POST POLIO RESIDUAL PARALYSIS OF LOWER LIMB

POLIOMYELITIS

• VIRAL INFECTION LOCALIZED IN THE ANTERIOR HORN CELLS OF THE SPINAL CORD & CERTAIN BRAIN STEM MOTOR NUCLEI.

• THE VIRUS,A MEMBER OF THE ENTEROVIRAL GROUP HAS 3 SUBTYPES -(BRUNHILDE,LANSING,LEON)

• OTHER MEMBERS- PRODUCE A PARALYTIC SYNDROME MIMICKING POLIOMYELITIS

• ROUTE OF TRANSMISSION: THROUGH GI TRACT & RESPIRATORY

TRACTHEMATOUGENOUS CNS

PATHOLOGY THE ANTERIOR HORN CELLS OF THE SPINAL

CORD,ESPECIALLY LUMBAR & CERVICAL, DAMAGED- -DIRECTLY: BY VIRAL MULTIPLICATION/ CYTOTOXIC

PRODUCTS OF VIRUS - INDIRECTLY: ISCHEMIA, ODEMA, HAEMORRHAGE

IN SURROUNDING GLIAL TISSUES

HIGHER CENTRE CHANGES (MEDULLA, PONS, BASAL GANGLIA,TEGMENTUM):PERIVASCULAR CUFFING, LYMPHOID INFILTRATION, THROMBOSIS

- REVERSIBLE & TRANSITORY

• DESTRUCTION IN SPINAL CORD OCCURS FOCALLY & WITHIN 3 DAYS- WALLERIAN DEGENERATION IS EVIDENT

• AFTER 4 MONTHS- GLIOTIC TISSUE & LYMPHOCYTIC CELLS FILL THE AREA OF DESTROYED MOTOR CELLS

• WEAKNESS CLINICALLY DETECTABLE > 60% MUSCLE INNERVATION DESTROYED

• PARALYSIS IN LL MUSCLES >> UL MUSCLES

CLINICAL COURSE

ACUTE STAGE:

• LASTS 7-10 DAYS• SYSTEMIC STAGE• PREPARALYTIC STAGE(CNS INVOLVEMENT)• PARALYTIC STAGE-SPINAL-FLACCID PARALYSIS FOCAL, ASYMMETRICAL -BULBAR-ENCEPHALITIS MEDULLARY RESPIRATORY CENTRE

TREATMENT OF ACUTE STAGE:

• BED REST• ANALGESIC & HOT PACKS- MUSCLE PAIN• ANATOMICAL POSITIONING TO PREVENT FLEXION

POSTURING & CONTRACTURES• GENTLE PASSIVE RANGE OF MOTION EXCERCISES OF

ALL JOINTS DAILY SEVERAL TIMES• SIGNS OF BULBAR POLIO

CONVALSCENT STAGE:

• BEGINS 2 DAYS AFTER TEMPERATURE COMES DOWN, UPTO 2 YEARS

• MAXIMUM RECOVERY-1 MONTH & COMPLETE IN 6 MONTHS

• LIMITED AFTER 2 YEARS• MUSCLES WITH >80% STRENGTH- SPONTANEOUS

RECOVERY• <30% STRENGTH AT 3 MONTHS- CONSIDERED

PARALYSED

TREATMENT:

• ASSESSMENT OF STRENGTH MONTHLY FOR 6 MONTHS, & THEN 3- MONTHLY

• PHYSIOTHERAPY• VIGOROUS PASSIVE EXCERCISES & WEDGING CASTS-

MILD/ MODERATE CONTRACTURES• CONTRACTURES > 6 MONTHS- SURGICAL MEASURES

CHRONIC STAGE:

• 24 MONTHS AFTER ILLNESS• CORRECTION OF LONG TERM CONSEQUENCES

OF MUSCLE IMBALANCE• PREVENTING/ CORRECTION OF SOFT TISSUE/

BONY DEFORMITIES

TENDON TRANSFERS

• TO PROVIDE MOTOR POWER TO REPLACE A PARALYSED MUSCLE(s)

• TO ELIMINATE DEFORMING AFFECT OF A MUSCLE WHEN IT ANTAGONIST IS PARALYSED

• TO IMPROVE STABILITY

ON SELECTING TENDONS:

• 1.EQUAL IN POWER TO PARALYSED MUSCLE• 2. TENDON MUST PASS IN DIRECT LINE FROM IT

MUSCLE TO POINT OF INSERTION• 3. TO PRESERVE GLIDING, IT MUST PASS THROUGH S/C

TISSUE,ITS OWN/SHEATH OF PARALYSED MUSCLE• 4. MUST BE UNDER NORMAL PHYSIOLOGICAL TENSION• 5. ATTACHED CLOSE TO INSERTION OF PARALYSED

TENDON AS POSSIBLE• 6. NERVE & BLOOD SUPPLY PRESERVED• 7. AGONIST PREFERED TO ANTAGONISTS• 8. CONTRACTURES RELEASED & JOINT MOBILISED• 9. RANGE OF EXCURSION TO BE SIMILAR TO MUSCLE

BEING REPLACED

FOOT & ANKLE

• MOST DEPENDENT – SIGNIFICANT STRESS- SUSCEPTIBLE TO DEFORMITIES FROM PARALYSIS

• COMMON DEFORMITIES-CLAWTOES, CAVOVARUS, DORSAL BUNION, TALIPES EQUINUS, TALIPES EQUINOVARUS, TALIPESCAVOVARUS, TALIPES EQUINOVALGUS, TALIPESCALCANEUS

• PLANTAR FLEXORS: TRICEPS SURAE (GASTRONEMIUS+SOLEUS),TIBIALIS POSTERIOR, FLEXOR HALLUCIS LONGUS, FLEXOR DIGITORUM LONGUS

• DORSIFLEXORS: TIBIALIS ANTERIOR, EXT. HALLUCIS LONGUS, EXT. DIGITORUM LONGUS,PERONEUS TERITUS

• INVERTORS:ANTR. & POSTR. TIBIALIS, FHL• EVERTORS: PERONEI (LONGUS,BREVIS,TERTIUS)

• <10 YRS- BONE RESECTIONS CONTRAINDICATED (SKELETAL IMMATURITY)

• TENDON TRANSFERS ALLOWED, BUT BETTER > 10 YRS

• >10 YRS- 1ST-STABILIZING BONE RESECTIONS DONE, FOLLOWED BY TENDON TRANSFERS

• ONLY THEN, OTHER LOWER LIMB DEFORMITIES CORRECTED, OR ELSE RECURRENCE OF FOOT DEFORMITIES

PARALYSIS OF SPECIFIC MUSCLES-TIBIALIS ANTERIOR

• LOSS OF DORSIFLEXION + INVERSION EQUINUS & CAVUS

• EXTENSORS OF TOES- OVERACTIVE TO REPLACE

TIB.ANTERIOR HYPEREXTENSION PROXIMAL PHALANGES+DEPRESSION METATARSAL HEAD

• UNOPPOSED ACTION OF PERONEUS LONGUS+ACTIVE TIB. POSTERIORCAVOVARUS DEFORMITY

• CONSERVATIVE - PASSIVE STRETCHING & SERIAL CASTING FOR EQUINUS CONTRACTURE

• SURGICAL- POSTERIOR ANKLE CAPSULOTOMY & TENDOCALCANEUS LENGTHENING—COMBINED WITH ANTERIOR TRANSFER OF PERONEUS LONGUS (TO BASE OF 2ND METATARSAL)

-CLAWTOE DEFORMITY- TRANSFER OF TOE EXTENSORS FROM DISTAL PHALANGES INTO METATARSAL NECKS

TIBIALIS ANTERIOR & POSTERIOR MUSCLES

• LOSS OF DORSI- & PLANTAR FLEXION + INVERSION

• HINDFOOT & FOREFOOT EQUINOVALGUS• DEFORMITY DEVELOPS RAPIDLY & BECOMES

FIXED AS TENDOCALCANEUS SHORTENS

• CONSERVATIVE: SERIAL CASTING TO STRETCH TENDOCAL. & TO PREVENT WEAKING OF TRICEPS SURAE

• SURGICAL: --ONE OF PERONEAL MUSCLES TRANSFERRED: P. LONGUS (GREATER EXCURSION)ANTERIORLY

TO BASE OF 2ND METATARSAL TO REPLACE TIB. ANTERIOR

- ONE OF TOE FLEXORS TO REPLACE TIB. POSTERIOR

TIBIALIS POSTERIOR

• ISOLATED PARALYSIS- RARELOSS OF INVERSION

• RESULTS IN HINDFOOT & FOREFOOT EVERSION

• FHL & FDL USED FOR TRANSFERS

TIBIALIS ANTERIOR, TOE EXTENSOR & PERONEAL MUSCLES

• LOSS OF DORSIFLEXION+ EVERSIONSEVERE EQUINOVARUS +CAVUS DEFORMITY (UNOPPOSED ACTION OF TIB. POSTR. & TRICEPS SURAE)

• TRT: -SERIAL CASTING CAN BE TRIED - LENGTHENING OF TENDOCALCANEUS - SOFT TISSUE RELEASE OF FOREFOOT CAVUS DEFORMITY - ANTERIOR TRANSFER OF TIB. POSTERIOR , - SUPPLEMENTED BY TRANSFER OF LONG TOE FLEXORS

PERONEAL MUSCLES• ISOLATED PARALYSIS-RARELOSS OF EVERSION• RESULTS IN SEVERE HINDFOOT VARUS DEFORMITY (UNOPPOSED

ACTION OF TIB. POSTERIOR)

TREATMENT:• LATERAL TRANSFER OF TIB. ANTERIOR (FROM MED. CUNEIFORM &

BASE 1ST METARSAL BASE OF 2ND METATARSAL)• CAN RESULT IN OVERACTIVITY OF

EHLHYPEREXTENSIONPAINFUL CALLUS BASE OF 1ST METATARSAL

• <5 YRS-LENGTHENING OF EHL TENDON• >5 YRS- TRANSFER OF EHL TENDON TO 1ST METATARSAL NECK

TRICEPS SURAE MUSCLES

• STRONGEST PLANTAR FLEXOR OF FOOT• LOSS OF PLANTAR FLEXION & UNOPPOSED

DORSIFLEXOR ACTION PROGRESSIVE CALCANEAL DEFORMITY

• REQUIRED FOR NORMAL FUNCTION OF LONG TOE FLEXORS & EXTENSORS & TO INTRINSIC MUSCLES OF FOOT

• PREVENTION: KEEPING FOOT IN SLIGHT EQUINUS DURING A/C STAGE-PREVENTS OVERSTRETCHING OF TRICEPS SURAE, & THE POSITION MAINTAINED IN CONVALESCENT STAGE

• IF TRICEPS SURAE WEAK—EARLY WALKING DISCOURAGED

SURGICAL-IF PROGRESSIVE DEFORMITY-TENDON TRANSFER

• MUSCLE SELECTED DEPENDS ON RESIDUAL STRENGTH OF TRICEPS SURAE

• IF FAIR MOTOR STRENGTH-POSTERIOR TRANSFER OF 2 OR 3 MUSCLES

• COMPLETE PARALYSES-AS MANY MUSCLES POSSIBLE

• TIB. ANTERIOR TRANSFERED POSTERIORLY (DRENNAN(DRENNAN)

• IF INVERTORS & EVERTORS BALANCEDPURE CALACANEOCAVUS DEFORMITY

• IF POSTERIOR TRANSFER OF ONLY ONE SETINSTABILITY

• CALCANEOVALGUS –BOTH PERONEALS TRANSFERRED TO HEEL

• CALCANEOVARUS—TIB. POSTERIOR+FHL TO HEEL

• RARELY,HAMSTRINGS USED TO REPLACE T. SURAE ,IF NO INVERTORS / EVERTORS PRESENT FOR TRANSFER

FLAIL FOOT

• ALL MUSCLES DISTAL TO KNEE JOINT PARALYSED---> EQUINUS DEFORMITY DUE TO PASSIVE PLANTAR FLEXION

• INTRINSIC MUSCLES RETAIN FUNCTION---> FOREFOOT EQUINUS / CAVOEQUINUS DEFORMITY

• TRT: RADICAL PLANTAR RELEASE /PLANTAR NEURECTOMY

• IN OLDER – MIDFOOT WEDGE RESECTION (FOREFOOT EQUINUS DEFORMITY)

DORSAL BUNION

• SHAFT OF 1ST METATARSAL- DORSIFLEXED• GREATER TOE-PLANTAR FLEXED• DEFORMITY PRESENT ONLY ON WEIGHT BEARING

• IF MUSCLE IMBALANCE NOT CORRECTED-IT BECOMES FIXED

• EXOSTOSIS CAN DEVELOP ON DORSUM OF METATARSAL HEAD

• WHEN FLEXION SEVERE ENOUGH-MP JOINT CAN SUBLUXATE & DORSAL PART OF METATARSAL HEAD CARTILAGE CAN DEGNERATE

• PLANTAR PART OF JOINT CAPSULE & FLEXOR HALLUCIS BREVIS CAN CONTRACT

• COMMON IMBALANCE B/W TIB. ANTERIOR & PERONEUS LONGUS

• TIB. ANTERIOR RAISES 1ST CUNEIFORM & BASE OF 1ST METATARSAL WHERE IT INSERTED MEDIALLY

• PERONEUS LONGUS, INSERTED LATERALLY BASE OF 1ST METATARSAL & MED. CUNEIFORM OPPOSES THIS

• WHEN PERONEUS L. WEAK/ PARALYSED-METATARSAL STRONGLY DORSIFLEXEDGREAT TOE BECOMES ACTIVELY PLANTAR FLEXED

(FOR A WEIGHT BEARING POINT ON MEDIAL SIDE OF FOREFOOT & TO ASSIDT PUSH OFF IN WALKING)

• LAPIDUS & HAMMOND OBSERVED MANY DORSAL BUNIONS DEVELOPED AFTER ILL ADVISED TENDON TRANSFERS FOR RESIDUAL POLIOMYELITIS

• BEFORE ANY TRANSER, THE EFFECT OF ITS LOSS ON 1ST METATARSAL SHOULD BE CONSIDERED

• IF TIB ANTERIOR PARALYSED—TENDON OF P. LONGUS/ P. BREVIS SHOULD BE TO THE 3RD CUNEIFORM RATHER THAN TO INSERTION OF TIB. ANTERIOR

BONY PROCEDURES(OSTEOTOMY & ARTHRODESIS)

• OBJECTIVE: TO REDUCE NUMBER OF JOINTS THE WEAKENED/ PARALYSED MUSCLES SHOULD CONTROL

• STABILIZING PROCEDURES:1.CALCANEAL OSTEOTOMY2. EXTRAARTICULAR SUBTALAR ARTHRODESIS3. TRIPLE ARTHRODESIS4. ANKLE ARTHRODESIS5. BONE BLOCKS TO LIMIT MOTION AT ANKLE JOINT

CALCANEAL OSTEOTOMY• CORRECTION OF HINDFOOT VARUS OR VALGUS

DEFORMITY

• CAVOVARUS – IT IS COMBINED WITH RELEASE OF INTRINSIC MUSCLES & PLANTAR FASCIA

• CALCANEOVARUS- COMBINED WITH POSTERIOR DISPLACEMENT CALCANEAL OSTEOTOMY

• FIXED VALGUS DEFORMITY- MEDIAL DISPLACEMENT OSTEOTOMY

DIILWYN-EVANS OSTEOTOMY

• FOR TALIPES CALCANEOVALGUS DEFORMITY• LENGTHENS CALCANEUS BY TRANSVERSE

OSTEOTOMY OF CALCANEUS & INSERTION OF BONE GRAFT TO OPEN A WEDGE & LENGTHEN LATERAL BORDER OF FOOT

SUBTALAR ARTHRODESIS

• GRICE & GREEN:• RESTORES HEIGHT OF MEDIAL LONGITUDINAL

ARCH• WHEN VALGUS DEFORMITY LOCALISED TO

SUBTALAR JOINT & CALCANEUS CAN BE MANIPULATED INTO NORMAL POSITION BELOW TALUS

• DENNYSON & FULFORD:

• SCREW INSERTED ACROSS SUBTALAR JOINT FOR INTERNAL FIXATION & AN ILIAC CREST GRAFT PLACED IN SINUS TARSI.

TRIPLE ARTHRODESIS

• MOST EFFECTICE PROCEDURE IN STABILIZING FOOT• FUSION OF SUBTALAR, CALCANEOCUBOID &

TALONAVICULAR JOINTS

• LIMITS MOTION TO PLANTAR FLEXION & DORSIFLEXION

• INDICATED WHEN MOST OF WEAKNESS & DEFORMITY ARE AT SUBTALAR & MIDTARSAL JOINTS

• RESERVED FOR SEVERE DEFORMITY IN CHILDREN 12 YEARS OR MORE

• EXACT TECHNIQUE DEPENDS ON TYPE OF DEFORMITY

• COMPLICATIONS: -PSEUDOARTHROSIS(TALONAVICULAR JT.)-DEGENERATIVE ARTHRITIS(ADDITIONAL STRESS ON

ANKLE JT. DUE TO LOSS OF MOBILITY)-AVN (EXCESS TALUS RESECTION)-FOREFOOT DEFORMITY (MUSCLE IMBALANCE)

ANKLE ARTHRODESIS

• FLAIL FOOT• RECURRENCE OF DEFORMITY AFTER TRIPLE

ARTHRODESIS

POSTERIOR BONE BLOCK(CAMPBELL’S)• TO ELIMINATE ANKLE

PLANTAR FLEXION IN EQUINUS DEFORMITY

• BONY BUTTRESS ON POSTERIOR ASPECT OF TALUS & SUPERIOR ASPECT OF CALCANEUS

• IMPINGED TO POSTERIOR LIP OF DISTAL TIBIA

• RARELY INDICATED• REPLACED BY TENDON

TRANSFERS

TALIPES EQUINOVARUS

• EQUINUS DEFORMITY AT ANKLE• INVERSION OF HEEL & MIDTARDAL JOINT• ADDUCTION & SUPINATION OF FOREFOOT

IN LONG STANDING CASES-• CAVUS DEFORMITY FOOT• CLAWING TOES

• PERONEAL MUSCLES WEAKENED/ PARALYSED• TIBIALIS ANTERIOR- NORMAL/ WEAKENED• TIBIALIS POSTERIOR-NORMAL• TRICEPS SURAE-CONTRACTED (MOTOR

IMBALANCE, GROWTH, GRAVITY, POSTURE)

TREATMENT:• ANTERIOR TRANSFER OF TIBIALIS POSTERIOR-

AIDS ACTIVE DORSIFLEXION• THE ENTIRE TENDON CAN BE TRANSFERRED

THROUGH INTEROSSEOUS MEMBRANE TO MIDDLE CUNEIFORM

• OR, TENDON SPLIT WITH LATERAL HALF TRANSFERRED TO CUBOID

TALIPES EQUINOVALGUS

• TIBIALIS ANTERIOR & TIBIALIS POSTERIOR WEAK

• PERONEI STRONG, TRICEPS SURAE CONTRACTED

• TRT: SUBTALAR ARTHRODESIS & ANTERIOR TRANSFER OF PERONEUS LONGUS & BREVIS

• AFTER SKELETAL MATURITY-TRIPLE ARTHRODESIS

TALIPES CAVOVARUS

• IMBALANCE OF EXTRINSIC MUSCLES OR PERSISTENT FUNCTION OF SHORT TOE FLEXORS & OTHER INTRINSIC MUSCLES WHEN FOOT IS OTHERWISE FLAIL

• EXAGERATED LONGITUDINAL ARCH+ SLIGHT FLEXION ON TOES

• PAINFUL CALLUSES ON PLANTAR ASPECT OF METARSAL HEADS

TRT: PRESURRE RELIEVED BY METATARSAL PADDING IN SOLE OF SHOE

• ARCH SUPPORT• SURGICAL- WEDGE OSTEOTOMY OF TARUS + STRIPPING

OF PLANTAR APONEUROSIS FROM PLANTAR SURFACE OF CALCANEUS

-MUSCLE IMBALANCE- TOE EXTENSORS TRANSFERRED TO NECKS OF METATARSALS (ACTIVE DORSIFLEXION CREATED)

TALIPES CALCANEUS• TRICEPS SURAE PARALYZED• OTHER DORSIFLEXORS FUNCTIONAL• RAPIDLY PROGRESSIVE DEFORMITY

TRT: EARLY TENDON TRANSFERS• IF NO ADEQUATE MUSCLES-TENODESIS OF

TENDOCALCANEUS TO FIBULA (WESTIN)

• IN SKELETALLY MATURE FEET-1ST-PLANTAR FASCIOTOMY + TRIPLE ARTHRODESIS

• 6 WEEKS LATER-PERNEOUS LONGUS & BREVIS+ TIBIALIS POSTERIOR TRANSFERRED TO CALCANEUS

• IF EXT. DIGITORUM LONGUS FUNCTIONAL-TRANSFER TO A CUNEIFORM

• TIBIALIS ANTERIOR TO CALCANEUS

KNEE

• DISABILITIES• FLEXION CONTRACTURE OF KNEE• QUADRICEPS PARALYSIS• GENU RECURVATUM• FLAIL KNEE

FLEXION CONTRACURE KNEE

• CONTRACTURE OF ILIOTIBIAL BAND• PARALYSIS OF QUADRICEPS, WHEN HAMSTRINGS

NORMAL/PARTIALLY PARALYSED

• ILIOTIBIAL BAND CONTRACTURE-ALSO GENU VALGUM

• BICEPS FEMORIS>MEDIAL HAMSTRINGS-GENU VALGUM + EXTERNAL ROTATION DEFORMITY OF TIBIA ON FEMUR

TREATMENT• FLEXION CONRACTURES OF 15-20 O –

POSTERIOR HAMSTRING LENGTHENING & CAPSULOTOMY

• MORE SEVERE CONTRACTURES- SUPRACONDYLAR EXTENSION OSTEOTOMY OF FEMUR

• >70o-DEFORMITY OF ARTICULAR SURFACE OF KNEE

• TENDENCY FOR POSTERIOR SUBLUXATION OF TIBIA ON FEMUR

TRT: DIVISION OF ILIOTIBIAL BAND & HAMSTRING TENDONS + POSTERIOR CAPSULOTOMY

• POSTOP- SKELETAL TRACTION GIVEN• LONG TERM USE OF LONG LEG BRACE• SUPRACONDYLAR OSTEOTOMY -2ND STAGE

PROCEDURE IN OLDER PATIENTS

QUADRICEPS PARALYSIS

• KNEE-VERY UNSTABLESEVERE DISABILITY

• TRT:TENDON TRANSFER IS REQUIRED –BICEPS FEMORIS, SEMITENDINOSUS, SARTORIUS, TENSOR FASCIA

• HAMSTRING TENDON- ONLY IF ANOTHER FLEXOR + TRICEPS SURAE(ALSO ACTION AS KNEE FLEXOR) IS FUNCTIONING. ALSO, HIP FLEXORS-GOOD FUNCTION

• GENU RECURVATUM AFTER HAMSTRING TRANSFERS CAN BE KEPT TO MINIMUM IF-

• 1. STRENGTH IN T. SURAE GOOD• 2.KNEE IS NOT IMMBOLISESD IN HYPEREXTENSION

AFTER SURGERY• 3. TALIPES EQUINUS, IF PRESENT, IS CORRECTED

BEFORE WEIGHT BEARING IS RESUMED• 4. PHYSICAL THERAPY IS BEGUN TO PROMOTE

ACTIVE KNEE EXTENSION

GENU RECURVATUM

• KNEE IN HYPEREXTENSION• 2 TYPES:• -CAUSED BY STRUCTURAL, ARTICULAR &

BONY CHANGES DUE TO LACK OF POWER IN QUADRICEPS

• -CAUSED BY RELAXATION OF SOFT TISSUES AT POSTERIOR ASPECT OF KNEE

• 1. QUADRICEPS LACKS POWER TO LOCK KNEE IN EXTENSION

• HAMSTRINGS & T. SURAE-NORMAL

• PRESSURES OF WEIGHT BEARING & GRAVITY CAUSE CHANGES IN TIBIAL CONDYLES-(ELONGATED POSTERIORLY & DEPRESSED ANTERIOR MARGINS); & ALSO, PROXIMAL TIBIAL SHAFT BOWS POSTERIORLYPARTIAL SUBLUXATION OF TIBIA

TRT:• SKELETAL DEFORMITY CORRECTED- OSTEOTOMY(IRWIN,

CAMPBELL)• TRANSFER OF HAMSRINGS TO PATELLA

Campbell’s closing wedge osteotomy

• 2.) HAMSTRINGS & T. SURAE WEAK HYPEREXTENSION & WEAKING OF POSTERIOR CAPSULE LIGAMENT

TRT:• SOFT TISSUE OPERATIONS-TRIPLE TENODESIS• PROLONGED BRACING OF KNEE IN FLEXION

PREVENTS AN INCREASE IN DEFORMITY IF IT IS <30 DEG.

• IF SEVERE-PERRY,O’BRIEN & HODGSON TENODESIS:

• - PROXIMAL ADVACEMENT OF POSTERIOR CAPSULE OF KNEE WITH 20 DEG FLEXION

• -CONSTRUCTION OF A CHECKREIN IN MIDLINE USING TENDONS OF SEMITENDINOSUS & GRACILIS

• -CREATION OF 2 DIAGONAL STRAPS POSTERIORLY WITH BICEPS TENDON & ANTERIOR HALF OF ILIOTIBIAL BAND

FLAIL KNEE

• KNEE UNSTABLE IN ALL DIRECTIONS• NO MUSCLE POWER TO OVERCOME

DEFORMITY

TRT:LONG LEG BRACE WITH A LOCKING KNEE JOINT

• OR, FUSION OF KNEE JOINT• FUSION-SATISFACTORY GAIT BUT

INCONVENIENCE WHILE SITTING

HIP

DEFORMITIES-

• FLEXION & ABDUCTION CONTRACTURES• PARALYSIS OF GLUTEUS MAXIMUS & MEDIUS• PARALYTIC HIP DISLOCATION

FLEXION & ABDUCTION CONTRACURES OF HIP

• ABDUCTION CONTRACTURE-MOST COMMON-OCCURS ALONG WITH FLEXION & EXT. ROTATION CONTRACTURES

• SPASM OF HAMSTRINGS, HIP FLEXORS, TENSOR FASCIA LATAE, HIP ABDUCTORS- IN A/C & CONVALESCENT STAGES

• PATIENT ASSUMES FROG LEG POSTION- IF MAINTAINED FOR FEW WEEKSCONTRACTURES

• ILIOTIBIAL BAND CONTRACTURE RESULTS IN:

• 1.FLEXION, ABDUCTION & EXTERNAL ROTATION CONTRACTURE HIP

• 2. GENU VALGUM & FLEXION CONTRACTURE KNEE• 3. LIMB LENGTH DISCREPANCY• 4. EXTERNAL TIBIAL TORSION / KNEE JOINT

SUBLUXATION• 5. SECONDARY ANKLE & FOOT DEFORMITIES• 6. PELVIC OBLIQUITY• 7. INCREASED LUMBAR LORDOSIS-B/L FLEXION

CONTRACTURES PULL PELVIC ANTERIORLY

• PELVIC OBLIQUITY-• WHEN PATIENT STANDS & AFFECTED LIMB

BROUGHT TO WEIGHT BEARING POSITON-PELVIC ASSUMES A OBLIQUE POSITION-ILIAC CREST LOW ON CONTRACTED SIDE

• LATERAL THRUST PUSHSES PELVIC TO NORMAL SIDE

• TRUNK MUSCLES ON AFFECTED SIDE LENGTHEN, CONTRACT IN OPP. SIDELUMBAR SCOLIOSIS

• PREVENTION IN EARLY STAGES:

• POSITION-HIPS IN NEUTRAL ROTATION,SLIGHT ABDUCTION & NO FLEXION

• FULL RANGE OF MOVEMENT IN ALL JOINT DAILY

• TO PREVENT EXT. ROTATION-A BAR SIMILAR TO DENIS BROWNE SPLINT-TO HOLD FEET IN SLIGHT INTERNAL ROTATION

• WATCH FOR CONTRACTURES & CORRECT BEFORE AMBULATION

• SURGICAL:

• FOR ABDUCTION + ER CONTRACTURES-COMPLETE RELEASE OF HIP MUSCLES (OBER YOUNT)

• SOUTTER’S RELEASE- RELEASE OF STRUCTURES FROM ASIS

• SEVERE DEFORMITIES- RELEASE OF ALL MUSCLES FROM ILIAC WING & TRANSFER OF CREST OF ILIUM (CAMPBELL)

PARALYSIS OF GLUTEUS MAXIMUS & MEDIUS MUSCLES

• RESULTS IN UNSTABLE HIP

• DURING WEIGHT BEARING ON AFFECTED SIDE-WHEN GLUTEUS MEDIUS ALONE PARALYSED, TRUNK SWAYS TOWARDS AFFECTED SIDE & PELVIS ON OPPOSITE SIDE ELEVATES (“COMPENSATED” TRENDELENBURG GAIT)

• GLUTEUS MAXIMUS –BODY LURCHES BACKWARD

• TRENDELENBERG TEST-• NORMALON BEARING WEIGHT ON ONE

LIMB & FLEXED OTHER HIP, PELVIS HELD IN HORIZONTAL, WITH GLUTEAL FOLDS AT SAME LEVEL

• IF GLUTEAL MUSCLES AFFECTED-LEVEL OF PELVIS ON NORMAL SIDE DROPS LOWER

• MGT:• TRANSFER OF EXTERNAL OBLIQUE TO GREATER TROCHANTER

FOR GL. MEDIUS PARALYSIS• OTHER OPTION-ILIOPSOAS -MUSTARD- ILIPSOAS TENDON TRANSFERED TO GREATER

TROCHNATER -SHARRAD-ENTIRE ILIACUS TRANSFERRED POSTERIORLY

• ADV:-HIP NOT FURTHER WEAKEND BY ELIMINIATING ILIOPSOAS AS HIP

FLEXOR-POWER ADDED TO HIP BY TAKING MUSCLE FROM ABDOMINAL

WALL-ACTS SYNERGESTICALLY(ILIOPSOAS-ANTAGONISTIC)-ILIUM NOT VIOLATED

PARALYTIC DISLOCATION HIP• POLIO<2 YRS, GLUTEAL MUSCLES PARALYSED BUT

FLEXORS & ADDUCTORS NORMALCHILD MAY DEVELOP PARALYTIC DISLOCATION HIP

• ALSO, IF FIXED PELVIC OBLIQUITY IN CONTRALATERAL ILIOTIBIAL BAND CONTRACTURE/ STRUCTURAL SCOLIOSIS

• WEAKNESS OF ABDUCTOR MECHANISMRETARDS GREATER TROCHANTER APOPHYSIS GROWTHPROXIMAL FEMORAL CAPITAL EPIPHYSIS GROWS AWAY FROM GREATER TROCHANTER INCREASES VALGUS DEFORMITY OF FEMORAL NECK & FEMORAL ANTEVERSIONHIP UNSTABLESUBLUXATION

• TREATMENT:

• REDUCTION OF FEMORAL HEAD INTO ACETABULUM IN DISLOCATIONS & RESTORATION OF MUSCLE BALANCE

• IF NOT REDUCED WITH TRACTION, OPEN REDUCTION & ADDCUTION TENOTOMY WITH PRIMARY FEMORAL SHORTENING, VARUD DEROTATION OSTEOTOMY OF FEMUR & APPROPRIATE ACETABULAR RECONSTRUCTION

• HIP ARTHRODESIS-LAST RESORT –FLAIL HIP

THANK YOU !!