Case 48: Multiple Large and Small Lesions of Both Legs Treated Successfully over Eight Years

This diabetic handyman was referred by his family doctor for a small paronychia of his big toe that was not improving with oral antibiotics(first photograph). His baseline vascular testing revealed evidence of patchy tibial disease in his leg; his brachial blood pressure was 172 mm Hg while the pressure in his leg differed at each site measured: 146 in the posterior tibial, 78 in the anterior tibial and 72 mm Hg in the peroneal arteries at the ankle. His dorsalis pedis was not detectable by Doppler and his posterior tibial disappeared below his internal malleolus. He was treated with the Mini-Boot and a few local injections and his foot color improved, his lesion disappeared and he believed his sensation became normal.

Reddened Right Foot and Especially Ruborous Toes 8/25/83

Color of Right Toes Closer to Rest of Foot but Still Reddened Compared to Left Foot

A responsible man in need of money he returned to work only to come back a few months later with an area of focal necrosis on his big toe. He had a few treatments, felt better and was again lost to follow-up.

Focal Necrosis of 1st Toe and Rubor of Foot 11/2/83

Focal Necrosis of Big Toe

He returned five months later with lesions on all five toes (photograph below). His blood pressure readings at the ankle were now 146 in the posterior tibial, 80 in the anterior tibial and 178 mm Hg in the peroneal arteries while his antihypertensive medications had lowered his brachial pressure to 110 mm Hg. Mini-Boot therapy and antibiotic soaks were again begun.

Breakdown of Four Toes 4/27/84

Infection Controlled and Lesions Dry 5/4/84

Autoamputation of End of Second Toe and Other Toes Intact 1/28/85

He again was ambulatory but limited by his coronary disease and congestive failure which was followed by his cardiologist and family doctor. He again disappeared to the care of his family doctor and did well until September 1986 when he abraded his lateral leg. He had intermittent boot treatment of the ulcer controlling the associated infection. Failure to continue treatment due to snow storms, however, resulted in new spreading infection and hospitalization, where he was treated with intravenous Ancef in addition to his local injections of gentamicin and boot treatments. When the infection was under control, he was transferred to our nursing center for continued Mini-Boot treatment and then discharged home. Noninvasive vascular testing had shown poor flow in the lateral leg: low waveforms in the peroneal artery and reversal of flow in the anterior tibial.

Breakdown and Cellulitis of Lateral Leg Following an Abrasion 2/24/87

Follow-up 5/2/88, Healed and Ambulatory

Doppler Studies Showing: Close-to-Normal Posterior Tibial Artery (3rd Row); Reversal of Flow in Anterior Tibial (2nd Row); Diminished Flow in the Peroneal (4th Row) and First Dorsal Metatarsal Arteries (1st Row); Low Antegrade Flow in the Anterior Tibial in the Upper Calf (Bottom Row); and a Modestly Good Pulse Volume Flow above the Ankle (Next to Bottom Row)... 12/26/86

He had an occasional toe callus and leg ulcer in the right leg as shown in August 1990. These did well with a few boot treatments.

Big Toe Ulcer 8/90

Small Lateral and Posterior Leg Ulcers 8/90

A few months later, unfortunately, he presented with a necrotizing cellulitis of his left shin and sloughed a large area of skin. Now the left leg received outpatient Long-Boot treatments with multi-electrolyte- antibiotic wet-to-dry dressings. Good granulations were produced (photograph) and the lesion slowly filled in. Occasionally, he was hospitalized by his cardiologist over the years for congestive heart failure. We would like to feel the months that he received Long Boot therapy for his leg lesions benefited his heart at these times; he generally was less dypsneic then. His leg treatments kept him ambulatory most of the years from 1983 until his sudden death in March of 1992.

Sloughed Skin Down to Muscle and Tendon of Left Leg 10/9/90

Producing Good Granulations during Outpatient Treatments

Leg Ulcer Close to Healed 11/6/91

Comments: This man was a good simple fellow who unfortunately had poorly controlled diabetes for years prior to presenting for his first foot problems. His heart and kidney problems made him an increased risk for any surgical considerations. He had a good conduit (his own bypass) in the posterior tibial to the ankle level. Unfortunately, the runoff into his foot was poor. Indeed, the collateral flow around his right calf seemed to be poor also perhaps explaining his large lesion in the distribution of the anterior tibial and peroneal arteries. His neuropathy compounded his problems likely contributing to the advanced state of many of his lesions when he presented. Most of his lesions were handled in an outpatient setting. Usual routes of antibiotics did not seem effective for him. He and his family were extremely grateful for his care in the boot facility. They and his other doctors attributed the maintenance of both of his legs to our staff.