Case 86: Stasis Disease and Traumatic Infected Ulcers Respond with Outpatient Booting

This 76 year old lady fell in her bathroom on December 11th, 1994 skinning her leg in an area of stasis dermatitis. Painful infected ulcers developed at the site. As the lesions did not respond to the rest, local antibiotic ointment and oral antibiotics prescribed by her physician, she followed the recommendation of a friend (another boot patient) and presented January 13th, 1995 for consideration of Circulator Boot therapy.

Stasis pigment and modest induration was found from her ankle to her mid-shin. Above the ankle on the medial aspect of the leg was a shallow ulcer with area of necrosis in its base.

She was treated forty minutes on weekdays in the Long-Boot with wet-to-dry dressings containing Sea Soaks and gentamicin over the ulcers.

Two weeks later the stasis pigment appeared to be fading and the ulcers had a clean base

And by five weeks the ulcers were largely healed... and total success soon followed.

She was discharged March 14th, 1995 with routine instructions for stasis disease... elevation, supporting stockings and skin care. She did well for almost three years.

Comments: While this lady had stasis disease a long time, her presenting ulcers had only been present a month. Her cure likewise took about a month. The benefit on her stasis pigmentation and leg induration has been long-lasting. She was a simple easy case for the boot. She represents a common patient that was spared more complicated therapies... intravenous antibiotics, hospitalization, debridements, whirlpool etc. Many such patient are treated for the same lesion for years in outpatient surgical clinics around the country..

Follow-up: She was treated for obesity, hypercholesterolemia, hypothyroidism and hypertension (L-thyroxine, metoprolol, hydrochlorothiazide, quinapril and Lipitor). While her laboratory values improved, her weight and exercise habits did not. On January 14, 1998 she experienced "a virus": cough, nausea, a little vomiting and diarrhea. She went to bed but became progressively sicker over the next few days. On the 19th of January, her husband wheeled her into the boot clinic with the leg below.

Her right lower leg was tender, hot, swollen and beet-red. The circumferences of her right leg versus her left leg were 60.3 vs 59 in the mid-thigh, 44.2 vs 38.7 at the mid-calf, 27.5 vs 22.5 at the ankle and 26.5 vs 22.8 cm at the mid-foot. She was admitted to Bryn Mawr Hospital for intravenous heparin and antibiotics. A Duplex scan of her leg revealed no obvious deep vein thrombi. Blood cultures were negative. Her leukocyte count was modest ly elevated to 12.2 with a differential count of 80% neutrophils, 11% lymphocytes and 9% monocytes. She was empirically treated with intravenous vancomycin and cefazolin. By the third hospital day, as it appeared likely that she was not at risk for a major pulmonary embolus and a good blood level of antibiotics had been achieved, she was started again on Long-Boot therapy with a rapid improvement in her comfort and a reduction in the swelling of her leg.

January 27, 1998: The reddening in the upper calf had largely faded. Her fever, leukocytosis and pain had abated. She felt well enough to get out of bed. By January 30th, the circumference of her right calf had decreased to 38.5 cm and of the ankle to 24 cm. Her hospital course, however, was complicated by the discovery of calcifications in her breast seen on her routine chest x-ray. A mammogram revealed a cancer that was confirmed by needle biopsy.

February 5, 1998. Her asthenia (actually a problem for many years) prolonged her hospital stay. As of March 14th, 1998, her leg is close to normal in color and her cancer has been removed.

Comments: There is a time when hospitalization is necessary. This lady had a severe cellulitis of her lower leg. In the pre-antibiotic era, she might have had an emergency above the knee amputation and died of sepsis anyway. Indeed, even in the antibiotic era, extensive cellulitis may progress to complications requiring amputation. Her leg problem developed in spite of bedrest at home for her "virus". Her leg was swollen likely secondary to the cellulitic and inflammatory process. As "bacteria swim and leukocytes crawl", it is desirable to reduce swelling and fluid collections. The administered antibiotics would not have reached any tissues that infarcted and the bacteria continue to proliferate in such infarcted tissue where they may release various catabolic enzymes and toxins. The lady had known stasis disease and it is possible that her cellulitis was secondary to thrombophlebitis. It is desirable to prevent the clot from extending in thrombophlebitis and if possible to reduce the clot and recover the function of any venous valves that are at risk. For these reasons, we treat these patients with the Long-Boot... and as in this lady, they do well. The boot maintains the patency of the arteries and veins. It reduces swelling. It helps achieve good tissue antibiotic levels..