Case 129: A Rise in Polarographic PO2 Determination after Booting and Healing of Resistant Neuropathic Ulcer.

This 51 year old insulin-dependent diabetic grocery clerk was referred by his general surgeon who had not been able to heal him with various modalities prescribed and overseen at weekly office visits over a year's time. The patient had had a transmetatarsal amputation for intractable ulcers of the distal foot and developed his current ulcer when he started to ambulate again. The ulcer measured 7.7 x 2 cm at its greatest width. Simple Collen's oscillometry readings were essentially normal: 2.5 units at the ankle (normal 1-5) and 10 at the calf (normal 3-8). Skin temperature readings around the ulcer were obtained in a constant temperature room and while more variable than might be expected were still adequate to have predicted healing: 30.9, 32.5, 32.8 28.2 and 26.1 degrees C (normal over 30.0 degrees C). Platinum polarographic electrodes were inserted beneath the skin at the base of his 1st and 5th metatarsals and readings were made before and after a single Long-Boot treatment. The PO2 tension rose 7-fold at the base of the first metatarsal and 4.5-fold at the base of the fifth metatarsal (normal, no rise). Because of the possibility that ischemia contributed the intractability of his ulcer, Long-Boot therapy was begun.

This picture was at the very end of the role of film resulting in loss of a portion of the frame. Lots of callus and seemingly good red tissue is seen. The photographs for this patient were printed on granular photography paper.

He received outpatient Long-Boot treatments 2-3 times a week for six months. In the first four weeks, the ulcer was reduced to 4.1 x 1.3 cm. The last 1.5 cm overlying a bony prominence was slow to close probably secondary to trauma with his return to ambulation. He returned to work wearing an air pad in the sole of his shoe.

The skin under the proximal 4th metatarsal was last to heal. His sensation improved also.

This hand photograph was taken two years later after his dermatologist had diagnosed necrobiosis diabeticorum from a skin biopsy of arm lesions. Some such skin changes are here seen at the wrist. The atrophy of his interosseous hand muscles was attributed to his diabetic neuropathy.

Comments: See our Neuropathy library and the contributions of Davis and Green 1959 and Wollersheim 1989; the former noted a lowering of PO2 polarographic readings after sympathectomy and the latter noted they rise after the administration of ephedrine in diabetics with neuropathy presumably due to closing of A-V shunts. This man had a significant rise in PO2 after booting and, with repeated booting, goes on to heal a resistant ulcer and senses an improvement in his sensation. His story supports the possibility of an important role for neuropathic microvascular disease in the causation of these ulcers.