Pre- and post-surgical evaluation of the impact on Hansen disease sequealae patients' quality of life submitted to orthopedic surgery for closure of chronic plantar ulcers.

INTRODUCTION: Leprosy is a chronic infectious disease that still persists as a public health problem in Brazil. Plantar ulcers are serious complications due to leprosy neuropathy and intensify the isolation and stigma of these individuals. The difficulty in closing these lesions associated with the fetid odor negatively impact the quality of life of people with these lesions. OBJECTIVE: To evaluate the clinical, socioeconomic conditions, degree of satisfaction and quality of life (QoL) of patients after healing of chronic ulcers on feet submitted to orthopedic surgery. METHODOLOGY: This is a qualitative, exploratory, descriptive and observational study carried out with 92 people after surgical treatment of chronic leprosy plantar ulcers. These patients were submitted to a semi-structured questionnaire raising questions of an epidemiological, socioeconomic and perception of quality-of-life order, comparing before and after the surgical procedure. RESULTS: Decrease in indicators - alcohol consumption, tobacco consumption, average monthly cost of analgesic medications, fetid wound odor, foot pain and number of dressings performed weekly; Recurrence of lesions in 55.4 % of cases, related to irregular use or lack of shoes and insoles; Improvement in self-perception of Quality of Life (QoL) in 89.1 % of patients after surgery. CONCLUSION: Orthopedic surgical treatment with resection of plantar bony prominences and skin grafting is an effective therapeutic method for closing chronic plantar ulcers in leprosy, resulting in a decrease in the financial costs employed and in an important improvement in the Quality-of-Life parameters of the individuals undergoing to this procedure. The availability and regular use of shoes and insoles is crucial to prevent recurrence of these injuries.

Epidemiological clinical profile and closure of chronic plantar ulcers in patients with leprosy sequelae undergoing orthopedic surgery in a municipality in western Amazon.

INTRODUCTION: Chronic plantar ulcers in leprosy are lesions resulting from motor and sensory alterations caused by Mycobacterium leprae. They are lesions refractory to conventional dressings and present high recurrence rates. OBJECTIVE: To evaluate the epidemiological clinical profile of patients with chronic plantar ulcers associated with bony prominences in the lesion bed and to evaluate the efficacy of orthopedic surgical treatment of these lesions. METHODS: This is a descriptive and analytical retrospective study with the evaluation of medical records of patients undergoing surgical treatment of chronic plantar ulcers from 2008 to 2018. The surgical technique applied consisted of corrective resection of bone prominences and the primary closure of the lesion with bipediculated local flap. RESULTS: 234 patients were submitted to surgery, 55.1% male with an average age of 69.5 years old. Of these, 82.9% were illiterate; and 88.5% with open lesions over 10 years. After surgical treatment, total wound healing occurred in an average time of 12 weeks. The variables that contributed to shorter healing time were: Patients' lower age group; regular use of orthopedic shoes and insoles and dressings performed by nurse aides in health units before surgery. Obesity was the factor that correlated with the delay of healing time. CONCLUSION: A higher incidence was observed in males and male and female illiterate patients. The regular use of shoes and insoles and dressings performed by nurse aides in health units contributed to shorter postoperative healing time. Orthopedic surgical treatment with corrective resection of bony prominences proved to be an efficient therapeutic method for the closure of chronic plantar ulcers. It is a reproducible method, justifying the importance of the orthopedic surgeon in the context of the multidisciplinary team to cope with these complex lesions.

Tratamento da úlcera plantar devido à hanseníase / Treatment of leprosy-induced plantar ulcers

Introdução: A úlcera plantar por hanseníase é uma lesão no pé resultante da falta de sensibilidade plantar. O objetivo é descrever o tratamento realizado em portadores de úlceras plantares por hanseníase. Métodos: Estudo de prontuários de portadores de úlcera plantar atendidos no Hospital Sarah em Brasília, de 2006 a 2016, quanto ao sexo, idade, etiologia, localização e tratamento. Resultados: Foram atendidos 27 pacientes, 17(62,96%) homens e 10 (37,04%) mulheres, procedentes de Goiás e DF, na faixa etária de 41 a 60 anos (40,74%). Todos necessitaram de um ou mais procedimentos cirúrgicos. Conclusão: Observou-se maior frequência no sexo masculino, grau avançado, localizadas no primeiro artelho. Todos necessitaram de procedimentos cirúrgicos e não cirúrgicos, evoluindo com cicatrização completa da ferida, amputação transtibial em um caso e de artelhos em sete casos, e 90% dos casos apresentaram recorrência da úlcera após um ano.

Introduction: Leprosy-induced plantar ulcers result from a lack of plantar sensitivity. Objective: This study aimed to describe the treatment provided to patients with leprosy-induced plantar ulcers. Methods: We retrospectively reviewed the medical records of patients with plantar ulcers treated at Sarah Hospital in Brasilia from 2006 to 2016 and collected information about sex, age, etiology, location, and treatment. Results: A total of 27 patients (17 [62.96%] men, 10 [37.04%] women; 40.74% were aged 41­60 years) were treated from Goiás and the Federal District. All required ≥1 surgical procedure. Conclusion: A higher frequency of advanced grade was observed in men, primarily on the first toe. All needed surgical and non-surgical procedures and achieved complete wound healing. Transtibial amputation was required in 1 case and toe amputation in 7 cases; 90% patients developed ulcer recurrence after 1 year.

Microsurgical Reconstruction of Plantar Ulcers of the Insensate Foot.

Background Plantar, neuropathic, or trophic ulcers are often found in patients with decreased sensation in the foot. These ulcers can be complicated by infection, deformity, and increased patient morbidity. Excision results in wider defects and local tissues are often insufficient for reconstruction Methods Total 26 free flaps were used in 25 patients to reconstruct plantar ulcers between years 2007 and 2013. The etiology included diabetic neuropathy (n = 13), leprosy (n = 3), spinal/peripheral nerve injury (n = 7), spina bifida (n = 1), and peripheral neuropathy (n = 1). The duration of the ulcer ranged from 1 to 18 years. Fifteen patients had associated systemic comorbidities and six had previous attempts. Free flaps used in reconstruction were the anterolateral thigh flap (n = 18), radial artery forearm flap (n = 4), and the gracilis muscle flap (n = 4). Recipient vessels were the posterior tibial artery (end to side) in 19 and the dorsalis pedis artery in 7. Results The average age at presentation was 44.6 years with mean duration of ulcer of 5.8 years predominantly located over weight-bearing areas. Mean size of ulcer was 59.45 cm(2) and mean follow-up period was 48 months. All flaps survived except a partial loss. Average time to resume ambulation was 6 weeks. Three patients had recurrence with mean follow-up of 48 months. Secondary flap reduction and bony resection was done in four. Conclusion Microvascular reconstruction of the sole has advantages of vascularity, adequate tissue, and leaving rest of the foot undisturbed for offloading. Three significant local conditions influencing selection and transfer of the flap include (1) distally located forefoot ulcers, (2) extensive subcutaneous fibrosis secondary to frequent inflammation, and (3) Charcot arthropathy. In our series, the anterolateral thigh flap is our first choice for reconstruction of these defects.

[Paradoxical reactions and responses during antibiotic treatment for Mycobacterium ulcerans infection (Buruli ulcer). Four cases from French Guiana]. / Réponses et réactions paradoxales au cours du traitement médicamenteux de l'infection à Mycobacterium ulcerans (ulcère de Buruli). Quatre observations en Guyane française.

BACKGROUND: In recent years, first-line therapy for Mycobacterium ulcerans infection in French Guiana has consisted of antibiotics active against this organism. Two regimens are used comprising rifampicin associated with clarithromycin or amikacin. PATIENTS AND METHODS: We describe four patients presenting apparent worsening of their lesions during treatment: ulceration of a nodular lesion in a 32-year-old woman and worsening of an ulcerated lesion in three patients aged 16, 27 and 79 years. DISCUSSION: In these 4 patients, we concluded that the symptoms were caused by a paradoxical response or a reaction, a phenomenon already described in tuberculosis and leprosy. Such worsening is transient and must not be misinterpreted as failure to respond to treatment. The most plausible pathophysiological hypothesis involves the re-emergence of potentially necrotizing cellular immunity secondary to the loss of mycolactone, a necrotizing and immunosuppressive toxin produced by M. ulcerans, resulting from the action of the antibiotics.

Squamous cell carcinoma masquerading as a trophic ulcer in a patient with Hansen's disease.

Nonhealing trophic ulcers in leprosy are a common phenomenon, but acute malignant transformations of the same are relatively rare. This study reports on a 35-year-old man previously treated for Hansen's disease with a squamous cell carcinoma involving the right foot with rapid lymphatic spread. He was being treated as a benign trophic ulcer for more than 12 months until he started developing huge inguinal lymph nodes and the ulcer rapidly increased in size. Squamous cell carcinomas are known to occur in ulcers of considerable duration but such rapid growth in such a short duration and rapid lymphatic spread is unusual in Marjolin's ulcer as the lymphatics are usually destroyed because of previous inflammation and scarring.

[Effect of different surgical methods on leprosy plantar ulcers].

OBJECTIVE: To explore the effects of different surgical methods on plantar ulcers in leprosy. METHODS: The clinical data of 71 patients with leprosy plantar ulcers and treated with different surgical methods between October 1950 and October 2006 were analyzed retrospectively. In group A, 34 cases underwent debridement, including 26 males and 8 females aged 53-88 years old (average 72.4 years old); the course of ulcer averaged 29.0 years; the size of ulcer ranged from 5 cm x 3 cm x 2 cm to 11 cm x 7 cm x 3 cm; the disability degrees of the affected foot was mild in 25 cases and severe in 9 cases according to the self-designed evaluation system. In group B, 22 cases received foot pressure rebuilding surgery, including 19 males and 3 females aged 48-83 years old (average 69.8 years old); the course of ulcer averaged 33.5 years; the size of ulcer ranged from 5 cm x 3 cm x 2 cm to 12 cm x 7 cm x 3 cm; the disability degrees of the affected foot was mild in 12 cases and severe in 10 cases. In group C, 15 cases were repaired with the transposition of toe flap, foot arch flap, acrotarsium flap, or medial tibia flap, including 11 males and 4 females aged 43-73 years old (average 64.6 years old); the course of ulcer averaged 29.3 years; the size of ulcer ranged from 6 cm x 3 cm x 2 cm to 11 cm x 5 cm x 3 cm; the disability degrees of the affected foot was mild in 9 cases and severe in 6 cases. No significant differences were evident among three groups in terms of the general information (P > 0.05), except for the difference between group A and group C on age (P < 0.05). RESULTS: Group A: 19 out of 34 cases healed and the average healing time was 46.8 days; all patients were followed up for 2-45 years (average 17.2 years); the rate of ulcer healing 1 year after operation was 55.9% (19/34); 12 healed ulcer patients relapsed at average 1.5 years after operation; the rate of ulcer healing at last follow-up was 20.6% (7/34). Group B: 18 out of 22 cases healed and the average healing time was 29.2 days; all patients were followed up for 2-50 years (average 13.3 years); the rate of ulcer healing 1 year after operation was 81.8% (18/22); 7 healed ulcer patients relapsed at average 3.3 years after operation; the rate of ulcer healing at last follow-up was 50.0% (11/22). Group C: 14 out of 15 cases healed and the average healing time was 27.1 days; all patients were followed up for 3-12 years (average 8.8 years). The rate of ulcer healing 1 year after operation was 93.3% (14/15); 7 healed ulcer patients relapsed at average 4 years after operation; the rate of ulcer healing at final follow-up was 46.7% (7/15). For the rate of ulcer healing 1 year after operation, there was a significant difference between group A and group B, and between group A and group C (P < 0.05), but no significant difference was evident between group B and group C (P > 0.05). For the rate of ulcer healing at the final follow-up visit, there was a significant difference between group A and group B (P < 0.05), but no significant difference was evident between group A and group C, and between group B and group C (P > 0.05). CONCLUSION: The surgical treatment of plantar ulcers in leprosy should include the alleviation of the plantar high-pressure zone and the transposition of the flaps, providing good short-term and long-term therapeutic effect.

Surgical treatment of three cases of plantar foot ulceration in leprosy.

Neurophatic foot ulceration (NFU) is a common problem in leprosy patients. Three cases of NFU, who did not respond to conservative measures, were treated with orthopaedic surgery. The purpose of the treatment was, by using different approaches, the reduction of bone hyper pressure areas, allowing the ulcer to heal.

Closure of simple heel ulcers by skin stretching.

A majority of heel ulcers, at least to begin with, extend to dermis or to the fat pad in its superficial part and an appropriate skin closure can heal these ulcers as most of the padding is in tact. Since the skin is adherent to the deeper structures with fibrous bands it has to be stretched or undermined (by cutting the fibrous bands) to close the wound without tension. 17 feet in 11 patients (10 males; one female) in the 12-54 year age-group were operated upon and followed up. Because skin is adherent to deeper tissues by fibrous septae, stretching of skin was planned to mobilize it for a tension-free closure. Of the 17 feet, 13 could be re-examined after 30 months or more. Most of the minor recurrences were seen in the first 6 months after surgery. Major recurrences were seen in 2 feet (one case). The suture line did not show hyperkeratosis and the scar merged well into the surrounding skin after one year. Available data suggest that simple heel ulcers can be made to heal with a good scar by skin-stretching and suture, and, by radiography of the foot, it is worth separating those cases in which ulcer is not extending deep involving calcaneum. The size of the ulcer in heel is important for the success of the operation. The procedure is not intended for big wounds (>15 mm in width).

A novel treatment for plantar ulcers in leprosy: local superficial flaps.

Plantar ulceration is the most common serious disability occurring in patients of leprosy. Growth and emergence of innovative procedures in plastic surgery has greatly revolutionized the treatment of this highly frustrating problem. In the present study, a total of 40 leprosy patients were included. These ulcers were managed using different types of local superficial flaps (advancement, rotation, transposition and first toe web flap). Majority of ulcers healed within 4 weeks and patients were discharged within 6-8 weeks postoperatively. Patients were followed up for a period of 6 months to 3 years. Ulcers recurred in only 25% of all the ulcers operated upon and we observed that management of plantar ulcers by using appropriate local superficial plantar flaps is a viable option and worth trying in view of low incidence of recurrence and relatively shorter duration of hospital stay.

Management of 34 chronic heel sinuses in leprosy, using a modification of a local rotation flap in Kolkata, India.

We have seen 55 trophic ulcers of the heel in 2 years in our hospital, between March 2000 and February 2002. Thirty-four were chronic heel sinuses, six cases of multiple sinuses and 28 cases of single sinus of the plantar aspect of the heel. All these cases were treated by excision of the sinus, paring the prominence of the calcaneum, or excision of the cavity within the calcaneum and coverage by a rotation flap or a modification of this flap. Over the past 6 years, we have evolved a modification of a rotation flap that requires a fusiform incision to excise the sinus, and a curved incision for the flap extending through the instep and the non-weight bearing heel. The fusiform excision, rather than the traditional triangulation, causes the flap to partly transpose rather than rotate completely. The flap is raised superficial to the plantar aponeurosis, exposing the aponeurosis from mid-sole to the heel. It is a modification of a rotation flap. The scarring over the weight-bearing sole is minimal, restricted only to the incision necessary for the excision of the heel sinus and this is its main advantage. Twenty-one of the 34 cases healed without complications. Thirteen cases had complications, of which six were treated non-operatively and seven required either a redo of the flap or another flap cover.

Role of flaps and skin grafts in the management of neuropathic plantar ulcers

In the neurologically impaired foot pressure ulcers are common. Pressure point reduction must always be addressed. Most ulcers, perhaps with the exception of huge heel ulcers, will heal by secondary intention if treated conservatively in the right manner. However, conservative treatment can be very time consuming and might sometimes leave unstable scars. For those with recurrent ulcers, the time taken off work to heal these ulcers can be economically debilitating. Skin grafting and flep coverage can be rewarding in selected cases. Follow up with proper footwear is of uttermost importance. Soft tissue coverage can only occur when all signs of infection have resolved and the foot has an adequate blood supply.

Excision arthroplasty: an effective method in the management of plantar ulcers with metatarsophalangeal joint infection in anaesthetic feet.

The cases of 30 patients with septic arthritis of the metatarsophalangeal (MTP) joints as a complication of plantar ulceration in leprosy who underwent excision arthroplasty and primary closure of the plantar ulcer were reviewed. Twenty-two of these patients were male. The commonest site of MTP joint involvement was the first MTP joint. The average longitudinal diameter of ulcers was 2cm, and most ulcers were oval in shape. Diagnosis was made on the basis of signs of infection over the MTP joint, discharge from the ulcer and examination with a probe. Infection in the joint ranged from simple synovial discharge to seropurient or purulent discharge. Treatment involved excision arthroplasty of the MTP joint, excision of the ulcer with primary closure of the plantar incision and dorsal or lateral drainage depending upon the direction in which the infection extended. In two patients, the plantar wound could not be closed as it was too large. Healing of the plantar incision took 2 weeks in 12 patients and 3 weeks in 14 patients. In four patients, healing did not occur by primary intention. In a follow up of 1-2 years, there was no recurrence in 24 patients, while four patients had recurrent simple ulceration. Two patients were lost to follow up. Review of the results of this procedure dealing with septic arthritis of MTP joints secondary to plantar ulceration shows that primary healing of the plantar incision could be achieved in 3 weeks. With regard to recurrence, even though only four out of 28 ulcers treated by this procedure recurred, other contributing factors should be considered in a prospective control study to support the view that this procedure has contributed to non-recurrence.

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 V. Use of the flap in the inguinal region and latissimus dorsi musculocutaneous flap.

The area of distribution of the superficial circumflex 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 an artery-pedicled island flap or as a free flap besides its use as a muscle graft, because of its 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 musculocutaneous 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 12th post-operative month. No ulcers had recurred in the other two cases during the follow-up at 48 and 114 months.