Case 152: Ulcers, Osteomyelitis, Peripheral Arteriosclerosis Obliterans and Neuropathy Benefited by Outpatient Booting and Antibiotics Given Only Locally

Patient HL was presented in synopsis form in Angiology (vol 48:s51-s54, 1997). She was referred by the Philadelphia affiliate of the American Diabetes Association for boot therapy on June 15th, 1989 at age 61 with an eighteen year history of type 2 diabetes, 41 pack-years of cigarette smoking and many years of having used amphetamines for narcolepsy. She had had femoral-tibial bypasses performed at a Philadelphia University Medical Center in her right leg in 1982 and 1988; both had occluded. She presented with painful lesions around her lateral malleolus, half-block claudication, insensate feet, background retinopathy, and an old anterior wall myocardial infarction.

Her hammer toes and the visible tendons in her distal foot may be explained by atrophy of the small muscles in the distal foot and her neuropathy. The fine strawberry reddening of her toes and the soles of her feet suggest arterial insufficiency.

June 15th, 1989: Her Doppler velocity waveforms were broad and monophasic in all three arteries at the ankle. The amplitude was very low in the anterior tibial and the peroneal arteries but of modest height in the posterior tibial where an ankle/arm index of 0.51 was found.

Her ulcers healed and she ceased to complain of claudication. She was advised that her baseline glycohemoglobin of 10.8% (normal 3.4-6.1%), total cholesterol 271mg/dl and triglyceride 357mg/dl also required attention. Eventually she agreed to change from her oral medications to insulin and to stop her amphetamines but she did not give up smoking . ACE inhibitors and diuretics were started for her hypertension. She returned to the care of a podiatrist close to her home where she had routine care of her calluses.

The plantar callus under her first metatarsal broke down and brought her back for care September 15th, 1992 with exposed cartilage and obvious osteomyelitis. She refused both oral and intravenous antibiotics as they had sickened her in the past. Hence, she was treated with local injections of antibiotics in and around the lesion and in our Sea Soak solutions. Mechanical debridements were limited to plucking loose cartilage or bone fragments and trimming callus.

March 1st, 1993: Her foot responded fairly rapidly while she limited ambulation. The latter, however, obviously prolonged her therapy. Here she had developed some Pseudomonas infection which responded nicely to our local measures.

Almost two years of intermittent therapy later. The tape reads, "HL 3/7/94 Outpatient Rx 7/92 No oral antibiotics - just local".

Associated with her healing was an improvement in her sensation. Here she laughed as her foot was tickled.

Healed she was but not happy. She did not like the long commute to the boot clinic (40-50 miles) and sought care closer to home periodically. She thought we should provide her local podiatrist with a boot... but she did not find a local podiatrist who wanted to accommodate her. As new lesions developed, she obtained care in various locations. In October, 1996, for example, she visited a Philadelphia academic Wound Center who advised her she needed vascular reconstruction procedures, hospitalization and intravenous antibiotics as she was at risk of losing both legs. With family losses, she found her way to a nursing facility where less ambulation was required and apparently her feet improved. She died there in April 1997 still with two legs.

Comments: We were able to salvage this lady's legs in spite of many hurdles: continued smoking, continued ambulation, poorly controlled diabetes, variable control of blood pressure and lipids and refusal to take systemic antibiotics. In spite of these difficulties, we were able to heal lesions that other academic centers could not. Loss to regular follow-up and care in the boot clinic was associated with new lesions that other physicians again found impossible-to-difficult to treat. We do not recommend her choices. Hospitalization is a necessity at times. Systemic antibiotics are desirable to prevent septic emboli. Return of sensation with boot therapy in patients like this one is common and would appear to be evidence for a vascular component in the pathogenesis of diabetic neuropathy.