The impact of the COVID-19 Pandemic on the delivery of lower limb arthroplasty

Main Article Content

Ashish Vasudev, BSc (Hons), MBchB Abdus Samee Wasim, BSc (Hons), MBBS, MRSC Akash Sharma, FRCS(Tr&Orth) Yuvraj Agrawal, FRCS(Tr&Orth)


Hip and knee arthroplasty is an extremely successful and cost-effective procedure that is widely performed to restore function and alleviate pain. The arrival of the SARS-CoV-2 virus (COVID-19) brought significant disruptions to delivery of surgery worldwide, including lower limb arthroplasty. Three years on from the start of the pandemic the effects of the virus are still present. This literature review aims to explore current data published from our single specialty orthopaedic centre and data collected nationally and internationally, on the impact of the COVID-19 pandemic on lower limb arthroplasty.

Elective hip and knee arthroplasty in the UK fell by approximately 40% and 50% respectively (2020 vs 2019) and by the end of 2021 the number of procedures completed still remained below pre-pandemic levels. As a result, elective waiting times are longer than ever before, with more patients suffering worse health states and a significant impact on quality of life. The UK National Hip Fracture Database showed an active COVID-19 infection was associated with a three-fold greater risk of 30-day mortality post lower limb arthroplasty. Several reports have also correlated peri-operative COVID-19 infection with increased risk of systemic complications with the virus such as pneumonia, deep vein thrombosis, pulmonary embolisms, acute kidney injury and myocardial infarction to name a few.

NHS England provided guidelines for safe recommencement for elective operating. Upon adoption of these recommendations, several orthopaedic units found similar rates of post-operative complications and mortality to pre-pandemic levels, demonstrating that safe elective care can be delivered even during an emergency pandemic setting. The development of rapid testing, use of personal protective equipment and introduction of pre- and post-operative isolation protocols were effective measures to allow elective surgery to restart. For infected individuals awaiting surgery, delays of at least seven weeks are recommended to reduce complication rates. There is limited literature discussing the impact of the vaccine on post-operative complications and mortality. Early reports however have suggested vaccinated individuals benefit from a reduced mortality risk in emergency cases of hip fracture surgery, but this is an area which would benefit from further research.


Keywords: The impact of the COVID-19, The impact of the COVID-19 pandemic, COVID-19 pandemic, COVID-19, delivery of lower limb arthroplasty, literature review

Article Details

How to Cite
VASUDEV, Ashish et al. The impact of the COVID-19 Pandemic on the delivery of lower limb arthroplasty. Medical Research Archives, [S.l.], v. 11, n. 3, mar. 2023. ISSN 2375-1924. Available at: <>. Date accessed: 20 apr. 2024. doi:
Review Articles


1. Daigle ME, Weinstein AM, Katz JN, Losina E. The cost-effectiveness of total joint arthroplasty: a systematic review of published literature. Best Pract Res Clin Rheumatol. Oct 2012;26(5):649-58. doi:10.1016/j.berh.2012.07.013
2. Konopka JF, Lee YY, Su EP, McLawhorn AS. Quality-Adjusted Life Years After Hip and Knee Arthroplasty: Health-Related Quality of Life After 12,782 Joint Replacements. JB JS Open Access. Sep 25 2018;3(3):e0007. doi:10.2106/JBJS.OA.18.00007
3. Gordon AM, Magruder ML, Conway CA, Sheth BK, Erez O. The Effect of COVID-19 on Elective Total Knee Arthroplasty Utilization, Patient Comorbidity Burden, and Complications in the United States: A Nationwide Analysis. J Am Acad Orthop Surg. Dec 15 2022;30(24):e1599-e1611. doi:10.5435/JAAOS-D-22-00193
4. 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. Int J Environ Res Public Health. Aug 21 2021;18(16)doi:10.3390/ijerph18168830
5. Barnes CL, Zhang X, Stronach BM, Haas DA. The Initial Impact of COVID-19 on Total Hip and Knee Arthroplasty. J Arthroplasty. Jul 2021;36(7S):S56-S61. doi:10.1016/j.arth.2021.01.010
6. Bedard NA, Elkins JM, Brown TS. Effect of COVID-19 on Hip and Knee Arthroplasty Surgical Volume in the United States. J Arthroplasty. Jul 2020;35(7S):S45-S48. doi:10.1016/j.arth.2020.04.060
7. Wong JSH, Cheung KMC. Impact of COVID-19 on Orthopaedic and Trauma Service: An Epidemiological Study. J Bone Joint Surg Am. Jul 15 2020;102(14):e80. doi:10.2106/JBJS.20.00775
8. Lee LS, Chan PK, Fung WC, 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(1):36. doi:10.1186/s42836-021-00093-5
9. Beaven A, Piper D, Plant C, Sharma A, Agrawal Y, Cooper G. Thirty-Day Mortality for Proximal Femoral Fractures Treated at a U.K. Elective Center with a Site-Streaming Policy During the COVID-19 Pandemic. JB JS Open Access. 2021;6(4)doi:10.2106/JBJS.OA.21.00009
10. Al-Jabir A, Kerwan A, Nicola M, et al. Impact of the Coronavirus (COVID-19) pandemic on surgical practice - Part 2 (surgical prioritisation). Int J Surg. Jul 2020;79:233-248. doi:10.1016/j.ijsu.2020.05.002
11. Worldometer. COVID-19 CORONAVIRUS PANDEMIC. Accessed 3rd February, 2023.
12. Agrawal Y, Vasudev A, Sharma A, et al. Morbidity and mortality in patients undergoing lower limb arthroplasty surgery during the initial surge of the COVID-19 pandemic in the UK at a single-speciality orthopaedic hospital. Bone Jt Open. May 2021;2(5):323-329. doi:10.1302/2633-1462.25.BJO-2021-0001.R1
13. Collaborative C. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. Jul 04 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
14. Abbott TEF, Fowler AJ, Dobbs TD, et al. Mortality after surgery with SARS-CoV-2 infection in England: a population-wide epidemiological study. Br J Anaesth. Aug 2021;127(2):205-214. doi:10.1016/j.bja.2021.05.018
15. Jefferson T, Spencer EA, Brassey J, et al. Transmission of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) from pre and asymptomatic infected individuals: a systematic review. Clin Microbiol Infect. Feb 2022;28(2):178-189. doi:10.1016/j.cmi.2021.10.015
16. GOV.UK. Coronavirus (COVID-19) in the UK. Accessed 2nd February, 2023.
17. Ayouni I, Maatoug J, Dhouib W, et al. Effective public health measures to mitigate the spread of COVID-19: a systematic review. BMC Public Health. May 29 2021;21(1):1015. doi:10.1186/s12889-021-11111-1
18. Physicians RCo. Facing New Challenges: The National Hip Fracture Database report on 2020. 2021.$file/NHFD%202021%20report%20v2a.pdf
19. Muñoz Vives JM, Jornet-Gibert M, Cámara-Cabrera J, et al. Mortality Rates of Patients with Proximal Femoral Fracture in a Worldwide Pandemic: Preliminary Results of the Spanish HIP-COVID Observational Study. J Bone Joint Surg Am. Jul 01 2020;102(13):e69. doi:10.2106/JBJS.20.00686
20. Egol KA, Konda SR, Bird ML, et al. Increased Mortality and Major Complications in Hip Fracture Care During the COVID-19 Pandemic: A New York City Perspective. J Orthop Trauma. Aug 2020;34(8):395-402. doi:10.1097/BOT.0000000000001845
21. Keny S, Bagaria V, Chaudhary K, Dhawale A. Emergency and Urgent Orthopaedic Surgeries in non-covid patients during the COVID 19 pandemic: Perspective from India. J Orthop. 2020;20:275-279. doi:10.1016/j.jor.2020.05.012
22. Mi B, Chen L, Xiong Y, Xue H, Zhou W, Liu G. Characteristics and Early Prognosis of COVID-19 Infection in Fracture Patients. J Bone Joint Surg Am. May 06 2020;102(9):750-758. doi:10.2106/JBJS.20.00390
23. Catellani F, Coscione A, D'Ambrosi R, Usai L, Roscitano C, Fiorentino G. Treatment of Proximal Femoral Fragility Fractures in Patients with COVID-19 During the SARS-CoV-2 Outbreak in Northern Italy. J Bone Joint Surg Am. Jun 17 2020;102(12):e58. doi:10.2106/JBJS.20.00617
24. Stevens S PA. IMPORTANT AND URGENT – NEXT STEPS ON NHS RESPONSE TO COVID-19. United Kingdom Government. NHS England - United Kingdom Government. Accessed 15th January, 2023.
25. Marx DC. Changes to prepare for and manage COVID surge (March/April 2020 - archive material). Accessed 15th January, 2023.
26. Khanna V, Nashikkar PS, Mahajan R, Tripathi S. Impact of Covid-19 pandemic on arthroplasty services and early experience after resuming surgeries at a 'non Covid' center. J Clin Orthop Trauma. Oct 2021;21:101515. doi:10.1016/j.jcot.2021.101515
27. Yoav Ben-Shlomo AB, Chris Boulton. The National Joint Registry 18th Annual Report 2021. 2021.
28. Yoav Ben-Shlomo AB, Chris Boulton. The National Joint Registry 19th Annual Report 2022. 2022.
29. Yapp LZ, Clarke JV, Moran M, Simpson AHRW, Scott CEH. National operating volume for primary hip and knee arthroplasty in the COVID-19 era: a study utilizing the Scottish arthroplasty project dataset. Bone Jt Open. Mar 2021;2(3):203-210. doi:10.1302/2633-1462.23.BJO-2020-0193.R1
30. Green G, Abbott S, Vyrides Y, Afzal I, Kader D, Radha S. The impact of the COVID-19 pandemic on the length of stay following total hip and knee arthroplasty in a high volume elective orthopaedic unit. Bone Jt Open. Aug 2021;2(8):655-660. doi:10.1302/2633-1462.28.BJO-2021-0022.R1
31. Silvestre J, Thompson TL, Nelson CL. The Impact of COVID-19 on Total Joint Arthroplasty Fellowship Training. J Arthroplasty. Aug 2022;37(8):1640-1644.e2. doi:10.1016/j.arth.2022.03.083
32. Sheridan GA, Hughes AJ, Quinlan JF, Sheehan E, O'Byrne JM. Quantifying the impact of the COVID-19 pandemic on orthopaedic trainees: a national perspective. Bone Jt Open. Oct 2020;1(10):645-652. doi:10.1302/2633-1462.110.BJO-2020-0149.R1
33. Karayiannis PN, Roberts V, Cassidy R, et al. 30-day mortality following trauma and orthopaedic surgery during the peak of the COVID-19 pandemic: a multicentre regional analysis of 484 patients. Bone Jt Open. Jul 2020;1(7):392-397. doi:10.1302/2633-1462.17.BJO-2020-0075.R1
34. Hall AJ, Clement ND, Farrow L, et al. IMPACT-Scot report on COVID-19 and hip fractures. Bone Joint J. Sep 2020;102-B(9):1219-1228. doi:10.1302/0301-620X.102B9.BJJ-2020-1100.R1
35. Physicians RCo. The challenge of the next decade: are hip fracture services ready? A review of data from the National Hip Fracture Database (January–December 2019). 2020.
36. Tripathy SK, Varghese P, Panigrahi S, et al. Thirty-day mortality of patients with hip fracture during COVID-19 pandemic and pre-pandemic periods: A systematic review and meta-analysis. World J Orthop. Jan 18 2021;12(1):35-50. doi:10.5312/wjo.v12.i1.35
37. Lim EJ, Kim M, Kim CH. Impact of the COVID-19 Pandemic on Mortality Following Hip and Knee Joint Arthroplasty Surgeries: A Systematic Review and Meta-Analysis. J Pers Med. Aug 31 2022;12(9)doi:10.3390/jpm12091441
38. Forlenza EM, Higgins JDD, Burnett RA, Serino J, Della Valle CJ. COVID-19 Infection After Total Joint Arthroplasty Is Associated With Increased Complications. J Arthroplasty. Jul 2022;37(7S):S457-S464. doi:10.1016/j.arth.2021.10.023
39. Terpos E, Ntanasis-Stathopoulos I, Elalamy I, et al. Hematological findings and complications of COVID-19. Am J Hematol. Jul 2020;95(7):834-847. doi:10.1002/ajh.25829
40. Desai AD, Lavelle M, Boursiquot BC, Wan EY. Long-term complications of COVID-19. Am J Physiol Cell Physiol. Jan 01 2022;322(1):C1-C11. doi:10.1152/ajpcell.00375.2021
41. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. Apr 2021;27(4):601-615. doi:10.1038/s41591-021-01283-z
42. Hogan BV, Peter MB, Shenoy HG, Horgan K, Hughes TA. Surgery induced immunosuppression. Surgeon. Feb 2011;9(1):38-43. doi:10.1016/j.surge.2010.07.011
43. Kayani B, Onochie E, Patil V, et al. The effects of COVID-19 on perioperative morbidity and mortality in patients with hip fractures. Bone Joint J. Sep 2020;102-B(9):1136-1145. doi:10.1302/0301-620X.102B9.BJJ-2020-1127.R1
44. Collaborative C, Collaborative G. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia. Jun 2021;76(6):748-758. doi:10.1111/anae.15458
45. Galivanche AR, Mercier MR, Schneble CA, et al. Clinical Characteristics and Perioperative Complication Profiles of COVID-19-Positive Patients Undergoing Hip Fracture Surgery. J Am Acad Orthop Surg Glob Res Rev. Oct 15 2021;5(10)doi:10.5435/JAAOSGlobal-D-21-00104
46. Knisely A, Zhou ZN, Wu J, et al. Perioperative Morbidity and Mortality of Patients With COVID-19 Who Undergo Urgent and Emergent Surgical Procedures. Ann Surg. Jan 01 2021;273(1):34-40. doi:10.1097/SLA.0000000000004420
47. Holzapfel DE, Meyer M, Thieme M, Pagano S, von Kunow F, Weber M. Delay of total joint replacement is associated with a higher 90-day revision rate and increased postoperative complications. Arch Orthop Trauma Surg. Nov 04 2022:1-8. doi:10.1007/s00402-022-04670-4
48. Clement ND, Scott CEH, Murray JRD, Howie CR, Deehan DJ, Collaboration I-R. The number of patients "worse than death" while waiting for a hip or knee arthroplasty has nearly doubled during the COVID-19 pandemic. Bone Joint J. Apr 2021;103-B(4):672-680. doi:10.1302/0301-620X.103B.BJJ-2021-0104.R1
49. Jabbal M, Campbel N, Savaridas T, Raza A. Careful return to elective orthopaedic surgery in an acute hospital during the COVID-19 pandemic shows no increase in morbidity or mortality. Bone Jt Open. Nov 2021;2(11):940-944. doi:10.1302/2633-1462.211.BJO-2021-0114.R1
50. Asopa V, Sagi A, Bishi H, et al. The safe resumption of elective orthopaedic services following the first wave of the COVID-19 pandemic : a review of 2,316 consecutive cases and implications for recovery following further waves. Bone Jt Open. Jan 2022;3(1):42-53. doi:10.1302/2633-1462.31.BJO-2021-0138
51. Cherry A, Montgomery S, Brillantes J, et al. Converting hip and knee arthroplasty cases to same-day surgery due to COVID-19. Bone Jt Open. Jul 2021;2(7):545-551. doi:10.1302/2633-1462.27.BJO-2021-0029.R1
52. Rashid F, Mahmood A, Hawkes DH, Harrison WJ, group Cc. Coronavirus in hip fractures (CHIP) 4 : has vaccination improved mortality outcomes in hip fracture patients? Bone Joint J. Dec 2022;104-B(12):1362-1368. doi:10.1302/0301-620X.104B12.BJJ-2022-0843.R1