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Case 24: Early Treatments and Few Problems - Cardiac Output Improved
This lady had been referred for bizarre insulin reactions. She had repeated spells of confusion attributed to her diabetes but associated with normal blood glucose levels. While her blood glucose levels did fluctuate widely, she proved to be myxedematous and her unusual reactions disappeared when her thyroid deficiency was corrected. She first complained of her feet in our office on April 26, 1984; she had a persistent tenderness and rubor of her instep. The possibility of cellulitis was considered and she was given a ten day course of ampicillin. The tenderness and reddening appeared to worsen. She was given a ten day course of Keflex. She was also advised to rest her foot as much as possible. The nature of her problem was not clear. Doppler studies showed her posterior tibial artery disappeared just below the malleolus; along the course of the redness no sounds were heard. Beginning on May 18th, the reddened areas were then infiltrated with gentamicin and her foot was pumped in the Mini-Boot. The pictures show her course..
 Beginning Boot and Gentamicin therapy |
 Second Day of Therapy |
 Followup 5/30 - No Treatments for Four Days |
She subsequently has had more typical foot problems. Her hammer toe deformities tend to promote plantar callus in spite of her prescribed footwear. On 11/13/85, for example, she presented with an infected ulcer in the callus beneath her 4th metatarsal head. A culture grew out Staphylococcus aureus, Staphylococcus epidermis and Enterbacter cloacae. She was given a prescription for Keflex and started on boot therapy. Our office procedure for her then was as follows: The lesion was first cleaned in sterile filtered sea water and Betadine. The lesion was infiltrated with gentamicin and the foot was then pumped in the Mini-Boot. When the antibiotic sensitivities of the organisms became known, her program was changed to include the addition of chloromycetin to Sea Soaks which was then used within the Mini-Boot. Her lesion quickly dried up.
 Infected Plantar Callus and 2nd Toe Sore Already Some Improved on 2nd Day of Treatment |
 12/4/85 Both Lesions Healing Nicely Necrosis |
She has learned to report lesions early and get treatment early. Thus, she has had courses of treatment for her left foot in 1987 and 1990 and for her right foot in 1992. The last episode was also timed with increased angina. At that time both feet were treated in the Long-Boot both relieving her foot problem and relieving her angina. She has recently participated in our heart study with the IQ electrical impedance monitor. The latter allows us to monitor many cardiac indices noninvasively before, during and after boot therapy. The increased output curves depicted in her study shown below correspond to an increase in her cardiac output from 5.34 L/min. to 14.26 L/min. Associated with this study and its three week course of treatment, was a significant reduction in her angina..
 The Top and 3rd Rows are her EKG tracings. The 2nd row is the baseline IQ curve and the 4th row is the IQ curve during boot therapy. |
Her hammertoe deformities continued to promote plantar callus and pull the skin tight over her metatarsal-phalangeal joints. The joints were readily palpable. Her husband was taught to sand down the callus. On occasion, however, debridements were necessary and small infected ulcers found. The latter were treated with local antibiotics and Mini-Boot therapy. To lessen the recurrence of such callus, her extensor tendons were cut to allow the toes to fall into a straighter position. The effect is seen in the pictures below.
 Here we see that the proximal phalanx of the big toe almost makes a right angle with the dorsum of the foot. The marked dorsiflexion was pulling the skin and fat pad tight over her metatarsal-phalangeal joints and reducing the padding over the joints. |
 The flexure tendon was cut allowing the big toe to partially straighten out 2/10/98. In this follow-up film 3/24/98, the improvement is readily seen. The plantar skin had more play. |
Comments: As of August 15th, 2000, this lady has not lost any portion of her feet. She is a good example of rapid response in the outpatient area. She has been seen early before extensive lesions have had time to develop. Her heart data is included to demonstrate again how the Circulator Boot differs from other external compression boots. Patients in heart failure, for example, may have purple feet; they constrict their circulation to maximize flow to their more vital proximal parts. A lymphedema boot will not relieve heart failure. Indeed, in forcing fluid toward the lungs it may actually worsen the condition. Here we see a large increase in cardiac output that may be attributed to the end-diastolic timing of our apparatus. The boot may also be set to pump during systole as a form of a stress test. In doing the latter, cardiac output is found to go down in patients with heart disease and remain relatively unchanged in our normal volunteers. For more data on the effects of Circulator Boot therapy on the heart, see Dillon Angiology 1998 in our boot library.