Case 40: Oxygen Tension Raised, Cellulitic Toe Healed and Toes Preserved in Neuropathic Foot

This 54 year old diabetic man averaged about 225 pounds in weight as a young man. He achieved 320 pounds several years before presentation when the diagnosis of diabetes was made and he was started on large doses of insulin. He required 18 months to heal a ulcer under his first metatarsal head, finally closing the ulcer about a year prior to his current problem. His current third toe problem began with the purchase of a new pair of shoes and was unresponsive to the care of his podiatrist. He was hospitalized in an Philadelphia academic hospital where after three days of intravenous antibiotics he was advised to have an open amputation of his second, third and fourth toes. Preferring to avoid such an outcome, he sought transfer to the Bryn Mawr Hospital.

Swollen and Infected Third Toe with Focal Necrosis of Toe Tip along with Superficial Ulcer and Mild Cellulitis of Shin 5/28/85

His dorsalis pedis and posterior tibial pulses were palpable. Subcutaneous PO2 measurements were made with polarographic technique with two ("A" and "B") electrodes imbedded in his foot and one ("C") in his forearm. The three electrodes had been standardized to identical readings in a standard solution. The readings in the tissue were in artificial units and were interpreted against each other. With his foot dependent, "A" read 15,9 and 17 units; "B" read 10,6 and 8.5 units: and "C" read 26 and 26 units. In the supine position, "A" read 8.5 and 12.2 units, "B"read 7.5 and 5.7 units, and "C" read 17 and 17.5 units. Oxygen tension was higher in the foot in the dependent position but significantly less than in the arm. After Mini-Boot therapy, "A" read 14.2 units, "B" read 22 and 20 units and "C" read 25.5 and 26 units. His glycohemoglobin was 12.4% on admission. Abundant Beta streptococci Group D and Pseudomonas aeruginosa were grown from his toe drainage. He was given cefazolin (Ancef) intravenously the first few days in the hospital. Gentamicin was injected into his swollen toe and distal foot prior to his first daily Mini-Boot treatment. Each morning his foot was initially cleaned in sterile filtered sea water soaks containing Betadine. His foot was pumped in the Mini-Boot in Sea Soak solutions containing gentamicin. On the 16th hospital day, the distal black portion of his third toe was cut off with suture scissors at the bedside. He was discharged at the end of the third week to be followed in the office where he healed uneventfully. He returned for a follow-up picture 10/30/85.

Back at Work and Healed

Comments: The palpable pulses in this man were deceiving. Associated with his neuropathy was modest hypoxia of his tissues. We hypothesized at the time that small thrombi in his foot were broken up by his boot therapy. Today, one might still entertain this idea but might add to it the possibility of vasodilatation due to the local elaboration of prostacyclin and/or nitrous oxide (see vascular hormone literature). Unfortunately, he developed another neuropathic ulcer a few years later and was advised by a friend to visit various other doctors in hopes of a permanent cure. He still had palpable pulses and was advised he again had a neuropathic ulcer. His internist believed the various offered opinions could not be made without an arteriogram and hospitalized him in his hospital for the procedure. He was found dead a few hours after the procedure in his room presumably from a delayed anaphylactic reaction. Unnecessary procedures can be dangerous!