2235例麻风垂足的分析

目的：了解麻风垂足的患病情况，为制定预防措施提供科学依据。方法：选择江苏11个县市存活的麻风治愈者及现症患者为调查对象，资料输入计算机统计分析。结果：麻风垂足的患病率为15．7％，单足（13．62％）高于双足（2．07％），男性（16．36％）高于女性（13．84％）,现症及复发病人（31．28％）高于治愈者（15．07％），BT、BB型麻风占23．56％及20．96％。麻风病期在5年以内发生垂足的少菌型麻风（72．41％）高于多菌型（50．47％）；发生过麻风反应的患者垂足占33．75％。垂足有足底溃疡（21．21％）、足骨破坏（19．17％）及足畸形（27．43％）多于无垂足的溃疡（15％）、骨破坏（15．09％）及足畸形（20．19％）。989只垂足可通过手术矫治，要求治疗者只占30％。结论：麻风垂足以男性、现症及复发病人多见且以单足为主，垂足发生的足底溃疡及足畸形明显增多，三分之二的垂足失去了手术矫治的机会，70％的患者对垂足的治疗没有信心。麻风垂足的发生与麻风诊断和治疗的延迟、麻风反应及麻风型别的不同有明显的关系。     

Xerosis and callus formation as a key to the diabetic foot syndrome: Dermatologic view of the problem and its management

The diabetic foot syndrome is a major complication of diabetes mellitus. The two most important pathophysiologic factors are peripheral arterial occlusion and peripheral neuropathy. The cutaneous lesion is a plantar ulcer, often accompanied by soft tissue and bone infections which can require amputation. Triggers include poorly fitting shoes, poor foot care, or overlooked foreign bodies, often coupled with a structural foot deformity. Increased plantar pressure, especially beneath the metatarsal heads, and the resultant callus play an important role. The patients often already have xerosis of the plantar skin with scales, fissures, erosions and impaired barrier function, complicating the situation. Prompt neurologic and vascular diagnostic studies, coupled with routine examination of the feet and primary prophylactic measures are most important. The most important therapeutic goals are optimal control of the diabetes mellitus, relieving pressure points and avoiding or reducing callus formation.     

Vibration sense and tarsal disintegration

The extent of loss of vibration and pressure sensations was assessed in 21 leprosy patients with disintegration of the tarsus. Feet which had and did not have tarsal disintegration both showed severe impairment of pressure sensation, but the loss of vibration sense was more severe in feet which had undergone the destructive process. It appears that loss of deep sensation is an important factor in the process of tarsal disintegration in feet which are already anaesthetic. Measurement of vibration sense using a biosthesiometer may be a valuable clinical test in the investigation and follow-up of the patient with the insensitive foot to identify those at risk of developing tarsal disintegration.     

Sensory recovery in the plantar aspect of the foot after surgical decompression of posterior tibial nerve. Possible role of steroids along with decompression

In leprosy, involvement of the posterior tibial nerve leads to sensory loss in the plantar aspect of the foot. As a result plantar ulcers are common and lead to deformity and disability. Restoration of plantar sensation can prevent ulcer formation. Posterior tibial decompression was done for the recovery of sensation in the plantar aspect of the foot. Seventy-two patients under went decompression on 84 feet, 25 received steroids pre- and post-operatively. The recovery of sensation was better if surgery was done before 6 months of onset of anaesthesia. Decompression along with steroids gave better results than decompression alone in patients with active neuritis especially in BT cases whereas in BB, BL and LL cases there was no significant improvement of sensation. The results are discussed.     

胫后肌腱前移术矫治麻风垂足的远期效果

目的 :　了解胫后肌腱前移术矫治麻风垂足的远期效果。方法 :　近 3年随访了 1985～ 1996年部分手术患者 ,对其 80例 82只足的步态、踝关节主动背屈、跖屈功能、移位肌肌力变化、有无足部畸形、溃疡发生以及患者对手术疗效的满意度等进行检查和记录 ,并结合标准综合评定手术疗效。结果 :　随访82只足中 ,远期效果优 5 1足、良 17足、尚可 12足及无效 2足。其中 :移位肌止于骨孔 37足中 ,优良 31足 ,2足移位肌腱滑脱。移位肌止于肌腱的 4 5足中 ,优良 37足 ,3足发生轻度的内翻 ,2足出现垂趾 ,2足肌腱止点处皮下粘连 ,3足发生溃疡 ,3足内翻复发。骨间膜法与皮下隧道法不论移位肌的止点是骨孔还是肌腱其术后优良足无差异 (P >0 .0 5 )。结论 :　胫后肌腱前移术加跟腱延长术矫治麻风垂足可获得优良的远期效果 ,选择移位肌腱路径及止点应依据垂足合并足内翻的程度、垂趾以及骨质疏松的有无 ,胫腓骨下段间隙的大小来确定。手术前、后移位肌肌力锻炼和步态训练也属必要     

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part II--First toe web and dorsal foot flaps

The first toe web flap consists of the skin and subcutaneous tissues of the contiguous sides between the great and second toes. It is based on the first dorsal metatarsal artery or the common plantar digital artery. This flap was used as artery pedicled island graft to reconstruct losses of skin and soft tissue cushion in the ball of the foot in the first and second metatarsal head region in 16 cases. Follow-up examination revealed that ulceration had recurred in one case due to dehiscence of the flap margin 12 months post-operatively. The other 15 patients have done well without recurrence at 48 to 124 months follow-up examination. The dorsal flap of the foot based on the dorsalis pedis artery, the corresponding veins and the deep peroneal nerve was designed in 1974 to resurface skin and soft tissue defects in the sole of the foot. This flap was used in 30 cases of leprosy with excellent results. During follow-up 36 to 120 months after surgery the plantar ulcer had recurred in only one case. All the others have done well. The long-term curative effect has thus proved satisfactory.     

The age-dependent deterioration in light touch sensation on the plantar aspect of the foot in a rural community in India: implications when screening for sensory impairment

Regular testing for impaired sensation is important in the management of diseases that can cause progressive nerve damage, such as leprosy. It has been shown that light touch sensibility decreases with age in the hands of healthy individuals, but little research has been undertaken to assess possible changes in the feet in developing countries. This information is needed to allow an appropriate level of sensation to be chosen when screening for nerve damage in the foot. To clarify this, a cross-sectional study on male adults was carried out in the rural town of Salur, Andhra Pradesh, India. A range of Semmes-Weinstein monofilaments were employed at 12 locations on the foot to determine sensation to light touch stimuli in individuals from each decade of adult life. It was found that in this population, sensibility threshold in the foot increases with age and this was noted in both soft and callous skin. This shows the increase was due to neurological factors, not merely due to an increase in callous deposition with advancing age. In the majority of individuals in their fifties and sixties, the callous skin at the forefoot and heel was unable to detect the 5.07 monofilament (equivalent to 8-12 g), previously recommended as a method to screen for plantar neuropathy. All areas of all feet were able to detect the 5.46 filament (approximately 30 g). The size of this study (54 individuals) prevents the determination of definitive normal ranges for each decade of life in this population. However, it does demonstrate the degree to which sensation deteriorates with age and could be used as an approximate guide when interpreting the results of sensory testing in similar rural areas of the developing world.     

Unusual ulceration in diabetes mellitus

A 35-year-old woman developed ischaemic changes over the soles of her feet within hours of admission to hospital moribund in hyperglycaemic coma. Skin and subcutaneous tissue separated but slow primary healing with scar tissue has taken place. An explanation for the plantar gangrene is offered.     

Radiological changes in hands and feet in disabled leprosy patients: a clinico-radiological correlation.

Seventy-six consecutive leprosy patients with disabilities were subjected to radiological examination of hands and feet, and bone changes were found in 63 of them (82.9%). Specific, nonspecific and osteoporotic bone changes were observed in 22.4%, 78.9% and 28.9% of cases respectively. Bone cysts (10.5%), subarticular erosions (10.5%) and enlargement of nutrient foramina (5.3%) were the common specific bone changes whereas bone absorptive changes (59.2%), soft tissue changes (39.5%) and concentric absorption (39.5%) were the most frequent nonspecific bone changes. Specific bone changes were more common in older patients (age 40 years) and nonspecific bone changes correlated with duration of disease, duration of deformity, and disability index. Osteoporotic bone changes were found to be affected by ageing and severity of disability of hands and feet.     

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part V. Use of the flap in the inguinal region and latissimus dorsi musculocutaneous flap

The area of distribution of the superficial circumflex iliac, superficial epigastric and superficial external pudental arteries is large and flaps based on them can meet the requirement of different recipient sites. We have transplanted free flaps based on the superficial epigastric artery for repairing plantar soft tissue defects in six leprosy patients. During the follow-up examination 58 to 118 months later there has been no recurrence of ulceration in any of these cases. The latissimus dorsi muscle, is mainly nourished by the thoracadorsal artery and the latissimus dorsi musculocutaneous flap is a large sized, composite structure with abundant blood provision and strong anti-infectious property. The latissimus dorsi flap can be used as an artery-pedicled island flap or as a free flap besides its use as a muscle graft, because of its constant vascular position, wide outer-diameter of the vessels and long pedicle. It can therefore be utilized for repairing soft tissue defect or replacement of paralyzed muscle. We have used the latissimus dorsi musculocutaneous free flap for repairing large skin and soft tissue defects resulting from plantar ulceration in three leprosy patients. During the follow-up period, one patient who had complete drop-foot and had refused corrective surgery had recurrence of the ulcer in the 12th post-operative month. No ulcers had recurred in the other two cases during the follow-up at 48 and 114 months.     

The threshold for protective sensation that prevents neuropathic ulceration on the plantar aspect of the foot: a study of leprosy patients in a rural community in India

The protective sensation threshold is an important concept in the prevention of plantar ulceration in leprosy patients. Previous studies have suggested that skin with sensory nerve damage on the plantar aspect of the foot which can still detect the 5.07 Semmes-Weinstein monofilament (approximately 10 g) is highly unlikely to develop ulceration. While the threshold is thought to be less than the 610 filament (approximately 75 g), no work just testing adjacent to current ulcers has been undertaken to assess this more accurately. This is important, as it has been shown that a significant proportion of healthy individuals who wear sandals or go barefoot in India may fail to detect this 5.07 filament in at least some areas of the sole, especially in older age groups, and in certain cases the 5.46 filament (approximately 30 g) is the lightest detected. In an attempt to address this problem, a cross-sectional study on 26 current plantar ulcers in male adults with stable neuropathy due to leprosy was carried out in the rural town of Salur, India. It was confirmed that the ability to detect the 5.07 filament (approximately 10 g) did prevent the development of ulceration while in contrast the ability to detect the 5.46 filament (approximately 30 g) did not. This suggests that the threshold for protective sensation lies between these two filaments. An approach is suggested which may help to differentiate feet genuinely at risk of ulceration from those merely unable to detect the 5.07 filament on account of thickened skin callus or advancing age.     

Squamous cell carcinoma in plantar ulcers in leprosy: a study of 11 cases

The objectives of our study were to describe and analyse the malignancies that occurred in plantar ulcers of leprosy patients. The possible predisposing conditions, duration and extent of the spread of the tumour were also studied. All patients with trophic ulcer of the foot attending the urban leprosy clinic in our hospital from January 1998 to January 2003 were screened for change to malignancy. During the study period, 79 cases of plantar ulcers in leprosy were seen. The mean age of these cases was 39.9 years with male-to-female ratio of 4:1. Eleven cases with plantar ulcers and malignant change were diagnosed in our hospital during the study period. The male-to-female ratio was 4.5:1. The mean age of these patients was 60.6 years. Their age ranged from 46 to 75 years. Nine of the cases were treated cases of borderline tuberculoid leprosy, while two had treated lepromatous leprosy. In our study, two distinct morphological types of malignant changes were seen. Histopathologically, all cases, except one, were of well-differentiated squamous cell carcinoma variation; one case had verrucous carcinoma. Though trophic ulcers are common in leprosy cases, only long-standing and neglected ones undergo malignancy.     

Correlation between the foot pressure index and the prevalence of plantar hyperkeratosis

BackgroundPlantar hyperkeratosis (HK) is a very prevalent foot lesion formed due to an alteration in the keratinisation process, thereby increasing keratynocites and accumulating multiple layers of the stratum corneum that leads to plantar pain. As foot shape and plantar pressures is related with their appearance, the aim of this study is to examine how foot posture and plantar pressure influence the appearance of this keratopathy.Material and methodsOn a sample of 400 subjects (201 men and 199 women), the plantar pressures were evaluated by the Footscan® platform in 10 zones. The clinical exploration consisted in the valuation of the Foot Posture Index (FPI), and the assessment of the appeerance (and location) or not of plantar calluses or hyperkeratosis.Results6.3% of the feet presented a highly supinated FPI, 15.5% were supinated, 57.3% corresponded to neutral, 17.3% were pronated and 3.8% were highly pronated. The participants with HK on the hallux, on the 1st, 2nd, 3rd or 5th MTH or on the lateral heel had a significantly higher pressure index (p < 0.001), ranging from 24.3 to 44% higher than those with no such alteration. Of the highly pronated feet, 66.7% presented HK in the hallux, while 32.3% of the supinated feet and 60% of the highly supinated feet presented it beneath the first MTH.ConclusionFoot posture influences the appearance of HK, though its association with plantar pressures. The participants with HK presented a mean foot pressure that was 32.3% higher than in those with no such condition. These values can be considered predictive for the appearance of HK and should be indicative of the need for preventive treatment.     

Leprous osteitis presenting as bone cyst and erosions

A 30-year-old man presented to the Hansen outpatient department with swelling and ulceration of toes for 2 months and swelling of the right fifth and fourth fingers and the left second finger for 1 month. In addition to skin lesions of lepromatous leprosy (subpolar type), there was nontender, non-fluctuant swelling of the right fifth and fourth fingers and left second finger. Skin over the right fifth finger showed sinus-like openings with associated purulent discharge. He also had swelling and ulceration of second left toe. Slit-skin smear (SSS) showed a bacterial index of 6+ from the ear lobes and cutaneous nodules, 4+ from the patch, and 3+ from normal skin. Modified Ziehl-Neelsen staining of the discharge extruding from the sinuses on the right fifth finger also showed abundant acid-fast bacilli. Radiography of the hands and feet showed lytic lesions in the distal epimetaphyseal region o proximal phalanx of the right fifth finger and left second finger and erosion of distal end of proximal phalanges of both second toes. Histopathological examination of biopsy specimen from the patch (back) showed features of lepromatous leprosy, and Fite-Faraco stain for tissue acid-fast bacteria (AFB) was strongly positive. Fine-needle-aspiration cytology (FNAC) from the lytic lesion in the bone also showed predominantly foamy macrophages with strongly positive staining for AFB with a few interspersed lymphocytes, epithelioid cells and Langhans giant cells. On the basis of these features, a clinical diagnosis of subpolar lepromatous leprosy with leprous osteitis was made. In today's clinical era of improved case detection and prompt treatment with effective multidrug regimens, advanced bone changes are rarely encountered. We describe this case of lepromatous leprosy that developed cavitating lesions of the phalanges of the hand, seen on x-ray as well-defined bone cyst and erosions.     

1990-2018年云南省新发麻风患者畸残情况分析

目的：分析云南省1990-2018年新发麻风患者2级畸残情况。方法：对1990-2018年11010例新发麻风患者资料进行分析。结果：新发病例中2级畸残2647例,2级畸残率24.04%。4006例少菌型患者中2级畸残者1294例（32.3%）, 7004例多菌型患者中畸残者1353例(19.3%)。对其中的2202例畸残者进一步分析,单侧和双侧眼部畸残分别为138例和184例,手部单双侧畸残分别为742例和430例,足部单双侧畸残分别为384例和144例。结论：少菌型（PB）比多菌型（MB）麻风患者畸残比例更高,手部畸残明显高于眼部和足部,手部和足部畸残常呈不对称性。     

Leprosy deformities: experience in Molai Leprosy Hospital, Maiduguri, Nigeria

A total of 410 patients (288 males, 122 females) aged between 9 and 60 years with an average age of 32.5 years were assessed for deformities of the eyes, hands and feet. The objectives were to find out the number and types of leprosy deformities in the leprosy population of the hospital, the proportion of those deformed among them and to establish the deformity baseline for the hospital. The study lasted 1 year, 38.78% (26.59% males, 12.20% females) of those investigated had one or more deformities. Apart from plantar and palmar insensitivity which accounted for 17.91% and 17.24% of all deformities, the most frequent deformities were mobile claw hand 12.94%, plantar ulcers 10.78% and palmar ulcers 5.97% respectively. With the exception of eye deformities, males accounted for a higher proportion of all deformities. Hand deformities were the most frequent of the three parts of the body studied. The patients' problems were highlighted and the need for adequate management and self-care were emphasized.     

Restoration of plantar sweat secretion in the feet of leprosy patients

As part of the studies on nerve damage and its consequences in leprosy, the status of sweat gland function in the anaesthetic sole of the feet of leprosy patients was investigated qualitatively and semi-quantitatively, before and after surgical decompression of the posterior tibial neurovascular bundle. Sweat prints of the feet of the patients were obtained pre-operatively and postoperatively on Whatman's No. 1 filter paper. The paper was treated with one percent Ninhydrin and the intensities of the Ninhydrin positive areas were quantitated. Forty one feet of thirty six patients have been studied in this manner. Sweat print analysis of twenty normal people have also been done, and included for comparison. This operative procedure has been found to effect an improvement in the sweat gland function in the feet of more than fifty percent of leprosy patients studied so far.     

A clinical and radiological follow-up study in leprosy patients with asymptomatic neuropathic feet

OBJECTIVES: An MRI study done in 2000 on 10 leprosy patients with neuropathic feet, without clinical complications such as ulcerations, osteomyelitis or Charcot deformities revealed abnormalities in nine patients, with degradation, interruption of subcutaneous fat and effusion/synovitis, all located in the first metatarsophalangeal (MTP) region. Since these MRI abnormalities may precede clinical complications of the foot, a follow-up study was performed. DESIGN: A new evaluation was based on a clinical examination and an MRI of the same patients who participated in the initial study. RESULTS: Four patients were lost to follow-up. Average follow-up period was 4-6 years. MRI abnormalities in the MTP 1 region in the first study were no longer visible in three patients, but were still present in two patients. In six patients new MRI findings were found, without clinical evidence of ulceration, osteomyelitis or Charcot deformity. No relationship was found between MRI findings in the MTP 1 region at the start of the study and the development of foot ulcers, callus or skin fissures in the MTP 1 region during follow-up. CONCLUSION: MRI findings of interruption and infiltration of the subcutaneous fat in leprosy patients with uncomplicated neuropathic feet do not necessarily have any clinical implication for the development of future foot problems.     

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part I--General considerations and summary of results

Recurrent plantar ulceration is a common and serious complication occurring consequent to impairment of the tibial nerve in leprosy patients. In spite of many therapies and long therapeutic course, it is extremely difficult to abolish this complication in many cases because of extensive skin and soft tissue cushion loss due to repeated infection. Since the early 70's we have been using microscopic surgical techniques to reconstruct the ulcerated area using eight types of the flaps. In this series of papers we review our experience (76 patients). Post-operatively, the flaps survived in all cases, the long-term results have proved satisfactory, and recurrent ulceration occurred in only three patients.     

Abnormal biomechanics of feet and their cause of hyperkeratoses

A brief review of pedal anatomy and the mechanisms enabling feet to function as organs of locomotion is presented. The importance of the subtalar joint is emphasized. Four major abnormalities disturbing normal foot function are noted, and the most commonly encountered of these alterations, rearfoot varus, is discussed in some detail. A series of pedal abnormalities in rearfoot varus occurs because in the foot's attempt to overcome its imbalance, it pronates excessively and causes development of callus, corn, hallux valgus, and even ingrown toenail. Haglund's deformity, soft corn, and tailor's bunion are also secondary to the abnormality. Attempts to restrict the germinal compensatory pronation by various forms of padding of the medial aspect of the foot are frequently rewarded by restoration of asymptomatic feet. Surgical means of restoring normal function are briefly discussed.