# Reconstructive Limb Salvage After COVID-19-Induced Gangrene and Amputation

## TL;DR

This paper discusses how severe gangrene from COVID-19, especially in diabetic patients, can be treated with reconstructive surgery to restore limb function.

## Contribution

The paper presents novel reconstructive techniques for managing severe gangrene caused by COVID-19 in diabetic patients.

## Key findings

- Transmetatarsal amputation with local tissue flap improved outcomes in a patient with midfoot gangrene.
- Lisfranc amputation and SCIP flap reconstruction helped a patient with extensive pedal gangrene regain function.
- Reconstructive methods are effective in managing severe gangrene following COVID-19 in diabetic individuals.

## Abstract

This case series describes the clinical course and reconstructive methods utilized for patients with diabetes and significant gangrene and necrosis following coronavirus disease 2019 (COVID-19) infection. COVID-19 produces mainly respiratory symptoms but has a variety of atypical presentations and sequelae. Serious complications are increased in patients with underlying medical conditions such as diabetes mellitus. By generating a prothrombotic milieu, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) increases the risk for arterial and venous thromboses. Inflammatory damage and micro-thromboses are thought to contribute to acro-ischemia, colloquially known as ‘COVID toes,’ which presents cutaneously as chilblain-like lesions. Necrosis can be severe and devastating, often resulting in major amputation. Two exemplary case reports are presented herein: first, a 57-year-old female presented for vascular evaluation with pedal gangrene to the midfoot one month after developing painful discoloration in her right toe. After angioplasty restored pedal blood flow, she received a transmetatarsal amputation (TMA) with a local tissue flap. Second, a 41-year-old female presented for vascular evaluation with extensive pedal gangrene three months after hospitalization for COVID-19. After arteriotomy improved pedal blood flow, she underwent a Lisfranc amputation followed by superficial circumflex iliac artery perforator (SCIP) flap reconstruction. Sufficient evidence suggests that COVID-19 impairs microcirculatory function and can be especially detrimental in diabetic patients. Reconstructive techniques in patients with severe gangrene with COVID toes help patients regain functionality.