Increased Amputation Rates In COVID Negative Patients During The COVID Pandemic
Benjamin Colby Powell, MD, Evan E. Foulke, MD, Michael R. Buckley, MD, Joshua D. Arnold, MD, Oscar H. Grandas, MD, Scott L. Stevens, MD, Mitchell H. Goldman, MD, Michael B. Freeman, MD, Michael M. McNally, MD.
University of Tennessee Medical Center Knoxville, Knoxville, TN, USA.
OBJECTIVES: The first case of COVID-19 diagnosed in the United States was January 28, 2020. As the pandemic emerged, many primary care physician offices and wound care centers temporarily closed and hospitals significantly reduced operative services. The aim of this study was to investigate patient factors in COVID negative patients undergoing major amputation during the COVID pandemic compared to preCOVID era.
METHODS: A retrospective single institution review from January 2017 to June 2020 was conducted on all patients undergoing major amputation. Patients were grouped into preCOVID era (January 2017-January 2020) and COVID era (February-June 2020). All patients who underwent toe or transmetatarsal amputations, revisions of prior amputations (not guillotine), or traumatic amputations (orthopedic/trauma service) were excluded. Statistical analysis was performed with descriptive statistics and categorical tests, including z-test and chi-square.
RESULTS: There were 253 lower extremity amputations identified: 70 amputations in the COVID era compared to 183 amputations in the preCOVID period. All patients in the COVID era had a negative COVID test prior to amputation. Groups were similar in age, race and gender. There were no differences in amputation level (50.8% AKA preCOVID, 48.6% AKA COVID) or staged guillotine amputations (16.9% preCOVID, 17.1% COVID). There was a statistically significant increase in average amputations per month from the expected preCOVID period (n=4.47, std 1.9) to the observed COVID period (n=14, std 2.8, z=10.76, p<0.0000001, d=4.81, FIGURE 1). Comorbidities were comparable with no difference in hypertension, coronary artery disease, congestive heart failure, end stage renal disease and tobacco use. Significant factors in major amputation during the COVID era included: diabetes (n=124, 68.5% preCOVID vs n=60, 85.7% COVID, p=0.006), hyperlipidemia (n=108, 59.3% preCOVID vs n=51, 72.9% COVID, p=0.046), and wound severity based on WIfI score (p=0.007). 
CONCLUSIONS: This study implies a significant impact of the COVID pandemic on increased major lower extremity amputation rates in COVID negative patients. Further investigation at a regional and national level is needed to more definitely determine factors in major amputation during the COVID era with limited patient access to healthcare.
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