Case 1: Necrotizing Cellulitis and Osteomyelitis
Her foot on transfer to Bryn Mawr Hospital for Circulator Boot therapy
Can this foot be saved?
Her infected foot was heavily pigmented. A large ulcer with a necrotic base occupied the dorsum of the foot over the 3rd,4th and 5th metatarsals. Rubber drains exited the webbing between the 1st and 2nd toes and the 4th and 5th toes. Necrotic tissue was seen under the flap of skin over the 1st and 2nd metatarsal bones and protruded through the webbing between the 1st and 2nd toes. The toes had a slight hammer-toe deformity but were intact. No pulses were detected in the foot.
Foot X-ray on admission to Bryn Mawr
Her foot X-ray showed the outline of her ulcer in the lateral foot. The 3rd, 4th and 5th metatarsal heads were demineralized and reported by the roentgenologists as being destroyed by osteomyelitis. Standard therapy called for a beneath-the-knee amputation.
How did it happen? A diabetic since childhood, she developed a fissure in her plantar callus as she walked around Disney Land. Noting a drop of pus on her sock, she sought the advice of the Disney Land doctor who prescribed an antibiotic and advised her to go home. She did and immediately went to her endocrinologist who cultured her foot and prescribed bedrest and oral cephradine. As the latter were ineffective in arresting spread of cellulitis over a few days, she was hospitalized.
Summary of the 12-day hospitalization in her community: She was given intravenous tobramycin and cefobid, which tested appropriate for the Beta-streptococcus and Eikenella species cultured from her foot. Again these antibiotics proved to be ineffective in arresting cellulitis which continued to spread. A bone scan showed ostemyelitis of her 3rd, 4th and 5th metatarsal heads. An incision and drainage procedure revealed advanced tissue necrosis.Peroxide soaks and whirlpool treatments were prescribed in hopes of gently debriding her foot. Blood transfusions were given to correct her anemia. She remained critically ill. Her attending physicians, which included specialists in diabetes, infectious disease and vascular and general surgery, unanimous recommended a beneath-the-knee amputation for the following reasons:
- Uncontrolled soft tissue and bone infection.
- Persisting systemic toxicity with:
- Spiking fevers
- Uncontrolled diabetes
- Loss of veins and poor access for intravenous treatments.
- Vaginal and rectal yeast infections
She refused amputation and requested another opinion. Her attending physicians along with her family doctor allowed that they already constituted five opinions. She requested another hospital and was transferred to Bryn Mawr Hospital for Circulator Boot therapy.
Her foot and leg were saved. Her treatment and its rationale were as follows:
Her infection began as an aggressive cellulitis. Early in her course, there was no abscess to drain. Such a procedure would have produced a large hole in already inflamed tissue. There was no place for surgery at that time and none was performed.
The bacteria had produced various digestive enzymes (collagenases, elastases etc) that had moved through the tissue planes and lymphatics in the foot damaging the tissue and small vessels leaving the inflamed tissue with a diminished blood supply. Her antibiotics were appropriate in kind and quantity but were not reaching the crucial areas in the foot.
The cultures from her home hospital showed her bacteria was sensitive to erythromycin. The latter was given orally to block septic emboli from her feet. Intravenous antibiotics were stopped; her arms were swollen and sore and she had no veins. Oral Nystatic and vaginal mycostatin were prescribed for her yeast infection.
Her foot was placed in a plastic bag with multielectrolyte solution (Sea Soaks) and dilute iodine (Betadine) to rinse off loose pus and debris. Such a soak began each day.
Her foot was then injected at multiple sites with gentamicin with the use of an insulin needle. The osteomyelitic areas between the metatarsal heads and the necrotic areas were especially infiltrated. Such injections were performed daily the first ten days of her treatments. Having put the antibiotic where we wanted it, we knew it got there!
Her foot was then placed within another plastic bag along with multielectrolyte solution (Sea Soaks) and then placed within the Miniboot. The latter pumped the foot after alternate heartbeats in the end-diastolic portion of her heart cycle. Gravity and the unopposed arterial pulse wave primed the foot with blood and the boot provided a driving force to disseminate the blood throughout the foot and to restore blood flow in the avascular areas. The pumping likewise disseminaated the injected antibiotics throughout the tissues and reduced swelling. After the boot treatment, the fluid in the bag was cloudy with debris.... the pumping action was debriding the foot in the most possible gentle manner. During her ten day hospitalization, her foot was pumped four times daily for forty minutes each.
She was transferred to a nursing home for further treatment and shortly thereafter to her own home where she performed the treatments herself, having rented a Miniboot.
Intact Foot Four Months Later
Comments: Experienced physicians, having reviewed her pictures and case history, can tell us of no other way this leg could have been saved. The intensity and frequency of her initial boot therapy and local antibiotic injections are to be appreciated. Less frequent therapy or interruption of therapy will allow relapse of infection. See (http://www.circulatorboot.com/literature/Methods5.html) for a case in point.
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