Nerve function loss after reconstructive surgery

Leprosy Mailing List – January, 23^rd, 2010

Ref.: Nerve function loss after reconstructive surgery

From: Piefer A., Kinshasa, Democratic Republic of Congo

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Dear Colleagues,

After years of political conflict reconstructive surgery has (re) started in the DR Congo (former Zaire) under basic conditions with a few cases. I would like to share a complication that I have just come across, hoping that readers of this mailing list can help us with their experience.

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 2^nd 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 Mission International in DR Congo

124 Avenue de la Mongala

Gombe, Kinshasa

Democratic Republic of Congo

E-mail: angelikap(at)tlmcongo.org or angelikapiefer(at)gmail.com