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Pages S51-S54 of Methods of Treatment
Combined Disease: ASO, Neuropathy and Osteomyelitis. Patient HL presented June 15, 1989 at age 61 with an 18-year history of diabetes, 41 pack-years of cigarette smoking and many years of amphetamine usage for narcolepsy. She had femoral-tibial bypasses in the right leg in 1982 and 1988; both occluded. She presented with a malleolar ulcer, half block claudication, insensate feet, background retinopathy and an old anterior wall myocardial infarction (Figure 9).
 Figure 9. Patient HL presented 6/15/89 with non-healing malleolar ulcers, hammer toes, and ruborous ischemic insensate skin. |
 Figure 10. Patient HL presented a second time on 9/15/92 with this plantar ulcer showing exposed cartilage and little reaction to her injury. |
Her arm ankle index was 0.51. She healed nicely with outpatient therapy only to return five years later with a large plantar ulcer with exposed bone and cartilage (Figure 10). She refused both oral and intravenous antibiotics claiming that they had sickened her in the past. She was given antibiotic injections in and around the ulcer with an insulin syringe and treated in the Mini-Boot with her foot immersed in multielectrolyte solution and appropriate antibiotics. She has continued to smoke. Her ulcer healed slowly. Lesions developing on the other foot were also successfully treated. At the time of her followup photograph in March, 1994, she remained healed and giggled when the plantar surface of her foot was tickled (Figure 11). She remains ambulatory to date but has had new lesions requiring treatment.
 Figure 11. Patient HL: Her foot healed and her sensation improved. She laughs when her foot is tickled. |
Comments: We have found the use of local antibiotics very effective, but do not recommend their usage in advanced infections without systemic coverage. She illustrates their effectiveness. While we may remove loose bone fragments, we generally do not remove intact osteomyelitic bone. If there are indications that it has been sterilized (sterile cultures, lack of drainage and a slow return of the sedimentation rate toward normal), we allow the bone to heal and remodel.... much as a fracture does. An improvement in sensation allowed this lady to feel the tickling of the soles of her feet. Such improvement is common in our patients with neuropathy perhaps reflecting a microvascular etiology of the disease. Infection, of course, has an adverse effect on effective blood flow to the foot: first, it increases the metabolic requirements of the tissue and competes for both oxygen and substrate; it increases tissue permeability and promotes swelling; it may increase tissue factors that promote local thrombosis of vessels; and it may invade and inflame the vessels themselves. Infection has an important negative effect on healing and outcomes and is added to our evolving formula.
V. Effective blood flow = f(variables)/infection or EBF=f(V)/Inf
or EBF = f(V) / (VP)(IFP)(Neur)(ASO)(Inf)
Pages S54-S58 of Methods of Treatment.
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