Case 8: Wagner 3 and then Wagner 5 Foot Salvaged

Osteomyelitis of 2nd toe, November 14th, 1988

This middle-aged black trash man with type 2 diabetes was referred for an infected right second toe with osteomyelitis in the distal phalanx in November 1988. His blood pressure ankle/arm index was 0.45. The second toe was treated as an outpatient and responded nicely to local antibiotic injections and Mini-Boot therapy. With ambulation, however, he noted persistent soreness and sought a vascular surgery consultation. An angioplasty and a tibial bypass were accomplished. With time the soreness disappeared.

He returned to work where he was required to wear rubber boots. Unfortunately, water from a trash can spilled down the boots unbeknown to him. An aggressive necrotizing cellulitis developed that did not respond to the initial treatments of his physician. He presented again in February, 1990, for boot therapy.

His 2nd, 3rd and 4th toes had been lost to a necrotizing infection, which extended well into the bases of the 1st and 5th toes.

The necrosis extended well into the arch towards his heel, February 15th, 1990.

Doppler studies showed questionable flow in his bypass. He was advised that the loss of his middle three toes and the necrosis of the bases of his first and fifth toes made it unlikely these toes would survive either. Again, it was pointed out that because of both the necrosis in his arch and the absence of a distal plantar flap which was needed to complete a transmetatarsal amputation, a BK amputation was the most likely site to heal. He preferred to give boot therapy a try..

Outpatient therapy was begun and continued over the next three years. During this time, he used crutches and a walking air cast. His therapeutic program included initial cleansing dilute hydrogen peroxide foot soaks, local antibiotic injections into the obviously infected areas of his foot, Miniboot treatments with his foot immersed in multi-electrolyte solutions containing antibiotics, oral antibiotics and occasional local debridements. His pictures tell his story.

The 1st and 5th toes mummified and were trimmed off.

Metatarsal stubs soon to be clipped off in office

July 29th, 1993, foot healed and shoe with insert obtained

Sensation improved and patient laughing as his foot is tickled

Dorsal view of foot, October 24th, 1997 office

Lateral view of foot

End-on and plantar aspect of foot

As of October, 1997, he has remained ambulatory wearing extra depth shoes and molded inserts. He has lost his wife and fares for himself. He has made few if any doctor appointments and was called in for the above follow-up pictures.

Comments: Prolonged outpatient therapy was possible in this man because he lived nearby and because he had sufficient upper body strength from his job and previous athletic interests to successfully use crutches to rest his foot. His cultures always grew out multiple organisms which, with time became increasingly resistant to antibiotics. For this reason, physical measures were used to attack his infection when possible: debridement of obviously loose and devitalized tissue sparing well-attached eschar, initial cleansing with dilute peroxide and occasional use of silver nitrate sticks in soupy necrotic areas. The most disturbing episode in his treatment was a syncopal spell after a local injection of vancomycin presumably due to a sudden release of tissue histamine. His course might have been shorter if the damage to his foot was not so extensive at presentation. Early referral helps but in a center like ours rarely occurs as the family physician exhausts standard therapies first and then refer on their failures. In most centers, if this man's leg were to be saved, he would have had a prolonged hospitalization, perhaps another bypass with a vein from the other leg and multiple debridements in the operating room leaving him with less of a foot, if any foot at all. Early in his treatment, his foot was essentially insensate; he was oblivious to the local injections of antibiotics and never required anesthetics for debridements. Like most of such patients, his sensation improved; he sensed pain with later injections and would laugh when his foot was tickled. Many ask if salvaging such a foot is worth the effort as they assume the cure will be temporary and eventual leg amputation almost certain. As the follow-up films show, his foot has lasted nine years since his initial presentation and almost eight years since its major episode of necrotizing cellulitis.... in spite of minimal follow-up and lack of medical supervision.