Case 2: Combined Disease: Heart, Venous, Cellulitis and Osteomyelitis with Eighteen Year Follow-up

Born on August 17th, 1920, this lady presented 180 cm in height and 109 Kg in weight. She had no distal pulses since 1981 and had retinal hemorrhages since 1982. She received boot treatments in 1986 for stasis disease and cellulitis of both legs and did well. She had hypertensive arteriosclerotic heart disease and episodes of congestive heart failure. High risk heart surgery was under consideration.

She presented January 7th, 1988 in a wheelchair with cellulitis and osteomyelitis of her left fifth toe and metatarsal head secondary to an insulin needle under her proximal phalanx.

[combined stasis disease, peripheral arteriosclerosis obliterans, osteomyelitis and coronary disease]

Cool, Edematous and Pigmented Leg with Ulcer and Pus at Base of 5th Toe

[osteomyelitis due to embedded insulin needle]

Needle Embedded in 5 Toe and Osteomyelitis of 5th MP Joint

She was treated with local antibiotic injections and both long and Miniboot therapies. Her foot and leg did well. As she attributed a sense of well-being to her boot treatments, she hired a nurse from our boot clinic and purchased a boot system to take home. She has continued to receive boot treatments daily to both legs. A compulsive eater, however, she has been unable to control her diabetes; her blood glucose levels have varied from 170 to 350 mg/dl. Nonetheless, her vision and cardiac function stabilized. Her cardiologist dismissed her from his immediate care.

stasis pigmentation reduced after therapy with Circulator Boot]

Five Year Follow-up ... Ambulatory All the While

Comments:Kicking a football to the moon would be a feat worthy of the attention of all... an unlikely event requiring some form of new technology. In the case of this lady are found several kicks to the moon: Her cardiologist was against all surgical procedures; the boot functions as a cardiac-assist device and its usage was associated with improvement in her cardiac status. Arterial reconstruction was contraindicated by her heart failure, stasis disease and diffuse tibial disease; all improved with her boot therapy. Amputation of her 5th ray was contraindicated; the amputation site was unlikely to heal. All of this was accomplished in a lady unable to control her blood glucose levels.

More follow-up: She did well in spite of her dietary non-compliance and poorly controlled diabetes until November 10th, 1995 when she returned to the boot clinic for routine follow-up and was found to have an asymptomatic bradycardia (pulse rate 40)and first degree AV heart block (PR interval 0.26). She was referred back to her cardiologist who obtained a Holter monitor study , which showed four instances of sinus arrest. An A-V pacemaker was subsequently inserted. She then appeared to develop angina and underwent coronary catheterization. On January 18th, 1996, she had bypass grafts to her left anterior descending and proximal obtuse marginal arteries with her saphenous veins. Postoperatively, she had edema and cellulitic changes from her ankle to her midcalf. With the "encouragement', she claims ("acquiescence" perhaps more likely), of her surgeon, she was discharged to our boot clinic where her leg did well with local antibiotic injections and Long-Boot therapy. In June of 1996, she returned again with an ingrown toenail and a ulcer that penetrated through callus over her second left hammer toe; Enterococcus was cultured from the ulcer which was treated quickly and successfully in the Mini-Boot with local gentamicin injections. She continued with her business ventures which took her to a building site where she unfortunately stepped on a nail on the 24th of September, 1997.

A roofing nail was imbedded in the end of her shoe.

[cellulitis and osteomyelitis result from roofing nail that penetrated shoe]

Looking inside the shoe, one saw the nail sticking up in the area of the 2nd toe.

The nail had penetrated the middle phalanx of her 2nd toe.

Her many drug allergies (clindamycin, sulfa, ciprofloxacin, amoxicillin/clavulanate and cephalexin) were to limit her therapies. Her photoelectricplethysmography tracings showed minimal pulsatile flow in her toes. Local gentamicin was injected into the nail hole and Mini-Boot therapy and oral doxycycline were prescribed. Cultures eventually grew out yeast, coagulase-negative staphylococci and Pseudomonas aeruginosa. The latter proved to be resistant to gentamicin. Her antibiotic treatment, hence, became local injections of ceftazidime and gentamicin, and oral fluconazole.

October 17th, 1997: Her proximal toe was swollen.

December 10th, 1997: The toe cellulitis was largely controlled but the nail track through the infected bone remained to be healed.

June 21, 1998: At follow-up she is seen to have some reactive hyperemia and an indentation in the side of the toe to mark the episode.

November 11, 1997: Osteomyelitis of the body and proximal head of the second proximal phalanx was noted.

Two views of her right foot at follow-up on November 16th, 1998: The body of the proximal phalanx of the second toe is seen to be intact. Some demineralization is seen in the metatarsal-phalangeal joint.

November 16, 1998: Her foot color had now returned to normal. She was treated during this episode at home by her private boot nurse.

September 5, 2000: Seen here at a routine visit for evaluation of her diabetes, her feet and legs were found to be doing well. She continues her home boot treatments.

February 20, 2004: Her feet and heart continue to do well, but her memory is failing....

Comments: Not included in her above history were cataract surgery and her vitrectomy, which left her with excellent vision. She continues with her home Long-Boot therapy because she had found it increases her comfortable walking distances. In summary, this lady has benefited from boot therapy in greatly improving her venous stasis disease (the stasis disease being one early contraindication to consideration of bypass surgery by her physicians), in supporting her heart, in healing two episodes of osteomyelitis associated with foreign bodies (a needle and a nail), in healing an infected hammer toe, in healing her cellulitic leg after her heart surgery and in improving her overall mobility.... all done as an outpatient. Cases like this lady have led many people to ask the Circulator Boot Corporation about home therapy. Several points about the home therapy of this lady should be noted, however. First, she bought the boot systems herself (not all insurance companies will pay for it). Second, she hired a highly qualified nurse from our boot clinic to be her private duty nurse at home. Finally, she was able to come into the boot clinic whenever the nurse had questions about her foot care. Now in the year 2004, she still has intact feet and vision and, except for her memory, is functioning well. Not too bad a feat for a non-compliant lady with chronic hyperglycemia, known loss of peripheral pulses for 23 years and documented retinal hemorrhages 22 years ago. Note, for those who may have reviewed this lady in the past, we rescanned her first three pictures 2/11/2003 with out new Hewlett Packard ScanJet and have provided you with images closer to her photographs.

Return to CBC Homepage
Return to Menu of Case Histories
Next Case