Case 193: 17000 Mile Round Trip Twice to Salvage Leg with Necrotizing Cellulitis, Distal Arteriosclerosis Obliterans and Osteomyelitis of the Calcaneus.

Born March 12th, 1929, this Saudi man was found to have diabetes in 1980 explaining his symptoms of fatigue and polyuria. He took oral agents until 1993 when he started insulin. His foot problems began when a nail perforated his toe in June of 1994. Subsequently a toe amputation and then a transmetatarsal amputation were performed. The latter was slow to heal and the heel of his foot broke down. He came to Bryn Mawr in hopes of avoiding leg amputation.

November 22nd,1995: He presented with an odoriferous necrotizing cellulitis of the right heel and a plantar abscess that admitted a few fingers into the depth of his foot. The distal aspect of the dorsum of his foot was reddened especially over the lateral three toes and metatarsal heads.

November 22nd: On the medial view of the foot and leg, a soft puffy area of the inner posterior heel and necrotic spots on the lower leg were seen. toe.

His routine chemistries included a blood glucose of 312mg/DL, an albumen of 3.0 G/dDL and a total cholesterol of 123 mg/DL, the latter two suggesting a decrease in stores of body protein. Likewise, both his hemoglobin (10.5 G/DL) and serum iron (23 mcg/DL) were low. His white count was 12.2 and his foot culture grew out Staphylococcus aureus (resistant only to penicillin) and Citrobacter koseri (resistant only to ampicillin). He had no palpable pulses below the knee. His anterior tibial and posterior tibial arteries were found by Doppler and had low monophasic wide waveforms. His ankle/brachial index was 1.26 (calcified vessels were seen on his x-rays). The pulse volume in his mid-foot was reduced to 0.6mm Hg.

Foot X-rays on November 30th, 1995: Air was seen in the soft tissue under the calcaneus. There was a small area of cortical destruction in the anterior calcaneus consistent with osteomyelitis. There was previous amputation of all of the toes in the mid-metatarsal region. Vascular calcifications and a superior calcaneal spur were seen.

Foot X-rays on November 30th, 1995: On a more oblique view, gas is again appreciated under the heel, the mid-calcaneal outline is fuzzy, and some periosteal reaction is seen.

His insulin program was readjusted to included fingerstick glucose determinations and insulin injections before meals and at bedtime. He was begun on outpatient Mini-Boot therapy. Before each treatment, his foot was first soaked in dilute hydrogen peroxide Sea Soaks solution to remove as much pus and loose debris as possible. The cavity of the foot was then irrigated with Sea Soaks containing gentamicin. The cellulitic areas were next infiltrated with gentamicin (40mg once daily) and Ticarcillin (100mg ) and the foot was pumped in a Sea Soaks bath containing gentamicin. He was treated twice daily 9 days in November, 25 days in December, 24 days in January and 15 days in February. As the cavity closed on the bottom of his foot, the irrigations were discontinued.

Plantar view on February 16th, 1996: The abscess cavities closed and the black eschar was gradually debrided back at its loose edges. Clean granulations were developing.

Posterior view of ankle on February 16th, 1996: The leg lesions (not shown) had long ago healed. The yellow fibrous tissue was adherent to the granulation tissue. It was usually debrided back only if it was obviously infected or loose.

He wanted to go home. He was given the following directions for home care:

• 1. Activity: Minimal weight-bearing on bad foot, active and passive exercises of right ankle and foot (wiggle toes, foot and ankle to maintain capacity to move these parts).
• 2. Keep foot out of non-sterile environments (do not put foot in shower or bathtub).
• 3. Wash foot daily with sterile solution.
  • a. May use previously boiled water to wash intact skin and blot dry.
  • b. Use Sea Soaks-antibiotic-Urecholine solution in sterile plastic bag to soak heel and foot twice daily. Massage heel through the bag to gently remove debris from the heel. The current Sea Soaks mixture is gentamicin 80 mg, Ticarcillin 500 mg, and 10 mg Urecholine per half gallon of Sea Soaks.
• 4. Foot cultures should be done if there is any new reddening or drainage. Your local doctor can advise you according to the report what antibiotic change, if any, you should have.
• 5. Clean sterile dressings should be applied after each foot soak.
• 6. For the present, he is to take Ciprofloxacin 500 mg twice daily as his antibiotic.

Home Polaroid pictures June 18th, 1996: The plantar view of the foot was almost normal.

Home Polaroid picture June 18th, 1996: The fibrous tissue has largely separated, clean granulations are present and the lesion is smaller.

He returned to the United States and Bryn Mawr for re-evaluation and treatment of his right foot on July 7th, 1997. He was found to be hypertensive (BP 172/88 in the right arm sitting) and to have bilateral arcus senilis, a right lens implant, modest retinal arteriolar narrowing, a large left retinal hemorrhage, slight gynecomastia, diminished-to-absent pedal pulses, 2+ pitting edema of the left ankle, a modestly enlarged prostate, an absent Achilles reflex, and absent vibratory, light touch and firm pressure sensations in his feet. He had been following his multi-dose insulin program and his glycohemoglobin was much improved (6.3%).

July 7th, 1997: He presented with abundant callus on his right foot and heel.

July 8th, 1997: The distal callus was debrided revealing relatively normal skin. Removal of the heel callus, however, revealed a penetrating soft central area admitting a culturette tip pointing to deep infection.

X-ray right foot on July 14th, 1997: On the lateral view, the roentgenologist noted bony loss as well as sclerosis at the posterior plantar surface of the os calcis. There was overlying ulceration. The findings were compatible with osteomyelitis.

X-ray right foot on July 14th, 1997: On the oblique view, the posterior inferior aspect of the calcaneus appeared fuzzy and slightly demineralized.

His erythrocyte sedimentation rate was 39 mm/hr. Cultures aspirated from his midfoot revealed a heavy growth of Klebsiella pneumoniae (sensitive to cefonicid and ceftriaxone), a heavy growth of Staphylococcus aureus (seensitive now only to tetracycline and vancomycin) and a moderate growth of Escherichia coli (sensitive only to ceftriaxone and intermediate to amoxicillin/clavulanate). Vascular testing included determinations of his arm/ankle indices (right 0.92 suggesting mild obstructive disease and left ankle over 1.26 pointing to pseudohypertension and medial calcinosis of the vessels under the cuff). Abnormalities in the Doppler waveforms pointed to significant occlusive disease: at the right ankle, they were low and monophasic in the anterior tibial and upside down (reversal of flow) in the posterior tibial.

He arrived taking Ciprofloxcin, which was continued until his cultures returned. He was then started on oral doxycycline and local injections into infected portions of the foot with ceftriaxone and vancomycin. As before, his daily outpatient treatment program began with cleansing sterile foot soaks (Sea Soaks containing approximately 10 ml of hydrogen peroxide per 250 ml Sea Soaks). The antibiotic injections were always followed by treatments in the Mini-Boot. On several days, he was also treated with the Long-Boot from his groin to his toes.

This photograph was taken on July 18th, the day before his departure. His foot did well. His distal foot was healed. The heel was greatly improved. The hole into his foot had closed. The needle injections, unfortunately, on some days were associated with bleeding into the skin causing some discoloration (the latter problem is minimized by holding a pressure dressing against the injection site a few minutes after the injections). A 4 mm soft area still persisted in the heel, however.

He was again provided with a discharge program:

• 1. Minimal walking and use of a "pressure relief" walker when he is on his feet.
• 2. Isometric exercises to maintain physical fitness.
• 3. Continued Doxycycline 100 mg daily for three weeks.
• 4. Repeat heel culture if ulcer not healed in 2-3 weeks.
• 5. Local antibiotic program for the heel:
  • a. Initial cleansing foot soak with Sea Soaks (or saline) and hydrogen peroxide [one cup Sea Soaks (250 ml) and one ounce (30 ml) peroxide]. The cleansing soak is to be done twice daily, first before the morning injections and soaks, and then in the late afternoon before his antibiotic soaks.
  • b. Prepare a 500 mg vial of Vancomycin diluted with 5 ml of sterile water containing no preservative and a 500 mg vial of ceftriaxone also diluted with 5 ml of sterile water. Keep the vials in the refrigerator.
  • c. Using an insulin syringe, pull up about 0.5 ml (50 units on the syringe) of each antibiotic in different syringes. Inject the antibiotic into the area of the heel ulcer using 2-3 injection sites for each syringe. These injections are to be given once daily.
  • d. Inject another 0.5 ml of each antibiotic into a fresh plastic soak bag and pour in 250 ml Sea Soaks. Immerse the foot in the Sea Soaks solution and massage the heel gently through the bag thus working the antibiotics into the heel tissue. The massage is a substitute for the Mini-Boot therapy and should take several minutes. The massage and foot soaks are to be done twice daily.
  • e. Sterile dressings are placed over the heel after both the morning and the afternoon treatments.

Comments: This man is presented to illustrate again for some of our nearby orthopedic specialists that it is not true that "all heel ulcers associated with osteomyelitis" have a poor prognosis; they must not come to leg amputation and they do not necessarily require debridements to remove the infected bone. Unlike case #187, this man had sufficient nursing care to keep him off his foot. He also illustrates that once the foot is sterilized and healing, much of the healing can be accomplished at home with good nursing care. Once the bone is sterilized and the blood supply restored, the damaged bone is slowly resorbed and new bone laid down. Changes in x-rays documenting the healing processes may occur over many months after the foot is clinically healed as judged by healing of ulcers, lack of inflammation and normalization of the sedimentation rate. Again, he is presented to illustrate the kind of home programs we prescribe for those who can reasonably discontinue coming to our "Boot" clinic and be cared for at home.