POLIOMYELITIS OFFOOT AND ANKLE

ByDr.tejaswi dussa

Post graduate in ms orthoGandhi hospital,

secunderabad

INTRODUCTION• picarno viruses• -Virus mainly localized in anterior horn cells and certain brain

stem motor nuclei

• Clinical manifestations: 1. asymptomatic infection (90-95%) 2. abortive poliomyelitis 3. non paralytic polio myelitis 4. paralytic polio myelitis (1%)• Clinical course • Three stages - acute stage - convalescent stage - chronic stage

Acute stage• 7-10 days• superficial reflexes absent • deep tendon reflexes disappear when the muscle group is

paralysed • Treatment-

- bed rest- Analgesics- Hot packs- Anatomical positioning of limbs to prevent flexion

contracture- Gentle passive ROM exercises

Distribution

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

Convalescent stage

• recovery phase • Varying degree of spontaneous recovery in

muscle power takes place• > 80% return of strength - recovered muscles• < 30% of normal strength - paralysed muscle

• Treatment:• Vigorous passive stretching exercises• Wedging casts for mild –mod contractures• Surgical release of tight fascia & aponeurosis• Lengthening of tendons may be neccesory for

contractures persisting longer than 6months• Orthoses used until further no recovery is

antcipated

Chronic stage

• Usually begins 24 months after the acute illness• This is the time for orthopedic intervention

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• Most Severely Paralysed Muscle

- Tibialis Anterior

• Most common muscle Paralysed - Quadriceps femoris

• Most commonly involved muscles in Upper Limb

- Deltoid and Opponens

Causes of deformity in Polio

• 1. muscle imbalance

• 2. posture and gravity effect

• 3. dynamics of activity

• 4. dynamics of growth

Goals of treatment

• To achieve maximal functional activity • Correction of significant muscle imbalances• Preventing or correcting of limb deformties• Static joint instability can be controlled by orthoses• Dynamic joint instability cannot be controlled by

orthoses, that results in fixed deformities• Soft tissue surgeries such as tendon transfer should

be done before the developement of fixed bony changes

FOOT AND ANKLE

oRTHOSIS

Claw toes

Foot drop

equinovalgus

equinovarus

What surgeries are done in Polio?

Balancing of power

Stabilization procedures

Correction of deformities

Limb lengthening

TENDON TRANSFER

• Tendon transfers are indicated when dynamic muscle imbalance results in a deformity

• Surgery should be delayed until the maximal returns of the expected muscle strength has been achieved

• Objectives of tendon transfer• To provide active motor power • To eliminate the deforming effect of a muscle• To improve stability by improving muscle balance

Criteria and selecting the tendon for transfer

• Muscle to be transferred must be strong enough

• Free end of transferred tendon should be attached as close as possible to the insertion of paralised tendon

• A transferred tendon should be retained in its own sheath or should inserted in the sheath of another tendon or it should be pass through the subcutaneous fat

• Nerve supply and blood supply of transferred muscle must not be impaired

• Joint must be in satisfactory position• Contracture must be released before tendon

transfer• Transferred tendon must be securely attached to

bone under tension slightly greater than normal• Agonists muscles are preferable to antagonists

• Phasic muscle transfer is preferable to nonphasic transfer

• A nonphasic muscle should be trained by extensive physiotherapy before tranfer

• the ideal muscle for tendon transfer would have the same phasic activity as the paralysed muscle , same size in cross section and of equal strength and could be placed in the proper relationship to the axis of the joint

• Child with dynamic deformity an apropriate tendon transfer

ARTHRODESIS

• Most efficient method for permanent stabilization of a joint

• When the control of one or more joints • Bony procedures can be delayed until skeletal

growth is complete• When the tendon transfer and arthrodesis is

combined in the same operation the arthrodesis is performed first

• Most dependent parts of the body sujected to significant amount of deforming forces

• M.c deformities includes- - equinus - equino varus

- equino valgus - calcaneous

- cavovarus - claw toes

- dorsal bunion

PPRP OF FOOT AND ANKLE

PEABODY’S CLASSIFCATION

1. limited extensor invertor insufficiency

2. gross extensor invertor insufficiency

3. evertor insufficiency

4. triceps surae insufficiency

1. LIMITED EXTENSOR INVERTOR INSUFFICIENCY

- tibialis anterior paralysis

- equinus and cavus

- plano valgus

• Transfer of EHL to base od 1st MT

• If valgus deformity is fixed talonavicular arthrodesis is combined

2. GROSS EXTENSOR INVERTOR INSUFFICIENCY

TYPE A

-paralysis of extensors of toes and tibialis anterior

-equinus

-equino valgus

• Transfer of peroneus longus to dorsum of 1st cunieform bone

• Talonavicular 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

• Hoke arthrodesis is combined in severe deformity

3.EVERTOR INSUFFICIENCY

paralysis of peroneal muscles

- varus foot

• Slight-mod impairement:

EHL to base of 5th MT

• Severe:-tibialis anterior to cuboid

EHL to base of 5th MT

• 4.TRICEPS SURAE INSUFFICIENCY

• Calcaneovarus deformity- tibialis posterior,FHL

• calcaneovalgus deformity- both peroneals attached to calcaneum

• calcaneocavus - transfer of peroneals,tibialis posterior

when to operate

1. wait for atleast 1 1/2 years after paralytic attack

2. tendon transfers done in skeletally immature

3. extra articular arthrodesis 3-8 years

4. tendon transfer around ankle and foot after 10yr of age can be supplimented by arthrodesis to correct the deformity

4. triple arthrodesis >10-11 years

5. ankle arthrodesis >18 years

CLAW TOE

• Hyperextension of MTP and flexion of IP• Seen when long toe extensors are used to substitute dorsiflexion of ankleTreatment:For lateral toesdivision of extensor tendon by z-plasty incision,dorsal capsulotomy of MTP

For great toeFHL transferred to prox.phalanx,IP joint arthrodesis (or) division of EHL ,proximal slip attached to neck of 1st MT,distal slip to soft tissues+ IP arthrodesis

Dorsal bunion

• Shaft of 1st MT is dorsiflexed and graet toe is plantar flexed

• Seen in muscle imbalance,m.c is between anterior tibial and peroneus longus muscle

Lapidus operation

• remove abnormal bone from MT head• If anterior tibial is overactive- detach its tendon

And transfer it to 2nd or 3rd cuneiform bone • remove the inferior wedge of bone from 1st

metatarso cuneiform joint • bring the end of the FHL through the tunnel in

1st MT and anchor to the capsule over dorsum of MTP joint

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EQUINUS FOOT

• Anterior tibial muscle• Peroneal and long toe extensor muscles• Treatment:• Serial stretching and cast• Achilles tendon lengthening• Posterior capsule release• • Posterior bone block of cambell• Lambrinudi operation• Pantalar arthrodesis

EQUINOVARUS DEFORMITY

• Tibialis anterior• Long toe extensors and peroneal muscle

• Treatment:• Young children4-8 yrs:• 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)

• Children >8yrs:• Triple arthrodesis• Anterior transfer of tibialis posterior• Modified jones procedure

EQUINO VALGUS DEFORMITY

• Anterior and posterior muscle weakness with strong peroneals and gastroconemius-soleus muscle

• Treatment:• Skeletally immature:• 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

CAVOVARUS DEFORMITY

• 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

• Extensor hallucis longus is transferred to the neck ofneck of 1st MT

CALCANEUS DEFORMITY

• Gastroconemius-soleus muscle

Keeping in slight equinus position during acute stage of poliomyelitis• Plantar fasciotomy ,intrinsic muscle release before

tendon transfer• Depends on residual strength of GS muscle• Transfer of peroneus brevis and tibialis posterior to

the heel• Both peroneals trasfered for calcaneo valgus

deformity• Posterior tibial and FHL can be transfered for

cavovarus deformity • Anterior tibial tendon can be transferred posteriorly-

DRENNAN TECHNIQUE

• For mild deformity –braces used • Tenodesis of achilles tendon to fibula• There is progressive equinous deformity with

subsequent growth in pt with achilles tenodesis

Flail foot

• All muscles paralised distal to the knee• Equinus deformity results because passive plantar

flexion and• cavoequinus deformity because – intrinsic muscle

may retain some function• Radical plantar release • tenodesis• In older pt mid foot wedge resection may be required• ANKLE ARTHRODESIS

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