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.

Lower limb angiography in leprosy.

Bilateral lower limb angiography was performed on 58 patients with leprosy and compared with bilateral lower limb angiography performed on 63 non-leprosy patients. The vessels in leprosy were narrow and constricted. Decreased blood flow through arteries in the distal third of the lower limb was present. Abnormal AV fistula formation in the thigh and calf muscles and in trophic ulcers of the feet was also seen. Deep inflammatory granulomatous reaction surrounding the arteries as a result of leprosy is a possible explanation for these angiographic findings and is felt to be related to trophic ulceration. These findings were specific for leprosy, precede clinical manifestations, and are helpful in management.

Peripheral vascular deficit in leprosy.

There is considerable controversy regarding the frequency and significance of vascular lesions in leprosy. Thirty-five patients of leprosy under 40 years of age, without any local and systemic arterial disease, with normal looking hands and feet, were subjected to brachial arteriography. One patient also had posterior tibial arteriography. Diagnosis of leprosy was confirmed by bacteriologic and histopathologic technics. Biopsy material was studied from the area of radiographic abnormality, similar material was obtained from nine matched control subjects at autopsy. Skin thermometry and reflex vasodilatation were studied in eight cases. Various fractions of serum lipids and cholesterol were estimated in all patients and found to be within normal range. Arteriographic abnormalities such as occlusion, narrowing, tortuosity, dilatation, poststenotic dilatation, irregularity and incomplete filling of the lumen by radio-opaque material, were seen in more than two vessels in 50% of the arteriograms in wrist and palm; digital vessels showed abnormality in 75% to 94% of cases. The ulnar artery was more frequently involved (74%) than the radial (50%). Superficial and deep palmar arches were equally affected. Increased vascularity in hypothenar eminence area was seen in three arteriograms. Marked increase in arcuate vessels was noted in 60% of patients. Some arcuate vessels were serving as collaterals. Histologically, all grades of vessels including capilaries showed changes in nearly half of the patients. Reflex vasodilatation was lost in three patients of dimorphous leprosy, and impaired or absent in three of five patients of lepromatous leprosy. There was no predilection for any form of leprosy to show arterial changes more than others. This study clearly demonstrates that the vascular involvement in leprosy is very frequent and must be playing an important role in causing mutilations and deformities of hands and feet.