Case 73: Both Legs Salvaged in Blind Manic-Depressive Man with Poorly Controlled Diabetes, Failed Bypass, Extensive Leg Necrosis and Osteomyelitis

MG presented at age 75 with a history of having diabetes for 27 years now complicated by cataracts, retinopathy, proteinuria, peripheral neuropathy, peripheral arteriosclerosis obliterans and a manic-depressive disorder. He developed an infection of his right second toe leading to initiation of boot therapy. He had little patience for the procedure and requested consideration of angioplasty and bypass. An arteriogram showed no continuous flow in either calf. Angioplasties of both the right popliteal and the right peroneal arteries were accomplished with little effect on the blood flow to his foot. He bled into his tissues after the procedure leading to swelling and discoloration of his scrotum, hip and thigh; the swelling was reduced with Long-boot therapy and his lymphedema proved to be transient. Mini-Boot therapy was continued for his foot and his toe demarcated. He chose surgical amputation rather than wait out an autoamputation. The amputation was a success and the right leg was no problem the rest of his life.

Faint calcifications in the scout film outline the course of the femoral arteries.

The popliteals were likewise visualized

And the anterior tibial was seen in the lower leg.

Doppler studies had shown good flow in his anterior tibial at the ankle, poor flow in his posterior tibial, peroneal and first metatarsal arteries and no flow in the 2nd and 3rd metatarsal arteries.

The arteriogram showed stenoses in the popliteal and peroneal arteries.

The stenoses were successfully dilated.

The anterior tibial stopped just above the ankle and there was no direct runoff into the foot.

A dorsalis pedis was seen in the foot but there were multiple stenoses in the foot and the metatarsals in the midfoot were not visualized.

After the angiogram and angioplasty, he had ecchymoses in the pubic area, in his groin, over his hip and down the lateral thigh. There was an oval swelling in the upper anterolateral thigh. He was treated with the Long-Boot and the findings proved to be transient.

He received Mini-Boot therapy after his toe was amputated. He eventually healed and the leg remained intact until his death 8.5 years later.

His left leg was another story. He presented with an infection of his left 2nd toe in the fall of 1992, again leading to the initiation of boot therapy. The cellulitis was quickly controlled but the infection penetrated into the distal IP joint and the patient determined that his toe was lost and he needed an amputation as he had had with his other foot. He went to his vascular surgeon who performed the amputation and a femoral-tibial bypass. Unfortunately, the bypass became occluded and the entire right anterior shin necrosed developing a black eschar from his tibial tuberosity to his ankle. At the same time, his toe amputation site broke down and he necrosed parts of his first and third toes. He refused leg amputation and requested boot therapy. He was transferred to our long term nursing-boot facility and begun on both Long- and Mini-Boot treatments. His manic-depressive state, his deafness, his blindness and his lack of cooperation complicated his nursing care. He had a living will requesting no unusual treatments... but boot therapy was desired. He did not want antibiotics but those given in the boot and injected locally were accepted as were some oral antibiotics. He fought with the nurses over his insulin and the fingerstick technique used to do bedside glucose determinations; most often he refused to allow his blood glucose level to be determined. His daughter tried to make his life more pleasant providing him with sweets. He ate irregularly. When his glucose was determined, it was generally either very high or low. When the nursing home boot service closed, he chose to commute from the nursing home to the office for boot treatments. From time to time, he tripped or fell in the nursing home traumatizing his legs and opening small lesions. Still, his leg and his foot healed and he became ambulatory. Still he was depressed in spite of the lithium provided by his psychiatrist. He frequently requested help in dying. In December, 1996 he again traumatized his leg opening a lesion which became infected. He refused blood tests. His usual doses of insulin was continued blindly. No antibiotics were prescribed as his will requested. Boot therapy and local antibiotics were discontinued. He became comatose and died.

His second toe infection improved but the ulcer at the distal MP joint penetrated into the joint.

This picture was taken February 25, 1993 at the nursing-boot home. The edges of the black eschar have been debrided back to allow access for our wet-to-dry dressings, which contained Sea Soaks with appropriate antibiotics, to the underlying tissue. This process of debridement, soaks and pumping had successfully healed the skin from the knee to the mid-shin. Note the scarred in tissue over the upper shin and lateral leg. Note also the necrosis of the 2nd toe amputation site and the small ulcer at the base of the 3rd toe. Osteomyelitis was present in the 2nd metatarsal head and eventually in the 3rd MP joint. These areas were injected locally with appropriate antibiotics. While his shin was healing, the outer distal portion of the big toe necrosed and became infected. This area too was then injected with antibiotics.

June, 1994: His leg was well healed and he was ambulatory.

His big toe healed also but the osteomyelitis and ulcer at the base of the 3rd toe was more indolent.

His leg served him well up to his final illness. Here he has skinned a small area of his lower leg, August 6th, 1996.

Here he had traumatized his 1st and 4th toes. August 6th, 1996.

Comments: The adverse events in the history of this man were associated with invasive medical procedures... a swollen ecchymotic leg, a failed bypass and necrosis of his lower leg. The angioplasty of the right leg had little benefit likely because of the severe distal occlusive disease. He was largely treated in our nursing-boot facility by a lay immigrant technician who spoke poor English. The nursing home itself is likely of average quality, being cited by Medicare periodically for various infractions. The patient had obvious severe arterial occlusive disease. The diet, diabetes control and overall cooperation of the patient were poor. Still in spite of these adverse factors, his boot program was able to salvage both legs.