Saving the Diabetic Foot During the COVID-19 Pandemic: A Tale of Two Cities

Abstract

Of all the late complications of diabetes, those involving the foot have traditionally required more face-to-face patient visits to clinics to treat wounds by debridement, offloading, and many other treatment modalities. The advent of the coronavirus disease 2019 (COVID-19) pandemic has resulted not only in the closing of most outpatient clinics for face-to-face consultations but also in the inability to perform most laboratory and imaging investigations. This has resulted in a paradigm shift in the delivery of care for those with diabetic foot ulcers. The approaches to this challenge in two centers with an interest in diabetic foot disease, including virtual consultations using physician-to-patient and physician-to-home nurse telemedicine as well as home podiatry visits, are described in this review and are illustrated by several case vignettes. The outcomes from these two centers suggest that we may be witnessing new possibilities in models of care for the diabetic foot.

Figure 1

Images from case 1. A: Foot ulcer on medial side of right hallux prior to lockdown. B: Radiograph of right hallux prior to lockdown showing extensive osteomyelitis and septic arthritis in both phalanges and interphalangeal joints. C: After 8 weeks of antibiotics, 6 weeks post-lockdown showing healed wound on right hallux.

Figure 2

Images from case 2. A: Dorsal view of the right foot showing sausage-shaped swelling of the second toe with tracking cellulitis (note previous amputation of third toe) when the patient first presented. B: Frontal view of same toes showing purulent discharge from metatarsal head wound at presentation. C: Plantar view of the right foot 6 weeks later after continuous treatment with oral antibiotics showing near healing of the wound, reduced erythema, and reduced swelling of the toe.

Figure 3

Image taken during telehealth-guided removal of maggots after 3 days of maggot debridement therapy in case 3. This patient had previously undergone a transmetatarsal amputation and received maggot debridement therapy at home rather than in the clinic or operating room.

Figure 4

Images from case 4. A: Gangrene and infection of the toes prior to amputation of toes performed under local anesthesia in a clinic setting. B: Four weeks post–partial amputation of digits 1–3, showing signs of healing.