Post polio residual paralysis PPT

POST POLIO RESIDUAL PARALYSIS
Presented by: Moderator
Dr. M. Sai krishna Dr.M.Pardhasaradhi
MS(ortho)
ANDHRA MEDICAL COLLEGE , VSKP

• Etymology
• Historical aspects
• Pathology
• Course of disease
• Pattern of deformities
• Principles of management
• Deformities of individual joints
• POST POLIO SYNDROME

Etymology
• The term derives from the Ancient
Greek poliós meaning "grey", myelós,
referring to the grey matter of the spinal cord,
and the suffix -itis, which
denotes inflammation., i.e., inflammation of
the spinal cord’s grey matter.

HISTORICAL ASPECTS
• The first description of paralytic poliomyelitis
was given by Underwood 1789.
• Causative org was found to be polio virus
identified by Karl Landsteinar in 1908.
• The first polio vaccine was developed in the
1950s by Jonas Salk.

• World Polio Day (24 October) was established
by Rotary International to commemorate the
birth of Jonas Salk.
• Albert Sabin developed live attenuated, oral
polio vaccine (OPV).

Introduction
• Polio is caused by poliovirus, that initially
invade the gastrointestinal tract and
subsequently spread to the central nervous
system (CNS).

Pathology
• Poliovirus multiplies in the intestinal wall and
then is disseminated throughout the body
through blood circulation.

• Poliovirus has a specific affinity for the anterior
horn cells. This causes lower motor neuron
type of flaccid paralysis and normal sensation.
The cells undergo necrosis.
• Cell recovery depends on the extent of
damage.
• With minimal damage, the cells recover
completely.
• Necrotic bodies are subsequently replaced by
scar tissue.

Introduction
Infectious disease characterized by
Asymmetric flaccid motor paralysis
• Clinical manifestations:
1. asymptomatic infection (90-95%)
2. abortive poliomyelitis
3. non paralytic polio myelitis
4. paralytic polio myelitis (1%)

The course of the disease
• The course of the disease is subdivided into
the following stages.
• 1. The acute phase (lasting from 5 to 10 days)
is the period of acute illness when paralysis
may occur
• 2. The convalescent phase or recovery phase
encompasses the period following the acute
phase, during this time a varying degree of
spontaneous recovery in muscle power takes

• 3. The chronic or residual phase is the final
phase. The residual paralysis is permanent. It
encompasses the rest of the patient’s life-
span.

Distribution
• Lower limb 92 %
• Trunk + LL 4 %
• LL + UL 1.33 %
• Bilateral UL 0.67 %
• Trunk + UL + LL 2 %

• This is explained by the fact that some
muscles have a short column of cells in the
spinal cord and others have long columns.
• Those with short columns develop complete
paralysis.

• Inaccessibility to medical care to majority of
childrens have led to large number of people
with moderate to severe deformalities.
Progressive deformities in residual
phase.

CAUSES OF PROGRESSIVE DEFORMITY
• MUSCLE IMBALANCE
• UNRELIEVED MUSCLE SPASM
• GROWTH
• GRAVITY AND POSTURE
• BONY DEFORMITIES

CAUSES OF PROGRESSIVE DEFORMITY
MUSCLE IMBALANCE –
• Flaccid paralysis is the main cause of
functional loss and muscle imbalance .
• when a muscle or a group of muscle is
paralysed,the opponent strong muscle pull the
joints to their side.

UNRELIEVED MUSCLE SPASM
• Muscle spasm,” a principal manifestation of
poliomyelitis in its early stages, is
characterized by protective contraction of the
muscles to prevent a potentially painful
movement
• This can be prevented by passive stretching
and splinting.

GROWTH
• Bony growth depends upon the stimulus by
active healthy stretching around the growth
plate , which is lacking in case of polio affected
childrens causing limb length inequality ,
attenuation of blood vessels and reduced
blood supply leading to reduced growth of the
bone.

GRAVITY AND POSTURE
• Gravity plays an important role in maintaining
the posture and deformity.
• Paralysed group of muscles are not in a
position to maintain posture.

• Bony Deformities
• Apart from deformities due to soft tissue
stretching and contracture, bony deformities
duly occur in polio patients over a period of
time.
• eg:, genu valgus due to persistent iliotibial
band contracture which subsequently lead to
subluxation at the knee.

HOW TO RECOGNIZE PARALYSIS CAUSED BY
POLIO
• Paralysis (muscle weakness):
– usually begins when the child is small, often during an
illness like a bad cold with fever and sometimes diarrhea
– Intact sensory system asymmetrical paralysis of the
muscles depending upon the segment of the spinal cord
involved.
– Paralysis is of the ‘floppy’ type (not stiff). Some muscles
may be only partly weakened, others limp or floppy

• In time the affected limb may not be able to straighten all the
way, due to shortening, or ‘contractures’, of certain muscles.
• The muscles and bones of the affected limb become thinner
than the other limb. The affected limb does not grow as fast,
and so is shorter.

• Unaffected arms or legs often become extra
strong to make up for parts that are weak.
• Knee jerks and other tendon reflexes in the
affected limb are reduced or absent

DEFORMITIES
• Vary according to degree of muscle imbalance,
or if patient presented in early phase or late
phase.
• Early stage
– Child is febrile with rigidity of neck and tender
muscles.
– Asymmetric involvement

• Most Severely Paralysed Muscle
- Tibialis Anterior
• Most common muscle Paralysed
- Quadriceps femoris
• Most commonly involved muscles in Upper Limb
- Deltoid and Opponens

• Late stage:
– Paralysis may result into wasting weakness.
– The common deformity at hip is flexion-abduction-
external rotation.
– The common deformity at knee is flexion, in severe
cases triple deformity comprising of flexion, posterior
sublaxation and external rotation.
– At foot equino varus is commonest others may be
equino valgus calcaneo valgus and calcaneo varus.

OTHER COMMON DEFORMITIES
• Weight bearing (supporting the body’s weight)
on weak joints can cause deformities.

Clinical Examination of a Polio
Patient
• The clinical assessment of a polio affected
patient is most important for phasing the
course of management taking into
consideration the residual muscle power, age
of the patient, severity of the deformities,
ambulatory status, socioeconomic
background.

CONTD
• Radiographic examinations of the joints are
essential, both weight bearing and non-weight
bearing to know the status of the joints in
terms of subluxation/dislocation to ascertain
the stability of the joints.

• Ambulatory Status
• Observation of Gait/Gait Analysis
 Abductor Lurch
 Extensor Lurch
 Hand to Knee Gait
 The Calcaneus Gait
 Foot Drop Gait
 Short Limb Gait

• Examination of the Joint
• Muscle Charting
 Grade 0 total paralysis (no contraction palpated)
 Grade 1 evidence of slight contractility but no joint movement
 Grade 2 complete range of motion with gravity eliminated
 Grade 3 complete range of motion against gravity
 Grade 4 complete range of motion against some resistance
 Grade 5 complete range of motion against maximal resistance

Differential diagnosis of post polio
paralysis

Prognosis
Prognosis depends on two factors:
• i. severity of initial paralysis, and
• ii. diffuseness of its regional distribution.

• If total paralysis persists beyond the second
month, significant recovery is unlikely.
• If the initial paralysis is partial, prognosis is
better.
• In general, the more extensive the paralysis in
the first 10 days of illness the more severe the
ultimate disability.

Management
• Management starts with diagnosis & accurate muscle
charting (assessing power & deformities)
• Discussion of expectations
• Assessment resources
• Family support

Management in convalescent phase
Objectives
Attainment of maximal recovery in individual
muscles.
Restoration and maintainence of normal range
of joint motion
Prevention of deformities
Achievement of as good a physiological status
of the neuromusculoskeletal system

Prevention of deformity
• firm rubber matress
• bed boards to be placed beneath matress and
should be hinged to permit sitting in the later
convalescent phase.
• Padded footboard to maintain ankles in
neutral position.
• Alternating change of position for maintaience
of good muscle tone of gluteus maximus and
erector spinae.

contd
• Knees should be held in slight flexion with
padded rolls under knee and behind the ends of
proximal tibia to prevent genu recurvatum and
posterior subluxation of knee.

• External rotation of thighs to be prevented.
• All the joints of the limbs are carried passively
through the ROM to relieve muscle pain.

MANAGEMENT OF MUSCLE SPASM
• Muscle spasm is protective contraction of
muscle to prevent potentially painful
movement.
• They are due to inflammatory changes in the
posterior ganglia and meninges.
• Application of moist heat intermittently.

General Principles—Principles of
Management of Polio Deformities
1. Strengthening of the unaffected muscles,
stretching of the shortened muscles.
2. Range of motion exercises of joints
3. Appropriate use of orthosis and splints, gait
and walking aids.

contd
4. Early correction of deformities not amenable
to conservative line of treatment by soft tissue
release procedures.
5. Restoring muscle balance by tendon
transfers.
6. Adequate compensation for equalizing the
leg length by modification in the footwear.

7. Stabilization of the joints by bony
blocks/arthrodesis and soft tissue plications.
8. Limb length equalization by limb
lengthening/ shortening.
9. Correction of bony deformities at an early
stage.

10. Special mention needs to be made regarding
management of pelvic obliquity and scoliosis
which are decompensating involving pelvis.

• PHYSICAL THERAPY
• SURGICAL TREATMENT

PHYSICAL THERAPY
In the residual stage the physical therapy
regimen is directed toward:
• Increasing motor strength of muscle by active
hypertrophy excercises.
• Preventing or correcting deformity by passive
stretching.
• Achieve maximum functional activity.

Active hypertrophy excersices
• Progressive resistance exercises entail the use
of activity graded in proportion to the
strength of the involved muscles; they are
recommended in the residual stage of
poliomyelitis to increase the strength and
improve the endurance of such individual
muscles or groups of muscles as a “fair”.

Passive Stretching Exercises
• When a limb is continuously maintained in
one position, contracture and fixed deformity
will develop as a result of the effects of gravity
and dynamic imbalance of muscles.
• Passive stretching exercises should be
performed gently.

Functional Training
• The purpose of a functional training program
is to enable the patient to overcome the
handicaps imposed by the physical disability.
• At times the activity of stronger muscles is
suppressed to prevent the development of
deformity.

ORTHOSES AND OTHER
APPARATUS
• Use of an apparatus may be necessary during
the asensitive period of the convalescent
stage and the residual stage of poliomyelitis.

• The primary objectives of the orthosis are :
to (1) support the patient and enable the patient
to walk and increase functional activity,
(2) protect a weak muscle from overstretching,
(3) augment the action of weak muscles or
substitute for those completely lost,
(4) prevent deformity and malposition, and
(5) correct deformity by stretching certain groups
of muscles that have been contracted.

General Principles of Orthosis
• Locomotion without an orthosis but with the
support of crutches should be attempted in
order to stimulate active muscular function
through the exercise of walking.
• Use of an orthosis should not, however, be
postponed if deformities appear likely to
develop from the stress of weight bearing

• In general, use of an orthosis should be as
minimal as the condition permits.
• The patient should understand clearly that
wearing the orthosis will help her in the early
convalescent stage of the disease and that it
may be discarded at a later date after training
or reconstructive surgery.

Specific Applications
LOWER EXTREMITY
Paralysed
muscle/group
Orthoses used
toe extensor and anterior tibial muscles dorsiflexion-assist spring orthosis
gastrocnemius and soleus muscles plantar flexion–assist spring below-knee
orthosis with a dorsiflexion stop at neutral
position
flail ankle and foot double-action ankle joint (both plantar
flexion–assist and dorsiflexion-assist), a varus
or valgus T-strap is added to the shoe

Paralysed
muscle/group
Orthoses used
knee above-knee orthosis with a drop-lock knee
joint is prescribed
genu recurvatum results from paralysis of
the triceps surae in the presence of some
strength of the quadriceps femoris
above-knee orthosis with a free knee joint
constructed so that complete extension of
the orthosis at the knee is prevented
flexion deformity of the knee is present as
a result of dynamic imbalance between the
hamstrings and quadriceps femoris
muscles,
Engen extension knee orthosis

UPPER EXTREMITY
Paralysed muscle/group Orthoses used
paralyzed shoulder muscles, particularly
the deltoid
sling, which allows functional use of the
forearm and hand. During the initial
period of 6 to 8 weeks, an abduction
shoulder splint may be worn at night and
during part of the day to prevent
overstretching of the deltoid muscle,
particularly when there is associated
paralytic subluxation or dislocation of the
shoulder joint.
wrist extensors are paralyzed cock-up wrist splint
weakness of the opponens of the thumb. opponens splint
intrinsic muscles of the hand are
paralyzed
, hyperextension of the
metacarpophalangeal joints is prevented
by a knuckle-bender dynamic splint.

• A multitude of operative procedures can be
performed both for the correction of paralytic
deformities and for the total physical
rehabilitation of a child with poliomyelitis.
These procedures may include
fasciotomy,
capsulotomy,
 tendon transfers,
 osteotomy, and
arthrodesis.

Tendon Transfers
• Tendon transfer entails shifting the insertion
of a muscle from its normal attachment to
another site to replace the active muscular
action that was lost by paralysis and to restore
dynamic muscle balance.

Principles of Tendon Transfer
1. The muscle to be transferred must have
adequate motor strength to carry out the new
function. Ordinarily, one grade of motor power
is lost after a muscle is transferred.
2. The range of motion of muscles must be similar
to that of the muscles for which they are being
substituted; furthermore, whenever muscles are
transferred in combination, their range of
contraction should not differ significantly.

3. The joints on which the transferred muscle is
to act should have functional range of
motion. All contractural deformity should be
corrected by wedging casts or soft tissue
release before tendon transfer.
4. The neurovascular supply of the transferred
muscle must not be damaged while
transferring the tendon

5. A smooth gliding channel with adequate
space must be provided for excursion of the
tendon in its new location. The paratenon and
synovial sheath are preserved over the tendon
surface during dissection. It is preferable to
pass the tendon beneath the deep fascia
through tissues that permit free gliding rather
than subcutaneously

6. In rerouting of the tendon, a straight line of
contraction must be provided between the
origin of the muscle and its new insertion.
Angular courses and passages over pulley
systems should be avoided

7. The tendon should be reattached to its new
site under sufficient tension so that the
transferred muscle will have a maximal range
of contraction. The transferred muscle should
be tested during the operation to ensure that
it will hold the part in optimal position.

ARTHRODESIS
• A relaxed or flail joint is stabilized by
restricting its range of motion.
• The object of arthrodesis in patients with
poliomyelitis is to reduce the number of joints
the weakened or paralyzed muscles must
control.

When to operate
Wait for atleast 1 ½ yrs after paralytic attack
 Tendon transfer done in skeletally immature
 Extra articular arthrodesis 3-8 yrs
Tendon transfer around ankle & foot after 10
yrs of age can be supplemented by arthrodesis
to correct the deformity.
Triple arthrodesis >10 yrs
Ankle arthrodesis >18 yrs

Postoperative Care and Training
• Support of the part in an overcorrected
position should be continued until the muscle
has assumed full function and there is no
tendency for the deformity to recur.
• A bivalved cast or an orthosis will hold the
transferred tendon in a relaxed position.

• It is best to teach the patient preoperatively to
localize active contraction in the muscle to be
transferred.
• Active exercises are continued
postoperatively as soon as the reaction to
surgery and pain have subsided.
• When tendon transfer is combined with
arthrodesis, muscle reeducation is delayed
until adequate bony union has taken place.

Pathomechanics:
• When gluteus maximus is paralyzed the
patient is unable to rotate the pelvis
backwards. The result is that in the supporting
phase of the affected limb, the trunk has to be
thrown backward at the hip joint, the anterior
muscles of the hip and the iliofemoral
ligaments act as a check.
Hip deformities

• Paralysis of abductors which stabilize the
pelvis during stance phase, in the frontal
plane, fail to do so effectively, thereby causing
drop of pelvis on the other side, which is
popularly referred to as Trendelenburg test,
and bilaterally affections typically lead to
wadding gait.

Hip Deformities may be as a result of:
I. Maintenance of wrong posture during acute
and convalescent phase. The frog posture
that the children tend to assume —
abduction external rotation of the hip and
knee in flexion
II. Muscle imbalance — contracture of
abductors — Tensor fascia lata and anterior
fibres of gluteus medius.

• Paralysis of the muscles around the hip can
cause severe impairment
–Flexion and abduction contractures of the
hip.
–Paralysis of the gluteus maximus and
medius muscles.
–Paralytic hip dislocation

Iliotibial band contracture
• The iliotibial band contracture produces flexion deformities of
the hip and knee on the same side.
The three-pronged attachment of the
upper part of the iliotibial band to
the iliac crest. There is a middle
prong (A) through the aponeurosis
over the gluteus medius, an anterior
one (B) through the tensor fasciae
latae, and a posterior one (C)
through the gluteus maximus.
Proximally, the location of the
iliotibial tract is anterior and lateral
to the axis of the hip, whereas
inferiorly, in a normal knee, it inserts
on the tibia well in front of the axis of
the knee joint.

• Straight-leg raising usually is limited.
• The patient assumes the frog position, with the knees and
hips flexed and the extremities completely externally rotated.
When this position is maintained for even a few weeks,
secondary soft tissue contractures occur; a permanent
deformity develops

• Flexion, abduction, and external rotation contracture
of the hip.
• The iliotibial band lies lateral and anterior to the hip joint,
and its contracture can cause flexion and abduction
deformity. The hip is externally rotated for comfort and, if
not corrected, the external rotators of the hip contract and
contribute to a fixed deformity

• Genu valgum and flexion contracture of the knee:
– With growth, the contracted iliotibial band acts as a taut
bowstring across the knee joint and gradually abducts and
flexes the tibia

Iliotibial band contracture deformities
• Limb-length discrepancy:
– Although the exact mechanism has not been clearly
defined and may be related more to the loss of
neurological and muscle function, a contracted iliotibial
band on one side may be associated with considerable
shortening of that extremity after years of growth.

• External tibial torsion, with or without knee joint
subluxation:
– Because of its lateral attachment distally, the iliotibial band
gradually rotates the tibia and fibula externally on the
femur; this rotation may be increased if the short head of
the biceps is strong. When the deformity becomes
extreme, the lateral tibial condyle subluxates on the lateral
femoral condyle and the head of the fibula lies in the
popliteal space.

• Secondary ankle and foot deformities:
– With external torsion of the tibia, the axes of the ankle and
knee joints are malaligned, causing structural changes that
may require surgical correction.

• Pelvic obliquity:
– When the iliotibial band is contracted, and the patient is
supine with the hip in abduction and flexion, the pelvis
may remain at a right angle to the long axis of the spine
– When the patient stands , the affected extremity is
brought into the weight-bearing position (parallel to the
vertical axis of the trunk), the pelvis assumes an oblique
position The iliac crest is low on the contracted side and
high on the opposite side.

• The trunk muscles on the affected side lengthen, and the
muscles on the opposite side contract. An associated lumbar
scoliosis can develop. If not corrected, the two contralateral
contractures (the band on the affected side and the trunk
muscles on the unaffected side) hold the pelvis in this oblique
position until skeletal changes fix the deformity

• Increased lumbar lordosis:
– Bilateral flexion contractures of the hip pull the proximal
part of the pelvis anteriorly; for the trunk to assume an
upright position, a compensatory increase in lumbar
lordosis must develop.

Positional Pes Varus.
• Positional pes varus results from an ill-fitted orthosis
that fails to compensate for the external tibial torsion.
• The axes of the knee and ankle joints do not occupy
the same horizontal plane in external torsion of the
tibia.
• When an above-knee orthosis manufactured with
these joints in the same horizontal plane is fitted to a
limb with external tibial torsion, the appliance will
force the foot into varus position so that the ankle is in
line with the knee joint

• Bivalved Casts.
• Passive Stretching Exercises.
Conservative Treatment

Surgery
• For abduction and external rotation
contractures, a complete release of the hip
muscles (Ober-Yount procedure) is indicated

Ober-Yount procedure
• Iliopsoas tendon, sartorius, rectus femorus, tensor fasciae
latae, gluteus medius and minimus

COMPLETE RELEASE OF MUSCLES
FROM ILIAC WING AND TRANSFER
OF CREST OF ILIUM

PARALYSIS OF THE
GLUTEUS MAXIMUS AND MEDIUS
• Paralysis result in unstable hip and an unsightly and fatiguing
limp.
• During weight bearing on the affected side when the gluteus
medius alone is paralyzed, the trunk sways toward the
affected side and the pelvis elevates on the opposite side (the
“compensated” Trendelenburg gait).
• When the gluteus maximus alone is paralyzed, the body
lurches backward

Treatment
• POSTERIOR TRANSFER OF THE ILIOPSOAS FOR PARALYSIS OF
THE GLUTEUS MEDIUS AND MAXIMUS MUSCLES

• Lowmans’s procedure
Ext oblique abdominal muscle to greater
trochanter

PARALYTIC DISLOCATION OF THE HIP
• If a child contracts limbs in poliomyelitis before age of 2 years,
and the gluteal muscles become paralyzed but the flexors and
adductors of the hip do not, the child may develop a paralytic
dislocation of hip.
• Muscle imbalance , coxa valga, laxity of capsule.
• Dislocation also can develop because of fixed pelvic
obliquity,in which the contralateral hip is held in marked
abduction, usually by a tight iliotibial band or a structural
scoliosis

Treatment
• Reduction of the hip in young children often can be achieved
by simple abduction, sometimes aided by open adductor
tenotomy and traction
• If the hip cannot be reduced by traction, open reduction and
adductor tenotomy may be required,
• In combination with primary femoral shortening, varus
derotation osteotomy of the femur, and appropriate
acetabular reconstructions

SURGICAL TREATMENT
• Dynamic balance about the hip is restored by
appropriate muscle transfers.
Age of onset of paralysis
<2 years Iliosoas transfer at the age 4-5 yrs. If the
coxa valga deformity is greater than 150
degrees, it is best to correct the
deformity and obtain a femoral neck–
shaft angle of 110 degrees before
iliopsoas transfer.
>2years iliopsoas transfer may be postponed
and the stability of the hip monitored
periodically. When the coxa valga
exceeds 160 degrees and the femoral
head starts to subluxate laterally,
varization osteotomy is performed. In
patients younger than 6 years, the
femoral neck–shaft angle is reduced to
105 degrees; in older patients the angle
is corrected to 125 degrees.

Lloyd roberts technique of IT oblique
osteotomy

ARTHRODESIS OF THE HIP
• Fusion of the hip in poliomyelitis may increase
the ability to walk and eliminate the need for
orthotic support.
• A stiff hip burdens the spine and knee with
abnormal stress and strain.

• Ligamentous instability of the knee,
progressive lumbosacral scoliosis, and trunk
instability secondary to extensive paralysis of
the abdominal muscles are absolute
contraindications to hip fusion in
poliomyelitis.

Knee deformities
• The disabilities caused by paralysis of the muscles acting
across the knee joint
– Flexion contracture of the knee
– Quadriceps paralysis.
– Genu recurvatum
– Flail knee

Flexion contracture of the knee Genu recurvatum

Quadriceps Femoris Paralysis
• The quadriceps is commonly affected by
poliomyelitis.
• When there is slight genu recurvatum with
adequate strength of the triceps surae and
hamstring muscles, the knee is stabilized by
locking it in hyperextension .
• Patients so treated are able to walk
satisfactorily.

• During the stance phase of gait, quadriceps
weakness is compensated for by tilting the
trunk and center of gravity of the body
forward.
• The only functional disabilities are difficulty
climbing steps and running. In the presence of
knee flexion deformity, however, the knee joint
becomes unstable because it cannot be locked
in hyperextension.

MUSCLE TRANSFER
to restore knee extension power,
biceps femoris,
 semitendinosus,
sartorius,
 tensor fasciae latae, and
 adductor longus.[

Treatment
• TRANSFER OF BICEPS FEMORIS AND SEMITENDINOSUS
TENDONS

Flexion contracture of the knee
• Flexion contracture of the knee can be caused by a
contracture of the iliotibial band.
• Iliotibial band also causes genu valgum and an external
rotation deformity of the tibia on the femur.
• Flexion contracture also can be caused by paralysis of the
quadriceps muscle when the hamstrings are normal or only
partially paralyzed.

Treatment
• <15 – 20* contracture:
– Posterior hamstring lengthening and capsulotomy.
• 20-70* contracture:
– supracondylar extension osteotomy of the femur

• >70* knee flexion contracture:
– Division of the iliotibial band and hamstring
tendons,combined with posterior capsulotomy.
– Skeletal traction after surgery is maintained through a pin
in the distal tibia; a second pin in the proximal tibia pulls
anteriorly to avoid posterior subluxation of the tibia.
– Long-term use of a long-leg brace may be required to allow
the joint to remodel.

GENU RECURVATUM
• In genu recurvatum the knee is hyperextended
• Genu recurvatum from poliomyelitis is of two types
– Lack of power in the quadriceps
– The hamstrings and the gastrocnemius-soleus muscles
weakness.

GENU RECURVATUM
• Lack of power in the quadriceps:
– The quadriceps lacks the power to lock the knee in
extension; the hamstrings and gastrocnemiussoleus
usually are normal
• The hamstrings and the gastrocnemius-soleus muscles
weakness:
– These muscle weakness causes hyperextension of the knee
often followed by stretching of the posterior capsular
ligament.

GENU RECURVATUM
• The pressures of weight bearing and gravity cause changes in
the tibial condyles and in the proximal third of the tibial shaft.
• The condyles become elongated posteriorly
• Their anterior margins are depressed compared with their
posterior margins

GENU RECURVATUM
• The angle of their articular surfaces to the long axis of the
tibia which is normally 90 degrees becomes more acute.
• The proximal third of the tibial shaft bows posteriorly
• Partial subluxation of the tibia may gradually occur.
• There is frequently calcaneus deformity of foot.

Treatment
• Closing wedge osteotomy for genu recurvatum.

• TRIPLE TENODESIS FOR GENU RECURVATUM

• Other Surgical methods of correcting genu
recurvatum.
• A . Irwin's technique.
• B. Modified dome osteotomy.
• C. Open-up wedge osteotomy.

FLAIL KNEE
• The knee is unstable in all directions.
• Muscle power sufficient to overcome this instability is
unavailable for tendon transfer.
Treatment :
• Locking knee long leg knee brace.
• Knee arthrodesis

• Foot and Ankle are the most dependent parts of the
body subjected to significant amount of
deforming forces
• M.c deformities includes-
1. Claw toes
2. Cavus deformity and claw toes
3. Dorsal bunion
4. Talipes Equinus
5. Talipes Equino Varus
6. Talipes Equino Valgus
7. Talipes Calcaneus

PEABODY’S CLASSIFCATION
1. Limited extensor invertor insufficiency
2. Gross extensor invertor insufficiency
3. Evertor insufficiency
4. Triceps surae insufficiency

LIMITED EXTENSOR INVERTOR
INSUFFICIENCY
Tibialis Anterior muscle paralysis produces slowly progressive deformity
1. Equinus
2. Cavus
3. Varying degree of plano valgus
Muscle power is redistributed by transferring the EHL tendon to base of 1st
metatarsal + plantar fasciotomy.

GROSS EXTENSOR INVERTOR INSUFFICIENCY
TYPE A
-Paralysis of Extensors of toes and Tibialis Anterior in the presence
of relatively normal Tibialis Posterior muscle. Produces
-Equinus
-Equino Valgus
• Transfer of Peroneus Longus to dorsum of 1st cunieform bone.
• Talo-navicular arthrodesis is combined if deformity is fixed.

• TYPE B
– Paralysis of both Tibialis Anterior & Tibialis Posterior
and toe extensors
– Transfer of both Peroneals to dorsum of foot.

EVERTOR INSUFFICIENCY
Paralysis of Peroneal muscles producing
- Varus foot
• Deformity produce Slight to moderate impairment:
Transfer of EHL to base of 5th MT.
• Severe:- Tibialis anterior to cuboid
EHL to base of 5th MT

TRICEPS SURAE INSUFFICIENCY
• Calcaneo-Varus deformity- Tibialis posterior,FHL are
transferred.
• Calcaneo-Valgus deformity- both peroneals attached to
calcaneum
• Calcaneo-Cavus in which both invertors and evertors
are strong. transfer of peroneals,tibialis posterior tendons
to calcaneus.

CLAW TOE
• Hyperextension of MTP
and flexion of IP
• Seen when long toe
extensors are used to
substitute dorsiflexion
of ankle

Treatment: For lateral 4 toes :
Procedure 1: division of extensor tendon by z-plasty
incision,dorsal capsulotomy of MTP joint.
Procedure 2:
Girdlestone- Taylor tendon transfor
Dorsolateral incision. Divide the long flexor tendon and suture
them to lateral side of proximal phalanx to extensor expansion.

Dickson and Diveley procedure
For great toe
-EHL tendon is divided proximal to IP joint.
-Proximal end is attached to taut flexor tendons.
-Distal part of extensor tendon sutured to soft tissues on
dorsum of proximal phalanx to assist maintain opposition of
raw surfaces of IP joint.
-Arthrodesis of interphalangeal joint.

Modified Jone’s procedure
• Division of EHL proximal to IP joint
• Proximal slip fixed to neck of 1st metatarsal
• Distal slip fixed to soft tissues
• Arthrodesis of IP joint by K wire fixation

CAVUS AND CLAW FOOT
• Primary deformity is forefoot Equinus resulting in clawing of
toes.
• Clawing disappear if mild cavus of short duration is corrected.
• In severe cavus large callosities or even ulcerations may
develop beneath the metatarsal heads.
• Clawing may lead to dorsal dislocation of MTP joint
• In severe cases all plantar stuctures may contract

Conservative : metatarsal bar on the shoe, metatarsal pads.
Surgical measures:
 Division PL tendon and imbricate to PB assuming that the
deformity is due to imbalance of Tibialis Anterior and PL.
 Arthrodesis of all IP joints assuming clawing is caused by
disturbance of function of intrinsic muscles of foot.
mild cavus with clawing

moderate
• young children : Steindler’s fasciotomy
• older children : Dwyers calcaneal
osteotomy.
Japas V osteotomy

Steindler’s fasciotomy
• stripping of fat and muscles from both superficial and deep
surfaces.
• Transverse division of fascia close to calcanea attachment.
• Release of long plantar ligament extending from calcaneus
to cuboid.

Cole’s Anterior wedge osteotomy
• indicated in cavus without various or calcaneus or gross
muscle imbalance.
• Advantage : preserves mid tarsal and sub-talar joints
• Disadvantage: shortens the dorm of foot.
• Osteotomy of the navicular and cuboid and defect is closed by
elevating the forefoot.

Japas V osteotomy.
• apex of v is proximal at highest point of cavus
• lateral limb extends to cuboid
• medial limb through intermediate cuneiform to medial border of foot.
• no bone is excised
• proximal border of distal fragment is pressed plantarwards, while
metatarsal heads are elevated correcting the deformity.

Hibb’s operation
• EDL tendons is divided and proximal end is inserted to 3rd
cuneiform.
• EHL tendon is divided and fixed to neck of 1st metatarsal.
• Interphalangeal joint arthrodesis.

DORSAL BUNION
• Shaft of 1st MT is
dorsiflexed and graet toe is
plantar flexed resulting in
prominent head of 1st
metatarsal. If severe may
result in subluxation of
MTP joint.

Pathogenesis :
• Imbalance between TA and PL : normally TA raises the 1st
cuneiform and 1st MT and PL opposes this action. Unopposed
action of TA causes this deformity. Thus before the transfer of PL,
the effect of its loss on 1st MT must be considered. Every
transfer of PL should be accompanied with midline transfer
of TA to 3rd cuneform.
• Weakness of Anterior and lateral compartment muscles.
unopposed action of posterior compartment muscles causes
excessive plantar flexion of great toe.

• Wedge of bone is removed from metatarso-cuneform and
naviculo-cuneform joint.
• If TA is overactive, transfer it to 2nd or 3rd cuneiform.
• FHL is detached and brought dorsally and attached to 1st
metatarsal, converting it into a plantar flexor of metatarsal
rather than great toe.
• Subcutaneous plantar tenotomy
• capsulotomy of 1st MTP joint.
lapidus technique

• any deforming
tendon except the
FHL is divided and
transferred to
dorsum of foot to
correct MT
displacement.
Fusion of joint.
Hammond technique

• Commonest deformity
• Planter flexors are
stronger than
dorsiflexors and tight
Tendo Achilles.
• If lateral imbalance is
there Equinuovarus or
Equinovalgus may result.
TALIPES EQUINUS

MANAGEMENT :
1. No intervention : mild equinus
2. Conservative management: exercises, serial casting, orthosis and
molded shoe wear.
3 .Surgical management:
a) soft tissue procedures
b) bony procedures

Lengthening of Tendo-achillis
1. Percutaneous Tenotomy
2. Z- plasty
Tendon transfer
1. Anterior transfer of TP
2. Anterior transfer of PL, PB

Cambells Posterior bone block
operation
• Usually combined with triple arthrodesis to correct lateral
instability.
• A mechanical bone block is constituted on posterior aspect of
talus and superior aspect of calcaneus in such a manner that
it will impinge on posterior lip of distal tibia and prevent
plantar flexion.
• Dorsiflexion is preserved.
• Complications: Recurrence of deformity, degenerative
arthritis, flattening of talus, ankylosis of ankle

LAMBRINUDI PROCEDURE
• Talonavicular and Calcaneocuboid joint arthrodesis
• Wedge of bone removed from distal and plantar parts of talus, so that talus
remains in equines but rest of foot is brought to corrected position.
Complications : recurrent of deformity
residual deformity
degenerative tarsal athritis
pseudoarthrosis of talonavicular joint
flattening of talus

pantalar arthrodesis
• Surgical fusion of Tibio-talar, subtalar, talo-navicular,calcaneo-
cuboid joints.
• Indications:
• Calcaneous or Equinus deformity combined with lateral
instability of foot and whose leg muscles are strong enough to
control the foot and ankle.
• Reccurance of deformity after post. bone block or lambrinudis
• Foot deformity with unstable knee due to quadriceps palsy.

Contraindications:
• If full extension of knee is not possible
• Insufficient hamstrings or triceps to prevent genu recurvatum
• When there is Equinus / Calcaneous deformity in addition to
unstable knee, whether pantalar arthrodesis will effectively
stabilize the knee may be determined before surgery by
applying a short leg walking cast.

Talipes equino varus
• Deformity: equinus at ankle,
inversion of heel at mid
tarsal joint, adduction of
forefoot. Cavus and clawing
may develop in long
standing cases.
• Weak peroneals
• Weak Tibialis anterior
• Normal triceps surae

• Equinus thus produced increases mechanical
advantage of TP which in turn encourages the
fixation of hind foot inversion and forefoot
adduction and supination.Cavus and clawing
develop when toe extensors help to dorsiflex
the ankle.

Treatment
Young children4-8 yrs:
• Double bar brace with ankle stop
• Stretching of plantar fascia and posterior ankle structure with
wedging casting
• TA lengthening
• Posterior capsulotomy
• Anterior transfer of tibialis posterior or
• Split transfer of tibialis anterior to insertion of p.brevis (if
tibialis posterior is weak)
• Anterior transfer of medial half of tendo-calcaneous(
Caldwell)

Children >8yrs:
• Steindlers fasciotomy
• Triple arthrodesis
• Anterior transfer of tibialis posterior
• Modified jones procedure
• When TP is weak TA is transferred laterally to
midline.

Talipes equino valgus
• Tibialis anterior and
Tibialis posterior are
weak and Peroneal
longus and brevis are
strong and the triceps
sure is strong and
contracted. Triceps
surae pulls the foot
into equinus and the
Peroneals into valgus.

Treatment: skeletally immature
• Double bar brace with ankle stop
• Shoe with an arch support and medial heel wedge
• Repeated stretching and wedging cast
• TA lengthening
• Anterior transfer of peroneals
• Subtalar arthrodesis and anterior transfer of peroneals
(Grice and green arthrodesis)
Skeletally mature :
• TA lengthening
• Triple arthrodesis followed by anterior transfer of
peroneals
• Modified Jones

TALIPES CAVOVARUS
Seen due to
imbalance of extrinsic
muscles or by
unopposed short toe
flexors and other
intrinsic muscle

• Plantar fasciotomy , Release of intrinsic
muscles and resecting motor branch of medial
and lateral plantar nerves before tendon
surgery
• Peroneus longus is transferred to the base of
the second MT
• EHL is transferred to the neck of neck of 1st
MT

TALIPES CALCANEUS
Due to unopposed
action of dorsiflexors

• Plantar fasciotomy ,intrinsic muscle release before
tendon transfer
• Transfer of TP and PL and FHL tendons to calcaneous.
Green and Grice
• Posterior transfer of Tibialis Anterior ( Peabody )
• When EHL and EDL strength is good, both tibials and
peroneials can be transferred posteriorly and EHL, EDL
transferred proximally to act as dorsiflexors of ankle.
• If adequate muscles are not available, Tenodesis of
Tendoachiles to fibula is done ( Westin )

Flail foot
• All muscles paralysed distal to the knee
• Equinus deformity results because passive
plantar flexion and
• Cavoequinus deformity because – intrinsic muscle
may retain some function.
Rx:
• Radical plantar release
• Tenodesis
• In older pt mid foot wedge resection may be
required
• ANKLE ARTHRODESIS

• Biomechanical classification of the muscle
around the shoulder joint (Saha 1967)
Prime Movers 1. Deltoi
2. Pectoralis major
Bulky muscles working on
a long lever. Exert major
clavicular head force for
lifting of arm during
abduction
Superior Supraspinatus The streering group by
virtue of their insertions
close to the periphery of
the humeral articular
surface and very near the
(part) junction of the neck-
shaft axis, steer the head
on the glenoid surface.
They also exert a stabilising
force, but their lifting force
is minimal
Horizontal steerer—
anterior
Subscapularis
Horizontal steerer—
posterior
Infraspinatus , teres minor

Intermediate group—
depressors
1. Pectoralis major
(sternal head)
2. Latissimus dorsi
3. . Teres major
They rotate humeral shaft
during elevation and
depress the head towards
later part. They also exert
a weak steering force on
the head

Pattern of the upper limb paralysis (Saha, 1967)
Group Muscles involved Joint sobluxation
I Serratus anterior levator
scapulae , Rhomboids
Trapezius Deltoid Rotators
May or may not be present
II Deltoid-anterior and
midpart Rotators, Girdle
muscles-normal.
May or may not be present
III Same as group II + paralysis
of elbow flexors and
supinators
Often present
IV partial paralysis of
trapezius, serratus, etc.
geenohumerae muscles,
muscles of elbow, wirst and
fingers
Always present
V FLAIL UPPER LIMB present

Treatment by Muscle and Tendon Transfer.
Muscle Requiring
Replacement or
Reinforcement
Action Choices of Muscles for Transfer
Supraspinatus Superior glider 1.Levator scapulae (first choice
because of the direction and
length of its fibers)
2.Sternocleidomastoid
3.Scalenus anterior
4.Scalenus medius
5.Scalenus capitis

Infraspinatus Posterior glider (acting from
behind)
1.Latissimus dorsi
2.Teres major
Subscapularis Posterior glider 1.Upper two digitations of
the serratus anterior
2.Pectoralis minor
3.Pectoralis major (whole or
part)

TENDON AND MUSCLE TRANSFERS
FOR PARALYSIS OF THE DELTOID
• The classic methods of transferring a single
muscle to restore abduction of the shoulder
do not consider the functions of the steering
muscles.

Bateman trapezius transfer for
paralysis of deltoid.

Arthrodesis of the Shoulder
• Arthrodesis of the shoulder is indicated when
there is paralytic subluxation or dislocation of
the shoulder and extensive paralysis of the
scapulohumeral muscles.

prerequisites
• Because scapulothoracic motion will serve as a
substitute for glenohumeral joint motion, it is
important that the motor strength of the trapezius
and serratus anterior be normal.
• Normal function of the hand, however, is a primary
requisite.
• It is best to delay shoulder arthrodesis until after
epiphyseal closure has taken place.

• The optimum position for shoulder fusion, as
recommended by the Research Committee of
the American Orthopedic Association, is 50
degrees of abduction, 20 degrees of flexion,
and 25 degrees of internal rotation. This
position is functional in that it allows the
patient to reach the face and top of the head
with the elbow flexed.

• The shoulder should never be fused in
external rotation because the limb will be
positioned in an awkward and functionally
poor position.

• The lesser degree of abduction is functionally
compensated for by fusing it in greater internal
rotation.
• The most acceptable position of shoulder arthrodesis
in females is 30 degrees of glenohumeral abduction,
5 to 10 degrees of flexion, and 45 degrees of internal
rotation

Methods of fusion:
• 1. Intraarticular
• 2. Extra-articular
• 3. Combination of above two
• 4. Compression arthrodesis.

Postpolio Paralysis of Elbow
and Forearm

• Most operations for paralysis of the muscles
acting across the elbow are designed to
restore active flexion or extension of the joint.

MUSCLE AND TENDON TRANSFERS TO
RESTORE ELBOW FLEXION
:(1) flexorplasty (Steindler),
(2) anterior transfer of the triceps tendon
(Bunnell and Carroll),
(3) transfer of part of the pectoralis major
muscle (Clark),

Bunnell modification of Steindler
flexorplasty

Bunnell anterior transfer of triceps for
paralysis of biceps

(4) transfer of the SCM muscle (Bunnell),
(5) transfer of the pectoralis minor muscle
(Spira),
(6) transfer of the pectoralis major tendon
(Brooks and Seddon), and
(7) transfer of the latissimus dorsi muscle
(Hovnanian).

Brooks-Seddon transfer of pectoralis
major tendon for paralysis of elbow
flexors

MUSCLE TRANSFERS FOR PARALYSIS OF THE
TRICEPS
• A good triceps is essential, however, to crutch
walking or to shifting the body weight to the
hands during such activities as moving from a
bed to a wheelchair.
• POSTERIOR DELTOID TRANSFER (MOBERG
PROCEDURE)

Affections of the Wrist and Hand in
Poliomyelitis

Common Patterns of Residual Polio Paralysis
pattern thumb fingers wrist
I Weak or paralyzed
oppositions and
abduction, normal
long flexor and
extensor muscle.
Weak intrinsics,
normal long flexors
and extensors.
normal flexors and
extensors.
II Paralyzed intrinsics
and weak long
flexor and
extensors
Paralyzed intrinsics,
weak long flexors
and extensors
Normal/weak
extensors, normal
flexors (at least the
flexor carpi ulnaris-
FCU
III Completely
paralyzed except
grade 1-2 power in
the long flexor or
extensor
Paralyzed intrinsics,
partially functioning
long flexors with
grade 2-3 power in
1 or 2 fingers
WRIST DROP

Thenar muscle paralysis with normal thumb
extensor and flexor. Finger and wrist motors also functional
pattern I paralysis of polio hand

Thenar muscle paralysis, weak thumb long flexors and
extensor, paralyzed finger intrinsics, weak finger flexors, normal
wrist motors-pattern II paralysis of polio hand

Deformities
• 1. Flexion and ulnar deviation of wrist with or
without fixed contracture.
• 2. Volar subluxation of the midcarpal articulation
contributing to or the cause of the above deformity.
• 3. Thumb web contracture
• 4. Thrapeziometacarpal (or carpometacarpal) joint
contracture
• 5. MCP joint extension contracture of 2 or more
fingers

Reconstruction for Pattern I Paralysis
Opponensplasty:
• Flexor digitorum sublimis of the ring finger
opponensplasty
• Extensor carpi ulnaris (ECU) opponensplasty
• Palmaris longus (PL) opponensplasty
• Hypothenar muscle opponensplasty (Huber
1921): The abductor digiti minimi (ADM

result of
opponensplasty
using the
palmaris longus
transfer to the
rerouted extensor
polllcls brevisnote

Reconstruction for Pattern II, Paralysis
For Paralyzed Thenar Muscles
• Extensor indicis (El) opponensplasty is done if
the extensor indicis is at least grade 4 or the
PL is transferred to the rerouted distal EPS
tendon, alternatives as in pattern I.

For Paralyzed Finger Intrinsics (Claw Fingers)
• PL
• ECRL
• ECRB

Reconstruction for Pattern III,
Paralysis
1st Stage
• For thenar muscle paralysis, the
trapeziometacarpal arthrodesis for
intermetacarpal bone graft procedure isdone
to maintain thumb in fixed palmar abduction.

• For the weak finger intrinsics (claw), volar
capsulodesis is done at the same stage.
• Followed by a 3 wks of plaster immobilization.

2nd Stage (To improve flexion of the fingers and
thumb)
• The FDP tendon slips are side-stitched or
tenodesed to each other at the distal forearm
so that whatever available flexion power there
is can be evenly distributed for all fingers.

3rd Stage (Drop Wrist)
• When the pronator or a strong superficialis
tendon is available, the transfer of either of
these to the ECRB tendon provides wrist
extension.
• The available FCU or FCR can also be
transferred to the EDC and EPL for finger and
thumb extension

Comprehensive Management of
Poliomyelitis and Deformities of Foot
and Ankle with the Ilizarov Technique

• The aims of the treatment of poliomyelitis
with the Ilizarov technique are .
• 1. To achieve comprehensive correction in
minimum time
• 2. To minimize the energy expenditure of
walking and improve gait
• 3. To discard the caliper or to minimize the
extent of bracing.

To this end the technique can be used to release
contractures,
correct deformities,
achieve joint stabilization and
arthrodesis
 to perform limb lengthening.
These procedures can be performed at various
levels simultaneously

uses
• Flexion deformity of knee
• Genu recurvatum
• Shortening
• Osteotomy correction
• Foot deformity correction

• Ankle fusion
• Hind foot lengthening
• Calcaneus deformity
• Triple arthrodesis

WHO officially declares India ‘polio-
free’ 27 /03/2014
• No polio cases were reported in India for the
past three years.
• This is the fourth of six WHO Regions to be
certified, marking an important step towards
global polio eradication.
• With this step, 80 per cent of the world’s
population now lives in certified polio-free
regions.

POST POLIO SYNDROME
• When new weakness appears in muscles
previously affected by the polio and/or
muscles thought to be unaffected originally, it
may or may not be accompanied by other
symptoms. This is a crucial point to
recognize—a patient can have PPS even if new
weakness is the only symptom

REFERENCES
• TACHDJAN’s Paediatric orthopaedics
• KULKARNI TEXT BOOK OF ORTHOPAEDICS
• CAMPBELL’s OPERATIVE ORTHOPAEDICS
• PARK TXT BOOK OF COMMUNITY MEDICINE
• JOURNALS
• INTERNET

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