Case 128: Potentially Dead Leg Made Functional for Seven Months until Cancer Death

This 74 year old insulin-dependent diabetic was referred on May 20th, 1994 for ischemic leg disease previously manifested by one half block intermittent claudication and now by areas of right heel necrosis, cellulitis (or ? early ischemic necrosis) distal to his lateral right malleolus and across his instep, and a large discolored area on his right lateral lower calf thought to represent early tissue necrosis. His ankle/arm indices were 0.15 and 0.79 in his right and left legs respectively. His prognosis was limited by the presence of known metastatic cancer from which he died on December 17th, 1997. Our job was to limit his difficulties due to his ischemic leg disease.

The insult to his right lateral foot and heel was obvious.... while its causation was not: ischemic necrosis? Cellulitis?... no history of trauma.

The development of necrosis in his heel splits pointed to an ischemic process.

This picture was taken through the metal sidings of his bed; the siding, unfortunately shaded his calf from the flash of the camera obscuring the area of interest. An ink line borders a sallow-blue area thought to be potentially devitalized tissue.

The process in his calf and instep were reversed. He was discharged and treated as an outpatient. His heel eschar grew larger until a Podus Splint was obtained to keep dependent pressure off the lateral heel in bed. He was ambulatory and pain free until a few days prior to his death.

Comments: This man had a poor prognosis due to his cancer. The skin changes in his legs suggested he might require a leg amputation or die of a dead leg before his cancer took him. Because there is a natural tendency to view treating such patients as futile, therapy may be withheld or delayed. He might have done better had he been referred for booting earlier. Again, we might not have had as much trouble with his heel if we had invested in a Podus splint (a boot with a well in the heel area that unweights the heel) sooner. Overall, the boot kept him out of the hospital and nursing home, self-sufficient and ambulatory most of the last seven months of his life.