The hand-foot impairment score as a tool for evaluating prevention of disability activities in leprosy: an exploration in patients treated with corticosteroids.

The hand-foot (HF) impairment score in leprosy patients is the sum of the WHO disability grades for hands and feet. This retrospective study explored the possibility of using the HF score for evaluation of the effectiveness of corticosteroid treatment programmes for nerve function impairment (NFI). Changes in the score were compared with changes in sensory testing (ST) and voluntary muscle testing (VMT) for 42 leprosy patients who received corticosteroid treatment. The WHO grade did not change in 30/60 (50%) of extremities gaining, and in 4/10 (40%) extremities losing sensation and/or muscle strength. However, 18/24 (75%) patients with a definite gain in function improved in HF score, while the HF score remained unchanged in 10/11 (91%) patients with no change in nerve function. Five patients with impairment in multiple extremities showed both gain and loss of sensation and/or muscle strength in the same or different extremities. Overall, improvement, deterioration and absence of change in NFI, as indicated by changes in ST and VMT were reflected correctly by the HF score in 28 (76%) of the remaining 37 patients. It was also shown that the HF score does not give appropriate information on the extent of the effect of corticosteroid treatment. This study illustrates that the HF score can not be used to support management of corticosteroid treatment of individual patients, but indicates this score to be a promising device for the evaluation of the effectiveness of corticosteroid treatment programmes. This study used the HF score because information on (changes in) eye impairment was not considered reliable. However, in principle, we consider the EHF score, which is the sum of the WHO disability grades for hands, feet and eyes, preferable for evaluation purposes. We strongly recommend further validation of the EHF score as a tool for evaluation of corticosteroid treatment programmes for patient groups with different distributions of NFI through prospective studies.

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 defects and also as an island flap. We have used this retrograde island flap for 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 of them. The medial knee flap consisting of the skin and subcutaneous tissue of the lower part of the medial side of the thigh and the upper part of 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 three leprosy patients. The flap survived in all cases and there was no recurrence of ulceration during the 70-148 months follow-up period.

Damage and regeneration of peripheral nerves in advanced treated leprosy.

Despite the rapidly falling prevalence of leprosy, the disability and handicap resulting from loss of protective sensation, due to irreversible nerve damage, will remain a huge medical problem for many years. To elucidate the location and consequences of permanent nerve damage in treated leprosy, a prospective study involving nine patients who underwent leg amputation was conducted. Full-length nerves dissected from amputated legs were studied with histological and immunohistochemical methods. Our main findings were that: in both lepromatous and tuberculoid leprosy nerve damage increased distally, culminating in total destruction of dermal nerves and sensory nerve endings; after the therapy-related decrease of inflammation large-scale nerve regeneration took place; and that regenerating axons persisted for decades and in tuberculoid leprosy they might reach the subcutaneous fat of the plantar skin. We conclude that nerve regeneration was blocked by fibrous replacement of the distal-most nerves and nerve endings, and that the theoretical basis of nerve grafting in leprosy is in need of further clarification. In some patients, autologous transplantation of skin flaps, probably irrespective of the duration of loss of sensation, might help in regaining protective sensation.

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.

[Surgery of leprous neuritis (a 16 mm colour-sound film--35 minutes (author's transl)]. / Chirurgie directe de la névrite lépreuse (film 16 mm en couleur de 35 minutes commentaire sonore en français titrage bilingue français--anglais.

When medical treatment is not sufficient, surgery may still improve leprous neuritis by:--opening of osteo-fibrous tunnels where is an external compression fixing the level of physiological blockade: the elbow for the cubital nerve, the wrist for the median nerve, the peroneal neck for the peroneal nerve, the instep for the tibial nerve;--opening the thickened and consequently inextensible epineurium, inducing a release of the compression acting upon the nervous bundles and permitting their recovery if they are not yet destroyed. The film describes the various techniques immediately effective in hyperalgic neuritis and giving valuable recoveries in forms showing already a functional impairment.

[Study of afferent conduction in the external saphenous nerve using the method of evoked cerebral potentials]. / Etude de la conduction afférente dans le nerf saphène externe par le technique des potentiels évoqués cérébraux

By the comparison of nerve action potentials and cerebral potentials evoked by the same electrical stimulus the propagation of the somaesthetic impulse to the cerebral cortex can be evaluated. This technique was applied to the fibres of the sural nerve in normal subjects and in patients presenting various lesions of the peripheral and central nervous system. Evoked cerebral potential afforded valuable data when it was not possible to record the nerve action potentials or when the lesion involved the central segment of the afferent pathway.