Case75: Stroke Patient with Large Leg Decubitus Eventually Dies but with an Intact Leg

This 83 year old hemiplegic female with a pulseless leg developed a large invasive decubitus. The lesion grew over five months in spite of the attention of her cardiologists and surgeons. The lesion was debrided but no granulations developed and the leg appeared to be lost. Her family refused to grant permission for the recommended above-the-knee leg amputation. Her cardiologist referred her for boot therapy.

Lesion several days after debridement: Note lack of granulations and lack of attachment of skin margins to deep tissues.

She was given wet-to-dry cleansing soaks before therapy with saline and Betadine. Then she was treated in the Long-Boot with a bag extending from her groin to her toes. She tolerated the treatment well and was left in the boot for two to five hours daily. Granulation tissue began to form within a week and she was grafted. She appeared to be relieved of pain. Her family was satisfied and grateful. She was transferred for custodial care to a nursing home where she died a few months later.

Her graft took except over a portion of a bare tendon. Betadine from earlier soaks stain areas of dry loose skin.

Comments: When a third party is paying the bill, family members commonly request treatments for the elderly that seem to have no value. This lady was not going to ever walk again. Indeed, her prognosis for life was poor in view of her major stroke and age. We have in such patients frequently recommended leg amputation; a flaccid leg increases the work of the nursing staff attending her. The leg gets in the way for both patient and nurse. Families commonly feel guilty that a decubitus developed in their loved one. The terms "decubitus" and bed sore" suggest neglect. In compensating for this "neglect" they may ask that everything possible be done now for the patient. This lady was too debilitated to consider any vascular reconstruction procedure that might have been offered. Here society had a tossup: the cost of booting was probably less than the cost of amputation, the pain of the patient was successfully relieved and the family was grateful and satisfied. From technical point of view, the treatment was a grand success for boot therapy. No other form of therapy had been considered reasonable or possible and the leg was saved.