When feet have ulcerated

An uncomplicated ulcer is only skin deep, does not involve bone or deeper structures, and usually heals easily if the patient rests his leg. A complicated ulcer has involved the bone underneath it. It has a deep sinus, or marked infection, and is much more difficult to heal.

When a leprosy patient has his first ulcer: (1) Help him to find the cause of his injury. Never let him accept that the cause was leprosy. Was it caused by repeated stress, or by a blow, a puncture, or a burn? (2) Concentrate all your educational energies on him. You can do much more for a patient with his first ulcer, than for one whose foot is already mostly destroyed.

If you can find some way of resting an ulcer it will usually heal. This means that he must ''not take one step' on it, until it has finally closed over, and all the scabs are off. If it is uncomplicated, this takes 4 to 6 weeks. You can: (1) Rest it in bed. Unfortunately, this is rarely achieved because: (a) staff do not understand the need for it and explain it to him, and (b) he has no pain, and thus has little incentive to stay in bed. (2) Get him to use a splint and crutches, continuously until his ulcer has healed. He won't do this unless you educate and supervise him carefully. (3) Make him a special curative shoe, with a rigid rocker bottom, and a specially moulded upper surface. Making shoes of this kind needs much skill, and is not described here. (4) Put his foot in a cast.

A plaster cast is one of the most practical ways of resting an ulcerated foot. It immobilizes the foot, it spreads the strain of weight-bearing, it is quick to apply, and it is easy and effective. You can apply one in a remote clinic and send the patient home[md]provided you tell him that he must provide himself with door-to-door transport. If you apply a cast on the indications listed below, it will usually allow an ulcer to heal in 6 weeks.

Unfortunately, although resting a patient's foot in a cast may heal an ulcer, it weakens his bones and ligaments, even if he walks in it. Bones only retain their normal strength if they are regularly used. Rest causes them to lose their minerals, and ligaments to lose their strength. The result is that when his cast is finally removed, he may be delighted to find that his ulcer is healed, but he may not realize: (1) that anaesthesia is preventing him from experiencing the stiffness and pain that protects a normal foot after a cast is removed, and (2) that he needs to practise self care to keep his ulcer healed. Consequently, he may be tempted to use his anaesthetic foot too vigorously, with the result that it dislocates, or its tarsal bones fracture, and he ends up with a neuropathic foot. So: (1) Use casts cautiously, and remember their risks. (2) When you remove one: (a) warn him of the sad consequences of energetic early exercise, (b) start a programme of ''walking training', which will return him slowly to full activity during 7 to 10 days, (c) be sure that he learns ''self care', (d) be sure also that both you and he watch carefully for ''hot spots', and (e) most important, admit him for at least a week at the time the plaster is removed, so that you can supervise him carefully while all this is done.

Bone damage is common, and serious, and may be the result of: (1) Sepsis spreading from an ulcer, particularly if he walks on it. (2) Mechanical strain, which is particularly likely to occur when the protective mechanism of pain is absent. (3) Disuse atrophy in bed, or in a plaster cast. (4) Invasion of the bone by leprosy bacilli (leprosy osteitis), which is common in lepromatous and borderline leprosy, but is seldom severe enough to cause collapse. (5) Steroid osteoporosis, which may predispose to fractures.

The best way to minimize bone damage is to treat ulcers carefully, so that bone is not damaged in the first place. There are however also some additional principles: (1) Keep the weight- bearing surface of his sole as large as you can. (2) When you remove bone surgically, don't do so unnecessarily. Make sure it really is dead or infected. Dead bone is usually grey or black; it has no periosteum, and so feels rough to a probe. When you nibble it with forceps its fresh surface is pale, and not pink. Ideally, you should allow a sequestrum to separate before you remove it, but this takes several weeks, during which time the ulcer will not heal. You can shorten this time by removing dead bone as described below.

When bone has been damaged, clean up the mess it has caused. For example, if there is a deep sinus under an ulcer, with bone involvement, rest the leg for a few days to localize the infection. Then remove the dead soft tissue and bone[md]perhaps one or more metatarsal heads, leaving his toes if you can.

The short equinus foot of leprosy is one of its end results, and is due to the absorption of bone, which may be due to: (1) Neglected ulcers and infections. (2) Paralysis of his extensor muscles. (3) Unduly radical surgery. Muscle imbalance may pull his heel up too much, or push his forefoot down too much, so that it increases the pressure on his metatarsal heads, and so causes worse ulceration and more shortening.

A boat-shaped foot is another of the late effects of neglected leprosy. His arch is destroyed, and instead of being concave, it becomes convex, often with ulcers and bony spurs on the convexity.

Fig. 30-6 PLANTAR ULCERS IN LEPROSY. A, where ulcers form in a flexible anaesthetic foot with intact muscles; the arrows show where ''pre-ulcer blisters' may track to. B, where ulcers form in a paralysed foot. If the patient has a peroneal palsy, he has ulcers at the lateral side of his foot; if he has complete foot drop his ulcers are anterior on the ball of his foot, under his metatarsal heads, or on his toes. C, and D, shows the same foot with a collapsed arch. Each of its bony prominences (a) to (f) has produced an ulcer. E, two ulcers in just such a foot. F, plantar ulcers and a lateral ulcer caused by collapse of the patient's longitudinal arch. G, a necrosis blister caused by fluid from a necrotic area tracking to the side of the foot. H, a ''pre-ulcer foot', with a swollen metatarsal pad, and separation of the first and second toes, due to fluid in the foot forcing the metatarsals apart. Try to recognize a foot at this stage before ulcers form. I, collapse of the medial arch. J, a normal arch. K, a boat shaped foot. The arch is reversed; ulcers form under the ''keel' of the boat. After McDowell F, and Enna CD, ''Surgical Rehabilitation in Leprosy', (1973) Figs. 40-1, 40-2, and 40-9, The Williams and Wilkins Company, with kind permission. J, and K, kindly contributed by Grace Warren.

FOOT ULCERS [s8]IN LEPROSY ACUTE ULCERS Put the patient to bed. Splint his foot and raise it to encourage drainage and prevent oedema. This is much the best treatment. Ambulant treatment seldom works. Either admit him, or make sure he does not walk one single step at home. Let him use bed pans, or crutches to reach the toilet. If necessary, fix a piece of wood to the dressings, as in B, Fig. 30-8, to make sure that he does not walk. If bed rest is impossible, see below under ''Difficulties'.

Local applications to an ulcer make little difference, so there is no need to change the dressings on it at short intervals. Dress it 2 or 3 times a week with hypochlorite (''Eusol'), hypertonic magnesium sulphate, sugar (which is best used daily, 57.3), or some mild antiseptic. Or, soak it, scrape it regularly to remove excess callus, oil it, and dress it daily. When discharge stops, you can apply a cast, leave the dressing unchanged for 6 weeks, and send him home. Or, you can continue daily care as a means of teaching him self care.

If he has fever and other signs of generalized infection, give him an antibiotic. Splint his leg to rest it and stop him walking.

CAUTION ! Antibiotics have no place in treating uncomplicated ulcers[md]what they need most is rest!

If he has a profuse discharge, or tender groin glands, raise his leg, and give him an antibiotic. Don't let him get out of bed, and don't give him a walking cast.

When the acute stage is subsiding, and there is no sign of spreading infection, explore the ulcer with a sterile blunt probe to find out if there is exposed bone in its base.

If bone is exposed, feel if there are any loose pieces or sequestra, and remove them. Pack the ulcer with hypochlorite until it is healing well, and continue to rest his leg.

If bone is not exposed and infection is controlled, either apply a cast and let him walk about, or continue bed rest with a splint and crutches.

Fig. 30-7 A PLASTER CAST FOR LEPROSY ULCERS. A, sites for extra padding under a plaster cast. B, a wooden rocker shod with car tyre. This has a single bar. If a patient has casts on both legs, double bars on the rockers will enable him to walk more easily. C, a rubber-soled sandal with plastic straps to wear over a plaster cast. D, a locally made B[um]ohler walking iron shod with car tyre. E, apply the cast while he lies face downwards. Ask your assistant to hold his toes up and to pull downwards on a loop of bandage placed as shown. This will flex his ankle, and help to form a better arch if one is needed. Apply the plaster over the bandage. Kindly contributed by Grace Warren.

A SHORT LEG WALKING CAST FOR LEPROSY INDICATIONS. A chronic non-inflamed ulcer, whose base is visible without any necrotic bone, tendon, or other necrotic tissue. If there is necrotic tissue, remove it before applying the cast.

CONTRAINDICATIONS. (1) Signs of inflammation or infection: heat or oedema of the dorsum opposite the ulcer, excessive discharge, or regional adenitis. (2) Involvement of a joint or synovial sheath (synovial discharge). (3) Dead bone or tendon or capsular sloughs in the base of the ulcer. (4) A long deep sinus with small openings whose base you cannot see.

METHOD. Here is the basic method, which assumes that the patient's toes will be open. Some surgeons cover them to keep out stones and sand. See also Section 70.6 on plastercraft.

Measure his feet for shoes before he goes into his cast[md]when he comes out of it he must not take a single step without them. Shape the B[um]ohler stirrup (walking iron, 81.3) to his leg before you apply the plaster.

Dress his ulcer with dry gauze or a simple ointment. Cover, but do not pack the wound; discharge must be able to escape easily.

Apply stockinette, a nylon stocking, or an evenly applied gauze bandage. Apply the minimum of padding to bony prominences only. Use strips of adhesive tape to fix 3 strips of padding as A, Fig. 30-7, but don't apply the tape directly to his skin. If you don't have padding, use many layers of bandage instead.

Lay him on his abdomen with his knee at 90[de] and his leg vertical. Apply a thick layer of plaster to his leg without pressure. End the cast 5 cm below the head of his fibula, to avoid pressure on his common peroneal nerve, and leave his toes open. Apply a back slab and circular reinforcing layers. Then fit a B[um]ohler iron or a walking board (wood with a piece of car tyre, F, 81-3). Let it dry for 48 hours. The cast must be dry before he walks on it.

Alternatively, a thin well-moulded layer of plaster, covered by a layer of fibre glass, will make a more long-lasting cast. Preferably, use fibreglass tape rather than sheet, because it lasts longer.

CAUTION ! (1) Don't mould the cast under pressure to obtain the required position, or you may cause ulcers and gangrene. (2) Ask an assistant to hold his ankle at exactly 90[de] or slightly dorsiflexed, as in E, Fig. 30-7, until the plaster has set; it must not be plantar-flexed or inverted or everted. (3) Don't press into the plaster with your fingers, or you may produce pressure points where more ulcers will develop (F, 70-5). (3) Remember that he cannot complain of pain. A wrongly applied cast may cause ulcers! So don't apply excessive pressure over a tight bandage.

If he has an ulcer on both feet, he may need a wheel-chair. If he has to move about on the floor, give him ''hand sandals' to protect his hands. Make these with a piece of microcellular rubber, and give them a single strap. If he has casts on both feet, double bars on the walking boards will allow him to walk. Or make flat casts and sandals to go over them as in B, Fig 30-7.

Leave the cast on for 6 weeks. When you remove it, the shoe that you measured him for earlier should be ready. Make sure that he has a period of ''walking training' before he resumes full activity (see above). Apply a firm bandage, and start him walking in a carefully graduated way. Check his foot for swelling or an increase of temperature. Rest it again if signs of inflammation return. Tell him to walk as little as possible, to take short steps, and to avoid uneven ground, sudden strains, and long walks.

If his ulcer has not completely healed in one cast, apply another.

BONE INVOLVEMENT [s7]IN LEPROSY THE INDICATIONS FOR REMOVING BONE. Consider removing bone if: (1) There is osteitis. (2) It is loose. (3) It is projecting into a septic cavity with no obvious blood supply around it. (4) It is projecting after an ulcer has healed, so that it forms a pressure point; if so cut it horizontally (see Section 30.7 on calcaneal spurs). (5) One metatarsal is obviously longer than the others, and the skin over it is ulcerating. Apart from the first metatarsal, which may usefully be longer, they should all be on the same line across his foot, so that he can walk without one of them sticking out prominently and taking extra stress.

Admit him. If this is impossible, give him a splint and crutches. Give him antibiotics pre- and postoperatively.

TO REMOVE DEAD BONE apply a tourniquet (3.9), try to loosen the bone, and cut it off at the line of separation. If this line has not yet formed, nibble it at the point where you see the periosteum is adherent again.

CAUTION ! (1) Don't remove bone from the base of an ulcer unnecessarily, especially in the heel. (2) Probing an ulcer will tell you if bone is exposed, but not if it is dead. Exposed bone may be healthy, but the soft tissues will take time to grow over it. (3) Never strip the periosteum unnecessarily, because this may kill the bone under it.

Fig. 30-8 MORE METHODS FOR LEPROSY. A, a patient's first ulcer is a critical time for health education. B, one way to prevent him walking on his ulcer while it heals, is to bandage a wooden bar to his leg. C, the sites of ulcer formation. Feel for warmth and deep tenderness in these sites when you examine his foot. D, if you cannot rest his ulcers by putting him to bed, you may be able to treat him in a walking prosthesis like this. E, an arthrodesis of the ankle joint, or F, a subtalar triple arthrodesis may be necessary if he has a severely equinus or equinovarus foot. A, to D, after Paul Brand, ''Insensitive Feet, A Practical Handbook on Foot Problems in Leprosy'. With the kind permission of the Leprosy Mission International. E, and F, after Ernest Fritschii..

DIFFICULTIES [s7]WITH LEPROSY FEET IF BED REST IS IMPRACTICAL: (1) Give him a splint and crutches, and ask him not to bear weight on the foot with the ulcer. The splint can be plaster (expensive and short- lasting), wood, plastic, wire (mesh fencing wire), or even a roll of paper or cardboard. Or, (2) apply a below-knee cast, as described above, for 6 weeks. Or, (3) attach a projecting bar to his foot as in B, Fig. 30-8, and give him crutches.

If a PLASTER CAST FOR AN ULCER IS IMPRACTICAL, you can: (1) Fit the kneeling leg prosthesis in D, Fig. 30-8, which is suitable for limited activity only. (2) Fit a ''healing shoe' which is less cumbersome than a cast, but also less effective. It must have: (a) a rigid sole with a central rocker, (b) an insole (ideally ''Plastazote') moulded exactly to the shape of his foot, (c) an upper strapped round his foot and ankle, so that they cannot move in relation to his shoe.

If his ULCER RECURS, check the way he cares for his feet. Does he inspect them and soak them daily and remove rough callus? Look at his shoes: (1) Is there increased pressure in some area which has caused necrosis? (2) Are the straps so loose that they allow movement of his foot in relation to the shoe, or so tight that they cut into him? (3) Can the contour or fit of his shoes be improved? (4) Does he always wear them?

Also, check how he walks. How far does he walk without resting? Can he walk less, or walk with less pressure on the ulcer, or more slowly or with shorter steps? Ask him to practise walking with his ankles tied with string, to limit his steps to 30 cm.

There are two possibilities: (1) You may be able to excise the ulcer, and all the scar tissue under it, and then graft it with split skin. This may provide a more suitable bed for the regrowth of subcutaneous tissue than the original scar tissue. Some surgeons think that split skin grafts break down too easily, and consider that better quality skin results from the next alternative. (2) You may be able to excise the scarred area, and close the gap you have made with monofilament sutures. This often requires the use of a relieving incision on the dorsum or side of his foot, and packing the cavity with hypochlorite (''Eusol') to encourage healing from the base or bottom of the wound. See Section 30.7 on the excision of metatarsal heads.

If he looks after his feet carefully and wears the right shoes, his ulcer should not break down again. If it does, and he is caring for his feet properly, there is some underlying abnormality, such as: (1) Sequestration of the bone under the ulcer. Remove sequestra surgically. (2) A bone spur which may need excising as described below. (3) A thick scar which splits under tension as he walks. (5) Inadequate subcutaneous tissue over his metatarsal heads. (5) Malignant change in the ulcer. (6) Claw toes which repeatedly ulcerate. Treat him as described below or refer him.

CAUTION ! When you treat ulcers avoid cutting into living bleeding tissue unless it is to: (1) Open an abscess. (2) Improve drainage from a deep sinus. (3) Remove necrotic tendon, muscle, or bone. (4) Remove a free lying sequestrum. (5) Remove bone that is so placed that healing and normal function are mechanically impossible.

If there is an ULCER ON THE LATERAL BORDER OF HIS FOOT (F, 30-6), it is likely to be associated with peroneal paralysis. Treat it by bed rest and splints or casts. When it has healed a toe-raising strap attached to the area of his fifth metatarsal head may help to prevent recurrence.

Alternatively, if the ulcer is in the middle of the lateral border, you can try to promote healing by surgically paring his cuboid or the base of his fifth metatarsal, and removing any infected tissue. Do this through a dorsolateral incision, which leaves a sufficient bridge of tissue between the incision and the ulcer. Turn back the infected tissues by subperiosteal dissection, trim the bone, remove necrotic tissue, excise the ulcer with an elliptical incision on the sole, and close this with monofilament to achieve primary healing of the plantar wound. Pack the dorsolateral wound, and allow it to close by granulation. Keep the mouth of the wound wide open until the depth of the cavity is clean and closing. A toe raising spring may help to prevent recurrence.

BONY DIFFICULTIES [s7]IN LEPROSY OTHER THAN NEUROPATHIC BONE DISINTEGRATION If a TERMINAL PHALANX PRESENTS in an ulcer at the tip of a toe (or finger), nibble it away with a bone nibbler. If it is badly infected, disarticulate it. If necessary, use a fish mouth incision over the top and down the sides, which will leave the pulp intact.

If you need to REMOVE PART OR ALL OF THE MIDDLE OR PROXIMAL PHALANGES, approach them through incisions at the sides of a toe (or finger).

If BONE IS EXPOSED UNDER A HEEL ULCER, be very careful about removing it from his calcaneus[md]you can easily remove too much, and a foot without a heel can be a problem. Patients can however walk on very little calcaneus or even none, if you provide them with a rubber heel-pad. Look for a calcaneal spur (see below).

If he has a SHORT FOOT, examine him carefully to see if his heel is taking its proper share of his weight. You can easily miss foot drop in a short foot. Ask him to walk on his heels; if he cannot do so, some of his muscles are weak. Lengthening his Achilles tendon may help, even to the point of making his calf muscles useless, because this will make him walk mainly on his heel, and less on the front of his foot. If he has definite paralysis of his dorsiflexors, he will be better with a tendon transfer (30.8). If this is not practical, fit him with a toe-raising spring.

NEUROPATHIC BONE DISINTEGRATION [s7]IN LEPROSY If his foot is HOT AND SWOLLEN, there are several possibilities.

If he has signs of an acute infection with lymphadenitis, treat him with rest, an antibiotic, and if necessary, drainage. His bones may not be neuropathic, and his foot may merely have a soft tissue infection.

If he has no lymphadenitis or signs of general infection, his hot foot may be the result of neuropathic bone disintegration. This can also follow a fracture. Admit him. Splint, bandage and rest his foot in bed. The heat and swelling should subside within a week. Then apply a firm supportive bandage and start ''walking training' (see above).

If heat and swelling do not return ,he had a sprain or minor injury.

If they rapidly return and persist, there is active pathology, so apply a cast for 6 weeks, check again, X-ray him again and plan treatment accordingly. After this interval stress fractures and other bony lesions will have caused enough osteoporosis to be seen. If you are in doubt, or have no X-rays, have another trial of walking. If heat and swelling return a second time, he has definite neuropathic bone disintegration, so reapply a well fitting walking cast for 6 to 12 months, depending on its site and severity.

If his TARSAL BONES DISINTEGRATE, you may see him in any of these three stages.

In the first stage, his foot is hot, it may be swollen, but its shape is unchanged. Raise it to allow swelling to subside. Apply a cast moulded to the shape of his foot, but without trying to change it, usually for 3 to 6 months.

In the second stage, his foot is still hot with active disintegration; its shape is abnormal, and it may be hypermobile. Raise it in a splint for 3 days to reduce swellling. Then lay him on his face as in E, Fig. 30-7, mould his foot into as functional a position as you can, accentuate its arch as much as possible, and apply a cast. Leave this on for for 6 to 12 months, and then mobilize him with care. If necessary, treat him for the complications of the third stage (see immediately below).

In the third stage, his foot is no longer hot, showing that his bone lesions are no longer active. If there are rough bones, which will be likely to cause ulcers, trim them. A high-risk shoe may keep him ulcer-free. You may be able to refer him for an arthrodesis, after which he may need a walking cast for 6 to 9 months. If he is lucky his foot will revert to the ''moderate risk' class; if it does not, he may continue to need a special prosthetic shoe or brace. Many of these patients can manage to live well in a simple sandal, with daily skin care.

If there is NO PRACTICAL WAY TO ESTABLISH A GOOD ARCH, at least try to get its bones healed and sclerosed. If the arch of his foot becomes completely flat, he should remain ulcer- free, but if the bottom of his foot becomes convex and boat- shaped, it will be more likely to ulcerate. If his talus and calcaneus are totally destroyed, consider amputation (see below).

If he has an old fixed deformity which cannot be altered, refer him for reconstructive surgery or supply him with a special moulded high-risk shoe.

If he has a residal BONY SPUR on the under surface of his calcaneus or elsewhere under an ulcer or scar, try conservative management with special footwear and daily skin care. If ulceration continues, excise it (30.7). Spurs may form under any prominent bone in a boat-shaped foot.

CLAWED TOES [s7]IN LEPROSY Ulcers are often associated with clawed toes.

If he has GRADE 1 CLAWED TOES, (weakness of the intrinsic muscles only, and mobile toes without contractures), his metatarsal heads will have to take excessive pressure, which may cause ulcers. Transfering his flexor tendons gives good results in this stage of clawing (30.7).

If he has GRADE 2 CLAWED TOES, (moderate contractures), you may be able to treat him with a tendon transfer only, or you may need to remove the metatarsal heads at the same time.

If he has GRADE 3 CLAWED TOES, (severe contractures with or without dorsal subluxation of his MP joints), he will probably have ulcers over his metatarsal heads. To straighten them, you may have to remove at least one phalanx, or the metatarsal head, or both. If the remains of his toes will not bear weight, because they are so badly scarred, do a transmetatarsal amputation (see below).

ANKLE DIFFICULTIES [s7]IN LEPROSY If his ANKLE BECOMES SWOLLEN AND WARM, three things may have happened: (1) He may have sprained his ankle. This is particularly likely to happen if he has a shoe with a rocker sole (the benefit from which may however outweigh the increased probability of a sprained ankle). His ankle needs immobilization. If the sprain is less severe, a firm bandage may be enough. If it is more severe, immobilize his ankle for 3 months in a plaster cast. (2) He may have neuropathic bone disintegration (see above). (3) His ankle joint may be infected (see below).

If he has a DISLOCATED ANKLE that you cannot reduce, or a fixed deformity of it, refer him for surgical correction.

If he has an EQUINUS or EQUINOVARUS FOOT, he may be able to walk quite well, but he will need elaborate footware to keep him ulcer-free. If walking is difficult, and particularly if he has fixed plantar flexion or inversion, refer him for an ankle arthrodesis (E, or F, in Fig. 30-8). When this has been done, an ordinary high moulded shoe, or a sandal of microcellular rubber, may be adequate to keep him free from ulcers.

If his FOOT IS INVERTED, a simple canvas shoe like a tennis shoe may be enough. If not, refer him to have it corrected surgically. When this has been done an ordinary high moulded shoe or a sandal of microcellular rubber may be enough to keep him free from ulcers.

SEPTIC DIFFICULTIES [s7]WITH LEPROSY FEET If SEPTIC ARTHRITIS involves the IP joint of a TOE, excise it through a dorsal incision, remove the remains of its ligaments and cartilage, pack the cavity, and keep his toe straight at its IP and MP joints, while it heals by granulation.

If SEPTIC TENOSYNOVITIS complicates an ulcer, draining the tendon sheath may assist healing. Drain it through an incision along the arch of his foot. Clean out all the infection, as far back as is necessary, to find and remove the infected tendon stump. Close his skin with monofilament, so as to leave the smallest possible scar on the weight bearing area. But leave both ends open, so that you can irrigate the lesion until it is clean. Allow it to heal by granulation.

If a SEPTIC TOE REQUIRES AMPUTATION, use a racquet incision on the dorsum (as in Fig. 75-28), leave the metatarsal head, and only resect the surface cartilage if there is septic arthritis of an MP joint. Drain or pack the wound dorsally.

If plantar ulceration is complicated by OSTEITIS of a METATARSAL HEAD, you may need to excise it. This will move the weight-bearing area proximally, so that more ulceration is likely. If you can save a toe in good position, it will help to protect the area of the new ''metatarsal head'. If you can save the distal part of his first toe, it will help to protect his second metatarsal head, which may otherwise soon ulcerate. Sometimes, you may have to remove several metatarsal heads. Do this through dorsal longitudinal incisions between them. If there are plantar ulcers over his metatarsal heads, excise them, and close the incisions in his sole with monofilament. Leave drains or packs in dorsally.

MALIGNANT DIFFICULTIES [s7]IN LEPROSY If a SQUAMOUS CELL CARCINOMA complicates a long- standing ulcer, the alternatives are local excision and amputation. You may be able to excise smaller lesions that don't involve bone, and are distal to his mid foot.