandemic on the same day discharge and complications following total hip arthroplasty: a nationwide analysis. Arthroplasty 2022;4:28. https://doi.org/10.1186/s42836-022-00131-w. Mehta A, Awuah WA, Ng JC, Kundu M, Yarlagadda R, Sen M, et al. Elective surgeries during and after the COVID-19 pandemic: Case burden and physician shortage concerns. Annals of Medicine & Surgery 2022;81. https://doi.org/10.1016/j.amsu.2022.104395. Czubak-Wrzosek M, Czubak J, Grzelecki D, Tyrakowski M. The Effect of the COVID-19 Pandemic on Total Hip and Knee Arthroplasty Surgical Volume in 2020 in Poland. IJERPH 2021;18:8830. https://doi.org/10.3390/ijerph18168830. Wilson JM, Schwartz AM, Farley KX, Roberson JR, Bradbury TL, Guild GN. Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19. HSS Jrnl 2020;16:85–91. https://doi.org/10.1007/s11420-020-09806-z. Brown TS, Bedard NA, Rojas EO, Anthony CA, Schwarzkopf R, Stambough JB, et al. The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States: A Multicenter Update to the Previous Survey. Arthroplasty Today 2021;7:268–72. https://doi.org/10.1016/j.artd.2020.11.025. Knebel C, Ertl M, Lenze U, Suren C, Dinkel A, Hirschmann MT, et al. COVID-19-related cancellation of elective orthopaedic surgery caused increased pain and psychosocial distress levels. Knee Surg Sports Traumatol Arthrosc 2021;29:2379–85. https://doi.org/10.1007/s00167-021-06529-4. Badin D, Ortiz-Babilonia CD, Harris AB, Raad M, Oni JK. Early Postoperative Complications in Total Hip and Knee Arthroplasties Before and During the COVID-19 Pandemic: A Retrospective Analysis of 38,234 Patients. Arthroplasty Today 2022;18:24–30. https://doi.org/10.1016/j.artd.2022.08.018. Sun J, Yang Y, Feng G, Liang C, Ling W, Liao H. Analysis of related factors of scheduled ICU before primary hip arthroplasty. BMC Anesthesiol 2022;22:221. https://doi.org/10.1186/s12871-022-01737-y. Arabi YM, Myatra SN, Lobo SM. Surging ICU during COVID-19 pandemic: an overview. Current Opinion in Critical Care 2022;28:638–44. https://doi.org/10.1097/MCC.0000000000001001. Shah KC, Poeran J, Zubizarreta N, McCardle K, Jebakumar J, Moucha CS, et al. Comparison of total joint arthroplasty care patterns prior to the Covid-19 pandemic and after resumption of elective surgery during the Covid-19 Outbreak: A retrospective, large urban academic center study. The Knee 2022;38:36–41. https://doi.org/10.1016/j.knee.2022.05.004. Wright AA, Cook C, Abbott JH. Variables associated with the progression of hip osteoarthritis: A systematic review. Arthritis & Rheumatism 2009;61:925–36. https://doi.org/10.1002/art.24641. Thaler M, Kort N, Zagra L, Hirschmann MT, Khosravi I, Liebensteiner M, et al. Prioritising of hip and knee arthroplasty procedures during the COVID-19 pandemic: the European Hip Society and the European Knee Associates Survey of Members. Knee Surg Sports Traumatol Arthrosc 2021;29:3159–63. https://doi.org/10.1007/s00167-020-06379-6. Abdelaal MS, Small I, Sherman MB, Courtney PM, Sharkey PF. One Year Later: The Lasting Effect of the COVID-19 Pandemic on Elective Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2022;30:e1474–82. https://doi.org/10.5435/JAAOS-D-22-00245. Forlenza EM, Chahla J, Forsythe B. Protecting Surgical Patient Safety During the Coronavirus Disease 2019 (COVID-19) Pandemic. Arthroscopy, Sports Medicine, and Rehabilitation 2021;3:e615–8. https://doi.org/10.1016/j.asmr.2020.09.005. Lee LS, Chan PK, Fung WC, Cheung A, Chan VWK, Cheung MH, et al. Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare for the next pandemic? Arthroplasty 2021;3:36. https://doi.org/10.1186/s42836-021-00093-5. Sequeira SB, Novicoff WM, McVey ED, Noble DM, Harb MA, Taliaferro JP, et al. Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic. J Am Acad Orthop Surg 2021;Publish Ahead of Print. https://doi.org/10.5435/JAAOS-D-20-00765. Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 28 Oct, 2025 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 16 Jul, 2025 Reviews received at journal 15 Jul, 2025 Reviewers agreed at journal 15 Jul, 2025 Reviewers agreed at journal 05 Jul, 2025 Reviewers agreed at journal 05 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviewers agreed at journal 29 Jun, 2025 Reviewers invited by journal 09 Oct, 2024 Editor assigned by journal 03 Oct, 2024 Editor invited by journal 16 Sep, 2024 Submission checks completed at journal 13 Sep, 2024 First submitted to journal 13 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4978724","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":486145351,"identity":"7a6b1a82-1b65-4953-afb4-dec519c3c630","order_by":0,"name":"Amir Ali Okhovat","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Amir","middleName":"Ali","lastName":"Okhovat","suffix":""},{"id":486145352,"identity":"28c12ebb-6186-479d-9019-1d413ea0e30b","order_by":1,"name":"Parmida Shahbazi","email":"","orcid":"","institution":"Tehran University of Medical 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14:14:09","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":20096,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-4978724/v1/32ef4ee31c847f43e89a86f3.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Impact of COVID-19 in Total Hip Arthroplasty: A Comparison Study in a Center without Elective Surgery Protocols","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe emergence of COVID-19 in March 2020 posed major public health challenges globally. The number of patients escalated quickly, and hospitals got filled with COVID-19 cases [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This situation placed an excessive burden on healthcare systems and providers, who had to allocate more resources to combat the pandemic. As a result, fewer resources were available for elective procedures such as orthopedic surgeries. Therefore, most of the elective orthopedic surgeries were postponed or canceled due to COVID-19 pandemic restrictions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTotal Hip Arthroplasty (THA) is one of the most common orthopedic surgeries. Most indications of THA are non-emergent operations, so THA was affected by these policies [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Some of the medical centers established an exclusive protocol for managing elective surgeries and THA surgeries got postponed or canceled [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDelaying surgeries may lead to higher levels of patient dissatisfaction, but it has not been shown to have an impact on mortality or morbidity rates [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, there are concerns that during the COVID-19 pandemic, there may be an elevated risk of post-surgery incidents such as superficial surgical site infections (SSIs) and myocardial infarction. One possible reason for the increase in SSIs is reduced follow-up for hip replacement patients during the COVID-19 pandemic, as outpatient visits declined partly due to patients' fear of contracting the virus [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAfter THA, some patients may require intensive care services, but considering the fact that Intensive Care Units (ICU) were filled with patients at that period, these patients may not receive the necessary care, and this can have serious implications for their recovery and outcome [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study aims to compare the post-operative outcomes of THA operations before and after the COVID-19 outbreak in a center that did not have a specific COVID-19 protocol for primary THAs. We hypothesized that the surgeries in these centers would have more post-operative complications due to fewer resources available for primary THAs. This study may provide insights into how to optimize surgical care during future pandemics or other resource-limited situations.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis cross-sectional study was conducted on patients who underwent THA at a single general university hospital. Data were collected from the Orthopedic subspecialty research center (OSRC) database, and two groups were formed based on the timing of the surgery: the pre-COVID-19 group (from April 21, 2017 to April 21, 2019) and the COVID-19 group (from April 21, 2020 to April 21, 2022). The patients were followed throughout their hospitalization.\u003c/p\u003e\u003cp\u003eAll participants who underwent THA and were above 18 years of age were included in the study. During the COVID-19 period, all patients underwent outpatient testing for COVID-19 two days prior to surgery. However, due to limitations in our data registry and documentation, we were unable to ascertain the COVID-19 history of these patients. Therefore, we deemed it inappropriate to underestimate their previous COVID-19 exposure during the pandemic. Patient with revision THA were excluded. To assess the outcome of surgeries, we recorded all complications such as Surgical Site Infection (SSI) and dislocation of the prosthesis, periprosthetic infection, extended wound drainage, implant loosening, nerve injury, Myocardial Infarction (MI), Deep Vein Thrombosis (DVT), arrhythmia, Acute Kidney Injury (AKI), gastrointestinal, Loss of Consciousness (LOC), sepsis, and genitourinary.\u003c/p\u003e\u003cp\u003eThe gathered data included the variables gender, age, past medical history (coronary artery disease (CAD), hypertension (HTN), and diabetes mellitus (DM)), anesthesia time (including the preoperative anesthesia induction, intraoperative period (i.e., surgery duration), and postoperative recovery under anesthesia care), pre-operation length of stay (LOS), post-operation LOS, LOS, in-hospital death, in-hospital complications, the number of pack cells that the patient received (before, during and after the operation), and the indication of surgery. Indications of these surgeries were divided into six groups: 1. Osteoarthritis 2. Rheumatoid and other inflammatory arthritis 3. Avascular necrosis 4. Post-traumatic arthritis 5. Developmental dysplasia of the hip and other congenital disorders 6. Trauma.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eCategorical variables were described as frequencies, and continuous variables were described using mean standard deviation (SD), or median. Proportions for categorical variables were compared using the chi-square or Fisher exact test. An Independent t-test was used to compare the numeric variable. We have analyzed our data using SPSS version 23 [International Business Machine (IBM), Armonk, NY, USA)]. In our study, we chose the level of significance as p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003cp\u003e\u003cem\u003eEthical consideration\u003c/em\u003e\u003c/p\u003e\u003cp\u003eAll patients were identified by a random computer-generated unique code, and no personal data was revealed to any party during data extraction or analysis. This study was approved by the medical ethics committee of TUMS under the code of: IR.TUMS.SINAHOSPITAL.REC.1401.091\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of a total of 372 THA cases, 68 revisions were excluded. Among 304 primary THA operations, 120 were performed before the pandemic, with 59 procedures (49.2%) performed on men. The remaining 184 operations were conducted during the COVID-19 pandemic, with 109 procedures (59.2%) performed on men. The analysis showed no significant difference between the genders during the study period, whether it was before the pandemic or during the COVID-19 period (p-value=0.099).\u003c/p\u003e\n\u003cp\u003eInterestingly, the mean age of participants during the COVID-19 pandemic (mean= 49.2±16.3) was significantly lower than that of the pre-COVID-19 pandemic (mean=53.7±17.1) (p-value=0.022).\u003c/p\u003e\n\u003cp\u003eThe most common surgical indications in both study periods were trauma, post-traumatic and degenerative joint disease, and avascular necrosis. However, as \u003cstrong\u003eTable 1\u003c/strong\u003e shows, there is a significant difference between etiologies in two periods. (p-value=0.010).\u003c/p\u003e\n\u003cp\u003eFrom the \u003cstrong\u003eTable 2,\u0026nbsp;\u003c/strong\u003eit can be seen that there is not significant difference between past medical histories (DM, HTN, and CAD) before and during COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in complication rates during and before COVID-19 pandemic as demonstrated in \u003cstrong\u003eTable 3\u003c/strong\u003e. Additionally, the number of in-hospital deaths was three, with two occurring before the pandemic، and one during it, and the difference was not statistically significant (p-value=0.564).\u003c/p\u003e\n\u003cp\u003eThe anesthesia time in pre-COVID-19 and COVID-19 time were 3.56±0.85, and 3.58±0.72 hours respectively without any significant differences between them (p-value=0.813).\u003c/p\u003e\n\u003cp\u003eDuring the COVID-19 pandemic period, the mean pre-operative LOS was significantly longer at 2.75±1.69 days compared to the pre-COVID-19 period at 2.28±1.5 days (p-value = 0.014). However, no significant differences were observed in the post-operative and total LOS between the two periods (p-values=0.43 and 0.26, respectively).\u003c/p\u003e\n\u003cp\u003eThere was no significant difference in the mean of the number of packed cell transfusions, neither before the operation, during the operation, nor after the operation, between the two periods. This is indicated in \u003cstrong\u003eTable 4\u003c/strong\u003e.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study was designed to assess and compare the outcomes of THA operations before and during the COVID-19 outbreak in a medical center that did not have a specific COVID-19 protocol for elective surgeries.\u003c/p\u003e\n\u003cp\u003eIt is notable that the mean age of participants during the COVID-19 pandemic was significantly lower than that of the pre-COVID-19 pandemic, which is consistent with the findings of another study [12]. However, another study by Gordon et al. did not find any significant differences in age between the two periods [3]. One possible explanation for these discrepant results is that, when not matched, there was no significant difference between the two time periods, but after matching hospitalized patients during the COVID-19 pandemic were significantly younger, as reported by Badin et al. [9]. Another possible explanation for the age difference observed during the pandemic period is that elderly patients were less likely to be admitted by surgeons, especially for elective surgeries, due to the increased risk of exposure to COVID-19 in medical centers. This, combined with the higher prevalence of morbidities in older patients, may have led to their higher anxiety and reluctance to seek medical care during the pandemic.\u003c/p\u003e\n\u003cp\u003eAmong THA etiologies osteoarthritis, rheumatoid and other inflammatory arthritis showed a significantly lower number of cases during the COVID-19 pandemic at our center. This observation could be attributed to the fact that these conditions are more prevalent in older individuals [13], who, as established, face a higher risk of morbidity and mortality from COVID-19 transmission [14]. Consequently, it is plausible that older patients with these conditions were less frequently referred to hospitals during the pandemic period.\u003c/p\u003e\n\u003cp\u003eIn line with the findings of Gordon et al.'s study, there were no significant differences in patient demographics, including gender and past medical history [3]. \u0026nbsp; However, Abdelaal et al. reported that without matching, there was no significant difference in these factors between the two study periods. Nevertheless, after matching for patient characteristics, gender and hypertension were found to be significantly different between the periods, with a higher proportion of men and lower rates of hypertension during the COVID-19 pandemic [15].\u003c/p\u003e\n\u003cp\u003eDuring the COVID-19 pandemic, our pre-operative LOS increased, potentially due to the anesthesiologist’s strict oxygen saturation restrictions. This led to delays as several patients with borderline saturation levels required pulmonary consultations. However, our post-operative and total LOS remained unchanging between the pre-pandemic and pandemic periods. In contrast to earlier studies that reported a decrease in average LOS during pandemics [3,9,12,15], this variation might be due to the lack of COVID-19 precautions, such as early discharge, which were not implemented in our hospital [16].\u003c/p\u003e\n\u003cp\u003eAnother reason that could be indicating the similarity in LOS observed in both periods is the absence of significant differences in medical and surgical complications between the pre-COVID-19 and COVID-19 periods, which is consistent with prior research [3,9,15].\u003c/p\u003e\n\u003cp\u003eThis study's findings are in line with Shah et al. [12], which also reported no significant differences in total operation time and pack cell transfusions between the pre-COVID-19 and COVID-19 periods. However, our results are in contrast to Gordon et al. [3], which observed longer total operation time during the COVID-19 period.\u003c/p\u003e\n\u003cp\u003eThe finding that there was no significant difference in mortality rate between the pre-COVID-19 and COVID-19 periods in this study is in contrast to another study that reported a significantly higher 30-day mortality rate during the COVID-19 period [3].\u003c/p\u003e\n\u003cp\u003eWhen interpreting the results of this study, it's crucial to consider that there is a limitation inherent in its retrospective design, despite the prospective collection of data, which may expose it to bias and confounding variables.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, while postponing non-emergent surgeries during the COVID-19 pandemic was necessary to prioritize resources, previous studies have shown that the cancellation of elective surgeries during the pandemic had various consequences for patients [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], particularly younger individuals who experienced greater changes in their symptoms, anxiety, and job security [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Elective surgeries should be resumed, but with measures in place to minimize pre-operation and total length of stay and ensure that older patients are not overlooked. Despite the absence of significant differences in complications and mortality rate between the pre-COVID-19 and COVID-19 periods, our study did not investigate the specific impact of protocols on patient outcomes. Thus, further research is necessary to evaluate the effectiveness of protocols in improving patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval\u0026nbsp;\u003c/strong\u003eAll patients were identified by a random computer-generated unique code, and no personal data was revealed to any party during data extraction or analysis. This study was approved in accordance with the Declaration of Helsinki and by the medical ethics committee of TUMS under the code of: IR.TUMS.SINAHOSPITAL.REC.1401.091\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u0026nbsp;\u003c/strong\u003eEvery human participant in the study declares their informed consent to participate in the study.\u003cbr\u003e\u003cstrong\u003eConsent to publication\u0026nbsp;\u003c/strong\u003eEvery human participant in the study declares their informed consent for the study to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003eData available on request. For access to the raw data analyzed in this study, please contact Dr. Parmida Shahbazi at [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors declare that they have no competing of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e The authors recieved no financial suppport for the research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026apos;s contributions\u0026nbsp;\u003c/strong\u003eAll authors contributed to the study conception and design. Material preparation and data collection were performed by AAO, MJB and MTN. PS analyzed and interpreted the data and was a major contributor to writing the manuscript. MS and TA reviewed and revised the manuscript. SHS and MG were the main designers of the study. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003enot applicable.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAmir Ali Okhovat\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003cstrong\u003e\u0026nbsp;Parmida Shahbazi\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMobina Taghva Nakhjiri\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohammad Javad Boroujerdi\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohammad Soleimani\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTina Azimzadeh\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSeyyed Hossein Shafiei\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMohammadreza Golbakhsh\u003c/strong\u003e declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgment\u0026nbsp;\u003c/strong\u003enot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSources of funding\u0026nbsp;\u003c/strong\u003eThe authors declare that they have received no financial support for the research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eFilip R, Gheorghita Puscaselu R, Anchidin-Norocel L, Dimian M, Savage WK. Global Challenges to Public Health Care Systems during the COVID-19 Pandemic: A Review of Pandemic Measures and Problems. JPM 2022;12:1295. https://doi.org/10.3390/jpm12081295.\u003c/li\u003e\n \u003cli\u003eBirkmeyer JD, Barnato A, Birkmeyer N, Bessler R, Skinner J. The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States: Study examines trends in US hospital admissions during the COVID-19 pandemic. Health Affairs 2020;39:2010\u0026ndash;7. https://doi.org/10.1377/hlthaff.2020.00980.\u003c/li\u003e\n \u003cli\u003eGordon AM, Magruder ML, Ng MK, Sheth BK, Conway CA, Hang Jason Wong C. The combined effect of policy changes and the covid-19 pandemic on the same day discharge and complications following total hip arthroplasty: a nationwide analysis. Arthroplasty 2022;4:28. https://doi.org/10.1186/s42836-022-00131-w.\u003c/li\u003e\n \u003cli\u003eMehta A, Awuah WA, Ng JC, Kundu M, Yarlagadda R, Sen M, et al. Elective surgeries during and after the COVID-19 pandemic: Case burden and physician shortage concerns. Annals of Medicine \u0026amp; Surgery 2022;81. https://doi.org/10.1016/j.amsu.2022.104395.\u003c/li\u003e\n \u003cli\u003eCzubak-Wrzosek M, Czubak J, Grzelecki D, Tyrakowski M. The Effect of the COVID-19 Pandemic on Total Hip and Knee Arthroplasty Surgical Volume in 2020 in Poland. IJERPH 2021;18:8830. https://doi.org/10.3390/ijerph18168830.\u003c/li\u003e\n \u003cli\u003eWilson JM, Schwartz AM, Farley KX, Roberson JR, Bradbury TL, Guild GN. Quantifying the Backlog of Total Hip and Knee Arthroplasty Cases: Predicting the Impact of COVID-19. HSS Jrnl 2020;16:85\u0026ndash;91. https://doi.org/10.1007/s11420-020-09806-z.\u003c/li\u003e\n \u003cli\u003eBrown TS, Bedard NA, Rojas EO, Anthony CA, Schwarzkopf R, Stambough JB, et al. The Effect of the COVID-19 Pandemic on Hip and Knee Arthroplasty Patients in the United States: A Multicenter Update to the Previous Survey. Arthroplasty Today 2021;7:268\u0026ndash;72. https://doi.org/10.1016/j.artd.2020.11.025.\u003c/li\u003e\n \u003cli\u003eKnebel C, Ertl M, Lenze U, Suren C, Dinkel A, Hirschmann MT, et al. COVID-19-related cancellation of elective orthopaedic surgery caused increased pain and psychosocial distress levels. Knee Surg Sports Traumatol Arthrosc 2021;29:2379\u0026ndash;85. https://doi.org/10.1007/s00167-021-06529-4.\u003c/li\u003e\n \u003cli\u003eBadin D, Ortiz-Babilonia CD, Harris AB, Raad M, Oni JK. Early Postoperative Complications in Total Hip and Knee Arthroplasties Before and During the COVID-19 Pandemic: A Retrospective Analysis of 38,234 Patients. Arthroplasty Today 2022;18:24\u0026ndash;30. https://doi.org/10.1016/j.artd.2022.08.018.\u003c/li\u003e\n \u003cli\u003eSun J, Yang Y, Feng G, Liang C, Ling W, Liao H. Analysis of related factors of scheduled ICU before primary hip arthroplasty. BMC Anesthesiol 2022;22:221. https://doi.org/10.1186/s12871-022-01737-y.\u003c/li\u003e\n \u003cli\u003eArabi YM, Myatra SN, Lobo SM. Surging ICU during COVID-19 pandemic: an overview. Current Opinion in Critical Care 2022;28:638\u0026ndash;44. https://doi.org/10.1097/MCC.0000000000001001.\u003c/li\u003e\n \u003cli\u003eShah KC, Poeran J, Zubizarreta N, McCardle K, Jebakumar J, Moucha CS, et al. Comparison of total joint arthroplasty care patterns prior to the Covid-19 pandemic and after resumption of elective surgery during the Covid-19 Outbreak: A retrospective, large urban academic center study. The Knee 2022;38:36\u0026ndash;41. https://doi.org/10.1016/j.knee.2022.05.004.\u003c/li\u003e\n \u003cli\u003eWright AA, Cook C, Abbott JH. Variables associated with the progression of hip osteoarthritis: A systematic review. Arthritis \u0026amp; Rheumatism 2009;61:925\u0026ndash;36. https://doi.org/10.1002/art.24641.\u003c/li\u003e\n \u003cli\u003eThaler M, Kort N, Zagra L, Hirschmann MT, Khosravi I, Liebensteiner M, et al. Prioritising of hip and knee arthroplasty procedures during the COVID-19 pandemic: the European Hip Society and the European Knee Associates Survey of Members. Knee Surg Sports Traumatol Arthrosc 2021;29:3159\u0026ndash;63. https://doi.org/10.1007/s00167-020-06379-6.\u003c/li\u003e\n \u003cli\u003eAbdelaal MS, Small I, Sherman MB, Courtney PM, Sharkey PF. One Year Later: The Lasting Effect of the COVID-19 Pandemic on Elective Hip and Knee Arthroplasty. J Am Acad Orthop Surg 2022;30:e1474\u0026ndash;82. https://doi.org/10.5435/JAAOS-D-22-00245.\u003c/li\u003e\n \u003cli\u003eForlenza EM, Chahla J, Forsythe B. Protecting Surgical Patient Safety During the Coronavirus Disease 2019 (COVID-19) Pandemic. Arthroscopy, Sports Medicine, and Rehabilitation 2021;3:e615\u0026ndash;8. https://doi.org/10.1016/j.asmr.2020.09.005.\u003c/li\u003e\n \u003cli\u003eLee LS, Chan PK, Fung WC, Cheung A, Chan VWK, Cheung MH, et al. Lessons learnt from the impact of COVID-19 on arthroplasty services in Hong Kong: how to prepare for the next pandemic? Arthroplasty 2021;3:36. https://doi.org/10.1186/s42836-021-00093-5.\u003c/li\u003e\n \u003cli\u003eSequeira SB, Novicoff WM, McVey ED, Noble DM, Harb MA, Taliaferro JP, et al. Patient Perspectives on the Cancellation of Elective Primary Hip and Knee Arthroplasty During the COVID-19 Pandemic. J Am Acad Orthop Surg 2021;Publish Ahead of Print. https://doi.org/10.5435/JAAOS-D-20-00765.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"SARS-CoV-2, Arthroplasty, Replacement, Hip, Hip Prosthesis, Elective Surgical Procedures","lastPublishedDoi":"10.21203/rs.3.rs-4978724/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4978724/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe COVID-19 pandemic has affected elective surgeries, including Total Hip Arthroplasty (THA). This study compared THA outcomes before and after the COVID-19 outbreak in a center without a specific COVID-19 protocol for elective surgeries.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis cross-sectional study included a total of 304 THA surgeries. The study period was divided into pre-COVID-19 outbreak (April 21, 2017 to April 21, 2019) and post-COVID-19 outbreak (April 21, 2020 to April 21, 2022) groups. Demographic characteristics, etiology of operations, anesthesia time, pre-operation length of stay (LOS), post-operation LOS, comorbidities, mortality, complications, and transfusion needs were compared between the two periods.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003ePatients during the COVID-19 pandemic were significantly younger (mean\u0026thinsp;=\u0026thinsp;49.2\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3 vs. 53.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1 years) (P-value\u0026thinsp;=\u0026thinsp;0.02). The most common indication for THA in both periods was trauma, but there was a significant difference in the distribution of etiologies between the two periods (P-value\u0026thinsp;=\u0026thinsp;0.01). Pre-operative LOS was significantly longer during the COVID-19 pandemic (mean\u0026thinsp;=\u0026thinsp;2.75\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69 days) compared to the pre-pandemic period (mean\u0026thinsp;=\u0026thinsp;2.28\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5 days) (P-value\u0026thinsp;=\u0026thinsp;0.01). However, there was no significant difference in post-operative LOS or total LOS. There were no significant differences in comorbidities between the two periods. In-hospital mortality was low in both periods, with no significant difference. Complications and transfusion needs did not show any significant differences.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eCOVID-19 pandemic led to younger THA patients, changes in etiologies, longer pre-operative LOS, but no difference in mortality, complications, anesthesia time or transfusion needs. Further research is needed to better understand the impact of the pandemic on elective orthopedic surgeries.\u003c/p\u003e","manuscriptTitle":"The Impact of COVID-19 in Total Hip Arthroplasty: A Comparison Study in a Center without Elective Surgery Protocols","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 14:14:04","doi":"10.21203/rs.3.rs-4978724/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-16T07:02:13+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-15T19:46:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104292809151359363101199242202663768841","date":"2025-07-15T18:41:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1220876091828708599173944583510887331","date":"2025-07-06T01:04:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22666707146339639426132072386314944135","date":"2025-07-05T20:12:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T17:55:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60023306841573485649122222327051936227","date":"2025-06-29T04:32:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-09T06:39:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-03T08:38:41+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-09-16T04:09:13+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-13T14:00:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-09-13T13:59:08+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"56b31cf8-280c-456c-9898-8bee96824b1c","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:07:54+00:00","versionOfRecord":{"articleIdentity":"rs-4978724","link":"https://doi.org/10.1186/s12891-025-09240-4","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2025-10-28 15:58:27","publishedOnDateReadable":"October 28th, 2025"},"versionCreatedAt":"2025-08-27 14:14:04","video":"","vorDoi":"10.1186/s12891-025-09240-4","vorDoiUrl":"https://doi.org/10.1186/s12891-025-09240-4","workflowStages":[]},"version":"v1","identity":"rs-4978724","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4978724","identity":"rs-4978724","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}