Reconstructive surgery in Leprosy

Leprosy - Introduction, classification, treatment, deformity correction and rehabilitation

1. "Leprosy work is not merely medical relief; it is transforming frustration of life into joy of dedication, personal ambition into selfless service" M ahatma Gandhi

2. RECONSTRUCTIVE SURGERY IN LEPROSY MODERATOR : Dr VIRUPAXA GOUDA PATIL PRESENTER : Dr GOUTHAM HANU T Dept. of GENERAL SURGERY, JJMMC, Davangere .

3. History of Leprosy 1893 : Doctor Armaur Hansen of Norway discovers M. Leprae bacilli 1950s: Doctors begin using Dapsone to treat leprosy Since 1982, Multi-Drug Therapy has made a huge impact

4. Epidemiology 80 % of the worldwide cases are found in five countries, namely India, Mynamar , Indonesia, Brazil and Nigeria.

5. World distribution of Leprosy 2003

6. WORLD STATUS Elimination of leprosy as a public health problem is defined as a prevalence rate of less than one case per 10,000 persons. Use of MDT reduced the disease burden dramatically.

7. INDIA 4,00,000 new cases per year The prevalence of leprosy - 52 per 10,000 in 1981 to 2.4 per 10,000 in July 2004. No primary prevention MDT is the only intervention July 2004 - 2.4 lakhs leprosy cases on record

8. LEPROSY A chronic infectious disease of the peripheral nerve, skin, and mucus membrane of URT Cause - Mycobacterium leprae and M . lepromatosis An intracellular, acid fast   bacterium , is  aerobic and rod-shaped . Every year January 27 is World Leprosy Day

9. Mode of infection Human-to-human via nasal discharge (droplet infection ) T hree other species can carry and (rarely) transfer M. leprae to humans: chimpanzees, mangabey monkeys, and nine-banded armadillos .

10. OTHER MODES OF TRANSMISSIONS Contact through the skin (rare). Arthropod-born infection (rare). Through placenta and milk.

11. Signs and Symptoms First symptoms : Numbness loss of temperature sensation As the disease progresses : The sensations of touch Pain E ventually deep pressure are decreased or lost.

12. CLASSIFICATION Ridley & Jopling Classification Based on Host Immunity TT BL LL BT BB BL

13. CLASSIFICATION WHO Classification Based on Bacterial Load Paucibacillary 1-5 skin lesions Multibacillary >6 skin lesions Slit Skin Smear Positive Negative

14. LEPROSY Paucibacillary (PB) Multibacillary (MB) Indeterminate Leprosy (IL) Tuberculoid Leprosy (TL) Borderline Tuberculoid (BT) Borderline Borderline (BB) Borderline Lepromatous(BL) Lepromatous Leprosy (LL)

15. Indeterminate leprosy : Hypopigmented patch, sensation normal, no palpable peripheral nerve and slit skin smear negative. Indeterminate Leprosy (IL)

16. Tuberculoid leprosy: Two hypopigmented patches, hypoasthetic well defined borders, palpable peripheral nerve and SSS negative. Tuberculoid Leprosy (TL)

17. Tuberculoid Leprosy: Annular, erythematous, anasthetic patch with well defined and raised borders and SSS Negative.

18. Borderline Tuberculoid Leprosy: Well-defined large anaesthetic patches with satellite lesions. SSS Negative. Borderline TUBERCULOID

19. Borderline Borderline Leprosy: Less defined, asymmetrically distributed hypoaesthetic patches. SSS positive. Borderline BORDERLINE

20. Borderline Lepromatous Leprosy: Numerous, hypoaesthetic almost symmetrically distributed patches . SSS positive. Borderline LEPROMATOUS

21. Lepromatous Leprosy: Leonin Face LEPROMATOUS LEPROSY

22. Diagnosis of Leprosy Clinical Examination. Slit Skin Smear. Skin Biopsy.

23. TT BT BB BL LL Skin Lesions No. of Bacilli Slit skin test Immunity Clinical spectrum of leprosy

24. TREATMENT

25. COMPLICATIONS OF LEPROSY & ITS MANAGEMENT

26. LEPRA REACTION ADVERSE EFFECT OF ANTI-LEPROTIC DRUGS DISABILITIES & DEFORMITIES PSYCHO-SOCIAL PROBLEMS COMPLICATIONS

27. DEFINITIONS IMPAIRMENT : The loss/ abnormality of the anatomical / physiological , structure/function. DEFORMITY : Visible alteration in the form, shape or appearance of the body due to impairment produced by the disease. DISABILITY : Lack of ability to perform an activity considered normal for a human being.

28. DISABILITIES Late diagnosis and late treatment with MDT Advanced disease (MB leprosy) Leprosy reactions which involve nerves Lack of information on how to protect insensitive parts Only about 10-15% of leprosy affected person develop significant deformities and disabilities.

29. TYPES OF DEFORMITIES: 1) SPECIFIC DEFORMITIES: Local infection with M.Leprae Most often in the face - facies leprosa Less often in the hand and only occassionly in the feet.

30. 2) Paralytic deformities : Due to damage to motor nerve Most often in the hand(claw finger ) Less often in the feet Occassionly in the face ( lagopthalomos , facial palsy)

31. 3) Anesthetic deformity : Occur as a consequence of neglected injuries in part rendered insensitive b/c of damage to sensory nerve. - Found most often on the feet and hand(ulceration , scar contrature , shortening of digits & skeletal disorganization of foot)

32. WHO GRADING OF DISABILITIES IN LEPROSY WHO Grade 0 Grade 1 Grade 2 EYES Normal vision, lid gap & blinking. Corneal reflex weak Reduced vision Lagophthalmos HANDS Normal sensation & m.power . Loss of feeling in the palm Visible damage i)wounds ii)claw hand iii)Loss of tissue FEET Normal sensation & m.power . Loss of feeling in the sole Visible damage i)wound ii)foot drop iii)loss of tissue.

33. Peripheral nerves Sensory Motor Autonomic Hypoaesthesia / anaesthesia Muscle paralysis Lack of sweating & sebum Ulcers Ulnar nerve Claw hand Radial nerve Wrist drop Lt. popliteal Foot drop Post. tibial Claw toes Facial n lagophthalmous Dry skin Cracked skin Ulcers

34. RECONSTRUCTIVE SURGERY Aim s: • Restore function and form as far as possible • Prevent further disability • Re habilitation process. Note : Not all patients are suitable.

35. The reconstructive possible for: Lagophthalmos Foot-drop Ulnar/median paralysis (fingers and thumb) Collapsed nose Successful outcome depends on Pre and post-operative physiotherapy Ability of patients to learn to use new ability

36. CRITERIA FOR REFERRAL FOR RCS Criteria have been grouped into three categories: Social and motivation Physical Leprosy treatment

37. SOCIAL AND MOTIVATIONAL CRITERIA Patients who benefit socially, occupationally or economically Potential to make a difference to patients’acceptance in their society Patients must be well motivated for their own health and follow instructions The surgery involves loss of economic activity for a period of several months.

38. PHYSICAL CRITERIA: Age : 15 -45 years Duration of muscle paralysis -at least one year and preferably not longer than 3 years. Suppleness of the joints Physiotherapy or surgery can reverse some contractures No infection of the skin

39. LEPROSY TREATMENT CRITERIA Completed the scheduled course of MDT or at least for 6 months Free from reactions and symptomatic neuritis for at least 6 months. Should not have had lepra reaction during the past 6 months unless the surgery is for neuritis. No tenderness of any major nerve trunk in the limbs.

40.   IRREVERSIBLE CLAW HAND Ulnar / median paralysis FOOT DROP Lateral popliteal nerve CLAW TOES Posterior tibial nerve LAGOPHTHALMOS Facial nerve. Irrespective of age lid gap (>6mm) WRIST DROP Radial nerve RECURRENT WOUNDS OF HANDS AND FEET Sequestrum removal. CATARACT Cataract in one or both eyes with Visual acuity < 6/60 GYNAECOMASTIA Testicular and liver damage MADROSIS Graft from scalp or temporal artery island flap SAGGING OF FACE/ MEGA LOBULE Destruction of elastic/ collagen fibres in dermis NASAL DEFORMITY Invasion and destruction of nasal tissue especially nasal septum.

41. PRIORITIES for reconstructive surgery High priority - Lagophthalmos Feet are usually considered the next priority followed by hands Surgery is most beneficial - when the disease is stable, MDT is established, and the muscle paralysis is not likely to progress or to recover.

42. COMPLICATIONS OF EYE

43. Involvment of the ophthalmic division of the (5 th .) trigeminal nerve Corneal sensation imparment Patients ignore injuries keratitis , conjunctivitis and ulcers Involvment of zygomatic & temporal braches of the (7 th .) facial nerve. Lagophthalmos Unable to close the eye ( unblinking stare)

44. How is lagophthalmos assessed? Observe the Frequency and Extent of Blinking Ask the Patient to Close the Eyes 'As in Sleep' Ask the Patient to Close the Eyes Tightly

45. Duration of lagophthalmos ≤ 6 months: prednisolone 40mg/day slowly reducing over 12 weeks Duration of lagophthalmos > 6 months with eyelid gap < 6 mm: Conservative treatment, e.g. sunglasses, 'think blink‘ Duration of lagophthalmos > 6 months with eyelid gap ≥ 6 mm: eyelid surgery

46. Surgery Static procedures:- Tarsorrhaphy Dynamic Procedures:- Temporalis Muscle transfer Above two are done only if the corneal sensations are intact If not:-Lid closure

47. Temporalis Muscle Transplantation

48. TARSORRHAPHY

49. Before and After surgery physiotherapy

50. FOOT DROP

51. FOOT DROP Due to damage of common peroneal nerve Paralysis for more than six months to one year- corrective surgery is advised. Orthotic device - Short leg iron with a foot-drop stop Stretching exercises - To prevent shortening of the Tendo - Achilles .

52. Diagnosis High stepping gait Sitting on a high stool with the leg hanging down free - unable to lift the foot Aim of surgery To restore active dorsiflexion of the foot. By Tibialis posterior transfer

53. PREREQUISITES Foot fitness for corrective surgery Foot fitness for Tibialis posterior transfer Functioning of Peroneus muscle Check for tightness of tendo Achilles Teach the patient isolated contraction of the Tibialis posterior muscle

54. TIBIALIS POSTERIOR TRANSFER (TPT)

55. Post-operative management Limb elevation for 72 hours Walking heel is given on fourth day Follow up after 3 weeks Physical therapy and exercises for re-educating the transferred muscle are then started

56. Re-education exercises First week Patient practices contracting the Tibialis posterior muscle, with gravity eliminated Second week Patient does exercises against gravity Third week Patient starts standing and then walking in a walkway with parallel bars for support and partially bearing weight on the foot. Fourth week Patient is allowed full weight-bearing and practises walking with a ‘heel to toe’ gait without support

57. Transfer of the Peroneous longus tendon to the toe extensors Paralysis of only the anterior group of muscles ( dorsiflexors ) and the peroneal muscles are of normal strength Tendon of Peroneus longus is tranferred to restore dorsiflexion of the foot.

58. Lengthening of tendo Achilles

59. Foot Drop Left Before and after

60. Complications Infection Adhesion Tension of the transferred tendon may be unequal Post-operative inversion/eversion deformities of the foot The Tibialis posterior may have become paralysed -Medial popliteal neuritis.

61. CLAW HAND

62. Definition F lattening of transverse metacarpal arch and longitudinal arches, Hyperextension of MCP joints Flexion of PIP and DIP joints  

63. Types of claw hand Complete : Involving all digits and resulting from combined Ulnar and Median Nerve palsy Incomplete : Involving only ulnar 2 digits as in isolated Ulnar Nerve palsy

64. Modified Bunnell’s procedure First week Flexing the PIP joint of the middle finger in isolation and ALL the fingers would be now flexing at the MCP joints. Second week Fingers should attain the 'intrinsic' position (MCP joints in flexion and IP joints in extension) by contracting the transferred muscle Third week Slow and increasing active flexion of the IP joints Fourth week Usage of hand in minor activities of daily living not requiring much power

65. Zancolli lasso insertion technique:

66. SUPERFICIALIS OPPONENSPLASTY CLAW THUMB DEFORMITY

67. EIP OPPONENSPLASTY

68. RADIAL NERVE PALSY The patient loses the ability to extend the wrist, fingers and thumb, movements that are essential for functional grasp. Three main goals when treating radial nerve palsy. Restoration of finger (MCPJ) extension, Restoration of thumb extension, Restoration of wrist extension.

69. WRIST EXTENSION

70. THUMB EXTENSION

71. FINGER EXTENSION

72. Nerve Abscess

73. Ulnar Nerve Abscess Longitudinal Epineurotomy

74. PLANTAR ULCERS ACUTE ULCER CHRONIC ULCERS SIMPLE COMPLICATED TREATMENT   ULCER DEBRIDEMENT POSTERIOR TIBIAL DECOMPRESSION

75. 1 Tips of toes 1st and 2nd degree claw deformity of toes 2 Dorsal knuckle of toes Claw toes and friction from uppers of shoes 3 Proximal phalanx of big toe Poor quality of scar 4 Under MTP joints 3rd degree claw-toes deformity, poor quality of scar 5 Under I st MTP joint Sesamoiditis , scar adherent to sesamoids , severe forefoot deformities, poor quality of scar 6 Middle of sole Tarsal disorganization with collapse of the longitudinal arch of the foot 7 Front part of heel Collapse of calcaneum 8 Heel pad Poor quality of scar Pathology involving calcaneum 9 Sides of the heel Chronic osteitis of calcaneum 10 Over lateral malleolus Chronically infected bursa Poor quality of scar

76. CLAW TOES

77. DEGREE OF DEFORMITY DESCRIPTION 1st degree deformity Deformity is mobile Toes can be actively straightened 2 nd degree deformity Flexion contractures develop at the interphalangeal joints,esp PIP Toe cannot be straightened even passively at these joints 3 rd degree deformity Proximal phalanx of the toe gets drawn up progressively Gets dislocated and comes to lie on top of the head of the metatarsal Tip of the toe does not contact the ground First degree corrected by transferring the Flexor digitorum longus tendon to the extensor expansion distal to the metatarsophalangeal joint Second degree arthrodesis of the proximal interphalangeal joints of the toes in the straight position. Third degree reposition the toes in front of the metatarsals and retain them there. TREATMENT

78. SCAR REVISION PROCEDURES Scar excision and direct closure Closure using local flaps Rotation flap Bipedicle flap Closure with filleted toe flap

79. MEGALOBULE NASAL DEFORMITY: Ant & antero -inferior part is commonly involved Nose loses its mucosal lining and its skeletal support - ‘ SUNKEN NOSE ’. POST NASAL EPITHELIAL INLAY GRAFTING OF GILLES Elongated ear lobe hangs down lose. Corrected by excising the infero -medial segment of lobule using curved incision( cresent wedge resection)

80. GYNECOMASTIA -Usually bilateral -Due to hormonal imbalance because of testicular and liver damage - WEBSTER’S OPERATION

81. COMMUNITY BASED REHABILITATION Aims to overcome activity limitation and participation restriction and thus improving QOL for disabled.

82. REFERENCES IAL Textbook of LEPROSY by Hemanta Kumar Essential Surgery in Leprosy by H Srinivasan Campbell’s textbook of Orthopaedics Internet