Case 99: Managed Care: In the Absence of Managed Care, Painful, Infected, Ulcerated, Inoperable Ischemic Leg Saved by Outpatient Booting and Local Antibiotics

Almost 74 years old, this lady was referred for boot therapy on August 20th, 1993. She had had progressive difficulty walking for four months. Historical risk factors for vascular disease had included many years of high blood pressure and elevations in her LDL-cholesterol. The latter had been thought to be balanced by high HDL-cholesterol levels. In June, her heel had been purple and sore leading her to consult her orthopod for the possibility of tendonitis. Some heel callus was debrided. She subsequently noted a small heel ulcer. She consulted a vascular surgeon at her community hospital who documented leg ischemia with Doppler studies. An arteriogram showed a 6.7 cm occlusion of her proximal popliteal and a small stenotic area in her proximal anterior tibial artery; both were ballooned open. Her peroneal and posterior tibial arteries were not visualized. Any benefit of the angioplasty was lost in a few weeks taking her back to her vascular surgeon who had nothing to offer. A friend then referred her for boot therapy.

Review of her arteriograms shows the blockage in the proximal poplieal that was ballooned.

In these subtraction films taken during the procedure, irregularity of the popliteal and the small stenosis in the proximal anterior tibial are seen.

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On August 20th, 1993 she presented with rest pain and difficulty walking any distance. She was particularly tender in her heel and in the callus under her 3rd metatarsal head. The latter was shaved back on presentation releasing approximately 0.5ml of pus. Pseudomonas aeruginosa was grown form her heel and coagulase negative Staphylococci from her plantar abscess. The circumference of the right ankle was 10 1/8th inches and the left 9 3/4 inches.

Her pulse volume tracings showed a marked decrease in the right calf and trace-to-absent flow at the ankle and mid-foot. Her transcutaneous PO2 level was "0" and PCO2 49 mm Hg on the dorsum of the foot. PPG tracings of the toes were flat.

The presence of a history of phlebitis and the findings of slight swelling of the right calf and ankle and multiple superficial varices on her thighs, calves and ankles led to venous testing also. A normal venous outflow study, short venous refill times and demonstrated Doppler reflux suggested that lower leg pretibial rubor was related to venous valvular incompetency. The lack of any deep vein thrombi lessened the threat of pulmonary embolus. She was advised that, unless bypass from her femoral to her anterior tibial could be accomplished, she would require a few months of outpatieint booting. Her 40+ mile commute was a factor. A Duplex scan showed both saphenous veins to be present from her groin to her ankles. Good veins were present for bypass.

In the meantime, her foot lesions were sterilized with appropriate antibiotic injections and Mini-Boot therapy: gentamicin in the heel and Vancomycin in the plantar abscess. Each day she was also given an Long-Boot treatment with a sleeve from her groin to her ankle.

By mid-November, her plantar abscess was healed and her skin color improved.

The heel also had fared well. Her transcutaneous as levels were still abnormal, however: TcPO2 13 mm Hg and TcPCO2 49 mm Hg.

By mid-December, her skin color was normal.

She was walking freely around the market but had to stop at perhaps after a block on the sidewalk.

Her friends advised her to seek another vascular surgery consultation, unfortunately in this case from a surgeon who had been a thorn in the development of our boot program. We provided him with the above photographs. He ordered an arteriogram and reported the films as showing a blocked popliteal, filling of the anterior tibial by collaterals around the knee, patency of the anterior tibial to the ankle and no sizable pedal arch. He wrote the family doctor that "If her situation continues to deteriorate , I think it will be a difficult decision to decide whether to try bypass into this patent but very compromised anterior tibial artery or to go straight away to a major amputation." He also advised the patient in a similar fashion with unforeseen results. She began to lie regarding her walking capacity. It turned out that she knew in the absence of lesions we charted her walking capacity as a guide as to her needs for additional booting. The charts are available for Medicare which, of course, was paying her bill. She was afraid we would dismiss her , which we did, when we learned she was walking two blocks without difficulty. She has done well and comes in periodically if she feels her legs are binding up.

Comments: As of February, 1997, this lady is doing well and has not lost any portion of her limbs. Had she enrolled in a Managed Care Medicare program, would she have done as well. Would the reviewing physician have allowed her referral, the appropriate on site vascular tests and the boot treatment. Medical reviewers have no difficulty in disallowing medical procedures but do not raise any protest when the surgeon declares a need for a procedure. Few reviewers have the expertise to pass judgment on these cases. The ranks of peripheral vascular medical specialists are thin. Few vascular surgeons follow patients with severe peripheral vascular lesions any length of time. Their attention is better rewarded by attempting a vascular procedure or amputating a part. Had this lady lost her leg, her medical and nursing expenses, of course, would not have stopped. Again, the cost of the hospitalization, the rehabilitation, the prosthesis and home nursing care would have dwarfed her outpatient booting costs.