Studies Note Increase In Amputations After Arrival Of COVID-19 Pandemic

In a recently published study in the Annals of Vascular Surgery, researchers found a more than twofold increase in major amputations and the degree of tissue loss for vascular surgery patients after the arrival of the COVID-19 pandemic in 2020 in comparison to patients in similar time frames in 2019 and 2018. 

For the study, researchers analyzed data on a total of 38 patients who underwent 46 vascular surgery procedures during a six-week period in March and April of 2020. They found a significant increase in the number of major amputations (42 percent in 2020 in comparison to 18 and 15 percent in 2019 and 2018 respectively). They also noted a significantly higher degree of tissue loss (90 percent Rutherford grade V and VI in comparison to 41 and 48 percent in 2019 and 2018 respectively). 

Also, a recent study in Diabetes Care revealed a more than threefold risk of amputation in 25 patients with DFUs admitted to a tertiary care center between March 9 and May 18, 2020 in comparison to 38 patients admitted to the center in the first five months of 2019. 

Erin E. Klein, DPM, FACFAS, DABPM, says amputations have increased in her practice since March and specifically notes the number of transmetatarsal amputations in these last several months in her practice already exceeds the total number from all of last year. Dr. Klein has also received significantly more calls from the ER about emergent cases. 

“Many offices closed and left patients without care. These patients ignore things for too long and then head to the ER with a severe systemic infection,” notes Dr. Klein. 

Adam L. Isaac, DPM, FACFAS says the study findings are predictable but adds that the current situation is reflective of a wave of patients returning for missed care through no fault of their own. He says this includes patients who simply needed periodic foot examinations or nail and callus care, and wound up developing ingrown nails or blisters that became ulcers. While these cases do not equate to major amputation, it is important to point out that there are other implications such as increased antibiotic usage and lost wages for these patients, says Dr. Isaac, the Director of Research with Foot and Ankle Specialists of the Mid-Atlantic (FASMA). 

“The increase in amputations is just another indirect effect of COVID-19 on health-care systems around the world,” says Lee C. Rogers, DPM, DABPM. “The pandemic interrupted care for chronic conditions but also led to a reduced willingness for patients to seek out care for emergencies. Thus, the effect on increasing amputations is not surprising.” 

Dr. Isaac relates being able to keep his offices open for urgent and emergent visits during the period of peak cases in his area. His practice’s Amputation Prevention Center is a “wound center without walls” that can provide advanced wound care in an office setting without patients having to go to a hospital for some of these services. 

“Many patients did express a higher level of comfort in seeking care in an office setting and as a result, we lost very few to follow up,” says Dr. Isaac. “Several regional tertiary care centers actually referred patients to us as they prepared for an influx of COVID-19 patients.” 

Patients have interestingly shown even higher levels of adherence to her treatment recommendations since the pandemic arrived in the United States, says Dr. Klein, a fellowship-trained foot and ankle surgeon. 

Practice pattern changes for podiatrists as a result of the COVID-19 pandemic will be long-term, notes Dr. Rogers, a member of the Board of Directors for the American Board of Podiatric Medicine. 

“Podiatrists should be prepared for permanent changes. I do predict that physician offices, hospitals and other health-care settings will see lasting changes in cleanliness, masks in clinical areas, distancing in waiting rooms, the use of telemedicine and other technologies like remote patient monitoring,” explains Dr. Rogers. 

Podiatry College Applications Increase During Unprecedented Times 

By Jennifer Spector, DPM, FACFAS, Associate Editor

Podiatry colleges received a total of 1,006 applications in the 2020 cycle from those hoping to attend podiatric medical school. This marks a three-year period of application growth with a 4.36 percent increase from last year. 

Moraith G. North, the Executive Director of the American Association of Colleges of Podiatric Medicine (AACPM), cites the continued diligence of the organization increasing awareness of careers in podiatric medicine, even during a global pandemic, as contributing to the increase in applications. She also shares that AACPM and the American Podiatric Medical Association (APMA) have worked to increase digital and virtual recruitment opportunities for students across the country. 

“The American Association of Colleges of Podiatric Medicine along with the nine U.S. schools and colleges of podiatric medicine amended long-standing admissions rules to allow candidates to interview virtually, waive unattainable requirements and pivoted to digital resources in record time,” explains Ms. North. 

Jeffrey L. Jensen, DPM, the Associate Dean of the Midwestern University School of Podiatric Medicine, agrees the collaborative effort contributed to a successful recruitment campaign, especially in light of unique challenges during the COVID-19 pandemic. 

Bryan D. Caldwell, DPM, MD, the Dean of the Barry University School of Podiatric Medicine, states that podiatric medicine and surgery remains an attractive career choice for many students. Although he shares that applications were below last year’s statistics for most of the 2020 cycle, he feels the increase that coincided with the pandemic could partially be due to the recent focus on those working in the medical profession. 

Ms. North acknowledges that the COVID-19-related amendments to the application process may have helped boost the final application numbers but maintains the work put into recruitment efforts over the past three years also plays a role. 

“Professional awareness is key,” says Dr. Jensen. “Students having the opportunity to shadow a doctor is also very important. When we interview prospective students, their excitement level is often directly related to their shadowing experience.” 

Dr. Caldwell says a focus on alumni success and input will be valuable for future recruitment efforts along with working closely and collaborating with local and nearby state associations. 

Could Outpatient Total Ankle Arthroplasty Decrease Complications? 

By Jennifer Spector, DPM, FACFAS, Associate Editor 

Could an outpatient setting be best for patients undergoing total ankle arthroplasty? 

In a recent study in the Journal of Foot and Ankle Surgery that included a meta-analysis of four studies and sensitivity analysis of five additional studies, researchers found a fivefold higher risk of short-term complications for inpatient total ankle arthroplasty cases. The authors concluded that surgeons may safely perform total ankle arthroplasty procedures in high-volume outpatient centers that are prepared to execute a “fast-track outpatient total joint protocol.” 

Rachel H. Albright, DPM, MPH, the lead author on the study, shares that the fast-track protocol for total ankle arthroplasty would naturally mirror that of total knee and hip replacements. Studies demonstrate the importance of developing comprehensive pre-and postoperative protocols for total ankle arthroplasty including patient education and follow-up, points out Dr. Albright. She also emphasizes proper patient selection and ensuring adequate patient support systems and resources to facilitate immediate outpatient recovery. 

“Surgeons should expect more clinical time dedicated to their joint replacement patients since responsibilities previously carried out by the hospital could now transfer to the surgeon and his or her staff,” points out Dr. Albright. 

She adds that the higher likelihood of complications in the inpatient setting may be related to selection bias in current studies. 

“Therefore, I would venture to guess that the inpatient setting itself isn’t actually more ‘dangerous’ or ‘risky,’ but neither is it more safe than the outpatient setting,” says Dr. Albright, who is hospital-employed in Darien, Conn. 

Dr. Albright feels that more high quality research will also be necessary before insurance companies will routinely approve total ankle arthroplasty in the outpatient setting, and encourages surgeons to document and publish their results in this pursuit.