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THE SURGICAL ASPECT OF NEGLECTED LEPROSY
RECONSTRUCTIVE AND OTHER SURGERY IN LEPROSY
UPDATE REPORTS.
1. REMEMBERING HAROLD GILLIES - GREAT PIONEERING SURGEON IN LEPROSY
The following information, where it is of a technical nature, is collated mainly from the Text-Book (“Surgical Reconstruction and Rehabilitation in Leprosy”) of Dr. Ernest P. Fritschi, M.B. FRCS, (Edin), D. ORTH, Former Director and Consultant Surgeon, Schieffelin Leprosy Research and Training Centre, Karigiri, North Arcot District, Tamil Nadu, India., with whom I had the privilege of working and assisting at the operating table and of seeing his surgical expertise which has brought healing to so many leprosy patients under his care. Because I am limited in the amount of material I can digitally transmit by Email, this material is prepared briefly, without literary frills. With this email, I am sending only “Surgery on the Hand “ . If you are interested in more, please request. Next comes “The Foot”, “Eye” etc. etc. If any point is not clear, please get back to me for more info..
It should be remembered that , if leprosy can be detected and adequately treated in the very early stages and health education given to inform the patient how to protect him/herself, no surgery is required. If a leprosy patient is in need of surgery to correct deformity, it means that his/her disease was detected too late. It is possible to have leprosy (Hansen’s Disease) and be totally unaware of having any sickness and that is when we must detect and treat it.
Deformities requiring surgical correction are - “Clawed Hand”, “Dropped Foot’, “Dropped Wrist”, “Lagophthalmos” (eye cannot close), “ Nasal Reconstruction” due to the nasal bridge bone eroding away. Septic surgery may involve cleaning up massive ulcers, amputation of limbs, removal of decayed metacarpal / metatarsal and other bones of hands and feet. Where Gynocomastia and Gynocotilia have resulted in a lepromatous male patient developing female-type breasts and nipples, for cosmetic reasons, these have to be amputated. Other forms of cosmetic surgery are performed to help the patient in his/her rehabilitation. Sometimes, swollen nerves have to incised to releave the pressure of a build-up of defence cells that could cause nerve paralysis. Sometimes, where maggot have accumulated in the sinuses because a patient with “nasal involvement” has failed to insert his nose plugs to keep out the blow-flies, surgery is required to open up the sinus passages for irrigation. Surgery sometimes is required for the taking of nerve biopsies for pathological testing. All this is totally unnecessary if a successful Control Programme detects the victims of the disease in the earliest possible stage.
THE PERIPHERAL NEURITIS OF LEPROSY:-
Most surgery in leprosy is due to Peripheral Neuritis because the leprosy bacillus has an affinity for the COOLER peripheral nerves and, in particular, their Schwann Cells . Antigens liberated by the dead and dying M.lepra provoke a violent immunological response and a build-up of defence cells (lymphocytes) resulting in pressure within the nerve, constricting the blood flow which nourishes the various types of nerves. Where the sensory nerves are deprived of the oxygen-carrying blood, anaesthesia results, causing loss of sensation in the affected area, exposing the patient to injuries due to cuts, burns etc. Injuries may result in ulcers needing septic surgery. Where the motor-nerves are deprived of nourishment (oxygen), paralysis may result, requiring tendon transplantation to make the patient mobile again. Where the autonomic nerves are starved , hair follicles may not receive adequate nerve supply resulting in the loss of hair in the cooler areas such as eye-brows. Loss of eyebrows enhances the stigma, for which reason, cosmetic graft-surgery is required to give the patient new eyebrows.
“Clawed Hand” :- This is one of the most common deformities, resulting from Ulnar and/or Median and/or Radial Nerve paralysis. The Ulnar nerve is mainly traumatised above the olecranon groove, when it is called “high ulnar paralysis”. Lesions sometimes occur in the ulnar nerve where it enters the ulnar canal at the pisiform in which case it is called “low ulnar paralysis”. (a) Wasting is seen in the hypothenar eminence in the thumb web region and, in thinner persons, in the spaces between the metacarpals. (b) Failure of abduction of the fingers is seen due to paralysis of the dorsal interossei - patient is unable to separate fingers against resistance. (c) Failure of adduction of the fingers due to paralysis of the palmar interreii..... Sometimes a patient cannot securely hold a piece of paper between the fingers. (d) The Lumbrical test : Only ring and little finger lumbricals are supplied by the ulnar nerve, the other two being supplied by the Median nerve. A patient may not be able to flex the straight finger against resistance at the metacarpo phalangeal joint only. (d) “Froment’s sign” : or “Book Test”.. The patient may not be able to hold a book between index finger and thumb. The Median Nerve is usually affected, where it is cooler (near the surface) just proximal to the wrist joint. The lesion involves the small muscles of the thenar eminence only - thumb lies flat against side of hand and is not able to abduct (“Ape Thumb”) .
Restoration of Finger Function is performed by one of the most common procedures in leprosy surgery - “The Extensor to Flexor Four-Tailed Graft” - EF4T Brand. ..... Ideally, this operation depends on the motor-power provided through the Extensor Carpi Radialis Longus muscle and its tendon. Before this procedure can be undertaken, the Extensor Carpi Radialis Longus muscle must be tested for strength by the operator applying resistance (pushing down on the patient’s wrist) while the patient tries to extend his wrist or twist it outwards. The tendon transplant involves stripping 25 - 30 cms. of graft material from the Plantaris Tendon in the leg . Through an incision made in the radial border of the forearm, the extensor carpi radialis longus tendon is withdrawn, cut and secured by forceps. Through another incision made in the palm of the hand, the free plantaris tension graft from the leg is inserted and tunnelled up the forearm to be removed through the incision already mentioned. The motor tendon is opened and, through a special technique, known as The Brand (named after Dr. Paul Brand) Tendon Anastomosis, the graft tendon is inserted into the motor tendon and sutured into position. The protruding (from the incision in the palm) graft tendon, now attached to the Extensor Carpi Radialis Longus tendon , is then drawn out and its end carefully divided along its fibres into four slips, one for each of the four fingers (excluding the thumb) . With the hand held in an inverted-cupped position, each of the four tails is tunnelled through the hand, from the palm and withdrawn at the base of each of the four fingers (top side) . These four tails are then grafted on to the tendons that activate the interphalangeal finger joints, with particular care given to correct tension.. With the repaired hand in a cupped, lumbrical position, a plaster cast is applied to remain in position for 3 weeks. Following the removal of the plaster cast and stitches, an intensive programme of physiotherapy is commenced.
Physiotherapy is of vital importance because the patient has to train his mind to use his muscles for other than their normal function. In the case of the above-mentioned procedure, the muscle that normally rotates the arm or “extends” the wrist, has been used to activate the once-“clawed” fingers. Both before and after reconstructive surgery, physiotherapy is most essential. The Physiotherapist has to “assess” the patient to determine if he has muscles which can be used to perform different functions. The patient must have a reasonably good “I.Q” so that he may re-educate his brain to make those muscles work in different ways until eventually, after regular exercise, the re-educated muscles automatically behave as they are meant to. The physiotherapist who is caring for leprosy patients must be a person with infinite love and patience who can “feel” with the patient. Unfortunately, there are those whose disease was not detected in time and their hands are so rigid and unflexible that no amount of surgery is able to restore any measure of function. Some patients need pre-operative education to exercise for months before any surgery, just to prepare their hands for reconstructive surgery.
The “Extensor to Flexor Four-Tailed Graft (EF4T Brand)” method of hand surgery is only one of several techniques. Others are “”Palmaris Longus Many-Tailed Graft (Lennox), “Sublimis Transfer (Stiles-Bunnel)”, “Fowler’s Operation - Extensor Proprius Transfer”, “Extensor Many-Tailed Graft (Brand)”, “Extensor Diversion Graft (Srinivasan)”, The Extensor Carpi Radialis Longus Tenodesis (Riodron)”, to name but a few..
In this study, I have given only the very barest of facts; enough to whet your appetite! For further information, see the following bibliography :-
Brand P.W. “The Reconstruction of Hand in Leprosy”, “Paralytic Claw Hand” J.Bone, “Tendon Grafting”, J.Bone, “Deformity in Leprosy”, R.G. Cochrane, “Reconstructive Surgery and Rehabilitation in Leprosy”, S. Karat, - others can be supplied.
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