How our surgeons’ culture of learning, innovation, and teaching has redefined what it means to be diagnosed with leprosy
This year we are celebrating 150 years of The Leprosy Mission and as a part of these celebrations, we are reflecting on the impact of the people who have worked at The Leprosy Mission throughout our history.
In this article, we are considering the innovations and impact of The Leprosy Mission’s surgeons. Without these pioneering individuals, the reality of day-to-day life for many persons affected by leprosy would be so much harder.
Our surgeons and their teams address and heal issues that are so fundamental to a person’s sense of self and their daily lives that these patients have quite literally danced for joy after their surgeries. The story of these surgeons is of course one of innovation and a dedication to learning, but it is even more about bringing hope with healing and providing patients a new chance in life.
© Sabrina Dangol
Leprosy is one of the oldest diseases on the planet and for millennia it has been causing devastation by disfiguring and taking away some of the most basic functions of the human body.
Leprosy causes damage to the hands, eyes, and feet if it goes untreated – as it did for everyone who contracted the disease throughout most of human history until a cure was developed in the 1980s. Today we have a cure for leprosy and the disease should be stopped early, but unfortunately, many people are not treated until the disease has already begun to cause damage to the body.
HandsIn the hands, leprosy paralyses the ulnar and median nerves and the muscles, tendons, and skin become stiff. If this happens, a person loses mobility in their fingers and cannot raise their thumb. Their hands can become clawed. If this happened to you, you would not be able to hold a pen, do up a button on your shirt, or eat using a knife or fork or with your fingers.
FeetLeprosy also paralyses the muscles that are responsible for lifting the front part of your foot. This is called Foot Drop. If this happened to you, you would not be able to point your toes towards the sky. Right now, if you were to walk you would find your heel hits the floor first and then the foot rolls on to the toes, which help to spring you forward.
If you had Foot Drop, you would find that your toes would drag along the floor as you walked and the method of walking – heel to toe – would be reversed and become toe to heel. This makes walking very difficult, increases the risk of tripping, and can cause serious damage to feet.
EyesDamage to facial nerves means that patients will have difficulty closing their eyes fully. If this affected you right now, you would try to blink and find that your eyelids had a gap of at least 3mm between them. If this goes untreated, eyes can become badly damaged as dust and dirt can get in.
In these situations, the eye will not have any sensation, so it is not easy to tell that there is dirt in your eye. Over time, the lens of the eye will become scratched by this dirt and dust and you would not be able to see. It would be like looking through glasses that someone has scratched with a sharp stone.
This damage – to eyes, hands, and feet – is what our surgeons have been learning to correct over the last 60-plus years. Today, thanks to a culture of innovation, learning, and teaching that spans across generations, there is little damage that leprosy can cause which they cannot correct.
The foundation of reconstructive surgery for leprosy was laid by Dr Paul Brand in the mid-20th century. Dr Brand, who had originally trained as a carpenter, applied his mechanical skills to medicine, pioneering tendon transfer techniques that restored function to hands damaged by leprosy.
His work began in India at the Christian Medical College in Vellore, where he observed that many leprosy patients suffered not only from the disease itself but also from the resulting disabilities that severely limited their daily lives.
Dr Brand's innovative approach involved transferring tendons from functional muscles to paralysed ones, allowing patients to regain movement and functionality in their hands and feet. For the first time in the four thousand year history of the disease, the effects of leprosy could be reversed.
This breakthrough was revolutionary, as it provided a practical solution to the debilitating effects of leprosy, enabling patients to perform basic tasks and regain their independence. His work as the first generation of leprosy surgeons laid the groundwork for future advancements in the field of reconstructive surgery for leprosy.
As Dr Paul Brand and his colleagues trained the surgeons around them, they began a process of training, learning, and innovation that continues to today.
Over the past several decades, reconstructive surgery for leprosy has seen numerous advancements. Early techniques were relatively rudimentary, focusing primarily on restoring basic function. However, as surgical methods and understanding of the disease progressed, more sophisticated techniques were developed, allowing for greater precision and better outcomes.
One of the significant advancements in recent years has been the development of direct and indirect lasso techniques. These methods, refined by surgeons like Dr Dundi Vijayakumar, Dr Jerry Joshua, Dr Premal Das, Dr Indra Napit, Dr Manotosh Elkana, and others, involve intricate tendon transfers tailored to the patient's specific needs and occupational demands.
Direct Lasso Technique: This technique involves taking a tendon and directly re-routing it to the pulleys or dorsal expansion. This method is typically used for patients with hypermobile joints to prevent post-operative deformities such as swan neck deformity. It allows patients to have more direct control and better functional outcomes, particularly in patients who require strong and stable hand movements for their daily activities, like farmers or labourers.
Indirect Lasso Technique: In this method, a tendon graft, often the Palmaris longus tendon, is used to extend and enhance the functionality of another tendon. This technique is particularly useful for patients who need fine motor skills for lighter work. The Palmaris longus tendon is chosen because of its minimal adverse effects, making it a suitable candidate for grafting. This method provides flexibility and precision, crucial for tasks that require delicate hand movements, like tailors or computer mechanics.
As our surgeons have learnt from each surgery they have performed, they have been able to create nuance in their operations that was hard to imagine in the early days of reconstructive surgery. They can assess a patients’ needs and select a type of reconstructive surgery that will allow them the best quality of life possible once they leave the hospital.
As the world of leprosy surgery has grown, so too has the world of physiotherapy. Without precise and consistent physiotherapy, patients would not have tendons that are ready for surgery, nor would they recover well after surgery.
Before surgery, patients undergo specific exercises to prepare their tendons and muscles. This preparation helps to strengthen the areas that will be affected by the surgery, enhancing the overall success of the procedure.
Post-operatively, patients are placed in casts to immobilise the affected areas and allow for proper healing. Following this immobilisation period, patients undergo guided rehabilitation exercises to restore function and strength. This rehabilitation process is critical for helping patients regain use of their hands and feet, enabling them to return to their daily activities. The comprehensive care provided ensures that patients not only achieve successful surgical outcomes but also experience significant improvements in their overall quality of life.
© Fabeha Monir
While surgeons have been innovating and evolving the techniques they use to repair the damage caused by leprosy, physiotherapists have been innovating in parallel. All of TLM’s surgeons acknowledge that their work would not be effective without their partners in physiotherapy, who have had to learn to adapt as each new generation of surgeons creates new innovations.
Dr Manotosh Elkana is one of The Leprosy Mission’s surgeons in India. When he started his medical career he was not interested in becoming a reconstructive surgeon, but then he met a boy who wanted to kill himself because of his clawed hands. As he says,
“I saw that boy have his hands healed and his whole attitude towards his life changed. When I saw that, I decided I wanted to be a reconstructive surgeon.”
Dr Manotosh encountered the power of reconstructive surgery with his very first solo surgery,
“The first surgery I did on my own was for Drop Foot on a young man. I wanted it to be a success, so I was very sure about everything I did and I kept the patient in the hospital just a little longer than necessary so I could be sure I had done a good job. On the day we discharged him from the hospital we gave him the instruction to not walk on the foot for a while longer, so it would have time to heal.
“That night I started my journey home and spotted a man dancing outside the ward. I realised it was the man we had just discharged and I raced over to him. I was very angry and told him he was going to undo the work we had done in surgery.
“He was a bit scared by my reaction, but he explained that he had a new wife and a baby who had been removed from him by his wife’s family because they feared leprosy. He wasn’t allowed to see them or meet his baby until he had recovered. Because we had corrected his Foot Drop, he could be reunited with his family. And so he danced.
“That night I realised how much we can transform a life with our surgery. Over the decades that I have been a surgeon, I have seen how all of my patients have stories like these. In India alone we perform between two and three thousand reconstructive surgeries a year. Imagine how many lives have been transformed like the man who had danced for joy.
“Of course, in any country it is hard to not have basic functions like walking, holding a spoon, or doing up a button. This removes some of your dignity as a person and I am glad that we get to restore that. But in India, the stigma behind leprosy and its impairments runs deep.
“When we greet one another in India we hold our hands together in front of us like in prayer and we say ‘Namaste’. If your hands are clawed, you start each greeting knowing that your hands will not press flat together and you are marked by the people around you with stigma. Many of our patients avoid public settings for this reason. I am so proud that we can help to repair them and bring them back to their homes and communities.”
It is thanks to a culture of learning and growth amongst our surgeons that these successes are possible. Within living memory, to be diagnosed with leprosy meant you would see your body destroyed and your dignity taken and there was nothing you could do to stop it. Thanks to surgeons across The Leprosy Mission and our partner organisations, that is no longer the case.
Our challenge for the generation to come will be to find new surgeons to take on this legacy and to choose to care for those who are so often on the margins of society. It is a career that does not come with fame or fortune, but it will make men dance for joy.
Selected research papers by TLM Surgeons
Efficacy of temporalis muscle transfer for correction of lagophthalmos in leprosy >
Reconstructive surgery in children to correct ulnar claw hand deformity due to leprosy >
Peroneal strength as an indicator in selecting route of tibialis posterior transfer for foot drop correction in leprosy >
Patients' perceptions of reconstructive surgery in leprosy >
