Case 151: Outpatient Healing of Difficult Ankle Ulcers in Diabetic with Arteriosclerosis Obliterans and Stasis Disease

This 70 year old diabetic came with a 30 year history of stasis ulcers over his internal malleolus. The ulcers appeared intermittently and in the past responded to treatment with an Unna boot (a snugly-fitting paste support boot). When he was 62, an difficult ulcer required hospitalization to accomplish healing. His current ulcers were painful and had been present for six weeks. The usage of a Jobst air stocking and the treatments of his family doctor had provided no benefit. He was referred for boot therapy on February 6th, 1981.

He had modest pigment, induration and two ulcers by his right internal malleolus.

He was given first Keflex and subsequently tetracycline for the E-Coli that was cultured from the ulcers. In addition, he was given hydrophilic ointment cream containing hydrocortisone and phenol to hopefully make his stasis dermatitis more comfortable. He was encouraged to continue conservative treatments and to come to the boot clinic as much as possible. His schedule allowed but two boot treatments a week. After the first three treatments, his ulcers were 50% healed and his pain decreased; he could "walk much better". And walk he did, perhaps slowing his healing which took a total of five months. His vascular tests over this time period showed a rise in blood pressure at the ankle in his anterior tibial from 94 to 111 mm Hg with a lesser rise in the posterior tibial (systolic arm pressure 130 on both occasions). More impressive were the increases in the height of the waveforms for his Doppler velocity curves: from 14 to 23 mm in the anterior tibial and from 6 to 27 mm in the posterior tibial.

The larger ulcer is shown here just prior to complete healing. He remained well and ambulatory the next few years and was lost to follow-up.

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Comments: A simple straight-forward case of a man with diabetes, stasis disease and arteriosclerosis obliterans. He would likely have healed faster with less ambulation and more frequent boot treatments.... but he was happy. Would today's HMO reviewer have been happy? In real life the doctor and the patient do the best they can under their circumstances. The reviewer best understands intense treatment programs within the hospital setting and, at the same time, wants to avoid them. This man's treatment was prolonged but still much cheaper than his previous hospitalizations.