Does Timing Matter? Postoperative Risk and the Optimal Timing for Total Joint Arthroplasty Following COVID-19 Infection

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.