The surgery of leprosy
From Primary Surgery
The best way to deal with leprosy is to recognize it early, and treat it adequately. If this fails, a patient needs surgery, because leprosy affects his nerves. Destruction of their sensory fibres makes the surface of his body anaesthetic, and thus liable to the injuries that result in open wounds and ulcers. Destruction of their motor fibres causes paralysis, wasting, and sometimes contractures of his muscles. Most nerves are mixed, so that both these things happen at the same time, with the result that his arms and legs become paralysed and anaesthetic. Because he has little sensation of pain, he does not know when he is injuring himself. This makes him neglect his painless surface injuries, so that they become steadily progressive ulcers. The contractures, ulcers, and deformities that result are not an inevitable part of leprosy. In a well-conducted leprosy program, there should be few of them when patients first present, and none later. They are the purpose of this chapter, and you should not see them very often.
Leprosy most commonly involves a patient's legs, but it can also involve his hands (31.4) and his eyes (31.2, 31.3). Pyogenic organisms readily enter through the lesions that leprosy causes in his skin, so that you may need to drain abscesses (5.2), treat bone, joint, and tendon sheath infections (Chapter 8), and enucleate his eye when its globe has become infected (24.14). Admit him to the general ward. If the staff behave naturally towards him, the other patients will too.
Here we assume you know about the medical treatment of leprosy. Surgically, your task is to: (1) Care for his primary and secondary impairments. (2) Set and record measurable objectives for preventing and limiting his disabilities, and plan how you are going to reach them. (3) Provide him with protective footware and aids. (5) Teach him self care to prevent further disability. (6) Teach the rest of the health care team how to do these things. Most leprosy work should be done by paramedical workers, and the present trend is for vertical programmes, with a specialized cadre of leprosy assistants, to be replaced by horizontal ones which manage many diseases. Much of what is described here can be done by paramedicals—if you teach and encourage them.
There are many practical details which we have little space for, so if you see many leprosy patients, try to get the TALC slide set by Grace Warren, and the manuals listed below.
Fritschi ER 'Surgical Reconstruction and Rehabilitation in Leprosy'. Available by purchase from: The Leprosy Mission, 80 Windmill Road, Brentford, Middlesex, TW8 0QH.
Neville Jane, Ed. A Footwear Manual for Leprosy Control Programmes, Parts I and II'. The German Leprosy Relief Association (DAHW) Postfach 348, D-8700 Wurzburg 11 West Germany. Also available free from The Leprosy Mission, see above.
Watson Jean. "Preventing Disability in Leprosy Patients'. Available from the Leprosy Mission, see above.
Brand P, Insensitive Feet, A Practical Handbook on Foot Problems in Leprosy'. Available free from The Leprosy Mission, see above
Warren Grace, The Care of the Nerve Damaged Limb' TALC slide set. Teaching Aids at Low Cost, The Institute of Child Health, 30 Guilford Street, London WCIN
Managing paralysis, especially during lepra reactions
A patient's nerves are involved early in tuberculoid and borderline leprosy, and later and less severely in lepromatous leprosy. This involvement can be slow, progressive, and irreversible. Or it can can occur suddenly during a Type One (see below).
Paralysis, whether slow or sudden, involves his nerves selectively: (1) His facial nerve, so that he cannot close his eye (lagophthalmos, 31.3). (2) His ulnar nerve at his elbow or wrist, so that his hand becomes clawed. (3) His median nerve at his wrist, so that he cannot oppose his thumb. (4) His radial nerve, so that his wrist drops (in the arm the ulnar nerve is most often affected, then the median, then the radial). (5) His lateral popliteal nerve at the neck of his fibula, so that he cannot dorsiflex his foot ('foot drop'). (6) His posterior tibial nerve behind his ankle, so that the intrinsic muscles of his foot become paralysed, his toes clawed, and his sole anaesthetic.
Both kinds of lepra reaction can cause paralysis, but need different management:
Type One reactions (also called non-lepromatous, reversal, or upgrading reactions) often cause sudden reversible paralysis in treated BT, BB, BL and rarely in LL leprosy. They make all the leprosy lesions in his skin and nerves swell acutely. His nerves become suddenly paralysed, and feel large and soft. They may be painless, or tender. His skin lesions may ulcerate, and the fibrosis that results may lead to a contracture. Recovery may take months, so don't let a contracture develop meanwhile! The sustained physiotherapy described below will prevent it. If he has an acute paralysis (but not otherwise), give him steroids for 6 to 12 weeks, as described below.
Type Two reactions are also called 'erythema nodosum leprosum' (ENL) reactions and occur in 50% of treated LL patients and occasionally in untreated LL or treated BL patients. During a few hours a crop of painful erythematous papules develop, typically on the extensor surfaces of his limbs, but in severe attacks over much of his body except his scalp. His skin may be thickened, especially over the backs of his hands and on his legs, where contractures may form. Meanwhile, his nerves are painful, and become steadily paralysed. Unfortunately, they are less likely to recover than after a Type One reaction. Give him clofazimine in high doses, and aspirin. If he has a severe acute episode, you can, if necessary, give him a short (10 to 21 days) course of steroids. If you prolong it, he is liable to all the long-term consequences of steroid therapy.
SUPPRESSION is indicated if a lepra reaction has caused paralysis, or uveitis (31.2). Continue the patient's antileprotic drugs in both types of reaction.
Suppress his Type One reactions with steroids for 6 to 12 weeks, or as long as there is activity. Start with a maximum of 30 mg of prednisolone daily in the mornings. As soon as the acute stage of reaction (swelling, redness, and pain) has subsided, gradually reduce his steroids, even if there is no sign of nerve-function returning. Reduce the dose by 5 mg daily each successive week (30 mg of prednisolone daily for a week, then 25 mg daily for a week. . ., until you are giving none).
His nerves may start to recover within 3 weeks, or they may not improve for 3 months, or a year, or longer. Meanwhile, manage them as described below.
Suppress Type Two reactions with clofazimine and aspirin or thalidomide (provided there is no possibility of pregnancy), as long as there continues to be any sign of them, however slowly improvement takes place. If you are going to use steroids, give him (or her) a short course only. Some contributors consider that the risks of steroids outweigh their benefits.
PHYSIOTHERAPY IN LEPROSY
A limb which is paralysed by leprosy needs physiotherapy to strengthen its muscles and prevent contractures, especially if paralysis is recent, actively progressing, or possibly only temporary, as in either type of leprosy reaction. Particular physiotherapy for his eyes (31.2), hands (31.4), and feet (31.5) is described elsewhere.
As long as there are signs of weakness, someone, preferably the patient himself, must put all his paralysed joints through their full range of movement each day, even if they cannot be actively maintained in their positions of function.
Protect his paralysed muscles by splinting his joints in their positions of function during sleep, and never allow a muscle to be overstretched. Make sure he does active physiotherapy to retain the mobility of all his joints. Even if all the intrinsic muscles of his hand are paralysed, it will be more useful to him if its joints are kept mobile with the daily exercises in Fig. 30-3. Start this protection the first day you diagnose a reaction.
When he shows signs of recovery, as shown by his pain decreasing, his nerves becoming softer, and his sensation and motor function returning, he must: (1) increase his range of active movement and strengthen his muscles with carefully graded active exercises. And, (2) practise any skilled coordinated movements that he will need later when he returns to his normal life. Tell him to start his exercises as soon as the acute symptoms of neuritis have subsided. Begin by doing each exercise 5 times, increasing to a maximum of 30 times, repeated 3 to 5 times daily. Teach him to do his exercises himself at home: but if he is to have reconstructive surgery, he may need more intensive preparation.
The eyes in leprosy, iritis (uveitis)
You will need a system of priorities when you approach a leprosy patient. The most important function you need to preserve is his sight. If he has also lost the feeling in his fingertips, blindness will separate him from his environment almost completely.
Leprosy causes: (1) Paralysis of his facial nerve, so that he cannot close his eye (lagophthalmos, 31.3). (2) Loss of sensation in the ophthalmic division of his fifth cranial nerve, which makes his cornea anaesthetic. (3) An acute iritis (uncommon), which is usually associated with a Type Two reaction. (4) A chronic iritis (common) causing atrophy of his dilator pupillae and a small unreactive pupil (see also Section 24.5).
Iritis is common in lepromatous leprosy. It usually comes on so slowly that he may not notice that there is anything wrong with his eyes, until they are severely damaged, and he starts to lose his sight from synechiae, cataracts, or secondary glaucoma (rare). An acute uveitis occurs mainly in patients who have a Type Two lepra reaction, and is less common if they are on clofazimine.
To detect uveitis, use a corneal loupe, and preferably a slit lamp microscope. Grossly, you may see mild ciliary hyperaemia on his conjunctiva next to the limbus. This is a good indication of activity, and you can always see it with a good light; but be careful to distinguish it from conjunctivitis. If you press his globe he may complain of pain. With a slit lamp, the earliest signs are keratic precipitates (KP) on the back of his cornea, a flare, and cells floating in his anterior chamber; these are also the last signs to disappear. If you are in any doubt, and you don't have a slit lamp, dilate his pupils. Any irregularity due to synechiae will then be diagnostic, but it will not tell you if his iridocyclitis is active. If dilatation relieves his pain it probably is active.
THE EYES IN LEPROSY
ROUTINE EXAMINATION. Examine the eyes of all leprosy patients regularly to detect. (1) Lagophthalmos and corneal exposure.(2) Chronic iritis, which may cause secondary glaucoma and blindness. See also Sections 24.1 and 24.5.
(1) Measure the patient's visual acuity. (2) Assess his normal eyelid closure as in sleep (not his forced eyelid closure). If his lids don't touch he has lagophthalmos. (4) Dilate his pupil with a short-acting dilator to see if it is irregular (a sign of iritis). (5) Stain his corneae with fluorescein to look for ulcers due either to lagophthalmos or an ananaesthetic cornea.
IRITIS IN LEPROSY
TREATMENT. Dilate his eyes with 1% atropine eye ointment, or atropine drops, hourly for three hours, or until they are dilated, and then once daily. Give him hydrocortisone or cortisone eye drops or ointment 3 or 4 times daily. If synechiae persist, continue atropine twice daily. If redness or pain persist, or if his corneae are cloudy, he may need steroids by subconjunctival injection, or rarely by mouth. If you give them, he must be taking his leprosy drugs at the same time. He should respond well, if you treat him early. If he has a chronic Type Two reaction (ENL), he may need atropine once weekly and steroid ointment daily for many months.
If his intraocular tension is raised (secondary glaucoma, 24.5 also give him acetazolamide 250 mg 6-houriy, until the inf lamation is under control. Use phenylephrine eye drops 10%3 times daily to lower his intraocular pressure, instead of atropine. Refer him if you can.
CAUTION! (1) If his eyes are not much better, and he still has pain after 7 days, refer him—urgent treatment may be necessary to save his sight. (2) Make sure that his eyes are examined every week and his pupils are regularly dilated.
If the disease has progressed far enough for 'ring synechiae' to be present, and his intraocular pressure is raised, refer him for a broad iridectomy to save his sight. Ideally, this should not be done until his eye is quiet and white, but this is usually impossible, because he will be blind before it happens.
If he develops a secondary cataract, this will need surgery, but it should not be done at the same time as the iridectomy. Always delay cataract extraction until you are absolutely sure an eye is quiet. This may take years! If his cataract is extracted too soon, while his uveitis is still active, he may become blind.
Lagophthalmos in leprosy
When leprosy involves the ophthalmic division of a patient's fifth nerve, his cornea becomes anaesthetic. When it involves the zygomatic branch of his seventh nerve, his orbicularis muscle is paralysed, so that he cannot shut his eyes properly (lagophthalmos}. The combination of these two lesions can have a devastating effect on his sight.
An anaesthetic cornea prevents him from noticing that he has something in his eye, or that it is dry. He loses his blink reflex, so that, even if he still has enough power in his seventh nerve to blink, he does not wash and wet his conjunctiva automatically. As a result, his cornea may be unprotected, especially while he sleeps, so that it may develop exposure keratitis, and ulcerate. If the centre of his cornea becomes opaque, his sight is spoilt. So warn him of the danger of an anaesthetic cornea, and examine his eyes regularly.
To decide if his cornea has been damaged, look for superficial scars, and use fluorescein drops, or papers, to search for central staining. If his cornea is anaesthetic, his eye is at great risk. If he has lagophthalmos, but his cornea is not anaesthetic, he may have enough sensation to complain of discomfort or burning.
To find out if he has significant lagophthalmos, ask him to close his eyes. If his cornea is completely covered, all is well. But if any part of it remains exposed, something must be done to protect his sight. Several operations are possible, but we only describe two methods of tarsorraphy. Both aim to reduce the gap between his lids when he tries to shut them. Tarsorrhaphy has cosmetic disadvantages, but it does save sight, and it is not difficult,so you should be able to do it if you care for leprosy patients. One of the most effective procedures, transfer of the temporalis muscle, is too difficult to be described here.
LAGOPHTHALMOS IN LEPROSY If a patient has any weakness in his eyelid muscles, teach him exercises for them, such as screwing up his eyes as strongly as he can.
INVESTIGATION. Test the sensation in his cornea with a wisp of cotton wool. Examine his lachrymal apparatus. If patency is in doubt, dilate the punctum and irrigate the sac with saline. You may be able to flush out the system. If it remains blocked, but there is no sign of infection and no regurgitation of mucus, you can operate, but he will need an antibiotic postoperatively.
NON-OPERATIVE TREATMENT If his paralysis is recent, treat him medically for a few weeks to see if it will recover. Warmth protects nerves in leprosy, so in cold weather ask him to keep his face warm with a woollen Balaclava helmet or a scarf.
If he has anaesthesia but not lagophthalmos, the stimulus to blink will be missing, but not the power to do so. So teach him to blink regularly.
(1) Artificial tears or even paraffin drops twice daily will help to protect his cornea. If you don't have medicinal paraffin, use the domestic kind. (2) Apply antibiotic eye ointment 3 times daily, especially at night. (3) Strap his upper lid to his cheek to prevent exposure of his cornea.
If he has a Type One reaction, give him steroids, as in Section 31.1a.
If his cornea is already ulcerated, give him antibiotics and atropine (24.3) until his cornea heals.
If he has iritis, dilate his pupil with atropine, and consider giving him topical steroids (24.5).
INDICATIONS FOR TARSORRAPHY. Any part of his cornea remaining exposed when he tries to shut his eyes. (1) Leprosy; if his cornea is already damaged, or he has reduced or absent corneal sensation and lagophthalmos, tarsorraphy is urgent. (2) Burns (58.28). (3) Facial paresis or paralysis; Bell's palsy. (4) Degloving injuries.
CONTRAINDICATIONS. (1) A cornea which is already damaged.(2) Lagophthalmos which is only temporary and will recover when the neuritis of a leprosy reaction recovers.
TARSORRAPHY (Margaret Brand)
CHOICE OF SITE. You can do a medial, or a lateral tarsorraphy. Close the medial or lateral half of his palpebral fissure with a pair of forceps, to determine which site is likely to be best, and how long the tarsorrhaphy should be. A medial one keeps the punctae in touch with the globe, and helps to relieve excessive tearing, which is common when the lower lid sags, as in A, Fig. 30-1. It is better cosmetically, but is more difficult,because the punctae and canalicuii are close to the operation site, and must not be damaged.
CAUTION! The tarsorraphy must be large enough to enable him to cover his whole cornea, when he tries to close his eyes. A common mistake is to make it too small, so that it is ineffective. You may have to do medial and lateral tarsorrhaphies at the same time, leaving a small opening through which he can just see.
A temporary central tarshorraphy may be indicated, if ulceration threatens his cornea, or has already occurred, particularly if sensation is poor.
METHOD: saterai tarsorraphy). You can operate on both eyes at the same session. Pinch his lids together to decide how much lid to suture. Mark the appropriate length of lid with a little gentian violet. Instil a few drops of amethocaine 2%. Inject 1 ml of local anaesthetic solution with adrenalin (optional) into each lid near the margin (A 5.3).
Hold his lids apart and make an incision along the grey line (just behind the lash follicles), between the marks you have made with gentian violet. Make another incision parallel to the first one and 1 or 2 mm from it. Dissect away a strip of tissue between these two incisions. Repeat the procedure on the second lid to leave two opposed, raw, bleeding areas. Join these areas with monofilament mattress sutures every 5 mm. Swab away all blood clot, and tie them over lengths of fine rubber or plastic tube, to prevent them cutting into his skin.
CAUTION! Make sure that no lashes project back between the sutures.
Preferably, cover his eye with a light dressing for 24 hours, and remove the sutures on the 14th day. If you have operated on both his eyes at the same time, leave them uncovered, and insert antibiotic drops 3 times daily until his lids have healed.
LATERAL TARSORRAPHY (McLaughlin) Incise his lower lid margin along its intermarginal line (the line where his lids touch anteriorly) medially from his outer can-thus for 5 or 6 mm. Remove a piece of the anterior lamella of the lower lid. Split the intermarginal line of his upper lid for the same distance, and remove a similar sector of tarsus and conjunctiva.
Evert his upper lid, and insert a 4/0 mattress suture from the skin to the bare area. Insert it through the bare area of his lower lid towards his conjunctiva. Then return, making a mattress suture about 3 mm long tied over a piece of fine rubber or plastic tube. When you tie it, his palpebral fissure will be shortened, and his lids will overlap.
Leprosy of the hands
A patient with leprosy can lose the feeling in his hands suddenly during a lepra reaction, so that he complains of an immediate numbness, or so slowly that he hardly notices it. When this happens, neglected bruises, blisters, and cuts cause scars that progressively destroy the pulps of his fingers. Painless cigarette burns are a common presentation. To prevent this happening he must learn how not to injure himself. Persuade him that it is the injury to his hands which leads to wounds, and not the disease itself. If he fail s to care for his fingers, and presents you with a severely disabled hand, there is little you can do, except to maintain such mobility as he has with physiotherapy. Patients are usually able to use their deformed hands quite well, and don't like having their fingers amputated.
Tendon transfers and arthrodeses are sometmes helpful, and a Z-plasty can be done to widen the web of the thumb, but these are all expert tasks.
Severe hand infections are common in leprosy patients, and usually present late. You will see abscesses (8.1), osteomyelitis (8.16), tenosynovitis (8.12), and gangrenous fingers.
HANDS IN LEPROSY Protect a patient's hands during hard work, either by making sure he wears protective gloves, or by adapting the handles of the tools he uses. He is more likely to consent to wear gloves,than to use modified tools. If he smokes (persuade him not to) he must use a cigarette holder. Make sure that his insensitive hands are soaked and oiled in the same way as his feet (31.5).
If the flexor surface of his finger cracks, don't let it heal with a short scar which will be likely to reopen when it is stretched—splint it straight while it heals. Use plaster strengthened with a stiff longitudinal wire, or a short length of stiff plastic hose pipe, cut with a tongue which projects into his palm. Observe his finger carefully for blueness. Initially,remove splints at night, until you are sure they are not occluding his circulation.
If the dorsum of his hand is scarred, so that his MP joints become hyperextended, severe disability will result. This can happen as the result of a lepra reaction, when a thick sheet of inflammatory tissue scars and perhaps ulcerates. Put his hand through a full range of movement daily during the reaction to keep it mobile. Later, a skilled surgical release may be possible.
If he has severely deformed finger(s), such as a terminal phalanx bent to 90°, consider amputation or, better, an arthrodesis with shortening of the bones to allow for the contracted tissue on the front of the joint. If his fifth finger is badly deformed, remove it with half its metacarpal (75-28). Its absence will hardly be noticed.
If paralysis is acute (within 3 months, and perhaps up to 6 months, but certainly no more), he has probably had a lepra reaction, and so has some hope of recovery. Give him full an-tileprosy treatment and steroids for 6 to 12 weeks. Splint his hand in the position of function (75.3) at night, and be sure he moves it by day. Ensure that all the joints of his hand are put through their full range daily, using the exercises D, and E, in Fig. 30-3.
If his ulnar nerve is acutely involved, rest his arm in a sling with his elbow at 90°, and put his whole arm through its full range of motion at least once a day.
r s jmbi cal< are Involved, he is in danger of developing a claw hand, so teach him the exercises in R and G, Fig. 30-3.
h c med ar lerve s , Dived, his thumb web may need stretching. Ask him to grasp the distal end of its metacarpal (not its phalanges), and pull it away from his fingers (not shown).
If paralysis is chronic and slowly progressive, recovery is unlikely, so ask him to do the exercises in Fig. 30-3. A paralysed hand is more useful if it is mobile rather than stiff, and is less likely to be damaged at work.
INFECTIONS IN LEPROUS HANDS (common) Watch for heat and swelling. Tenderness is often absent and fluctuation is too late to be useful. His first complaint may be painful glands in his axilla. The same principles apply as in normal hands (Chapter 8), with one great difference—the pain which prevents a normal person from using his infected hand cannot protect an anaesthetic one. So make sure that a leprosy patient rests his infected hand, and apply a splint to make sure he does. Apply it in the position of safety (75.3) with his MP joints flexed, his IP joints almost fully extended, and his thumb abducted, as if he were holding a tennis ball.
CAUTION! Antibiotics without rest are a waste of time, money and his fingers!
If infection starts as a macerated skin crease in a paralysed finger, splint it with a posterior splint in just sufficient extension to open out the finger and expose it to the air. If a posterior splint is difficult, use a palmar one. If there is any discharge, give him an antibiotic also.
If you feel rough bone at the base of an ulcer or sinus in his hand, and pus oozes from a joint he has osteomyelitis or septic arthritis (8.15). If you feel rough bone at the bottom of a sinus over the tip of his finger, he has osteomyelitis of his terminal phalanx. If only part of a phalanx is dead, allow dead bone to separate spontaneously. Otherwise, you are likely to open the joint, and he will lose more finger length. If most of a phalanx is dead, disarticulate the joint and remove the base.
If he has septic arthritis, aim for a fibrous arthrodesis, or a bony ankylosis. Splint his hand and fingers as nearly as possible in the position of function (7.16), and give him an antibiotic. Immobilize his infected joint for at least 4 to 6 weeks after the infection is controlled, and the ulcer healed, while putting all his other joints through their full range of movement daily. If splinting one finger is difficult, you may be justified in splinting it with one of its neighbours (75-14), depending on their condition. Curette dead bone and granulations, and pack the cavity with hypochlorite ('Eusol) or sugar (57.3) to encourage sequestra to discharge and granulations to fill the cavity. An ankylosis usually takes 12 weeks and a fibrous arthrodesis 6 to 8 weeks.
If his septic arthritis does not heal, excise the joint. Make a dorsal incision, remove the joint surfaces, and any dead tissues, and splint the joint in a position of function (75.3). Pack the cavity that remains, and allow it to heal by granulation. Keep the joint splinted in the position of function, and wait 12 weeks for an ankylosis.
If he has septic tenosynovitis, it is likely to be the result of spread from a pulp infection. Splint his hand in the position of function. If drainage is not free make a further opening in his middle palmar crease.
If he has a grossly swollen hand, with pitting oedema of the dorsum, and obliteration of the concavity of his palm, he has a midpalmar space infection—see Section 8.9.
The care of anaesthetic feet
A patient's feet are even more important than his hands. He may be able to work with a paralysed hand, but if he cannot walk, he will probably be unable to undertake the essential activities of daily life. All over the world, leprosy patients who are being adequately treated medically, are being allowed to walk about on ulcerated feet. The dressings that cover their ulcers do not prevent them from deepening, ana widening, and involving the hones underneath. The quiet progressive destruction of these feet is not inevitable—and can be minimized. It may be a losing game, so play it as cleverly as you can, and try to retain the usefulness of a patient's foot as long as possible.
Ulcers can be caused by: (1) Constant mild pressure, which causes necrosis by impairing tne blood supply to the tissues, as in paraplegic ulcers (64.13). In a normal person ischaemia soon causes pain, so that the ischaemic part is moved, and its blood supply restored. In an anaesthetic limb there is no pain, so that the ischaemic tissue is allowed to become necrotic and ulcerates. (2) A strong force which cuts, shears or tears the tissues. In the foot, the strength of the force is less important than the small area over which it is applied. (3) The frequent repetition of moderate forces, which cause inflammation that weakens the tissues. This is an important cause of ulcers, so try to keep the pressure on a foot low. (4) Forces which spread infection to soft tissues and bone. An infected foot is so painful to a normal person, that he has to rest it—a leprosy patient does not do this spontaneously. (5) A previous ulcer. This is the commonest cause. If a patient has never had an ulcer, he may escape without one—if he is careful. If however he has already had nine ulcers, he will probably get a tenth.
The key to preventing ulcers is: (1) To teach a patient how not to injure himself in the first place, and (2) to teach him 'self care' for any injuries he does receive, in their earliest stages. All primary care workers should be able to teach this. When his tissues have been damaged, they will usually heal, if he rests them completely. Surgery is much less important than rest, at the right time, and tor the right length of time. Antibiotics without rest will not heal ulcers.
Ulcers commonly start in the deeper tissues, and develop slowly over several days, so teach him to recognize an ulcer as a 'hot spot' in its 'pre-ulcer' stage, before the skin over it has been broken. A hot spot is a warm area of skin, usually with swelling, that occurs after activity, and persists during at least 2 hours of rest. In an anaesthetic foot, a hot spot may be the only indication of some underlying pathology, such as a fracture, disintegrating bone, a strain, or an abscess. Any of these may break through to the surface, and form an ulcer. The patient, or a friend, must learn to look for hot spots, because they mean ' 'Stop!" He must take them seriously, and rest his foot until all signs of inflammation have gone. Rest at the hot spot stage is the only way to avoid the serious damage that starts the downhill road to amputation.
The risk of an anaesthetic foot developing an ulcer depends partly on his shoe (if he has one), and partly on how much he walks. The less he walks the better. Perhaps he can ride a donkey, or a bicycle? The kind of shoe he needs depends on the state of his foot, as defined by the 'degree of risk' below. Many patients with moderate, or even high risk feet, can remain free from ulcers without moulded shoes if: (1) they practise self care, (2) they have microcellular rubber insoles in their sandals or shoes, (3) they limit their walking, and (4) they take small steps. Moulded shoes are more difficult to make, and many hospitals manage without them. With a little instruction a local cobbler should be able to make a suitable unmoulded shoe in the local style, with the necessary insoles and straps, and using only the local materials. If you want him to make a moulded shoe, he will need these special materials:
• MICROCELLULAR RUBBER, 5 m2 x10 mm only. This has a closed bubble structure, and is much more resilient than ordinary 'foam rubber'. Some shoe factories can provide it. It is not the same as the foam plastic used for cheap sandals, which is less resilient. Car tyres make good soles, and inner tubes can make uppers.
•FOAMED POLYETHYLENE, 1 cm thick, as 'Plastazote' (Smith and Nephew) 5 m2 only. This is a light thermoplastic which a skillful cobbler can use to make a moulded shoe, for a moderate- or severe-risk foot. It resists wetting and is easily cleaned, but it does need an oven. Its main disadvantage is that it wears away in less than 6 months. Heat a piece of sheet to exactly 140°C in an oven and hold it at that temperature for five minutes: place it on a 10 cm polyurethane foam pillow; and then ask the patient to stand still on it until it is cool, or let him sit while you force his foot down on it, as in C, Fig. 30-5. It will not burn him, and will set in the shape of his sole, as in illustrations D, and E, in this figure. Be sure to support moulded 'Plastazote' with microcellular rubber, or cork and latex, built up to produce a flat sole; it is not resilient enough to make an insole by itself.
• FOOTPRINT MAT, also called a Harris mat, rubber, (DOW Canada), two only of each thickness (optional). This is a mat with little rubber ridges which you ink. Place a piece of paper on the inked mat and ask the patient to walk on it. The greater the pressure, the blacker the ink impression. If you are really interested in the care of leprosy feet, get a footprint mat: its use is described in Paul Brand's book on insensitive feet (31.1).
LOOK FOR SWELLING AND REDNESS FEEL FOR 'HOT SPOTS'
FEET IN LEPROSY
SELF CARE'. Teach a leprosy patient to: (1) Recognize that his anaesthesia is abnormal. (2) Care for his anaesthetic limbs, so that they are not injured. (3) Inspect his limbs daily, so that he can remove any thorns, and recognize and care for any wound, either open or closed, while it is still small, and before it gets worse. (4) Rest his limbs when they are injured. (5) Recognize and understand the seriousness of 'hot spots'. (6) Treat his first ulcer as the calamity that it really is.
CAUTION! (1) Persuade him that it is injury to his anaesthetic feet and not the disease itself which leads to ulceration and loss of tissue. (2) He must limit his walking, if he has a hot spot,or an area of deep tenderness.
EXAMINING AN INSENSITIVE FOOT. Look for swellings, injuries and callositis. Are any of his toes pushed apart (with oedema from an injury)? Examine the arches of his feet as he stands, and look for flattening. Feel his whole foot. Warmth or swelling suggest active pathology, and the need for extra care. Press deeply over the common sites of ulceration in A, and B, Fig. 30-6. He may still feel deep pain, when he has lost all ordinary sensation.
Watch him walking barefoot. You can easily miss a dropped foot, if it is also short. Ask him to walk on his heels. He cannot do this if his anterior tibial or peroneal muscles are weak. Finally,don't forget to look at his shoes!
SKIN CARE. Denervation of the skin reduces its natural secretions and makes it dry, so that it more easily cracks, fissures, and becomes infected. Softening dry skin reduces these dangers, and may allow any fissures that have formed to heal. So ask him to get plain water, without detergents, into his dry feet (or hands) by soaking them for 15 to 20 minutes at least twice a day. Then ask him to cover his skin with petroleum jelly ('Vaseline'), or any kind of grease or oil (including car oil). It is the water that is important, not the grease which keeps it in.
If fissures are already well established, pare away the thick callus with a knife, or ask him to rub it away with a pumice or other stona Remove rough callus regularly, because it may split and crack, or cause ulcers by pressure.
OTHER WAYS TO PREVENT ULCERS. When necessary remember to: (1) Correct deformities. If he has a dropped foot, fit a toe raising strap (J, 30-4). (2) Ask him to take short steps, which will reduce the pressure on the front of his foot and his heel. (3) Ask him to avoid any hard edges or knots in his shoes or socks. (4) Beware of newly healed ulcers. The scar will not have had time to become supple, and is in danger from any shearing force applied to it.
PRE-ULCERS'. Try to recognize a 'pre-ulcer foot' because 3 days to 3 weeks of immediate bed rest at this stage may prevent a serious ulcer forming. Look for: (1) swelling of his sole, (2) separation of his toes, (3) necrosis blisters at the side of his foot, caused by fluid which has tracked from the necrotic area above his plantar fascia, as in G, Fig. 30-6, (4) 'hot spots', (5) redness, (6) pain (if he still has any sensation), especially pain on deep pressure.
FEET AT RISK FROM LEPROSY
A LOW RISK FOOT is anaesthetic, but has little or no scarring. It needs protection and a resilient sole. The possibilities include: (1) A resilient insole in a well-fitting shoe, which is one size larger than one he usually wears. This may be enough. Don't make the insole too thick, and make sure his shoe is well fastened, so that it does not slip and produce blisters. (2) A car-tyre sandal with an insole of microcellular rubber.
A MODERATE RISK FOOT is anaesthetic, has multiple scars, and has lost some of the subcutaneous fat pad on its sole. A shoe for a foot like this needs to be moulded, to take the weight off the metatarsal heads, and spread it evenly over the entire sole. Such a foot will however do fairly well in a simple car-tyre and microcellular rubber sandal—if he keeps the callus well pared down. Or, make a piece of moulded 'Plastazote' as described above. When it has set firm, build microcellular rubber up underneath it, and then fit this to a car-tyre sole. If it is made as a sandal, it will need a retainer for the heel moulded into it. A shoe with a moulded sole is better than a sandal at preventing the foot slipping out, but it must have a well-fitting upper with buckles, laces, or straps, so that it remains in its correct relationship to the foot.
A HIGH RISK FOOT has, in addition, a mild deformity, such as flattening of the arches, and shortening, or loss, of toes. It needs a shoe which is moulded to conform to it completely, and has a rigid sole. Build microcellular rubber up under a sole of moulded 'Plastazote', and carve a wooden rocker clog to fit it; then fit this with a hard rubber sole. A clog is rigid, so its front end must be boat-shaped as in G, Fig. 30-4. Some of these feet do well in microcellular rubber sandals—if their owner looks after them carefully.
A DISINTEGRATED FOOT has a major bony deformity such as fragmentation of its tarsal bones, or is 'boat-shaped', or has a dislocated ankle. Rehabilitation is difficult; he may need reconstructive surgery and a proper orthopaedic boot. See also Section 31.6D.
PROTECTIVE FOOTWARE FOR LEPROSY Instruct a cobbler to make the footwear described above, and to follow the local styles where he can. Make the straps broad, and adjustable with buckles or laces, so as to allow for swelling or bandages. The simplest protection for an ulcerated foot is a metatarsal bar, stuck or stitched to the outside of the sole, just behind the metatarsal heads, as in N, Fig. 30-4.
CAUTION! (1) Never use nails or wire to make or repair shoes for leprosy patients—glue and sew them. (2) If his foot is significantly inverted or everted, only major surgery will allow him to walk satisfactorily. (3) New shoes need special care. Warn him to walk short distances only until the leather has become adjusted to his foot—meanwhile he should use his old ones most of the time.
PARALYSIS OF THE FEET IN LEPROSY
If paralysis developed quickly and is acute (and is still within 3 months, and perhaps up to 6 months, but certainly no more), he has probably been in reaction (Type One) and has some hope of recovery. Give him full antileprosy treatment and steroids for 6 to 12 weeks (31.1a). Treat him as described below.
If he has a posterior tibial nerve palsy, either: (1) Apply a firm bandage to limit friction at the back of his ankle. Combine this with a heel retainer, to minimize the use of the small muscles of his foot, and trauma to his anaesthetic sole. Or, (2) apply a padded plaster boot.
If he has an acute common peroneal nerve palsy, or a palsy of its branches, so that he has a flapping gait and foot drop,passive exercises will help to stretch his Achilles tendon and prevent a contracture: (1) Ask him to squat with his heels flat on the ground. (2) Ask him to stand erect about 70 cm from a wall, to keep his feet flat on the ground, and with the palms 0f his hands flat on the wall to do 'press ups' in the vertical position.
He also needs some protective device. Either: (1) By day, fit him with a toe-raising spring as in J, Fig. 30-4. If he is cooperative,this will be easier and cheaper, and will allow him to do some work. By night, apply a posterior slab to hold his ankle in neutral. Or, (2) apply a complete plaster cast, including his foot and leg up to the middle of his thigh, with 15° of flexion of his knee, and with his ankle in neutral, taking care that the cast does not press on the nerve. Leave it on for 6 weeks.
If his common peroneal nerve paralysis has persisted 6 months in spite of medical measures and physiotherapy, it is probably permanent. He may be helped by the lengthening of his Achilles tendon, and the transfer of his tibialis posterior tendon to the front of his foot to make it into a dorsiflexor (31.8). If this is impossible, or while waiting for surgery, fit him with a toe-raising strap.
If he also has plantar ulceration with his foot drop, be sure to use a posterior slab or a cast. If his ankle is not supported, his tendo Achilles is likely to contract on bed rest. Give him crutches while his ulcer heals, so that he does not even take one step on it.
If he has clawed toes, transfer his flexor longus tendon to the extensor expansion on each toe (N, and O, 30-9).
FIND A CAPABLE COBBLER AND HELP HIM TO HELP YOUR PATIENTS
When feet have ulcerated
An uncomplicated ulcer is only skin deep, does not involve bone or deeper structures, and usually heals easily if the patient rests his leg. A complicated ulcer has involved the bone underneath it. It has a deep sinus, or marked infection, and is much more difficult to heal.
When a leprosy patient has his jirst ulcer: (1) Help him to find the cause of his injury. Never let him accept that the cause was leprosy. Was it caused by repeated stress, or by a blow, a puncture,or a burn? (2) Concentrate all your educational energies on him. You can do much more for a patient with his first ulcer, than for one whose foot is already mostly destroyed.
If you can find some way of resting an ulcer it will usually heal. This means that he must 'not take one step' on it, until it has finally closed over, and all the scabs are off. if it is uncomplicated, this takes 4 to 6 weeks. You can: (1) Rest it in bed. Unfortunately,this is rarely achieved because: (a) staff do not understand the need for it and explain it to him, and (b) he has no pain, and thus has little incentive to stay in bed. (2) Get him to use a splint and crutches, continuously until his ulcer has healed. He won't do this unless you educate and supervise him carefully. (3) Make him a special curative shoe, with a rigid rocker bottom, and a specially moulded upper surface. Making shoes of this kind needs much skill, and is not described here. (4) Put his foot in a cast.
A plaster cast is one of the most practical ways of resting an ulcerated foot. It immobilizes the foot, it spreads the strain of weight-bearing, it is quick to apply, and it is easy and effective. You can apply one in a remote clinic and send the patient home— provided you tell him that he must provide himself with door-to-door transport. If you apply a cast on the indications listed below, it will usually allow an ulcer to heal in 6 weeks.
Unfortunately; although resting a patient's foot in a cast may heal an ulcer, it weakens his bones and ligaments, even if he walks in it. Bones only retain their normal strength if they are regularised. Rest causes them to lose their minerals, and ligaments to lose their strength. The result is that when his cast is finally removed, he may be delighted to find that his ulcer is healed, but ht: may not realize: (1) that anaesthesia is preventing him from experiencing the stiffness and pain that protects a normal foot after a cast is removed, and (2) that he needs to practise self care to keep his ulcer healed. Consequently, he may be tempted to use his anaesthetic foot too vigorously, with the result that it dislocates, or its tarsal bones fracture, and he ends up with a neuropathic foot. So: (1) Use casts cautiously, and remember their risks. (2) When you remove one: (a) warn him of the sad consequences of energetic early exercise, (b) start a programme of 'walking training', which will return him slowly to full activity during 7 to 10 days, (c) be sure that he learns 'self care', (d) be sure also that both you and he watch carefully for 'hot spots', and (e) most important, admit him for at least a week at the time the plaster is removed, so that you can supervise him carefully while all this is done.
Bone damage is common, and serious, and may be the result of: (1) Sepsis spreading from an ulcer, particularly if he walks on it. (2) Mechanical strain, which is particularly likely to occur when the protective mechanism of pain is absent. (3) Disuse atrophy in bed, or in a plaster cast. (4) Invasion of the bone by leprosy bacilli (leprosy osteitis), which is common in lepromatous and borderline leprosy, but is seldom severe enough to cause collapse. (5) Steroid osteoporosis, which may predispose to fractures.
The best way to minimize bone damage is to treat ulcers carefully,so that bone is not damaged in the first place. There are however also some additional principles: (1) Keep the weight-bearing surface of his sole as large as you can. (2) When you remove bone surgically, don't do so unnecessarily. Make sure it really is dead or infected. Dead bone is usually grey or black; it has no periosteum, and so feels rough to a probe. When you nibble it with forceps its fresh surface is pale, and not pink. Ideally, you should allow a sequestrum to separate before you remove it, but this takes several weeks, during which time the ulcer will not heal. You can shorten this time by removing dead bone as described below.
When bone has been damaged, clean up the mess it has caused. For example, if there is a deep sinus under an ulcer, with bone involvement, rest the leg for a few days to localize the infection. Then remove the dead soft tissue and bone—perhaps one or more metatarsal heads, leaving his toes if you can.
The short equinus foot of leprosy is one of its end results, and is due to the absorption of bone, which may be due to: (1) Neglected ulcers and infections. (2) Paralysis of his extensor muscles. (3) Unduly radical surgery. Muscle imbalance may pull his heel up too much, or push his forefoot down too much, so that it increases the pressure on his metatarsal heads, and so causes worse ulceration and more shortening.
A boat-shaped foot is another of the late effects of neglected leprosy. His arch is destroyed, and instead of being concave, it becomes convex, often with ulcers and bony spurs on the convexity.
FOOT ULCERS IN LEPROSY
ACUTE ULCERS Put the patient to bed. Splint his foot and raise it to encourage drainage and prevent oedema. This is much the best treatment. Ambulant treatment seldom works. Either admit him, or make sure he does not walk me single step at home. Let him use bed pans, or crutches to reach the toilet. If necessary, fix a piece of wood to the dressings, as in B, Fig. 30-8, to make sure that he does not walk. If bed rest is impossible, see below under 'Difficulties'.
Local applications to an ulcer make little difference, so there is no need to change the dressings on it at short intervals. Dress it 2 or 3 times a week with hypochlorite ('Eusol'), hypertonic magnesium sulphate, sugar (which is best used daily, 57.3), or some mild antiseptic. Or, soak it, scrape it regularly to remove excess callus, oil it, and dress it daily. When discharge stops, you can apply a cast, leave the dressing unchanged for 6 weeks, and send him home. Or, you can continue daily care as a means of teaching him self care.
If he has fever and other signs of generalized infection, give him an antibiotic. Splint his leg to rest it and stop him walking.
CAUTION! Antibiotics have no place in treating uncomplicated ulcers—what they need most is rest!
If he has a profuse discharge, or tender groin glands, raise his leg, and give him an antibiotic. Don't let him get out of bed, and don't give him a walking cast.
When the acute stage is subsiding, and there is no sign of spreading infection, explore the ulcer with a sterile blunt probe to find out if there is exposed bone in its base.
If bone is exposed, feel if there are any loose pieces or sequestra,and remove them. Pack the ulcer with hypochlorite until it is healing well, and continue to rest his leg.
If bone is not exposed and infection is controlled, either apply a cast and let him walk about, or continue bed rest with a splint and crutches.
A SHORT LEG WALKING CAST FOR LEPROSY INDICATIONS. A chronic non-inflamed ulcer, whose base is visible without any necrotic bone, tendon, or other necrotic tissue. If there is necrotic tissue, remove it before applying the cast.
CONTRAINDICATIONS. (1) Signs of inflammation or infection: heat or oedema of the dorsum opposite the ulcer, excessive discharge, or regional adenitis. (2) Involvement of a joint or synovial sheath (synovial discharge). (3) Dead bone or tendon or capsular sloughs in the base of the ulcer. (4) A long deep sinus with smalt openings whose base you cannot see.
METHOD. Here is the basic method, which assumes that the patient's toes will be open. Some surgeons cover them to keep out stones and sand. See also Section 70.6 on plastercraft. Measure his feet for shoes before he goes into his cast— when he comes out of it he must not take a single step without them. Shape the B6hler stirrup (walking iron, 81.3) to his leg before you apply the plaster.
Dress his ulcer with dry gauze or a simple ointment. Cover,but do not pack the wound; discharge must be able to escape easily.
Apply stockinette, a nylon stocking, or an evenly applied gauze bandage. Apply the minimum of padding to bony prominences only. Use strips of adhesive tape to fix 3 strips of padding as A, Fig. 30-7, but don't apply the tape directly to his skin. If you don't have padding, use many layers of bandage instead.
Lay him on his abdomen with his knee at 90° and his leg vertical. Apply a thick layer of plaster to his leg without pressure. End the cast 5 cm below the head of his fibula, to avoid pressure on his common peroneal nerve, and leave his toes open. Apply a back slab and circular reinforcing layers. Then fit a Bonier iron or a walking board (wood with a piece of car tyre, F, 81-3). Let it dry for 48 hours. The cast must be dry before he walks on it.
Alternatively, a thin well-moulded layer of plaster, covered by a layer of fibre glass, will make a more long-lasting cast. Preferably, use fibreglass tape rather than sheet, because it lasts longer.
CAUTION! (1) Don't mould the cast under pressure to obtain the required position, or you may cause ulcers and gangrene. (2) Ask an assistant to hold his ankle at exactly 90° or slightly dorsiflexed, as in E, Fig. 30-7, until the plaster has set; it must not be plantar-flexed or inverted or everted. (3) Don't press into the plaster with your fingers, or you may produce pressure points where more ulcers will develop (F, 70-5). (3) Remember that he cannot complain of pain. A wrongly applied cast may cause ulcers! So don't apply excessive pressure over a tight bandage.
If he has an ulcer on both feet, he may need a wheel-chair. If he has to move about on the floor, give him 'hand sandals' to protect his hands. Make these with a piece of microcellular rubber, and give them a single strap. If he has casts on both feet, double bars on the walking boards will allow him to walk. Or make flat casts and sandals to go over them as in B, Fig 30-7.
Leave the cast on for 6 weeks. When you remove it, the shoe that you measured him for earlier should be ready. Make sure that he has a period of 'walking training' before he resumes full activity (see above). Apply a firm bandage, and start him walking in a carefully graduated way. Check his foot for swelling or an increase of temperature. Rest it again if signs of inflammation return. Tell him to walk as little as possible, to take short steps, and to avoid uneven ground, sudden strains, and long walks.
If his ulcer has not completely healed in one cast, apply another.
BONE INVOLVEMENT IN LEPROSY
THE INDICATIONS FOR REMOVING BONE. Consider removing bone if: (1) There is osteitis. (2) It is loose. (3) It is projecting into a septic cavity with no obvious blood supply around it. (4) It is projecting after an ulcer has healed, so that it forms a pressure point; if so cut it horizontally (see Section 31.7 on calcaneal spurs). (5) One metatarsal is obviously longer than the others, and the skin over it is ulcerating. Apart from the first metatarsal, which may usefully be longer, they should all be on the same line across his foot, so that he can walk without one of them sticking out prominently and taking extra stress.
Admit him. If this is impossible, give him a splint and crutches. Give him antibiotics pre- and postoperatively.
TO REMOVE DEAD BONE apply a tourniquet (3.9), try to loosen the bone, and cut it off at the line of separation. If this line has not yet formed, nibble it at the point where you see the periosteum is adherent again.
CAUTION! (1) Don't remove bone from the base of an ulcer unnecessarily, especially in the heel. (2) Probing an ulcer will tell you if bone is exposed, but not if it is dead. Exposed bone may be healthy, but the soft tissues will take time to grow over it. (3) Never strip the periosteum unnecessarily, because this may kill the bone under it.
DIFFICULTIES wi TH LEPROSY FEET
IF BED REST IS IMPRACTICAL: (1) Give him a splint and crutches, and ask him not to bear weight on the foot with the ulcer. The splint can be plaster (expensive and short-lasting), wood, plastic, wire (mesh fencing wire), or even a roll of paper or cardboard. Or, (2) apply a betow-knee cast, as described above, for 6 weeks. Or, (3) attach a projecting bar to his foot as in B, Fig. 30-8, and give him crutches.
If a PLASTER CAST FOR AN ULCER IS IMPRACTICAL, you can: (1) Fit the kneeling leg prosthesis in D, Fig. 30-8, which is suitable for limited activity only. (2) Fit a 'healing shoe' which is less cumbersome than a cast, but also less effective. It must have: (a) a rigid sole with a central rocker, (b) an insole (ideally 'Plastazote') moulded exactly to the shape of his foot, (c) an upper strapped round his foot and ankle, so that they cannot move in relation to his shoe.
If his ULCER RECURS, check the way he cares for his feet. Does he inspect them and soak them daily and remove rough callus? Look at his shoes: (1) Is there increased pressure in some area which has caused necrosis? (2) Are the straps so loose that they allow movement of his foot in relation to the shoe, or so tight that they cut into him? (3) Can the contour or fit of his shoes be improved? (4) Does he always wear them?
Also, check how he walks. How far does he walk without resting? Can he walk less, or walk with less pressure on the ulcer, or more slowly or with shorter steps? Ask him to practise walking with his ankles tied with string, to limit his steps to 30 cm.
There are two possibilities: (1) You may be able to excise the ulcer, and all the scar tissue under it, and then graft it with split skin. This may provide a more suitable bed for the regrowth of subcutaneous tissue than the original scar tissue. Some surgeons think that split skin grafts break down too easily, and consider that better quality skin results from the next alternative. (2) You may be able to excise the scarred area, and close the gap you have made with monofilament sutures. This often requires the use of a relieving incision on the dorsum or side of his foot, and packing the cavity with hypochlorite ('Eusol') to encourage healing from the base or bottom of the wound. See Section 31.7 on the excision of metatarsal heads.
If he looks after his feet carefully and wears the right shoes, his ulcer should not break down again. If it does, and he is caring for his feet properly, there is some underlying abnormality, such as: (1) Sequestration of the bone under the ulcer. Remove sequestra surgically. (2) A bone spur which may need excising as described below. (3) A thick scar which splits under tension as he walks. (4) Inadequate subcutaneous tissue over his metatarsal heads. (5) Malignant change in the ulcer. (6) Claw toes which repeatedly ulcerate. Treat him as described below or refer him.
CAUTION! When you treat ulcers avoid cutting into living bleeding tissue unless it is to: (1) Open an abscess. (2) Improve drainage from a deep sinus. (3) Remove necrotic tendon, muscle, or bone. (4) Remove a free lying sequestrum. (5) Remove bone that is so placed that healing and normal function are mechanically impossible.
If there is an ULCER ON THE LATERAL BORDER OF HIS FOOT (F, 30-6), it is likely to be associated with peroneal paralysis. Treat it by bed rest and splints or casts. When it has healed a toe-raising strap attached to the area of his fifth metatarsal head may help to prevent recurrence.
Alternatively, if the ulcer is in the middle of the lateral border, you can try to promote healing by surgically paring his cuboid or the base of his fifth metatarsal, and removing any infected tissue. Do this through a dorsolateral incision, which leaves a sufficient bridge of tissue between the incision and the ulcer. Turn back the infected tissues by subperiosteal dissection, trim the bone, remove necrotic tissue, excise the ulcer with an elliptical incision on the sole, and close this with monofilament to achieve primary healing of the plantar wound. Pack the dorsolateral wound, and allow it to close by granulation. Keep the mouth of the wound wide open until the depth of the cavity is clean and closing. A toe raising spring may help to prevent recurrence.
BONY DIFFICULTIES IN LEPROSY OTHER THAN NEUROPATHIC BONE DISINTEGRATION
If a TERMINAL PHALANX PRESENTS in an ulcer at the tip of a toe (or finger), nibble it away with a bone nibbler. If it is badly infected, disarticulate it. If necessary, use a fish mouth incision over the top and down the sides, which will leave the pulp intact.
If you need to REMOVE PART OR ALL OF THE MIDDLE OR PROXIMAL PHALANGES, approach them through incisions«t the sides of a toe (or finger).
If BONE IS EXPOSED UNDER A HEEL ULCER, be very careful about removing it from his calcaneus—you can easily remove too much, and a foot without a heel can be a problem. Patients can however walk on very little calcaneus or even none, if you provide them with a rubber heel-pad. Look for a calcaneal spur (see below).
If he has a SHORT FOOT, examine him carefully to see if his heel is taking its proper share of his weight. You can easily miss foot drop in a short foot. Ask him to walk on his heels; if he cannot do so, some of his muscles are weak. Lengthening his Achilles tendon may help, even to the point of making his calf muscles useless, because this will make him walk mainly on his heel, and less on the front of his foot. If he has definite paralysis of his dorsiflexors, he will be better with a tendon transfer (31.8). If this is not practical, fit him with a toe-raising spring.
NEUROPATHIC BONE DISINTEGRATION IN LEPROSY
If his foot is HOT AND SWOLLEN, there are several possibilities.
If he has signs of an acute infection with lymphadenitis, treat him with rest, an antibiotic, and if necessary, drainage. His bones may not be neuropathic, and his foot may merely have a soft tissue infection.
If he has no lymphadenitis or signs of general infection, his hot foot may be the result of neuropathic bone disintegration. This can also follow a fracture. Admit him. Splint, bandage and rest his foot in bed. The heat and swelling should subside within a week. Then apply a firm supportive bandage and start 'walking training' (see above).
If heat and swelling do not return ,he had a sprain or minor injury.
If they rapidly return and persist, there is active pathology, so apply a cast for 6 weeks, check again, X-ray him again and plan treatment accordingly. After this interval stress fractures and other bony lesions will have caused enough osteoporosis to be seen. If you are in doubt, or have no X-rays, have another trial of walking. If heat and swelling return a second time, he has definite neuropathic bone disintegration, so reapply a well fitting walking cast for 6 to 12 months, depending on its site and severity.
If his TARSAL BONES DISINTEGRATE, you may see him in any of these three stages.
In the first stage, his foot is hot, it may be swollen, but its shape is unchanged. Raise it to allow swelling to subside. Apply a cast moulded to the shape of his foot, but without trying to change it, usually for 3 to 6 months.
In the second stage, his foot is still hot with active disintegration; its shape is abnormal, and it may be hypermobile. Raise it in a splint for 3 days to reduce swellling. Then lay him on his face as in E, Fig. 30-7, mould his foot into as functional a position as you can, accentuate its arch as much as possible, and apply a cast. Leave this on for for 6 to 12 months, and then mobilize him with care. If necessary, treat him for the complications of the third stage (see immediately below).
In the third stage, his foot is no longer hot, showing that his bone lesions are no longer active. If there are rough bones, which will be likely to cause ulcers, trim them. A high-risk shoe may keep him ulcer-free. You may be able to refer him for an arthrodesis, after which he may need a walking cast for 6 to 9 months. If he is lucky his foot will revert to the 'moderate risk' class; if it does not, he may continue to need a special prosthetic shoe or brace. Many of these patients can manage to live well in a simple sandal, with daily skin care.
If there is NO PRACTICAL WAY TO ESTABLISH A GOOD ARCH, at least try to get its bones healed and sclerosed. If the arch of his foot becomes completely flat, he should remain ulcer-free, but if the bottom of his foot becomes convex and boat-shaped, it will be more likely to ulcerate. If his talus and calcaneus are totally destroyed, consider amputation (see below).
If he has an old fixed deformity which cannot be altered, refer him for reconstructive surgery or supply him with a special moulded high-risk shoe.
If he has a residal BONY SPUR on the under surface of his calcaneus or elsewhere under an ulcer or scar, try conservative management with special footwear and daily skin care. If ulceration continues, excise it (31.7). Spurs may form under any prominent bone in a boat-shaped foot.
CLAWED TOES IN LEPROSY
Ulcers are often associated with clawed toes.
If he has GRADE 1 CLAWED TOES, (weakness of the intrinsic muscles only, and mobile toes without contractures), his metatarsal heads will have to take excessive pressure, which may cause ulcers. Transfering his flexor tendons gives good results in this stage of clawing (31.7).
If he has GRADE 2 CLAWED TOES, (moderate contractures), you may be able to treat him with a tendon transfer only, or you may need to remove the metatarsal heads at the same time.
If he has GRADE 3 CLAWED TOES, (severe contractureswith or without dorsal subluxation of his MP joints), he will probably have ulcers over his metatarsal heads. To straighten them, you may have to remove at least one phalanx, or the metatarsal head, or both. If the remains of his toes will not bear weight, because they are so badly scarred, do a transmetatarsal amputation (see below).
ANKLE DIFFICULTIES IN LEPROSY
If his ANKLE BECOMES SWOLLEN AND WARM, three things may have happened: (1) He may have sprained his ankle. This is particularly likely to happen If he has a shoe with a rocker sole (the benefit from which may however outweigh the increased probability of a sprained ankle). His ankle needs immobilization. If the sprain is less severe, a firm bandage may be enough. If it is more severe, immobilize his ankle for 3 months in a plaster cast. (2) He may have neuropathic bone disintegration (see above). (3) His ankle joint may be infected (see below).
If he has a DISLOCATED ANKLE that you cannot reduce, or a fixed deformity of it, refer him for surgical correction.
If he has an EQUINUS or EQUINOVARUS FOOT, he may be able to walk quite well, but he will need elaborate footware to keep him ulcer-free. If walking is difficult, and particularly if he has fixed plantar flexion or inversion, refer him for an ankle arthrodesis (E, or F, in Fig. 30-8). When this has been done, an ordinary high moulded shoe, or a sandal of microceliular rubber,may be adequate to keep him free from ulcers.
If his FOOT IS INVERTED, a simple canvas shoe like a tennis shoe may be enough. If not, refer him to have it corrected surgically. When this has been done an ordinary high moulded shoe or a sandal of microceliular rubber may be enough to keep him free from ulcers.
SEPTIC DIFFICULTIES WITH LEPROSY FEET
If SEPTIC ARTHRITIS involves the IP joint of a TOE, excise it through a dorsal incision, remove the remains of its ligaments and cartilage, pack the cavity, and keep his toe straight at its IP and MP joints, while it heals by granulation.
If SEPTIC TENOSYNOVITIS complicates an ulcer, draining the tendon sheath may assist healing. Drain it through an incision along the arch of his foot. Clean out all the infection, as far back as is necessary, to find and remove the infected tendon stump. Close his skin with monofilament, so as to leave the smallest possible scar on the weight bearing area. But leave both ends open, so that you can irrigate the lesion until it is clean. Allow it to heal by granulation.
If a SEPTIC TOE REQUIRES AMPUTATION, use a racquet incision on the dorsum (as in Fig. 75-28), leave the metatarsal head, and only resect the surface cartilage if there is septic arthritis of an MP joint. Drain or pack the wound dorsally.
If plantar ulceration is complicated by OSTEITIS of a METATARSAL HEAD, you may need to excise it. This will move the weight-bearing area proximally, so that more ulceration is likely. If you can save a toe in good position, it will help to protect the area of the new 'metatarsal head'. If you can save the distal part of his first toe, it will help to protect his second metatarsal head, which may otherwise soon ulcerate. Sometimes, you may have to remove several metatarsal heads. Do this through dorsal longitudinal incisions between them. If there are plantar ulcers over his metatarsal heads, excise them, and close the incisions in his sole with monofilament. Leave drains or packs in dorsally.
MALIGNANT DIFFICULTIES IN LEPROSY
If a SQUAMOUS CELL CARCINOMA complicates a longstanding ulcer, the alternatives are local excision and amputation. You may be able to excise smaller lesions that don't involve bone, and are distal to his mid foot.
Operations on the feet in leprosy
xMost leprosy ulcers don't need an operation, but there are some simple operations which you should be able to do. Try to correct clawed toes, because they predispose to ulcers at the tip of a toe, on the knuckle, and under the metatarsal head. Apart from the anaesthetic to tolerate a tourniquet if you sedate him well. If necessary use axillary (A 6.18), wrist (A 6.20), hand (A 6.21), or ankle (A 6.24) blocks, or subarachnoid (spinal) anaesthesia (A 7.4), or ketamine (A 8.1).
If you are excising an ulcer or scar on his sole, you may be able to close the gap you have made by primary suture. This will allow healing by first intention, and will improve the quality of his plantar skin. To do this, excise the ulcer with an elliptical incision, and close the wound with deep mattress sutures (4-7) of '0' monofilament to eliminate dead spaces. Keep the wound dry, and leave the sutures in for 3 weeks. If you can only close an ulcer under excessive tension, consider using a lateral or dorsal relieving incision, right down to the bone. Loosely pack the dorsal incision, and leave it to granulate as described below. Make sure the bridge of skin, between the ulcer and the relieving incision, is adequate to maintain the circulation.
CAUTION! Only close clean surgical incisions by primary suture. Even some of these need drains to minimize haematoma formation. Remove the drains after 48 hours.
If you are excising a deep ulcer with a sinus track leading from it, put gentian violet into the track. If you cut away all the violet tissue, you should have removed the base of his ulcer, tracks and all.
If you are excising a heel ulcer, make a 'fish mouth' relieving incision around the back or lateral margin of the sole of his heel, as in K, Fig. 30-9. Excise and suture the plantar defect, as described above. Consider packing the 'fish mouth' wound as described below, and allowing it to heal by granulation.
If you are doing some other operation on a foot and it happens to have an open, and potentially infected, ulcer pack it as described below.
PACKING A WOUND OR ULCER. Loosely pack it with gauze strips or bandages and allow it to heal by granulation. If you use gauze squares, be sure to leave part of each piece outside the wound, so that it will not be forgotten inside. Soak the packs in hypochlorite, sugar solution, acriflavine emulsion, magnesium sulphate and glycerine, or normal saline. Remove the dressings at 5 days. Provided there is no deep infection, lightly repack the depth of the wound, but keep its mouth widely open. Repeat this every 2 or 3 days, until it has healed by granulation.
TO EXCISE A CALCANEAL SPUR (OR OTHER BONY PROJECTION)
A normal calcaneus has a spur which projects forwards along the line of the plantar ligaments parallel to the ground; this is harmless. If an abnormal spur, associated with an ulcer, projects vertically downwards, remove it. Also remove any irregular bone that has developed because of a fracture or an infection, and which threatens to cause ulcers by pressure from within. Don't remove these bony projections through the ulcer, because this will make the plantar scar bigger.
Instead, paint the ulcer with gentian violet. Then make an incision round the back or lateral side of the patient's heel, as in J, to M, in Fig. 30-9, so as to avoid his medial calcaneal vessels. Deepen the incision to the bone, and lift his heel pad off the bone by clean sharp dissection. Continue the incision, so as to raise a flap of heel and plantar fascia, and mobilize the ulcer. Then excise and suture it as described above. Trim his calcaneus with an osteotome to leave a flattened surface. Don't remove bone unnecessarily, or leave new sharp edges or corners to form new ulcers.
If his ulcer had already healed before the operation, insert a drain and stitch the flap back, provided there is no tension.
If his ulcer is open, excise its edges, and sew it up with deep stitches, leaving a pack in place under it, and coming out of the relieving incision as described above. The skin wound from his ulcer should heal by first intent, leaving a gap round the edge of his heel flap to heal by granulation.
If he has osteitis, excise or curette the sinus tracks and insert a pack.
If osteitis is already draining through the centre of his heel, curette and pack the lesion, without trying to excise the ulcer. Stop all weight-bearing until his ulcer is healed; give him a splint. When the infection is controlled, trim any rough bone. Alternatively, as soon as his osteitis is controlled, you may be able to excise the ulcer scar, pack the lesion laterally, and allow it to heal by granulation.
Don't let him walk on trimmed bone for 6 weeks, or until his wound is fully healed, and its scabs are off—unless he is in a piaster cast.
AMPUTATIONS IN LEPROSY INDICATIONS. Conserve as much bone and soft tissue as you can. The only absolute indications for a below knee amputation are: (1) malignancy, which cannot be removed in any other way. (2) Gangrene. (3) Grossly infected ulcers with inadequate bone, so that they are no longer weight-bearing.
METHOD. Ideally the stump should have sensation. If not, he will need a good prosthetist and careful training. Use one of the methods below, and only do a below-knee amputation as a last resort: it may however be the operation of choice if the tibial area is sensitive. The method of Anderssen and Perssen was specially devised for leprosy. Use a tourniquet (3.9), and see Sections 56.1 and 56.8. The longer his tibial stump, the easier it will be for him to learn to walk with a prosthesis. If he is a healthy young adult, you may be able to take skin flaps almost to his malleoli. If his circulation is poor make a shorter stump. If you amputate through his foot, try to leave as large a weight-bearing surface as you can.
If his foot has become shortened, his toes may remain projecting, and make it difficult to fit a shoe, or they may be subject to excessive pressure. If so amputate them.
If the soft tissue under his metatarsal heads has become so scarred that it constantly reulcerates, remove the distal ends of his metatarsals through dorsal incisions. Keep his toes in line with his sole by bandaging them to a flat board while they heal.
If his foot is chronically scarred and ulcerated, and he has lost part of all his toes, but has good sole tissue proximally, do a transmetatarsal amputation, as in D, Fig. 30-9. Make a dorsal incision and divide the bones along a line proximal to the scar. Without removing tissue from the sole, turn a long sole flap, including the scar up, and around the ends of the bones, bringing the suture line dorsally. The most proximal line for this amputation is through his tarsometatarsal joints (Lisfranc amputation). At this level, you will have to saw through the neck of his 2nd metatarsal, the base of which is more proximal.
CAUTION! Foot operations leaving shorter stumps are prone to develop complications. So avoid them, unless arthrodeses or stabilization of the ankle are possible.
If he has severe ulceration, poor toes, and not enough sole tissue for a long sole flap, make an incision right round the dorsal and plantar surfaces of his forefoot, at the base of his toes. If possible try to keep some of the skin of his toes on the foot flap (E, in Fig. 30-9). The dorsal skin flap does not need to be as wide as the plantar one, so when you incise his foot laterally to make them, do so as far dorsally as you can (F).
Starting at the base of his toes, strip the soft tissues off the bones, and remove all rough infected pieces of bone, far enough back for the most distal part of the remaining healthy bone to lie over a fairly healthy area of skin. Trim all his metatarsals to a suitable length, so that one does not stick out in front of the others. Smooth the rough bone ends. The dorsal and plantar flaps should meet in front of his foot. Excise any ulcers on the sole of his foot, and suture the gaps you have made with monofilament longitudinally as described above.
CAUTION! Don't suture the end of his foot. Instead, pack it and allow it to heal by granulation. This will increase the tissue over the ends of his metatarsals, and allow you to operate while he is still infected and ulcerated.
Try to stop him walking for at least 6 weeks. If absolutely necessary, put him into a walking cast, with his ankle in good dorsiflexion, and with sufficient plantar protection to stop him bumping the healing area. Leave the end of his granulating foot protruding for dressings.
If his heel pad has some sensation and a good prosthetist is available, consider doing a Symes amputation (56.9). A Symes stump is too short and too small to be used for weight-bearing unless he has a good elephant boot.
TENDON TRANSFERS FOR CLAW TOES (Girdfestone type)
v CATIONS. Mobile clawed toes in Grades One or Two (31.6). This operation allows his toes to take more part in weight-bearing, and so protects his metatarsal heads.
ANAESTHESIA. (1) Toe or ankle blocks (A 6.21). (2) Ketamine (A 8.1). (3) Subarachnoid anaesthesia (A 7.4).
METHOD. Under a tourniquet, incise along the midline of the medial side of the middle and proximal phalanges of the toe whose tendon you want to transfer. Proximally, curve the incision dorsally to reach the dorsum of his foot at the distal end of the web. Find his long flexor at his DIP joint. Hold it in forceps, and cut it distally. Cut his flexor sheath back to the middle of his proximal phalanx. Lift the skin and soft tissue off the dorsum of his proximal phalanx and interphalangeal joint, and transfer his long flexor tendon so that it runs diagonally across his proximal phalanx, and reaches the long extensor tendon of that toe. Suture it to his long extensor tendon,proximal to his PIP joint. If his flexor digitorum longus is transferred at this level it will remain a flexor of his MP joint, but will now extend his PIP and DIP joints. Close his skin with monofilament. Splint his foot on a flat board for 3 weeks, and don't allow him to walk. There is no need for physiotherapy.
REMOVING TOE TiPS FOR LEPROSY
INDICATIONS. (1) Fixed flexion of his toes, so that he is walking on the tips of his toes, or on his nails. (2) Repeated ulcers on the tips of his toes.
METHOD. Cut round his nail and across the skin over his DIP joint. Dissect out his distal phalanx, leaving all pulp possible (H, Fig. 30-9). Close the incision with a few mattress sutures (I), and don't worry about dog ears: they will soon atrophy.
EXCISING METATARSAL HEADS FOR STIFF CLAWED LEPROSY TOES
INDICATIONS. More than one stiff, clawed toe of Grades Two or Three, or ulcers under his metatarsal heads. Sepsis is not a contraindication, because you leave the dorsal wound open and pack it.
Aim to reduce the scarred area, by shortening the metatarsals of one or all of his toes, so bringing his toes down to take some weight. Keep all incisions dorsal where you can, and aim for a mobile pseudarthrosis, not an ankylosis.
METHOD. Over his stiff toe make a dorsal incision which is long enough for you to see his MP joint, and 2 cm of his metatarsal. Elevate his periosteum, and remove his metatarsal head with bone nibblers or cutters. Base the site of bone section on the thickness and quality of his plantar skin. Save as much plantar surface as you can, provided it is of reasonable quality. Smooth the remaining shaft with a small bone file or nib-bler. You should now be able to straighten his toe; if it is still dorsiflexed, remove a little more metatarsal. If there is much scarring under his metatarsal heads, consider removing all of them. Don't leave one metatarsal obviously longer than the others. Excise any ulcers on the sole, as above, and close the gaps with monofilament.
Try to avoid damaging his proximal phalanges. If you can find any flexor digitorum longus tendons, release them distally and anchor them over his proximal phalanges, as in the claw toe method above.
For each toe, cut the branches of extensor digitorum longus and brevis to prevent extension. Tack the proximal cut end of the tendon to the remains of his metatarsal to prevent it reattaching itself to the distal end.
Leave the dorsal incision open, pack the wound, and allow it to heal by granulation. Splint his toes straight on a board for three weeks or longer, while his foot heals. When excessive discharge has stopped, consider applying a cast with a window and letting him walk. Ideally, he should not walk, unless he is in a walking cast, for a minimum of 6 weeks, or until his foot is fully healed and the scabs are off.
If you are operating on the head of his 1st or 5th metatarsal,do it in the same way. Make an incision on the medial or lateral side of his foot, but make sure there is enough width in the skin bridge to prevent it necrosing. The width of the flap of skin between the excised ulcer and the relieving incision must be at least half its length (as in making flaps and pedicles).
If all his toes are affected, you can remove all his metatarsal heads through 3 or 4 longitudinal incisions.
If he has marked osteoporosis, apply a walking cast for 2 to 5 months to allow his damaged bones to recalcify, as they will do when infection is controlled. His bone will still look osteoporotic on X-ray; but, provided he returns to walking gradually, it should recalcify without breaking.
Tibialis transfer for foot drop, from leprosy and other causes
A dropped foot, which a patient is constantly tripping over, is a great disability, but it is also a treatable one, whatever its cause: (1) If he has a strong tibialis posterior and gastrocnemius, and a mobile ankle, you may be able to transfer his tibialis posterior tendon. (2) If surgery is impractical, you can fit him with: (a) A toe-raising spring, as in Fig. 30-4, if necessary made with canvas or plastic straps, and using the rubber from an inner tube as the 'spring'. Or, (b) calipers, which will need careful fitting on an anaesthetic limb, if they are not to cause friction burns.
When leprosy has paralysed his lateral popliteal nerve, he cannot dorsiflex his ankle, so that as he walks he is liable to injure the lateral side of his foot, his toes, and the ball of his foot. Severe ulcers and marked deformity may follow. Transferring his tibialis posterior tendon to the dorsum of his foot will restore the dor-siflexion of his ankle, and reduce the risk of ulcers. Refer him if you can, but if you cannot, learn how to do the operation yourself under expert instruction. If this too is impossible, and you are a careful caring operator, follow the method below. It is the most complex method described here, and it right at the edge of Primary Surgery. If leprosy is common in your district, it will be a procedure which is well worth learning, but only provided that there is someone who can prepare him for surgery, and reeducate him afterwards. Reconstructive surgery without physiotherapy is useless; but you can do the physiotherapy yourself, if you take enough time. Tibialis posterior and gastrocnemius are normally used together in walking. An important part of physiotherapy is getting him to separate these actions.
Detach his tibialis posterior from its insertion into his navicular, and divide its distal end into two slips. Thread these under the skin of the front of his leg and foot. Weave the medial slip into the distal end of his tibialis anterior tendon. Weave the lateral slip into: (1) the distal end of his peroneus tertius tendon (only 75% of people have one; it is really the fifth tendon of extensor digitorum longus, and is inserted into the medial part of the dorsal surface of the fifth metatarsal). This is the First Method, D, in Fig 30-11. Or, (2) if he lacks a peroneus tertius, and his peroneal muscles are weak enough to be sacrificed, weave the lateral slip into the distal end of his peroneus brevis tendon (E, the Second Method). Or, (3) if his peroneal muscles are not weak enough to sacrifice, or if the lateral slip of his tibialis posterior is too short to reach the lateral side of his foot, take a piece of tendon and use this as a free graft (not illustrated).
Make four incisions: Incision One, above and behind his medial malleolus, to let you free the muscle belly of his tibialis posterior. Incision Two, over his navicular, to free the insertion of its tendon. Incision Three, on the medial side of the dorsum of his foot, to let you weave the medial slip of his tibialis posterior tendon into the tendon of his tibialis anterior. Incision Four on the lateral side of the dorsum of his foot, to let you weave the lateral slip into his peroneus tertius or brevis. With the Second Method, you may have to make three more incisions, Five, Six, and Seven.
(1) Be sure to join his various tendons at just the correct length and tension, to get the right degree of dorsiflexion and aversion of his foot (this is the position in which the lateral side of his foot is higher than the medial side). His foot must be tightly dorsiflexed when you put it into plaster. To help you we tell you how to make a special foot-drop-positioning splint. This is critical. (2) If your tendon weave gives way, your work is wasted, so be sure to keep his foot dorsiflexed until it has united firmly. (3) Avoid subsequent toe drop by suturing his transferred tibialis posterior to the extensor tendons of his toes. (4) Don't be tempted to anchor his tibialis posterior to a hole drilled in his foot. This may work with other diseases, but in leprosy it will promote the disintegration of his tarsal bones.
TIBIALIS POSTERIOR TRANSFER—TFF Grace Warren's method
EXAMINATION. Check the power of: (1) The patient's tibialis posterior. Ask him to invert his foot against resistance (move it medially). The only other inverter is tibialis anterior, which is usually powerless or very weak in patients needing this transfer. (2) His peroneal muscles. Ask him to evert his foot, and feel his peroneal tendons contracting behind his lateral malleolus (if they are strong, you don't want to sacrifice them).
INDICATIONS. (1) Foot drop from any cause, provided he has a strong tibialis posterior and gastrocnemius (see below), and a mobile ankle. (2) If he has leprosy all these conditions must apply: (a) His leprosy must have been controlled, and he must have been free of reaction for at least 6 months, (b) His lateral popliteal nerve should have shown no sign of improving after 6 months of chemotherapy and the use of a toe-raising spring, (c) His tibialis posterior must be at least 'Power 4', and preferably '4+ or 5' (27.2). (d) He must have no ulcers or infections, (e) Preferably, he should be skin-smear negative, (f) His ankle must be suitably mobile, so test it like this:
Flex his knee to 90°. If you cannot passively dorsiflex his ankle beyond 0°, tendon transfer alone is contraindicated.
Straighten his knee. If you can passively dorsiflex his ankle to 15° (unusual), a tendon transfer alone is enough. If you cannot do this (usual), you will have to combine tendon transfer with lengthening his Achilles tendon at the same time. Not lengthening his Achilles tendon is a common cause of failure.
If his ankle is too stiff to dorsiflex without inverting, he will not get a good gait. So refer him for a wedge osteotomy, perhaps with a tendon transfer later. TENDON TRANSFERS FOR HIS TOES. If a foot is not being dorsiflexed normally, its toe flexors shorten. If you correct his foot drop, his toes will remain abnormally flexed, unless you do something to correct them. So his clawed toes also need tendon transfers (see 31.7), either at the same time that you transfer his tibialis posterior, or later. If you don't do this, he may walk with his toe-nails turned under his toes, which will ulcerate.
RECORD THE PROGRESS OF HIS FOOT Do this as a baseline preoperatively. Do it again when he comes out of plaster, and at regular intervals afterwards. Record the angles of rest, active dorsiflexion, and active plantar flexion with his knee straight, and passive dorsiflexion with his knee at 90°.
PREOPERATIVE PHYSIOTHERAPY is necessary to strengthen his tibialis posterior. Ask him to sit with his affected foot resting on his other knee and to invert it without using his Achilles tendon as in C, Fig. 30-10. Hang a weight (starting with 500 g and increasing to 4 kg, as the muscle strengthens) on the front of his foot, and ask him to lift this by inverting it. This exercise will help him to localize the action of the muscle that is to be transferred, so that it is easier for him to use afterwards.
ANAESTHESIA. (1) Subarachnoid anaesthesia (A 7.1). (2) Ketamine (A 8.1). (3) General anaesthesia (A 10.1). (4) Pethidine and diazepam (A 8.8); his foot will be partly anaesthetic anyway. PERIOPERATIVE ANTIBIOTICS. An infected tendon transfer is a real disaster, so give him him chloramphenicol and metronidazole (2.9).
EQUIPMENT AND TECHNIQUE. Make a foot-drop-positioning splint, as in D, 30-10, from hardwood, hooks, hinges, screws, and two short chains. Boil or autoclave it. Ideally, you should use a 22 or 30 cm curved Anderssen tunneller, but you can use long Kocher's forceps. You will also need a leg rest, or cradle, to hold his leg about 20 cm above his bed after surgery. Ask your carpenter to make a tubular metal or wooden frame with webbing across it (E, 30-10).
For tendons use 2/0-4/0 braided multifilament (nylon, pro-lene, polyglycolic acid ['Dexon'], 'Vicryl', or silk [less satisfactory])or stainless steel (not catgut), on round-bodied, preferably trocar-pointed needles, or use Mayo cervix needles. For skin use nylon monofilament or steel.
For a tendon use several small stitches rather than one large one, and make sure that no single stitch bites more than half its thickness (which makes it liable to break later). Rough tendon ends are harmless on the dorsum of the foot, but if a tendon needs to glide, as when you weave peroneus brevis to tibialis posterior above the ankle, use fine (6/0) nylon monofilament to close over and bury the ends of both the tendon and the larger sutures, so as to prevent them sticking to surrounding structures.
CAUTION! (1) Clamp a tendon as close to its cut end as you can, and excise the crushed area, which should be as short as possible. (2) Watch for and avoid the main vessels. There is no need to tie off all small ones.
PREPARATION. Lay him on his back, apply a tourniquet to his thigh (3.9), and sterilize his whole leg and foot below his knee. Clip a sterile towel round his thigh, so that you can lift his sterile leg without breaking sterility. A sandbag under the drapes will steady his leg, until you place it on the footboard.
INCISION ONE. Make a gently curved incision on the medial aspect of his leg, starting 2 cm above his calcaneus and 1 cm in front of his Achilles tendon, running parallel to the tendon for 5 cm, and then curving up to reach his tibia about 14 cm above his medial malleolus. Cut his fat and deep fascia, and find his Achilles tendon. Open its sheath, and lengthen it by one of the procedures in Fig. 27-11. Suture it so that his ankle will dorsiflex to 15-25° with his knee straight.
Lift the tissues proximal to his medial malleolus, until you see the tendons, under his deep fascia. Slit this to find his tibialis posterior tendon which lies deeper than his flexor digitorum longus, F, 30-11, also D, Fig. 27-11. Make sure you havegot the right tendon by pulling on it and seeing what it does— tibialis posterior inverts his foot, and does not flex his toes.
CAUTION! Keep his exposed tendons moist by covering them with saline-soaked gauze.
INCISION TWO. Pull his tibialis posterior above his medial malleolus to find where it is inserted into his navicular. Make a 2-3 cm incision along the plantar side of the tendon, from his navicular proximally. Incise into the tendon sheath and raise the tendon with a blunt hook or curved forceps.
CAUTION! Make sure you have got the right tendon. It is the only one which is inserted into his navicular, and is usually thick and strong and the size of your little finger.
Clamp his tibialis posterior tendon with Kocher's forceps, as far distally as you can easily reach it, on the medial aspect of his foot, and cut it distal to this (don't follow or try to cut it where it inserts distally, among the arches of his foot). Pull it up into Incision Two, and free it from any adhesions, which would make it difficult to pull out of its sheath later. If there is a large sesamoid bone in it, remove this and reattach the Kocher's. Don't pull it out of its sheath yet.
INCISION THREE. Find his tibialis anterior on the dorsomedial aspect of his navicular. It is the most medial of the tendons on the front of his ankle. Twist his foot into dorsiflexion and abduction to see it more clearly.
Make a 'J:shaped incision, with its long arm along the medial side of his tibialis anterior tendon, from the lower end of his tibia to his navicuio-cuneiform joint, and its short arm crossing the tendon laterally for 1 cm. Reflect the flap at the level of his deep fascia, and try not to cut his dorsalis pedis artery. Find his tibialis anterior tendon (check that you are not pulling on his extensor hallucis longus), and open its sheath.
INCISION FOUR is a quarter-circle curved incision, with its convexity towards his toes, extending from 2.5 cm lateral to the distal end of Incision Three, and passing across the dorsum of his foot, to reach the base of his fifth metatarsal, but not extending over the bone itself. Use big scissors and the 'push and spread technique' (4-8) to raise all his superficial tissues off the deep fascia over the dorsum of his foot, so that you can see his toe extensors, his peroneus brevis, and his peroneus tertius (if he has one) inserting into the shaft of his fifth metatarsal. Define and dissect out his peroneus tertius as far from its insertion as you can, above his extensor retinaculum. Cut its tendon free proximally, separate it from its muscle fibres, and leave it free, attached distally to its insertion.
Keeping above his extensor retinaculum, raise his skin and superficial fascia to join Incisions Three and Four, and make a skin bridge.
CAUTION! His superficial fascia is thin here. Be careful not to cut his extensor retinaculum, which is his deep fascia at this point.
Use finger dissection, and blunt Kocher's, to tunnel up under his skin above his extensor retinaculum, keeping in the midline initially, and then turning medially towards the proximal end of Incision One.
Return to the proximal end of Incision One. Starting about 7 cm above his ankle, raise his skin from the deep structures. Complete the tunnel joining incisions One, Three, and Four. Tunnel under his skin and preserve his long saphenous vein. Make a pocket into which the muscle belly of his tibialis posterior will fit. If necessary, cut the deep fascia over the crest of his tibia, but avoid cutting his tibial periosteum (if you do it will promote adhesions later).
Above his medial malleolus put a finger under his tibialis posterior tendon, remove Kocher's forceps from its distal end in Incision Two, and pull the tendon up into Incision One (C, in Fig. 30-11). Reclamp its distal end, and use the clamp to give you a good grip for traction, while your finger frees its muscle belly from the surrounding tissue at the back of his tibia.
CAUTION! (1) Be careful to retract flexor digitorum longus posteriorly, so that tibialis posterior comes to lie anteriorly (F, 30-11 shows the anatomy of these tendons), between his flexor digitorum longus and his tibia (you don't want tibialis posterior to twist round digitorum longus). (2) Be careful not to damage his main vessels, the muscle fibres of his tibialis posterior, or his periosteum.
Using finger dissection, a Langenbach retractor, and if necessary scissors, free his tibialis posterior, until it will lift up and roll easily round the edge of his tibia in an oblique direction towards the base of his fifth metatarsal (which it will usually reach), crossing the centre of his leg about 4 cm above his ankle joint. Enlarge the tunnel if necessary.
When you have freed the tendon sufficiently to reach the dorsum of his foot, clamp its distal end with two Kocher,s, and divide it between them. Pull the two slips apart into a 'Y' with 6 cm arms. To prevent them separating any further, put a stitch where they meet, so that it will lie inside them when they lie together (G).
If his tibialis posterior will not reach the dorsum of his foot, check that you have freed its belly sufficiently.
Pass long Kocher's proximally, in the midline of his leg, from Incision Four for about 10 cm, and then deviate towards the proximal end of Incision One. Pick up both slips of his tibialis posterior, and pull them through on to the dorsum of his foot.
Pass the Kocher's from incision Three to Incision Four. Pull one slip of tendon into Incision Three and leave the other one in Incision Four. Keep a Kocher's on each slip.
Pass your finger along his tibialis posterior tendon to make sure it lies easily in its new bed, that it runs smoothly round his tibia, and that no fascia obstructs its direct pull.
Use everting monofilament sutures (4-7) to close Incisions One and Two, without closing his deep fascia.
Put his foot on the positioning splint, to hold his knee at 80-90° of flexion, and his ankle at 20-25° of dorsiflexion, with his foot everted. While you adjust the tension in his tendons, ask an assistant to hold his foot in this position; or tie it to the foot splint with sterile bandages.
CAUTION! (1) Don't let his foot invert. (2) Get his heel into the angle of the board.
Through Incision Three, place a Kocher's across about a quarter of his tibialis anterior tendon 2 cm from its insertion. While your assistant holds the distal part of this tendon tense, use a No. 15 blade to make a small longitudinal incision in it (Stab One), just distal to the kocher's. Push a haemostat into Stab one, enlarge it a little and pull the slip of tibialis posterior tendon through it. Make Stab Two at 90° to Stab One 0.5 cm distal to it, and then pull the tendon slip through that. Make Stab Three 0.5 cm further distally again, and pass the tendon through that, as in H, Fig. 30-11 (if the tendon is not long enough, two stabs will do). Don't suture this 'weave' yet. Turn to Incision Four.
THE FIRST METHOD is indicated if he has a peroneus tertius of suitable size. Holding the distal end of his tibialis posterior tight in Kocher's, weave the distal end of his peroneus tertius through it, in the same way that you wove his tibialis posterior through his tibialis anterior. Make Stab One in his tibialis posterior about level with the proximal end of his fifth metatarsal, just distal to his extensor retinaculum; make Stabs Two and Three more proximally. When the two tendons are woven together, work them along one another, until there is no slack tendon. Then, holding both firm so that they are just in tension,with his foot on the positioning board and his ankle everted, join them with 6 small sutures, passing through a little of each tendon, as in D, Fig. 30-11.
CAUTION! As you suture the tendons, make sure they lie in the line of the pull of tibialis posterior, and are not raised away from his foot. If they are not in this line, they will be loose subsequently.
If there is spare tibialis posterior tendon left over, suture it to his peroneus brevis, or his extensor retinaculum, and tuck in any loose ends, so that they grow into the periosteum. If there is any spare peroneus tertius left over, stitch it so that it cannot attach itself above his ankle and limit movement.
Return to Incision Three. Move the woven tendons along one another until they lie snugly, and the tension in the medial slip is the same as that in the lateral one with his foot in the correct position on the splint. Suture the medial weave in the same way.
CAUTION! Don't make the medial slip too tight, or his foot will invert. Check the position of his toes. While your assistant holds them as straight as he can, use a few small stitches to join the slips of his tibialis posterior to his extensor digitorum and extensor hallucis, as they cross.
THE SECOND METHOD is indicated if he has no peroneus tertius tendon, or it is too small:
If his peroneus brevis is paralysed (most patients), use it. Proceed as above until you have woven his tibialis posterior and his anterior together. Peroneus brevis is inserted into the base of his fifth metatarsal. Slip a blunt hook under it, and pull it, so that you can feel it under his lateral malleolus.
Make Incision Five over his peroneus brevis tendon as it passes under his lateral malleolus. Peroneus brevis lies deep to peroneus longus under his lateral malleolus, so you will have to hook out the deeper of the two tendons you find there. Pull it distally, and cut it off as far proximally as you can. This will leave the distal tendon as long as possible, without the need to make Incision Six. Return to Incision Four, you should be able to pull 8 cm of peroneus brevis into it. Weave peroneus brevis into the lateral slip of tibialis posterior and suture them as above. Close Incision Five.
If his peroneal muscles are still functioning (unusual), so that they had better not be sacrificed, take a free tendon graft from either: (1) his plantaris tendon from beside his Achilles tendon, or (2) a toe extensor. Weave and suture this free graft into his peroneus brevis as far distally as possible (to provide the best toe lift and eversion), and then into the lateral slip of his tibialis posterior, as described above. If you use plantaris and it is long enough, use it double for added strength (this method is not illustrated).
WITH BOTH METHODS check that the position of his ankle is satisfactory by lifting his leg off the splint, keeping his knee well flexed, and checking the angle of his foot and ankle—it should be in 15-20° of dorsiflexion and show no inversion. If it drops to 10° or inverts, undo some stitches and tighten them. Don't worry if it is high (20-25°): it will stretch later.
If sure you have cut no major arteries (usual), leave the tourniquet on until you have applied the cast. Otherwise, let it down, control bleeding by applying pressure for 5 minutes, carefully keeping his foot in position on the splint, and then close Incisions Three and Four.
CAUTION! Don't plantarflex his foot while you do this.
THE CAST must keep his foot dorsiflexed and everted, and leave the dorsum of his ankle free. For this it needs a backslab and two side struts or braces.
Ask your assistant to stand beside the patient, facing the foot of the table, to flex his knee, and to flex and externally rotate his hip. His knee should rest on your assistant's abdomen. Your assistant's hand which is furthest from the patient should be flat on the sole of his foot (to avoid pressure areas), with its little finger over the head of his fifth metatarsal, its fingers straight, and with the patient's ankle 20-25° dorsiflexed and everted. His hand must stay in this position until the cast has set. Ask him to support the patient's calf with the flat of his other hand, moving it as the cast is applied.
CAUTION! The patient cannot complain of pain because his foot is anaesthetic, so pad his heel well, or he may get pressure ulcers.
With his foot in this position, firmly but not too tightly bandage on wool, with extra layers over his heel. Apply an 8-layer 15 cm backslab from the tips of his toes to his mid upper calf (your assistant's hand will be between the backslab and his sole). Secure the slab with a 10 cm bandage. Start at his big toe (A, 30-12), go across his sole medial to lateral, and pass three turns round his forefoot, just proximal to his toes. Then pass two turns round his lower leg (this will leave a strut of bandage at the lateral side of his ankle, and enable you to give his foot a good everting tiit as you do so). Then bring the bandage down the medial side of his ankle (to provide a medial strut) and run a turn or two round his forefoot. Continue until the bandage is finished. Apply another 10 cm bandage at the upper end of the backslab. Only now should your assistant remove his hand. Strengthen the side struts and the foot, but leave the front oj his ankle and his toes open.
CAUTION! (1) Make sure his toes are not dorsiflexed. (2) Don't leave finger depressions in the cast (F, 70-5). (3) Don't pull the bandages tight.
POSTOPERA1 IVELY raise his foot on 2 pillows or in a special splint (E, Fig. 30-10), so that his tibia is parallel to his bed, but about 20 cm above it, and his knee is bent. If necessary (unusual in leprosy), give him morphine. Check the colour of his toes and his pulse hourly for 24 hours.
There will be blood marks on the cast. If the circulation to the toes is impaired, bivalve the cast, open it at least 1 cm, rebandage it, but don't remove it.
On Day 4 get him up on crutches, without weight-bearing.
Fourth week, (fifth week if physiotherapy supervision is limited). Readmit him, and bivalve his cast down the two sides, so that the struts are left attached to the posterior half of the cast (reinforced if necessary), which he can use as a protective resting splint while he is being rehabilitated.
CAUTION! (1) Keep his foot dorsiflexed when you remove his sutures. If you don't, his flexors, aided by gravity, may pull away his healing tendons. Start exercises the day you remove the cast.
Fifth week, (first week after removal of the cast) Teach him to use his transfer in its new position. Lie him on his back (with his hips flexed and externally rotated, and his knees flexed), with both his feet in the frog position, so that the soles of his feet are almost touching each other. Ask him to do the inverting movement he did before surgery, his unoperated foot first. When he does that satisfactorily ask him to do it with both his feet together, and with his eyes closed (the movement produced by the transfer is not what he is used to seeing). Hold his operated foot with your palm flat on his sole, so that it cannot plantarflex. When he can do this without looking, let him look; the first movement may be very slight. Then let him graduate to doing it with only one leg.
Concentrate on getting him to dorsiflex his foot without using his gastrocnemius muscle, while trying to get a long, slow pull on his foot. Slowly increase the range and strength of the exercises with his leg horizontal in bed. Once he can do them, let him sit and watch them. After about 5 days, when he can move his transferred muscle easily and on command, sit him on the edge of his bed, and let him dangle his legs over it. Once he sits, he is lifting his foot against gravity, so he must not start doing this until he can isolate his transferred muscle and use it without gastrocnemius.
CAUTION! (1) These exercises are fatiguing. During the first week, encourage him to do them many times a day for 5 minutes only, with 10 minutes rest periods with his foot back in its cast. (2) He must not plantarflex his foot: his strong gastrocnemius can easily pull the sutures out of his tendon transfer.
Sixth week. If he can isolate his transfer, and has good movement, let him stand with crutches or in parallel bars, instruct him like this: "Put your operated foot on the ground behind your other foot. Lift up your toes (by contracting your transferred muscle), lift up your foot as if you are walking, and put it down heel first in front of your other foot. Lift it up and put it back again behind the other one". Progress to walking carefully with crutches. Make sure that every step uses the transferred tendon, and that contraction is held until his foot reaches the ground again. Let him walk for periods of 10 minutes and rest for 10 minutes.
Seventh week,. While he waiks with crutches, check that he uses his transfer with each step. Practise on steps: slopes and stairs. When he is confident, graduate to walking without crutches.
When he is not doing physiotherapy, bandage on the posterior hast of the cast, until he learns to control his foot without trying tc plantarflex it. He should be walking reasonably A/eli at the end of the seventh week, and be able to discard his cast by day. Continue the protective splint at night until the end of the third month.
When he is off crutches, he can start rising on tiptoe while supporting himself with his hands on a table. His tendon join will gradually stretch, and his muscles will adapt to the range of movement required of them—provided you did not damage his periosteum, and so promote the formation of adhesions above his ankle.
CAUTION! (1) Don't try to force his foot into plantar flexion: it will gradually come down as he walks. (2) He must not start plantar flexion too early, or he will lose the power of dorsiflexion. (3) Unless he learns to walk using the transfer with each step, he will not get a good gait; but even if he doesn't use it properly he should be much improved.
DIFFICULTIES WITH THS TENDON TRANSFER
The main difficulty is to persuade him to care for his feet for years to come.
If his TIBIALIS POSTERIOR TENDON IS SHORT, or is badly scarred, so that its whole length cannot be used, transfer what tendon is available, and insert it into his tibialis anterior tendon more proximally. Then attach his peroneus brevis as in Method Two, taking it long so that it bypasses the scarred region.
If the lateral slip of his TIBIALIS POSTERIOR WILL NOT REACH the lateral side of his foot without causing excessive eversion, and his peroneal muscles are not functioning, use a longer piece of peroneus brevis than that described in the second method. If necessary, there is 25 cm of free tendon. Don't make Incision Five but instead make Incision Six 10 cm long, starting 1 cm behind his lateral malleolus and running up his leg in line with his fibula. Cut down until you see his deep fascia, cut this in the line of the tendon, and find peroneus brevis (usually deep to peroneus longus). Cut it out of the muscle (which will not be used), pull it back into his foot at Incision Four, weave it into the lateral slip of his tibialis posterior, and repair Incision Six.
CAUTION! Check his peroneal tendons behind his lateral malleolus, because peroneus longus and brevis are often attached together there. If necessary cut his peroneal retinaculum, behind but not below his lateral malleolus, so that you can pull his peroneus brevis down and out at the base of his fifth metatarsal without harming the tendon.
Weave, adjust, and suture his peroneus brevis to his tibialis posterior as in the Second Method. Then tunnel its free end back under his skin and, through a small J-shaped Incision Seven, suture it to the periosteum on the neck of his fifth metatarsal, as in E, Fig. 30-11. This will give him a better anterior lift if he has a very mobile foot.
If PRESSURE OF THE DRESSING causes sloughing and infection, dress and graft the bare area.
If his wound becomes INFECTED, his tibialis posterior tendon may adhere to other structures, or break. Splint his leg and apply a hypochlorite ('Eusol') dressing. Rest it until you have controlled infection, then slowly resume exercises.
If he DOES NOT USE HIS TRANSFER, he was not taught adequately. Good physiotherapy is essential.
If his TOES CURL UNDER HIS FOOT, ulcers may form and he may lose them. Keep exercising them to prevent stiffness, and correct them surgically if necessary.
If his FOOT IS SLACK ON THE LATERAL SIDE, and tends to invert, consider doing another operation to tighten the tendon, and perhaps bring peroneus brevis into the graft.
Other leprosy problems
Surgery for leprosy of the eyes is discussed elsewhere (31.2). Here we discuss leprosy as it affects the mouth and breasts. If a patient has even the most minimal injury anywhere, treat it with the very greatest care. Cover any break in his skin to prevent secondary infection, and splint the part to allow it to heal in a functional position.
If a patient CANNOT CLOSE HIS MOUTH because his facial nerve is paralysed, his gums may dry and he may dribble rood and drink and be socially unacceptable. Refer him to have his plantaris tendon or a strip of his fascia lata transferred to support his lip, by slinging it from his zygoma or temporalis fascia on both sides. Although this is a static sling, it will keep his mouth closed, improve his appearance, and stop him dribbling. If he has no lagophthalmos he may be able to have a temporal muscle transfer to reactivate his mouth.
THE BREASTS IN LEPROSY
If a MAN'S BREASTS ENLARGE and trouble him (gynaecomastia), do a simple mastectomy by the Webster method as in P, Fig. 30-9. Make sure his breasts are enlarged and he is not merely fat. Make an incision half the way round the margin of the areola. Leave a small piece of breast tissue immediately under his nipple, and drain the cavity towards his axilla. Bring the drain out some distance from his areola, so that you can close the surgical incision and get a good scar. He will probably be very pleased with this simple procedure. Don't remove any fat, or you will leave a depressed area.