Chronic Leg Ulcer Responds to Circulator Boot and Sheldon M.Kahn, M.D., F.A.C.P

Dr. Kahn (now retired) writes: "Chronic, very large, deep non-healing ulceration left lower extremity, subsequent to thermal burn, resulting from accidental spilling of molten cooking lard, sustained many years ago (?1937). Wound of the left leg extends vertically >18 cm, from mid-tibial region to just proximal to the metatarsal head area of the dorsum of the foot, and is circumferential, i.e., extends around the entire lower leg as denoted, with full-thickness depth of 0.9-1.3 cm.(Stage IV). The exposed tissues appear locally and superficially necrotic and ischemic, are irregulary scarified, dessicated (dry, hard, mummified) with persistent polymicrobial colonization/?superficially infected, principally with Pseudomonas species and Staph aureus. The heel and sole were spared; toes of fairly good color and temperature; foot and toes sensate."

April 20th, 1994. Pre-treatment photograph.

April 20th, 1994.

He continues: "This wound has been resistant to sustained healing, and has broken down progressively and extensively over the past two years. Numerous treatment attempts and multiple hospitalizations have failed to achieve satisfactory healing, and the patient has experienced unrelenting (neuropathic) pain as well as local tenderness, requiring round-the-clock analgesic medication. Even with this, effective pain control was not achieved, and prior to starting Circulator Boot treatments, no improvement was evident in terms of healing or cleansing the wound, using twice daily dressing changes, with the application of zinc oxide and local antibiotics. The patient was told that amputation of the leg was the only definitive therapeutic recourse. She rejected this option (amputation), but became depressed and irritable, refused physical therapy and voiced suicidal ideations. When offered the alternative proposal, i.e., serial treatments utilizing the Circulator Boot, with the explanation that this would be done in an attempt to achieve as much healing as could be attained by such conservative measures, she readily accepted (informed consent given).

This treatment was begun on 21 April 1994, utilizing daily (6 times per week, excluding Sunday) treatments with the Circulator Pneumatic End-Diastolic Compressor (mini) Boot."

Dr. Kahn goes on to describe his treatment rationale: "The treatments were directed to cleansing and gently but progressively debriding the devitalized tissues as well as to minimize the degree of microbial colonization and growth in the wound, while simultaneously enhancing circulation, via collateral neo-angiogenesis and improved local hemodynamics. The wound is bathed and dressed using a physiologic multi-electrolyte solution (Sea Soaks), to which specified amounts of urecholine and a local anesthetic (1% lidocaine solution) were added as well as local antibiotics, guided by periodic and sensitivity wound studies. These same components were utilized in the wet bag pumping solution as well as in the wet-to-dry dressings applied after each treatment and likewise with the next dressing change done approximately 12 hours later.

Again, Dr.Kahn continues: "Treatments have been carried out 6 times/week (omitting Sundays), with local wet to dry dressing changes twice a day, (once during each compression boot treatment) incorporating the same or similar components in the wet dressings, as noted above. Initially, systemic oral antibiotics were given (Ciprofloxasin, later TMP/SMX) as prophylaxis against the (remote) possibility of systemization of sepsis, attendant to these treatments. When, after about 4 weeks, it became evident that wound cleansing, gradual debridement and healing had begun without any evidence of systemic sepsis, the oral antibiotics were discontinued."

July 9th, 1994.

Dr. Kahn went on to note: "Further healing was evidenced by the development of clean and well vascularized granulation tissue, followed by filling in of the deep wound defect with connective tissue (ingrowth of stromal interstitial elements), remodeling and neo-epithelialization. The new dermal tissues were seen to spread from the edges of the wound (mostly from the distal foot region to proximal progression and more quickly in the lateral and posterior than over the medial aspect), as well as from the development of a number of isolated and initially scattered epithelial "islands" which coalesced to heal over the wound.

Early on, the patient experienced significant lessening of pain, with a decreased need for analgesic medication, (now taken only occasionally or PRN, and often none for extended periods). She also experienced a feeling of increased well-being, improved mood and weight gain without edema."

November 2nd, 1994.

November 3rd, 1994.

Comments: We do not have the long term follow-up on this lady. She obviously benefited from her treatments with the Circulator Boot. She had years of pain and unsuccessful treatments earlier. While the costs of treating patients like this with the boot are not trivial, they do spend large sums on other alternative treatments and hospitalization. Her costs would have been less if she had had boot treatments years earlier and her quality of life would have been improved.

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