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Pages S48-S51 of Methods of Treatment
Arterial Insufficiency: Predominant tibial disease: Patient MA was an 87 year old feisty lady who had had her left leg amputated in 1975. She continued to live alone and look after her diabetes herself. Her right heel began to ulcerate in March of 1986 taking her to various doctors and plastic surgeons. With the experience of her left leg in mind, she refused to get a vascular surgery opinion. In spite of the fact that her ulceration grew to the extent shown in Figure 5, she still managed to care for herself crawling around her house on her hands and knees.
 Figure 5. Patient MA. Necrosis of back of heel and Achilles tendon on presentation, 9/23/87. |
Her physicians recommended an AK leg amputation in view of her extensive gangrene. She refused and came 900 miles for boot therapy. Here we found she lacked palpable pulses below her groin and that Doppler sounds in her posterior tibial and peroneal arteries were absent while low broad monophasic waveforms in the anterior tibial were present. Her ankle/arm index was 0.35. Her heel x-ray showed significant osteolysis within the posterior aspect of the os calcis. Debridements were limited to clipping loose hanging eschar and paring away necrotic materials at the skin edges periodically to allow the skin margin access to the newly forming granulations. Cultures were periodically obtained. Before the first boot treatment of each day, debris and secretions were rinsed from the lesion with multi-electrolyte solution (Sea Soaks) and gentamicin was injected into the necrotic areas of the lesions. Later in her care, the soaks were followed by a 30-second exposure to ultraviolet light to minimize the growth of molds and resistant staphylococci. When her lesions were damp and oozing, wet-to-dry dressings soaked with multi-electrolyte solution containing appropriate antibiotics were used and later, when the lesions were clean, sterile Vaseline gauze was applied over the ulcer. When the surrounding skin became dry and irritated, it was coated with Valisone cream. With fresh dressing wrapped in place with gauze, her leg was then pumped from groin to toes with the monitor at the 3:1 setting. Three to four such treatments were given in the hospital daily until her leg was stabilized (10 days) and thereafter continued in a nearby nursing home. When her leg was close to healed, she was referred back to her hometown academic center in the hope that the therapy could be continued there (Figure 6).
 Figure 6. Patient MA, 4/29/88; her foot was almost healed and she was referred back to an academic center in her home city for follow-up. |
Rather, the physicians again recommended bypass surgery and, when they found they could perform no surgery, prescribed their soaks and dressings. Her leg deteriorated (Figure 7) leading her to return to our nursing home.
 Figure 7. Patient MA. Her leg deteriorated at home and she returned to our nursing home 5/9/89 for boot therapy. |
 Figure 8. Patient MA. She was healed again and discharged to a hometown physician who was now equipped with a Circulator Boot system. |
Her routine therapies were reinstituted and her leg healed (Figure 8). She was referred for follow-up to a doctor in her hometown area who had acquired a Circulator Boot System and could administer booster treatment as needed.
Comment: This patient was treated intermittently over two years. Such extensive lesions take months to heal regardless of how the leg is revascularized or how long they receive maximum care in the hospital. Referral for boot treatments early in the course of her disease would have considerably shortened her course of therapy.
IV. Effective blood flow = f (variables) / ASO or EBF = f (V) / ASO or EFB = f(V) / (VP)(IFP)(Neur)(ASO)
Pages S51-S54 of Methods of Treatment.
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