Prospective analytical study of assessment of off loading by Total Contact Cast in treatment of non healing plantar ulcers in anaesthetic foot.

BACKGROUND: Chronic planter ulcer, also known as trophic ulcer, shows no tendency towards healing. It is usually seen in sensory deficient foot. The clinical result of a sensory, motor or autonomic loss of a nerve function is frequently the same--ulceration, although the exact cause may vary. The treatment principle involves dressing and avoiding pressure on the ulcerated site called 'offloading' and patient education for prevention. AIM OF THE STUDY: To determine the outcome of non-healing planter ulcers in an anaesthetic foot treated with offloading, total contact casting (TCC), in terms of rate and duration of healing and percentage of ulcers healed based on improvement of Wagner's grading with respect to the clinical profile of the patient. METHOD: Detailed examination of the patients was done, and neuropathic foot confirmed. Surgical debridement of the ulcer was done to take off all the necrotic tissues, periwound callus, and infected material down to viable tissues. Once the ulcer became clean, a total contact cast was applied with a walking iron for ambulation. TCC was renewed every 2 weeks and rate of healing was assessed. RESULT: 80% of the cases healed within 8 weeks, healing defined by complete re-epithelisation of wound. Average duration of healing of an ulcer was 6.73 ±1.92 weeks. LIMITATIONS OF THE STUDY: Small sample size and the lack of control subjects for comparison. CONCLUSION: Offloading with total contact casts is believed to be the gold standard method with better and faster healing rates.

The story of a deformed leprous foot.

Eccrine syringofibroadenoma (ESFA) is a rare adnexal tumour of eccrine ductal proliferation. A 50 year old treated case of leprosy presented with a chronic non healing ulcer of 5 years duration on the deformity laden right foot. Multiple verrucous papules and plaques were seen surrounding the ulcer which showed histopathological findings consistent with ESFA. Although ESFA constitutes a rare association with leprosy, considering the load of treated cases in our country and elsewhere, it may represent an under-reported entity which requires more attention in the post elimination era.

Nodular melanoma in trophic ulceration of a leprosy patient: a case study.

UNLABELLED: Non-healing chronic trophic ulceration is very common in leprosy patients. Marjolin's ulcer consists of the malignant transformation of a chronic ulcerative lesion. Nodular melanoma developing from Marjolin's ulcer, caused by a trophic ulceration of a leprosy patient, is very rare with only a few cases reported in the literature. Due to the disguised presentation of these malignancies within trophic ulceration lesions in leprosy, neoplastic transformation is frequently overlooked, leading to misdiagnosed and delayed treatment. This paper reports a case of an 83-year-old man with lepromatous leprosy and chronic ulceration on the foot for 22 years. Over a period of 2 months, the ulcer enlarged, turned black, and became more painful. The patient underwent regional excision and immunotherapy after the diagnosis of malignant nodular melanoma. After 9 months follow-up, no metastasis was found. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.

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.

Lucio's phenomenon, an uncommon occurrence among leprosy patients in Sri Lanka.

BACKGROUND: Lucio's phenomenon is a rare manifestation of untreated leprosy which is seen almost exclusively in regions surrounding the Gulf of Mexico. Its occurrence elsewhere though documented is considered uncommon. We present a case of Lucio's phenomenon in a previously undiagnosed leprosy patient who presented to us with its classical skin manifestations. CASE PRESENTATION: A 64 year old South Asian (Sri Lankan) male with a history of chronic obstructive airway disease presented to us with fever and cough. He had a generalized smooth and shiny skin with ulcerating skin lesions afflicting the digits of the fingers. The lesions progressed to involve the extremities of the body and healed with crusting. Based on the clinical and investigational findings Tuberculosis and common vasculitic conditions were suspected and excluded. The unusual skin manifestations prompted a biopsy, and wade fite stained revealed Mycobacterium bacilli. In context of the clinical picture and histological findings, Lucio's phenomenon was suspected. A clinical diagnosis of Lucio's phenomenon occurring in the backdrop of lepromatous leprosy was made. CONCLUSION: Though leprosy is still a prevalent disease, it has manifestations that are not easily recognized or fully appreciated. Regional patterns of atypical manifestations should not limit better understanding of rarer manifestations as it will aid in clinching an early diagnosis and instituting prompt treatment, thereby reducing morbidity and mortality.

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.

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.

[Atypical mycobacteriosis of the skin caused by Mycobacterium abscessus in an immunocompetent woman]. / Atypische Mykobakteriose der Haut durch Mycobacterium abscessus bei einer immunkompetenten Frau.

Mycobacterium abscessus is the most pathogenic of the fast-growing mycobacteria, and it is resistant to most of the antimicrobial and tuberculostatic drugs available. This non-tuberculous mycobacterium is significant in medicine because it can contaminate post-traumatic wounds and be a causative agent in chronic skin and soft tissue infection after surgical procedures.A 60-year-old immunocompetent woman was suffering from chronic ulcers and abscesses on the heels and malleoli of both feet. Histological examination revealed a granulomatous inflammation with detection of acid-fast rods, albeit without fibrinoid necrosis. The repeated detection of atypical mycobacteria, which were ultimately identified as Mycobacterium abscessus, allowed the diagnosis of an atypical mycobacteriosis of the skin. This was successfully treated first with clarithromycin and rifabutin and later with a combination of ethambutol, minocycline, clofazimine and azithromycin.

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).

Leprous osteitis presenting as bone cyst and erosions.

A 30-year-old man presented to the Hansen outpatient department with swelling and ulceration of toes for 2 months and swelling of the right fifth and fourth fingers and the left second finger for 1 month. In addition to skin lesions of lepromatous leprosy (subpolar type), there was nontender, non-fluctuant swelling of the right fifth and fourth fingers and left second finger. Skin over the right fifth finger showed sinus-like openings with associated purulent discharge. He also had swelling and ulceration of second left toe. Slit-skin smear (SSS) showed a bacterial index of 6+ from the ear lobes and cutaneous nodules, 4+ from the patch, and 3+ from normal skin. Modified Ziehl-Neelsen staining of the discharge extruding from the sinuses on the right fifth finger also showed abundant acid-fast bacilli. Radiography of the hands and feet showed lytic lesions in the distal epimetaphyseal region o proximal phalanx of the right fifth finger and left second finger and erosion of distal end of proximal phalanges of both second toes. Histopathological examination of biopsy specimen from the patch (back) showed features of lepromatous leprosy, and Fite-Faraco stain for tissue acid-fast bacteria (AFB) was strongly positive. Fine-needle-aspiration cytology (FNAC) from the lytic lesion in the bone also showed predominantly foamy macrophages with strongly positive staining for AFB with a few interspersed lymphocytes, epithelioid cells and Langhans giant cells. On the basis of these features, a clinical diagnosis of subpolar lepromatous leprosy with leprous osteitis was made. In today's clinical era of improved case detection and prompt treatment with effective multidrug regimens, advanced bone changes are rarely encountered. We describe this case of lepromatous leprosy that developed cavitating lesions of the phalanges of the hand, seen on x-ray as well-defined bone cyst and erosions.

Squamous cell carcinoma in plantar ulcers in leprosy: a study of 11 cases.

The objectives of our study were to describe and analyse the malignancies that occurred in plantar ulcers of leprosy patients. The possible predisposing conditions, duration and extent of the spread of the tumour were also studied. All patients with trophic ulcer of the foot attending the urban leprosy clinic in our hospital from January 1998 to January 2003 were screened for change to malignancy. During the study period, 79 cases of plantar ulcers in leprosy were seen. The mean age of these cases was 39.9 years with male-to-female ratio of 4:1. Eleven cases with plantar ulcers and malignant change were diagnosed in our hospital during the study period. The male-to-female ratio was 4.5:1. The mean age of these patients was 60.6 years. Their age ranged from 46 to 75 years. Nine of the cases were treated cases of borderline tuberculoid leprosy, while two had treated lepromatous leprosy. In our study, two distinct morphological types of malignant changes were seen. Histopathologically, all cases, except one, were of well-differentiated squamous cell carcinoma variation; one case had verrucous carcinoma. Though trophic ulcers are common in leprosy cases, only long-standing and neglected ones undergo malignancy.

Actinomycotic mycetoma due to Nocardia brasiliensis in a case of leprosy.

Various bacterial and fungal infections associated with non-healing ulcers in cases of leprosy have been reported (G Ebenzer et al, 2000, Rama Ramani et al, 1990). There are no reports of mycetoma associated with leprosy patients in the literature. We report here a case of actinomycotic mycetoma due to Nocardia brasiliensis associated with the non-healing plantar ulcer of a leprosy patient.

Neoplastic transformation of chronic ulcers in leprosy patients--a retrospective study of 23 consecutive cases.

A retrospective analysis of chronic ulcers among leprosy patients seen over the last 20 years yielded 23 cases of neoplastic transformation. It showed a peak at the sixth decade, an incidence of 3.66/100 among hospitalised ulcer cases and male/female ratio of 1.6:1. Borderline tuberculoid was the most common type of leprosy involved (40%). Squamous cell carcinoma was the most common neoplasia. Its usual site was plantar ulcers. Heel ulcers showed relatively greater predeliction for malignancy (38.5%). Histopathological proof of malignancy is desirable and that may require multiple biopsies. Metastasis is rare but potentially fatal. The surgical treatment must provide a functional, trouble-free limb. Forefoot or Lisfranc's amputation for distal third ulcers and below-knee amputation for large midfoot and ulcers are procedures of choice. Wide excision may be used in select cases.

Exposure to pulsed magnetic fields in the treatment of plantar ulcers in leprosy patients--a pilot, randomized, double-blind, controlled clinical trial.

A pilot, randomized, double-blind, controlled clinical trial to study the effect of exposure to pulsed magnetic fields (PMF) on the rate of healing of plantar ulcers in leprosy patients was undertaken. Twenty patients were randomly allocated to receive standard wound-care treatment (controls) and 20 others received standard treatment plus exposure to PMF (sinusoidal form, 0.95 to 1.05 Hz, amplitude +/- 2400 nano Teslas) (study group) for four weeks. Assessment of the outcome of treatment was based on the volume of ulcers, calculated from the maximal length, breadth and depth of the ulcer recorded on the day of admission, at one and two weeks and at the end of treatment. The analysis of the results was based on 15 control patients and 18 PMF patients after deletion of four patients due to irregularity in attendance and three others on account of suspected malignancy of the ulcers. In the control group, the geometric mean volumes of the ulcers were 2843 and 1478 cu mm on the day of admission and at the end of the treatment (P = 0.03); the corresponding values in the PMF group were 2428 and 337 cu mm, respectively (P < 0.001). A decrease in the volume of 40% or more was observed in 53% of control patients and 89% of PMF patients (P = 0.02); a decrease of 80% or more was observed in none of the controls and in 33% of PMF patients. These findings strongly suggest that exposure to PMF causes a significantly more rapid healing of plantar ulcers in leprosy patients.