poliomyelitis ankle and foot

1. Poliomyelitis- Deformities
around ankle & foot
Presenter : Dr. Y. Shravan kumar, II Yr PG
Moderator: Dr. M. Anil Reddy sir
Chair Person: Dr. Koner Rao sir
Professor: Dr. J.Mothilal sir
Dept of Orthopaedic Surgery, PIMS

2. FOOT AND ANKLE
• Most dependent parts of the body, subjected to significant stress,
so are susceptible to deformities from paralysis.
• Most common deformities are
Claw toes, CavoVarus, Dorsal Bunion, Talipes Equinus,
Talipes Equinovarus, Talipes Cavovarus, Talipes Equinovalgus,
Talipes calcaneus.
• Ambulation requires stable plantigrade foot with even weight
distribution between heel & forefoot and no fixed deformity.
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3. Claw toes Cavovarus Equino valgus
Equinus Equinovarus Calcaneus

4. TENDON TRANSFERS
• When tendon transfers and arthrodesis are done simultaneously,
arthrodesis should be done first.
• Transfer of a tendon is preferred to its excision.
• In severe paralysis requiring arthrodesis, some weakness of dorsi
& plantar flexors is present hence evertors and invertors are
transferred to midline of foot anteriorly/ posteriorly into calcaneum
& TA.
• When a muscle is discarded, 7-10 cms of tendon should be
excised to prevent scarring.
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5. PARALYSIS OF SPECIFIC
MUSCLES
Common deformities of foot and ankle are described according to muscles
involved.
Tibialis anterior:
Origin: upper ½ or 2/3 of lateral surface of shaft of tibia and
adjacent interosseus membrane.
Insertion: medial cuneiform & base of 1st metatarsal.
Action: Dorsiflexion & inversion
Nerve supply: Deep peroneal nerve (L5).
Arterial supply: Anterior tibial artery.
Antagonists: Tibialis Posterior, Gastrocnemius-Soleus,
Peroneus longus
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6. Tibialis anterior
• Paralysis causes
— loss of dorsiflexion , inversion
— Equinus, Cavus, Planovalgus
—Extensors of toe become overactive resulting in
hyperextension of proximal phalanges, depression of MT heads
— Cavovarus results from unopposed activity of PL & posterior
tibial muscle.
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7. Tibialis anterior

8. Tibialis anterior
• Correction of Equinus contracture- passive stretching & serial
casting
—Sx: Posterior ankle capsulotomy + Achilles tendon
lengthening + Anterior transfer of PL tendon to base of 2nd MT ( OR)
EDL can be recessed to dorsum of midfoot.
• Correction of claw toe deformity— Transfer of long toe extensors to
necks of metatarsals.
• Correction of cavovarus deformity— PL transferred to base of 2nd
MT + EHL transferred to neck of 1st MT
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9. Anterior & posterior tibial
muscles
-results in equinovalgus
valgus = eversion + abduction
- shortening of Achilles tendon & peroneal muscles—>fixed deformity.
- deformity is similar to congenital vertical talus on standing lateral
radiograph.
- serial casting before surgery to stretch Achilles tendon & to avoid
weakening of gastro-soleus.
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10. Anterior & posterior tibial
muscles
- if both tibialis muscles are paralysed and peroneal muscles are
normal,
1)PL transferred to base of 2nd metatarsal (to replace anterior
tibialis)
2)One of the long toe flexors replaces posterior tibialis
-Peroneus brevis is sutured to distal stump of PL tendon.
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11. Tibialis Posterior
Origin: posterior surface of interosseous membrane & adjacent
region of tibia & fibula.
Insertion: Tuberosity of navicular,medial cuneiform.
Action: Inversion and plantar flexion
Nerve supply: Tibial nerve (L4,L5).
Arterial supply: Posterior tibial artery.
Antagonists: peroneus longus and brevis
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12. Tibialis
Posterior

13. Tibialis Posterior
Isolated paralysis is rare—> Hind foot & fore foot eversion
Surgery: FDL tendon is transferred and attached to navicular
For 3-6 yrs old — conjoined EDL & peronius tertius tendons
through transverse tunnel in talar neck & tendon sutured back
onto itself.
For severe valgus 1) PL transferred to medial side of talar neck
2)PB transferred to lateral side of talar neck
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14. Anterial Tibial, Toe Extensors &
Peroneal muscles
Severe equinovarus develops when posterior tibial & Gastrocnemius-
Soleus are unopposed.
Posterior tibialis muscle increases forefoot Equinus & Cavus deformity.
Further Equinovarus results from contracture of Gastrocnemius-Soleus.
Management: 1) Stretching by serial casting
2) Lengthening of Achilles tendon
3) Radical soft tissue release of forefoot cavus deformity
4) Anterior transfer of Posterior tibialis to base of 3rd
MT/middle cuneiform & anterior transfer of long toe flexors.
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15. Peroneal muscles
Peroneus longus:
Origin: Upper lateral surface of fibula, head of fibula, lateral tibial
condyle.
Insertion: Under surface of lateral sides of distal end of medial
cuneiform & base of 1st MT
Action: Eversion & plantar flexion
Nerve supply: Superficial peroneal nerve (L5,S1)
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16. Peroneal muscles
Peroneus brevis:
Origin: lower 2/3rd of the lateral surface of the shaft of fibula.
Insertion: lateral tubercle at the base of 5th metatarsal
Action: Eversion of foot
Nerve supply: Superficial Peroneal Nerve (L5,S1)
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17. Peroneal muscles

18. Peroneal muscles
Isolated paralysis of peroneal muscles is rare, if present hind foot varus
deformity due to unopposed activity of tibialis posterior.
Calcaneus becomes inverted, fore foot adducted, varus is increased
during gait by action of invertors.
Unopposed tibialis anterior —>dorsal bunion.
Management:
1) Anterior tibialis transferred to base of 2nd MT
2) Isolated transfer —>overactivity of EHL —> hyperextension of
hallux —> painful callus under 1st metatarsal head.
3) In chidren <5yrs, lengthening of EHL tendon.
4) >5yrs – transfer of EHL to neck of 1st metatarsal.
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19. Peroneal and Long toe
extensors
Causes less severe equinovarus deformity
Surgery:
-Transfer of anterior tibial tendon to base of 3rd
metatarsal/middle cuneiform.
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20. Gastrocnemius-Soleus
Strong muscle group, lifts entire body weight
Paralysis with unopposed dorsiflexors results in calcaneal
deformity
Adequate tension in Achilles tendon is required for normal function
of long toe flexors & extensors & intrinsic muscles
Weak Gastrocnemius-Soleus—posterior tibial, peroneal muscles
& long toe flexors can’t plantar flex hindfoot but can depress
metatarsal heads—> Equinus
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21. Gastrocnemius-Soleus
 Shortening of intrinsics and plantar fascia —>forefoot cavus
 Long axis of tibia and calcaneus coincide
 Surgical correction is indicated to prevent development of
calcaneal deformity and to restore hind foot plantar flexion.
 Surgery: Tendon transfer posteriorly to supplement/ substitute
gastro-soleus.
*if power is fair- posterior transfer of 2 or 3 muscles is sufficient
*if completely paralysed- all available muscles transferred.
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22. Gastrocnemius-Soleus
Plantar fasciotomy+ intrinsic muscles release for forefoot cavus deformity.
Anterior tibial muscle can be transferred posteriorly( DRENNAN TECHNIQUE).
In more severe deformity, transfer of toe extensors to metatarsal heads and
fusion of interphalangeal joints to prevent claw toe deformity.
If invertors and evertors are balanced- pure calcaneo cavus
If gastro soleus power is fair- transfer of PB and posterior tibial muscles to
heel.
For calcaneo valgus- both Peroneals transferred to heel.
For cavovarus - posterior tibial and FHL are transferred.
westin and defiore recommended tenodesis of Achilles tendon to fibula for
paralytic calcaneovalgus deformity.
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23. Gastrocnemius-Soleus
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westin and Defiore tenodesis of Achilles tendon

24. FLAIL FOOT
 When all muscles distal to knee are paralysed – equinus
deformity results due to passive plantar flexion.
 Residual intrinsic muscle activity- forefoot equinus /cavo equinus
deformity.
 Surgery: Radical plantar release + Plantar neurectomy
Midfoot wedge resection for forefoot equinus.
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25. DORSAL BUNION
 Shaft of first meta tarsal is dorsiflexed, great toe is plantar
flexed.
 Results from muscle imbalance.
 Deformity becomes more on weight bearing.
 MTP joint is flexed, first MT head is displaced upwards, first
cuneiform tilted upwards.
 Exostosis forms on dorsum of metatarsal head.
 Flexion of great toe –>subluxation of MTP joints –> plantar part
of joint capsule and FHB gets contracted.
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26. DORSAL BUNION
 Two types of muscle imbalance cause bunion.
 Most common- Dorsiflexion of first MT (10)
Plantar flexion of great toe(20)
2) Plantar flexion of great toe(10)
Dorsiflexion of first MT (20)
 Most common muscle imbalance is between anterior tibial and
peroneus longus.
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27. DORSAL BUNION
 Anterior tibial raises first cuneiform and base of first metatarsal, PL has
opposite action
 If PL is weak/ parlysed/ transferred – first MT dorsi flexed by anterior
tibialis.
 Great toe becomes actively plantar flexed.
 Dorsal bunions result after ill advised tendon transfer.
 If anterior tibial is paralysed, then PL tendon/ PL+ PB should be
transferred to third cuneiform rather than to insertion of anterior tibial
or PB transferred to insertion of anterior tibial.
 If PL tendon is transferred, proximal end of distal segment should be
fixed to the bone.
 If triceps surae is weak/ paralysed- PL transferred to calcaneum, anterior
tibial to midline of foot.
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28. DORSAL BUNION
SURGERY FOR DORSAL BUNION
 Transfer of anterior tibial to third cuneiform
Second and less common muscle imbalance:
Paralysis of all muscles of foot except triceps surae and long toe flexors.
 Action of long toe flexors—> plantar flexion of great toe—> head
of 1st MT displaced upwards.
 Surgery: Transfer of FHL to neck of 1st MT + plantar closing
wedge osteotomy of 1st MT
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29. BONY PROCEDURES (OSTEOTOMY
AND ARTHRODESIS)
 The no of joints that are controlled by paralysed muscles should
be reduced by arthrodesis.
 Stabilizing procedures for ankle and foot are of 5 types
1. Calcaneal osteotomy
2. Extra articular subtalar arthrodesis
3. Ankle arthrodesis
4. Triple arthrodesis
5. Bone blocks to limit motion at ankle joint.
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30. CALCANEAL OSTEOTOMY
 For correction of hindfoot varus/ valgus in growing children.
 For cavo varus, it can be combined with release of intrisic
muscles and plantar fascia.
 For calcaneovarus, it is combined with posterior displacement
calcaneal osteotomy.
 Fixed valgus deformity requires medial displacement osteotomy.
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31. DILLWYN EVANS OSTEOTOMY
 For talipes calcaneovalgus as an alternative to triple arthrodesis
in children between 8-12 yrs.
 Reverse of the original technique used in clubfoot
 Lengthens calcaneus by transverse osteotomy and insertion of
bone graft to open a wedge and lengthen lateral border of foot.
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32. DILLWYN EVANS OSTEOTOMY
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33. SUBTALAR ARTHRODESIS
 For correction of equino valgus deformity.
 Deformity d/t paralysis of anterior and posterior tibial
—>unapposed action of peroneals (valgus) and gastro soleus
(equinus).
 Calcaneus is everted, displaced laterally and posteriorly.
 Two techniques for sub talar arthrodesis.
1) Grice and Green
2) Dennyson and Fulford
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34. SUBTALAR ARTHRODESIS
GRICE AND GREEN ARTHRODESIS:
Extra articular subtalar fusion.
To restore height of medial longitudinal arch in children between 3-8 yrs.
Done when valgus deformity is localized to subtalar joint and calcaneus can be
manipulated into normal position.
Contraindicated when forefoot is not mobile enough to be made plantigrade.
Complictions: varus deformity and increased ankle joint valgus due to over
correction.
DENNYSON AND FULFORD ARTHRODESIS:
Screw is inserted across subtalar joint for internal fixation and an iliac graft is placed
in sinus tarsi.
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35. Grice & Green Arthrodesis
Curvilinear incision on lateral aspect of foot over subtalar joint
Soft tissue dissection
Subtalar joint reached
Foot is inverted to position calcaneus beneath talus
Graft beds prepared by removing thin layer of cortical bone from inferior surface of talus
& superior surface of calcaneus
Bone graft harvested & shaped
Grafts placed in sinus tarsi, with foot in over corrected position
Long leg cast applied with knee flexion, ankle in maximum dorsiflexion, foot in corrected
position
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36. Grice & Green Arthrodesis
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37. Dennyson & Fullford Arthrodesis
Oblique incision over sinus tarsi, sinus tarsi exposed
With calcaneum in corrected position, bone awl is passed through
neck of talus across sinus tarsi, upper surface of calcaneus,
inferolateral surface of calcaneus
Mini fragment cancellous screw is passed across subtalar joint
from neck of talus into calcaneus
Sinus tarsi filled with iliac crest bone graft
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38. Dennyson & Fullford Arthrodesis

39. Triple Arthrodesis
- Most effective stabilising procedure in foot
- Fusion of
1) Sub-talar joint
2) Calcaneo-Cuboid joint
3) Talo- Navicular joint
- Allows only movement at ankle
- Indicated when most of the weakness & deformity are at sub-talar
& mid tarsal joints
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40. Triple Arthrodesis
Triple arthrodesis is performed to
1. Obtain stable & static realignment of foot
2. Remove deforming forces
3. Arrest progression of deformity
4. Eliminate pain
5. Eliminate use of short leg brace
6. Obtain a more normal looking foot
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41. Triple Arthrodesis
- Reserved for severe deformity in children above 12 yrs
- Technique depends on type of deformity
- In talipes Equino-valgus, medial wedge with portion of talar head
and neck is excised
- In talipes Equino-varus, lateral subtalar wedge is resected
- In talipes calcaneo-cavus, wedge is removed from subtalar joint
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42. Triple Arthrodesis
Steps:
1. Oblique incision over sinus tarsi
2. Soft tissue dissection
3. Capsules of all 3 joints incised circumferentially
4. Appropriate bone wedges removed
5. Bone graft placed around talonavicular joint & in sinus tarsi
6. Correction maintained with steinmann pins or k-wires
Complications :
1. Most common- psuedarthrosis of talonavicular joint
2. Degenerative arthritis
3. Osteonecrosis
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43. Triple arthrodesis

44. Labrinudi Arthrodesis
- For correction of isolated fixed equinus deformity in children > 10yrs
- Inactive dorsiflexors & peroneals with active triceps surae cause foot
drop deformity
- Wedge of bone is removed from plantar distal part of talus, so that talus
remains in complete equinus & remainder of foot is repositioned to
desired degree of plantar flexion
Complications include
1. Ankle instability
2. Residual varus/ valgus
3. Psuedarthrosis of talonavicular joint
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45. Ankle Arthrodesis
- For flail foot or recurrence of deformity after triple arthrodesis
- Compression arthrodesis is for older children & adolescents
- Subcutaneous plantar fasciotomy & lengthening of Achilles tendon
is done followed by ankle arthrodesis
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46. Pantalar Arthrodesis
Fusion of tibiotalar , talonavicular, subtalar, calcaneo cuboid joints
Indicated for flail feet with quadriceps paralysis
Ankle fused in 5 to 10 degrees of plantar flexion
Done in 2 stages- first in foot, 2nd in ankle
Complications include psuedarthrosis, plantar callosities, excessive
heel equinus
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47. Tendon transfer techniques

48. Talipes Equinovarus
Equinus deformity of ankle
Inversion of heel & at mid tarsal joints
Adduction & supination of fore foot
d/t weakness of peroneals & normal posterior tibial
Surgery:
Anterior transfer of posterior tibial tendon to middle cuneiform OR
tendon can be split with lateral half transferred to cuboid
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49. Talipes Equino valgus
- d/t weak anterior & posterior tibial with strong PL, PB & triceps is strong but
contracted
- Triceps pulls foot into equinus, peroneals into valgus
Surgery:
Subtalar arthrodesis & anterior transfer of PL, PB.
Paralysis of anterior tibial alone—> moderate valgus, more during
dorsiflexion, disappear in plantar flexion
Surgery:
Transfer of PL to 1st cuneiform, transfer of EDL OR Jones procedure
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50. Talipes Equino valgus
Paralysis of posterior tibial alone—> planovalgus
Surgery:
Transfer of PL, FDL, FHL or EHL
Paralysis of both—> extreme deformity similar to rocker bottom flat
foot
Surgery:
Transfer of PL to base of 2nd MT to replace ant tibial +
Transfer of one of the long toe flexors to replace post tibial
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51. Talipes Equino valgus
Surgery for equino valgus:
- In children 4- 10yrs— Extra articular subtalar arthrodesis + achilles
tendon lengthening
- In skeletally mature— Triple arthrodesis + achilles tendon
lengthening
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52. Talipes Calcaneus
- d/t Gastrocnemius-Soleus paralysis with active dorsiflexors
- Calcaneotibial angle - intersection of axis of tibia & line along
plantar aspect of calcaneus
- Normal is 70-800 , in equinus > 800 , in calcaneus< 700
Surgery:
Plantar fasciotomy & Triple Arthrodesis followed 6 weeks later by
transfer of PL & PB & post tibial to calcaneus
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53. Calcaneotibial angle
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54. REFERENCES
• Turek’s orthopaedics, 7th edition
• Campbell’s operative orthopaedics, 13th & 11th edition
• Internet
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55. Thank you
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