Case 50: Chronic Bunion Ulcer Improved, Complicated by Osteomyelitis and Then Cured

This 76 year old type 2 diabetic former smoker presented with a three month history of a nonhealing bunion ulcer. He had two-five block claudication, a history of a previous myocardial infarction and a history of a previous femoral-popliteal bypass. His ankle/arm index was 0.48 and his Doppler waveforms were low and broad at the ankle. His photoelectricplethysmographic waveforms were also low to absent on most toes but were measurable on the big toe. Below are shown the effects of booting on the PPG tracing of the big toe.

Photoelectricplethysmography (PPG) Analysis during Boot Therapy with the PPG Probe on the Dorsum of the Big Toe and the Boot Bag Compressing the Leg from the Groin to the Ankle

It is seen that the height of the PPG waveform was increased 20-fold from 5mm (40:1) to 25mm (10:1) or 100mm (40:1) mm during 2:1 booting with the Long-Boot. However, as he had mostly tibial vessel disease and he was presenting with an infected ulcer, he was treated with local antibiotics and the Mini-Boot.

Begun on Mini-Boot Therapy and Appeared to Be Slowly Healing

He had been self-referred to our office and returned to his family physician for his routine checkup. "What's boot therapy?", said the physician. "Here's where I want you to go"... and off he went

Returns with Cellulitis from Toes to Instep

And X-Ray Findings of Osteomyelitis of the First Metatarsal Head

Ulcer Almost Healed and Post-Inflammatory Pigmentation on Dorsum of Foot

As he did not live in our community and commuting was difficult, he was hospitalized in Bryn Mawr for two weeks and given intravenous antibiotics, local injections of gentamicin into the joint space and Miniboot therapy. His foot gradually healed.

Comments: This man then developed a major problem with his left foot, which seemed to respond to therapy. He chose, however, to summer in South New Jersey, his foot deteriorated, he developed a Pseudomonas pneumonia and eventually died. Other pictures of this man's difficulties may be added later. The history and pictures given here illustrate PPG response to booting, the problem of interruptions in therapy that accompanies outpatient programs, and a favorable outcome of a bunion ulcer complicated by osteomyelitis.