Case 87:Florida Man with Peripheral Neuropathy and Arteriosclerosis, Multiple Foot Ulcers and Osteomyelitis Does Well with Mini-Boot and Tenotomy

At age 73 this Florida man was admitted to the Bryn Mawr Hospital on December 2nd, 1987 with complaints of ulcers and poor arterial circulation in both feet. He had a history of poorly-regulated diabetes for 30 years. He had claudication in his right calf since 1980. A femoropopliteal bypass in 1980 afforded some relief. Both feet had been numb for three years. He had a history of two myocardial infarctions and had sacrificed his left saphenous vein for a 4-vessel coronary bypass procedure June of 1980 leaving the left leg with no veins for future bypass. He had had laser therapy of his diabetic retinopathy and presented with vision of 20/60 in the right eye and 20/70 in the left. He had impotency attributed to his neuropathy, arteriosclerosis and hypogonadism. His foot ulcers began in June of 1987 with a blister that progressed over the summer despite the antibiotics and debridements of his podiatrist. He was hospitalized in September 1987 when the arteriograms below were accomplished. A focal 70% stenosis in the right popliteal was dilated. His lesions continued to enlarge and on his presentation to Bryn Mawr he had multiple areas of breakdown: the bunion ulcer (picture below), an ulcer over the right lateral malleolus, a scab over the left internal malleolus and an ulcer on the dorsum of the left fourth proximal interphalangeal joint. All were treated at Bryn Mawr and eventually healed. Attention is here paid to the largest ulcer on the right foot.

His largest ulcer exposed the bone and capsule of his right first metatarsal-phalangeal joint.

In his right leg, the Florida arteriograms showed an occlusion of the upper superficial femoral artery, a patent femoropopliteal graft and occlusion of all of the runoff vessels at the trifurcation..

Just above the ankle, the right anterior tibial reconstituted in a thin short segment.

Admission Doppler studies were compatible with his arteriograms: low wide monophasic signals were present over the locations of the anterior tibial, posterior tibial and peroneal arteries at the ankle. His sensation was grossly abnormal: vibratory sense was diminished, light touch sensation was diminished-to-absent, and firm touch sensation (as a stick) was absent in the feet. Two point discrimination beneath the knee was increased to 13 cm. His Achilles reflexes were absent. His graft was palpable above the right knee while his left popliteal was diminished-to-absent and all his pedal pulses were gone. He was predominately treated in the Mini-Boot and slowly improved.

He returned to Florida the day before Christmas with a Mini-Boot system to continue his treatments at home. His feet felt less numb to him. His ulcer was clean and small fine vessels extended down from the skin in upper portion of the ulcer.

He returned in August, 1987 because his flexor tendons had deteriorated and his big toe was displaced dorsally and overriding the second toe. We recommended over the phone that he have his extensor tendons cut but his Florida physicians would not do the procedure.

With the first toe held in place, a pressure ulcer was seen on the 2nd toe and the tense portions of the extensor tendons could be seen and palpated.

The extensor tendon was cut at the bedside allowing the toe to drop into a physiological position. A small ulcer penetrating to the bone was also seen at the base of the 3rd toe.

Xrays showed septic arthritis and osteomyelitis of the 1st metatarsal-phalangeal joint and osteomyelitis involving the distal ends of the proximal phalanges of the second and third toes under their ulcers. Staphylococcus aureus was recovered and was sensitive to the Ancef and gentamicin given intravenously. His daily hospital routine included an initial cleansing foot soak in dilute Betadine and Sea Soaks followed by Mini-Boot therapy with his foot immersed in Sea Soaks containing 0.1% neomycin, urecholine and, later when yeast were cultured, Amphotericin-B.

At the end of his three week hospitalization, his lesions were all improved. He continued his treatments with a Circulator Mini-Boot at home and wrote us to report all of his lesions healed.. He was ambulatory until his death four years later.

Comments: This man likely had no other options for salvage of his legs than our boot therapy. He had no veins to consider distal bypass. He had significant coronary disease and was a high risk candidate for any major surgery including leg amputations. With the help of his family, he was able to look around the country and find help, a privilege not granted to most patients in managed care programs. His tenotomy procedure was simple and carried out at the bedside by his medical doctor; it effectively took the pressure off the dorsum of his second toe and decreased the lateral pressure on the third toe also..