As Warned, Diabetic Amputations Spiked During Pandemic

During the COVID-19 pandemic and subsequent lockdown, diabetic patients in the U.S. presented with more severe infections, more emergencies and were more likely to undergo diabetic amputations than before the pandemic. One study found that patients were 10.8 times more likely to undergo a lower limb amputation during the pandemic than before it began.

Experts predicted the risks of postponing wound care. A special communication in the March 2020 issue of the Journal of the American Podiatric Medical Association noted that “diabetic foot ulcer procedures and surgeries may be misclassified as non-essential, but without regular podiatric care, vascular diagnostics, or surgical intervention, these patients are at risk of quickly becoming infected, which will lead to an increase in amputations and deaths.”

With access to in-person care limited, those who may have sought emergency care to prevent lower limb amputation postponed care for fear of contracting COVID-19. An estimated 20 million Americans suffer from conditions that require prompt intervention to prevent lower limb amputation and hundreds of thousands of Americans face non-traumatic limb amputations every year—85% caused by preventable complications related to peripheral artery disease or diabetic foot ulcers.

Despite the growth of remote care via telehealth, it’s not easy to evaluate diabetic patients, especially those with chronic diabetic foot ulcers (DFU), from afar. That’s why some warned of the risks of postponing wound care and advocated that it should be designated an essential service during the pandemic.

Diabetic Limb Loss Increased

Researchers at Grant Medical Center in Columbus, Ohio found that that their patients had increased odds of diabetic limb loss during the pandemic compared to before. Specifically, the amputation statistics showed that patients were:

- 8 times more likely to undergo any amputation
- 5 times more likely to undergo a major amputation (below-the-knee or higher)
- For patients undergoing amputation, odds of a major amputation were 3.1 times higher
- Infections were more severe, and a larger proportion of the cases were classified as emergent

Researchers reviewed the charts of diabetic inpatients seen by the foot and ankle surgery service between January 1 and August 31, 2020. The study evaluated 270 patients, 120 pre-pandemic (January 1 to March 17) and 150 during the pandemic (March 18 to August 31).

When it came to infection severity, there were no significant difference between the two groups in terms of diabetes type, presenting pathology and degree of limb loss.

Here’s what was significant among the diabetic amputation statistics:

- More bilateral presentation in the pre-pandemic group (14.7%) vs. pandemic group (5.33%).
- More uninfected cases pre-pandemic (18.26%) vs. during the pandemic (7.48%).
- More mild and severe cases during the pandemic (35.37% and 14.97%, respectively) vs. before (29.57% and 9.57%, respectively).
- Greater proportion of emergent cases during the pandemic (6%) than before.

“We speculate that the abrupt interruption of and limited access to DFU wound care and limb preservation led to increased severity of DFU infections and major amputations as well as patients’ perception of safety of care,” the researchers noted.

Meanwhile, a study at the University of California San Francisco reported a similar increase in limb-threatening foot infections during the first two months of COVID-19 lockdown, as well as an increase in the ratio of major to minor amputations and nearly triple the number of major amputations compared to pre-pandemic levels. The researchers also noted that patients with chronic limb threatening ischemia are often elderly and have significant morbidities, likely explaining their reluctance to seek care during the pandemic.

Novel Ways to Prevent Diabetic Amputations During a Pandemic

One study looked at the management of diabetic foot problems during the pandemic at two centers: the Manchester Royal Infirmary in Manchester, England, and The Keck School of Medicine of the University of Southern California.

With the pandemic severely limiting office visits and lab tests, the clinics had to find other ways to treat their patients with diabetic foot problems including active DFU, significant ischemia and Charcot neuroarthropathy.

Both clinics implemented new methods of care, while focusing on outpatient care when possible. In L.A., 57% of clinical visits were moved to telemedicine, in Manchester 18%. Each also implemented additional solutions, including:

- Educating patients, caretakers and home nursing agencies on dressing changes, monitoring for infection and light local debridement, including larval therapy for wound cleansing and slough removal
- Sending patients with critical limb-threatening ischemia or severe rest pain for vascular testing and intervention
- Having podiatrists make home visits for DFU treatment

In contrast, in Ontario, Canada, treating limb-threatening complications of diabetes, such as toe or partial-foot amputations and revascularization, remained prioritized COVID-19. Hospitals also continued to evaluate patients with urgent in-person ambulatory issues. As a result, diabetic amputation statistics in 2020-2021 never exceeded the 2019-2020 rates, according to one study.

Diabetic Foot Ulcer