Case 67: Both Legs Kept Functional over 8 Years in Spite of Arteriosclerosis, Neuropathy, Cellulitis, Osteomyelitis, Diabetes, Pernicious Anemia and Dementia

At age 66, this diabetic man was hospitalized at Bryn Mawr July 1988 under the care of a general surgeon and a vascular surgeon. His podiatrist had trimmed a "plantar wart" a few weeks earlier. He had two debridements and six weeks of intravenous antibiotic therapy, two in the hospital and four by the visiting nurse at home. His foot initially remained stable but an abscess developed and led to re-hospitalization on September 30, 1988. His vascular surgeon again debrided his foot and drained his abscess. His ankle/arm blood pressure index was 0.6 in the right leg and the pulse volume curve was flat across his right transmetatarsals. Beta-Streptococci, Staphylococcus aureus, Klebsiella oxytocia and Enterobacter were all cultured and found to be sensitive to gentamicin. His whirlpool therapy and intravenous Cefoxitan appeared not to be helping. He was advised that a leg amputation might be necessary. A Circulator Boot consultation was requested October 4th, 1988.

Plantar Ulcer and Nonblanching Purple 3rd and 4th Toes, October 5th, 1988.

Incision and Drainage Site between 4th and 5th Toes and Rubor of 2nd to 4th toes and of Dorsum of Foot, October 5th, 1988.

Local injections of gentamicin into the foot and intravenous Unasyn , Mini-Boot therapy with his foot immersed in Sea Soaks containing Sea Soaks and gentamicin (and later other antibiotics) were commenced. On October 30th, 1988, he was discharged to receive office booting and home foot soaks. The latter included an initial cleansing Betadine-Sea Soaks soak Followed by a soak of Sea Soaks containing gentamicin, vancomycin, and Urecholine. Oral Bactrim-DS provided systemic antibiotic coverage. His program was modified as necessary in the office. The pictures show his progress.

The 3rd and 4th toes mummified and were clipped off in the office. The planar ulcer healed and the patient chanced a trip with his wife to Europe, November 21, 1988.

The stumps healed. Follow-up May 12th, 1989.

Callus tended to form at the previous plantar ulcer site.

H required insulin to control his diabetes and, unfortunately, he continued to smoke. He developed increasing symptoms of organic brain syndrome along with a stumbling gait. He presented again on March 20th, 1990 with osteomyelitis of his first metatarsal joint.

Swollen Bluish 1st Toe and Penetrating Ulcer into 1st MP Joint, March 20, 1990.

Sloughing of Skin over Side of 1st Toe Exposing 1st MP Joint.

His 1st toe was cut off in the office and his Mini-Boot treatments continued. The amputation site healed and his 2nd toe was pushed over toward the 5th toe. He was ambulatory wearing an air cast during his treatments. June 18, 1991.

Having switched back to a shoe with molded inserts, he developed an ulcer under his 5th metatarsal head that also responded to treatment. March 22, 1994.

Callus tended to form under the 1st MT head but the foot remained intact. August 14th, 1995.

His left foot in the meantime had had problems also. His ankle/arm index had slipped to 0.67 when he presented August 18th, 1989 with an ulcer over his 5th toe bunion and with a cellulitis over he dorsum of the foot to his lateral malleolus. X-rays showed osteomyelitis of the metatarsal head and the MP joint. The left foot was treated like the right: in this case antibiotic injections into the 5th toe bunion area, the MP joint laterally and between the 4th and 5th toes. The latter site was treated because of the intertriginous ulcer at the base of the 5th toe. These all healed and the left foot remained intact until he presented with macerated ends of his 2nd and 3rd toes in August, 1995. When last seen in March 1996 before committal to a nursing home because of dementia, his feet were intact except for a small ulcer under his left 3rd toe.

Bunion Ulcer and Cellulitis of Dorsum of Left Foot and Ankle, June 18th, 1989.

Exposed Bone in Ulcer Depth.

Macerated Toes, August 11th, 1995.

Comments: This man had combinations of problems: diabetes with peripheral neuropathy and peripheral arteriosclerosis obliterans, pernicious anemia (discovered in dementia workup), nicotine addiction, and multiple episodes of trauma and infection related to his progressive dementia. When he was initially referred for boot therapy, standard therapies had failed and leg amputation was being considered. With boot therapy, his legs were kept functional for eight years. Most of his boot treatments and care were performed in the office. His wife was spared through the eight years the burden of caring for an amputee.