Case 30: Last Leg Saved in Lady with Multiple Lesions

At age 73, this lady presented on May 19th, 1993 with a history of type 2 diabetes mellitus, an appendectomy and cholecystectomy in 1957, coronary artery bypass surgery in 1980, right leg femoral-tibial bypass in 1984, coronary artery angioplasties in 1983 and 1984, a second coronary artery bypass in 1986, a mastectomy for breast cancer in 1986, a right toe amputation in 1989 and a right leg amputation later in 1989. Her diabetes had been poorly regulated on oral agents with her records showing blood glucose levels commonly in the 150-200 mg/dl range.

Her current problems began on February 19th, 1993 when she was hospitalized for a cellulitis of her left leg for three weeks. Her cellulitis improved with her antibiotic therapy but she developed ischemic lesions on her big toe and ulcers remained on her lateral leg and instep. She had an arteriogram which showed an occluded superficial femoral artery, few collaterals in the lower leg, an open upper segment of the popliteal and loss of the lower popliteal, peroneal and posterior tibial arteries. The anterior tibial artery was occluded both proximally and distally and there was no runoff into the foot. Even if she had a vein available for bypass, and she did not, she would not have been an ideal candidate for the operation.

In the left leg, the superficial femoral, lower popliteal, the proximal and distal anterior tibial, the peroneal and the posterior tibial arteries are all occluded.

She was referred May 19th, 1993 for boot therapy. Her femoral pulse was 2+ (quickly found with firm palpation); more distal pulses were absent. Photoelectricplethysmographic tracings of her toes were faint to absent as were Doppler tracings of the tibial arteries at the ankle and the pulse volume tracing in the midfoot. Low rounded pulse volume waveforms were found in the thigh down to the ankle.

Left Foot on Presentation: Note penetrating ulcer in the instep, three areas of focal necrosis on the big toe and bunion and the purple blood blister on the end of the second toe

The lower third of her left lower leg was ruborous. The lesions shown were painful and walking was impossible. She was fortunate enough to have a dedicated husband who initially could transport her by wheelchair for all of her evaluations and treatments. She had a large eschar over her lateral lower calf. This lesion also was quite painful. A portion of the eschar was cut away at the time of her initial photographs to show a yellow necrotic base to the lesion

Lateral Leg on Presentation: Note discoloration beginning in midcalf, large necrotic lesion in lower lateral leg and necrotic lesion in instep.

She was given both Long-Boot and Mini-Boot treatments. During the long boot treatments, the air bag was placed to cover the area between her groin and her ankle; improving the arterial flow across the thigh and knee was the goal. Dressings wetted with Sea Soaks and appropriate antibiotics were kept on her lesions during the boot treatments. During the Mini-Boot treatments, the air bag extended from her knee to her toes; the goal was to improve the arterial flow in the calf and into the foot. When her lesions were dry, the boot therapy might be done dry. When her toe lesions were open and granulating, for example, the Mini-boot treatment was performed with her foot immersed in Sea Soaks and appropriate antibiotics. Occasional small debridements of loose eschar or callus were performed as necessary. Her pictures tell her story..

Her overall skin color is improving but the big toe lesions, which are at the "end of the line', are coalescing . 9/27/93

The lateral leg ulcer is now smaller and has clean granulations. The instep ulcer persists. 9/27/93

The toe lesions have coalesced further and appear as brown eschar. The skin is healthy but pink.10/11/93

Skin is growing at the margin of the leg ulcer and the instep lesion is smaller. 10/11/93

The toe eschar has separated leaving poor granulations. Bone of the distal phalanx is showing. 4/1/94

Only a small area of the leg ulcer persists and the instep ulcer is closed. The toe ulcers were healed now also. 5/1/95

Final Picture of Foot

Final Picture of leg. 7/3/95

She was pain-free after the first few months of therapy and able to use her prosthesis and ambulate later in her therapy. She commuted over 70 miles daily for much of her treatments. Recently she was again found to have a cancer and has been debilitated in the hospital. Her husband, who has become more aware of vascular problems than most men (watching his wife and seeing other patients undergoing treatment in our offices) is worried lest her leg break down again. He would like boot treatments to be provided in his local hospital. If she recovers sufficiently to travel, he plans to bring her back.

Comments: This lady was treated over two years. Initially, she was seen six days a week. Later she was tapered to three days a week. She is a delightful lady... but one who has been extremely expensive for the health system:. two heart operations, two coronary angioplasties, a leg bypass, a toe amputation, a leg amputation and then boot therapy. The latter likely was among the least costly and least risky procedures. And the boot treatments might have been less costly had they been begun earlier when she noted claudication. Hopefully, some day there will be an economical procedure (boot or other) available to head off problems like hers. Obviously, close attention to risk factors would help. In her case, boot therapy allowed her to escape a second leg amputation and to maintain her mobility for a few years. The costs of her boot therapy, of course, are to be compared to the costs of a second leg amputation and the subsequent cost of care for a bilateral amputee.