Case 158: Large Leg Ulcer Healed with Boot and Grafting in Bedridden Man Who Quickly Breaks Down Again. Was it worth It?

This 80 year old man had a femoral-popliteal bypass at a nearby hospital in 1981. A year later the graft became occluded and an arteriogram showed absence of the superficial femoral artery, patency of 25% of the deep femoral, no reconstitution of the popliteal and no tibial arteries except for a faint distal segment of the posterior tibial artery. Leg amputation was advised at the nearby hospital and also at a University Medical Center where his family took him for consultation. He was bedridden and had had his lesions for a year when his visiting nurse referred him to Bryn Mawr for boot treatment.

He presented May 4th, 1983 with a large odoriferous ulcer behind his right lower leg. His Achilles tendon was exposed and necrotic.

No Doppler sounds were detected in the tibial vessels at the ankle while faint sounds were heard at the posterior tibial in the calf where his pressure was taken and a faint pulse volume curve found.

After nine days of Long-Boot therapy, the vascular tests at the ankle level were improved.

The necrotic Achilles was cut away and wet-to-dry dressings applied over his ulcer during his boot therapy. Healthy granulations developed and a plastic surgeon was consulted for grafting.

The graft took and his ulcer healed./B>

After 21 days of Long-Boot therapy, his vascular tests showed continued improvement.

Healed and good as new? No, the man remained at bedrest, developed a knee contracture and a new decubitus over his lateral malleolus where a large area of bone was exposed. In view of his inability to care for himself, his chronic bedridden state and his knee contracture, his family was advised that above-the-knee amputation was his best option and no attempts were made to heal his new ulcer. He had an above-the-knee leg amputation.

Comments: This man's leg was healed with boot therapy when others offered no hope. The benefit was brief. This man falls into a group of patients in whom no efforts at leg salvage are likely warranted: those with chronic illness, diminished cerebral function and an inability to get our of bed regardless of the state of their legs. The likelihood of saving legs in this setting is increased by the existence of a devoted spouse (or private duty nurses around the clock) who is willing to re-position the legs multiple times throughout the day and night to prevent the development of contractures and decubiti.