The prevention of diabetic foot ulceration: how biomechanical research informs clinical practice

ABSTRACT Background Implementation of interprofessional clinical guidelines for the prevention of neuropathic diabetic foot ulceration has demonstrated positive effects regarding ulceration and amputation rates. Current foot care recommendations are primarily based on research regarding the prevention of ulcer recurrence and focused on reducing the magnitude of plantar stress (pressure overload). Yet, foot ulceration remains to be a prevalent and debilitating consequence of Diabetes Mellitus. There is limited evidence targeting the prevention of first-time ulceration, and there is a need to consider additional factors of plantar stress to supplement current guidelines. Objectives The first purpose of this article is to discuss the biomechanical theory underpinning diabetic foot ulcerations and illustrate how plantar tissue underloading may precede overloading and breakdown. The second purpose of this commentary is to discuss how advances in biomechanical foot modeling can inform clinical practice in the prevention of first-time ulceration. Discussion Research demonstrates that progressive weight-bearing activity programs to address the frequency of plantar stress and avoid underloading do not increase ulceration risk. Multi-segment foot modeling studies indicate that dynamic foot function of the midfoot and forefoot is compromised in people with diabetes. Emerging research demonstrates that implementation of foot-specific exercises may positively influence dynamic foot function and improve plantar stress in people with diabetes. Conclusion Continued work is needed to determine how to best design and integrate activity recommendations and foot-specific exercise programs into the current interprofessional paradigm for the prevention of first-time ulceration in people with Diabetes Mellitus.

Fatores relacionados ao desenvolvimento de úlceras em pacientes com diabetes mellitus / Factors related to the development of ulcers in patients with diabetes mellitus / Factores relacionados al desarrollo de úlceras en pacientes con diabetes mellitus

Objective: To identify factors related to the development of ulcers in the lower limbs of insulin-dependent users residing in the city of São José de Mipibu/RN. Method: Quantitative research; we obtained data thought interview followed by static inspection and application of Semmes-Weinstein monofilaments to assess the threshold of plantar tactile sensitivity. The Ethics Committee of the Potiguar University of Natal/RN approved this research, under the Certificate of Presentation for Ethical Consideration number 0037.0.052.000-11. Results: The age range was 21-72 years old; 68.4% were female; 63.3% were living in urban areas. We can highlight as factors related to development of ulcers in the lower limbs: sedentary lifestyle (71.6%), hypertension (65%) and a history of cardiovascular disease (56.7%). In the evaluation of the feet, 26.7% had dry skin; 15% had scaly skin; 38.3%, farinaceous nails; 30%, thickened nails and 35%, dermatitis. Regarding the tactile sensitivity, 18.3% had anesthesia of the affected limb. Conclusion: The data suggests that this population is likely to develop more severe and disabling complications of Diabetes Mellitus.

Objetivo: Identificar fatores relacionados ao desenvolvimento de úlceras em membros inferiores de usuários insulinodependentes residentes no município de São José de Mipibu/RN. Método: Pesquisa quantitativa; os dados foram obtidos mediante entrevista seguida da inspeção estática e aplicação dos monofilamento de Semmes-Weinstein para avaliação do limiar da sensibilidade tátil plantar. Pesquisa aprovada pelo Comitê de Ética em Pesquisa da Universidade Potiguar de Natal/RN, CAAE 0037.0.052.000-11. Resultados: A faixa etária foi de 21 a 72 anos; 68,4% do sexo feminino; 63,3% residentes em zona urbana. Fatores relacionados ao desenvolvimento de úlceras em membros inferiores: sedentarismo (71,6%), hipertensão (65%) e antecedentes de doenças cardiovasculares (56,7%). Na avaliação dos pés, 26,7% pele ressecada, 15% descamativa, 38,3% unhas farináceas, 30% espessadas e 35% dermatites. Quanto à sensibilidade tátil, 18,3% apresentaram anestesia do membro afetado. Conclusão: Os dados sugerem que a população estudada é suscetível a desenvolver complicações mais severas e incapacitantes do Diabetes Mellitus.

Objetivo: Identificar factores relacionados al desarrollo de úlceras en miembros inferiores de usuarios insulinodependientes residentes en el municipio de São José de Mipibu/RN. Método: Investigación cuantitativa; los dados fueron obtenidos mediante entrevista seguida de la inspección estática y aplicación de los monofilamentos de Semmes-Weinstein para evaluación del umbral de la sensibilidad táctil plantar. Investigación aprobada por el Comité de Ética en Investigación de la Universidad Potiguar de Natal/RN, CAAE 0037.0.052.000-11. Resultados: El grupo fue de 21 a 72 años; 68,4% de sexo femenino; 63,3% residentes en zona urbana. Factores relacionados al desarrollo de úlceras en miembros inferiores: sedentarismo (71,6%), hipertensión (65%) y antecedentes de enfermedades cardiovasculares (56,7%). En la evaluación de los pies, 26,7% piel resecada, 15% descamada, 38,3% uñas farináceas, 30% espesadas y 35% dermatitis. Referente a la sensibilidad táctil, 18,3% presentaron anestesia del miembro afectado. Conclusión: Los datos sugieren que la población estudiada es susceptible a desarrollar complicaciones más severas e incapacitantes del Diabetes Mellitus.

Causas referidas para o desenvolvimento de úlceras em pés de pessoas com diabetes mellitus / Root causes for the development of foot ulcers of people with diabetes mellitus

OBJETIVO: Analisar as causas referidas na etiologia das úlceras em pés de pessoas com Diabetes mellitus (DM). MÉTODOS: Estudo seccional, quantitativo, realizado no Ambulatório de Diabetes de um Hospital Universitário em Ribeirão Preto - SP. Os dados foram coletados com instrumento estruturado e exame físico dos pés de amostra de 30 pacientes diabéticos. RESULTADOS: Amostra com idade média de 57,5 anos, predominância do sexo masculino e baixa escolaridade; 90% possuíam DM tipo 2, de longa duração e mal controlado; obesidade/sobrepeso em 77% e insensibilidade plantar em 93,3%. A região metatarsiana foi o local de úlcera referido com maior frequência, e a causa foi a calosidade. CONCLUSÃO: as causas referidas envolvidas na etiologia das úlceras correspondem, de forma direta ou indireta, a fatores extrínsecos que podem ser prevenidos com cuidados básicos e de baixo custo. A insensibilidade plantar, fator fundamental desencadeador das úlceras, no entanto não foi reconhecida pelas pessoas.

OBJECTIVE: To analyze the root causes referred to in the etiology of foot ulcers in people with diabetes mellitus (DM). METHODS: A sectional study, quantitative, conducted at the Diabetes Clinic of a University Hospital in Ribeirão Preto - SP (Brazil). Data were collected using a structured instrument and physical examination of the feet of a sample of 30 diabetic patients. RESULTS: The sample had a mean age of 57.5 years, was predominantly male with a low educational level; 90% had type 2 DM, long-term and poorly controlled; obesity / overweight in 77%; and, 93.3% had plantar insensitivity. The metatarsal region was the site of ulcer most frequently mentioned, and the cause was the callus. CONCLUSION: The root causes involved in the etiology of these ulcers correspond, directly or indirectly, to extrinsic factors that can be prevented with basic care and at low cost. The plantar insensitivity, a key factor triggering the ulcers, was not recognized by these people.

OBJETIVO: Analizar las causas referidas en la etiología de las úlceras en piés de personas con Diabetes mellitus (DM). MÉTODOS: Estudio seccional, cuantitativo, realizado en el consultorio externo de Diabetes de un Hospital Universitario en Ribeirão Preto - SP. Los datos fueron recolectados con un instrumento estructurado y examen físico de los piés de una muestra de 30 pacientes diabéticos. RESULTADOS: muestra conformada por personas con una edad promedio de 57,5 años, predominio del sexo masculino y baja escolaridad;el 90% poseían DM tipo 2, de larga duración y mal controlado; obesidad/sobre peso en el 77% e insensibilidad plantar en el 93,3%. La región metatarsiana fue referida, con mayor frecuencia, como el lugar de la úlcera y la causa fue la callosidad. CONCLUSIÓN: Las causas que están involucradas en la etiología de las úlceras corresponden, de forma directa o indirecta, a factores extrínsecos que pueden ser prevenidos con cuidados básicos y de bajo costo. Entre tanto la insensibilidad plantar, factor fundamental desencadenante de las úlceras, no fue reconocida por las personas.

Hematological parameters in association with outcomes in sickle cell anemia patients.

Introduction: Sickle cell disease (SCD) has a wide range of clinical presentation. We evaluated hematological parameters, which are widely evaluable and assessable, as indices of clinical outcome in SCD. These parameters, although largely established as indices of clinical outcome in other SCD populations, have not been widely evaluated in African patients. Materials and Methods: One hundred and thirty six consecutive stable SCD patients who presented in the sickle cell clinic of a teaching hospital were studied retrospectively using a questionnaire. Hematological parameters of full blood count (FBC) for each patient were obtained using a cell counter. FBC parameters such as White blood cell count (WBC) were then statistically correlated with complications such as ankle ulcers, osteomylitis and others. A Chi-square text was used to compare frequencies and generate P values. Results: The presence of sickle cell complications was significantly associated with raised white blood cell count (WBC) above 11 × 10 9 /l (P0 = 0.03).The WBC of the patients increased with increasing numbers of complications ( P = 0.07). Mean packed cell volume (PCV) and WBC tended toward the reference range for age and sex (in apparently normal individuals) as the age at diagnosis of SCD increased. This trend was significant for PCV (P = 0.01). Conclusion: Our data provide additional support that widely evaluable and assessable hematological parameters such as PCV and WBC can be used as indices to predict SCD outcome in African patients. This is likely to impart positively on individualized therapy.

A pilot study on the effects of a polyherbal formulation cream on diabetic foot ulcers.

Background & objectives: Diabetic foot ulcers are the most common cause of non-traumatic lower extremity amputations in developing countries. The aim of this pilot study was to evaluate the safety of using a polyherbal formulation in healing diabetic foot ulcers in comparison with standard silver sulphadiazine cream among patients with type 2 diabetes. Methods: A total of 40 (M:F=29:14) consecutive type 2 diabetes patients with foot ulcers were enrolled in this study. They were randomly assigned to two groups of 20 each; Group 1 was treated with polyherbal formulation and group 2 with silver sulphadiazine cream. All the patients were followed up for a period of 5 months. The baseline ulcer size was noted and photograph of the wound was taken at the baseline and at each follow up visit. Number of days taken for healing of the wound was recorded. Results: The mean age of patients, duration of diabetes and HbA1c% were similar in both the study groups. The mean length and width of the ulcers was also similar in both the groups at baseline visit. There was a significant decrease in the size of the wound (length and width) in both the study groups (P<0.001). The mean time taken for the healing of the ulcer was around 43 days in both groups. Interpretation & conclusions: Diabetic wound cream prepared by using polyherbal formulation was found to be effective as well as safe in healing diabetic foot ulcers like the standard silver sulphadiazine cream.

Características dos pacientes de um programa de prevenção do pé diabético atendidos em consulta de enfermagem / Profile of patients participating in a diabetic foot prevention program provided by nursing staff

Introdução: O pé diabético é o evento final das complicações crônicas do diabetes melito (DM) e inclui vasculopatia e neuropatia diabética. Isoladamente ou em conjunto, representam uma problemática para os pés dos pacientes tornando-os vulneráveis. Objetivo: Identificar o tipo de pé e seus fatores de risco em pacientes ambulatoriais de um hospital geral de atenção terciária. Métodos: Estudo transversal e retrospectivo, sendo realizado em prontuários. Incluiu-se 1189 pacientes, DM 1 e 2 que tiveram seus pés examinados pela primeira vez na consulta de enfermagem de 1997 a 2008. A amostra foi por conveniência e os dados foram coletados em duas etapas: 1)de um livro de registros preenchido após o primeiro exame; 2)dos prontuários dos pacientes. Resultados: Apresentaram DM2 93,1% dos pacientes, 87,5% caucasianos, 50,1% de mulheres, aposentados (33,1%), até oito anos de estudo e casados (66,6%). Tinham pés alterados 676 pacientes (neuropáticos e mistos 27%/28,3%), 69,5% de homens, (P=0,001). A média da hemoglobina glicada foi 7,83±2,16 e os com alterações nos pés tinham mais tempo de duração da doença (12,6 anos), eram mais idosos (63 anos) e tabagistas, tinham algum grau de retinopatia, nefropatia, cardiopatia isquêmica, os achados com significância estatística (P=0,001). Conclusão: Múltiplos fatores de risco diretos e indiretos para o desenvolvimento de úlceras foram identificados nos pacientes, os quais podem aumentar o risco de amputações trazendo um custo pessoal e social elevados.

Background: Diabetic foot is the final event of chronic complications of diabetes mellitus (DM), including diabetic vasculopathy and neuropathy. Whether isolated or not, these events pose difficulties for diabetic patients' feet and make them vulnerable. Aim: The present study was to identify the type of diabetic foot and the risk factors in outpatients of a tertiary-care general hospital. Methods: Cross-sectional and retrospective study. Data were collected from medical records. We included 1,189 patients with type 1 and 2 DM who had their feet examined for the first time by the nursing staff between 1997 and 2008. We used a convenience sample and data were collected in two phases: first we analyzed the data recorded after the first examination, and then we analyzed the medical records. Results: DM2 was present in 93.1% of the patients, of whom 87.5% were Caucasians, 50.1% were women, 33.1% were retired, and 66.6% had at most 8 years of schooling and married. In our sample, 676 patients had diabetic feet (27% neuropathic and 28.3% mixed) and 69.5% were men (P=0.001). Mean glycated hemoglobin was 7.83±2.16 and the patients with diabetic feet had a longer duration of DM (12.6 years), were older (63 years) and smokers, had some degree of retinopathy, nephropathy, and ischemic heart disease. All these findings showed statistical significance (P=0.001). Conclusion: Multiple direct and indirect risks factors for the development of ulcers were found in these patients. These factors may increase the chance of amputations leading to high personal and social cost.

Estudo comparativo da sensibilidade nos pés de diabéticos com e sem úlceras utilizando o PSSDÕ / Comparative study of the sensitivity of diabetic lower extremities with and without ulcers using the PSSDÕ

INTRODUÇÃO: Determinar e comparar limiares de sensibilidade cutânea nos pés de pacientes diabéticos com úlcera em apenas um dos membros inferiores. MATERIAIS E MÉTODOS: 20 pacientes foram estudados, a média de idade e de conhecimento do diabetes foi 61,6 e 12,4 anos, respectivamente. Todos os pacientes foram previamente testados com o monofilamento de Semmes-Weinstein nº 5,07. A sensibilidade foi avaliada usando o teste de discriminação entre dois pontos e o PSSDÕ (Pressure-Specified Sensory Device) para avaliar os limiares de sensibilidade de maneira quantitativa, em g/mm². Testadas três áreas da pele: polpa do hálux, dorso do pé e parte medial do calcâneo, incluindo-se quatro testes, um ponto estático, um ponto dinâmico, dois pontos estáticos e dois pontos dinâmicos. RESULTADOS: A distância média de discriminação de dois pontos em mm foi superior nos pés com úlceras, mas a diferença entre os membros inferiores teve significância estatística apenas para o hálux. Com o PSSDÕ, todos os pacientes tiveram limiares de pressão superior nos pés com úlcera, em comparação com os pés sem úlcera, em todos os testes e com significância estatística. CONCLUSÃO: O PSSDÕ foi capaz de diferenciar níveis de sensibilidade entre membros com e sem úlcera em pacientes diabéticos, com significância estatística.

INTRODUCTION: To determine and compare thresholds of cutaneous sensitivity of lower extremities in diabetic patients with an ulcer on only one lower extremity. METHODS AND MATERIALS: The study group included 20 patients with mean age of 61.6 and average time with diabetes of 12.4 years. All patients were previously tested using Semmes-Weinstein monofilament 5.07. Sensitivity was evaluated using the two point discrimination test and the PSSDÕ (Pressure-Specified Sensory Device) in order to assess touch thresholds in a quantitative manner, in g/mm². Three skin areas were tested: hallux pulp, dorsum of foot and medial heel, including four tests: 1 point static, 1 point moving, 2 points static and 2 points moving. RESULTS: Mean 2 point discrimination distance in mm was higher in feet with ulcers, but the difference between extremities was only statistically significant for the hallux. With the PSSDÕ, all patients had higher pressure thresholds in feet with ulcers when compared with feet without ulcers, in all tests, with statistical significance. CONCLUSION: The PSSDÕ was able to differentiate levels of sensation between extremities with and without ulcers in diabetic patients, with statistical significance.

Plantar pressure distribution patterns during gait in diabetic neuropathy patients with a history of foot ulcers

OBJECTIVE: To investigate and compare the influence of a previous history of foot ulcers on plantar pressure variables during gait of patients with diabetic neuropathy. INTRODUCTION: Foot ulcers may be an indicator of worsening diabetic neuropathy. However, the behavior of plantar pressure patterns over time and during the progression of neuropathy, especially in patients who have a clinical history of foot ulcers, is still unclear. METHODS: Subjects were divided into the following groups: control group, 20 subjects; diabetic neuropathy patients without foot ulcers, 17 subjects; and diabetic neuropathy patients with at least one healed foot ulcer within the last year, 10 subjects. Plantar pressure distribution was recorded during barefoot gait using the Pedar-X system. RESULTS: Neuropathic subjects from both the diabetic neuropathy and DNU groups showed higher plantar pressure than control subjects. At midfoot, the peak pressure was significantly different among all groups: control group (139.4±76.4 kPa), diabetic neuropathy (205.3±118.6 kPa) and DNU (290.7±151.5 kPa) (p=0.008). The pressure-time integral was significantly higher in the ulcerated neuropathic groups at midfoot (CG: 37.3±11.4 kPa.s; DN: 43.3±9.1 kPa.s; DNU: 68.7±36.5 kPa.s; p=0.002) and rearfoot (CG: 83.3±21.2 kPa.s; DN: 94.9±29.4 kPa.s; DNU: 102.5±37.9 kPa.s; p=0.048). CONCLUSION: A history of foot ulcers in the clinical history of diabetic neuropathy subjects influenced plantar pressure distribution, resulting in an increased load under the midfoot and rearfoot and an increase in the variability of plantar pressure during barefoot gait. The progression of diabetic neuropathy was not found to influence plantar pressure distribution.

Problemas en los pies de los pacientes con diabetes (segunda entrega): evaluación y manejo de las infecciones / Feet problems in diabetic patients (second part): evaluation and management of infections

La afección del pié en los pacientes con diabetes constituye por su importancia una entidad en si misma. En el espectro de su afectación encontraremos desde simples cambios en la sensibilidad y el trofismo de la piel, hasta úlceras de diferente magnitud, lesiones necróticas y osteomielitis, que pueden conducir a amputaciones y aún, comprometer la vida del paciente. En una entrega anterior desarrollamos aspectos generales del pié en las personas con diabetes y en particular, el abordaje de las ulceras no infectadas. En esta entrega se profundiza sobre el abordaje y manejo de las infecciones del pie, particularmente de las lesiones ulceradas y la osteomielitis.

Prevention-of-impairment-and-disabilities activities in leprosy after integration: role for physical medicine and rehabilitation personnel.

Referral options for specialist care for prevention of impairment and disabilities are imperative in order to make an integrated leprosy control system work. This requires an understanding of the disease, in addition to the special skills for managing specific disabilities. Physical medicine and rehabilitation (PMR) personnel are better equipped to handle leprosy-related disabilities. They are well versed with biomechanical aspects of deformities, and are competent to provide splints, orthoses, etc. to the needy persons, and they can assess sensory motor functions and deformities. If PMR personnel can be trained in deformity correction they can become valuable resource persons for secondary and tertiary care of leprosy-affected persons. PMR persons, therefore, have the opportunity to volunteer themselves for this job to fill the void created by the fading out of leprosy surgeons. They will also have to bear additional responsibility to train general health care workers so as to empower them to look after the needs of those disabled by leprosy, many of whom will continue to be available for a number of years to come.

Foot abnormalities in diabetics: prevalence and predictors in Basrah

Diabetic foot abnormalities are clearly one of the most important complications of diabetes mellitus [DM] and the leading cause of hospitalization with substantial morbidity, impairment of quality of life, and engender high treatment costs. The aim of this study was to estimate the prevalence of diabetic foot abnormalities among patients with type 2 DM and the predictors of these abnormalities in Basrah. This was a cross sectional study of patients attending the out patient clinic of two hospitals in Basrah [the General and the Teaching] for the period from January to the end of December 2005. All patients had type 2 DM. The total number of patients was 182 [80 males and 102 females]. Diabetic foot abnormalities were reported in 46.7% of patients. Most patients had more than one abnormality. Structural foot abnormalities reported in diabetic patients were prominent metatarsal heads in 36.2%, wasting in 11.5% hammer toes in 10.9%, pes cavus in 5.4%, claw toes in 3.8%, and amputees in 2.1%. While skin changes included dryness of the skin in 17%, fissures in the skin in 14.7%, callosities in 14.2%, Tinea pedis in 13.7%, foot ulcer in 13.7% and nail changes in 7.1%. Peripheral neuropathy and dermopathy were seen in 21.9% and 6% respectively. Variables predicting foot abnormalities were higher age, male sex, less school achievement, longer duration of DM, higher BMI, smoking history, low social class, insulin use, hypertension, heart failure and proteinuria

Análise retrospectiva dos pés de pacientes diabéticos do ambulatório de diabetes da Santa Casa de Belo Horizonte, MG / Retrsopective analysis of diabetic feet from patients followed in the diabetic clinic at Santa Casa of Belo Horizonte, MG

O pé diabético é uma das complicaçöes mais comuns do diabetes, causando uma queda significativa da qualidade de vida dos pacientes vulneráveis, além de seu elevado custo econômico. No presente trabalho, analisamos, retrospectivamente, 234 pacientes diabéticos no ambulatório de pé diabético, através de exames clínico-laboratoriais e avaliaçäo dos pés utilizando o monofilamento de l0g Semmes Weinstein, martelo neurológico básico, doppler vascular e pedígrafo. Os pacientes foram catalogados quanto à idade, sexo e duraçäo do diabetes sendo que a média foi de 10 anos de doença. Observamos que, inicialmente, mais de 30 por cento dos pacientes apresentavam perda da sensibilidade protetora, calosidades e lesöes dermatológicas, todas fatores de risco para o desenvolvimento de úlcera de pé. Notou-se ainda a desinformaçäo sobre a doença. Em resumo, os dados do trabalho mostram uma grande prevalência de alteraçöes e os autores alertam para a importância do atendimento enfocando os pés dos pacientes visando uma assistência global e preventiva para evitar complicaçöes futuras.

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.

A case of hereditary sensory and autonomic neuropathy (HSAN) type II.

We describe a case of hereditary sensory and autonomic neuropathy (HSAN) type II in a child with a penetrating foot ulcer, acral sensory impairment, and anhidrosis. This is the first documentation of HSAN in Sri Lanka.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part IV. Use of medial leg flap and medial knee flap.

The medial leg flap, based on the cutaneous branches of the posterior tibial artery is raised from the middle and lower regions of the medial aspect of the leg. It has a long pedicle, and it can be used as a free flap to reconstruct the distant soft tissue defects and also as an island flap. We have used this retrograde island flap for surfacing ulcerated areas in six leprosy patients. The flap survived in all cases. At 24 to 60 months follow-up examination, ulceration had not recurred in any of them. The medial knee flap consisting of the skin and subcutaneous tissue of the lower part of the medial side of the thigh and the upper part of the leg, is suitable for covering soft tissue cushion defects of the extremities because of the constant vessels, long pedicle, wide diameter, well-recognizable sensory nerves and less subcutaneous fat. We have used the medial knee flap for the resurfacing sizeable raw areas due to ulceration in three leprosy patients. The flap survived in all cases and there was no recurrence of ulceration during the 70-148 months follow-up period.

Techniques for covering soft tissue defects resulting from plantar ulcers in leprosy: Part III. Use of plantar skin or musculocutaneous flaps and anterior leg flap.

Anatomical studies suggest that five types of plantar flaps namely, the lateral and medial plantar flaps, the Abductor hallucis-, the Flexor digitorum brevis-, and the Abductor digiti minimi-myocutaneous flaps, can be incised from the central section of the sole. The advantages of a plantar flap are recognizable neurovascular bundles of the sole, wide calibre of constantly located blood vessels, identical histological structure of the donor and the recipient sites, hidden donor site and absence of functional deficit. We have used the plantar flaps in seven cases. There has been no recurrence of ulceration in any of them during the follow-up period of 12 to 108 months. An anterior leg flap based on the cutaneous branches of the anterior tibial artery, with firmly anchored vessels, a long pedicle with wide vessels may be used not only as a free flap graft for reconstruction of moderate degree distant defects but also as a retrograde island flap graft for the reconstruction of adjacent tissue defect. We have used the retrograde island flap graft based on the anterior tibial artery in five cases of plantar ulceration with satisfactory results. There was no recurrence of ulceration during the follow-up period of 48 to 72 months.

Neoplastic transformation of chronic ulcers in leprosy patients--a retrospective study of 23 consecutive cases.

A retrospective analysis of chronic ulcers among leprosy patients seen over the last 20 years yielded 23 cases of neoplastic transformation. It showed a peak at the sixth decade, an incidence of 3.66/100 among hospitalised ulcer cases and male/female ratio of 1.6:1. Borderline tuberculoid was the most common type of leprosy involved (40%). Squamous cell carcinoma was the most common neoplasia. Its usual site was plantar ulcers. Heel ulcers showed relatively greater predeliction for malignancy (38.5%). Histopathological proof of malignancy is desirable and that may require multiple biopsies. Metastasis is rare but potentially fatal. The surgical treatment must provide a functional, trouble-free limb. Forefoot or Lisfranc's amputation for distal third ulcers and below-knee amputation for large midfoot and ulcers are procedures of choice. Wide excision may be used in select cases.