Legs Referred for Boot to Drs. Filip and Preske

All too Frequently with Advanced Lesions after Standard Therapies Had Failed
and No Other Form of Therapy Available

Gangrenous Legs Salvaged by Circulator Boot and Drs. Filip and Preske

This lady presented to a sister hospital with sepsis and a blood sugar of 700. Her vascular surgeon was quoted as saying that all medical therapies would fail and that he would eventually get to do his AK leg amputation. She was transferred to Bryn Mawr Hospital for boot therapy in lieu of amputations. The pictures speak for themselves.

Gangrene of the left plantar surface on presentation.

Breakdown of the dorsum of the foot and lower leg.

And breakdown below, above and at the knee.

After ten days, she was transferred to a nearby nursing home and commuted to the Boot Center for her treatments: cleansing soaks, maggots, local antibiotic injections into obviously infected areas and Long Boot treatments. Loose necrotic areas were debrided while firm eschar was allowed to remain to spontaneously fall off in the future.

Healthy granulation tissue with a few small islands of necrosis still to separate.

The dorsum of the foot and ankle have healed.

A more lateral view of the knee and mid-leg shows the eschar contracting with healthy skin around it.

Meanwhile, how was the right foot doing. It also was being treated.

Breakdown of the ball of the right foot and big toe.

Some eschar still to separate, but much improved.

One done: the right foot is now healed.

The multiplicity of lesions on the left leg has required more time. The ulcers around the knee continue to close.

The left foot also is closing. Additional work is obviously needed.

Comments: This patient was failing standard treatments before boot therapy was instituted. She was at risk of bilateral limb amputations which constitute a significant threat to life in her age group. Her obesity and history of inactivity and deconditioning have added difficulty to her rehabilitation..

Leg at Risk after Two Vascular Procedures Saved by Boot Therapy

This lady had persistent foot pain after a femoral-popliteal bypass procedure. Her vascular surgeon then attempted to bring arterial flow to her midfoot. The distal incisions became infected and she returned to the operating room for an incision and drainaige procedure. She continued to have pain and swelling in her foot. The right second toe became discolored and part became black. Her cardiologist consulted Dr. Preske who recommended boot therapy. With boot therapy and local antibiotics, her foot, including an area of osteomyelitis, healed completely.

Distal Foot Breakdown after Surgery in an Ischemic Foot

Healed with Circulator Boot Therapy

Clinic Provides Follow-up Care for Previous Boot and Surgical Patients

This man had been referred to Dr. Dillon's office in December 1999 with a 23 year history of diabetes and a sore foot for about two months. His internist and podiatrist had prescribed Augmentin, Cipro and then Levaquin in turn without controlling his foot infection. His distal pulses were absent. He could not feel the 5.07 monofilamentand 12-inch. Two-point discrimination pointed to advanced diabetic neuropathy. A foot/brachial index at a University Center had been noted to be 0.38 a few weeks prior to his referral. Staphylococcus aureus and Stenotrophomonas were recovered from his foot. With the permission of Aetna-US Healthcare, he was begun on local antibiotics and Mini-Boot therapy with his foot immersed in Sea Soaks and appropriate antibiotics. As the pictures show, he did well.

The dorsum of his foot was reddened to the instep. Infected bone was prominent in the base of the intertriginous ulcer.

Some post inflammatory pigment remained on the dorsum of his foot which now was more pale than the examining hand. The ulcer was essentially closed here and the underlying bones healed.

He traumatized his big toe again two years later. Again, standard therapies were not working leading him to return to the office now under the guidance of Drs. Filip and Preske. The latter again treated him with the Mini-Boot, local antibiotics and Sea Soaks successfully healing the toe.

The outside portion of the big toe ulcer was soft and macerated.

The ulcer contracted as the skin closed to a wedge-shaped lesion with a necrotic base.

The ulcer was essentially closed here and went on to heal entirely.

Dead Toe Successfully Amputated and Osteomyelitis of metatarsals Healed

This 53 year old diabetic presented with an erythematous, edematous and necrotic right third toe. His toe was amputated and, when healing appeared quesionable, boot therapy was begun. He was booted initially as an inpatient while he received intravenous antibiotics. He was then booted as an outpatient for 6 weeks until his skin was healed and his sed rate 15 mm/hr.

The toe tissue appeared necrotic to the bone.

Several days postoperatively the amputation site was questionable.

Demineralization of the second and third metatarsal heads pointed to osteomyelitis.

Small Ulcer Resistant to Standard Care over Two years Cured with Boot

This diabetic lady had undergone therapy for two years in an attempt to cure her plantar ulcer. The ulcer persisted in spite of multiple debridements, skin grafting and both intravenous and oral antibiotics. She was booted daily from May 4th to May 24th and then three times a week until she was healed and discharged on July 10th. She returned for a follow-up picture on August 2nd.

The foot appears slightly reddened and, especially on the heel, dry. A faint imprint of her bandage is seen along with some residual adhesive material.

A small intracutaneous red spot remained at the site of the ulcer on follow-up. The skin overall appears pink, clean and well hydrated.

Cellulitic Toe with Terminal Necrosis and Osteomyelitis

Fails to Heal with Standard Therapy but Heals with Boot

This 65 year old diabetic lady had not improved with intravenous antibiotics and bed rest. She was given boot therapy during the last three days of her hospitalization and then as an outpatient three times a week until she healed.

2nd toe red, swollen and a bit out of focus.

Necrotic tip of toe with osteomyelitis.

Color largely restored.

Tip of 2nd toe healed. Some callus on end of 3rd toe.

Leg of 70 Year old Dialysis Patient Saved with Boot

This diabetic lady was followed by her hemodialysis and medical team: family doctor, vascular surgeon and nephrologist. She had had previous vascular surgery in her right leg. She was referred for boot with multiple areas of necrosis in her left foot.

Note the black eschar on the heel and on the dorsum of the foot over the proximal first metatarsal.

The toes were darkened. There was callus and areas of focal necrosis on the big toe where the distal phalanx was exposed.

She was treated three days a week as an outpatient on her non-dialysis days.

The skin color and turgor are improved. The heel and dorsum of the foot are healed. Much of the distal necrosis of the big toe has sloughed off.

The color of the toes more approximates that of the rest of the foot.

Case in Progress

59 Year Old Diabetic Nurse with Extensive foot Gangrene

This lady presented with a right foot that was gangrenous and grossly infected. She had already undergone amputations of her fourth toe and 4th metatarsal head. The foot deteriorated after the surgery and she was referred for boot. She was advised that maggot therapy would be appropriate over the weekends when she received no boot therapies but refused. While her therapy was begun in the hospital, it has largely been carried out as an outpatient.

Black eschar and ulceration are seen over the 2nd to 5th metatarsals. Intense red rubor is seen adjacent to the breakdown areas and, especially if it does not blanch with pressure, may indicate irreversible damage and more breakdown of tissue to be expected. The big toe is already breaking down and the others are at risk. Aggressive daily therapy is needed in such patients, but as in this case less therapy is frequently accomplished. One does the best one can.

The skin at risk did break down and the toes mummified. Granulations are forming in the midfoot.