Reconstruction of moderately depressed nose in leprosy (a long-term follow-up).

Fifty seven leprosy patients having moderately collapsed nose were taken for nasal reconstruction. The bone graft was obtained from the second metatarsal of the foot. It was corticoperiosteal and placed in between lining and the nasal skin. 48 patients were reviewed periodically at 3 months, initially for 2 years and irregular visits at 3 to 5 year intervals in last 25 years. The nasal architecture and donor site problems were evaluated. 26 patients were completely satisfied, 14 patients were happy with shape of the nose along with some other problems. 6 cases showed the poor results. Two cases developed the deformity after seven years of correction. The details of the technique and the problems occurring during and long-term follow up have been discussed.

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.

An attempt towards prevention and management of disabilities and deformities in leprosy.

History of prevention of deformities is practically as old as the appearance of the deformities themselves, unfortunately without much understanding to start with. In medieval era and even earlier, leprosy and deformities were treated synonymously and the disease's infectivity too was closely associated with appearance of deformities. Hence, to reduce chances of deformities caused by leprosy in healthy population, the patients having deformities were driven away from the society presuming that only deformed patients spread the disease. Unfortunately, it never worked. However, in later period, factors behind the deformities and disabilities were recognized and understood. These are basically limited to involvement of peripheral nerves and their proper management (medical treatment, surgical interventions, physiotherapy, ergonomics and counseling) by one rule of thumb i.e. early, timely and adequately.

Results of surgical decompression of ulnar nerve in leprosy.

Ulnar neurolysis in 279 cases of leprosy was performed with objectives of relief in neuritic pain and impending/ existing sensory motor loss of varying extent. Of the above, 193 could be followed between 3-10 years. Neuritic pain was first to disappear. 48.7% of the 193 cases showed sensory recovery. Motor power gain and/or further fall in muscle power was prevented as a result of preventive neurolysis in 173 (89.6%) cases. In this series benefits of appropriate and timely surgical intervention have been observed.

Protective sensibility--its monofilament nylon threshold equivalents in leprosy patients.

An attempt has been made to definite the levels of "protective sensibility" in terms of perception thresholds to monofilament nylon induced touch/pressure stimuli. Certain problems were observed while interpreting the observations. There appears to be a range of threshold values instead of a clear cut-off point. We suggest that a monofilament nylon stimulus two times the normal threshold value for that patient be taken as cut-off point. This will make the observations of Birke and Sims (1986) and Hammond and Klenerman (1987) reasonable without having any need to exclude the cases who defy the boundaries laid by them. Since the genesis of plantar ulcer is multifactorial, it appears logical to include all patients who have a certain degree of hypoaesthesia, for special ulcer care program. The likely problems while using monofilament nylons in the field and their possible solutions have also been outlined.

Evaluation of results of surgical decompression of median nerve in leprosy in relation to sensory--motor functions.

Median nerve decompression was performed in 29 leprosy patients of which 20 were followed up for varying periods. It has been observed that the decompression was beneficial, sensory recovery was seen in 90% cases and in 45% cases the muscle strength improved and the process of deterioration was arrested in another 25% cases.

Rifampicin and isoniazid in the treatment of leprous nerve abscesses.

Thirty nine cases of borderline tuberculoid leprosy having nerve abscesses (15 with sinuses) were treated with daily dose of rifampicin and isoniazid for six months along with standard multidrug therapy. The patients were followed up for three to five years. No recurrence of abscess or sinus was observed. Observations indicate that medical approach is required at times to supplement surgical intervention for management of these cases.

Extensor indicis opposition transfer in the ulnar and median palsied thumb in leprosy.

Twenty seven opponensplasties for ulnar and median paralysis in 25 leprosy patients were performed using extensor indicis proprius. An additional transfer of the radial half of flexor pollicis longus to extensor pollicis longus was done to stabilize the metacarpophalangeal joint of the thumb. The biomechanical aspects of extensor indicis proprius tendon transfer were studied and results evaluated using various anatomical and functional parameters. Extensor indicis proprius provides adequate strength to position the thumb. However, sometimes it does not reach its new insertion. There is no significant deficit at the donor site but in a few cases the index finger may lose its capability for independent extension and sometimes a proximal interphalangeal joint contracture may develop.

Single tendon--two insertion versus two tendon transfers for reablement of ulnar-median palsied thumb in leprosy.

Twenty-three opponensplasties for ulnar median paralysis in 20 leprosy patients were performed by two different procedures i.e. extensor indicis proprius and flexor digitorum superficialis transfers using standard techniques. The results were evaluated using various objective and subjective, anatomical and functional parameters. Two tendon transfers appeared to be superior to single tendon two insertion transfers. It was concluded that if situation permits, two tendon transfers should be performed for combined ulnar median paralysis.

Neuritic leprosy: further progression and significance.

Sixteen neuritic cases have been seen developing cutaneous lesions. These cutaneous lesions by and large appear within 4 months after the diagnosis of neuritic leprosy. Leprosy pathology in cutaneous lesions has been found ranging between indeterminate and borderline lepromatous group. Development of cutaneous lesions does not seem to be influenced by age, sex or number of nerves or lepromin status. Neither lesions seem to appear in any particular part of the body. Therapy, duration and type i.e. monodrug or multidrug, also does not seem to influence the development of cutaneous lesions in either way. It appears that neuritic cases with either very early (indeterminate) or with advanced multibacillary neural pathology may develop skin lesions. Skin lesion possibly appear following reversal reaction in skin. Cases with newly developed skin lesions well respond to standard therapy. Development of cutaneous lesions by neuritic cases possibly indicates towards the natural history of the disease, conforming to the hypothesis that leprosy is basically neural in inception and that all other forms emerge from it.

Sensory functions in limbs of normal persons and leprosy patients with peripheral trunk damage.

The threshold to touch was tested in hands and feet of normal persons using Semmes-Weinstein graded monofilament nylons. The minimum stimulus to which response could be elicited was nylon number 3.61 in palms and 4.31 in soles. These numbers relate to the logarithm of the force applied, 3.61 corresponding to 0.217 gm force and 4.31 to 2.35 gm force respectively. The area of pain insensitivity complained by the patient more or less corresponds to that revealed by objective testing. It was interesting to observe that loss of pain sensitivity was confined to a smaller area compared to touch and thermal insensibility in the part innervated by the same nerve trunk.

Surgical correction of saddle nose deformity in leprosy--one stage procedure.

In twenty-four leprosy patients having mild to moderate nasal deformity, a corticoperiosteal bone graft obtained from second metatarsal bone was placed in a pocket created between the lining and cover of the nose. The cases were evaluated later, mean follow-up period being 4 1/2 years. The results were satisfactory in 13 patients. Improved shape was reported in 7 and poor in 3. The bone graft got incorporated and consolidated at the recipient site in 16 cases. The main donor site problem was overriding of the donor toe. The operated cases need health education for after-care of nose since nasal mucosa is atrophic.

Trigeminal neuralgia--a presenting feature of facial leprosy.

Trigeminal neuralgia is a well recognized clinical entity. However, it has not been reported to mimic leprosy or vice versa. Of the 3 cases reported here, 2 initially presented with neuralgic symptoms similar to that seen in trigeminal neuralgia and later developed borderline lesions on the face. The 3rd case demonstrated a tingling sensation along with firm and palpable supraorbital nerve (a branch of trigeminal nerve), and a very early skin lesion on the face pointed to the need to consider neuritic type leprosy before concluding the final diagnosis of a disease like trigeminal neuralgia which calls for a different therapeutic approach.

Evolution of early lesions in leprosy.

We observed 29 patients presenting with vague peripheral neurological symptoms for 6 months or more. During this period, 16 developed clinical leprosy, 3 developed borderline tuberculoid leprosy and the other 13 developed neuritic leprosy. Of these 13 cases 11 subsequently developed skin lesions similar to those seen in indeterminate and in borderline tuberculoid leprosy. Based on the above observations, an attempt has been made to explain the evolution of early lesions of leprosy.

Borderline-tuberculoid relapse in lepromatous leprosy.

We report details of 2 patients who had been treated for a long time by dapsone monotherapy and who had remained smear negative for over 10 years, but were found to have relapsed with borderline-tuberculoid (BT) leprosy.