Case 66: Two Legs Do Poorly with Bypass Surgery but Do Well with Boot Therapy Once It Is Aggressively Applied

At age 70, this "type 2" diabetic domestic worker had had an unsuccessful femoropopliteal bypass in the left leg along with a sympathectomy at an academic center with an aggressive wound healing clinic. Her vascular surgeon advised a BK amputation. The end of her first toe was black and necrotic as was the middle of the second toe where it abutted the first toe. The ankle/arm index of her left leg was 0.22 and her right 0.82. PPG tracings of her toes were flat. She was admitted July 26th, 1991 to the Bryn Mawr Hospital for intensive booting and, after several days, transferred to our long term nursing boot facility where it was continued. In both facilities she was booted four times daily. Once her pain was controlled and healing obvious, she was discharged to complete healing with office treatments.

She presented with black necrosis of the first toe and adjacent aspects of the second toe, July 26, 1991.

She was fully ambulatory and auto-amputations of the first and second toes healed, June 17, 1992.

She returned January 22, 1993 with a small ulcer on the right medial shin. Doppler flow was found to be lost down her right posterior tibial and peroneal arteries. Having finished the prolonged course of booting described above on her left leg and relying on others for transportation to the office, she was hesitant to commit to daily booting; she was booted 1-3 times a week and by the end of April appeared to be well-healed.

She returned January 22, 1993 with a painful shin ulcer on the right leg.

After modest amounts of outpatient booting, only a small scab persisted at the ulcer site, April 27, 1993.

Her ulcer, however, quickly recurred, perhaps encouraging her employer and previous vascular surgeon to suggest bypass on the right leg. The surgery proved difficult and her course became complicated. On Aug. 6th, 1993, she had an arteriogram and on August 9th, she had a right femoral-tibial bypass. On the 19th, she had a thrombectomy and ligation of presumed A-V communicators. Her arm/ankle index was 0.37. Her leg subsequently swelled with lymph fluid and it appeared that lymph channels had been ligated. On September 6th, calf muscle and muscle compartment transfers were accomplished by the plastic surgeon to restore a lymphatic outlet to the lymphedematous lower leg. A skin graft was attempted to close her ulcer. The graft appeared to take but later sloughed off in part and her ulcer extended distally. She then returned to regular booting. The ulcer healed proximally but extended distally towards the foot. She was ambulatory but in modest pain during this time interval. Eventually, she healed totally and as of this writing in December, 1996 is healed and ambulatory.

The ulcer extended distally. The exposed tendon was cut away. She received predominantly Mini-Boot treatments.

The proximal margin of the ulcer healed moving distally eventually leaving a small ulcer at the ankle which healed.

Comments: This lady illustrates several points. Both legs were salvaged when her surgeons had lost hope. Both legs eventually required lots of booting. A therapy once or twice a week will not be effective in patients with severe impairments. The boot restores blood flow proximally before it improves it distally. Here the ulcer actually migrated distally. Failure to heal or relapse of a lesion commonly is interpreted by the surgeon as an indication for amputation or bypass when more frequent boot treatments may adequately improve blood flow to allow healing or pain relief. Regional vascular insufficiency does occur; here the lower medial shin was very ischemic and broke down while the foot and posterior calf remained healthy. While third party payers attempt to avoid such protracted therapy programs, the patient is always grateful and pleased to have both legs. The cost considerations of many third party payers do not include quality of life; independence in ambulation, diet and toilet needs; home nursing costs; nursing home costs; and changes in life expectancy. While it is said to be the function of insurance programs to allow patients to have chronic and expensive care, many of the for-profit managed care groups today would not have allowed this lady to undergo her treatments.