July 2021

Limb Preservation in a Post-pandemic World: Virtually or Physically We’re all in this Together

By Ryan T. Crews, PhD, CCRP; Brian D. Lepow, DPM; and David G. Armstrong, DPM, MD, PhD

The past 18 months have proven challenging for everyone; however, those afflicted with diabetes have borne a heavier load than most. The increased mortality associated with diabetes1 has justifiably received much attention. However, one of the key drivers of the cost of caring for diabetes pre-pandemic, the diabetic foot, also warrants attention relative to COVID-19. Delayed or missed clinical appointments, non-adherence to preventative measures, lockdowns, and physical inactivity have all been cited as possible contributors to increases in lower extremity amputations2 and decreases in preventative measures such as lower limb revascularization procedures.3 Prior to the pandemic, the goal for most patients with wounds was healing at any cost.4 Now, goals have shifted as has the site of wound care, which subsequently reduces access to certain pre-pandemic practices and protocols. The focus now has become preventing these serious complications and avoiding hospitalization.

Despite these setbacks there are some reasons for optimism as we approach a post-pandemic new normal. Necessity spurred the uptake of advances in remote patient monitoring and care that will outlast the blight of COVID-19. There are numerous reports in the literature of rapid increases in the use of telemedicine to provide foot care in patients’ homes.5,6 Similarly the pandemic has been forecast to be a catalyst for increasing the implementation of smart technologies for remotely monitoring the at-risk foot.7 Smart shoes and socks, as well as other home monitoring devices such as networked bathmats that assess for pre-ulcerative inflammation of feet, have already shown promise for identifying impending diabetic foot ulcers (DFUs) and allowing for intervention before such wounds form.

While advances in remote monitoring and artificial intelligence offer substantial potential for improvements in care for the diabetic foot, outcomes are ultimately dependent upon what patients and providers do with the information provided by these technological resources.

Another positive outcome to emerge during the COVID-19 pandemic was the formation of the American Limb Preservation Society (ALPS) in 2020. ALPS is an entity devoted to uniting varied specialists’ efforts to save lower limbs. Both the literature8 and anecdotal evidence are in agreement that interprofessional team-based care is critical to sparing limbs. Eleven years ago, Mills et al. highlighted the minimum constituents of such teams as being podiatric and vascular surgeons.9,10 However, there are many more “skill positions” that contribute to such teams and ensure not only that limbs are spared, but patients are able to live their best lives with their intact limbs. Podiatric and vascular surgeons are uniquely qualified to assess and treat urgent matters such as active DFUs and chronic limb threatening ischemia, but the expertise of other specialists can greatly enhance short- and long-term outcomes. We have previously introduced the concept of patients with healed DFUs as being in a state of remission that implies these patients, like cancer patients in remission, require a vigilant continuance of care. There is a large and diverse group of professionals who can help with both the physiological complications of these patients’ soles and the psychosocial complications of these patients’ souls.

ALPS is looking to bring together diabetes educators, endocrinologists, infectious disease specialists, interventional radiologists and cardiologists, nurses, pathologists, pedorthists, physical therapists, plastic surgeons, podiatric surgeons, psychologists, vascular surgeons, clinical scientists, and others to collectively put an end to preventable amputations.

The advances in telehealth care and patient monitoring supercharged by COVID-19 present new opportunities for these varied constituencies to meaningfully collaborate in shared decision processes with patients in order to obtain the optimal results for at-risk feet and the people who are attached to those feet.4,11 ALPS seeks to be the clearinghouse for driving such collaborative initiatives. While the challenges diabetes poses for lower limbs are daunting, we believe the future is bright.

Ryan T. Crews, PhD, CCRP, is an associate professor at the Dr. William M. Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at Rosalind Franklin University of Medicine and Science in North Chicago, Illinois.

Brian D. Lepow, DPM, is an assistant professor in the Division of Vascular and Endovascular Surgery at Baylor College of Medicine in Houston, Texas.

David G. Armstrong. DPM, MD, PhD, is a professor of surgery and Director of the Southwestern Academic Limb Salvage Alliance (SALSA) at the Keck School of Medicine of University of Southern California in Los Angeles. Dr. Armstrong also serves on the Editorial Advisory Board of Lower Extremity Review.

REFERENCES
  1. Zahid MN, Perna S. Continent-wide analysis of COVID 19: total cases, deaths, tests, socio-economic, and morbidity factors associated to the mortality rate, and forecasting analysis in 2020–2021. Int J Environ Res Public Health. 2021;18(10):5350.
  2. Rogers LC, Snyder RJ, Joseph WS. Diabetes-related amputations: a pandemic within a pandemic. J Am Podiatr Med Assoc. 2020;3:20-248.
  3. Mariet AS, Benzenine E, Bouillet B, Vergès B, Quantin C, Petit JM. Impact of the COVID-19 epidemic on hospitalization for diabetic foot ulcers during lockdown: a French nationwide population-based study. Diabet Med. 2021;e14577.
  4. Rogers LC, Armstrong DG, Capotorto J, et al. Wound center without walls: the new model of providing care during the COVID-19 pandemic. Wounds. 2020;32(7):178-185.
  5. Shin L, Bowling FL, Armstrong DG, Boulton AJ. Saving the diabetic foot during the COVID-19 pandemic: a tale of two cities. Diabetes care. 2020;43(8):1704-1709.
  6. Schmidt BM, Munson ME, Rothenberg GM, Holmes CM, Pop-Busui R. Strategies to reduce severe diabetic foot infections and complications during epidemics (STRIDE). Journal of diabetes and its complications. 2020;34(11):107691.
  7. Najafi B. Post the pandemic: how will COVID-19 transform diabetic foot disease management? J Diabetes Sci Tech. 2020;14(4):764-766.
  8. Crews RT, Lepow BD, Mills JL, et al. A limb is a peninsula-and no clinician is an island: introducing the American Limb Preservation Society (ALPS). Foot & Ankle Surgery: Techniques, Reports & Cases. 2021;1(1):1-2.
  9. Mills JL, Sr., Armstrong DG, Andros G. Rescuing Sisyphus: the team approach to amputation prevention. J Am Podiatr Med Assoc. 2010;100(5):315-316.
  10. Armstrong DG, Conte MS, Rogers LC, Mills JL. The offspring of Sisyphus: steady progress in the decade since the toe and flow JAPMA-JVS special issue on limb preservation. J Am Podiatr Med Assoc. 2021;17:20-137.
  11. Rogers LC, Lavery LA, Joseph WS, Armstrong DG. All feet on deck—the role of podiatry during the COVID-19 pandemic: preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. J Am Podiatr Med Assoc. 2020. DOI: 10.7547/20.051.

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