Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part I - general considerations and summary of results

Recurrent plantar ulceration is a common and serious complication occuring consequent to impairment of the tibial nerve in leprosy patients. In spite of many therapies and long therapeutic course, it is extremely difficult to abolish this complication in many cases because of extensive skin and soft tissue cushion loss due to repeated infection. Since the early 70 we have been using microscopic surgical techniques to reconstruct the ulcerated area using eight types of the flaps. In this series of papers we review out experience. Post operatively, the flapes survived in all cases, the long term results have proved satisfactory, and recurrent ulceration occurred in only three patients

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part II - first toe web and dorsal foot flaps

The first toe web flap consists of th skin and subcutaneous tissues of the contiguous sides between the great and second toes. It is based on the first dorsal metatarsal artery or the common plantar digital artery. This flap was used as artery pedicled island graft to reconstruct losses of skin and soft tissue cushion in the ball of the foot in the first and second metatarsal head region in 16 cases. Follow up examination revealed that ulceration had recurred in one case due to dehiscence of the flap margin 12 months post operatively. The other 15 patients have done well without recurrence at 48 to 124 months follow up examination. The dorsal flap of the foot based on the dorsalis pedis artery, the corresponding veins and the deep peroneal nerve was designed in 1974 to resurface skin and soft tissue defects in the sole of the foot. This flap was used in 30 cases of leprosy with excellent results. During follow up 36 to 120 months after surgery the plantar ulcer had recurred in only one case. All the orthers have done well. The long term curative effect has thus proved satisfactory

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part III - use of plantar skin or musculocutaneous flaps and anterior leg flap

Anatomical studies suggest that five types of plantar flaps namely, the lateral and medial plantar flaps, the Abductor hallucis, the Flexor digitorum brevis, and the Abductor digiti minimi myocutaneous flaps, can be incised from the central section of the sole. The advantages of a plantar flap are recognizable neurovascular bundles of the sole, wide calibre of constantly located blood vessels, identical histological structure of the donor and the recipient sites, hidden donnor site and absence of functional deficit. We have used the palntar flaps in seven cases. There has been no recurrence of ulceration in any of them during the follow up period of 12 to 108 month. An anterior leg flap based on the cutaneous branches of the anterior tibial artery, with firmly anchored vessels, a long pedicle with wide vessels may used not only as a free flap graft for reconstruction of moderate degree distant defects but also as a retrograde island flap graft for the reconstruction of adjacent tibial artery in five cases of plantar ulceration with satisfactoryresults. there was no recurrence of ulceration during the follow up period of 48 to 72 months

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part IV - use of medial leg flap and medial knee flap

The medial leg flap, based on the cutaneous branches of the posterior tibial artery is raised from the middle and lower regions of the medial aspect of the leg. It has a long pedicle, and it can be used as a free flap to reconstruct the distant soft tissue and also as an island flap. We have used this retrograde island flap for a surfacing ulcerated areas in six leprosy patients. The flap survived in all cases. At 24 to 60 months follow up examination, ulceration had not recurred in any for them. The medial knee flap consisting of the skin and subcutaneous tissu of lower part of the medial side of the thih and upper part the leg, is suitable for covering soft tissue cushion defects of the extremities because of the constant vessels, long pedicle, wide diameter, well recognizable sensory nerves and less subcutaneous fat. We have used the medial knee flap for the resurfacing sizeable raw areas due to ulceration in there leprosy patients. the flap survived in all cases there was no recurrence of ulceration duriong the 70-148 months follow up period

Techniques for covering soft tissu defects resulting from plantar ulcers in leprosy: Part V - use of the flap in the inguinal region and latissimus dorsi musculocutaneous flap

The area of distribution of the superficial cicunflex iliac, superficial epigastric and superficial external pudental arteries is large and flaps based on them can meet the requirement of different recipient sites. We have transplanted free flaps based on the superficial epigastric artery for repairing plantar soft tissue defects in six leprosy patients. During the follow up examination 58 to 118 months later there has been no recurrence of ulceration in any of these cases. The latissimus dorsi muscle, is mainly nourished by the thoracadorsal artery and the latissimus dorsi musculocutaneous flap is a large sized, composite structure with abundant blood provision and strong anti infectious property. The latissimus dorsi flap can be used as a muscle graft. because ofits constant vascular position, wide outer diameter of the vessels and long pedicle. It can therefore be utilized for repairing soft tissue defect or replacement of paralyzed muscle. We have used the latissimus dorsi musculotacutaneous free flap for repairing large skin and soft tissue defects resulting from plantar ulceration in three leprosy patients. During the follow up period, one patient who had complete drop foot and had refused corrective surgery had recurrence of the ulcer in the 12 post operative month. No ulcers had recurred in the other two cases during the follow up at 48 and 114 months

Transplantation of fibula with vascular pedicle for fusion of ankle in leprotic drop-foot

Devascularized bone grafts are pieces of dead bone they simply serve as scaffods for new bone to grow and fill the gap, taking a long time when they succeed in doing so. In constrast, vascularized grafts being living tissues have short healing time, great vitality and strong infection resisting capacity. We report here the successful use of vascularized grafts of the lower end of fibula for fusing the ankle in five leprosy patients

Diagnostic exploration of enlarged peripheral nerves in suspected cases of leprosy. An analysis of 55 cases

In 55 cases presenting with enlarged peripheral nerves without any skin lesions, a rice grain sized biopsy of the nerve lesion was taken for histopathological examination. As a result definitive diagnoses could be established: leprosy was diagnosed in 32 cases. In 23 cases the cause of nerve enlargement was not leprosy: post traumatic neuritis 9, cysts 5, hypertrophic neuritis 3, nonspecific 4, neurofibroma 1, and amyloidosis 1. In all of these cases there was a deficit of the nerve function and postoperatively there were no complications. The authors, as a result of this experience, believe that surgical exploration nad biopsy is a harmless diagnostic tool for establishing a definitive diagnosis o fleprosy in cases presenting with enlarged peripheral nerves without any skin lesions. In 23 out of 55 such cases the nerve enlargement was proved to be other causes than leprosy