Case 96: Infected Ischemic Neuropathic Leg Escapes Amputation as Hospital Nurse Advises Patient Surreptitiously to Seek Boot Therapy

At age 66, this lady presented with a long history of massive obesity and poorly controlled diabetes for many years; standing but 63 inches (160 cm) tall, she had achieved a maximum body weight of 250 pound (114 Kg). Perhaps related to her uncontrolled diabetes, she had lost weight in the last few years to 170 pounds. She was admitted to the Bryn Mawr Hospital March 25th, 1994 having had several admissions to another nearby community hospital. In January 1992, she was admitted for osteomyelitis of the right foot and treated unsuccessfully with inpatient and outpatient antibiotics. She was re-admitted in March 1992 for resection of her 3rd to 5th metatarsal-phalangeal joints. In January 1994, she had a 14-day admission for cellulitis of the left foot. A history of hypertension, congestive heart failure, cholecystectomy, an abdominal hysterectomy and medical noncompliance were noted on her records. She was discharged to have her antibiotics followed by the visiting nurse. She was again admitted February 28th, 1994 with the cellulitis spreading from a plantar ulcer along her arch and up to her ankle. On March 3rd, she went to the operating room for debridement of her septic tenosynovitis. On March 13th, she returned to the operating room for another debridement. Cultures revealed a methicillin-resistant Staphylococcus aureus. On March 18th, she had an arteriogram., which showed diffuse disease. The left superficial femoral was moderately stenosed. The popliteal had irregular plaques. The tibial-peroneal trunk was open but the peroneal and posterior tibial arteries were not patent. The anterior tibial had a critical stenosis in its proximal third and was occluded distally with reconstitution of several irregular and narrow vessels to a small and very narrow dorsalis pedis. The plantaris artery was not demonstrated. By March 21st, her various physicians concluded that leg amputation was appropriate. A floor nurse disagreed and surreptitiously advised the patient she might do better at Bryn Mawr.

On presentation her operative site was necrotic and ulcerated. The necrosis extended into the arch and the cellulitis to the heel.

With the foot extended straight out, the skin became increasingly pale from the heel to the toes.

Her noninvasive vascular tests explained her physical findings. Photoelectricplethysmographic (PPG) tracings of her toes in the left foot were flat while those in the right foot were very low. Doppler studies showed reduced flow in the posterior tibial in both legs but the vessels were hard and could not be compressed with the blood pressure cuff. In the anterior tibial, the Doppler velocity was 20cm/sec in the right leg and 5cm/sec in the left. No Doppler sounds were heard over the metatarsal arteries in the left foot.

Her laboratory studies confirmed the serious nature of her illness. She was anemic (hemoglobin 8.1 gm/dl). She had a modest leukocytosis (13500), a shift to the left (increased number of bands), a thrombocytosis (882,000), hypoalbumenemia (2.7 gm/dl) and an elevated alkaline phosphatase (366). Her cultures again grew out her methicillin-resistant Staphylococcus aureus. In the hospital, she was treated first with cleansing irrigations and soaks of her foot; Sea Soaks containing both Vancomycin and gentamicin was used both for the irrigations and within the Mini-Boot. The more necrotic areas of her foot were also injected with the same two antibiotics before her boot treatments. Urecholine was also added to the Sea Soaks during the Mini-Boot treatments. On April 5th, when her foot was stabilized and improving, she was discharged from the hospital to our nursing home facility to continue the same treatments for the next three weeks. Thereafter, she has been followed as an outpatient in the doctor's office. Her pictures show her course:

Here in December 1994, the plantar aspect of her foot was doing well.

But she was ambulatory and traumatizing her 2nd toe in improper shoes.

In March, she split open her scar....

and, while the end of the 2nd toe had done well, this intertriginous ulcer penetrated to the bone. It was treated with local antibiotic injections and more Mini-Boot sessions.

The toe did well and, again she was active on her feet. She returned with an ulcerated plantar callus in June, 1995.

Date on this photograph illegible... but with more therapy, she again healed. She is, of course, a high risk for recurrent ulcers and must be followed closely.

Comments: Her case, of course, roused the curiosity of her insurance case manager. How does one know when to treat such a case? First, one might ask if the foot is so badly damaged that it would be useless if it healed. In her case, obviously "no". Indeed, she may use her feet too much. Next, one asks if we can heal such a foot when standard techniques fail... are we wasting the time and money of the insurance company in the effort? Obviously again, we healed her. What for complete healing then is the time frame? We advise the insurance company two to four months if we are allowed to keep her in the hospital and longer if she must be ambulatory? Where can the treatment be done? Anywhere, hospital, nursing home, office or patient's home, if there is a trained technician to perform the treatment. What about relapses? Yes, these patients will relapse. They seem to think they are cured once their feet are healed and act as if they had normal feet. They must learn to wear appropriate shoes and limit the stresses on their feet. Would amputation of her leg have been more economical. Yes, if she died with the procedure. No, if she took many months to heal and to acquire a working prosthesis in the rehabilitation hospital. The amputation, of course, would limit her freedom and put additional stresses on her remaining leg. The usual costs of amputation would pay for multiple extensive courses of outpatient boot therapy.