Case 130: Refractory Plantar Ulcer in Diabetic with Neuropathy and Arteriosclerosis Obliterans Healed and Legs Maintained for Life with Intermittent Therapy

This nun had had known diabetes for over ten years. In December 1984, her family physician referred her to a podiatrist for treatment of an ulcerated plantar callus. Over the next three months, her lack of healing led to a hospitalization at Bryn Mawr where she had orthopedic, neurological and vascular surgery consultations. Her EMG documented significant neurological changes. Her arteriogram showed a severe stenosis in the left distal superficial femoral artery and multiple areas of stenosis in the right popliteal and anterior tibial and peroneal arteries. Her right posterior tibial was totally occluded. The hospital vascular laboratory reported a lack of palpable popliteal and pedal pulses, blood pressures in the right leg of 84 in the foot, 146 above the ankle, 192 at the calf and 220 in the upper thigh. In the left leg the pressures at the same levels were respectively 138,134,164 and 220. Daily whirlpool, intravenous antibiotics, and bedrest appeared to have no benefit. She was discharged unhealed and instructed to remain at bedrest. She was readmitted to the hospital when her discharge and pain increased. A Staphylococcus resistant to penicillin and ampicillin was cultured. She was referred for boot therapy.

Unable to heal the ulcer now over six months in spite of hospitalization, she was referred for boot therapy on June 5th, 1985.

She was successfully treated, largely as an outpatient, with a program that included an initial cleansing soak in concentrated Sea Soaks and Betadine, local gentamicin injections into the ulcer base and surrounding tissue and boot treatments with her foot inserted into the Mini-Boot with Sea Soaks and gentamicin.

Callus tended to reform and was shaved away as needed to maintain a smooth soft surface. October 10th, 1985.

The skin texture and quality slowly improved. October 29th, 1985.

No sooner had she been discharged with a healed right foot, then she arrived with an ulcer on her left foot. Eventually the right foot required treatments for various lesions in November 1985, January 1986 and January 1993. The left foot was healed of various lesions in November 1985, February 1986, December 1986, and March 1992. She died in November 1993.

Comments: The lesions of this lady were small compared to many shown on our Website. Still they were troublesome and expensive as they led to hospitalizations and multiple ineffective treatments when her physicians could not heal her. With boot therapy, we preserved her feet and their function for eight years. We did not obtain bone scans, x-rays, MRI's etc. when she was first referred; such tests are expensive and only rarely alter our therapy.