Case 115: First Leg Does Well for Seven Years While "Control" Leg Breaks Down and Requires Long Term Treatments Until Death

At age 63, this diabetic male smoker was referred for boot therapy by his general surgeon after the amputation site over his first metatarsal had broken down. He had known chronic obstructive lung disease and coronary heart disease. X-rays showed osteomyelitis of the medial dorsal aspect of the first metatarsal and calcification of his pedal arteries. Ankle blood pressures were greatly elevated pointing to medial calcinosis of his tibial vessels. The cuff pressure of his maximal pulse volume measurement at the ankle was 89 mm Hg.

The plantar flap had necrosed over his first metatarsal. A Staphylococcus aureus was cultured.

At six months, his distal foot was essentially healed, but he presented with a new problem: a fracture of his calcaneus and a heel ulcer. Pseudomonas was recovered from the heel drainage. He was given a walking air cast which we padded to unweight his heel as much as possible. Again he was treated with local (gentamicin) and oral antibiotics (Cipro) and Mini-Boot therapy. By November, his foot was again healed.

November 25th, 1986: right foot intact.

June 13th, 1989: right foot again intact after treatment of another small ulcer. Hereafter his right foot remained healthy while his "control" left foot broke down.

February 12th, 1991, he presented with a callus and an ulcer under his left 5th metatarsal head. Vascular testing revealed high but wide monophasic waveforms in each of the tibial vessels at the ankle. His foot was insensate.

Coagulase (-) Staphylococci and yeast were grown from the ulcer. The sallow color seen in his 5th toe is not well appreciated in the picture.

Local gentamicin, Mini-Boot therapy and oral Clindamycin were administered as an outpatient. He continued to smoke and ambulate oblivious of any danger to his toe and foot.

The 5th toe turned black and was clipped off in the office. He continued to ambulate and even play golf. The area of black necrosis increased.

In July, he was shifting his weight to his outer left foot in driving on the 8th golf tee when he snapped his 5th metatarsal bone. In the absence of pain he finished his afternoon of golf.

When he arrived for his boot treatment, bone fragments were plucked from the mid-metatarsal area and his local care and boot therapy were continued.

He remained ambulatory wearing an Air Cast and padding to unweight his ulcers. The right foot remained intact. The dead material separated from the left foot leaving clean exposed muscle. September 12th, 1991

Thin skin began growing down the lateral foot across the plantar surface. The thicker plantar skin was slow to grow. Focal necrosis of the ends of his toes developed. Infection in the proximal soft area of his ulcer led was associated with fever and a six day hospitalization in January 1992.

Besides his local antibiotics, Urecholine was infiltrated along the margin of the thick plantar skin to encourage its growth. Atropine was infiltrated along the margin of the thin skin laterally to slow its growth. In March, he required hospitalization for congestive heart failure.

In spite of his ambulation and continued smoking, he continued to heal receiving outpatient Mini-Boot treatments. His toes had recovered nicely. October 16th, 1992.

To get the foot rest that he seemed to need, he was placed in our nearby nursing home and its boot program. Unfortunately, he continued to smoke there and was found walking to the bathroom, standing to shave and walking on the lawn with visitors. He never seemed to believe that his insensate foot was in trouble and could not adhere to any restrictions placed on his foot. He tired of the nursing home environment and, at the suggestion of friends, sought the advice of an academic wound care center in Philadelphia. The surgeons there noted a transcutaneous PO2 of 4 mm Hg on the dorsum of his foot and 44 mm Hg on the chest wall leading them to advise him he could never heal his foot without vascular reconstruction and offered him hospitalization. Our more complete testing, however, showed that he had good PPG waveforms in the margins of his lesions, that his oxygen saturation was always somewhat reduced due to his chronic lung disease, that it commonly dropped further with his heart failure and that his TcPO2's improved with nasal oxygen. He wisely decided to remain in the nursing home. His boot therapy program, however, was changed to include some Long-Booting to support his heart. His heart difficulties led to three hospitalizations in 1993: for congestive heart failure, for a myocardial infarction and finally for congestive heart failure. While in the coronary care unit, he was indeed off his feet and not smoking; his lesions improved on each occasion.

At the time of his last hospitalization, the side of his foot was very close to healed, but he had developed a heel decubitus.

Comments: When his surgeons referred this man in 1986, he was not thought to be a good candidate for vascular surgery. His right leg did well for seven years while his left leg broke down. Common sense would suggest that he would have done well to have had both legs pumped beginning in 1996; arteriosclerosis is a generalized disease, not one limited to a single leg. Medicare and insurance companies, however, have not paid for treatment of a diseased but relatively asymptomatic leg.

Why so few hospitalizations? He was hospitalized when he was disabled and sick. He did not benefit from a long stay in the nursing home because he could not stay off his feet and he continued to smoke. He was given the analogy of skinning an animal many times (One makes an incision in an animal's hide, grabs the edge of the skin and pulls it off the underlying muscle and fat... So shear forces pulled his skin off his underlying foot muscles as he casually walked around the nursing home etc.) We used to hospitalize patients like this man for many months in the old Philadelphia General Hospital and, if kept off their feet, they commonly got better.

Outpatient care of these patients is frustrating. Their lesions heal slowly. They may or may not make their therapy sessions. Especially if they have an insensate foot, they may grow accustomed to their life, damaged foot and all.

The desire of the wound care surgeons to do bypass was interesting. Patients with either or both COPD and congestive heart failure not infrequently have blue fingers and toes.