Case 17: Salvage of Both Legs Afflicted by Nonhealing Heel and Instep Lesions

This 64 year old man presented with histories of longstanding type 1 diabetes, a previous smoking habit and episodes of heart failure and cerebral transient ischemic attacks. He had had successful femoral-popliteal bypasses leaving him with ankle/arm blood pressures of 0.66 at the right ankle and 0.75 at the left. He had developed chronic heel ulcers which had not responded to the care of his physicains at two previous hospitals. Skin grafts had been attempted but the pressure of his bandages had resulted in breakdown of the skin over the insteps of both feet. Unable to walk, he was transferred to the Bryn Mawr Hospital in a wheelchair (first and second photographs).

(1) Heels on Presentation

(2) Insteps on Presentation

Gentamicin was injected into his heel and instep infections and he was treated with the Long-Boot over an area from his groin to his ankles and in the Mini-Boot with his feet immersed in appropriate antibiotics. His heels initially did well (third photograph), his mobility improved and he was discharged for outpatient treatments. The dark staining on his skin was due to Betadine soaks which had been utilized prior to his treatments to remove drainage and cleanse his ulcers. It also may have retarded healing and has uncertain activity against Pseudomonas. Both instep lesions became infected leading to readmission to the hospital and debridements of the instep eschar (fourth photograph).

(3) Heels Doing Well

(4) Infected Eschar Debrided

The instep ulcers progressed poorly over the next several weeks in spite of the presence of loud Doppler sounds in his insteps. His Betadine soaks had been continued (fifth photograph) and were now discontinued in favor of a multi-electrolyte solution (Sea Soaks-TM) containing antibiotics (sixth photograph). The difference in the vascularity of the lesion was striking and obvious healing soon commenced.

(5) Betadine and Retarded Healing

(6) Sea Soaks and Improved Vascularity

His treatments continued again in the office. The instep lesions developed granulations that covered the exposed tendons (seventh photograph). His heels closed first happily making walking easier (eighth photograph).

(7) Granulations Covering Tendons

(8) Heels Healed

His insteps went on to heal. Photographs nine and ten show his feet when he was discharged from the office. He did well for seven years and placed himself under the care of physicians closer to home. He developed more strokes and an impaired ischemic left leg. Therapy to the leg was deemed impractical. A left AKA was performed and he died three weeks later.

(9) Healed Insteps at Discharge

(10) Healed Heels at Discharge

Comments:Boot therapy appeared to have saved this man from bilateral BK amputations. The poor response of his lesions to Betadine points out the need for attention to local factors in healing. The usage of Sea Soaks was associated with skin growth. His long term course was unfortunate. Possibly had he had early boot therapy following his later strokes his left leg might have been saved. Still boot therapy helped him gain eight years of freedom and spared society the costs of his long term nursing care.