Case 107: Recurrence and Persistence of Foot Ulcers Lead Diabetic with Peripheral Neuropathy and Arteriosclerosis Obliterans to Chose Bypass Surgery in Another City

At age 62, HS, an insulin-dependent diabetic, presented on August 28th, 1995 with a chief complaint of new rubor of his left foot. `He has a past history of 30-pack years smoking and hypertension for 36 years. He noted half-mile claudication. He had had amputations of his left 3rd, 4th and 5th toes for infected diabetic ulcers. His relative weight was found to be 1.25 and his BMI 29.97. Bruits were found in his groins. His femoral pulses were palpable (2+) bilaterally but his popliteal and distal pulses were absent. Numbness and paresthesias of his feet pointed to diabetic neuropathy. His ABI was 0.98 at the right ankle and 0.70 at the left. Doppler velocity tracings were wide and about 10 cm/sec in the left anterior tibial and 13 cm/sec in the left posterior tibial. The tracings were flat in the 1st dorsal metatarsal and about 3 cm/sec in the 5th dorsal metatarsal. The transcutaneous PO2 level over his second metatarsal head was 47mm Hg and the PCO2 37 mm Hg. Sugar control, blood pressure control, weight reduction and exercise were recommended.

An EKG on June 11th, 1996 showed a sinus rhythm with an intraventricular conduction delay, a prolonged QT-interval and ST-wave changes suggestive of ischemia. The computer readout of a Holter monitor on June 25th, 1996 showed a minimal rate of 56, a maximal rate of 94 and 77 episodes of RST depression of 1mm or more lasting 8 hours, 19 minutes and 31 seconds. The actual tracings did not appear ominous but he was advised he likely had significant coronary heart disease.

He presented August 1st, 1996 with a 2-day history of an abscess under his left first metatarsal head.

A heavy growth of Staphylococcus aureus sensitive to most antibiotics was cultured from the abscess. He was given a prescription for Duricef 500 mg TID, injected locally with gentamicin and begun on Miniboot therapy, receiving 10 treatments up to August 18th. Vascular testing August 2nd had shown that his ABI had fallen to 0.64 at the left ankle and that the Doppler velocity had fallen to about 4 cm/sec in the left posterior tibial while remaining about 10 cm/sec in the left anterior tibial. He did well. Loose skin was debrided August 14th revealing normal skin beneath and he was discharged.

His enthusiasm for golf took him again to the links and a new blister on September 16th. Again Staphylococcus aureus was cultured. He received five local gentamicin injections and Miniboot treatments in September and again appeared to be healed.

On October 12th, he telephoned from his vacation spot in Maryland where he again was playing golf. He had noticed drainage from a callus under the ball of his "good" foot. Augmentin and local neosporin cream were prescribed. He returned to the boot clinic October 14th with an established plantar abscess from which Staphylococcus aureus was again cultured The abscess was irrigated with Sea Soaks containing gentamicin and vancomycin and again he began on oral antibiotics, cleansing foot soaks, local antibiotics and Miniboot treatments receiving treatment on most weekdays from October 14th through the month of December..

The culture probe entered the plantar ulcer and was easily passed along a tract along the side of the first metatarsal. The skin over the medial and dorsal aspects of the first metatarsal were reddened and inflamed. The tissue in the base of the ulcer was damaged easily accepting the locally injected antibiotics.

Again, he was treated as an outpatient and was given a walking air cast to lessen the shear forces on his foot. The tissue turgor and color slowly improved but he had an established ulcer with a necrotic base. X-rays on November 4th , 1996 and March 18th, 1997 showed no evidence of osteomyelitis. He was treated throughout January and February. He felt his sensation has largely returned to his feet. His pictures show his progress.

The left foot was doing well. December 18th, 1996..

Right foot on January 29th, 1997.

Left foot on January 29th, 1997.

He then took a business trip to Florida the first few weeks of March. He was instructed to irrigate his ulcers with Sea Soaks containing antibiotics and urecholine. He returned to therapy in April and May and was lost to follow-up in June. He had periodic cultures throughout the spring that revealed mostly yeast. A scant growth of coagulase- negative Staphylococcus was recovered in May.

On May 13th, repeat vascular testing was accomplished. His pulse volume values were 1.2mm Hg (vs 0.5-0.6 on 8/2/96) at the right ankle, 1.0 mmHg (vs 1.2) at the right calf, 0.8 mm Hg at the left ankle (unchanged),and 1.1mm Hg (vs 0.8) at the left calf. The Doppler velocities were 13 cm/sec (vs 4) in the left posterior tibial, 16cm/sec (vs 11) in the left anterior tibial, 11 cm/sec in the right posterior tibial and 3 cm/sec in the right anterior tibial. The velocities had not been determined in the right foot previously as it was not ulcerated in August 1996. His ABI's were 1.54 at the right ankle and 0.67 at the left ankle. A repeat EKG had abnormalities similar to those described above. He was given the following status report: (1) Someday he might want his saphenous veins for coronary bypass; (2) while his femoral pulses were palpable, the Doppler's of the femorals were slightly widened and some iliac disease was likely; (3) falloff of the Doppler velocities in the midthigh and further falloff to the popliteals pointed to significant occlusive disease in his superficial femoral; (4) tibial occlusive disease explained the variable further falloff seen in his various tibial vessels; (5) he had both borderline arterial flow and peripheral neuropathy in his feet making healing difficult. This report advice was much the same as that offered the previous August. He was offered the following options: (a) continue the same local treatments and Miniboot treatments as at present (disadvantage in obvious slow response and relapses); (b) add long boot therapy to improve flow through thigh into his lower leg; (c) do arteriogram and distal bypass surgery. He had been interested in the cardiac actions of boot therapy and in joining our heart study protocol. Long boot therapy had not previously been done because he required the Miniboot and local antibiotics to control his foot infection and because he did not have the time to spend two hours daily for both treatments in the office. In joining the heart study, the long booting was free but did require an afternoon appointment. He chose to join the heart study while at the same time he began to explore the possibility of bypass surgery. The following show the results of his initial heart data.

In this part of his study, his cardiac output, stroke volume, heart rate and ejection fraction were followed during Long-Boot therapy to both legs with the use of the Renaissance IQ Corporation electrical impedance apparatus. Note the large gradual increases in stroke volume and cardiac output. The long term benefit of such treatment is now under study.

He did not complete the study as with our knowledge and approval he sought an opinion on his foot ulcers in another city where surgery was urgently pressed on him and he was advised he had osteomyelitis that also required a surgical approach. Our last culture obtained June 2nd revealed abundant yeast. As of June 26th he had spent three weeks in the hospital and had had a distal bypass. His surgeons advised him to do the other leg also.

Right foot, May 1997.

Left foot, May 1997.

Comments: Unfortunately, the camera was poorly focused for our last photographs and his remaining lesions are not readily appreciated. This patient is an example of patients for whom we have trouble pushing possible surgical options. Initially, we had a very satisfied customer; he had been healed as an outpatient when his previous doctors had hospitalized him and still amputated his toe. But we were also the bearer of bad news: his heart was not normal and his various activities were more than his feet could bear. Golfing, a new found love, might have to cease. Our x-rays had not shown osteomyelitis and, if they had, it would not have changed our therapy; as our other cases show, we can cure it with our local antibiotic treatments. He relapsed and his recovery was slow... but safe and steady. Still slow. Such patients are bound to find their way to other consultants who will give them advice from their experience and trade. (If you walk into a flower shop, you are offered flowers. If you walk into a butcher shop, you are offered meat. Etc.) If he had visited a storefront chelation shop, he would have been offered chelation. He visited prominent and leading surgical specialists who would and did claim their techniques were the gold standard of therapy for him... and with some weeks of hospitalization, they cured his current lesions. The patient was impressed and made very anxious by the immediate insistence by the surgeons that he had osteomyelitis (? resolving changes from the infections we had treated) in both feet, that his legs were in danger and that he required immediate bypass surgery. He telephoned us from his Boston bedside for guidance. I advised him that his surgeons were excellent and, as we were "zealots" in what we do, they too were "zealots" in their surgical approaches. Like many centers, they did not request his previous records. They did not discuss his potential needs for coronary bypass surgery. He recounted no discussion of cardiovascular risk. Again, they did not discuss the potential adverse effects of leg bypass on male potency. Our long term follow-up is limited to the comments of common acquaintances who tell us that he has had to return to the vascular surgeons few times for additional procedures.

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