Case 33: Pathological Obesity, Degenerative Joint Disease, Congestive Heart Failure, Venous Stasis, Lymphedema and Cellulitis Spell Recurrent Trouble

At age 65 years, this short obese lady was referred for boot therapy by her vascular specialist in 1987. Her lesions had not healed after hospitalization, five months of outpatient therapy by her family physician and consultation with three other physicians. She had a devoted son who was able to transport her across the city for a course of outpatient boot therapy. The leg healed nicely.

Multiple Ulcers on Anteriolateral, Lateral and Medial Aspects of Leg 10/21/87

Healed as Outpatient 2/18/88

She continued to gain weight claiming that arthritis in her knees made it impossible for her to walk and exercise. She returned 7/12/90 at 309 pounds with ulcers and cellulitis of the right leg (no photograph available) She was treated with topical wet-to-dry dressings with Sea Soaks and antibiotics, oral antibiotics and the Long-Boot.

Resolving Cellulitis and Ulceration of Right Lateral Calf 7/16/90

Again her legs responded nicely to outpatient therapy and again she was instructed in routine skin care for the patient with stasis disease: cleanliness, elevation when possible and support stockings. Her obesity made use of the latter difficult. She also had the services of her local family physician and the visiting nurse.

She returned 11/3/92 with minor ski n lesions of the right leg but extensive cellulitis and ulcerations of the left. She required hospitalization at Bryn Mawr as she did on subsequent exacerbations of her disease process: obesity, venous insufficiency, cellulitis, scarring of her lymphatics and lymphedema. Her degenerative joint disease and poor muscle tone prevented ambulation and normal pumping of her musculature.

Right Leg Doing Relatively Well While "Control" Left Leg Now Extensively Inflamed, Discolored and Painful 11/3/92

She was again treated in the usual fashion: systemic antibiotics, appropriate antibiotics added to her Sea Soaks wet-to-dry dressings and Long-Boot therapy. In addition, heparin and later coumadin was added to her therapy although we had no evidence of thromboembolic disease (pulmonary emboli, palpable thrombi in her legs etc). Her legs again improved. Transportation now to our boot center was a major undertaking for her son. He was unable to take her for outpatient booster treatments. City ambulance service was not available for transportation to the suburbs.

Right Leg Weeping Edema Fluid 3/23/93

Signs of trouble were obvious when she did make an office visit. Her legs were swollen and weeped edema fluid. The potential for new infection was obvious.

Legs Overall Doing Well and Office Booting Discontinued in Favor of Starting Jobst Booting at Home 8/16/93

To lessen expense and simplify her transportation problems, she was provided with a Jobst Boot for home use. Both her son and the visiting nurse were to oversee the treatments. The nurse periodically called the office with poor reports. The patient was essentially immobile and her legs were not doing well. On 1/24/94, she arrived in the Emergency Room in difficulty: both legs were badly ulcerated, weeping and infected.

Home Treatments a Failure, Right Leg 1/24/94

Left Leg 1/24/94

Again she responded to our usual treatments. Once her infection was well-controlled, a weight reduction diet was again ordered and physical therapy was begun in attempts to mobilize her as much as possible. The efforts were essentially fruitless. She remained immobile and the only action her legs experienced was the pumping of the Circulator Boots.

Right Leg Healed before Discharge from Office 4/21/94

Left Leg Healed before Discharge from Office 4/21/94

She rapidly relapsed at home and developed new lesions, became septic and died.

Comments: Massive cellulitis like this lady developed always poses the risk of sepsis and death. Her family physicians were unable with the tools at their disposal to heal her legs either in the home or the hospital. As transportation became a problem and outpatient therapy with the Circulator Boot became less frequent, she had to be hospitalized to reverse increasingly severe lesions. Such lesions may be expected to exact some toll: additional lymphatic scarring and additional weakness and muscle wasting. In our office, Circulator Boot treatments to both legs simultaneously delivered approximately 4800 compressions to each leg an hour. Medicare provided but one Jobst Boot which delivered perhaps sixty compressions an hour to but one leg. Neither the frequency or the vigor of such compressions are in a league with what the Circulator Boot delivers and the therapy proved inadequate. Medicare has not paid for home use of the Circulator Boot. If it were available for home use, many of the elderly would find its application too difficult to master. This lady might have fared better if she lived closer to our boot center and had been able to get proper booster treatments. On the other hand, her inability to take responsibility for her obesity and its damaging effect on her joints might have eventually led to the same results in the end....