Case 44: Boot Heals Transmetatarsal Dorsal Flap

Patient RC was a 58 year old diabetic with a long history of peripheral vascular disease approached with multiple surgical; interventions: (1) March 1970, aorto-iliac endarterectomy; (2) August, 1970, iliac endarterectomy; (3) 1973, aorto-iliac bypass; (4) June 1975, revision of left graft anastomosis, thrombectomy of right profunda and of the left limb of the graft, and a sympathectomy; (5) November 1979, a dacron femoropopliteal bypass graft on the left; (6) December 1979, a left saphenous vein femoropopliteal graft; and (7) January 21, 1980, a left transmetatarsal amputation. At the time of the latter procedure, the patient was complaining of claudication, a swollen tender foot and an ischemic discolored big toe. After 100 days of conservative care by his surgeon, his dorsal flap had not healed and was held in place with Steri-tapes.

Non-Healing of Dorsal Flap

Non-invasive vascular testing at the ankle showed trace pulse waves on an electronic oscillometer and broad low Doppler waveforms at the posterior tibial artery. Only faint sounds were heard over the anterior tibial and no clear waveforms forms could be recorded. The blood pressure was read as 80 at the posterior tibial and less than 20 m Hg at the anterior tibial. His brachial pressure was 110 mm Hg.

Doppler Waveforms at the Proximal Dorsalis Pedis (Distal Anterior Tibial) at the Ankle on Presentation

Almost Flat Electronic Oscillometry Tracing at Ankle on Presentation

He received twenty-eight outpatient boot treatments from May until he was healed in July. Periodic vascular testing showed slow improvement in his blood flow. Poorly formed Doppler waveforms developed in his dorsalis pedis and in his electronic oscillometer at the ankle. His foot healed. His claudication lessened . His golf game, he claimed, improved. He subsequently required monthly booster treatments to maintain his leg comfort.

Detectable Doppler Waveforms in Dorsalis Pedis on June 11th

Improved Waveforms on the Electronic Oscillometer on June 11th

Healed and Ambulatory in July

Comments: This man raises lots of interesting points. Yes, booting has a role in helping to heal postoperative wounds. No, a palpable pulse is not necessary to heal a wound. We do find that the presence of at least an audible Doppler signal in the artery immediately serving the wound area is necessary for healing... and the sound should be pulsatile as opposed to constant. Likely with his complaints prior to his transmetatarsal amputation, we would have tried to heal him without the surgery; he merely had a discolored big toe and a swollen foot. In general, it takes more blood flow to heal a foot than it does to maintain it. Again, any amputation disrupts the flow through the small vessels and it takes modest flow to recover from the insult of the procedure. Insurance companies are wary of "maintenance" physical therapy. In this man, his leg would tighten up if he went a month without booting. Is the monthly "booster" treatment a maintenance treatment or a treatment of another "acute" episode of ischemia? If such patients are allowed to go several weeks into their relapse, it becomes increasingly difficult to reverse their problem. If they visit their vascular surgeon during one of these "relapse periods", they may be advised to try another bypass procedure as "booting obviously does not work". Which is cheaper and safer, monthly booting or another vascular procedure? Depending on the vascular surgeon, the vascular procedure may be attempted and the limb all too frequently lost.