Case 22: Healing of Open Resection of 4th and 5th Rays, of Plantar Ulcer and of Autoamputations of 1st Three Toes in an Ischemic Foot

This 62 year old man was referred for evaluation as his vascular surgeon was out of town. A former smoker and an insulin-dependent diabetic, he had developed an infection in his 5th left toe in June, 1987. He was eventually referred to his vascular surgeon who hospitalized him in September.

The AP X-ray of the foot showed gas in the soft tissue between the 1st and 2nd metatarsal heads.

The oblique view confirmed the findings. Osteomyelitis was a possibility, Aug 24, 1987.

The surgeon ordered intravenous gentamicin for a week and performed an open resection of the 4th and 5th rays. The patient was discharged to heal at home. A week later, he developed an infection between the first and second toes and was referred 9/21/87 for boot evaluation. He was hospitalized with fever and renal failure.

Foot on Presentation

The renal failure was attributed to his week of gentamicin therapy which appeared to have also left him with a permanent dysfunction of his vestibular system and a loss of his equilibrium in the upright position. His vascular testing revealed an ankle/arm index of 0.52 in the left leg and 0.78 in the right. His vascular surgeon returned and urged immediate leg amputation, insisting the problem was too advanced for boot therapy. The family sought another vascular surgery opinion and were advised they might try the boot and consider a bypass operation later if his renal function improved. As for his prospects with boot therapy, the boot service advised him that his three toes were unlikely to survive because the large open wound following the removal of the 4th and 5th rays threatened the 3rd toe, because the deep infection at the base of the first toe had left the toe very white and ischemic, and because he was breaking down proximally in his arch. On the other hand, we advised him, he had a large size 12 foot giving us plenty to work with and he had a good chance of salvaging 50-75% of his foot. His therapy was begun. It included local injections of antibiotics into the webbing between the first and second toes and later into his stumps. He received Mini-Boot treatments with his foot immersed in Sea Soaks and, again, antibiotics. And he received Long -Boot treatments with a sleeve from his groin to his ankles. His therapy was largely carried out in the office where his toes were clipped off when they mummified.

November 27th , 1987

January, 1988 - Closing

He received only minor debridements subsequently. Sharp debridement along the skin edges perhaps every other week provided space for the skin to grow. Loose pieces of ligament or tendon were trimmed. No effort was made to cut back to healthy tissue that might be closed primarily. The goal was to gain as long a foot as possible.

June 15th (left)and August 10th, 1988 (Right)

November, 1988 (Left) and Discharge March, 1989 (Right)

His right foot (his "control" ) had become painful 12/10/87. Treatment was begun on it four days later. Subsequently both feet were treated simultaneously. The right foot did well.

The Right Foot Did Well

The kidney function improved initially during his boot therapy only to fail in 1990 and bring him to hemodialysis. His legs, his constant dysequilibrium and now his uremia promoted depression. He chanced a trip to Hawaii in February 1991 and died there.

Comments: There are many unanswered questions here. Why no initial bypass? Why no early referral for boot therapy and local antibiotics. Why the gentamicin toxicity leaving him with vertigo and renal failure? The record does not answer these and other questions. Boot therapy has not had the blessing of all physicians. Our boot service does not employ the services of the vascular surgeons regularly. It does not utilize the efforts of the podiatrists, the infectious disease service, the invasive roentgenologists, the orthopedic service or the general surgeons. In the outpatient realm, we avoid the visiting nursing service in patients who are able to make it to the office for treatment: we can change the dressings.... we believe our combination of oral and local antibiotics is safer and cheaper than their intravenous infusions. Most of our patients do well with boot therapy alone ....and as outpatients if referred early in their illnesses. While the Circulator Boot has been presented on several occasions to our hospital Medical Service and has been presented to multiple meetings outside of our hospital, it still has not been presented to our surgical service and likely never will. Unfortunately, politics and economic rewards do play roles in patient care. See the article by Zarin and that by Wexler et al in the Invasive Procedures section of our medical literature for more commentary in this regard. Regarding the toxicity of gentamicin, its use in local injections into the foot, as opposed to its intravenous use, has been free from side effects and toxicity. We have not had a problem with kidney or ear toxicity in 20 years. We generally find trivial amounts in the serum after injection of the foot or toe and now have essentially stopped measuring blood levels. Lost perhaps in this discussion is the central fact: therapy with the Circulator Boot was again able to save a leg in a very difficult situation.