Case 63: Minimal Clinic Attendance Enough to Heal Resistant Ulcer at Amputation Site on Left Foot but Not Sufficient for Right Foot Which Needs More to Heal

At age 59, this bellhop was referred January 16th, 1990 with a 20-year history of insulin-dependent diabetes, a previous smoking habit and a relative weight of 1.08. His job keeps him on his feet most of every day. His left second and third toes had been removed in his community hospital and the skin over the amputation site had sloughed off leaving an ulcer that did not heal in spite of rest and intravenous antibiotics in the hospital. In addition, he had a plantar ulcer in his arch at the site of a previous callus..

Plantar Ulcer at Previous Callus Site

Infected Ulcer at Amputation Site

His deep tendon reflexes were gone and two-point discrimination was minimally increased to 1.5cm. Doppler studies showed pseudohypertension at the ankle. The waveforms were best preserved in the posterior tibial and were low and wide in the anterior tibial and peroneal at the ankle. A low wide waveform was also found in the first dorsal metatarsal artery. The changes in the Doppler waveforms pointed to the presence of moderate arteriosclerosis obliterans. He was treated in the office with oral Bactrim-DS, multi-electrolyte (Sea Soaks) foot soaks containing Urecholine and vancomycin, and the Mini-Boot. Four months later he was healed. Having a forty mile commute for his treatments, once he was stable he limited his program to daily foot soaks at home (the Sea Soaks with Urecholine and antibiotics) and Mini-booting once a week.

The plantar ulcer healed nicely. Small amounts of callus were occasionally trimmed.

Once clean granulations were present, the skin closed in from the sides

This man had many strikes against him: He had not done well with his previous therapies. His job required a lot of walking. He was commuting from another state. He had limited health coverage. He was not able to come for daily treatments. Still, he did follow directions, wear a walking air cast and boot when he could. In the case of his left foot, it was enough.

October 21, 1991, he presented again with the necrotic spot shown above under his left 1st metatarsal head.

Abundant Staphylococcus aureus (sensitive to Bactrim, clindamycin and vancomycin) was cultured on the 21st of October from his new right foot lesion. X-ray showed no osteomyelitis. Hospitalization for intravenous antibiotics, debridement or ray amputation was refused. He preferred outpatient treatment with a walking Air Cast and our usual treatments (oral antibiotics, Mini-Boot after local antibiotic injections, and usage of Sea Soaks containing antibiotics both at home and in the Mini-Boot. Unfortunately, he again showed up for treatments when the spirit moved him. This time it was not enough

Feb 18th, his lesion extended around the head of the first metatarsal.

Feb 25th, necrosis extended across the dorsum of the foot to the second metatarsal and the big toe was mummifying.

The entire first toe appeared lost.

Finally sick and febrile, he did agree to hospitalization 2/25/92 to 3/9/92. Intravenous antibiotics, local antibiotic injections and Mini-Boot treatments with his foot immersed in Sea Soaks constituted his treatment. He was not interested in surgical procedures. Autoamputations as necessary were planned. His temperature became normal. His diabetes was controlled and he appeared to be doing well. He requested discharge to attend to business.

.

May 5th, the first toe has been disarticulated. metatarsal.

July 14th, bleeding after removal of a spot of necrotic tissue.

July 28th, healthier tissue developing..

Obviously necrotic material was removed at his office visits. Again because of financial concerns, he managed 3-4 visits (and boot treatments) a month through July 1992. He had gone on disability and remained home where he did continue his foot soaks with Sea Soaks and appropriate antibiotics. His foot gradually healed.

.

Here he presented to have callus trimmed from his fully healed foot, December 1st, 1993.

Comments:It is easy to say that this man would have done better and healed sooner if he had attended his treatments more frequently and consistently. He developed his lesions after many years of smoking and poorly regulated diabetes. Free access to medicine has not greatly reduced either of these risks factors. Education may have an effect. This uneducated man did what he had to and little more. His illness was prolonged but he was able to heal both legs.