This document discusses reconstructive surgeries for leprosy, including procedures for foot drop, claw hand, lagophthalmos, and soft tissue reconstruction. Key surgeries mentioned are posterior tibial tendon transfer for foot drop, Zancolli lasso procedure for claw hand, temporalis muscle transfer for lagophthalmos, and various flap procedures for soft tissue defects. Post-operative care including physiotherapy is emphasized for successful outcomes. Hospitals performing reconstructive surgeries for leprosy in India are also listed.

1. RECONSTRUCTIVE
SURGERIES
IN
LEPROSY
DR.KRISHNA PRIYA S
PG-1
PSGIMSR

2. Aim
•Restore function and form as far as possible
•Prevent further disability
•Prevention of disability and rehabilitation process

3. •`Impairments' defined - problems in body function or structure
such as a significant deviation or loss.
eg ; loss of sensation; contractures
• `deformity' is a structural, visible, impairment.
• `defect' either a functional or structural impairment.
• `Disability' umbrella term - impairments, activity limitations and
participation restrictions.

4. Types of Deformities:-
Specific Deformities:-
arise due to local infection with M.lepra - loss of eyebrows,
nasal deformities.
(face>hands=feet)
Paralytic Deformities:-
damage to motor nerves like claw finger, foot drop, facial palsy.
(hands>feet>face)
Anesthetic deformities:-
from insensitivity because of damage to sensory nerves like ulceration,
mutilation.
(feet>hands>face)

5. Precaution:
Successful outcome depends on
•Pre and post-operative physiotherapy
•Ability to learn to use new ability

7. Criteria for referral for RCS
The criteria have been grouped into three categories:
•Social and motivation
•Physical
•Leprosy treatment

8. Social and motivational criteria:
•All patients who benefit socially, occupationally or economically -
considered.
• potential to make a difference to patient's acceptance in their society
and family and to improve socio-economic situation.
•Patients- well motivated and responsible for their own health and follow
instructions on treatment and care of their eyes, hands, and feet before
surgery

9. •Patients not well motivated in self-care not likely to be willing to
participate in pre and postoperative physiotherapy.

10. Physical criteria:
•Age : 15 -45 years
•Duration of muscle paralysis -at least 1 year and preferably not ˃ 3
years.
Severe contractures or stiff joints not suitable, although
physiotherapy or surgery reverse some contractures.
No infection of the skin
scabies,
no deep cracks, wounds or ulcers
at time of referral.

11. Leprosy treatment criteria
•Completed 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 past 6 months unless
surgery for neuritis.
•No tenderness of any major nerve trunk in limbs

12. LAGOPTHALMOS

14. Lagophthalmos in patients with leprosy-
•exposure keratitis
-corneal and conjunctival dryness → blindness and disfigurement.
Function of eyelids is controlled by oculomotor nerve and facial nerve.
In leprosy patients, the oculomotor nerve - levator muscle to lift the
eyelids.
Paralysis of facial nerve prevents orbicularis oculi muscle from closing
the eyelid

15. Temporalis muscle transfer introduced in 1934 by Gilles
• temporalis fascia exposed - longitudinal incision in temporal
region
•A strip of 2 - 3 cm in width outlined from zygomatic arch to the
parietal bone
•The muscle with attached pericranium and overlying fascia
stripped down to zygomatic arch and divided into two parts

16. •If strips of tissue did not reach the medial canthal region, a prolongation
with a fascial strip necessary
•From a lateral canthal incision, a tunnel dissected through each lid, close
to eyelid margin
•A second, slightly curved incision - to expose the medial palpebral
tendon
•The two strips were threaded through tunnels and fixed to medial
palpebral tendon and to themselves
• was done under tension
so that the upper lid overlaps
lower lid by a few mm

18. •The eye bandaged to prevent swelling for 3 days postop.
•The sutures at medial canthus & eyelids removed - day 7 postop & scalp
sutures - day 10
•patient given semi-solid diet for 3 weeks and postoperative physiotherapy
and patient education begun
•helpful to strengthen transfer by use of chewing gum initially and later
microcellular rubber
• important part of postop physiotherapy is development of a THINK-BLlNK
reflex.
done by getting patient to blink regularly whenever a certain visual stimulus

19. Reconstructive Procedures of the Extremities

21. FOOT DROP

22. •Foot drop - loss of dorsiflexion and lead to
development of high-steppage gait
• ankle dorsiflexors, overpowered ankle plantar
flexors
•paralysis of common peroneal nerve (lateral
popliteal nerve) or posterior tibial nerve paralysis.

23. Anterolateral compartment- leg -
dorsiflexion of the foot at the ankle
These muscles—
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus and
Peroneus tertius
—are supplied by br. of the deep
peroneal nerve

24. Posterior tibial tendon transfer procedure.
the blue arrow - location of posterior tibial tendon insertion, the yellow
arrow - medial malleolus, the red arrow - proximal incision site overlying
proximal part of posterior tibial tendon.

25. The posterior tibial tendon is exposed at its insertion over the
navicular tuberosity

26. The posterior tibial tendon is withdrawn from the proximal incision.
The muscle belly is clearly seen

27. A hemostat (arrow) is used to make wide opening and a generous
window in the interosseous membrane + to create a route for the
harvested tendon to be transferred to the anterolateral compartment in
the leg

28. The lateral aspect of leg - skin markings indicate distal fibula and outlines of
calcaneus, cuboid, and base of 5th metatarsal. arrow points to incision
through which the hemostat is brought out through a generous opening
made in the interosseous membrane.

29. The end of posterior
tibial tendon is prepared
for transfer by suturing
it and passing the suture
across the interosseous
membrane opening.
The posterior tibial
tendon is brought out
through the
anterolateral exposure
in leg.

30. A subcutaneous tunnel
created with blunt rod
inserted from
proximal exposure in
the leg and exits at
exposure site made
over cuboid bone.
posterior tibial tendon
routed through the prev.
made tunnel, with end
visible through the
exposure over cuboid
bone. arrow points to
end of the transferred
posterior tibial tendon

31. A bone tunnel is
drilled into the
cuboid bone to
accept end of the
posterior tibial
tendon.
The end of posterior
tibial tendon fixed in the
tunnel (arrow) with the
use of an interference
screw ; also attaches
tendon to the
periosteum and the
adjacent peroneus
tertius muscle for
additional stability.

32. CLAW TOES

33. Dorsolateral incision made over the
corresponding toe and the extensor
expansion identified.
The flexor tendon sheath exposed &
incised, taking care to avoid injury to
digital neurovascular bundle
The long flexor tendon is isolated
The long flexor tendon is divided
close to its insertion,
and transferred dorsally slightly distal
to the extensor expansion, under
correct tension, thus correcting
flexion, external rotation
The long flexor tendon both slips
should be transferred to the extensor
tendon

34. CLAW HAND

35. •Ulnar nerve at elbow is most commonly involved - clawing of the
fingers, particularly ring and little finger
•causing instability, incoordination, imbalance
• Correction of the deformity involves prevention of hyperextension at
the MCP joint so normal extensors can extend the IP joints and initiate
flexion of the proximal phalanx of the fingers

36. Zancolli lasso procedure
the flexor digitorum superficialis (FDS) of middle finger
divided in to 4 slips (one for each finger)
and reattached to itself after passing through the proximal pulley.

37. The tendon split into 4 slips, one slip for each
finger
The slips passed deep to palmar aponeurosis
along flexor sheath with tendon tunneller.
slips then passed under proximal pulley of
correspond finger & through opening distal to
pulley, and the tendon was taken out and
brought palmar to pulley and proximally
The slip was sutured to the same slip (thus
forming a lasso) under proper tension with
metacarpophalangeal joint in 20º to 30º flexion
and the wrist in 30º flexion.

38. •Any excess tendon slip was cut off
• performed for all 4 fingers starting from index finger, using the flexor
digitorum superficialis of the middle finger.
• After obtaining complete haemostasis, the wound closed and
dressed, and a posterior below-elbow plaster of Paris slab was applied
with MCP joints in 60º to 70º flexion and the wrist in 20º flexion,
leaving the IP joints free

40. APE THUMB

41. The intrinsic muscles divided into 5 groups:
Thenar Hypothenar Palmar (volar) interossei Dorsal interossei
Lumbricals
The 4 thenar muscles :
Abductor pollicis brevis (APB) : abducts thumb away from palm
Flexor pollicis brevis (FPB) : flexes the thumb MCP joint
Opponens pollicis : abducts, flexes, and pronates the first metacarpal
Adductor pollicis : adducts the thumb toward the palm
With these muscles, thumb brought from lateral to medial position
across palm in opposition to the four digits.

42. •Ulnar nerve innervates most of intrinsic muscles in hand: all 7
interossei, the 3 hypothenar muscles, the adductor pollicis, deep head of
the FPB, and the two ulnar lumbricals
• All remaining intrinsic muscles— the two radial lumbricals, APB,
opponens pollicis & superficial head of FPB— by the median nerve.

43. •Median nerve injury at wrist preserves extrinsic muscle function
•The first two lumbricals, the APB, and the opponens pollicis are
paralyzed
•When patient slowly makes a fist, the index and middle fingers lag
behind 4th & 5th fingers - lack of initiation of flexion at the MCP
joints by lumbricals
•The thumb rests in the plane of the palm and cannot oppose the
fingers
•The patient can flex the thumb terminal phalanx because the FPL is
not paralyzed.

44. Opponensplasty
aims to restore ability to abduct the thumb from the palm and oppose
against the four digits
Tendon transfers used for opponensplasty :
radial slip of the flexor pollicis longus (FPL),
extensor digiti minimi (EDM),
palmaris longus, or
flexor carpi radialis (FCR) to extensor pollicis brevis (EPB),
abductor digiti minimi (ADM),
flexor carpi ulnaris (FCU) extended with a tendon graft

45. commonly used tendon transfers employs
FDS of the fourth finger as a motor
FDS tendon divided close to distal
insertion and rerouted around FCU at
wrist.
The thumb immobilized in opposition,
with wrist in neutral position, for 3 weeks
with splints.
After 3 weeks, all splints are removed and
exercises started

46. SOFT TISSUE RECONSTRUCTION

47. Heel ulcers and scars
-excision, or
-calcaneal paring - remove bony prominence of calcaneum,
and the defect can be reconstructed using one of many options:
• Local rotation flap
• Flexor digitorum myocutaneous flap
• Medial plantar artery island flap
• Reversed sural artery flap or inferiorly based fasciocutaneous flaps
• Free Latissimus dorsi muscle flap

48. Metatarsal head ulcer treated with a
toe web flap
Lateral malleolar ulcers debrided &
left to heal by secondary intention -
immobilized in splints or casts.

49. Nerve Surgery

50. NERVE FUNCTION ASSESSMENT (NFA)
Early diagnosis and treatment of leprosy and related neuropathy only
way to prevent severe nerve impairment
it is necessary to conduct NFAs several times a year, more frequently if
the patient exhibits reactions.
In the field or health center, very basic instruments used NFA:
• Nerve palpation for size , tenderness
• Pin prick for pain
• Voluntary muscle test (VMT) with grading: normal, weak, or absent
• Ballpoint pen, wool, or “monofilaments” for sensation
Monofilaments + VMT - most dependable tests for field

51. In secondary or referral centers, the essential tests for NFA are :
• Monofilaments for sensation
• VMT
• Vibrometer
• Two-point discrimination Neuromyoelectric studies
• Optional: laser Doppler flowmetry
• Graded instrumental tests for temperature

52. DECOMPRESSIVE SURGERY
Indications for surgery
•Nerve abscess
• No improvement/worsening neuropathy treated adequately for 4
weeks ± reaction
• Recurrent reactions, repeated ˃ 3 times
•Control of severe pain
• CI to use of steroids: pregnancy, TB, diabetes, hypertension, gastric
ulcer, and other infections
• Severe ADE to corticosteroids
•Ulnar nerve dislocated or subluxed in the groove at the elbow

53. COMPLICATIONS OF NERVE SURGERY
• The patient - stressed because of surgery, precipitate a reaction ,
usually a Type 2 reaction.
• A post-surgical hematoma - perineural fibrosis and scarring.
• Incomplete decompression of all constricting structures.
• Unstable ulnar nerve with dislocation or subluxation.
• Lesions of subcutaneous nerves, esp the medial cutaneous nerve of
the forearm - painful neuroma.
• Iatrogenic lesions of any nerve, ( endoscopic technique )
• Elbow instability after an epicondylectomy

54. •To overcome constraints incentive - Rs 5000/- to LAP belonging to BPL
families for each major operation
• The incentive paid to all patients from B.P.L. family, operated in a
Government or NGO Institution.
•success of surgery depends on post op care including physiotherapy
•therefore essential to review the operated cases regularly at least till 6
months after the operation.
•Therefore, disbursement of the incentive money is to be linked up with
the follow-up visits of the case as indicated below:
•After completion of surgery on release from hospital – Rs.3000/-
•Follow-up visit after one month (4-6 weeks) of operation – Rs.1000/-
•Follow-up visit after 3rd month of operation – Rs.1000/-

55. The names of Government institutions performing Re-constructive Surgery
(RCS) in leprosy affected persons
1. Patna Medical College, Bihar.
2. Darbhanga Medical College, Bihar.
3. Cuttack Medical College, Orissa.
4. King George Medical College, Lucknow, Uttar Pradesh.
5. Regional Institute of Medical Science Ranchi, Jharkhand.
6. SSKM Hospital, Kolkatta, West Bengal.
7. Government Medical College Hospital, Bhopal, Madhya Pradesh.
8. Berhampur Medical College, Orissa.
9. Leprosy Home & Hospital Cuttack, Orissa
10. All Indian Institute of Physical Medicine Mumbai, Maharashtra
11. Central Leprosy Training & Research Institute, Chengalpattu
12. Regional Leprosy Training & Research Institute, Raipur
13. JALMA ICMR, Agra, Uttar Pradesh
14. R.G. Kar Medical College Hospital, Kolkata, West Bengal
15. N.R.S. Medical college, Kolkata, West Bengal
16. District Hospital Deharadun, Uttarakhand
17. Government Medical College, Chandigarh
18. General Hospital, Puducherry 19. Medical College, Dhule, Maharashtra
20.Medical college, Aurangabad, Maharashtra