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.

Total knee arthroplasty for neuropathic arthropathy in a patient with leprosy.

Patients with leprosy are known to tend to develop neuropathic arthropathy, known as Charcot joint. There are no case reports of total knee arthroplasty (TKA) in patients with leprosy with polyarticular neuropathic arthropathy, and the results are unknown. In this study, we report a case of TKA in a patient with leprosy with polyarticular neuropathic arthropathy and discuss its outcomes and indications. Right TKA using the NexGen Legacy Constrained Condylar Knee implant was performed in a 62-year-old man with neuropathic arthropathy in multiple joints with clinical symptoms, particularly in the right knee. Seven years post-operation, the American Knee Society Score-knee and -function, which represent knee function and activities of daily living on a scale of 100 points, were significantly improved compared with preoperative values, from 30 to 99 points and 0 to 60 points, respectively. Indications for arthroplasty for neuropathic arthropathy should be carefully considered in each individual case. In this case, the patient had neuropathic arthropathy in multiple joints; however, TKA was performed because recovery of function in the right knee was expected to significantly improve the patient's activities of daily living, and a good mid-term clinical outcome was achieved. Therefore, indications for arthroplasty should be considered in patients with systemic neuropathic arthropathy such as leprosy, and with accurate assessment and appropriate implant selection, good long-term outcomes may be expected.

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.

Endoneural abscess of common popliteal nerve as first clinical manifestation of leprosy: the first reported case in history in a low-incidence country.

A migrant from Palestine came to our attention for weakness of dorsiflexion of the left foot and hypoesthesia of the homolateral common peroneal nerve territory. Skin biopsies from skin lesions in the hypoesthetic area were not diagnostic. Radiological investigation showed focal nerve enlargement with a possible focal lesion. At this time, and given the uncertainty of the diagnosis, we had to choose between medical therapy with steroid and a surgical exploration of the nerve. We decided for the latter option. Intraoperatively, we found a focal round enlargement of the nerve. Epineurotomy was performed at that level, revealing a round caseous granulomatous mass that was excised. Microbiological examination revealed presence of Mycobacterium Leprae allowing diagnosis of leprosy. Medical therapy was then started, leading to resolution of clinical symptoms. Endoneural lepromatous abscesses are uncommon lesions that should be suspected in patients presenting with peripheral nerve dysfunction with anamnesis of travel in leprosy endemic regions or contacts with people from endemic regions with or even without skin lesions. Detection of endoneural abscesses is of critical importance because prompt surgical excision in conjunction with medical therapy leads to improvement of symptoms and permits correct diagnosis. In times of large human migrations from leprosy endemic areas, knowledge of this uncommon presentation of leprosy and its management will help lead to the best management of these patients.

Orthopedic Surgical Foot Management in Hansen Disease.

Hansen disease remains a common problem worldwide with 750,000 new cases diagnosed each year. Nerve injury is a central feature of the pathogenesis because of the unique tendency of Mycobacterium leprae to invade Schwann cells and the peripheral nervous system, that can be permanent and develop into disabilities. The orthopedic surgeon has an important role in the management of neuropathy, performing surgical release of the tibial and common peroneal nerves in potentially constricting areas, thus providing a better environment for nerve function. In cases of permanent loss of nerve function with drop foot, specific tendon transfers can be used.

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.

Neurosurgical treatment of leprosy neuropathy in a low-incidence, European country.

INTRODUCTION: Leprosy is nowaday increasingly encountered in non-endemic countries. Nerve involvement is common. Swelling of the nerves may lead to entrapment neuropathy causing pain and neurological deficits. Delay in diagnosis and treatment may lead to loss of chance of improvement. Surgical decompression in conjunction with medical therapy allows relief of symptoms. METHODS: We present a retrospective series of 21 patients surgically treated in our center for leprosy entrapment neuropathy. We report presentation, treatment, and outcome at follow-up including a brief literature review. RESULTS: Twenty-one patients were treated for nerve entrapments in four different anatomical districts. We reported good clinical outcomes mainly in motor deficits but also in improvement of sensitive deficits and pain symptoms. We did not experience surgical complications. DISCUSSION: Although there is a lack of high-quality prospective studies comparing medical and surgical treatment of leprosy neuropathy, benefits of surgery are widely reported in series and case reports from endemic countries. There is scant literature from low-incidence countries even if leprosy incidence is nowaday increasing in these countries and will likelihood further increase in the future. Our results are in line with the literature presenting good outcomes after surgery. CONCLUSION: We believe that a precise knowledge of the pathology and its management is crucial also for physicians who work in low-incidence countries to maximize healing chances with timely diagnosis and treatment.

Análise dos resultados de neurolises em pacientes com hanseniase / Analysys of the results of neurólises in patients with leprosy

O objetivo deste estudo é avaliar a eficácia da neurólise cirúrgica no tratamento da neurite periférica em pacientes com hanseníase. Trata-se de um estudo retrospectivo de vinte e cinco pacientes hansenianos submetidos à neurólise com média de idade de 39,4 anos. A perda sensitiva foi quantificada pelo método dos monofilamentos de Siemmens-Weistein e a dor foi informada pelo paciente através de escala numérica analógica. As variáveis foram analisadas pré e pós operatoriamente. O Teste da Binomial, utilizado para a análise comparativa entre as avaliações sensitiva, mostrou variação não significativa estatisticamente (p > 0,05) nas medições pré e pós-operatórias, indicando ausência de progressão da parestesia. Houve melhora significativa da dor em todos os pacientes. Conclusão: a neurólise cirúrgica foi eficaz no alívio da dor e interrompeu a progressão da perda sensitiva na neuropatia periférica de hansenianos.

Ulnar nerve sonography in leprosy neuropathy.

A 23-year-old woman presented with a half-year history of right forearm sensory and motor dysfunction. Ultrasound imaging revealed definite thickening of the right ulnar nerve trunk and inner epineurium, along with heterogeneous hypoechogenicity and unclear nerve fiber bundle. Color Doppler exhibited a rich blood supply, which was clearly different from the normal ulnar nerve presentation with a scarce blood supply. The patient subsequently underwent needle aspiration of the right ulnar nerve, and histopathological examination confirmed that granulomatous nodules had formed with a large number of infiltrating lymphocytes and a plurality of epithelioid cells in the fibrous connective tissues, with visible atypical foam cells and proliferous vascularization, consistent with leprosy. Our report will familiarize readers with the characteristic sonographic features of the ulnar nerve in leprosy, particularly because of the decreasing incidence of leprosy in recent years.

Role of Reconstructive Surgery (RCS) in Improving the Quality of Life of Leprosy Afflicted Persons.

Since time immemorial, stigma has been associated with leprosy mainly due to deformity and disability which in turn affects the physical, psychological, social and economical well being of some of the leprosy afflicted persons (LAPs). To prevent and correct deformities Government of India has focused on early diagnosis and appropriate treatment. In addition government has been providing services of Reconstructive Surgery (RCS). RCS corrects the deformity and is expected to help in reducing the stigma in society and reintegrate the affected persons in to society so that they become economically self reliant and carry out their normal livelihood activities without any prejudice. As the stigma has cultural background, this study has.been carried out with to assess the existing stigma level in pre RCS in society in parts of Odisha and compare with that of post RCS. The study was conducted in Sonepur district of Odisha. The sample size is the entire universe of all the 60 patients who had undergone the RCS process, during these the recent years. The methods adopted for data collection were the tools like questionnaire schedules, interview, observation, FGD and in depth case studies. Almost 86% of these Leprosy afflicted persons (LAPs) were very satisfied due to improvement in acceptance by their family, friend, relatives and society after surgery because of the correction of deformity by RCS as it enabled them to get back into normal life. The economical status improved in 8/60 (13%) after RCS, some becoming capable of earning more than Rs. 10,000/- per month after RCS. To conclude, in this settings of Sonepur (Odisha). RCS appeared to help the LAPs in improving their social acceptance thereby reducing stigma and also improving their economic status thus empowering them to lead their life as a normal human beings. There is need to enlarge and expand these studies to other parts of state/region so that the link with beliefs, type of disabilities and also type of surgery could be better understood and the knowledge generated could be applied to get optimum results.

Reconstructive surgery in children to correct ulnar claw hand deformity due to leprosy.

OBJECTIVES: To study the impact of tendon transfer surgery for ulnar claw hand correction in children with leprosy. SUBJECTS AND METHODS: All the children who underwent reconstructive surgery for ulnar nerve paralysis during the period 2007 to 2012 were included in the study. Unassisted angle, grasp contact, pinch contact and functional assessment were the main outcome measures. All the surgical procedures were performed by the same surgeon and pre- and post-operative therapy protocol was same for all the patients. A common surgical audit form was used to record assessments for all the patients. RESULTS: In this case series, 82 hands of 79 patients with ulnar paralysis were included. All the children had lasso surgery. In 83% of hands, flexor digitorum superficialis of middle or ringer finger was used, while in the remaining patients palmaris longus or extensor carpi radialis longus with fascia lata graft was used as the motor tendon. The unassisted angle decreased in all the patients, indicating correction of claw fingers. Hand function improved after surgery and it showed steady progress during follow-up. CONCLUSION: The deformity due to leprosy in the hands of children is a tragedy as it hampers the use of hands in daily routine activities, school work and other social interactions. Tendon transfer surgery should be done on children to correct established clawed fingers as it yields good results and helps in facilitating hand function to complete daily activities and lead a normal life.

Evaluation of surgical treatments for leprosy sequelae using the Salsa and Dash scales / Avaliação dos tratamentos cirúrgicos das sequelas de hanseníase pelas escalas Salsa e Dash

OBJECTIVE: to compare the SALSA and risk awareness scales with the DASH scale in assessments on leprosy surgery. METHOD: before the operation and 90 days afterwards, we applied the tests to 14 patients (11 females and three males) of ages from 28 to 67 years, who were operated between November 2011 and May 2012. RESULTS: the patients were evaluated after the operation using the SALSA and DASH scales, to measure their relationships and results. CONCLUSION: despite the small sample, this study showed that there were similar relationships of results between the SALSA/risk awareness and DASH scales...

OBJETIVO: comparar as escalas funcionais Salsa (Screening of Activity Limitation and Safety Awarenses)/consciência de risco e Dash (Disabilities of the Arm, Shouder, and Hand) nas avaliações de cirurgias hansênicas. MÉTODO: aplicamos os testes no pré-operatório e com 90 dias de pós-operatório em 14 pacientes, 11 do sexo feminino e três do masculino, entre 28 e 67 anos, operados de novembro de 2011 a maio de 2012. RESULTADOS: os pacientes foram avaliados no pós-operatório pelas escalas Salsa/consciência de risco e Dash para aferir suas relações e seus resultados. CONCLUSÃO: este estudo, apesar da casuística pequena, demonstrou que há relação similar dos resultados entre as escalas Salsa/consciência de risco e Dash...

Brain involvement by leprosy presenting as a frontal cystic lesion.

Leprosy has a predilection for peripheral nerves and is not considered to involve the CNS. The idea that the CNS is exempt from Mycobacterium leprae bacilli has been suspected from a clinical perspective or CSF study in leprosy patients. However, there has been no direct evidence for CNS involvement by leprosy in a living patient. To the best of the authors' knowledge, the present case is the first report providing histopathological and molecular evidence for CNS involvement by leprosy in a living patient. Brain MRI revealed a 2-cm cystic lesion in the right frontal lobe of the patient. The medical history revealed that the patient had been receiving multidrug therapy for borderline lepromatous leprosy. Neuronavigation-guided craniotomy and lesion removal were performed due to a presumptive diagnosis of low-grade glioma. The brain specimen demonstrated variably thickened blood vessels and densely scattered foamy macrophages in the perivascular spaces and parenchymal stroma. Fite acid-fast stain displayed red granular inclusions that were suggestive for fragmented M. leprae. M. leprae-specific nested polymerase chain reaction amplification showed positive bands, and DNA sequencing also demonstrated homology with the M. leprae genome. This case supports the notion that M. leprae can involve the cerebral cortex regardless of cranial nerve engagement.

Understanding of Tendon Transfer in Radial Nerve Palsy in Leprosy.

Involvement of Radial Nerve in leprosy is not very common. Only 0.2% of Radial Nerve deformities is observed. There are various procedure to correct the wrist function. We have analyzed various motor units to correct the wrist function as per the patient requirement.

Quality of life and its domains in leprosy patients after neurolysis: a study using WHOQOL-BREF.

Surgical nerve decompression in leprosy is indicated to prevent or treat nerve damage, and to improve sensory motor function and quality of life (QoL). The purpose of this study was to describe QoL of leprosy patients after surgical nerve decompression. Participants who underwent neurolysis in the last 5 years were recruited. The assessment consisted of collecting demographic and clinical information, QoL and its domain scores. Descriptive statistical analysis of demographic and clinical data was presented. Included 33 patients (43 +/- 11.0 years) who had neurolysis with a total of 61 nerves operated. The results of WHOQOL-bref showed that overall QoL mean was 11.2 (+/- 3.63) and domains scored as follow: physical (11.0 +/- 3.56), environment (11.47 +/- 2.11), psychological (13.29 +/- 2.79) and social relations (15.03 +/- 3.66). Measures of QoL should become part of the standard battery of tools used to assess health and well-being and it may contribute to identifying patients' needs in rehabilitation.

Peroneal strength as an indicator in selecting route of tibialis posterior transfer for foot drop correction in leprosy.

OBJECTIVES: Tibialis posterior tendon transfer (TPT) technique, using either the Circum-tibial (CT) or Inter-osseus (IO) route is the standard surgical technique to correct foot drop. The selection of the route of transfer is usually dependent on the surgeon's preference. This study aims to identify criteria to help make that selection. SUBJECTS AND METHODS: A study was carried out on 381 feet during the period 1999 to 2010. All the patients operated during this period were included in the study. The CT route was used for those with peronei power 4 or 5, while the IO route was used when peronei power was 3 or less. RESULTS: In this case series the mean effective range of motion (above 90 degrees) was 11 and 12 degrees in CT and IO routes, respectively. The results were comparable in terms of rest position, active dorsiflexion and effective range of motion. All patients had a post-operative heel to toe gait, except for one of the 381 operated feet. Only three of the 381 feet had a reduction in navicular height of more than 2 cm, the medial arch being maintained in the others. CONCLUSIONS: TPT is a standard procedure to correct foot drop deformity in leprosy. Pre-selection for route of transfer, CT or IO, based on peronei strength avoids the complication of iatrogenic inversion. The technique of insertion and routine tendo-achilles lengthening provides a good range of movement. The deep tunnelling has not compromised the results, while giving excellent cosmetic appearance.