Case 53: Ischemic Cellulitic Foot with Bare Osteomyelitic Bone Saved

Patient BR was discovered to have diabetes about the 14th of August 1993 and was referred to a community diabetologist who started him on oral agents. He had a history of a myocardial infarction in 1975. Because of a non-healing ulcer of the great toe, he was sent for vascular studies and admitted to the hospital. His admission white count was 20,800. His bilirubin was 1.5mg/dl. Multiple bacteria were grown from his foot drainage: E-Coli, Enterococci and Diphtheroids. In addition, Beta-streptococci were grown from tissue taken from his first toe. On August 20th, his foot was debrided in the operating room. On August 30th an arteriogram and a femoral-tibial bypass graft were accomplished with the distal anastomosis into the posterior tibial artery 13 cm below the knee. The runoff was patent to the distal calf. September 1st, he was referred for boot therapy..

Presenting to the boot service with a black eschar extending from his mid-arch to remaining proximal phalanx of his big toe which was hard and mummified.

His overall physical fitness was poor. He had significant myocardial ischemia. His cardiologist obtained an ECHO-cardiogram which showed a dilated left ventricle with an ejection fraction estimated at best to be in the 30-35% range. His vascular surgeon again debrided his foot on the 8th of September. His urologist cystoscoped him on the 21st of September and found an atonic neuropathic bladder. Thereafter, he emptied his bladder with a Foley catheter or, when at home, with multiple self-catheterizations. His problems weighed heavily on his spirits and he was greatly depressed; he commonly lay on his back without moving for many hours; he developed a large sacral decubitus.

The distal first toe has been amputated. The plantar surface of the proximal phalanx is bare and dry. He was given a walking cast and discharged to care in the boot office. September 27th, 1993

His hospital "boot program" included local antibiotic injections into and around the compromised portions of the foot and Mini-Boot treatments. In the office, his sacral decubiti were irrigated with Sea Soaks and antibiotics and packed with gauze wetted with appropriate antibiotic solution. His decubiti slowly healed. He initially was given Mini-Boot therapies with his foot immersed in Sea Soaks and appropriate antibiotics. The latter were chosen from the culture and antibiotic-sensitivity data periodically obtained: February 1994, Diphtheroids and Coagulase-negative Staphylococci; May 1994, Enterobacter cloacae; and August 1994, Pseudomonas aeruginosa. As his tendency to develop congestive heart failure and his fatigue were apparent, Long-Boot therapy with the bag extending from his groin to his ankle or instep was also introduced.

The arch is closing. The edges of the bone on the first phalanx were periodically shaved away to allow granulations to cross marrow and the bone, November 13th, 1993.

Further coverage of bone and arch, December 14th, 1993.

As the overall healing of his foot improved, the patient was offered the option of returning to the hospital to have the exposed portion of his first proximal phalanx removed surgically to speed his course. He refused. Rather he continued to wear his walking cast and tried to return to work. He found even part time work exhausting, however. As his foot healed, he was tapered back on his booting and, as a single man, spent more time by himself at home. He became progressively weak and malnourished. He began to fall at home and was unable to rise form the floor. A two week hospitalization improved his overall status somewhat in March of 1996, but he relapsed at home and soon died.

Clean white bone cortex is still exposed distally, April 1994.

Small spot still to go...Getting treated twice a month. October 1995.

Comments: This man is an example of the damage infection can do if it is not aggressively and effectively treated early. The extent of the damage to this man's foot was alarming to many who felt a leg amputation was indicated. The exposure of dry bone again was an indication to many for removal of his first ray assuming that dry infected exposed bone could never heal. They were obviously wrong. The man did well while he was regularly under treatment. Finding himself unable to work and having great difficulty, in spite of our letters attesting to his multiple problems, in obtaining disability insurance payments, he both missed meals and his boot sessions. The Long-Boot sessions had appeared to benefit his cardiac status and energy levels. He failed in spirit and body and died.