COVID 19 Impact on Limb Loss and Techniques to Improve Outcomes
Every 17 seconds worldwide, there is a major amputation being performed. In the United States, 1.6 million people are living with lower-extremity amputations. This number is projected to rise to 3.6 million by 2050.1
The COVID-19 pandemic resulted in a massive increase in major amputations among patients with critical limb ischemia and diabetic foot ulcers. A review of international studies suggests that the rate of major amputation was, in some cases, 10 to 15 times higher in 2020 as compared to preCOVID-19 rates. Some of this increase was due to facility-related factors that decreased access to care. The increase was also partially due to patient-related factors, including difficulty traveling and fear of seeking care during the pandemic's height.
COVID-19 itself has also presented challenges to limb preservation efforts. A swath of studies showed that amputation rates were higher among patients infected with COVID-19, and resulted in worse outcomes, as compared to patients who were not infected with COVID-19. Research has also indicated that open revascularization attempts are less successful in patients with COVID-19.
Khanjan 'KJ' Nagarsheth, MD, vascular surgeon and co-director of the University of Maryland Medical Center's Limb Preservation program, shares an overview of COVID-19’s impact on limb loss, the role of phantom pain in patient outcomes, and information about leading-edge nerve repair options for amputees.
At the University of Maryland Medical Center (UMMC), the rate of amputations doubled since April of 2020. In light of the increased volume, the limb preservation team has needed to take a strategic approach to managing more patients while continuing to pay attention to the long-term implications of major amputations.
Long-Term Impact of Amputation
Amputations can have a devastating long-term impact. The current three-year survival rate for below-knee amputation is 57 percent, and the three-year survival rate for above-knee amputation is just 39 percent.3 Three years after surgery, only 10 to 15 percent of people with above-knee amputations on average are up and ambulating on their prosthetic.
Nevertheless, there is a bias toward above-knee amputation, in part because above-knee amputations tend to heal better. Based on disease state, the ratio of below-knee amputations to above-knee amputations should be about 2.5 to 1. In reality, they're 1 to 1.4 That means fewer people are being given the opportunity to ambulate and return to function.
At UMMC, the team does revascularization endovascularly if possible and as a result, garners much better outcomes, and salvages many more legs, with the minimally invasive approach. In addition, the limb program at UMMC has decreased its rate of major amputation by 42 percent over the last four years.
Role of Chronic Pain
Many people don't ambulate after amputation because of chronic post-amputation pain. This often takes the form of phantom limb pain, described as a burning, aching, throbbing or stabbing pain in the limb that has been amputated. Phantom limb pain affects 50 to 80 percent of amputees, and it rarely gets better without a corrective procedure.5 Half of all amputees are on long-term opiates for chronic pain.
Current research suggests that phantom pain happens because a neuroma forms when the nerve is cut. Tying the nerve off leads to ischemia of the nerve end, causing a neuroma.
There are two techniques that have proven to be effective in preventing neuroma formation:
Surgeons at UMMC's limb preservation program have seen tremendous results with these two techniques. Greater than 90 percent of patients experience relief from phantom pain, and 90 percent are able to reduce opiate use.6 The procedures add only about 30 minutes to the amputation procedure, and they can also be performed well after the amputation in patients who are experiencing chronic phantom pain.
These surgical nerve repairs have changed the game for our patients, getting them off opiates and giving them a better quality of life afterward. Strong technique and a strategic approach to amputation can make the difference between someone who is ambulatory and someone who is nursing home bound.
1Ziegler-Graham K, MacKenzie EJ, Ephraim PL, Travison TG, Brookmeyer R. Estimating the prevalence of limb loss in the United States: 2005 to 2050. Arch Phys Med Rehabil. 2008 Mar;89(3):422-9. doi:
2Casciato DJ, Yancovitz S, Thompson J, Anderson S, Bischoff A, Ayres S, Barron I. Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. J Am Podiatr Med Assoc. 2020 Nov 3:20-224. doi: 10.7547/20-224. Epub ahead of print. PMID: 33146723.
3Kennedy G, McGarry K, Bradley G, Harkin DW. All-Cause Mortality Amongst Patients Undergoing Above and Below Knee Amputation in a Regional Vascular Centre within 2014-2015. Ulster Med J. 2019 Jan;88(1):30-35. Epub 2019 Jan 22. PMID: 30675076; PMCID: PMC6342035.
4Aulivola B, Hile CN, Hamdan AD, Sheahan MG, Veraldi JR, Skillman JJ, Campbell DR, Scovell SD, LoGerfo FW, Pomposelli FB Jr. Major lower extremity amputation: outcome of a modern series. Arch Surg. 2004 Apr;139(4):395-9; discussion 399. doi: 10.1001/archsurg.139.4.395. PMID: 15078707.
5Ephraim PL, Wegener ST, MacKenzie EJ, Dillingham TR, Pezzin LE. Phantom pain, residual limb pain, and back pain in amputees: results of a national survey. Arch Phys Med Rehabil. 2005 Oct;86(10):1910-9. doi: 10.1016/j.apmr.2005.03.031. PMID: 16213230.
6Dumanian, Gregory A. MD∗; Potter, Benjamin K. MD†; Mioton, Lauren M. MD∗; Ko, Jason H. MD∗; Cheesborough, Jennifer E. MD∗; Souza, Jason M. MD†; Ertl, William J. MD‡; Tintle, Scott M. MD†; Nanos, George P. MD†; Valerio, Ian L. MD§; Kuiken, Todd A. MD, PhD∗; Apkarian, A. Vania PhD¶; Porter, Kyle MAS||; Jordan, Sumanas W. MD, PhD∗,§ Targeted Muscle Reinnervation Treats Neuroma and Phantom Pain in Major Limb Amputees, Annals of Surgery: August 2019 - Volume 270 - Issue 2 - p 238-246 doi: 10.1097/SLA.0000000000003088