Leprosy Mailing List – January, 23rd, 2010
Ref.: Nerve function loss after reconstructive surgery
From: Piefer A., Kinshasa, Democratic Republic of Congo
Dear Colleagues,
After years of political conflict reconstructive surgery has (re) started in the DR Congo (former
The situation has been as following:
8 cases were operated (2 cases for TMT, 1 cases of TPT, 4 cases for lumbrical replacement, of which one had an opponent’s replacement at the same time). Post operative 3 out of the 4 cases who received hand surgery present complication after surgery which was done in early December 2009 (we are still in the post operative therapy phase). Neither the case with ulnar / median correction nor the other cases presented similar complications. Surgery was performed by a surgeon under training with a very experienced supervisor (external consultant for leprosy reconstructive surgery). All patients have a detailed VMT/ST pre operative and as far as possible under the post operative situation a VMT / ST was done at the end of the 2nd week of post operative therapy in order to assess the complications.
Here are the main findings:
Person operated | Surgery performed | Complication post operative | Observations | Treatment given to date |
16 year old woman, completed PB MDT in May 2009, clinically with the only nerve function loss of the right ulnar nerve with remaining weak function of the 1st dorsal interossei and the ADD pollicis | Palmaris Longus extended with fascia lata to pulley insertion right hand | Loss of radial nerve and high median nerve function incl. loss of Palmaris Longus and pronator teres and brachioradialis. Partial ulnar nerve function remaining in the same way as pre-operative (1st dorsal interossei and the ADD pollicis) | Axillary block for the anaesthesia did not work, Ketamine was given. Duration of tonique about 1 ¾ hrs. Post op elevation during 3 weeks in POP, remaining thumb function gave the impression that all is ok. The extend of loss was discovered immediately after POP was removed after 3 weeks. No pain anywhere in the upper limb | Stimulation with ice and mobilisation as possible with continuing post op programme. Started 40 mg Prednisolone and Vit. B (Triblex forte) 2 days after POP was removed. |
young man in his mid twenties, completed MB MDT in 2003, clinically with multiple nerve function impairments: bilateral mild lagophthalmos, loss of ulnar nerve function in the right hand, weakness in dorsi flexion of the right foot | EF4T with pulley insertion (ECRL transferred) right hand | Loss of radial nerve and high median nerve function incl. Loss of pronator teres and brachioradialis. | Axillary block for the anaesthesia did not work, Ketamine was given. Duration of tonique a little over 2 hrs. Post op elevation, immediate complains about sensation loss and swelling, immediate loss of thumb and finger movement. No pain anywhere in the upper limb. | POP was split after 2 days and conservative treatment for swelling as well as a short course (2 weeks) of Prednisolone (starting 40 mg). Prednisolone short course 40 mg (2 weeks, ongoing) and Vitamine B (Triblex forte) 2 days after POP was removed. |
59 yr old man, completed MDT MB in 2008, left ulnar paralysis, mild lagophtalmos left eye. | Palmaris Longus extended with fascia lata to pulley insertion left hand | Loss of FPL, flexion of index, weakness in opponens and AB of the thumb as well as PL, loss of pronator teres and brachioradialis. Possible weakness in finger flexion– at this stage difficult to test | Axillary block for the anaesthesia did not work,local anaesthetics were given. Duration of tonique a little over 1 ½ hrs. Post op elevation, mild swelling first 2 days. | Normal post op programme is followed with active mobilisation of thumb and pronation/supination. |
AB = Abduction or Abductor ... (muscle)
ADD = Adduction or Adductor ... (mucle)
ECRL = Extensor Carpi Radialis Longus
EF4T = Extension to Flexion 4 tails (surgical method for reconstruction of lost lumbrical function)
FPL = Flexor Pollicis Longus
MB MDT = multibacillary multidrug therapy
PB MDT = paucibacillary multidrug therapy
PL = Palmaris Longus
POP = plaster of Paris
post op = post operative
ST = sensory testing
TMT = Temporalis Muscle Transfer (technique to reconstruct lagophthalmos)
TPT = Tibialis Posterior Tendon Transfer
VMT = voluntary muscle test
We would be grateful for any comments and suggestions.
With best wishes and many thanks,
Angelika Piefer
The Leprosy
124 Avenue de
Gombe, Kinshasa
Democratic
E-mail: angelikap(at)tlmcongo.org or angelikapiefer(at)gmail.com
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