Case 21:Severe Ischemia, Multiple Episodes and Local Treatment of Osteomyelitis

At age 59, this man was admitted to the Bryn Mawr Hospital with a history of type 1 diabetes mellitus, pain in his heel at a point of focal necrosis, diffuse lower leg pain, twenty foot claudication and a paronychia of his big toe. An arteriogram at a University Medical center had shown an occluded superficial femoral in the distal third of the thigh, a diseased popliteal artery and no good runoff vessels in the lower leg.

No Opportunity for Bypass Seen at University Center

His leg pain diminished over a two-week hospitalization allowing full ambulation and permitting outpatient treatment. His baseline vascular studies on 12/14/78 had shown blood pressures at the ankle in the anterior tibial of 76mm Hg and 64 mm Hg in the posterior tibial. An electronic oscillometer read 0.75 units. On 1/27/79, after 70 Long-Boot treatments during his two-week hospitalization and one month outpatient program, his pressures had risen respectively to 96 and 94 mmHg and his oscillometer reading had increased to 1.5 units. A little whitish material remained at his previous area of focal necrosis and he was doing well. He disappeared from the clinic.

Painful Focal Necrosis in his Heel

Pain-free and Healed

He returned 6/13/79 with a small ulceration again at the heel. His blood pressures had dropped to 61mm Hg in the anterior tibial and 70 in the posterior tibial. He was given eight Long-Boot treatments as an outpatient over the next six weeks both healing his ulcer and raising his blood pressure readings to 80mm Hg in the anterior tibial and 74mm Hg in the posterior tibial. He again was lost to follow-up only to return 11/27/79 with a blister on his right little toe and another falloff in his ankle blood pressure readings: 46mm Hg in the anterior tibial and 50mm Hg in the posterior tibial. As these were the lowest readings he had had, he was admitted to the hospital for ten days and pumped four times daily both raising his blood pressures and healing his ulcer. He again disappeared and did well until November 1982 when he was readmitted with a cellulitis of his foot and an osteomyelitis of his 4th toe.

Osteomyelitis of 4th Toe

Toe Healed (Staple Holding Photograph to Record)

For four weeks he received various antibiotics intravenously. His cellulitis was readily controlled but the drainage from his osteomyelitis continued to grow Staphylococcus aureus. He was advised that a toe amputation was not only wise but mandatory if his infection was not again to invade his foot. He refused as the surgeon would not promise him the amputation site would heal. In frustration, Dr. Dillon exclaimed that we had done everything to save his toe except putting the antibiotic physically right into the bone. Why not do that, the patient suggested. Hence, before his boot therapy, he then received six injections on separate days of 40 mg gentamicin into the toe adjacent the area of osteomyelitis. On occasion, some of the gentamicin was noted to run out of a small intertriginous ulcer that faced the fifth toe. This ulcer was thought to be the likely original portal of entry for the staphylococcal infection. His ulcer healed. His toe healed. He again disappeared and was fully ambulatory until he had a massive myocardial infarction at a shopping mall in July 1984.

Comments: There are a number of points to be made in the case of this man. First, his vascular surgeons felt they had nothing to offer him in 1978 except leg amputation. Patients who are difficult for the vascular surgeon will be difficult for the boot also; it requires more pumping to reverse more disease. Second, relapse does not mean failure and reason for leg amputation. It is a simple thing merely to pump again. Many of the legs that were eventually amputated over the years were initially saved and then lost to follow-up as the family doctor and his surgeon did not consider the possibility of merely pumping again (Dillon RS: Fifteen years of experience in treating 2177 episodes of foot and leg lesions with the Circulator Boot. Angiology 48, Number 5, Part 2: S17-S34, 1997). Third, new lesions and hospitalization may be prevented in many patients if the patient returns for regular follow-up and appropriate vascular testing. Fourth, local injection of antibiotics into and around osteomyelitic lesions proved very effective and would have considerably shortened his hospitalization. Because of his case and another in the hospital at the time, our technique of the local injection of antibiotics into and around osteomyelitic lesions was born. Finally, it is likely we might have headed off his fatal heart attack. In patients at great risk like this man, we are using the Omni Holter monitor and both discovering rhythm disturbances and silent ischemic episodes. In many patients, serial monitor studies may show that Long-Boot therapy reverses the abnormal RST changes documented on the monitor. The tendency of this man to disappear from follow-up increased his risks for both leg and heart problems. Nonetheless, his leg was spared over six years and he was a satisfied customer.