Cases #173-177: Diabetic Foot: A Mini-Symposium Considering Cost and Effectiveness

The reader is invited to imagine how he/she might have treated these patients in the absence of boot therapy.

A 66 year old diabetic male referred with a toe lesion of four days duration. He had no dorsalis pedis pulse. His toe culture revealed Beta-streptococcus and coagulase-negative staphylococcus.

He was treated with the Mini-Boot and local injections of gentamicin and vancomycin.

In the last five months, this type 2 diabetic former smoker had been hospitalized twice in his community hospital for osteomyelitis of his left big toe. Persistent drainage led to consideration of toe amputation. Having read an article in his local newspaper about our treatment, he commuted 100 miles daily for boot therapy. Baseline July 23, 1990.

His toe rapidly responded to local injections of gentamicin. Cured August 3, 1990. He returned in May of 1991 and June of 1993 with other toe infections that also rapidly responded.

This 67 year old diabetic man was referred for focal necrosis of his heel and 50 feet claudication. His ankle/arm index was 0.45. The sign reads" 7/12/90 F.E.M. ulcer healed - no limit in walking - Rx started in OPD 4/3/90... then 50 step claudication. Ulcer present since 1/90... Fem-tibial bypass failed after 3 mos - done 10/13/89."

He returned May 9th, 1994 for a small non-healing ulcer of his big toe. This responded rapidly to a few treatments.

On March 25th, 1993, this 86 year old insulin-dependent diabetic woman was referred with painful ulcers of her left 4th and 5th toes. Her ankle/arm index was 0.79 but her photoplethysmographic tracings were flat in her toes.

She did well with Mini-Boot treatments containing Sea Soaks and gentamicin.

FS did well until October 1993 when she developed discomfort in her whole left leg. He family doctor identified the discomfort as ischemic disease and obtained an arteriogram that showed an occlusion in her left iliac artery. Angioplasty was accomplished and may have dislodged cholesterol emboli to her feet which became very ischemic.

Boot therapy was again requested and she did well. Unfortunately, she did not return for follow-up pictures.

Our alert boot technicians found her entering the hospital in February 1998, then almost 92 year old. She was admitted for congestive heart failure. Her feet were still intact.

This type 2 elderly diabetic woman had been referred earlier for uncontrolled diabetes. Now she was referred for a 5th toe ulcer she developed wearing a new pair of shoes. Drainage had persisted and a red streak developed up her foot in spite of taking Augmentin 875 mg twice daily for a week. Her dorsalis pedis pulse was palpable. Her sed rate was 56 mm/hr. Her toe x-ray showed loss of the lateral cortex of the 5th middle phalanx and loss of the head of the proximal 5th phalanx, findings read as compatible with osteomyelitis by the radiologist.

Coagulase-negative sensitive to gentamicin were recovered from her drainage. The Augmentin was continued. Gentamicin was injected locally into her toe and she was treated in the Mini-Boot. The drainage ceased. The redness disappeared. Her sed rate dropped to 17 mm/hr. Her ulcer closed.

Comments: The first patient had an infected necrotic toe tip that might have responded to oral or intravenous antibiotics. Many thought he was certain to lose the toe. The osteomyelitis of the second patient had not been cured after two hospitalizations and a big toe amputation was in the offing. Many would have removed his toe if they thought the amputation would heal. The third patient had lost his distal bypass, had severe claudication and a heel ulcer that had not healed for six months. Some might have attempted to redo his bypass while others would have merely observed his course and offered leg amputation if his status deteriorated. The fourth patient had painful ischemic toe ulcers that might have invited angioplasty or bypass; she did well for several months with boot therapy only to suffer cholesterol emboli after an angioplasty was accomplished leaving her with advanced ischemia that invited amputation. The fifth patient had an infection spreading up her foot from a toe infection that involved the bone. She likely would have been hospitalized in most centers for intravenous antibiotics and might have come to a toe amputation. In contrast, boot therapy was accomplished as an outpatient and no amputations ensued. The cost of treating all five patients was possibly less than the potential costs of hospitalization for any one of them?