Chapter 17. The surgery of leprosy

Table of Contents
Introduction
Managing paralysis, especially during lepra reactions
The eyes in leprosy, iritis (uveitis)
Lagophthalmos in leprosy
Leprosy of the hands
The care of anaesthetic feet
When feet have ulcerated
Operations on the feet in leprosy
Tibialis transfer for foot drop, from leprosy and other causes
Other leprosy problems
The surgery of neglected infection
Tropical ulcers
Mycobacterium ulcerans infection (Buruli ulcer)
Mycetoma
Gross enlargements of parts of the body (elephantiasis)
Podoconiosis (non-filarial endemic elephantiasis of the lower legs)
The surgery of filariasis
Elephantiasis of the scrotum and penis
The surgical complications of typhoid fever
Pigbel disease, [s8]necrotizing enteritis, necrotizing jejunitis, enteritis necroticans
The surgery of intestinal amoebiasis
Invasive intestinal amoebiasis
Extraintestinal amoebiasis
Hydatid disease
Other problems in tropical surgery

Introduction

The best way to deal with leprosy is to recognize it early, and treat it adequately. If this fails, a patient needs surgery, because leprosy affects his nerves. Destruction of their sensory fibres makes the surface of his body anaesthetic, and thus liable to the injuries that result in open wounds and ulcers. Destruction of their motor fibres causes paralysis, wasting, and sometimes contractures of his muscles. Most nerves are mixed, so that both these things happen at the same time, with the result that his arms and legs become paralysed and anaesthetic. Because he has little sensation of pain, he does not know when he is injuring himself. This makes him neglect his painless surface injuries, so that they become steadily progressive ulcers. The contractures, ulcers, and deformities that result are not an inevitable part of leprosy. In a well-conducted leprosy program, there should be few of them when patients first present, and none later. They are the purpose of this chapter, and you should not see them very often.

Leprosy most commonly involves a patient's legs, but it can also involve his hands (30.4) and his eyes (30.2, 30.3). Pyogenic organisms readily enter through the lesions that leprosy causes in his skin, so that you may need to drain abscesses (5.2), treat bone, joint, and tendon sheath infections (Chapter 8), and enucleate his eye when its globe has become infected (24.14). Admit him to the general ward. If the staff behave naturally towards him, the other patients will too.

Here we assume you know about the medical treatment of leprosy. Surgically, your task is to: (1) Care for his primary and secondary impairments. (2) Set and record measurable objectives for preventing and limiting his disabilities, and plan how you are going to reach them. (3) Provide him with protective footware and aids. (5) Teach him self care to prevent further disability. (6) Teach the rest of the health care team how to do these things. Most leprosy work should be done by paramedical workers, and the present trend is for vertical programmes, with a specialized cadre of leprosy assistants, to be replaced by horizontal ones which manage many diseases. Much of what is described here can be done by paramedicals[md]if you teach and encourage them.

There are many practical details which we have little space for, so if you see many leprosy patients, try to get the TALC slide set by Grace Warren, and the manuals listed below.

Fritschi EP, ''Surgical Reconstruction and Rehabilitation in Leprosy'. Available by purchase from: The Leprosy Mission, 80 Windmill Road, Brentford, Middlesex, TW8 0QH.[-3] Neville Jane, Ed. ''A Footwear Manual for Leprosy Control Programmes, Parts I and II'. The German Leprosy Relief Association (DAHW) Postfach 348, D[nd]8700 W[um]urzburg 11 West Germany. Also available free from The Leprosy Mission, see above.[-3] Watson Jean, ''Preventing Disability in Leprosy Patients'. Available from the Leprosy Mission, see above.[-3] Brand P, ''Insensitive Feet, A Practical Handbook on Foot Problems in Leprosy'. Available free from The Leprosy Mission, see above[-3] Warren Grace, ''The Care of the Nerve Damaged Limb' TALC slide set. Teaching Aids at Low Cost, The Institute of Child Health, 30 Guilford Street, London WCIN IEH Fig. 30-0 THE CAUSES OF DISABILITY IN LEPROSY. Damage to the sensory, autonomic and motor components of nerves is folowed by anaesthesia, dryness of the skin and paralysis. A further cause of damage is direct invasion of the tissues by [f10]Myc. leprae. From Bryceson A, and Pfaltzgraff RE, ''Leprosy', (2nd edn 1979), Fig. 9.1. Churchill Livingstone, with kind permission.