Case 47: Open Ray Amputations Avoided

This 78 year old diabetic lady developed an infection after stepping on a tack. She was hospitalized for a week in her community hospital (hospital bill $15101) where she had two incision-and-drainage procedures and was advised she should have her toes and metatarsal heads removed. At her family's request, she was transferred to Bryn Mawr for boot therapy.

Reddened Dorsum of the Foot and Compromised 2nd and 3rd toes on Presentation

Purple Second Toe Thought To Be Non-Viable

Her white count was 14000 and her culture grew out Staphylococcus aureus. She was begun on intravenous Impenem and local injections of gentamicin into the obviously infected and cellulitic areas. The injections were given once daily and followed by Mini-Boot therapy with her foot immersed in a bath of multi-electrolyte solution (Sea Soaks) containing Vancomycin and gentamicin. Once stabilized, she was transferred to our nursing home facility where the she received antibiotics orally, locally by injection and in the Mini-Boot bath. The pictures tell her story.

Infection Controlled at 13 Days but Damage to Repair

Booting Continues in Antibiotic Solution

Six Weeks and Almost Cured

“BandAid and Neosporin Stage”

Follow-up and Healed

Fully Ambulatory

She returned 4/10/92 with a superficial ulcer of her left foot that had not healed over two months. It responded quickly to boot therapy . The ankle/arm index of her left leg was 0.65. Finally, she returned for a visit in February 1994 then suffering from congestive heart failure and a few superficial lesions on her right calf. Long distance commuting was too much for her and we did not see her again. She died In May 1994.

Comments: Tissue damage from infection is commonly and unfortunately equated to ischemic gangrene. The enzymes elaborated by bacteria can damage tissue and can cause a chemical and bacterial arteritis that will promote local thrombosis of small vessels and indeed produce ischemia. In this case the tissue was damaged but not irreversibly once the infection was controlled. Our local usage of antibiotics ensured a effective antibiotic tissue level where we needed it. The boot helped keep the vessels patent, reduced swelling and disseminated the injected antibiotics. The denuded tissue was benefited by the use of multi-electrolyte solutions providing a media in which the cells could thrive.