Saphenous nerve transfer: A new approach to restore sensation of the sole.

BACKGROUND: Loss of protective sensation of the sole may lead to repeated trauma, chronic nonhealing ulcers, and even amputation. Saphenous nerve (SN) to posterior tibial nerve (PTN) transfer can restore sensation of the sole. METHOD: This study was conducted in a tertiary referral center in Central India. Twenty-one patients (32 feet) diagnosed with loss of sensation of the sole were included in this study. Causes of loss of sensation were Hansen's disease (n = 18), complex sciatic nerve injury (n = 1), lumbosacral spinal tumor (n = 1), and lumbosacral meningomyelocele (n = 1). Seventeen feet (14 patients) had ulcers on the sole. Preoperative and postoperative sensory tests performed on the sole included tests for touch, pain, temperature, pressure, vibration, and two-point discrimination. Results were classified as per the British Medical Research Council (MRC) scoring system. RESULTS: Seventeen patients (26 feet) were available for follow-up at 6 months after surgery. All patients had improvement in sensory parameters. Ulcers completely healed in 13 feet and reduced in size in four feet. MRC score improved from S0 in 22 feet and S1 in 10 feet to S3 + in 20 feet, S3 in four feet, and S2 in two feet. CONCLUSIONS: Sensory neurotization with SN transfer to PTN can restore protective sensation to the sole and help in the healing of ulcers.

Electrophysiological evaluation of peripheral and autonomic involvement in leprosy.

OBJECTIVE: Motor and sensory nerve conductions, F responses, sympathetic skin responses and R-R interval variations (RRIV) were studied to determine the type of peripheral neuropathy among patients with leprosy. METHODS: Twenty-nine consecutive patients with leprosy (25 male, 4 female) hospitalized in the "Istanbul Leprosy Hospital" between January - December, 1999 were included in this study. Ten patients had borderline lepromatous leprosy, and 19 had lepromatous leprosy. None of the patients studied had the tuberculoid form. The mean age was 55 +/- 12 years. The control group consisted of 30 (26 male, 4 female) healthy volunteers (mean age: 58.1 +/- 7.8 years). All subjects included in the study underwent neurological examination and electrophysiological evaluation. Standard procedures were performed for evaluating sensory and motor conduction studies. Motor studies were carried out on both left and right median, ulnar, tibial and common peroneal nerves while median, ulnar, sural and superficial peroneal nerves were examined for sensory studies. Sympathetic skin response recordings on both hands and RRIV recordings on precordial region were done in order to evaluate the autonomic involvement. RESULTS: The lower extremity was found to be more severely affected than the upper, and sensory impairment predominated over motor. Of 58 upper limbs examined, no sympathetic skin responses was recorded in 46 (79.3%). Compared with the controls, the RRIVs of the leprosy patients were found to be reduced during both resting and deep forced hyperventilation. CONCLUSION: Our results indicate that leprosy causes a predominantly axonal polyneuropathy that is more severe in the lower extremities. Sensory nerve damage is accompanied by autonomic involvement.

A epineurectomia do tibial posterior no tratamento do mal perfurante plantar de origem leprosa

Os autores adotam a descapsulização do nervo tibial posterior como medida fundamental no tratamento do mal perfurante plantar. Aconselham, a fim de acelerar a cura, acrescentar a descapsulizações do nervo ciático popl¡teo externo, que pode, tambem, estar comprometido. Realizaram quatro descapsulizações do nervo tibial posterior, sendo as duas últimas acompanhadas pelas descapsulizações do nervo ciático popl¡teo externo e interno. O primeiro caso, embora não tivesse boa evolução em virtude das condições péssimas de nutrição da pele no terço inferior da perna, com deiscência da sutura e cicatrização anormal, serviu para demonstrar o acentuado comprometimento do nervo nesse n¡vel e na garganta do pé. Todavia, as outras descapsulizações resultaram, sem outra espécie de tratamento, e sem repouso absoluto, na cura rápida do mal perfurante plantar, com o restabelecimento da sensibilidade, melhora das condições vasomotoras e da adaptabilidade do pé em relação à marcha. Os resultados satisfatórios obtidos permaneceram 9 meses decorridos da segunda descapsulização e 6 meses da terceira e quarta descapsulizações. Abordam o nervo através de uma incisão em jota (J) no sulco retromaleolar interno, a meia distância com o tendão de Aquiles, numa extensão de 15-16 cm até atingir o n¡vel do canal do calcâneo, começando-a em certa altura do terço inferior da perna. Aberto o plano aponevrótico, é realizada a libertação do nervo das aderências interfasciculares do nervo. No fechamento da ferida cirúrgica a incisão aponevrótica não é suturada.