Case 54: Boot Eliminates Rest Pain and Timely Injection Instantly Cures Infection

At 83 years of age, this lady had had stasis dermatitis predominantly in the right leg for many years. She developed rubor, swelling and rest pain in the left leg and consulted a senior vascular surgeon at a nearby University Center. An arteriogram showed no opportunity for bypass and she was referred for boot therapy, her pain then of three months duration. She had one-two block claudication of the left leg. She took Percodan at night for the pain in her toes and Hygroton for her leg swelling and arterial hypertension. Her sitting brachial blood pressure was 178/72. She had a left carotid bruit. Her femoral pulses were strong but her popliteal and pedal pulses were absent. She had a small intertriginous ulcer on her left big toe.

Her Legs on Presentation Showing Bilateral Stasis Pigmentation and Recent Rubor of the Left Foot

Vascular testing showed good Doppler sounds down to the popliteals. The left anterior tibial could be traced to the mid-shin but distally no Doppler sounds were found.

Doppler blood pressures were 198 in the mid-thigh and zero at the calf and ankle in the anterior tibial. The posterior tibial could not be detected anywhere. The Doppler tracings were flat.

After boot treatments three to four times a day, each treatment about 40 minutes, for fourteen days, Doppler waveforms were demonstrable in both her posterior tibial and dorsalis pedis arteries and sounds were audible to the base of her big toe. In spite of low blood pressure readings at the ankle (42-44mm Hg), she was discharged pain-free at her request to continue boot treatments as an outpatient. As an outpatient, her pain recurred. A small paronychia was noted and promptly treated successfully with local injections of gentamicin. She continued with boot treatments two-three times a week for four weeks when the vascular tests below were obtained and she was pain-free.

Doppler tracings at the ankle after nine weeks of therapy : dorsalis pedis (upper tracing) with an ankle blood pressure of 88 mm Hg and posterior tibial (lower tracing) with an ankle pressure of 87 mm Hg.

Here she had had two months of treatment and was free of pain.

Her right leg had been asymptomatic during these weeks and had not been treated. It served as a control.

In the right leg, the baseline Doppler tracing (upper) was broad but tall with a blood pressure of 89mm Hg at the ankle. The posterior tibial was faint and had an estimated pressure of 68mm Hg.

The right leg follow-up tracings again showed a broad relatively tall waveform in the dorsalis pedis with a blood pressure of 94 mmHg. On this occasion, the posterior tibial was inaudible.

Her pain reoccurred and she was readmitted to the hospital. An arteriogram was done to determine if she had become a candidate for bypass. In the left leg the superficial femoral was occluded below the mid-thigh; the popliteal was not seen; collaterals were seen to and around the knee; thin collateral flow was seen in the mid-calf; and a few inches of the anterior tibial was seen above the ankle. It was elected to avoid vascular surgery and continue boot therapy.

This arteriogram was taken after 13 months of intermittent therapy. No major vascular continuous conduit was seen below the mid-thigh in either leg.

It was a good decision. She did well for the next two and a half years. She then presented with a painful callus on the sole of her foot. Other than the callus little was to be seen. The Doppler blood pressure in the anterior tibial was 60 mm Hg in keeping with her recent readings. The callus was shaved and a small amount of drainage recovered and cultured; abundant coagulase-negative Staphylococcus was later reported. The callus was injected with local gentamicin which was seen to travel subcutaneously within channels not seen prior to the injection. The injection was followed by Mini-Boot therapy. No further pain and no drainage was seen after the first treatment but she was given two additional injections and boot treatments for good measure. Her legs served her well thereafter until she died of a brain tumor two years later.

The callus under the second metatarsal head was injected. The gentamicin ran up the thin shiny tract toward the web space between the first and second toes and in a faint parallel tract between the second and third metatarsal heads. Her acute problem was solved by the first injection.

Comments: This lady illustrated many points. First, severe ischemia is best served by multiple treatments a day most conveniently in a hospital or nursing home setting. Second, booster treatments may prevent relapse. Third, a severe relapse may require another vigorous course of treatment and does not mean either leg amputation or bypass surgery is indicated. Next, pain in the presence of detectable Doppler flow is quite likely to be due to infection rather than ischemia. Again, early infection may be hard to detect. Finally, early treatment of the infection may relieve the pain and prevent widespread tissue destruction that would require many months of treatment to heal. Also to be appreciated from her photographs is the decrease in her stasis pigmentation, a common finding in our stasis patients undergoing multiple boot therapies.