Long-term D-Dimer Elevation Post-COVID-19: It s Significance in Thrombotic Complications Following Joint Replacement Surgeries

Research Article

Austin Anesthesiol. 2023; 3(1): 1005.

Long-term D-Dimer Elevation Post-COVID-19: It s Significance in Thrombotic Complications Following Joint Replacement Surgeries

El Jellouli Wiam¹; El Gaabouri Mohammad²; Nadir Houda²; Alioui Mohammed²; Houmad Houssein²; Choubi Mouncif²; Abou Elalaa Khalil²*

¹Department of Scientific Research Faculty of Medicine and Pharmacy Mohammed V University Rabat Morocco

²Department of Anesthesiology and Intensive Care, Mohammed V Military Hospital, Faculty of Medicine and Pharmacy Mohammed V University Rabat Morocco

*Corresponding author: El Jellouli Wiam Department of Scientific Research Faculty of Medicine and Pharmacy Mohammed V University Rabat Morocco. Email: wiam2404@gmail.com

Received: August 08, 2023 Accepted: September 14, 2023 Published: September 21, 2023

Abstract

Background: Patients recovering from COVID-19 may experience persistent elevations in D-dimer levels, increasing their risk of thrombosis. This study aimed to investigate the impact of persistent elevated D-dimer levels in patients with a history of COVID-19 on postoperative outcomes after knee and hip arthroplasty.

Methods: A prospective cohort study was conducted from March 2021 to September 2022 at the Military Teaching Hospital Mohammed V in Rabat. Patients scheduled for total knee or hip replacements were included. Those with a history of COVID-19 (n=75) were tested for D-dimer levels during pre-anesthetic evaluation. Patients were classified into normal (n=63) or elevated D-dimer (n=12) groups. Follow-up included monitoring for asymptomatic Deep Vein Thrombosis (DVT) six weeks after surgery.

Results: Among 335 patients, 75 had a history of COVID-19. Elevated D-dimer levels were associated with a higher rate of hospitalization (45.3%) and more severe COVID-19 cases (58.3%). However, preoperative D-dimer levels did not significantly impact the incidence of thromboembolic complications after joint replacement surgeries.

Conclusion: While patients with a history of COVID-19 may have persistent elevations in D-dimer levels, our study did not find a significant association with postoperative thromboembolic complications. Preoperative risk stratification remains important for perioperative planning, but modifications to thromboprophylaxis in these patients may not be warranted. Further research is needed to better understand the impact of COVID-19 on postoperative outcomes and identify potential risk factors for complications in this population.

Keywords: COVID-19; D-Dimer levels; Thromboembolic complications; Joint arthroplasty

Introduction

D-dimer is a protein fragment that is produced when a blood clot is broken down in the body. Elevated levels of D-dimer can indicate the presence of a blood clotting disorder or an increased risk of thrombosis [1,2]. In the context of COVID-19, it has been observed that patients with severe disease are at a higher risk of developing blood clots and other coagulation abnormalities. Even after recovering from COVID-19, some patients may continue to experience persistent elevations in D-dimer levels, which could potentially increase their risk of developing blood clots [3].

In patients who are planned for arthroplasty of the knee and hip, the risk of Venousthromboembolism (VTE) is already high due to the surgical procedure itself [4-6]. However, the presence of persistent elevations in D-dimer levels in patients who have recovered from COVID-19 may further increase this risk [7]. This could have significant implications for the management of these patients, as the use of prophylactic anticoagulation therapy may need to be adjusted based on their D-dimer levels [8].

Therefore, it is important to investigate the prevalence of persistent elevations in D-dimer levels in patients who have recovered from COVID-19 and are planned for arthroplasty of the knee and hip. By identifying patients who are at a higher risk of developing VTE due to persistent elevations in D-dimer levels [9,10] appropriate prophylactic measures can be taken to minimize this risk and ensure optimal patient outcomes [11,12].

Our study aims to investigate D-dimer levels in patients who have recovered from COVID-19 and are scheduled for knee and hip arthroplasty. The primary objective of this research is to assess whether there exists a persistent elevation of D-dimer levels in these patients, which could potentially signify an increased susceptibility to Venous Thromboembolism (VTE) post-surgery. Furthermore, the study seeks to delve into the possible correlation between elevated D-dimer levels and various clinical outcomes, including the occurrence of postoperative thromboembolic complications. Ultimately, our research aims to contribute to clinical decision-making and enhance patient outcomes by identifying potential risk factors and tailoring appropriate prophylactic measures.

Methods

Study Design: This is a prospective cohort study conducted at the Operating Room of the Military Hospital Mohammed V in Rabat over duration of 18 months, spanning from March 2021 to September 2022. The primary objective of the study is to assess the influence of elevated D-dimer levels in patients who have recently recovered from COVID-19 (within the last 6 months) on the outcomes of prosthetic joint surgery.

Inclusion and Exclusion Criteria: Patients eligible for inclusion were those scheduled for total joint prosthetic surgery, encompassing both Total Knee Replacement (TKR) and Total Hip Replacement (THR). Patients with a history of prosthetic revision or trauma were excluded from the study.

Diagnostic Measures: Patients with a documented history of COVID-19 (verified as positive for SARS-CoV-2 IgG antibodies) and planned for joint replacement underwent D-dimer level assessment during their pre-anesthetic evaluation before the surgery. D-dimer levels were categorized according to the established normal laboratory range, with values <500 ng/ml considered within the normal range, and values >500 ng/ml classified as elevated. Patients displaying elevated D-dimer levels underwent preoperative lower extremity echodoppler and contrast-enhanced CT scans to detect any potential presence of thrombosis and/or pulmonary embolism. Additionally, patients with a history of COVID-19 who underwent joint replacement were monitored for asymptomatic Deep Vein Thrombosis (DVT) using a bilateral Doppler ultrasound of the lower limbs performed six weeks post-surgery.

Statistical Analyses: The study's sample size for this exploratory analysis was not pre-determined, but an estimated range of 50 to 200 patients with a history of COVID-19 infection was assumed to be included. Descriptive statistical methods, comprising absolute and percentage frequencies, chi-square tests for categorical data, and mean ± standard deviation as well as t-tests for continuous data, will be employed to describe data and conduct group comparisons. Notably, fibrinogen CRP will not be analyzed due to the limited number of observations in the D-dimer group exceeding 0.5. A significance level of 0.05 has been set for all analyses.

Results

Characteristics of Patients with and without History of COVID-19

During the study period from March 2021 to September 2022, a total of 335 patients were scheduled for total joint replacement surgery (THA or TKA) at the Traumatology-Orthopedics Services I and II of the Mohammed V Military Hospital in Rabat. The mean age of the patients was 65.24±10.06 years, with 189 females and 146 males, yielding a male-to-female ratio of 0.77. The patients had an average Body Mass Index (BMI) of 30.14±5.78. Out of the total patient cohort, 75 patients had confirmed COVID-19 exposure more than 2 months prior, representing a rate of 22.3%.

Regarding patients with recent COVID-19 history, 75 patients (42 females, 56%) were consecutively enrolled with a mean post-COVID-19 interval of 118 days (ranging from 68 to 142 days). Their mean age was 64.22±10.03 years, and comorbidities were observed in 58 patients (77.3%). The most common comorbidities included hypertension (26.6%), type 2 diabetes (16%), asthma and COPD (8%), and ischemic heart diseases (5.3%). The average BMI was 30.24±5.89.

Among participants with mild COVID-19 (n=41, 54.6%), none required hospitalization or thromboprophylaxis. Among those with moderate to severe disease, 34 patients (45.3%) were hospitalized, with 7 (9%) requiring ICU admission. All hospitalized patients received heparin-based prophylaxis during their stay, and none required invasive ventilation.

Table 1 summarizes the demographic and clinical characteristics of patients, Table 2 further details the demographic and clinical features of patients with recent COVID-19 history.