Case 132: Both Legs Benefit. Lesions in Left Leg Slow to Heal and Do Not Respond Elsewhere but Do Eventually Heal with Boot Therapy.

This 68 year man was a former smoker and a type-one diabetic. He had had two coronary artery bypass procedures. He was referred by his general surgeon on June 21st, 1989 because of failure to heal after two operations done because of gangrene and cellulitis of the left big toe: first an amputation of the big toe and later an amputation of the first metatarsal head. The incisions had become infected and leg amputation was in the offing. He arrived in a wheelchair and was unable to walk. His vascular testing showed ankle/arm indices of 1.08 and 0.45 and second toe/arm indices of 0.2 and 0.19 in the right and left legs respectively.

On presentation, the skin over the 1st and 2nd metatarsals was crimson and his skin incisions were necrotic.

He was treated with local antibiotic injections and Mini-Booting with his foot immersed in Sea Soaks containing appropriate antibiotics (initially gentamicin). The distal portion of his incision overlay infected bone and was discouragingly slow to heal. The distal portion of his second toe autoamputated.

His pain was essentially gone. He was able to walk. His skin color had improved. But the area under the 2nd toe had not healed. June 29th, 1990.

He sought a second opinion from physicians advertised on the radio as operating a wound-healing center in Philadelphia. They removed his second toe stub and performed new angiograms of both his legs and heart. They applied Procuren to the wound site. His distal foot still would not heal. He was offered more surgery at the wound center but declined and returned for more booting... about two years since he had left us. Prior to his foot ulcer, he had had 1/2 block claudication; with his boot therapy his distance increased to 2-5 blocks. During the course of the treatment of his left leg, he complained of pain in his right leg. The latter was also relieved by boot therapy.

August 17th, 1992. Just a small spot still to heal at the second toe amputation site.

Comments: This patient had leg ischemia that was not thought to be operable by the vascular surgeons at two institutions. While we obviously had improved his situation with our initial treatments, he did not heal. Perhaps we might have scraped the bone at the base of his second toe or some such. We hesitate to traumatize the foot too much with our debridements as each incision becomes another wound to heal. Area-wide data systems might help reduce health costs in these patients and improve our outcome studies. The patients commonly go from institution to institution. Did repeat angiograms have to be done at the wound center? Do they think they healed this man? The wound care center provided inpatient care that was likely much more expensive than our outpatient program. The patient hopefully benefited from care at both sites.