Case 119: Two Legs Salvaged from Necrotizing Cellulitis

This 78 year old diabetic man had been scheduled for a leg amputation at a nearby hospital where he had undergone a ray resection of his third toe and its metatarsal head in the past. His current problem had not responded to two months of antibiotics in the hospital, a few weeks in a nursing home and months of daily outpatient care in his surgeon's office. On May 31st 1984, he arrived in a wheelchair with an odoriferous infected foot the night before his scheduled amputation.

His foot is shown here after his first Mini-Boot treatment in Sea Soaks and gentamicin solution.

His baseline Doppler studies showed monophasic waveforms of modest amplitude in the anterior tibial and of diminished to absent amplitude in the posterior tibial and peroneal arteries. The blood pressures were 180 in the arm and at the ankle, 200 in the anterior tibial, 80 in the posterior tibial and zero in the peroneal. He was hospitalized at Bryn Mawr. Gentamicin was injected into the depths of his ulcer on all but three occasions. His foot was immersed in antibiotic solution within a plastic bag and pumped in the Mini-Boot three to four times daily. After three weeks, he was transferred to our boot service at a nearby nursing home where his foot was pumped twice daily in antibiotic-Sea Soaks solution. His foot sensation returned and his foot healed.

He returned for follow-up September 25th, 1984 and appeared to be doing well. Just before he left, however, his family telephoned to be sure we examined his other foot.

He proved to have a gangrenous left 5th toe, which we clipped off in the office, and a spreading cellulitis across his arch.

The right foot remained well-healed but he had a necrotizing cellulitis in the left arch.

The left foot responded well to similar therapy: gentamicin injections and booting within carbenicillin-solutions.

Comments: The right foot had not responded to the usual forms of therapy and was clearly salvaged by the boot. The left foot is an embarrassment in that its lesions developed presumably under our watch. Patients seem to have a denial process making it difficult for them to report problems with the "good" leg. A timely injection into his toe might have aborted the entire problem with the left leg. Again, a Medicare code making it cost-effective for the therapist to treat both legs at the same time might have solved the problem; the left leg might have been treated along with the right leg and the breakdown of the left leg prevented.