Case 199:The Second Leg Threatened by Ischemia, Cellulitis, Gangrene and Osteomyelitis

Born May 1st, 1934, this lady had glycosuria during pregnancy in 1960. Overt diabetes developed in 1980. She developed leg cramps after a heart bypass in 1992. She had progressively more difficulty and developed a spot of gangrene in her right 1st toe. She had a bypass in January 1997, which failed. She had a right below-the-knee amputation in May 1997. Her left leg became progressively painful leading to an arteriogram in July 1997. Her superficial femoral was occluded in Hunter's canal. Various arterial segments were visualized: a portion of the dorsalis pedis in the foot, a portion of the anterior tibial at the ankle, and the middle two-thirds of the anterior tibial in the calf. The left leg was bypassed in September 1997; her pain was worse postoperatively. She had another arteriogram on January 30th, 1998. Patent femoral-popliteal bypasses were found bilaterally. The distal anastomosis was perhaps 50% narrowed in the left leg. A short occlusion was present in the distal left popliteal. The left posterior tibial and peroneal were occluded. The left anterior tibial appeared to be patent to the foot. She presented in our boot clinic on February 25th, 1998 having developed peripheral rubor and rest pain. She also had exertional dypsnea and stable angina. She was referred for Long-Boot therapy to a Circulator Boot clinic close to her home in New Jersey where she had multiple treatments over a few months. She thought her leg became less red and did well with the treatments. The therapist trained by the Circulator Boot Corporation, however, moved away from New Jersey with her husband. The therapist who replaced her noted that hyperbaric oxygen paid more money and discontinued boot therapy. The patient then sought the opinion of a wound-healing clinic again close to home where she was again advised to try more vascular surgery and/or a second leg amputation. Frightened at the thought of surgery and noting that her left leg seemed to have had more disease than the amputated right leg, she returned for boot therapy to the Bryn Mawr Circulator Boot Clinic on August 17th, 1998. Faint PPG arterial flow was found to disappear in the toes when the foot was elevated 10 inches. She was advised not to elevate her foot. Very faint Doppler flow was heard in the left posterior tibial and faint monophasic flow was heard in the anterior tibial at the ankle. The pulse volume curves were rounded and 0.2 mm Hg high in the midfoot, 0.5 mm Hg at the ankle and 0.8 mm Hg at the calf. She had a 2.0 by 1.0 cm area of focal gangrene on the outer side of the left big toe. Rubor and tenderness of the toe and distal foot suggested cellulitis. She was begun on both Long- and Mini-Boot therapy and given a prescription for Bactrim-DS.

Local gentamicin injections into the eschar were associated with a lessening of the pain in the toe and metatarsal area.

Diflucan was added when yeast were recovered. She thought her sensation was improved in the toe.

She was admitted to the hospital with increasing pain and redness suggesting cellulitis.

She had been treated unsuccessfully as an outpatient. Culture of her drainage grew out Enterococcus and coagulase-negative Staphylococci both sensitive to ampicillin and Vancomycin. The big toe had become partially devitalized and slightly blue. Toe amputation appeared to be a poor option in view of the possible cellultis in the metatarsal area and the poor blood flow in the foot. An attempt at bypass or a leg amputation again appeared in the offing. A foot x-ray showed no evidence of osteomyelitis. She was given both intravenous and local antibiotics and multiple boot treatments. She was discharged on her insulin, Nitro-Dur and Cardizem to the Transient Care Unit where she improved her walking capacity.

The infection episode had left her skin necrosis over the distal half of her toe.

With additional Long- and Mini-Boot treatments, the distal necrotic tissue is beginning to separate and the underlying tissue to heal.

Bending the toe upwards showed the open distal interphlangeal joint.

The toe and the foot were doing well. The interphalangeal joint remained open.

The distal toe was healing nicely. It was felt the open joint was likely infected and antibiotics were injected into the joint space.

Now, only a small ulcer remained to heal.

All but covered with normal skin.

The foot in general had normal color. Initially treated 20-25 times a month, she was now receiving 7 Long- and 7 Miniboot treatments a month. Her sed rate was 26mm/hr and she was ambulatory.

A small callus continued to form at her ulcer site. Vancomycin injected into the joint space through the plantar skin exited through a one mm ulcer in the callus. Over the next several months, she received 4 Miniboot treatments after such Vancomycin injections in hopes of closing the fistula and ulcer.

Irrigations of the fistula were sterile. Her sed rate remained in the 20's. PPG tracings of her toes now showed obvious pulsations even with her feet elevated 3.5 feet above the examining table. Because of the persistent fistula and her angina, she has continued to come for treatments 3-4 times a month. Her callus is then trimmed back. The fistula is occasionally irrigated with an insulin needle placed through the plantar skin. The Long Boot treatment relieves her angina for variable periods... days to weeks.

Comments: In view of the other patients shown in this series, the problems of this patient do not seem impossible. Bypass surgery on her right leg, which had been thought to have less arterial disease than the left leg, had failed. Again, her angina posed an increased risk for surgery. Her remaining leg was threatened by ischemia, cellulitis, focal gangrene and osteomyelitis. As the vascular status of her toe improved, she had the option of amputation of the toe... an option that could not be guaranteed to be successful. With further treatments, the healing process continued. All accomplished as an outpatient.