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polio in lower extremity

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Poliomylitis:

P oliomylitis Dr Aftab Hussain

HISTORY:

HISTORY It is likely that polio has plagued humans for thousands of years. An Egyptian carving from around 1400 BCE depicts a young man with a leg deformity similar to one caused by polio. The term derives from the Ancient Greek poliós ( πολιός ), meaning "grey", myelós (µ υελός “marrow”), referring to the grey matter of the spinal cord, and the suffix - itis , which denotes inflammation.

HISTORY OF DISEASE:

HISTORY OF DISEASE The first mention of the disease as we understand it today seems to have been by Michael U nderwood in 1784, in the first edition of his treatise on the Diseases of Children. The most important part of Underwood's description is as follows: " Debility of the Lower Extremities

HISTORY:

HISTORY On October 19, 1835, Dr. John Badham , of Worksop , Notts , sent to the London Medical Gazette an article entitled "Paralysis in Childhood : Four Remarkable Cases of Suddenly Induced Paralysis in the Extremities, Occurring in Children, without any Apparent Cerebral or Cerebrospinal Lesion." This was published November 14 , 1835.

HISTORY:

HISTORY The disease was later called infantile paralysis, based on its propensity to affect children.

HISTORY:

HISTORY Three years later, Dr. Jonas Salk became a national hero when he developed the first safe and effective polio vaccine in 1955 with the support of the March of Dimes. In the two years before the vaccine was widely available, the average number of polio cases in the U.S. was more than 45,000. By 1962, that number had dropped to 910.

PATHOLOGY:

PATHOLOGY Acute poliomyelitis is caused by small ribonucleic acid (RNA) viruses of the enterovirus group of the picornavirus family. The single-stranded RNA core is surrounded by a protein capsid without a lipid envelope, which makes poliovirus resistant to lipid solvents and stable at low pH. Three antigenically distinct strains are known, with type I accounting for 85% of cases of paralytic illnesses. Infection with one type does not protect from the other types; however, immunity to each of the 3 strains is lifelong.

PATHOLOGY:

PATHOLOGY This group of RNA viruses colonize the gastrointestinal tract — specifically the oropharynx and the intestine. The incubation time (to the first signs and symptoms) ranges from three to 35 days, with a more common span of six to 20 days

Poliomyelitis Pathogenesis:

Poliomyelitis Pathogenesis Entry into mouth Replication in pharynx, GI tract, local lymphatics Hematologic spread to lymphatics and central nervous system Viral spread along nerve fibers Destruction of motor neurons

Poliomyelitis Pathogenesis:

Poliomyelitis Pathogenesis The ant. Horn motor cells may be damaged by viral multiplication or toxic byproducts of the virus or indirectly by ischemia, edema, and hemorrhage in the glial tissues. Destruction of the spinal cord occurs focally and within 3 days wallerian degeneration is evident.

Clinical course:

Clinical course Symptoms range :from mild malaise to generalized encephalomyelitis with widespread paralysis. Hyperesthesia or paresthesia in the extremities and muscular pain is common. Muscles are tender even to gentle palpation.

Poliomyelitis:

Poliomyelitis According to Sharrard, weakness is clinically detectable only when more than 60% of the nerve cells supplying the muscle have been destroyed. Paralysis occurs twice as often in the lower extremity as in upper extremity.

Poliomyelitis:

Poliomyelitis The most commonly affected muscles are the Quadriceps, glutei, tibialis anterior, medial hamstrings, and hip flexors. Deltoid, triceps, and pectoralis major.

Poliomyelitis:

Poliomyelitis Patients have some or full recovery from paralysis, most clinical recovery occurs during the 1 month and almost complete within 6 months. Limited recovery may occur for about 2 years.

Poliomyelitis:

Poliomyelitis In cases with paralysis superficial reflexes usually are absent first, and deep tendon reflexes disappear when the muscle group is paralyzed. DDX.: Guillain-Barre syndrome, and other forms of encephalomyelitis

course of poliomyelitis:

course of poliomyelitis divided into three stages: acute , convalescent, and chronic .

ACUTE STAGE:

ACUTE STAGE The acute stage generally lasts 7 to 10 days, and up to 95% of all anterior horn cells may be infected. Symptoms range from mild malaise to generalized encephalomyelitis with widespread paralysis. With upper spinal cord involvement, diaphragmatic dysfunction and respiratory compromise can be life threatening.

Acute stage treatment:

Acute stage treatment Treatment of poliomyelitis in the acute stage generally consists of bed rest, analgesics, and anatomical positioning of the limbs to prevent contractures. Gentle , passive range-of motion exercises of all joints should be performed several times daily.

Convalescent Stage:

Convalescent Stage The convalescent stage begins 2 days after the temperature returns to normal and continues for 2 years. It has been estimated that approximately half of the infected anterior horn cells survive the initial infection, and muscle power improves spontaneously during this stage, especially during the first 4 months and more gradually thereafter.

Convalescent Stage treatment:

Convalescent Stage treatment Treatment of this stage is similar to that during the acute stage. Muscle strength should be assessed monthly for 6 months and then every 3 months. Muscles with more than 80% return of strength recover spontaneously without specific therapy. According to Johnson, an individual muscle with less than 30% of normal strength at 3 months should be considered permanently paralyzed.

Chronic stage :

Chronic stage The chronic stage of poliomyelitis usually begins 24 months after the acute illness . During this time, the orthopaedist attempts to help the patient achieve maximal functional activity by management of the long-term consequences of muscle imbalance.

Goals of treatment:

Goals of treatment correcting any significant muscle imbalances . Preventing or correcting soft tissue or bony deformities.

End result of muscle imbalance:

End result of muscle imbalance Static joint instability usually can be controlled indefinitely by orthoses . Dynamic joint instability eventually results in a fixed deformity that cannot be controlled with orthoses

General treatment guidelines:

General treatment guidelines Young children are more prone to develop bony deformity than are adults because of their growth potential. Soft tissue surgery, such as tendon transfers, should be done in young children before the development of any fixed bony changes. bony procedures for correcting a deformity usually can be delayed until skeletal growth is near

Tendon transfer:

Tendon transfer Tendon transfers are indicated when dynamic muscle imbalance results in a deformity that interferes with ambulation or function of the upper extremities.

Objectives of tendon transfers:

Objectives of tendon transfers (1) to provide active motor power to replace function of a paralyzed muscle or muscles, (2) to eliminate the deforming effect of a muscle when its antagonist is paralyzed, (3) to improve stability by improving muscle balance.

Phasic or active muscles:

Phasic or active muscles Muscle transfers, whenever possible, should occur between agonistic muscles that are phasic , or active at the same time in the gait cycle.

Gait cycle:

Gait cycle swing-phase muscles anterior muscles of the leg are predominantly. the hamstrings are swing-phase muscles. stance-phase muscles Posterior muscles, or flexors, are stance-phase muscles in leg; in the thigh, the quadriceps is characteristically a stance-phase muscle.

Phasic transfer principles:

Phasic transfer principles Phasic transfers retain their preoperative phasic activities and regain their preoperative duration of contraction and electrical intensity. In contrast, nonphasic muscle transfers often retain their preoperative phasic activity and fail to assume the action of the muscles for which they are substituted and are not recommended. Some nonphasic transfers are capable of phasic conversion; however, phasic conversion is somewhat unpredictable and requires extensive postoperative physical therapy.

Lower extremity vs upper extremity :

Lower extremity vs upper extremity T he lower extremities are designed primarily to support the weight of the body, it is important that their joints are stable and their muscles have sufficient power. In the upper extremity, reach, grasp, pinch, and release require more mobility than stability and more dexterity than power.

FOOT AND ANKLE:

FOOT AND ANKLE claw toes, cavovarus foot, dorsal bunion, talipes equinus , talipes equinovarus, talipes cavovarus , talipes equinovalgus, and talipes calcaneus .

Anatomy of ankle and foot:

Anatomy of ankle and foot

Pattern of muscle paralysis and resultant deformity:

Pattern of muscle paralysis and resultant deformity Muscle paralysis Deformity Anterior Tibial Muscle slowly progressive deformity— equinus and cavus or varying degrees of planovalgus ----- cavovarus defomity finally Anterior and Posterior Tibial Muscles equinovalgus Posterior Tibial Muscle. rare but can result in hindfoot and forefoot eversion Anterior Tibial , Toe Extensor, and Peroneal Muscles severe equinovarus deformity or cavovarus deformity Peroneal Muscles Rare but hindfoot varus deformity Peroneal and Long Toe Extensor Muscles less severe equinovarus deformity Gastrocnemius-Soleus Muscles rapidly progressive calcaneal deformity

TALIPES EQUINOVARUS:

TALIPES EQUINOVARUS Anterior Tibial , Toe Extensor, and Peroneal Muscles Paralysis results into SEVER equinovarus deformity or less sever form results from parylsis of Toe Extensor, and Peroneal Muscles.

EQUINOVARUS PATHOGENESIS:

EQUINOVARUS PATHOGENESIS The posterior tibial muscle increases forefoot equinus and cavus deformity by depressing the metatarsal head and shortening the medial arch of the foot. Further equinus and varus deformity results from contracture of the gastrocnemius - soleus , which acts as a fixed point toward which the plantar intrinsic muscles pull and increase forefoot adduction.

EQUINOVARUS PATHOGENESIS:

EQUINOVARUS PATHOGENESIS equinus deformity of the ankle, inversion of the heel, and, at the midtarsal joints, adduction and supination of the forefoot.

TREATMENT:

TREATMENT Stretching by serial casting may be attempted, but lengthening of the Achilles tendon usually is required. Anterior transfer of the posterior tibial to the base of the third metatarsal or middle cuneiform can be supplemented by anterior transfer of the long toe flexors. Arthrodesis usually is not required; the deformity can be controlled by physical therapy and orthoses

Talipes EQUINOVALUS:

Talipes EQUINOVALUS Anterior and Posterior Tibial Muscles paralysis.

pathogenesis:

pathogenesis hindfoot and forefoot equinovalgus is more rapid and the deformity becomes fixed as the Achilles tendon and peroneal muscles shorten. This deformity may be similar to congenital vertical talus on a standing lateral radiograph, but the apparent vertical talus is not confirmed when a plantar flexion lateral view is obtained.

pathogenesis:

pathogenesis The gastrocnemius-soleus pulls the foot into equinus and the peroneals into valgus position; when the extensor digitorum longus and the peroneus tertius muscles are also strong, they help to pull the foot into valgus position on walking.

treatment:

treatment Serial casting is used before surgery to stretch the tight Achilles tendon and to avoid weakening the gastrocnemius - soleus . If the peroneal muscles are normal,and both tibialis muscles are paralyzed , one of the peroneal muscles must be transferred. Because of its greater excursion, the peroneus longus is transferred to the base of the second metatarsal to replace the anterior tibial and one of the long toe flexors replaces the posterior tibial .

treatment:

treatment skeletally immature foot Treatment of this deformity in a skeletally immature foot is difficult. Subtalar arthrodesis and anterior transfer of theperoneus longus and brevis tendons usually suffice until skeletal maturity is reached skeletally mature Talipes equinovalgus in skeletally mature patients usually requires triple arthrodesis and lengthening of the Achilles tendon

Talipies Cavusvarus and claw toes:

Talipies Cavusvarus and claw toes slowly progressive deformity— equinus and cavus or varying degrees of planovalgus -

pathogenesis:

pathogenesis paralysis of the anterior tibial muscle results in loss of dorsiflexion and inversion power. Or Anterior Tibial , Toe Extensor, and Peroneal Muscles paralysis. The extensors of the long toe, which usually assist dorsiflexion , become overactive in an attempt to replace the paralyzed anterior tibial muscle, causing hyperextension of the proximal phalanges and depression of the metatarsal heads. cavovarus deformity occasionally results.

Radiographs of cavus foot & claw toes:

Radiographs of cavus foot & claw toes

Claw toe treatment ( jones technique):

Claw toe treatment ( jones technique)

Modified jones technique:

Modified jones technique

claw toe deformity (Hibbs procedure):

claw toe deformity ( Hibbs procedure)

Treatment of cavovarus:

Treatment of cavovarus Plantar fasciotomy and release of intrinsic muscles may be necessary before tendon surgery for a fixed cavovarus deformity. peroneus longus is transferred to the base of the second metatarsal and the extensor hallucis longus is transferred to the neck of the first metatarsal. Osteotomies at hind,mid and forefoot to correct their respective cavus deformity.

Samilson crescentic osteotomy of calcaneus (hind foot cavus):

Samilson crescentic osteotomy of calcaneus (hind foot cavus )

Japas technique (mid foot cavus):

Japas technique (mid foot cavus )

Jahss technique:

Jahss technique

Greenstick metatarsal osteotomies(forefoot cavus):

Greenstick metatarsal osteotomies (forefoot cavus )

Calcaneal deformity:

Calcaneal deformity The gastrocnemius - soleus is a strong muscle group in the body, lifting the entire body weight with each step. Paralysis of the gastrocnemius - soleus , leaving the dorsiflexors unopposed,

pathogenesis:

pathogenesis Adequate tension of the Achilles tendon is important to the normal function of the long toe flexors and extensors and to the intrinsic foot muscles. If the gastrocnemius-soleus is weak, the posterior tibial , the peroneal muscles, and the long toe flexors cannot effectively plantar flex the hindfoot ; however, they can depress the metatarsal .

pathogenesis:

pathogenesis Shortening of the intrinsics and plantar fascia draws the metatarsal heads and the calcaneus together, similar to a bowstring. The long axes of the tibia and the calcaneus coincide, negating any residual power in the gastrocnemius - soleus .

calcaneotibial angle importance:

calcaneotibial angle importance The calcaneotibial angle is formed by the intersection of the axis of the tibia with a line drawn along the plantar aspect of the calcaneus . Normally, this angle measures between 70 and 80 degrees; in equinus deformity it is greater than 80 degrees, and in calcaneus deformity it is less than 70 degrees.

PowerPoint Presentation:

When the tenodesis is fixed at 70 degrees or more at the time of surgery, a tendency to develop a progressive equinus deformity with growth has been noted. Progressive equinus also is directly related to the patient’s age at surgery: the younger the patient, the greater the calcaneotibial angle and the more likely the development of progressive equinus deformity with subsequent growth.

calcaneotibial angle:

calcaneotibial angle

treatment:

treatment Surgical correction is indicated to prevent development of calcaneal deformity and to restore hindfoot plantar flexion. In the acute stage, the only absolute indication for tendon transfer in children younger than 5 years old is a progressive calcaneal deformity.

Treatment protocole of calcaneal deformity:

Treatment protocole of calcaneal deformity The combination of muscles transferred posteriorly depends on the residual strength of the gastrocnemius - soleus and the pattern of remaining muscle function.

Fair power:

Fair power If the motor strength of the gastrocnemius - soleus is fair, posterior transfer of two or three muscles may be sufficient for normal gait.

Completely paralysed gastrosolus:

Completely paralysed gastrosolus If the gastrocnemius - soleus is completely paralyzed, as many muscles as are available should be transferred.

tenodesis of the Achilles tendon:

tenodesis of the Achilles tendon Westin and Defiore recommended tenodesis of the Achilles tendon to the fibula for paralytic calcaneovalgus deformity

Calcaneal tenodesis:

Calcaneal tenodesis

if no invertors or evertors are present for transfer,:

if no invertors or evertors are present for transfer, the hamstrings can be used to replace the gastrocnemius - soleus . Prerequisites for this procedure include complete paralysis of the gastrocnemius - soleus , strong medial hamstrings or biceps femoris muscles, and strong ankle dorsiflexors and quadriceps muscles

DORSAL BUNION:

DORSAL BUNION In a dorsal bunion deformity, the shaft of the first metatarsal is dorsiflexed and the great toe is plantar flexed; it usually results from muscle imbalance. In its early stages, the deformity is not fixed but is present only on weight bearing, especially walking. If the muscle imbalance is not corrected, the deformity becomes fixed, although it remains more pronounced on weight bearing.

Dorsal bunion:

Dorsal bunion

Pathogenesis of dorsal bunion:

Pathogenesis of dorsal bunion Tibialis anterior strong The most common imbalance is between the anterior tibial and peroneus longus muscles. When the peroneus longus is weak or paralyzed or has been transferred elsewhere, the first metatarsal can be dorsiflexed by a strong anterior tibial muscle. Flexor hallucis strong The second and less common muscle imbalance results from paralysis of all muscles controlling the foot except the gastrocnemius - soleus group,and the long toe flexors,which are strong.

Causes of dorsal bunion :

Causes of dorsal bunion Muscle imbalance. It can develop in conjunction with a hallux rigidus . severe congenital flatfoot with a rocker-bottom deformity.

Lapidus operation:

Lapidus operation

BONY PROCEDURES (OSTEOTOMY AND ARTHRODESIS):

BONY PROCEDURES (OSTEOTOMY AND ARTHRODESIS) The object of arthrodesis in patients with poliomyelitis is to reduce the number of joints the weakened or paralyzed muscles must control. The structural bony deformity must be corrected before a tendon transfer is performed.

Traditional 5 types of foot & ankle stabilization:

Traditional 5 types of foot & ankle stabilization (1) calcaneal osteotomy , (2) extraarticular subtalar arthrodesis , (3) triple arthrodesis , (4) ankle arthrodesis , and (5) bone blocks to limit motion at the ankle joint. note: choice of operation depends upon age of the patient and the particular deformity that must be corrected

calcaneal osteotomy:

calcaneal osteotomy Calcaneal osteotomy can be performed for correction of hindfoot varus or valgus deformity in growing children.

SUBTALAR ARTHRODESIS:

SUBTALAR ARTHRODESIS extraarticular subtalar Fusion(Grice and Green) Ideally, this procedure is performed when the valgus deformity is localized to the subtalar joint and when the calcaneus can be manipulated into its normal position beneath the talus. Intraarticular subtalar fusion( Dennyson and Fulford ) a technique for subtalar arthrodesis in which a screw is inserted across the subtalar joint for internal fixation and an iliac crest graft is placed in the sinus tarsi.

Grece & Green extra articular subtalar fusion:

Grece & Green extra articular subtalar fusion

Intra articular subtalar Fusion:

Intra articular subtalar Fusion

TRIPLE ARTHRODESIS:

TRIPLE ARTHRODESIS The most effective stabilizing procedure in the foot is triple arthrodesis . fusion of the subtalar , calcaneocuboid , and talonavicular joints.

Advantages of triple arthodesis:

Advantages of triple arthodesis (1) to obtain stable and static realignment of the foot, (2) to remove deforming forces, (3) to arrest progression of deformity, (4) to eliminate pain, (5) to eliminate the use of a shortleg brace or to provide sufficient correction to allow fitting of a long-leg brace to control the knee joint, and (6) to obtain a more normal-appearing foot.

Age limit :

Age limit Generally, triple arthrodesis is reserved for severe deformity in children 12 years old and older; occasionally, it may be required in children 8 to 12 years old with progressive, uncontrollable deformity

PowerPoint Presentation:

LAMBRINDI TECHNIQUE The Lambrinudi arthrodesis is recommended for correction of isolated fixed equinus deformity in patients older than 10 years ELMSLIE TECHNIQUE

ELMSLIE TECHNIQUE :

ELMSLIE TECHNIQUE

LAMBRINDI TECHNIQUE :

LAMBRINDI TECHNIQUE

bone blocks to limit motion at the ankle joint:

bone blocks to limit motion at the ankle joint surgical procedure in which a bone graft is placed adjacent to a joint to limit motion of the joint mechanically or to improve the stability of the joint. Indication is definite paralytic foot drop with active calf muscles.

Bone block technique:

Bone block technique

KEY FEATURES of POLIO :

KEY FEATURES of POLIO Occasional diagnostic problem. Intact Sennsory System No mental handicap Asymmetrical Paralysis Contracture (Static / Dynamic) but non-spastic The clinical examination play very important role as radiograph and other investigations do not help in deciding the type treatment. An Orderly examination & muscle charting is the only way to detect “Remaining Muscles", that are the single most important element in decision-making process.

Paralytic knee:

Paralytic knee (1) flexion contracture of the knee, (2) quadriceps paralysis, (3) genu recurvatum , and (4) flail knee.

Knee Anatomy:

Knee Anatomy

Posterior aspect of knee:

Posterior aspect of knee

Lateral aspect of knee:

Lateral aspect of knee

SILENT FEATURES OF FFC OF KNEE :

SILENT FEATURES OF FFC OF KNEE Most common deformity & controversial treatment. Treatment plan for FFC knee should include consideration of proximal & distal affections of the limb. Usually hip and knee contractures are tackled simultaneously or at short interval between the two, start with knee first than hip. Spare Gastrocnemius & posterior capsule at soft tissue correction. In sever flexion Contracture: soft tissue correction followed by skeletal traction. The remaining deformities are tackled with bone osteotomy .

flexion contracture of the knee:

flexion contracture of the knee caused by a contracture of the iliotibial band ; (contracture of this band can cause not only flexion contracture but also 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:

treatment Mild FFC (15-40) Contractures of 15 to 20 degrees or less in young children can be treated with posterior hamstring lengthening and capsulotomy . More severe contractures usually require a supracondylar extension osteotomy of the femur SEVER FFC (70 OR MORE) Treated by 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.

SUPRACONDYLAR EXTENSION OSTEOTOMY:

SUPRACONDYLAR EXTENSION OSTEOTOMY

SUMMARY:

SUMMARY Gradual traction (double pin). Serial casting / Wedging casts. Soft tissue release. Posterior capsulotomy . Supracondylar osteotomy, 5o recurvatum. External fixator – gradual correction.

QUADRICEPS PARALYSIS:

QUADRICEPS PARALYSIS Disability from paralysis of the quadriceps muscle is severe because the knee may be extremely unstable, especially if there is even a mild fixed flexion contracture. Several muscles are available for transfer to the quadriceps tendon and patella: the biceps femoris , semitendinosus , sartorius,and tensor fasciae latae

QUADRICEPS PARALYSIS,FFC & recurvatum relationship :

QUADRICEPS PARALYSIS,FFC & recurvatum relationship When there is slight recurvatum , the knee may be stable if the gastrocnemiussoleus is active,such a deformity is desirable because it stabilizes the knee in walking. if there is even a mild fixed flexion contracture along with quadriceppps paralysis walking is not possible.

PREREQUISTIES OF TENDON TRANSFER :

PREREQUISTIES OF TENDON TRANSFER Transfer of one or more of the hamstring tendons is contraindicated unless one other flexor in the thigh and the gastrocnemius-soleus , which also acts as a knee flexor, are functioning. If a satisfactory result is to be expected after hamstring transfer, the power not only of the hamstrings, but also of the hip flexors, the gluteus maximus , and the gastrocnemius-soleus must be fair or better; when the power of the hip flexor muscles are less than fair, clearing the extremity from the floor may be difficult after surgery.

PREREQUISTIES OF TENDON TRANSFER :

PREREQUISTIES OF TENDON TRANSFER A normal gastrocnemius-soleus is desirable because it aids in preventing genu recurvatum and remains as an active knee flexor after surgery; it may not always prevent genu recurvatum , however, which can result from other factors.

Recurvatum after hamstring transfers can be kept to a minimum if:

Recurvatum after hamstring transfers can be kept to a minimum if (1) strength in the gastrocnemiussoleus is fair or better; (2) the knee is not immobilized in hyperextension after surgery; (3) talipes equinus , when present, is corrected before weight bearing is resumed; (4) postoperative bracing is used to prevent knee hyperextension (5) physical therapy is begun to promote active knee extension

GENU RECURVATUM:

GENU RECURVATUM In genu recurvatum the deformity is the opposite of that in a flexion contracture and the knee is hyperextended . Mild genu recurvatum can cause some disability, but when the quadriceps is severely weakened or paralyzed, such a deformity is desirable because it stabilizes the knee in walking.

GENU RECURVATUM TYPES:

GENU RECURVATUM TYPES caused by structural articular and bone changes stemming from lack of power in the quadriceps. that caused by relaxation of the soft tissues around the posterior aspect of the knee.

GENU RECURVATUM:

GENU RECURVATUM

Pathogenesis :

Pathogenesis articular and bone changes In the first type, the quadriceps lacks the power to lock the knee in extension; the hamstrings and gastrocnemiussoleus usually are normal. relaxation of the soft tissues In the second type, the hamstrings and the gastrocnemius-soleus muscles are weak. Hyperextension of the knee results from stretching of these muscles, often followed by stretching of the posterior capsular ligament

Prognosis & treatment:

Prognosis & treatment The prognosis after correction of the first type of recurvatum is excellent. The skeletal deformity is corrected first, and then one or more hamstrings can be transferred to the patella. Irwin described an osteotomy of the proximal tibia to correct the first type of genu recurvatum caused by structural bone changes.

Irwin Closing wedge osteotomy for genu recurvatum:

Irwin Closing wedge osteotomy for genu recurvatum

Relaxed soft tissue treatment for genu recurvatum:

Relaxed soft tissue treatment for genu recurvatum triple tenodesis of the knee has been described. If the deformity is 30 degrees or less , prolonged bracing of the knee in flexion usually prevents an increase in deformity. When the deformity is severe , however, bracing is ineffective, the knee becomes unstable and weak, the gait is inefficient

Principles of treating genu recurvatum:

Principles of treating genu recurvatum The fibrous tissue mass used for tenodesis must be sufficient. Healing tissues must be protected until they are fully mature, use a brace that limits extension to 15 degrees of flexion for 1 year. The alignment and stability of the ankle must meet the basic requirements of gait.eg equinus must be corrected

Triple tenodesis components:

Triple tenodesis components proximal advancement of the posterior capsule of the knee with the joint flexed 20 degrees construction of a checkrein in the midline posteriorly using the tendons of the semitendinosus and gracilis . Creation of two diagonal straps posteriorly using the biceps tendon and the anterior half of the iliotibial band.

Triple tenodesis:

Triple tenodesis

FLAIL KNEE:

FLAIL KNEE When the knee is unstable in all directions, and muscle power sufficient to overcome this instability is unavailable for tendon transfer, either a long-leg brace with a locking knee joint must be worn or the knee must be fused . When both legs are badly paralyzed , one knee can be fused and the other stabilized with a brace.

KAFO:

KAFO Funded by: U.S. Department of Education, Rehabilitation Services Administration Award # H235J050020 http://www.pandocare.com/products.html Courtesy of Westcoast Brace & Limb

HIP & PELVIS:

HIP & PELVIS Paralysis of the muscles around the hip can cause severe impairment. This impairment may include flexion and abduction contractures of the hip, hip instability and limping caused by paralysis of the gluteus maximus and medius muscles, and paralytic hip dislocation.

FLEXION AND ABDUCTION CONTRACTURES OF THE HIP:

FLEXION AND ABDUCTION CONTRACTURES OF THE HIP An abduction contracture is the most common deformity associated with paralysis of the muscles around the hip. Spasm of the hamstrings, hip flexors, tensor fasciae latae , and hip abductors is common during the acute and convalescent stages of poliomyelitis .

ANATOMY OF ILIOTIBIAL BAND:

ANATOMY OF ILIOTIBIAL BAND Proximally, the fascia lata arises from the coccyx, the sacrum, the crest of the ilium , the inguinal ligament, and the pubic arch and invests the muscles of the thigh and buttock. Distally ,,all of the attachments of the fascia converge to form the iliotibial band on the lateral side of the thigh.

PATHOGENESIS & IMORTANCE OF ILIOTIBIAL BAND:

PATHOGENESIS & IMORTANCE OF ILIOTIBIAL BAND Flexion, abduction, and external rotation contracture of the hip. Genu valgum and flexion contracture of the knee. Limb-length discrepancy( exact mechanism unkown ) External tibial torsion, with or without knee joint subluxation Secondary ankle and foot deformities. Pelvic obliquity Increased lumbar lordosis .(Bilateral flexion contracture)

TREATMENT:

TREATMENT Ober-Yount procedure a complete release of the hip muscles is indicated. For mild to moderate contracture. Campbell technique complete release of all muscles from the iliac wing with transfer of the crest of the ilium

treatment (ober yount) :

treatment ( ober yount )

Campbell technique :

Campbell technique

PARALYSIS OF THE GLUTEUS MAXIMUS AND MEDIUS MUSCLES:

PARALYSIS OF THE GLUTEUS MAXIMUS AND MEDIUS MUSCLES One of the most severe disabilities from poliomyelitis is caused by paralysis of the gluteus maximus or the gluteus medius or both; the result is an unstable hip and an unsightly and fatiguing limp.

Trendelenburg test:

Trendelenburg test When a normal person bears weight on one extremity and flexes the other at the hip, the pelvis is held on a horizontal plane and the gluteal folds are on the same level; when the gluteal muscles are impaired, and weight is borne on the affected side, the level of the pelvis on the normal side drops lower than that on the affected side. when the gluteal paralysis is severe, the test cannot be made because balance on the disabled extremity is impossible.

Isolated paralysis medius or maximus:

Isolated paralysis medius or maximus gluteus medius alone is paralyzed the trunk sways toward the affected side and the pelvis elevates on the opposite side (the “compensated” Trendelenburg gait). gluteus maximus alone is paralyzed the body lurches backward.

Prognosis & Treatment:

Prognosis & Treatment When one or both of these muscles is paralyzed, function can be improved only by transferring muscular attachments to replace the gluteal muscles when feasible. These operations are only relatively successful. When the gluteal muscles are completely paralyzed, normal balance is never restored. Although the gluteal limp can be lessened.

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

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

Sharrard transfer of iliopsoas muscle:

Sharrard transfer of iliopsoas muscle

PARALYTIC DISLOCATION OF THE HIP:

PARALYTIC DISLOCATION OF THE HIP If a child contracts poliomyelitis before age 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 the hip before he or she is grown. Unless this muscle imbalance is corrected, dislocation is likely to recur regardless of other treatment.

Causes of dislocated hip:

Causes of dislocated hip paralysis of the gluteal muscles with normal flexor and adductors. fixed pelvic obliquity in which the contralateral hip is held in marked abduction, usually by a tight iliotibial band or a structural scoliosis. Weakness of the abductor musculature retards the growth of the greater trochanteric apophasis. the hip becomes mechanically unstable and gradually subluxates .

Goals of treatment of paralytic hip dislocations:

Goals of treatment of paralytic hip dislocations reduction of the femoral head into the acetabulum and restoration of muscle balance .

treatment:

treatment 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/ osteotomy

treatment:

treatment Hip arthrodesis rarely is indicated and should be used as the last alternative for treatment of a flail hip. The Girdlestone procedure is the final option for failed correction of the dislocation.

LEG-LENGTH DISCREPANCY:

LEG-LENGTH DISCREPANCY variety of factors, including abnormal limb growth, abnormal muscle forces, and joint contractures

LEG-LENGTH DISCREPANCY:

LEG-LENGTH DISCREPANCY Leg lengthening in general and especially in neuromuscular patients is associated with a high complication rate. option are ; Ilizarov ( high complication rate ) Close intramedullary nail for tibial lengthening in patients with poliomyelitis has been reported to decrease mean healing time compared With lengthening without a nail.

Trunk:

Trunk To understand the deformities and disabilities that may occur when the muscles of the trunk and hips are affected by poliomyelitis requires knowledge of the normal actions and interactions of these muscles.

mechanism:

mechanism Different muscle groups, bone levers, and Weightbearing thrusts symmetrical and triangular relationship ,

Bone levers :

Bone levers the femoral head, neck, and trochanter , which provide a lever for the abductor muscles; bone lever of the pelvis through which the trunk muscles act;

PowerPoint Presentation:

AB:trochteric bone lever CE:pelvic bone lever

Weightbearing thrusts ( direction of load) :

Weightbearing thrusts ( direction of load) the weight-bearing thrust on the femoral head. the weight-bearing thrust through the midline of the pelvis from above.

PowerPoint Presentation:

AC:WBT ON FEMORAL HEAD EF:WBT OF PELVIS

GROUP OF MUSCLES:

GROUP OF MUSCLES ABDUCTORS OF HIP LATERAL TRUNK MUSCLES

TRIANGLES :

TRIANGLES When the body is balanced, the triangles above and below the pelvis are symmetrical. Abductor triangle and trunk triangle should be balanced .

Normal walking:

Normal walking the abductors of the hip on the weight-bearing side pull downward on the pelvis and the lateral trunk muscles on the opposite side pull upward; these two sets of muscles hold the pelvis at a right angle to the longitudinal axis of the trunk.

PowerPoint Presentation:

Abductor triangle;DGH DEF;TRUNK TRIANGLES.

PELVIC OBLIQUITY:

PELVIC OBLIQUITY an abduction contracture of the hip, line BC is shortened; as the affected extremity is placed in the weightbearing position, the femur, acting through the contracted abductor group, BC, depresses the pelvis on that side.

PowerPoint Presentation:

Apparently long limb Abduction contracture Apparently short limb Normal limb(adducted limb)

PELVIC OBLIQUITY:

PELVIC OBLIQUITY true pelvic obliquity pelvic obliquities arise from contractures distal to the iliac crest. true pelvic obliquity from contracture of the iliotibial band. Secondary pelvic obliquity When contractures are absent distal to the iliac crest, a pelvic obliquity should not be considered a true one but one secondary to scoliosis.

Treatment protocole (scoliosis guide):

Treatment protocole (scoliosis guide) Before starting treatment, the degree of fixation of the lumbar scoliosis should be determined by radiographs. When lumbar scoliosis is not fixed, the pelvic obliquity is corrected by treating the flexion and abduction contracture of the hip. the lumbar scoliosis is fixed, the scoliosis is corrected first by instrumentation. After this treatment has been completed, the contractures around the hip are released.

scoliosis:

scoliosis Fixed or structural scoliosis is not correctable on lateral bending and cobbs angle will be more than 25 degree. Non structural scoliosis will be corrected on lateral bending.

Treatment:

Treatment Release of iliotibial band . the weight borne on the adducted extremity (the apparently short one) can be shifted nearer the midline by valgus osteotomy . When the pelvic obliquity is extreme, and the femoral head of the abducted extremity (the apparently long one) is almost within the center of gravity, varus osteotomy of the femur is indicated.

PowerPoint Presentation:

Apparently long limb Abduction contracture Apparently short limb Normal limb(adducted limb)

PowerPoint Presentation:

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