Closing the Wound Care Gap: Addressing Disparities in Amputations and Limb Preservation

Example case description at baseline: A 49-year-old female with a 6.0 cm² DFU (Wagner Grade 2/3) on the large toe, following amputation, achieved ≥90% debridement and ≥75% granulation by day 4, and wound healing in 8 weeks.

Patient photo provided by Cyaandi R. Dove, DPM

Health care disparities in amputations and limb preservation are a major challenge across the US, exacerbated by demographic and economic factors. Today, more than 5.6 million Americans live with limb loss and limb difference. Certain populations are at higher risk, facing disparities linked to healthcare inequities including unequal access to limb-preservation services.¹

This article explores the historical and contemporary landscape of wound care, including the slow changes in limb preservation strategies and the persistent inequalities that exist, offering insights into how these challenges can be addressed.

Wound Care of the 1990s

I underwent my podiatric residency training in San Antonio in the late 1990s, an exciting period for diabetic limb salvage. At the time, despite our concerted efforts, amputations were a common sequelae of diabetic foot ulcers. I have now returned to San Antonio to conduct research as a member of the podiatric faculty. It is disheartening to see that podiatrists are still facing the same challenges today when attempting to prevent major, nontraumatic amputations.

25 years ago, wound care was an underdeveloped field, with limited data and few evidence-based practices. The specialty of wound care was largely based on dogmatic practices of the time when limb salvage was not widely popularized. Advanced treatments such as biologics were rare, with poorly recorded outcomes which were often palliative until a definitive amputation was performed. This historical context is essential for understanding the development of limb preservation strategies and the ongoing challenges. 

Shift to Limb Preservation & Multidisciplinary Approaches

As the severe consequences, both physical and psychological, of major amputations became clearer, the medical community shifted its focus to limb preservation. Research has shown that major foot amputations are associated with mortality rates that are higher than many common cancers. Armstrong et al published that the 5-year mortality rate of patients undergoing major lower extremity amputation surpasses 70%.² Additionally, there was a shift toward multidisciplinary approaches. This was not a new concept. Several forward-thinking physicians heralded the need for multidisciplinary teams as early as 1911, including Maurice J. Lewi, MD, in New York City, and Dorgan MB et al, when performing foot screening for diabetic patients.³ Other luminaries such as Paul Brand, CBE, and Elliott Joslin, MD, were vocal advocates for utilizing a team approach to the art of limb salvage as well. These teams, comprised of specialists in glycemic control, wound management, vascular surgery, and infection management, improved patient outcomes by providing a more holistic approach to care.

Despite these advances in limb preservation, significant challenges remained, particularly in addressing the care inequalities revealed by early studies.

In San Antonio, for example, the local population surged from 1 million in 1997 to 1.5 million in 2023. Among the city's large working class is a Latino population that faces unique health care challenges including limited access to limb preservation services. Similar disparities among a variety of populations are prevalent in cities across the nation. Unfortunately, these disparities, often affecting marginalized populations, were not thoroughly examined at the systemic level, highlighting a gap in the broader application of limb preservation strategies.

Introduction of Skin Substitutes

Example case description at 3-month follow up.

Patient photo provided by Cyaandi R. Dove, DPM

Recent technological advancements, especially the development and use of human cellular and tissue-based products (HCTP) and advanced skin substitutes, have transformed limb preservation. These innovations signal a promising shift towards more effective treatment options.

Apligraf, which obtained FDA approval for diabetic foot ulcers (DFUs) in 2000⁴, was one of the earliest bioengineered tissues that gained wide acceptance and use by wound care specialists. These products offer effective, but expensive solutions for complex wounds, and may reduce amputations.

Recent changes in Medicare coverage of these skin substitutes threaten to setback the industry and exacerbate existing healthcare disparities. Medicare has historically provided coverage for these advanced treatments, but recent policy shifts may disproportionately affect the vulnerable populations who rely on the program. Without access to these advanced wound care products, patients will be at higher risk of complications leading to amputations. This situation highlights the need for additional wound care approaches, together with policies that ensure equitable access to life-saving treatments, regardless of socioeconomic status.

Improving Wound Bed Treatment

Effective wound care is fundamental to limb preservation, especially in populations where access to advanced therapies may be limited. Returning to the core principles of wound management is crucial. Proper wound bed preparation is a critical step in the healing process, and adhering to the TIME algorithm—Tissue management, Inflammation and infection control, Moisture balance, and Edge of wound advancement—can optimize conditions for healing.

Thorough debridement is essential before applying advanced skin substitutes or split-thickness skin grafts. It removes necrotic tissue and biofilm, creating a healthier environment that promotes healing. Innovative biological approaches, such as bromelain-based enzymatic debridement treatments such as those offered by companies such asMediWound, are proving effective in preparing the wound bed. Enzymatic debridement not only facilitates better preparation but can also be administered in outpatient or community-based settings, making it a viable option for underserved areas.

Amputation and limb loss disproportionately affect economically disadvantaged individuals, often due to delays in accessing effective wound care. Enzymatic debridement addresses this issue by providing a cost-effective solution that accelerates the healing process of wounds, such as diabetic foot ulcers (DFUs), promoting faster wound closure, and reducing infection risk. This approach could significantly benefit underserved populations by lowering the incidence of limb loss and improving overall health outcomes.

Closing the Gap in Wound Care Disparities

Addressing wound care disparities requires proactive efforts from both local healthcare communities and broader institutions such as federally funded and academic hospitals. Advocacy for continued Medicare coverage of advanced wound care products is essential, as is the development of alternative support systems for patients who may be excluded from existing healthcare frameworks. Exploring new innovative and cost-effective methods for effective wound bed treatment is crucial.

Additional community engagement, coupled with institutional accountability, can help mitigate the impact of policy changes and ensure equitable access to these modern medical treatments. The disparities in amputations and limb preservation in San Antonio, across Texas, and the wider US highlight the complex interplay between technological advancements, health care access, and social determinants of health.

While significant progress has been made in developing advanced wound care treatments and multidisciplinary teams, these benefits are not being equitably distributed. Addressing these disparities requires a multifaceted approach that includes improving access to care, advancing medical technology, and addressing systemic issues. By focusing on community engagement, institutional accountability, and health equity, we can work toward a future where limb preservation is accessible to all, regardless of race, geography, or socioeconomic status.

References

1. Caruso M, Harrington S. Prevalence of limb loss and limb difference in the United States: implications for public policy. Avalere Health; 2004
2. Armstrong DG, Tan TW, Boulton AJM, Bus SA. Diabetic foot ulcers: a review. JAMA. 2023 Jul 3;330(1):62-75. doi: 10.1001/jama.2023.10578.
3. Dorgan MB, Birke JA, Moretto JA, Patout CA Jr, Rehm KB. Performing foot screening for diabetic patients. Am J Nurs. 1995 Nov;95(11):32-6; quiz 37.
4. FDA approves Apligraf for use in the treatment of diabetic foot ulcers. News release. Medscape. June 23, 2000. Accessed January 29, 2025. https://www.medscape.com/viewarticle/411962?form=fpf

Cyaandi R. Dove, DPM, is an assistant professor in the department of orthopedics, division of podiatry at the University of Texas Health Science Center, San Antonio, where she directs clinical research and guides a fellowship program focused on the delicate balance between health equity and medical advancement. Her true passion lies in the spaces where innovation and equity converge, with the firm belief that by bringing these forces together, we can shift the tide of limb preservation. As a board member of the American Limb Preservation Society, Amputation Prevention Alliance, and Save a Leg, Save a Life, Dove is dedicated to a future where knowledge and compassion work hand in hand.