Case 72: Leg Amputation Avoided as Distal Small Vessel Disease and Infection Successfully Treated with Local Antibiotics and Mini-Boot

SL, a former smoker, presented at age 77 in a wheelchair with a history of insulin-dependent diabetes, hypertension and an impaired intellect due to a previous stroke. Her foot had been deteriorating over two months in spite of the care of her diabetologist and vascular surgeon who hospitalized her and provided appropriate intravenous antibiotics (gentamicin, Cefobid and Cephalexin) and local foot care. She was offered a leg amputation or transfer to the Bryn Mawr Hospital for boot therapy. Her daughter chose the latter.

Presentation for Boot, November 20th, 1983./B>

Baseline vascular testing revealed broad low Doppler waveforms in both the anterior tibial and posterior tibial at the ankle associated with blood pressures of 130mm Hg. Doppler sounds in her metatarsal arteries were barely detectable. She was treated in the Mini-Boot with her foot immersed in Sea Soaks containing gentamicin. Forty milligrams of gentamicin was injected into her lesions before the first morning treatment during the first ten days and 500mg Cefazolin in one ml volumes was injected the first four mornings. Initially, as she was combative and uncooperative, she was restrained in her chair. Healing was slowed since she picked at her ulcers and insisted on walking as her foot improved. Once, her foot was stabilized, she was transferred to a nearby nursing home for long term boot therapy where she healed and her daughter chose to keep her because of her impaired mental status. She required additional booting in May 1985, April 1988 and February 1989 when new foot lesions occurred. She kept her leg until her death on June 19th, 1989.

Healed and Ambulatory

Comments: The loss of Doppler sounds in the distal foot to many represents diabetic small vessel disease, an entity challenged by some. This lady had tibial disease along with further loss in the foot. While she remained in the nursing home because of her mental impairments, her ambulatory state greatly reduced her nursing needs and improved her quality of life.