Case 100: No Treatment Modality Other Than Boot for 18 Years and Both Legs Preserved

At age 47, this man was referred April 27th, 1979 to the Bryn Mawr Hospital by the chief of vascular surgery at a Philadelphia Medical School. He had a 27 year history of regional enteritis treated for most of that time with glucocorticoids. Most likely as a complication of that steroid therapy, he developed widespread atherosclerosis that involved both legs. Femoral-popliteal bypass grafts and sympathectomies had been performed bilaterally. Angioplasty had been unsuccessfully attempted on the left leg. He could walk less than 100 feet and had the lesions shown below.

June 27th, 1979

Dry Gangrene of 1st and 4th Right Toes and Focal Necrosis of the Heel

Focal Necrosis under Left 1st Toenail

Both feet had approximately the same color.

The year being 1979, he was allowed to stay in the hospital for intensive boot therapy. His noninvasive vascular tests improved. The Doppler waveform in the left dorsalis pedis increased 2.8 fold, for example. The rise in the blood pressure values was less impressive: the pressure in the anterior tibial at the ankle rose from 84 and 58 to 96 and 88 mm Hg in the left and right legs respectively. The pressure on the posterior tibial rose from 64 and 72 to 100 and 72 mm Hg respectively in the left and right legs.

The toes were soaked daily in saline and Betadine and every few days the loose black eschar was trimmed back with a scalpel to clear the area in front of the margin of healthy skin.

Microabscesses were uncovered by the debridements and their cleansing helped alleviate his pain.

New skin was seen to grow at the debrided margins. With that sign and with the improvement in his vascular tests, amputations of his fourth and first toes were successfully accomplished.

His lesions and incisions healed.

He claimed his legs felt better than they had in years.

He returned to work and the care of his New Jersey gastroenterologist. When new lesions developed on his left leg, the latter referred him to an academic wound healing center in Philadelphia. Arteriography showed no easy bypass procedure. Calcifications were found in his arteries from his groin to his toes. Flow was seen down a grossly irregular superficial femoral to the mid-popliteal in the left leg where the vessel was occluded. There were numerous collaterals around the knee and ankle. The ankle/arm index was 0.36 in the left leg and 0.81 in the right. PPG tracings of the toes were flat. No treatment other than leg amputation was offered. He returned February 16th, 1993 to Bryn Mawr seeking boot therapy.

The toe swelling and reddening slowly subsided. He was given Long-Boot treatments also.

Being now 1993, he was not hospitalized but treated in the office a few times a week initially then on Saturdays only. His ulcer tip was injected with appropriate antibiotics and the foot pumped in the Mini-Boot.

The 2nd toe healed but a dimple and a pinhole fistula down to the distal phalanx persisted for several months. Gentamicin was injected down the fistula before his Mini-Boot therapies and the fistula eventually closed.

He had no obvious lesions in his right leg but it was numb and ischemic. Hence, he was given treatments to both legs. The numbness abated and he has continued to work. His only hospitalizations since 1979 were occasioned by gastrointestinal bleeding associated with his regional enteritis.

Comments: Before referral for boot therapy, this man had been evaluated by two prominent Philadelphia vascular centers. He has done well for 18 years. He started with our early boot prototypes and is now treated with our latest modifications. In 1979, he was treated in the hospital where only one leg at a time was treated; he had difficulty traveling. In recent years, he was treated in the office where both legs were treated simultaneously. At present, he comes into the office periodically when his legs tighten up. He has no other available modality of treatment. He is frightened at his future prospects for treatment. His company has joined an HMO. So far his primary care physician has allowed him to seek boot treatment. He is worried.