Tag Archives: Leprosy

Orthopedic approach of the leprous foot

by Thiago Batista Faleiro1*, Gildásio de Cerqueira Daltro2, Alex Guedes3, Renata da Silva Schulz4Jorge Eduardo de Schoucair Jambeiro5, Maria Betânia Pereira Toralles6pdflrg

The Foot and Ankle Online Journal 9 (1): 5

Leprosy is a disease known for thousands of years with pathophysiology and treatment established for decades. Nevertheless, there are still cases of delayed diagnosis and poor monitoring of previously diagnosed patients. The combination of deformity and insensitivity in the feet is responsible for severe functional limitations and the formation of ulcers that evolve to amputation. Knowledge of the natural history of foot in leprosy contributes to the adoption of therapeutic measures in a timely manner in order to ensure better quality of life to the patient.

Keywords: Leprosy; orthopedic procedures; foot deformities

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0005

1-Titular Member, Brazilian Society of Ortopedia and Traumatology (SBOT). Titular Member of the Brazilian Association of Medicine and Surgery of the Ankle and Foot. E-mail: thiagofaleiro@yahoo.com.br
2-Titular Member, Brazilian Society of Ortopedia and Traumatology (SBOT). Titular Professor – Lecturer, Department of Experimental Surgery and Surgical Specialties (DCEEC), Faculty of Medicine of Bahia (FMB), Federal University of Bahia (UFBA). E-mail: gildasio.daltro@yahoo.com.br
3-Titular Member, Brazilian Society of Ortopedia and Traumatology (SBOT). Adjunct Professor – Doctor, Department of Experimental Surgery and Surgical Specialties (DCEEC), Faculty of Medicine of Bahia (FMB), Federal University of Bahia (UFBA). E-mail: alexguedes2003@yahoo.com.br
4-Nurse Specialist in Clinical Surgery by the State University of Rio de Janeiro (UERJ), Master in Nursing by the Fluminense Federal University (UFF). E-mail: renata.s.schulz@gmail.com
5-Full Member, Orthopedics and Traumatology Brazilian Society (SBOT). Member of the Brazilian Surgery and Foot and Ankle Medical Association. Head of Foot and Ankle Surgery Group of the University Hospital Santa Isabel, Salvador, Bahia, Brazil
6-Medical, Clinical Genetics Course Professor, Faculty of Medicine of Bahia (FMB), Federal University of Bahia (UFBA). Salvador, Bahia, Brazil
* – correspondence: thiagofaleiro@yahoo.com.br


Leprosy is an infectious, contagious and curable disease caused by Mycobacterium leprae whose major route of infection is respiratory mainly transmitted by untreated multibacillary patients. It is considered a multisystemic infection affecting the skin and peripheral nerves [8]. Currently, 80% of new cases are concentrated in countries located in the intertropical band: India, Brazil, Myanmar, Madagascar, Nepal and Mozambique [18]. In 2011, the prevalence rate was 1.24 per 10,000 inhabitants in Brazil [15].

Damage on the peripheral nervous system before, during and even after the end of treatment, that is, after the end of the specific therapy (multidrug therapy) is responsible for most of the deficits and deformities associated with leprosy [13]. The diagnosis and treatment of neuritis should be carried out early, as these are the main factors for preventing such complications. Neurites under six months of evolution respond best to corticotherapy [30]. On lower limb, lesions of the common peroneal and posterior tibial nerves are the most common, found in 79 and 82% of cases, respectively [11]. Nerve damage causes changes in tactile sensitivity and proprioception, making it particularly susceptible to trauma and limb muscle weakness, generating physical deformity. These changes need to be diagnosed and treated early in order to prevent permanent disability and emotional sequelae in infected individuals [17]. In a study conducted in Turkey [4], the prevalence of disability by the involvement of the feet was 73.3%, among which 19.8% had plantar insensitivity and 37.2% had plantar ulcers. Patients affected by leprosy have limitations related to reduced ability to walk and to the severity of involvement of the feet [28]. The natural evolution of leprosy can be didactically presented as shown in the left column of Figure 1. The recommended treatment for each phase of the disease is in the right column of Figure 1.

 1

Figure 1 Left column: sequence of pathological events leading to disability in leprosy; Right column: recommended treatment for each phase of the progression of the disease.

Although known for thousands of years and with established pathophysiology and therapeutics, there is still a delay in the diagnosis of leprosy, particularly given the long incubation period of the disease which is (often) asymptomatic, its insidious character and the lack of preparation by health professionals [27]. The objective of the present review is to address the most important aspects related to orthopedic approach to the involvement of the feet in leprosy.

Diagnosis

The diagnosis of leprosy in the majority of the Brazil states is still delayed, happening between one and half to two years after the first symptoms [1]. In Brazil, 5.7% of diagnosed patients already have sensory and/or motor lesions and deformities, all preventable [24].

The Ministry of Health [21] defines the diagnosis of leprosy through the presence of one or more of the following criteria:

  1. Skin Injury (ies) with altered sensitivity;
  2. Neurological involvement with neural thickening;
  3. Positive bacilloscopy.

Thus, performing sensitivity tests, palpation of accessible nerve trunks and evaluation of functional neurology (sensory, motor and autonomic) is required for diagnosis of leprosy.

Search for cutaneous sensitivity (thermal) – the first to be compromised -, pain sensitivity and tactile sensitivity – the last to diminish and disappear-, is performed. When in doubt, additional tests are done, such as histamine and pilocarpine tests [2].

Physical examination should begin by careful ectoscopy for changes, ulcers or deformities in the skin. Also, it is important to check the active and passive joint mobility as well as the degree of muscle strength in different related segments (Table 1, see PDF version).

Palpation of nerve trunks should seek to check for increased volume or pain and paraesthesia. In the case of the common peroneal nerve, the patient must keep the legs hanging; the nerve must be palpated on the posterior surface of the fibula at the level of the lap. The tibial nerve must be palpated with the foot kept in passive inversion and plantar flexion, posterior to the medial malleolus [22].

Leprous Neuropathy

In nerve trunks, millions of Mycobacterium leprae spread around each compartment and layer of nerves, initially without any apparent tissue reaction. There is usually some swelling, but with time the proliferation of fibroblasts will create diffuse cicatrisation in the nerve and finally complete fibrosis and loss of function. This process may take years to be completed and it is observed in almost all peripheral nerves, from proximities the spinal cord to the periphery [30].

The treatment of acute neuritis (painful or silent) is initially conservative with prescription of corticosteroids, being prednisone the most frequently used. This is applied with a loading dose of 1 to 2 mg/kg/day according to the severity of the case. This dose should be maintained until regression of signs and symptoms, followed by weaning phase, which must be done slowly and gradually over a period of at least six months [26].

This process gives rise to intrinsic and extrinsic neural compression developed in three basic stages: irritative (stage I) – characterized by pain, paresthesia and hyperesthesia; compressive (stage II) – characterized by hypoesthesia and paresthesia; and deficit (stage III) – characterized by anesthesia, paralysis and atrophy. Surgical treatment (external neurolysis) in stages II and III is considered the alternative that allows the most promising results, particularly in stage II in which the patient may experience reversion of wholly or partially sensory-motor loss. At stage III, external neurolysis inhibits the intraneural degenerative process; however, clinical regression will rarely happen, making it necessary to associate it with operations of rehabilitative nature [14].

Neurolysis consists in the release of the nerve trunk of anatomical areas under anguish, reducing the edema, inflammation and intraneural compression. Its indications are not well defined in the literature [31]. The following criteria are used in Brazil [20]:

  1. Contraindication to the use of nerve abscess corticoids;
  2. Refractoriness to clinical treatment after four weeks;
  3. Subintrant neuritis or neuropathy (after three episodes);
  4. Non-treatable or chronic pain;
  5. Neuritis of the posterior tibial.

Neuritis of the posterior tibial nerve, often silent, does not respond well to treatment with corticoids. Decompression of the nerve trunk can be indicated either as preventing the plantar perforating illness (in cases presenting early signs and symptoms of neuropathy), as a therapeutic intervention (in cases with signs and symptoms of fully established tibial lesion) [29] (Figure 2A and B).

2a2b

Figure 2 Neurolysis of the peroneal and tibial nerves, respectively.

Treatment of “Footdrop”

Among the deformities caused by the injury of the common peroneal and posterior tibial nerves, we found the equinovarus foot and, less frequently, the equine foot. The first deformity, equinovarus foot, the more serious, is the result of paralysis or paresis of important dorsiflexor muscles and foot eversion as a result of damage to the superficial and deep branches of the common peroneal nerve, located in the height of the lap of the fibula. Also important, the second deformity is due to paralysis or paresis of the dorsiflexor muscles consequent only of injury of the deep branch [25]. As a result, the patient loses the ability to elevate her foot during march. This corresponds to the so-called footdrop and slapping gait, very disabling, which may cause damage to the plantar region and induce rigid foot deformities. The transfer technique of posterior tibial muscle to correct these deficiencies was described by Brand [3] and is now the most used operative modality.

“Claw” Toes

The intrinsic muscles of the foot maintain their structure while walking and thus regulate the mechanics and the distribution of loads on the march. When intrinsic muscles are paralyzed due to neuropathy of the tibial nerve, as in leprosy patients, there is a high prevalence of plantar ulceration and deformities, especially when muscle weakness is associated with loss of sensitivity [34]. The typical deformity of neuropathic feet consists in “claw” toes (Figure 3), which can be divided into two types [23]:

  1. Mobile: when it is possible to passively move the metatarsophalangeal and interphalangeal joints;
  2. Rigid: when the joints are in a rigid position and there is no passive correction of the deformity.

3

Figure 3 Clinical aspect of a patient with “claw” toes deformity.

In the case of toes with flexible “claws”, the transfer of the flexor digitorum longus to the extensor apparatus, described by Girdlestone-Parrish, is a useful mean for correction. Although satisfaction varies in the literature, this technique remains a useful tool in the surgeon’s arsenal to treat the deformity, decrease pain and help to prevent ulcers [16].

In cases of rigid “claw” toes, often associated with joint degeneration, surgical treatment involves arthrodesis or resection arthroplasty. The proximal interphalangeal arthrodesis has several advantages including reduced risk of recurrence and more predictable posture of the foot [10]. However, loss of mobility can predispose to ulcer formation. Thus, resection arthroplasty should be considered as the best therapeutic option for smaller toes in insensitive feet.

Plantar Ulcers

The plantar region is often center of ulcers due to biomechanical changes and decreased sensitivity. Muscular atrophy, muscle weakness and deformities alter the biomechanics, contributing to foot bone disorder. This makes the patient execute maladjusted march, causing new pressure points. Furthermore, leprosy patients have decreased or abolished sensitivity with consequent decrease in the physiological protection needed to prevent cutaneous lesions [5].

The feet are characterized as the most commonly affected site by skin ulcers (52% of cases) often in individuals who have disability classified in stage II and positive bacilloscopy as detected by spectral and operational classifications [12].

Conservative treatment of plantar ulcers should be instituted as early as possible. Success rates as high as 98% are possible with use of accelerators such as alginate, hydrocolloid and collagen, developed to fit the physiology and the needs of the healing of wounds [6]. The use of orthoses can reduce the time of wound healing [7].

In cases where the conservative treatment fails, it is necessary the introduction of surgical treatment, which must meet five objectives [33]:

  1. Removal of infectious foci, such as sequestration;
  2. Removal of localized bony prominences, which can cause ulceration;
  3. Bone realignment to produce a more functional unit;
  4. Reduce the excessive mobility (through osteotomies and arthrodesis);
  5. Stabilization in motor neuropathy (tendon transfer, tenodesis or arthrodesis).

Amputations

Amputation removes the damaged segment, but must provide residual stump eligible to receive prosthesis, allowing the patient to ambulate for the rest of his life. A fundamental principle in the management of these patients is the need for constant observation for the presence of wounds or sores on the stump, proper gait training and a well-built prosthesis [9].

Among leprosy patients, the main causes for amputation are complicated chronic ulcers with infection who develop osteomyelitis and bone resorption [19]. All amputation levels are used in leprosy patient surgery. The criterion of choice is the same used in amputations for other reasons: the surgeon must select the most distal amputation level possible based on pathology, preoperative functional demands and intraoperative finding [32].

Conclusion

The leprous neuropathy constitutes a major operative challenge for foot and ankle surgeon for two main reasons: the diversity of techniques – the necessary domain – and the fact that many patients require more than one surgical approach. Still, the best approach is prevention. Early steroids and neurolysis well indicated lead to the goal of a plantigrade and functional foot free of ulcers.

References

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  2. Araújo MG. Leprosy in Brazil. Rev Soc Bras Med Trop. 2003; 36(3):373-82.
  3. Brand PW, Selvapadian AJ. Tranfer of the tibialis posterior in footdrop deformities. Indian J Surg. 1960; 21:157.
  4. Cakiner T, Yüksel A, Egït AS, Cagri G, Karaçorlu M, Kültür A. The extent of leprosy-related disabilities in Istanbul Leprosy Hospital. Lepr Rev. 1997; 68(1):43-9.
  5. Chauhan VS, Pandey SS, Shukla VK. Management of plantar ulcers in Hansen’s disease. Int J Low Extrem Wounds. 2003;2:164-7.
  6. Córtes SMS, Alvarez RRA. Evaluation of wound healing stimulated by accelerators, in adult patients with leprosy and plantar ulcers. 2011; 14(159):434-9.
  7. Cross H, Sane S, Dey A, Kulkarni VN. The efficacy of podiatric orthoses as an adjunct to the treatment of plantar ulceration in leprosy. Rev Lepr; 66(2):144-57.
  8. Cunha MHC, Macedo GM, Batista KNM, Xavier MB, Sa Neto S, Nascimento FSN. Avaliação clínicoepidemiológica em pacientes multibacilares em uma unidade de referência de hansenologia da amazônia. Hansen Int. 2008; 33(2): 9-16.
  9. Duerksen F. Amputação e reabilitação do amputado. Cirurgia reparadora e reabilitação em hanseníase. 1997; 41(2): 341-49.
  10. Ellington JK. Hammertoes and clawtoes: proximal interphalangeal joint correction. Foot Ankle Clin. 2011;16(4): 547-58.
  11. Garbino JA. Neuropatia hanseniana: Aspectos clínicos, fisiopatológicos, dano neural e regeneração. In: Opromola DVA. Noções de hansenologia. Bauru: Instituto Lauro de Souza Lima. Centro de estudos Dr. Reynaldo Quagliato; 2000. p. 79-89.
  12. Gomes FG, Frade MAC, Foss NT. Ulceras cutaneas na hanseniase: perfil clinico epidemiologico dos pacientes. An Bras Dermatol. 2007;82(5):433-7.
  13. Hatano K, Matsuki T, Makino M. The trend of leprosy treatment in which the prevention of peripheral nerve damage being as its main theme. Nihon Hansenbyo Gakkai Zasshi. 1998; 67:353-60.
  14. Jambeiro JES, Almeida BJA, Galvão RM, Guedes A, Neto ATC. Avaliação da neurólise ulnar na neuropatia hansênica. Acta Ortop Bras. 2008; 16(4):207-13.
  15. Jarbas Barbosa. Situação Epidemiológica Hanseníase: Brasil 2011. Brasília: Secretária de Vigilância em Saúde, Ministério da Saúde; 2012.
  16. Kwon JY, De Asla RJ. The use of flexor to extensor transfers for the correction of the flexible hammer toe deformity. Foot Ankle Clin. 2011; 16(4):573-82.
  17. Leite VMC, Lima JW, Gonçalves H. Neuropatia silenciosa em portadores de hanseníase na cidade de Fortaleza, Ceará, Brasil. Cad Saúde Pública. 2011; 27(4):659-65.
  18. Magalhães MCC, Rojas LI. Diferenciação territorial da hanseníase no Brasil spatial differentiation of leprosy in Brazil Epidemiol. Serv Saúde. 2007;16(2):75-85.
  19. Marques CM, Moreira D, Almeida PN. Atuação fisioterapêutica no tratamento de úlceras plantares em portadores de hanseníase: uma revisão bibliográfica. Hansenol Internat. 2003; 28(2):145-50.
  20. Mendes PD, Telles C, Parise M, Acioly MA. O papel da cirurgia descompressiva no tratamento da neuropatia em Hanseníase. Hanseníase indd. 2011;10(1):49-56.
  21. Ministério da Saúde (Brasil). Guia para o controle da hanseníase. Brasília: Ministério da Saúde; 2002.
  22. Ministério da Saúde (Brasil). Manual de Prevenção de Incapacidades. Cadernos de prevenção e reabilitação em hanseníase. Brasília: Ministério da Saúde; 2008.
  23. Ministério da Saúde (Brasil). Manual de reabilitação e cirurgia em hanseníase. Cadernos de prevenção e reabilitação em hanseníase. Brasília: Ministério da Saúde; 2008.
  24. Ministério da Saúde (Brasil). Vigilância em saúde: situação epidemiológica da Hanseníase no Brasi. Brasília: Ministério da Saúde. Disponível em: http://portal.saude. gov.br/portal/arquivos/pdf/boletim_novembro.pdf. Acesso em 16 jan 2014.
  25. Moreira HM. Resultados da Técnica Cirúrgica de Transferéncia do Músculo Fibular Longo para Dorsilflexão do Pé Eqüino Móvel em Hanseniase. Hansen lnt. 2001;26(2):99-104.
  26. Nobre ML, Oliveira MLW. Condutas frente as neurites hansênicas. Manual de Condutas Sociedade Brasileira de Dermatologia/Departamento de Hanseníase. 2006; 191-99.
  27. Pimentel MIF, Nery JAC, Borges E, Gonçalves RR, Samo EN. Influência do tempo de evolução prévio ao diagnóstico inicial incapacidades presentes no exame inicial de pacientes portadores de hanseníase multibacilar. Hansen Int. 2002; 27:77-82.
  28. Ramos JMH, Souto FJD. Incapacidade pós-tratamento em pacientes hansenianos em Várzea Grande, Estado de Mato Grosso. Rev Soc Bras Med Trop. 2010; 43(3): 293-97.
  29. Sociedade Brasileira de Hansenologia, Academia Brasileira de Neurologia, Sociedade Brasileira de Neurofisiologia Clínica. Hanseníase: Diagnóstico e Tratamento da Neuropatia. Projeto Diretrizes. Associação Médica Brasileira e Conselho Federal de Medicina; 2003. 13 p.
  30. Van Brakel WH, Khawas IB. Nerve function impairment in leprosy: an epidemiological and clinical study – Part 2: Results of steroid treatment. Lepr Rev. 1996; 67:104-18.
  31. Van Veen NHJ, Schreuders TAR, Theuvenet WJ. Decompressive surgery for treating nerve damage in leprosy. A Cochrane review. Rev Lepr. 2009; 80:3-12.
  32. Vincent Y, Ng MD, Gregory C, Berlet MD. Evolving techniques in foot and ankle amputation. J American Academ Orthop Surg. 2010;18(4): 223-35.
  33. Warren, G., ‘The Surgical Conservation of the Neuropathic Foot’, Annals of the Royal College of Surgeons of England, vol. 71, 1989, pp. pp. 236 – 242.
  34. Win MM, Theuvenet WJ, Roche PW, De-Bie RA, Van-Mameren H. The paper grip test for screening on intrinsic muscle paralysis in the foot of leprosy patients. Int J Lepr Other Mycobact Dis. 2002; 70(1): 16-24.

A Unique Method of Plantar Forefoot Ulcer Closure using the Ilizarov Device: Series of 11 Patients with Leprosy

by B. Jagannath Kamath, M.S. (Ortho)1 , Praveen Bhardwaj, M.S., (Ortho)2

The Foot & Ankle Journal 1(1):3

Introduction: Recurrent plantar ulcer is a common and serious problem of anesthetic feet in leprosy. There are many methods described in the literature to deal this problem, but it still remains a great challenge for the treating surgeon. The problem lies not only in attaining the coverage and healing of the ulcer but also to prevent its recurrence. The skin of the forefoot is a specialized one and hence procedures aimed at providing skin from elsewhere will tend to fail. The local flaps described in the literature are effective, but forms a major surgery for this group of patients, requires an expert to perform and are not devoid of complications, which if occur can be disastrous. We are herein describing a technique of closure of these forefoot ulcers, which makes use of the biomechanical properties of the skin and provided closure of these ulcers by slow and sustained stretching of the surrounding natural skin. It thus provides the specialized plantar skin coverage for the ulcers.

Method: We have used this technique in eleven leprosy patients with forefoot ulcers. Four patients had ulcers under the head of first metatarsal, four under the heads of first and second metatarsals, two under the second metatarsal head and one under the heads of fifth metatarsals. Size of the ulcers at its maximum length ranged from 2 – 4 cm.

Results: The technique successfully resulted in healing of all the ulcers without any significant complication. All the ulcers could be closed in ten days and all of them healed well within six weeks.

Conclusion: We found the technique to be very effective. It providing the specialized plantar skin for healing the ulcers is most attractive feature. The technique is simple and free of any major complication. The device used to achieve the closure is very inexpensive, can be easily made and is easy to use.

Key Words: Forefoot ulcers in leprosy; technique of closure; stretching; provides specialized skin cover; simple, inexpensive and effective.

ISSN: 1941-6806/08/0101-0003
doi: 10.3827/faoj.2008.0101.0003

Recurrent plantar ulceration is a frequently seen problem in anesthetic feet of leprosy. The seriousness of these ulcers lie in the fact that it can be difficult to keep the ulcers healed. Management of these chronic ulcers can be very frustrating for the patient and for those involved in their treatment. Ulcers occur in about 30 percent of the patients suffering with leprosy and are most commonly seen at the forefoot. [1] The factors contributing to the onset of these ulcers are impaired sensation, atrophy and fibrosis of muscles of foot and alteration of sympathetic enervation that in turn produces dryness, anhidrosis and hyperkeratosis. As the intrinsic muscles of the foot, which are secondary stabilizers of the metarsophalangeal joints become ineffective, it results in clawing of the toes making the heads of the metatarsals very prominent because of hyperextension of the metacarpophalangeal joints and flexion at the interphalangeal joints. Additionally, the loss of transverse and longitudinal arches of the foot increases the irregular distribution of the weight across the midfoot and metatarsal heads. Ulcers are more common on the plantar forefoot because this is where the greatest forces are concentrated. Ulcers are most common under the first metatarsal head; they also less commonly appear under the second and fifth metatarsal heads. The tissues in this area are highly specialized for the purpose of weight bearing and hence are difficult to reconstruct. [2] Any procedure to cover the defect in this area should ideally provide a stable local tissue. The distant flaps or free flaps described to cover these areas in our view fail because they lack the special architecture for absorbing impact and shear which the plantar skin is subjected to. Quite a number of local flaps are described to get the specialized plantar skin to cover the skin defects. [2-4]These flaps are quite successful, but are technically demanding as the plantar skin allows very little mobilization and if the flaps fail it leaves one in disastrous situation. Some skin stretching techniques have been described in recent past to close skin defects. [5-10]These techniques utilize viscoelastic properties of skin. Biomechanical properties of skin like mechanical creep, recruitment and stress relaxation allows the skin to stretch. We have used this ability of the skin to close the forefoot ulcers in leprosy patients. The technique described is simple, effective and inexpensive. It has given very satisfying results in our experience.

Materials and Methods

Patient selection is very crucial and may dictate the final results. We recommend the procedure for:

1. Ulcers which are not grossly infected
2. The ulcer should not be extending to the bone
3. Size of the ulcer should not exceed 4 cm
4. No diabetes mellitus
5. No peripheral vascular disease

We had eleven cases, which met the criteria mentioned above. Procedure was performed for all these patients; details are described in the table 1.

Case No.

Size of the Ulcer Site of the Ulcer(Under the Head of) Time taken for closure
1. 2 cm First metatarsal 5 days
2. 2.5 cm First metatarsal 5 days
3. 2.5 cm Fifth metatarsal 6 days
4. 3.5 cm First & second metatarsals 8 days
5. 3 cm Second metatarsal 8 days
6. 4 cm First, Second & third metatarsals 10 days
7. 3.5 cm First & second metatarsals 9 days
8. 4 cm First metatarsal 10 days
9. 2.5 cm Second metatarsal 7 days
10. 3.5cm First & second metatarsals 8 days
11. 3cm First metatarsal 8 days

Table 1: Patient details and time taken for ulcer closure.

Thorough debridement and freshening of the edges is mandatory as the highly keratinized scar tissue accompanies the plantar ulcers, which must be excised. We avoid excessive undermining of skin margins as this could risk their viability when a strong stretching force is employed for obtaining extra skin. Also K-wire assembly will be unstable if excessive undermining of the margins is done and may even make insertion of K-wires technically difficult.

Description of Device

The Ilizarov device consists of :

1. Two K-wires of size 1.5 to 1.8 mm. (Figure 1 A)
2. Two specially designed custom-made K-wire holding bolts, which are without any threads and are free to slide over the threaded rods. K-wires are transfixed to these bolts by using either inbuilt or external bolts as shown in the figure no.1. The corners of the bolts are rounded to prevent the sharp edges abrading the skin. (Figure 1 B)
3. Two threaded rods used in Ilizarov’s apparatus in Orthopedic surgery. (Figure 1 C)
4. Eight threaded bolts used in Ilizarov’s apparatus, which can be threaded on to the rod. (Figure 1 D)

Figure 1 Components of the device: A: K-wires; B: K-wire holding bolt; C: threaded rod; D: nuts.

Technique

An example of a forefoot ulcer is shown preoperatively. (Figure 2) The K-wires are passed on the either side of the ulcer at a distance of about one cm from the edge deep enough to engage in the dermis. (Figure 3) It is important to have the K-wires deep enough in the dermis and at equal depth throughout its extent to exert a strong and uniform approximating force. The K-wires are secured onto the K-wire holding bolts. (Figure 1 & 3) Threaded rods are passed into the K-wire holding bolts on both the sides and are secured in place by two threaded bolts on the outer aspect of each K-wire holding bolt. (Figure 3) These threaded bolts will thus approximate the K-wire holding bolts and hence the K-wires as they are tightened.

Figure 2 Preoperative photograph of a patient showing the ulcer present under the heads of metatarsals extending from base of first metatarsal to that of the third metatarsal.

Figure 3 Photograph taken after initial approximation of the wound as was easily possible in the early postoperative days.

We start approximating the wound on the first postoperative day. Each single turn of the threaded bolt causes the K-wires on either side to approximate the wound by 1mm on both sides and causing 2mm decrease in the wound size.

The speed of approximation depends of the skin condition, which is vigilantly monitored. Skin pallor, tautness of skin and shininess and excessive pain are the indicators of temporary stoppage of approximation process. Generally in the beginning we are able to approximate about 5-6 mm and gradually decrease it as the time passes by. In all the cases we have been able to achieve complete closure in 10 days or less. We have experienced that it is possible to achieve a greater degree of closure in medio-lateral direction than the antero-posterior direction. After approximation is achieved the skin edges are sutured and the fixator is maintained for another week. (Figure 4) The patient is kept non-weight bearing for another two weeks. Patients are then advised regarding foot care and hygiene and are asked to avoid static standing for more than 10 minutes at a time. Prevention of recurrence is very crucial. Secondary procedures like metatarsal osteotomy may be done if required to prevent recurrence once the ulcer is closed. (Figure 5)

Figure 4 Photograph after the complete approximation was achieved. At this point the edges are sutured together with a strong non-absorbable material.

Figure 5 Photograph of the same patient showing the ulcer completely closed.

Discussion

Treatment of ulcers in leprosy remains a challenge to the treating surgeon. The various options available are casts, modified foot wears, local flaps and distant flaps.

The non-operative methods are useful only in cases where the size of the ulcer is small and thus for larger ulcers surgery is the only option. The distant flaps fail to provide the specialized plantar skin and hence are likely to fail. The various local flaps described in the literature are quite handy but form a major surgical procedure requiring an expert to perform them and have grave consequence if they fail. The application and principle of gaining tissue by recruitment using force is not new and has been successfully applied to wound coverage problem for years. [5-10] Skin stretching results in significant histo-morphological changes in collagen fibers of the dermis and results in their rapid realigning in response to the stretching force and become aligned in the direction of the stretching force, perpendicular to the wound margin. [11]

Although the technique of tissue expansion was first reported by Newman as early as 1957, [12] it became more popular only after Randovan’s [13] description in 1982. In their experimental and clinical study Liang et al introduced the technique of pre-suturing. [8]

They described the properties of skin, which contribute to its expansion and can be used to close the skin defect. These include: inherent expansion, mechanical creep and biological creep. Inherent extensibility is defined as the excess skin that allows primary excision and closure. Mechanical creep is a biomechanical property of the skin, which allows it to gradually stretch beyond its limits; this is because of straightening of the normally randomly aligned collagen fibers. Biological creep is the property of skin to increase the tissue by mitotic activity, which has been demonstrated to occur within 24 to 48 hours in response to persistent expansion pressure. [14]

Tissue stretching procedures have been widely used, but its use for the sole of the foot has been infrequently reported. This is probably because of the thick plantar skin. Malaviya has described a technique of closure of simple heel ulcers by skin stretching. [15] This is an intraoperative technique in which two needles are places on either side of the ulcer and these needles are than approximated by passing sutures around these needles. This technique may be handy in case of small and superficial wounds only. The device designed by the authors has the strength required to approximate the thick plantar skin and has proved effective in closing ulcers as big as 4 cm. The thicker K-wires, which are passed in deeper dermis and are at equal depth throughout the length, provide a strong grip on the skin required for approximating the thick plantar skin. The device provides control on all the four corners of the wound by virtue of the K-wires. Each corner of the wound can be individually and independently subjected to skin stretching. This differential stretching is a very special feature of our device, which is not possible with any device described, even the patented devices marketed. If it is observed that the skin is becoming tight at any one place, the stretching can be stopped only at that place with continuing stretching to other areas. The compressing rods are on either side of the ulcer; contrary to many marketed stretching devices, which have the compressing rod transversing across the wound and allows for easy care of the ulcer.

The authors device initially uses the mechanical creep to bring about the coverage and probably after two days also induces biological creep accounting for the good results achieved in this report. A patented device-like “sure closure” costs more than 700 dollars per box, but our device will not cost more than a few dollars and can be easily made.

In conclusion, a rather simple solution to overcome otherwise complex situations of skin shortage has been described. We have found that addition of this technique to our armamentarium has effectively increased our options in closure of problematic forefoot plantar ulcers in leprosy.

References

1. Liwen D, Futian Li, Zaiming W, Juan J, Guocheng Z, Jinhu P, Jugen Z, Yongliang Y. Technique for covering soft tissue defects resulting from plantar ulcers in leprosy: Part I- General consideration and summary of results. Indian J Lepr, 1999; 71(3); 285-309.
2. Colen LB, Replogle SL, Mathes SJ. The V-Y flap for reconstruction of forefoot. Plastic Reconstr Surg, 1988; 81(2); 220-228.
3. Lennox WN. Plastic surgery of the anesthetic foot of leprosy. Lepr Rev, 1965; 36(3); 109-117.
4. Giraldo F, De Haro F, Ferrer A. Opposed transverse extended V-Y plantar flaps for reconstruction of neuropathic metatarsal head ulcers. Plastic Reconstr Surg, 2001; 108(4); 1019-1024.
5. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin. Plastic Reconstr Surg, 1993; 92(2); 260-269.
6. Stahl S, Har-Shai Y, Hirshowitz B. Closure of wound in the extremity using a skin stretching device. J Hand Surgery, 1996; 21B(4); 534-537.
7. Browne T. Closing a wide wound by using two stout spinal needles and three Allis forceps. Plastic Reconstr Surg, 1998; 101(4); 1159-1161.
8. Liang MD, Briggs P, Heckler FR, Futrell W. Presuturing- A new technique for closing large skin defects: Clinical and Experimental study. Plastic Reconstr Surg, 1988; 81(5); 694-703.
9. Concannon MJ, Puckett CL. Wound coverage using modified tissue expansion. Plastic Reconstr Surg, 1998; 102(2); 377-384.
10. Abenavoli FM. A simple tissue extensor. Plastic Reconstr Surg, 2002; 109(5); 1763-1764.
11. Melis P, Noorlander ML, van der Horst CMAM, van Noorden CJF. Rapid alignment of collagen fibers in the dermis of undermined and not undermined skin stretching with a skin-stretching device. Plastic Reconstr Surg, 2002; 109(2); 674-680.
12. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon. Plastic Reconstr Surg, 1957; 19; 124-128.
13. Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plastic Reconstr Surg, 1982; 69; 185-202.
14. Lew D, Fuseler JW. The effect of stepwise expansion on the mitotic activity and vascularity of subdermal tissue and induced capsule in the rat .J Oral MaxilloFac. Surg, 1991; 49; 848-853.
15. Malaviya GN. Closure of simple heel ulcers by skin stretching. Indian J Lepr, 2005; 77(3): 53-63.


Address correspondence to: Dr. B. Jagannath Kamath. Jyothi Mansion, Opposite Prabhat Theatre, K. S. Rao Road, Mangalore, India. Pin- 575001. Phone: 91-0824-2440233; Mobile: 91-9845235747
E-mail: bjkamath@satyam.net.in 

1Associate Professor of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India.

2Assistant Professor of Orthopaedics, Kasturba Medical College, Mangalore, Karnataka, India.
E-MAIL: drpb12@yahoo.co.in

© The Foot & Ankle Journal , 2008

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