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.

The potential role of magnetic resonance imaging in patients with Hansen's neuropathy of the feet: a preliminary communication.

A magnetic resonance imaging (MRI) protocol was performed in leprosy patients with a neuropathic foot and superficial ulcers and/or localized cellulitis but no clinical suspicion of osteomyelitis. The aim of the study was to determine if unsuspected osteomyelitis was present in this defined group of leprosy patients. A total of 15 neuropathic feet from 9 patients were included. Clinically and on MRI, the forefoot was predominantly affected. MRI findings of osteomyelitis were found in 4 feet. In feet with osteomyelitis, 3 had a superficial ulcer and 3 had clinical signs of localized cellulitis. A clinical diagnosis of cellulitis was confirmed on MRI in 2 feet.A striking discrepancy between clinical and MRI findings was found.This study shows that, compared with clinical evaluation, MRI is a sensitive method for the detection of unsuspected osteomyelitis in neuropathic feet with superficial ulcers and/or cellulitis. MRI findings in this group of patients may influence clinical decision making and may prevent further complications, because osteomyelitis requires more aggressive medical treatment. This preliminary communication should pave the wave for designed controlled studies so that patients with Hansen's neuropathy may get the best medical care.

A clinical and radiological follow-up study in leprosy patients with asymptomatic neuropathic feet.

OBJECTIVES: An MRI study done in 2000 on 10 leprosy patients with neuropathic feet, without clinical complications such as ulcerations, osteomyelitis or Charcot deformities revealed abnormalities in nine patients, with degradation, interruption of subcutaneous fat and effusion/synovitis, all located in the first metatarsophalangeal (MTP) region. Since these MRI abnormalities may precede clinical complications of the foot, a follow-up study was performed. DESIGN: A new evaluation was based on a clinical examination and an MRI of the same patients who participated in the initial study. RESULTS: Four patients were lost to follow-up. Average follow-up period was 4-6 years. MRI abnormalities in the MTP 1 region in the first study were no longer visible in three patients, but were still present in two patients. In six patients new MRI findings were found, without clinical evidence of ulceration, osteomyelitis or Charcot deformity. No relationship was found between MRI findings in the MTP 1 region at the start of the study and the development of foot ulcers, callus or skin fissures in the MTP 1 region during follow-up. CONCLUSION: MRI findings of interruption and infiltration of the subcutaneous fat in leprosy patients with uncomplicated neuropathic feet do not necessarily have any clinical implication for the development of future foot problems.

MRI in clinically asymptomatic neuropathic leprosy feet: a baseline study.

This study was undertaken to analyze the magnetic resonance imaging (MRI) findings in the clinically asymptomatic neuropathic feet of leprosy patients. Since in the literature no MRI data are available concerning the asymptomatic neuropathic foot in leprosy, the interpretation of MRI examinations in clinically suspected neuropathic feet in leprosy is difficult. We examined 10 adult leprosy patients with clinically asymptomatic neuropathic feet. Inclusion criteria were a normal or near normal neuropathic foot, without signs of inflammation. All patients underwent an MRI protocol with the inclusion of two-point Dixon chemical shift imaging as fat suppression sequence. We found MRI changes in almost all patients. The most striking were the changes located in the region of the first metacarpophalangeal (MTP) joint. These changes ranged from degradation and interruption of the subcutaneous fat to effusion/synovitis in the first MTP joint. This study reveals significant MRI changes in clinically asymptomatic neuropathic feet in patients with leprosy. These changes may relate to the development of ulcerations. MRI may play an important role in detecting feet at risk and may influence clinical decision making.

[Cutaneous neoplasms during leprosy: 2 case reports]. / Néoplasie cutanée au cours de la lèpre: a propos de deux cas.

The authors report on two cases of dermal neoplasia in foot trophic disorders observed in leprous subjects. The report includes the description of the clinic and histologic data as well as the surgical technique used; finally, it underlines the importance of a precocious diagnostic so as to obtain a good therapeutic result.

Management of the insensitive foot in diabetes: lessons learned from Hansen's disease.

Diabetes mellitus is the number one cause of lower extremity amputation (LEA) in the United States, accounting for about 60,000 cases per year. While the combination of reduced blood supply and the loss of sensation to the foot in a diabetic are responsible for the high incidence of LEAs, in most cases it is the loss of sensation that is primarily responsible for the initial foot wound and its failure to heal. The authors review the four mechanical causes for foot ulceration and eventual amputation. Based on an understanding of how feet ulcerate, the National Foot Treatment Center in Carville, LA has developed an insensitive foot screening and treatment program for "diabetic" foot ulcers that is more than 90% effective in healing plantar ulcers.

Clinical evaluation and care of the insensitive foot.

Until fairly recently, foot deformity was accepted as part of the natural course of a disease with associated sensory loss such as Hansen's disease or diabetes. Now we recognize that most of this deformity is caused by physical forces and that, with proper care, deformity can be prevented. The therapist must perform accurate methods of assessment such as inspecting and palpating the skin, testing for sensory loss, recording footprints, and measuring foot volume and must provide knowledgeable treatment techniques. The patient must be taught how to care for his feet and how to prevent continued trauma with subsequent infection and bony absorption, which ultimately result in deformity that could have been prevented. These evaluation, treatment, and education techniques are discussed in detail.

Cauliflower growths in neuropathic plantar ulcers in leprosy patients

A clinical and histopathological review of thirteen cases of cauliflower growths occuring in neurophatic plantar ulcers in leprosy patients is presented. The majority of these lesions were found to be pseudo-epitheliomatous hyperplasias although a considerable number showed atypical histological features. Conservative surgical treatment by deep but limited local excision is advocated.