Retrospective Review of Complications and Outcomes in COVID-19–Positive Patients With Comorbidities Undergoing Limb Salvage Procedures in a Tertiary Care Wound Center

John D. Bovill, BS; Lauren E. Berger, BA; Samuel S. Huffman, BS; Daisy Spoer, MS; Romina Deldar, MD; JiMin Ko, BA; Aleek L. Aintablian, MS; Cameron Akbari, MD; Christopher E. Attinger, MD; Karen K. Evans, MD

Disclosures

Wounds. 2023;35(6):109-116.

Abstract and Introduction

Abstract

Introduction: COVID-19 illness is associated with increased operative risks, ranging from delayed wound healing and coagulopathy to increased risk of mortality.

Objective: This article describes the authors' recent experience of the implications of COVID-19 on limb salvage procedures.

Materials and Methods: Patients who underwent LE limb salvage procedures within 30 days of a positive COVID-19 diagnosis were retrospectively reviewed. Patient demographics, comorbidities, surgical factors, postoperative complications, and management were collected.

Results: Of 597 patients screened from February 2020 to March 2022, a total of 67 (11.2%) were diagnosed with COVID-19, of which 17 received the diagnosis within 30 days of surgery and were thus included. Average follow-up was 43 ± 3.2 months, at which point 6 (35.3%) were fully healed. The mortality rate at the most recent follow-up visit was 29.4% of patients (n = 5). Two patients required admission to the SICU following index procedure, and 1 necessitated a return to the operating room.

Conclusion: COVID-19 may negatively affect the wound healing process while increasing the mortality rate amongst patients with multiple or severe comorbidities undergoing limb salvage procedures. Medical providers need to be aware of the complexity of these patients and apply a multi-disciplinary protocol to obtain successful outcomes.

Introduction

As of February 2022, more than 78 million cases of SARS-CoV-2, the virus that causes COVID-19, have been documented in the United States alone.^[1] As the virus has spread globally, considerable evidence has emerged linking COVID-19 with a hypercoagulable, hyperinflammatory state that leads to venous and arterial thromboembolism and dysregulation of wound healing pathways.^[2–4] Upregulation of proinflammatory cytokines and subsequent dysregulation of coagulation in COVID-19 infection can lead to PE and deep vein thrombosis,^[2,5–7] as well as extrapulmonary thromboses such as acute limb ischemia, large vessel arteriosclerosis obliterans, myocardial infarction, and stroke.^[8–12] This same hyperinflammatory state has been associated with poor wound healing and locally elevated proinflammatory cytokines.^[13] While COVID-19 is an independent risk factor for surgical mortality, the attributable risk of perioperative death due to infection remains difficult to isolate.^[14]

At the authors' limb salvage center, patients with complex LE wounds often require microsurgical reconstruction. Patients typically undergo extensive surgical debridement before, during, and after LE reconstruction and amputation procedures. When patients continue progressing with standard treatment but are not candidates for FTT, the need for eventual amputation is discussed. Patients with chronic LE wounds typically have multiple coexisting medical comorbidities—such as diabetes, hypertension, and PVD—that negatively affect their microvasculature and wound healing. Superimposing the robust inflammation of COVID-19 infection in those with baseline vascular dysfunction poses theoretical additional perioperative risks and alterations in wound healing amongst patients undergoing LE reconstruction surgery. Although surgical guidelines have been proposed for managing patients during the pandemic,^[15–18] there is currently a paucity of literature specifically focused on LE reconstructive procedures to guide surgeons in making evidence-based operative decisions. The authors describe their recent experiences with 17 patients who underwent LE limb salvage procedures—including FTT, amputation, and debridement—within 30 days of their COVID-19 positive diagnosis.

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Table 1. Patient Demographics
CHARACTERISTIC	NO. OF PATIENTS (%) (N=17)
Sex
Male	12 (70.6)
Female	5 (29.4)
Age, y
Mean ± SD	56 ± 17.3
Range	31–86
Race
White	4 (23.5)
Black	10 (58.8)
Hispanic	1 (5.9)
Other	2 (11.8)
CCI (median, IQR)	5 (2, 8.5)
BMI, kg/m²
Mean ± SD	28.7 ± 6.3
Range	18.9–35.16
Smoking status
Nonsmoker	11 (64.7)
Current smoker	2 (11.8)
Previous smoker	4 (23.5)

Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; IQR, interquartile range; SD, standard deviation; y, years.

Table 2. Patient COVID-19 Details
PATIENT	AGE (y)/SEX	DAYS FROM COVID-19 DIAGNOSIS TO PROCEDURE^a	COVID-19 SYMPTOMS	TREATMENT RECEIVED FOR COVID-19	COVID-19 VACCINATION STATUS	COVID-19 VACCINE MANUFACTURER
1	55/M	25	Symptomatic	None	None	-
2	40/M	-12	Symptomatic	None	None	-
3	42/M	18	Asymptomatic	Remdesivir	Booster	Pfizer
4	73/M	24	Asymptomatic	None	Initial	NR
5	44/M	30	Symptomatic	None	None	-
6	86/M	5	Asymptomatic	None	None	-
7	82/F	2	Asymptomatic	None	Initial	Pfizer
8	62/F	16	Symptomatic	None	None	-
9	58/F	-15	Symptomatic	None	None	-
10	59/F	31	Symptomatic	None	Booster	NR
11	62/F	-22	Asymptomatic	None	None	-
12	59/M	12	Symptomatic	None	None	-
13	31/M	3	Asymptomatic	None	None	-
14	49/M	1	Asymptomatic	None	None	-
15	86/M	8	Asymptomatic	None	None	-
16	31/M	12	Asymptomatic	None	Initial	J&J
17	77/M	7	Asymptomatic	None	None	-

^aNegative values indicate that the COVID-19 diagnosis occurred after the index procedure.
Abbreviations: F, female; M, male; NR, not recorded; y, years.

Table 3. Operative Details and Complications
PATIENT	PROCEDURE	WOUND LOCATION & LATERALITY	COMORBIDITIES	ANGIOGRAM	ANGIOGRAM INTERVENTION	POST-ANGIOGRAM INTERVENTION VESSEL-RUNOFF	OSTEOMYELITIS	POSTOPERATIVE AC REGIMEN	COMPLICATIONS	RETURN TO OR
1	ALT flap	L foot	Diabetes, PVD, CKD, CHF, hypercoagulable trait	Yes	Yes	3	No	Continuous heparin	Partial flap necrosis	Yes
2	L BKA, R ALT flap	Bilateral foot gangrene	Active smoker, hypercoagulable trait	No	No	0	Yes	Enoxaparin sodium injection	No	No
3	MPJ amputation of digits 1–5, LD free flap	L lateral malleolus to distal forefoot	Diabetes, PVD, hypercoagulable trait	Yes	Yes	2	No	SQH	Necrosis, gangrene	Yes
4	AKA	No open wounds; RLE cool to the touch from foot to mid-leg (ischemia)	Active smoker, PVD, CVA/TIA	Yes	No	0	No	Enoxaparin sodium injection	Necrosis, patient stepped up to SICU for hypotension	No
5	BKA, TMR	L plantar heel	Diabetes, PVD, ESRD	No	No	0	No	SQH	No	No
6	AKA	R knee and lateral thigh	Diabetes, former smoker, CKD, COPD	No	No	0	Yes	SQH	Intraoperative PE, patient stepped up to SICU due to hypotension after surgery with delirium	No
7	I&D	L posterior calf	Active smoker, PVD	No	No	0	No	Clopidogrel bisulfate	No	No
8	DBT	L medial ankle	Diabetes, PVD, ESRD, CHF	No	No	0	Yes	SQH	No	No
9	DBT	Gangrene right and left lower leg and foot secondary to PVD	Diabetes, PVD, CVA/TIA, CKD, CHF	Yes	Yes	R 2, L 2	No	SQH	No	No
10	DBT	Sacral	Hypercoagulable trait	No	No	0	No	SQH	No	No
11	DBT	L gangrene proximal peroneal muscles due to septic embolism	Diabetes, MI, CVA/TIA	No	No	0	No	Enoxaparin sodium injection	No	No
12	DBT	R anterior and lateral tibia	Diabetes, active smoker, current malignancy	No	No	0	Yes	Enoxaparin sodium injection	No	No
13	DBT	Bilateral hip seromas, septic	None	No	No	0	No	Enoxaparin sodium injection	No	No
14	DBT	R trochanteric ulcer	None	No	No	0	Yes	Enoxaparin sodium injection	No	No
15	DBT	R heel/calcaneus	Diabetes, PVD, MI, CHF	No	No	0	Yes	SQH	Nonhealing wound	No
16	I&D	Bilateral femur osteomyelitis	None	No	No	0	Yes	Enoxaparin sodium injection	No	No
17	BKA	L heel/leg wound	Diabetes, former smoker, PVD, CKD, CHF	No	No	0	No	SQH	No	No

Abbreviations: AKA, above knee amputation; ALT, anterolateral thigh; BKA, below knee amputation; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CVA/TIA, cerebrovascular accident/transient ischemic attack; DBT, debridement; ESRD, end-stage renal disease; I&D, incision and drainage; L, left; LD, latissimus dorsi; LE, lower extremity; MI, myocardial infarction; MPJ, metatarsophalangeal joint; OR, operating room; PE; pulmonary embolism; PVD, peripheral vascular disease; R, right; SICU, surgical intensive care unit; SQH, subcutaneous heparin; TMR, targeted muscle reinnervation.

Table 4. Long-term Outcomes
PATIENT	FOLLOW-UP (MOS.)	HEALED AT MOST RECENT FOLLOW-UP	AMPUTATION	REASON(S) FOR AMPUTATION	AMBULATORY	AMBULATORY ASSISTANCE	DECEASED
1	4.4	No	Yes	Infections, gangrene, and necrosis of the wound and periwound area	No	No	No
2	2.5	Yes	Yes	Distal knee disarticulation incision line became gangrenous	No	No	No
3	5.4	No	Yes	Fulminant necrosis/gangrene	No	Cam boot on R, NWB on L, uses wheelchair	No
4	LTFU	N/A	Yes	Non-salvageable limb following multiple revisions for infectious hardware	No	No	Yes
5	5.8	Yes	No	N/A	Yes	Walker	No
6	2.8	No	No	N/A	No	No	Yes
7	1.3	No	No	N/A	No	No	Yes
8	1.7	No	No	N/A	Yes	Walker	No
9	LTFU	N/A	No	N/A	No	No	No
10	7.7	No	No	N/A	Yes	Uses assistance	No
11	5.3	No	Yes	Non-salvageable necrotic infected wounds following TMA	Yes	Uses assistance	No
12	6.3	Yes	No	N/A	Yes	Uses assistance	No
13	1.4	Yes	No	N/A	No	No	Yes
14	5.3	No	No	N/A	No	No	No
15	13.4	Yes	No	N/A	No	No	No
16	1.2	Yes	No	N/A	Yes	No assistance	No
17	LTFU	N/A	Yes	Gas gangrene, infection, and non-salvageable limb	LTFU	No	Yes