Case 83: Both Legs Salvaged in Man with Diabetes, Severe Cardiovascular Disease and Osteomyelitis at Amputation Sites
At age 65, this insulin-dependent diabetic man had a femoro-popliteal bypass in his right leg in 1984 in New York City. He continued his smoking and eating habits developing increasing problems with both legs. In April 1988, he had a transtarsal amputation of his right foot and an amputation through the proximal phalanx of his left big toe. Neither healed. His New York surgeon wrote us saying that his bypass was still open but that there was a high grade stenosis at its distal end probably from intimal hyperplasia and that runoff to the foot was only by a diseased and attenuated peroneal artery. His lack of a saphenous vein and his past history of a cardiac arrest also decreased his prospects for surgery. He was hence considered a possible candidate for bilateral leg amputations. Wheelchair bound, he was a difficult candidate for outpatient treatment and he was initially admitted to Bryn Mawr Hospital August 9th, 1988.
His flap had broken down at his right foot amputation site and infected bone was exposed. Likewise, the proximal phalanx of his left big toe was exposed and infected..
Baseline x-rays at Bryn Mawr showed gas in the soft tissues of his right ankle and changes of osteomyelitis at both amputation sites. Doppler sounds at his ankles were monophasic. His ankle/arm index was 0.65 at the right ankle and 0.54 at the left. Over the next several weeks, he was given our standard treatment: (a) an initial cleansing foot soak, in this case An ounce of Betadine in approximately 200 ml of Sea Soaks, (b) Mini-Boot treatments with his feet immersed in Sea Soaks containing appropriate antibiotics (gentamicin, vancomycin, chloramphenicol, ceptazidime and Amphotericin-B were used at various times); (c) local antibiotic injections into the obviously infected soft tissue in the left foot and ankle. In this fashion Coagulase-negative Staphylococci, Enterococci and Achromobacter xylosoxidans were eliminated and his feet did well. He was largely treated at our nursing home-boot center but did require transfer back to the hospital for an episode of pneumonia and heart failure.
Here on January 15th, 1989, he is healed and ambulatory.
At the same time, his left foot was also healed.
In spite of every discouragement, he continued to smoke and take his diabetes casually. His right foot broke down in a small area in December, 1989 and responded to a few outpatient treatments. He died December 28th, 1990 with congestive failure with both legs intact.
Comments: This man was referred to us because of his poor heart function. Had he been a better operative risk, he likely would have undergone further attempts at bypass surgery in both legs. He obviously did not need more surgery. He needed to stop smoking and control his diabetes. Had he lived locally, he might have benefited also from long term booting for its effect on his heart function .
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