60-year-old gentleman presented to my office yesterday requ | Figure 1

Case Overview

60-year-old gentleman presented to my office yesterday requesting a "cortisone injection." Not surprisingly, he has right foot pain. He remembered that I gave him an injection for a neuroma in 2009 with good results. He is not diabetic. He is under the care of a vascular surgeon at a local wound care center. Wound VAC on medial ankle for non-healing venous stasis ulcer. Has undergone RF ablation for venous disease. The only pulse I could identify is a weak lateral tarsal artery. I sent him back to his vascular surgeon. He was upset that I would not give him the injection.

Cases

68-Year-Old Male - Medical History

68 years old male a retired military officer has DM since 1995 and he said he was taking metformin until 2022 when he started taking premixed insulin injections and he had done 5 PCI and 4 foot catheterizations in different time intervals. He takes atorvastatin for hyperlipidemia and hypertension controlled on amlodipine.

• Condition started in 2017 when patient started to feel gradual pain like walking on pedals on ventral aspect of his left foot, continuously progressive. It radiated to calf muscles aggravated by walking for long distances and relieved by pain medication or by rest after walking. After 3-4 months, his little toe of the same foot started to change color to blue then black without smell or discharge.
• He sought a doctor who told him to routinely wash and sanitize the area for two times a day. After 1-2 months, he noticed small worms coming out of his little toe, as well as the area around the third to fifth metatarsals on the ventral aspect.
• He returned to the same doctor who prescribed anti-inflammatory medication and antibiotics, continuing for 2-3 months. Then he was advised to amputate his little toe, following which they amputated his fourth toe, and then his third toe, lastly his first toe, each at different intervals he doesn’t remember.
• After this series of amputations, he changed his doctor, who is wanting to perform lower limb arterial bypass for him but is waiting for anaesthesiologist approval because of his heart condition. The surgeon cannot perform full leg amputation due to insufficient blood supply in limb to support it.
• While waiting, he has been admitted to the hospital 6 times, with stays lasting 1-3 days for the debridement of his foot gangrene. During his seventh admission, lasting 14 days, his foot debridement was done two times a day. He takes responsibility for any complications that may occur during surgery and will not file lawsuits or arbitration against the hospital or surgeon.

Patient Observations

I walked into my treatment room today to find that my patient had his leg dangling over the edge of the chair. His toes had a deep red discoloration. He mentioned that the small wound on his foot has become very painful and that when in bed, he needs to hang his leg over the bed to sleep. As I elevated his foot onto the treatment chair, his foot turned white. The wound became too painful to touch.

Clinical Cases

• 65+ Year Old Male: Has been treating wounds himself over several years. Referred to vascular; unna boot placed. Both wounds full of maggots that were not placed by the vascular surgeon.
• 28-Year-Old Male: Brought to ER after a motorcycle accident. Foot involved in transmission chain, resulting in a large skin lesion, but without bone exposure. X-rays revealed fractures in the 5th and 4th toes. Treated with Kirschner wire for both and compressive wound care.