[Peripheral nerve surgery in leprosy]. / La chirurgie des nerfs périphériques dans la lèpre.

Leprosy has nearly disappeared in France but continues to affect two million patients in the world. Involvement of the peripheral nerve must be identified and requires surgical treatment, which can provide good results for pain and function. The author reviews the most frequently affected peripheral nerves and reports her personal series, with surgery performed concomitantly with the medical treatment of the disease.

Bilateral temporoparietal fascial free flaps for reconstruction of bilateral hand defects: a report of two cases.

Bilateral temporoparietal fascial free flaps were used for reconstruction of bilateral hand defects in two male patients. A 42-year-old man sustained crushed injury to both hands with avulsion defects and exposed bones and tendons. The two separate procedures were performed under general anesthesia. The temporoparietal fascial free flap was skin grafted on the ward on the following day after the operation. The other patient was a 61-year-old leprosy patient who had bilateral high ulnar nerve palsy for 28 years. One simultaneous procedure was performed under local anesthesia for harvesting the temporoparietal fascial free flaps and under brachial block for preparation of the recipient sites. The free flaps were used for augmentation of the atrophic first web spaces. The postoperative results of the two cases were satisfactory. The functions of both hands were restored with normal gliding mechanism of the tendons in the first case, and permanent correction of the atrophic web spaces was demonstrated in the second case. The temporoparietal fascial free flap is an ideal flap for coverage of hand defects as well as augmentation of first web space atrophy.

[Nasal leprosy: impact of multitherapy in the morphology and physiology of the nose]. / Lepra nasal: impacto de la multiterapia en la morfología y la fisiología nasal.

INTRODUCTION: The multi-drug therapy protocol has allowed leprosy patients following this strategy to achieve complete recovery without developing neurotrophic sequelae or deformities. OBJECTIVES: To assess the impact of multi-drug therapy on the development of nasal deformities and nasal airway patency. PATIENTS AND METHOD: In an overall group of 84 patients studied, 38 were treated with a therapy based on a single drug and 22 were treated with multi-drug while 24 subjects formed a control group. Nose morphology was determined by anterior rhinoscopy. Nasal patency and flow resistances were measured by anterior rhinomanometry. The results were compared by using the Anova test for a single variable. RESULTS: The nasal structures in the group with therapy based on a single drug underwent resorption of bone and cartilage in the structures of the nose and increased flow resistance. In the group receiving the multi-drug protocol, there were no significant morphological alterations and nasal patency and flow resistance remained within normal levels. CONCLUSIONS: The multi-drug therapy is effective in preventing the development of nasal deformities and maintains normal nasal airflow.

Management of 34 chronic heel sinuses in leprosy, using a modification of a local rotation flap in Kolkata, India.

We have seen 55 trophic ulcers of the heel in 2 years in our hospital, between March 2000 and February 2002. Thirty-four were chronic heel sinuses, six cases of multiple sinuses and 28 cases of single sinus of the plantar aspect of the heel. All these cases were treated by excision of the sinus, paring the prominence of the calcaneum, or excision of the cavity within the calcaneum and coverage by a rotation flap or a modification of this flap. Over the past 6 years, we have evolved a modification of a rotation flap that requires a fusiform incision to excise the sinus, and a curved incision for the flap extending through the instep and the non-weight bearing heel. The fusiform excision, rather than the traditional triangulation, causes the flap to partly transpose rather than rotate completely. The flap is raised superficial to the plantar aponeurosis, exposing the aponeurosis from mid-sole to the heel. It is a modification of a rotation flap. The scarring over the weight-bearing sole is minimal, restricted only to the incision necessary for the excision of the heel sinus and this is its main advantage. Twenty-one of the 34 cases healed without complications. Thirteen cases had complications, of which six were treated non-operatively and seven required either a redo of the flap or another flap cover.

[Surgical decompression treatment of leprous neuritis at the Bom-Pastor Hospital (Brazilian Amazonia)]. / Traitement chirurgical de décompression des névrites lépreuses à l'hôpital Bom-Pastor (Amazonie brésilienne).

PURPOSE: Only leprosy resource centres undertake surgery for neuritis. Patients' accessibility to this surgical procedure is poor because these centres are often far from their homes. The aim of our work is to study the feasibility of neuritis surgery in the field. METHODS: A surgeon trained in this surgery was recruited by Bom-Pastor hospital in Brazilian Amazonia, which is located 400 km away from the leprosy resource centre. Patients operated from May 1996 to December 1997 were enrolled in this retrospective study. RESULTS: A total of 45 operations were carried out during 17 procedures on 13 patients, among which 12 were multibacillary cases. The decompression surgery was performed with a median delay of 1 year after leprosy diagnosis and 3.5 months after the neuritis diagnosis. Among 17 operations, 14 were performed for painful neuritis of recent onset unsuccessfully treated with corticoids or recurring during the month after corticoids were withdrawn. The other three operations were performed for long-standing neuritis with paralysis and deformity. Pain was relieved in all the cases of recent neuritis, except for one patient who suffered from a serious steroid-dependant erythema nodosum leprosum. An improvement of motor function was observed in one out of three patients with long-standing neuritis. Adverse effects were few: a scar infection with a rapid recovery and a keloid scar. Two neurites recurred 2 and 10 months after the surgery. CONCLUSIONS: In an endemic leprosy region, field access to surgery for neuritis appears to prove real progress in the management of leprosy neuritis.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part III. Use of plantar skin or musculocutaneous flaps and anterior leg flap.

Anatomical studies suggest that five types of plantar flaps namely, the lateral and medial plantar flaps, the Abductor hallucis-, the Flexor digitorum brevis-, and the Abductor digiti minimi-myocutaneous flaps, can be incised from the central section of the sole. The advantages of a plantar flap are recognizable neurovascular bundles of the sole, wide calibre of constantly located blood vessels, identical histological structure of the donor and the recipient sites, hidden donor site and absence of functional deficit. We have used the plantar flaps in seven cases. There has been no recurrence of ulceration in any of them during the follow-up period of 12 to 108 months. An anterior leg flap based on the cutaneous branches of the anterior tibial artery, with firmly anchored vessels, a long pedicle with wide vessels may be used not only as a free flap graft for reconstruction of moderate degree distant defects but also as a retrograde island flap graft for the reconstruction of adjacent tissue defect. We have used the retrograde island flap graft based on the anterior tibial artery in five cases of plantar ulceration with satisfactory results. There was no recurrence of ulceration during the follow-up period of 48 to 72 months.

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.

Heel ulcer in leprosy treated with fasciocutaneous island flap from the instep of the sole.

Twenty-four leprous patients with longstanding ulcer of the weight bearing area of the heel underwent reconstruction by use of fasciocutaneous island flap from the instep. One flap was lost because the vascular pedicle was accidentally severed during the dissection. Infection delayed healing in three cases, and one patient developed minor necrosis of the edge of the flap without any adverse consequences. The remaining 18 cases healed without complications. Follow-up of 14 patients 3 to 10 months after the operation showed excellent results in all but the one whose flap was lost. The operation is recommended for difficult reconstructions of the heel.

[Surgical treatment of leprous neuritis. The results in 114 operations]. / Traitement chirurgical des névrites lépreuses. Résultats de 114 interventions.

One hundred and fourteen surgical operations for neuritis were performed in 50 patients coming from areas where leprosy is endemic. The neurological signs included pain and/or sensorimotor deficit. The surgical procedure consisted of transposition and/or neurolysis. Pain subsided in 86 per cent of the cases, and the sensorimotor deficit was reduced in 78.9 per cent. The effects of surgery on pain always appeared on recovery from anaesthesia or on the day following the operation. The results were particularly good in young subjects and in patients with neurological signs of recent onset. Poor results were observed only in cases of old and painless neuritis with motor deficit, the latter being usually unchanged. Few studies have been published on large series of leprous neuritis patients treated surgically. Surgery in such cases must be associated with a medical treatment, failing which the patient is exposed to relapses.

Incidencia das deformidades da mao na hanseniase / Incidence of the deformities of the hand in leprosy

Os autores fizeram um levantamento das deformidades nas mãos de 360 portadores de hanseníase virchoviana, e verificaram que as amiotrofias são as mais frequentes. As menos frequentes são os processos reabsortivos do quinto dedo da mão E. Tecem considerações finais sobre a forma de prevenção. Os processos terapêutico-cirúrgicos, plásticos e ortopédicos só têm êxito quando realizados no início do processo da deformação, o que depende de educação sanitária constante e sistemática do doente.

Tratamento do mal perfurante plantar com um extrato de sangue desproteinizado (Solcoseryl): primeiros resultados

Após considerações gerais sobre a importância do problema do mal perfurante plantar como incapacidade f¡sica e sua gênese, o autor expõe as caracter¡sticas de um produto obtido do sangue de amimais jovens (Solcoseryl) e usado no tratamento desta complicação tardia de lepra. Em quatorze anos obtem doze curas com um m¡nimo de cinco e um máximo de 38 aplicações, e em dois casos obtem melhora evidente. Os resultados são ilustrados por fotografias anteriores e posteriores ao tratamento. Concluiu-se que, pela ação cicatrizante rápida, é de utilidade no tratamento, em regime ambulatorial, do mal perfurante plantar de origem leprótica.

Un caso de intensa neuritis hipertrofica del mediano

Los autores presentan el caso de un enfermo lepromatoso con gran hipertrofia del nervio mediano al que consideran pocas veces hipertrofiado en la lepra hasta el extremo de producir la gran tumoración cutánea. El tratamento con vitamina B1, B12 e incluso con corticosteroides durante 5 meses mejoraba escasamente el cuadro neurítico que empeoraba rapidamente, lo que motivó el decidirse por la intervención quirúrgica, apreciándose que el nervio mediano enormemente hipertrofiado estaba estrangulado por el ligamento anular del carpo, que fue incindido. El resultado ha sido magnífico, desapareciendo el cuadro neurítico immediatamente y no habiendo recidivas no obstante el proceso reacciónal que se presentó después de la intervención y en curso del cual no ha tenido el enfermo ninguna sintomatología del mediano