Case 105: Amputation Averted and Claudication Relieved in Both Legs

At age 74 this lady had insulin-treated diabetes and an active smoking addiction. She was referred for a toe ulcer that had been present since a child walked on her toes six months earlier. She had been treated with soaks and vaseline only to have her skin peel. Her family physician referred her to a nearby community hospital where an arteriogram showed a 1 cm area of obstruction in the mid portion of the right superficial femoral artery and high grade areas of stenosis in the left mid-superficial femoral artery. The tibial vessels showed progressive tortuosity and obliterative disease with a posterior artery remaining patent to the level of the ankles but with microscopic lumens. The pedal vessels appeared to be obliterated with the same process. The possibility of a transmetatarsal amputation was considered by her surgeon. She had had bilateral sympathectomies at yet another hospital. Antibiotics and Trental had provided her with no benefits. She was taking Tylox every four hours for pain. She was referred for a "boot" opinion.

Lesions were found under the 1st and 3rd toes. The 2nd toe had previously been amputated.

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She was treated with both Long- and Miniboots. Her initial culture grew out Enterococci. Initially, neomycin was added to the Mini-Boot bath. As the bacterial flora changed, the added antibiotic was changed to Chloromycetin, Ancef, gentamicin and lastly vancomycin. The changes in her vascular tests were not striking. In the right posterior tibial at the ankle, the blood pressure rose from 80 to a high of 86 and the height of the Doppler writeout rose from 9 to 20 mm. The pressure rose from 57 to 68 in the anterior tibial and from 55 to 80 in the peroneal arteries. The pulse volume curve increased from 7 to 17 mm at the ankle level. Her lesions, however, did well and her walking distance increased from "difficulty walking a couple of feet" to walking three to four "good" blocks. The left leg had also had claudication and was likewise treated successfully.

The overall foot condition was much improved. The 1st toe is healed. Here, only a few granulations were left to heal on the 3rd toe.

Comments: This lady appeared to have few other therapeutic options. She did well with our therapy but, unfortunately, continued her smoking addiction. She died with her legs on but virtually with a cigarette in her hand.