Case 170: Diabetic Foot: Leg Salvage in Lady Who Had Had Multiple Bypasses and a Non-Healing Big Toe Amputation

This 55 year old lady was referred for boot therapy on October 28, 1994, by her physician at a Philadelphia University Medical Center. She gave a history of having had various procedures and hospitalizations on her right leg eventually culminating in a right beneath-the-knee amputation. She had had five hospitalizations within the last year for her remaining leg: three for bypass procedures, one for a fifth toe amputation and the last for a big toe amputation. The latter had not healed in spite of referrals to various specialty clinics at the University center and this open ulcer led her to our clinic. Her most recent arteriogram, done in August 1994, showed a few narrowed areas in he superficial femoral, complete occlusion of her popliteal artery, lots of small collaterals around the upper knee and no runoff down the calf. Pulse volume studies done in August at the University Center showed small wide waveforms at the ankle and pressures likely raised by medial calcinosis of the vessels at the ankle level. Clinical clues pointing to severe arterial disease included blanching of her foot when elevated 30 degrees, slight return of color to the balls of her feet at a 5 degree elevation and rubor on dependency. Diminished-to-absent vibration senses, diminished light touch sensation, an inability to feel the 5.10 fiber on her foot and two-point discrimination of 8 inches on her lower leg all pointed to significant peripheral neuropathy. As her HMO would not give either permission to treat her or to perform additional non-invasive vascular studies, no additional studies were done and she was advised regarding standard foot care measures. Feeling betrayed by the HMO, she resigned from it and found insurance that would cover her treatments. Boot treatments were finally begun on January 25th, 1995. Over the course of the treatments, various pathogens were recovered from her ulcer bed: Pseudomonas aeruginosa, Enterococcus species, coagulase-negative Staphylococcus, methicillin-resistant Staphylococcus aureus, and yeast. These were treated with local injections of various antibiotics (ampicillin, gentamicin, vancomycin). The same antibiotics were placed in her Sea Soak baths along with Fungizone during her Mini-Boot treatments. She generally was given both a Long-Boot treatment (groin-to-midfoot) and a Mini-Boot treatment at each visit. She came for treatments initially five days a week and then tapered back to 2-3 visits a week and then to 1-2 visits a month.

Baseline photographs inadvertently were not taken as it was not clear her insurance company would allow treatment. Here February 7, 1995 new skin is seen to be moving in over the amputation site.

February 18, 1995: She was pain free and ambulatory. The small defect exposed bone which had been chronically infected.

She slowly healed but continued to form callus over the amputation site. Here at a monthly visit on October 30, 1997 she was about to have the callus cut back and receive her last boot treatment.

Comments: Again, this was a lady that cost the insurance a lot of money for hospitalizations for multiple amputations and bypass procedures. Her transportation from the city to the suburbs for treatment was not easy for her and her drop-off in the frequency of her treatments prolonged her care. Her leg was saved without hospitalizations, without home care and home intravenous antibiotic treatments. Our treatment was successful when treatments in a prestigious institution failed. Was there any other way this lady could have been treated?