Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part V. Use of the flap in the inguinal region and latissimus dorsi musculocutaneous flap.

The area of distribution of the superficial circumflex iliac, superficial epigastric and superficial external pudental arteries is large and flaps based on them can meet the requirement of different recipient sites. We have transplanted free flaps based on the superficial epigastric artery for repairing plantar soft tissue defects in six leprosy patients. During the follow-up examination 58 to 118 months later there has been no recurrence of ulceration in any of these cases. The latissimus dorsi muscle, is mainly nourished by the thoracadorsal artery and the latissimus dorsi musculocutaneous flap is a large sized, composite structure with abundant blood provision and strong anti-infectious property. The latissimus dorsi flap can be used as an artery-pedicled island flap or as a free flap besides its use as a muscle graft, because of its constant vascular position, wide outer-diameter of the vessels and long pedicle. It can therefore be utilized for repairing soft tissue defect or replacement of paralyzed muscle. We have used the latissimus dorsi musculocutaneous free flap for repairing large skin and soft tissue defects resulting from plantar ulceration in three leprosy patients. During the follow-up period, one patient who had complete drop-foot and had refused corrective surgery had recurrence of the ulcer in the 12th post-operative month. No ulcers had recurred in the other two cases during the follow-up at 48 and 114 months.

Transplantation of fibula with vascular pedicle for fusion of ankle in leprotic drop-foot.

Devascularized bone grafts are pieces of dead bone and they simply serve as scaffolds for new bone to grow and fill the gap, taking a long time when they succeed in doing so. In contrast, vascularized grafts being living tissues have short healing time, great vitality and strong infection-resisting capacity. We report here the successful use of vascularized grafts of the lower end of fibula for fusing the ankle in five leprosy patients.

Final report about Stage II Collaboration Project on Leprosy Rehabilitation.

OBJECTIVE: To undertake the pilot experiments of prevention of disability (POD) in 14 different geographical areas to serve as examples for future development of rehabilitation work in China and in Asia. METHODS: According to the principles and national criterion, 27 000 people affected by leprosy were selected and assessed using disability record forms at beginning and followed up regularly for observing changes of different indicators. RESULTS: A total of 197 neuritis cases were detected and treated with prednisolone out of 1 407 new or active cases. Self-care training of eyes, hands and feet were conducted for 10 500 disabled people affected by leprosy. Comprehensive therapy was given to 1 804 cases having complicated ulcers of which 1 055 cases have got their ulcers healed. Out of 706 prostheses, 613 were given to patients with satisfactory results. Surgical treatment was given to 269 cases and 251 have shown good progress. CONCLUSION: Most of patients have got benefit from the project in function or appearance which is very helpful for their going back to the society and agreed by foreign experts during the final evaluation. The experiences from the project can be implemented in the whole country.

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.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part I--General considerations and summary of results.

Recurrent plantar ulceration is a common and serious complication occurring consequent to impairment of the tibial nerve in leprosy patients. In spite of many therapies and long therapeutic course, it is extremely difficult to abolish this complication in many cases because of extensive skin and soft tissue cushion loss due to repeated infection. Since the early 70's we have been using microscopic surgical techniques to reconstruct the ulcerated area using eight types of the flaps. In this series of papers we review our experience (76 patients). Post-operatively, the flaps survived in all cases, the long-term results have proved satisfactory, and recurrent ulceration occurred in only three patients.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part II--First toe web and dorsal foot flaps.

The first toe web flap consists of the skin and subcutaneous tissues of the contiguous sides between the great and second toes. It is based on the first dorsal metatarsal artery or the common plantar digital artery. This flap was used as artery pedicled island graft to reconstruct losses of skin and soft tissue cushion in the ball of the foot in the first and second metatarsal head region in 16 cases. Follow-up examination revealed that ulceration had recurred in one case due to dehiscence of the flap margin 12 months post-operatively. The other 15 patients have done well without recurrence at 48 to 124 months follow-up examination. The dorsal flap of the foot based on the dorsalis pedis artery, the corresponding veins and the deep peroneal nerve was designed in 1974 to resurface skin and soft tissue defects in the sole of the foot. This flap was used in 30 cases of leprosy with excellent results. During follow-up 36 to 120 months after surgery the plantar ulcer had recurred in only one case. All the others have done well. The long-term curative effect has thus proved satisfactory.

A field trial of detection and treatment of nerve function impairment in leprosy--report from national POD pilot project.

As part of a collaborative project between the Ministry of Health of China (MOH) and The Leprosy Mission International (TLMI) on leprosy rehabilitation and prevention of disability (POD), a total of 1407 patients was monitored for possible nerve function impairment (NFI) through standardized clinical nerve function assessment between May 1995 and February 1998. Of these, 191 patients were found to have NFI and were put on a fixed regimen of prednisolone. In this study, 36.7% of NFI occurred before diagnosis of leprosy, 35.6% developed during MDT and 25.7% after their release from MDT. Overall, 7.5% (105 out of 1407) of all patients, or 55.9% of patients with NFI, suffered from silent neuropathy. Of the affected nerves, 62.6% had silent neuropathy. Sensory impairment responded to prednisolone satisfactorily, giving a recovery rate of 73.8%, 76.5% and 81.0% in ulnar, median and posterior tibial nerve, respectively. Sensibility in patients even with a NFI duration longer than 6 months made significant improvement (p < 0.05). Motor function improvement was less satisfactory, especially in ulnar and c. popliteal nerve. The possible reasons are analysed. Our findings with regard to sensibility changes confirm that once it becomes clinically detectable, NFI is no longer at the 'early' stage. More sensitive tests are necessary to detect real 'early' sensory impairment in the field. Our study also indicates that with well-trained field staff and proper equipment for nerve function assessment, early detection and treatment of NFI can be practical and effective.

Prevention of disability and rehabilitation--results from a collaborative project in China.

Eight different geographical districts in China varying in urban and rural characteristics from 6 provinces and 2 municipalities were selected as pilot areas of the project. The interventions included early detection and treatment of neuritis, self-care training, adapted footwear, surgery, comprehensive treatment of complicated ulcers, and prostheses. Main changes in eye, hand and foot impairments between baseline assessment and assessment at 2 years have been presented in this paper.