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"
Mahatma 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.
5.2 million in 1985
8.05lakhs in 1995
7.53lakh at the
end of 1999
2.13lakhs in 2008

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 )
• Three other species can carry and (rarely)
transfer M. leprae to humans: chimpanzees,
mangabey monkeys, and nine-banded
armadillos.

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

11. Signs and Symptoms
 First symptoms :
 Numbness
 loss of temperature sensation
 As the disease progresses :
 The sensations of touch
 Pain
 Eventually 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
PositiveNegative

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. 1. Clinical Examination.
2. Slit Skin Smear.
3. Skin Biopsy.

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

24. TREATMENT

25. MDT
for PB leprosy
6 months
Monthly dose
Rifampicin
600mg
Daily dose
Dapsone 100
mg

26. MDT for MB
leprosy
12 months
Monthly dose
Rifampicin 600mg
Clofazimine 300mg
Daily dose
Dapson 100mg
Clofazimine 50 mg

27. COMPLICATIONS OF
LEPROSY & ITS
MANAGEMENT

28. 1) LEPRA REACTION
2) ADVERSE EFFECT OF ANTI-LEPROTIC DRUGS
3) DISABILITIES & DEFORMITIES
4) PSYCHO-SOCIAL PROBLEMS
COMPLICATIONS

29. 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.

30. 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.

31. 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.

32. 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)

33. 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)

34. 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.

35. 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

36. RECONSTRUCTIVE SURGERY
Aims:
• Restore function and form as far as possible
• Prevent further disability
• Rehabilitation process.
Note: Not all patients are suitable.

37. • 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

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

39. SOCIALAND MOTIVATIONALCRITERIA
• 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.

40. 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

41. 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.

42. 𝑪𝒐𝒏𝒅𝒊𝒕𝒊𝒐𝒏𝒔 𝒕𝒉𝒂𝒕 𝒓𝒆𝒒𝒖𝒊𝒓𝒆 𝒔𝒖𝒓𝒈𝒊𝒄𝒂𝒍 𝒊𝒏𝒕𝒆𝒓𝒗𝒆𝒏𝒕𝒊𝒐𝒏:
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.

43. 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.

44. COMPLICATIONS OF EYE

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

46. 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

47. • 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

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

49. Temporalis Muscle Transplantation

51. TARSORRHAPHY

53. Before and After surgery
physiotherapy

54. FOOT DROP

55. 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.

56. 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

57. 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

58. TIBIALIS POSTERIOR TRANSFER (TPT)

61. 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

62. 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

63. 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.

64. Lengthening of tendo Achilles

65. Foot Drop Left Before and after

66. 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.

67. CLAW HAND

68. Definition
Flattening of transverse metacarpal
arch and longitudinal arches,
Hyperextension of MCP joints
Flexion of PIP and DIP joints

70. 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

71. Modified Bunnell’s procedureFirst 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

72. Zancolli lasso insertion technique:

73. SUPERFICIALIS
OPPONENSPLASTY
CLAW THUMB DEFORMITY

74. EIP
OPPONENSPLASTY

75. 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.

76. WRIST EXTENSION

77. THUMB EXTENSION

78. FINGER EXTENSION

79. Nerve Abscess

80. Ulnar Nerve Abscess
Longitudinal Epineurotomy

81. PLANTAR ULCERS
• ACUTE ULCER
• CHRONIC ULCERS
▫ SIMPLE
▫ COMPLICATED
TREATMENT
 ULCER DEBRIDEMENT
 POSTERIOR TIBIAL DECOMPRESSION

82. 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 Ist 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

83. CLAW TOES

84. DEGREE OF DEFORMITY DESCRIPTION
1st degree deformity  Deformity is mobile
 Toes can be actively straightened
2nd degree deformity  Flexion contractures develop at the interphalangeal
joints,esp PIP
 Toe cannot be straightened even passively at these
joints
3rd 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

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

86. 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)

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

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

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