Case 42: Successful Therapy of Osteomyelitis of the Os Calcis and Peripheral Ischemia in Stroke Patient

This patient was transferred from a nursing home to the Bryn Mawr Hospital on the 4th of November 1993 to the service of her family physician. She had been receiving local foot care, antibiotics and surgical debridements in the nursing home under the direction of her podiatrist. She presented in the hospital with a cool cyanotic foot and a large heel ulcer. A bone scan was read as showing osteomyelitis of her os calcis. The infectious disease consultant described a necrotic heel eschar several centimeters across with minimal surrounding reddening or reaction of the tissue. An arteriogram showed marked atherosclerosis of the superficial femoral artery, a diminutive popliteal, proximal loss and distal reconstitution of both the posterior tibial artery, which did extend into the foot, and the peroneal artery, which was lost again above the ankle. The anterior tibial was occluded proximally. On the 17th of November, the vascular surgeon did a femoral to distal posterior tibial in-situ bypass and a debridement of the heel. Her postoperative vascular studies showed ankle/arm indices of 0.9 in the right leg and 1.18 in the left leg. Her heel cultures grew Staphylococcus aureus, Xanthomonas and yeast. Boot therapy was requested. At that time, her right leg was flaccid (hemiparesis from the previous stroke) and her foot was relatively anesthetic. The infectious disease consultant favored additional heel debridements to remove all infected bone and tissue. In lieu of the latter, Mini-boot therapy with both local antibiotic injections prior to the therapy and antibiotic-Sea Soaks solutions within the boot were commenced in the hospital. She was transferred back to the nursing home and plans for transportation to the office for outpatient boot therapy were made. On December 30th, the nursing home reported coldness and mottling of her foot. Doppler testing revealed monophasic sounds at the ankle suggesting that her bypass was lost. Her compression boot therapy was changed to Long-Boot therapy with the inner bag extending from her groin to the malleoli. Ice storms interrupted her therapy and resulted in another hospital admission for her heel ulcer, for new induration and reddening of her inner thigh (suggesting cellulitis and phlebitis) and for venous distention at the knee, the latter again pointing to venous obstruction. Anticoagulants were begun. After venous testing showed no deep vein occlusion, compression boot therapy was resumed. Again, she was sent to her nursing home residence and the outpatient boot program was continued. Her antibiotics, both oral and local, and her boot treatments were altered as needed. She slowly progressed and her ulcer healed. She was dismissed from boot therapy 2/20/95. The office photographs show that portion of her story.

Settling into the Office Program of Long-Boot, Mini-Boot and Local Antibiotics

Ulcer Smaller, Skin Pink and Granulations Healthier

A Cold Day and Foot Cool but Healed

Comments: This lady had many difficult problems: a paretic leg susceptible to stasis and decubiti, advanced arteriosclerosis obliterans, osteomyelitis of her os calcis, a failed bypass and dependency on others for her care. She did not want to lose her leg. Could the leg have been saved by other means? Was the cost of salvaging the leg justified? Her treatments gave her hope and a brighter outlook on life. The leg did help her in transfers from wheelchair to bed to toilet etc....important things for her and those caring for her. But given her stroke, she was never to walk without assistance again.