Case 18: Leg with Ischemic-Neuropathic Ulcer Saved and Renal Function Improved with Boot Therapy

Plantar Soft Tissue Separated from Clean Granulations Proximally and Necrosis of Plantar Tissue and Fat Distally

At age 78, this Saudi male was admitted to the Bryn Mawr Hospital on April 14th, 1987 with a 23 year history of insulin-dependent diabetes now complicated by eye disease, kidney disease and the above foot ulcer. He had been admitted to his local University Hospital January 20th with a right swollen and ulcerated big toe. X-rays had shown air in the soft tissues of his foot. His serum albumen was 2.7 grams/dl. The big toe was amputated February 7th. The flap did not heal and indeed a large ulcer slowly formed extending from the toe amputation site to calcaneous. Leg amputation was recommended. His surgeon, however, saw the Annals of Surgery article on boot therapy and advised the patient that boot therapy might be worthwhile. The patient flew to Bryn Mawr April 14th.

While he had no pedal pulses, Doppler sounds were present at the ankle. Light touch and vibratory sensation were absent. Two-point discrimination for the firm pressure of a thin stick was increased to 20 to 25 centimeters. He was given oral erythromycin to prevent septic emboli when his foot was pumped in the Mini-Boot. He had multiple Mini-Boot treatments with his foot immersed in various antibiotic-Sea Soaks solutions (commonly gentamicin). As his foot became stabilized, Long-Boot treatments were begun to support his heart and improve his renal function. The treatment was effective with his BUN decreasing from 76 to 71, then to 38 and 33 mg/dl; it was 38 at the time of discharge. Likewise his creatinine decreased from 2.1 (a moderately increased value for a 55Kg and 66 3/8 inch [168.6 cm] tall thin male) to 1.3 mg/dl. He did well. Follow-up correspondence in the spring of 1992 found him well and his leg still intact.

SteriTapes were used to gently hold the skin edges against the red granulations. The skin edges thickened, rounded and grew together closing the gap. Here SteriTapes were used until the skin was well-knit together to prevent the edges from splitting apart.

Comments: The combination of neuropathy, distal ischemia and infection almost claimed the leg of this man. Boot therapy was likely effective in treating each of these factors. It may improve the microvascular component of neuropathy. A language barrier in this man made it difficult to follow changes in his sensation but other patients with neuropathy commonly experience an improvement in their sensation with boot therapy. The effects of boot therapy on vascular tests has been published (see literature section on pneumatic boots). We have found immersion of the infected foot in antibiotic solutions during Mini-Boot therapy to be very effective in curing troublesome infection. An improvement in renal function with approximately a fall of 50% in both BUN and creatinine is commonly seen in azotemic boot patients receiving long term Long-Boot therapy. Boot therapy is certainly cheaper and safer than dialysis. We have mentioned this effect of boot therapy at various meetings of the American Diabetes Association but have not drummed up any interest.