Saphenous nerve transfer: A new approach to restore sensation of the sole.

BACKGROUND: Loss of protective sensation of the sole may lead to repeated trauma, chronic nonhealing ulcers, and even amputation. Saphenous nerve (SN) to posterior tibial nerve (PTN) transfer can restore sensation of the sole. METHOD: This study was conducted in a tertiary referral center in Central India. Twenty-one patients (32 feet) diagnosed with loss of sensation of the sole were included in this study. Causes of loss of sensation were Hansen's disease (n = 18), complex sciatic nerve injury (n = 1), lumbosacral spinal tumor (n = 1), and lumbosacral meningomyelocele (n = 1). Seventeen feet (14 patients) had ulcers on the sole. Preoperative and postoperative sensory tests performed on the sole included tests for touch, pain, temperature, pressure, vibration, and two-point discrimination. Results were classified as per the British Medical Research Council (MRC) scoring system. RESULTS: Seventeen patients (26 feet) were available for follow-up at 6 months after surgery. All patients had improvement in sensory parameters. Ulcers completely healed in 13 feet and reduced in size in four feet. MRC score improved from S0 in 22 feet and S1 in 10 feet to S3 + in 20 feet, S3 in four feet, and S2 in two feet. CONCLUSIONS: Sensory neurotization with SN transfer to PTN can restore protective sensation to the sole and help in the healing of ulcers.

Decompression of peripheral nerve trunks in leprosy prevents the development and progression of deformities?

Peripheral nerve involvement results in deformities formation in leprosy. High doses of (40-60 mg) steroids along with the anti-leprosy drugs is preferred even though the 70-75% cases develop deformity with the above treatment. 772 ulnar nerves, 120 median nerves and 108 posterior tibial nerves not responding to above medical treatment in 12 weeks, were undertaken for external and internal nerve trunk decompression. These cases were followed-up for 5-20 years at various intervals. The pain in nerves (neuritis) recovered in all cases of ulnar, median and posterior tibial nerves. Full sensory recovery with pin prick/feather or cotton wool touch was seen in 50% cases of all the three nerves. 20% cases maintain the pre-operative levels of sensory status. Plantar ulcers healed within 6 months after decompression of posterior tibial nerve. Only 6 cases showed reoccurrence. Overall motor recovery in ulnar nerve was seen 89% and 70% in median nerve. The sensory recovery restores protective sensation which prevents secondary injuries. The improvement of motor power gave better functional hands and improved the appearance which in absence of surgical intervention was not possible.

Avaliação neurologica completa na neuropatia hanseniana / Complete neurologica assessment in Hansen´s disease

Dada a importância da afectação neurológica da Doença de Hansen, os autores tentam descrever neste artigo a forma de realizar uma exploração neurológica completa. Para efeito, são focados os pontos fundamentais desta prática, como a palpação e identificação dos nervos periféricos engrossados, o estudo da sensibilidade superficial e profunda, a exploração da mobilidade voluntária, o exame dos reflexos e a avaliação dos processos neutróficos secundários ao trauma. Devemos destacar que, na maioria das situações, para o diagnóstico da doença e fundamentalmente no trabalho de campo, realizaremos uma exploração baseada em todos estes pontos, embora muito mais simplificada. Como anexo do artigo serão apresentados os resultados obtidos com a exploração neurológica de 71 doentes controlados no Sanatório Fontilles.

Denatured muscle grafts for nerve repair. An experimental model of nerve damage in leprosy.

About 20% of patients with leprosy develop localised granulomatous lesions in peripheral nerves. We report experiments in guinea-pigs in which freeze-thawed autogenous muscle grafts were used for the treatment of such mycobacterial granulomas. Granulomas were induced in guinea-pig tibial nerves and the animals were left for 7 to 100 days in order to assess maximal damage. The local area of nerve damage was then excised and the gap filled with denatured muscle grafts. Clinical assessment after periods up to 150 days showed good sensory and motor recovery which correlated well with the histological findings. The muscle graft technique may be of value for the treatment of chronic nerve lesions in selected cases of leprosy.

Sensory recovery in the plantar aspect of the foot after surgical decompression of posterior tibial nerve. Possible role of steroids along with decompression.

In leprosy, involvement of the posterior tibial nerve leads to sensory loss in the plantar aspect of the foot. As a result plantar ulcers are common and lead to deformity and disability. Restoration of plantar sensation can prevent ulcer formation. Posterior tibial decompression was done for the recovery of sensation in the plantar aspect of the foot. Seventy-two patients under went decompression on 84 feet, 25 received steroids pre- and post-operatively. The recovery of sensation was better if surgery was done before 6 months of onset of anaesthesia. Decompression along with steroids gave better results than decompression alone in patients with active neuritis especially in BT cases whereas in BB, BL and LL cases there was no significant improvement of sensation. The results are discussed.

Fisiopatologia da neurite hanseniana / Physiopathology of the neuropathy in leprosy

A hanseniase é uma enfermedade com potencial de incapacidades físicas das mais notáveis. O comprometimento do sistema nervoso é constante e aproximadamente 30% dos doentes sofrem lesöes neurológicas graves. As manifestaçöes dermatológicas e os estudos bacteriológicos encontram-se bem estabelecidos. No entanto, o conhecimento das lesöes nervosas näo atingiu o mesmo desenvolvimento, fazendo com que a terapêutica do comprometimento, neurológico esteja longe de ser satisfatória e as medidas preventivas dificilmente colocadas em prática. Este trabalho tem por finalidade contribuir para o esclarecimento de alguns aspectos de comprometimento dos nervos periféricos nesta doença

Restoration of plantar sweat secretion in the feet of leprosy patients.

As part of the studies on nerve damage and its consequences in leprosy, the status of sweat gland function in the anaesthetic sole of the feet of leprosy patients was investigated qualitatively and semi-quantitatively, before and after surgical decompression of the posterior tibial neurovascular bundle. Sweat prints of the feet of the patients were obtained pre-operatively and postoperatively on Whatman's No. 1 filter paper. The paper was treated with one percent Ninhydrin and the intensities of the Ninhydrin positive areas were quantitated. Forty one feet of thirty six patients have been studied in this manner. Sweat print analysis of twenty normal people have also been done, and included for comparison. This operative procedure has been found to effect an improvement in the sweat gland function in the feet of more than fifty percent of leprosy patients studied so far.

[Remote results of the surgical decompression of the posterior tibial nerve in the neuropathies of Hansen's disease]. / Les résultats éloignés de la décompression chirurgicale du nerf tibial postérieur dans les neuropathies de la maladie de Hansen.

Results are reported of surgery to the posterior tibial nerve affected by leprosy in 50 patients. A total of 90 neurolyses were performed using a similar technique. Study of the effect of surgery on the course of plantar sensitivity showed that 3 groups of nerves can be distinguished. Nerves in group 1 (21 totally paralyzed nerves) responded poorly to surgery (38% useful results) while on the contrary nerves in group 3 (non-paralyzed nerves) represented the ideal indication, surgery being truly prophylactic. In group 2 nerves a useful result was obtained in 82%. Indications for use of this surgical procedure are discussed, and more particularly the parameters affecting the quality of the results: severity of lesion, immunologic type of disease.

The surgical management of nerve lesions in the lower limbs. Clinical evaluation, surgical technique and results.

The author present his experience of the repair of nerve lesions in the lower limb. The cases are classified into four main groups: traumatic lesions; acute and chronic compression; tumours and leprosy. The traumatic lesions include those associated with a clean wound, missile injuries, traction injuries and a miscellaneous group. The diagnosis and treatment of the different lesions are discussed. The results of nerve grafting using microsurgical techniques are presented. The results are good enough, even in severe traction injuries, to recommend the repair of nerve lesions of the lower limbs in the circumstances which are outlined.

[Perforating plantar ulcer. Interfascicular neurolysis of the posterior tibial nerve]. / Le mal perforant plantaire. Neurolyse interfasciculaire du nerf tibial postérieur.

The authors report the case of a 45-year-old man with perforant ulceration of the foot. The rapid evolution of the cutaneous and bone lesions (three years) necessitated a bilateral intermetacarpo-phalangeal amputation. After conventional therapy, a large necrotic zone remained on the sole of the left foot as well as hyperkeratosis of the right foot. Following Bourrel's protocol for the treatment of leprosy, the authors proposed a posterior tibial nerve neurography, which confirmed the compression of the nerve in the tarsal tunnel. In addition, histological examination of the nerve branches of the sole of the foot showed fibrous thickening of the nerve, endoneural invasion by fibroblasts, and loss of myelin. An interfascicular neurolysis of the posterior tibial nerve at the level of the tarsal tunnel together with a periarterial sympathectomy on both sides, led to rapid recovery. At the same operation, a skin graft was used to cover the skin defect with excellent results in ten days. Ten months later healing remains complete.

Bilan de recherches physiopathologiques sur la nevrite lepreuse: 1-role de la temperature, des microtraumatismes par elongation ou subluxation nerveuse et de la striction canalaire / ?

(Role of temperature, microtraumatisms by elongation or subluxation and canalar stricture.)Cold has a slight aggravating effect on leprosy which is observed in some countries as Iran, South Russia, North India and the Andean cordillera. The subluxation of the ulnar nerve has facilitating effect in the development of the neuritic damage in a limited number of patients. The elongation is important for the production of the ulnar neuritis. The canalar stricture is a major factor causing nerve damage in leprosy. It explains the segmentary localization of the principal damages of the leprous nerves in the proximal areas situated above the tunnels. Intraneural hypertension appears first and is responsible for the swelling of the nerve which gets entraped inside the tunnel. A circulus viciosus is, then, created which maintains and aggravates the intraneural hypertension

Surgical decompression of posterior tibial neurovascular complex in treatment of certain chronic plantar ulcers and posterior tibial neuritis in leprosy.

Seventy-one cases of posterior tibial neurovascular surgical decompression in leprosy are analyzed and reviewed. Thirteen had chronic refractory posterior tibial neuritis while 58 had chronic nonhealing plantar ulcers. The plantar ulcers were associated with posterior tibial neuritis and/or vascular insufficiency. The clinical and operative findings together with the results are presented and the physiopathology of neurovascular compression is discussed. The operative procedure is described. The presence of pale granulation tissue in a nonhealing ulcer seems to be a characteristic finding in these cases. Neurovascular compression in the tunnel, behind and also below the malleolus, was present in all. In operative procedures, the importance of incising the inferior calcaneal bands is stressed. The results show that the neuritis was cured in all cases, while in 53 of 58 cases the plantar ulcers healed in a short period after the decompression. This stresses the value of this procedure. The prophylactic potential of this procedure needs to be evaluated.