Case 81:Auto-Transmetatarsal Amputation of Left Foot and Revascularization of Right Leg in Alzheimer's Patient

At age 88, this lady, who had type-2 diabetes and progressive Alzheimer's disease leading to her confinement in a nursing home, was referred for ischemia of her left foot. She presented with gangrene that included her big toe bunion and, on the plantar surface, the ball of her foot. Her big toenail had fallen off exposing bare bone. The skin from her toes to her tarsals was either black or ruborous. The dead areas were numb and lent themselves to debridement at the bedside. A mummified toe was removed one day and a metatarsal head another. The foot was slowly whittled back over weeks at the bedside. She was given Miniboot treatments daily with her foot immersed in Sea Soaks and appropriate antibiotics. Her foot eventually healed. She used the leg mostly for transfers to her bed, toilet and wheelchair.

Exposed bone was clipped off at the surface and dead areas debrided eventually giving a good red granulation base.

She healed across the proximal metatarsal level of her foot.

About a year later, she skinned her arm and developed a extensive cellulitis of the arm for which she was hospitalized. Her right leg was then noted to be cold and pulseless below the groin. Her doctor again requested a boot consultation. A vigorous one week course of Long-Boot therapy was prescribed (three to four full leg treatments lasting 40-90 minutes each). Normal color and warmth returned to the leg and she was returned to her nursing home. Periodic boot therapy to both legs maintained blood flow to her legs successfully another two years. At that time all supportive care was discontinued at the request of her family because of the progression of her mental impairment.

Comments: Treatment of this lady was initially begun as a "holding action": her multiple impairments did not seem to justify or permit hospitalization for an arteriogram and consideration of bypass surgery. Hospitalization for a transmetatarsal amputation again seemed unwarranted as it appeared it would not likely heal without some method of revascularization. She, thus, began boot treatment in the nursing home and eventually healed her foot. Her pain was relieved. She could do her transfers. Her quality of life was improved. She is included to demonstrate that she, and patients like case 8, can heal such legs.