Case 59: Inpatient and Nursing Home Aggressive Booting Heal Plantar Ulcer and Salvage Leg

This 67 year old lady was admitted to the hospital with a 25-cent sized foul-smelling ulcer under her right fourth and fifth toes. She had a 1-2 pack per day smoking habit for over 40 years and had had diabetes for 10 years that had been treated with oral agents. Her ulcer and pain had been benefited little from a three-week hospitalization elsewhere where a femoral balloon angioplasty was performed. Leg amputation had been advised.

Necrotic Fat in Base of Ulcer

---

On admission to Bryn Mawr Hospital, it was apparent that her previous antibiotics had not sterilized her lesion; Gamma-streptococcus, E.Coli, Pseudomonas aeruginosa and Diphtheroids were all grown from her lesion. Her admission red cell sedimentation rate was 70 mm/hr and fell to 50 over her two-week hospital stay. The Pseudomonas was resistant to all antibiotics but the aminoglycosides. Serial foot x-rays showed poor bone detail and osteoporosis. Doppler testing showed no detectable flow in the posterior tibial and peroneal arteries at the ankle and only faint flow in the anterior tibial. Pulse volume tracings at the ankle revealed only tremor while faint undulations were present at the calf. Her blood pressure above the knee was 120 mm Hg, in the upper thigh 190 mm Hg and in the arm 137 mm Hg.

Foot Soak in Small Volume of Sea Water and Betadine with Use of Clear Plastic Bag

She was treated first with a cleansing foot soak of Betadine and purified sea water, a hypertonic solution. Her soaks were usually performed with her bagged foot placed in a basin full of water of appropriate temperature so that the water in the basin would push the bag and its contents of soak solution against and around the foot thus minimizing our usage of soak solutions. After the soak, her lesion was usually infiltrated with gentamicin. Then the foot was again bagged, isotonic purified sea water containing gentamicin added to the bag, and the foot was pumped in the Mini-Boot. This treatment was followed by a Long-Boot treatment in which a sleeve was utilized to pump her leg from her groin to her mid-foot. The local gentamicin injections were given only once a day. She had two Mini-Boot and two Long-Boot treatments a day. She was transferred to a nursing home where the boot therapy was continued for three months. Her foot healed and she did well subsequently.

Ulcer Almost Healed with 9x5 mm Scab

Scab Pared Back and Ulcer Healed

Comments: The previous therapy this lady was receiving was not sufficient to sterilize her foot let alone heal it. She was lucky enough to be treated in an era when hospitalizations were not cut short and aggressive boot therapy could be continued in a nursing center. Her lesion was not large but it had been unresponsive to the usual modes of therapy. She did respond to boot therapy but her course was slow. She was relieved of pain within several days. Wound closure took longer. Skin does not grow over necrotic fat. Good granulation tissue must first form and that takes time. An initial aggressive debridement was not done. The foot was ischemic and a debridement was likely to extend and enlarge her ulcer. The described soak and boot techniques sterilized her lesion and slowly and gently debrided it.... and healed it with minimal tissue loss.