poliomyelitis, deformities of hip

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

2. General principles
2

3. General principles
‣ Surgery can be done 6 months after acute phase
‣ In skeletal immature (children <10 years)- only soft tissue
procedures
‣ Poliomyelitic extremity is atrophied and has decreased rate of
longitudinal growth
‣ Inequality of lower extremities require temporary or permanent
epiphyseal arrest of longer extremity
‣ Fragile bones are susceptible to fracture , callus formation and
union are normal
3

4. General principles
According to Peabody
‣ Deformity can be 1) Static
2) Dynamic - by muscle imbalance
‣ In skeletally immature, deformity corrected by Arthrodesis alone -
recurrence occurs as imbalanced muscle forces continue to act
‣ During growth period tendon transfer is done , after 10 yrs of age
supplemented with bone procedure
4

5. General principles
‣ Static deformity can be controlled by brace in child , arthrodesis in
adults
‣ Dynamic deformity can be controlled by tendon transfer in both
groups
‣ In child with static deformity, with arthrodesis recurrence is rare
‣ In child with dynamic deformity with arthrodesis alone recurrence
is possible
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6. Tendon transfers
6

7. Tendon transfers
‣ Definition
‣ Indication
‣ Objectives
7

8. Tendon transfers
TENDON TRANSFER:
‣ Done to substitute for a paralysed muscle and to restore muscle
balance
‣ Tendon transfer shifts a tendinous insertion from its normal
attachment to another location so that its muscle can be
substituted for a paralysed muscle in the same region
INDICATION :
‣ Dynamic muscle imbalance resulting in a deformity that interferes
with ambulation or function of upper extremities
‣ should be done only after maximum return of expected muscle
strength
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9. Tendon transfers
Objectives:
‣ To provide active motor power to replace function of paralysed
muscle.
‣ To eliminate deforming effect of a muscle when its antagonist is
paralysed.
‣ To improve stability by improvising muscle balance.
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10. Principles of Tendon transfers
1. Strength
2. Efficiency
3. Excursion
4. Neurovascular
5. Articular
6. Tension
10

11. Principles of Tendon transfers
1. STRENGTH : Muscle to be transferred must be strong , a rating
good /better as it loses at least 1 grade in power after transfer
2. EFFICIENCY : Transferred tendon should be attached close to
the insertion of the paralysed muscle as possible & located in as
direct a line as possible between muscle origin & its new
insertion
3. EXCURSION: should have a range of excursion similar to the
muscle it is reinforcing / replacing.
-retained in its own sheath / into sheath of another tendon/
through tissue such as subcutaneous fat - gliding
-routing through fascial/ osseous tunnels - scarring and
decreased excursion
11

12. Principles of Tendon transfers
NEUROVASCULAR:
-Nerve and blood supply should be intact
ARTICULAR:
-Joint should be in a satisfactory position , all contractures
should be released
TENSION:
-should be attached under tension slightly greater than normal
-If tension is insufficient , excursion is used in removing slack
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13. Principles of Tendon transfers
‣ between agonistic muscles, phasic at same time in gait cycle
‣ Thigh muscles: Quadriceps - stance phase muscle
Hamstrings - swing phase muscle
‣ Leg muscles : anterior - swing phase
posterior - stance phase
‣ Phasic transfer retain preoperative phasic activities & regain pre-
operative duration of contraction & electrical intensity
‣ Non phasic transfer not recommended
‣ Some non-phasic transfers are capable of phasic conversion but
unpredictable
13

14. Principles of Tendon transfers
IDEAL MUSCLE FOR TENDON TRANSFER:
‣ should have same phasic activity
‣ Of same size in cross section
‣ Equal strength
‣ Could be placed in proper relationship to axis of joint to allow
maximum mechanical effectiveness
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15. Arthrodesis
15

16. Arthrodesis
‣ A relaxed or flail joint is stabilised by restricting its ROM
‣ a brace may control a flail joint, but a reconstructive operation
would not only eliminate the need for brace but also improves
function
‣ Arthrodesis is the most efficient method of permanent stabilisation
of a joint
‣ Function of LL - to support weight of body , so joints should be
stable , muscle should have sufficient power
‣ Function of UL - reach, grasp, pinch & release, require mobility
than stability & dexterity than power
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17. Arthrodesis
‣ Operation to obliterate ROM in UL joints should be done
only after careful study
‣ Weakness of LL - usage of ambulatory assistive device -
any surgery that affects UL can effect ambulation
‣ Arthrodesis of shoulder
‣ Elbow rare
‣ wrist - useful for some , wheel chair, wrist extended
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18. Deformities of lower
limb
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19. Deformities of lower limb
‣ During acute and convalescent stage , patient lies in frog leg
position due to spasm of hip flexors, hip abductor , TFL ,
hamstrings .
‣ Hip-flexion abduction , external rotation , knee- flexion, foot -
equinovarus
‣ Soft tissue contractions : Inter-muscular septa , facia over
muscles—> fibrosis of muscles—> contractures
19

20. Most common deformities of lower limb
1. Flexion-abduction deformity of hip
2. Pelvic tilt / obliquity : hip abduction contracture—> opposite side
of pelvis ride high—> hip adduction , subluxation
3. Exaggerated lumbar lordosis & anterior inclination of pelvis
secondary to hip flexion contracture - Methods to demonstrate
lumbar lordosis
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21. 21

22. 22

23. Most common deformities of lower limb
4. Lumbar scoliosis convex towards affected side
5. External torsion of leg on femur
6. Genuvalgum & flexion of knee , Genu Recurvatum
7. Equinovarus of foot
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24. Deformities of HIP
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25. HIP
Paralysis of muscle around hip can cause
1. Flexion & abduction contracture
2. Instability & limping due to paralysis of gluteus maximus
and medius
3. Paralytic hip dislocation
25

26. Flexion-Abduction contracture
• Abduction deformity- Mc deformity
• Occurs in conjunction with flexion & external rotation
• Sometimes - adduction with flexion & IR occurs
• If contracture is B/L & severe- locomotion only as
quadruped
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27. Flexion-Abduction contracture
Irwin has stated:
“Iliotibial band with its allied structures is
probably the greatest deforming factor in the lower
trunk & lower limb following an attack of
poliomyelitis”
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28. Flexion-Abduction contracture
Fascia lata & iliotibial band
‣ Deep fascia of the thigh
‣ Encloses muscles of thigh
‣ Forms the outer limit of the fascial compartments of thigh,
which are internally separated by inter-muscular septa
‣ Thickened at its lateral side- iliotibial tract
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29. Fascia lata & Ilio-Tibial band
‣An investment for the whole of the thigh
‣Varies in thickness in different parts
‣Thicker in the upper and lateral part of the thigh,
‣Receives a fibrous expansion from the gluteus maximus
‣Tensor fasciae latae is inserted between its layers
‣Very thin behind and at the upper and medial part- covers adductors
‣Stronger around the knee- receiving fibrous expansions from tendon of
the biceps femoris laterally, from the sartorius medially, and from
quadriceps femoris in front
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30. Fascia lata
30

31. Fascia lata & Ilio-Tibial band
Attachments :
‣ Back of sacrum and coccyx posteriorly, iliac crest laterally, in front to the
inguinal ligament, superior ramus & inferior ramus of the pubis, ischial
tuberosity, lower border of the sacrotuberous ligament.
‣ Passes down over the gluteus medius to the upper border of the gluteus
maximus, where it splits into two layers, one superficial and the other
beneath, at the lower border of the muscle the two layers reunite and form
a strong band
‣ This band is continued downward - iliotibial band and is attached to the
lateral condyle of the tibia & head of fibula at Gerdy’s tubercle
‣ Band lies in a plane anterior to hip joint & posterior to knee
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32. Ilio tibial band
32

33. Iliotibial band contracture
Contracture of the iliotibial band can contribute to the following
deformities:
1.Flexion, abduction, and external rotation contracture of the hip
-Iliotibial band lies lateral and anterior to the hip joint,
contracture can cause flexion and abduction
-Externally rotated for comfort only
-If not corrected, external rotators contract & contribute to a
fixed deformity.
2. Genu valgum and flexion contracture of the knee
3. Limb-length discrepancy
-related more to the loss of neurologic and muscle function
-contracted iliotibial band on one side may be associated with con-
siderable shortening of that extremity after years of growth
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34. Iliotibial band contracture
4. External tibial torsion, with or without knee joint
subluxation
- Tibia and fibula externally rotated on femur
-If severe, lateral tibial condyle subluxates on the lateral
femoral condyle and the head of the fibula lies in the
popliteal space.
5. Secondary ankle and foot deformities
With external torsion of the tibia, the axes of the ankle
and knee joints are malaligned
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35. Iliotibial band contracture
6. Pelvic obliquity
‣ patient is supine with the hip in abduction and flexion, the pelvis remains
at a right angle to the long axis of the spine
When the patient stands, affected extremity is brought into the weight-
bearing position—pelvis becomes oblique—lower on affected side
‣ lateral thrust forces pelvis towards unaffected side
‣ Trunk muscles lengthen on affected side, contracted on unaffected side
7. Increased lumbar lordosis
‣ To maintain upright erect posture, compensatory lumbar lordosis develops
35

36. Measures to prevent flexion-abduction
deformity
• During acute & convalescent stages
-hip in neutral rotation
-slight abduction , No flexion
-full range of passive motion in all joints several times in a day
-to prevent rotation, a bar similar to Denis-Browne splint is used
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37. Surgical correction
• Minor contracture- simple fasciotomy around hip & knee
• For AB-ER - complete release of hip muscles (OBER-
YOUNT)
• For severe deformities - complete release of all muscles
from iliac wing with transfer of crest of ilium (CAMPBELL
TECHNIQUE)
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38. Ober-yount procedure
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39. Ober -Yount procedure
• Complete release of flexion abduction & external rotation contracture
• Position : lateral
• Incision : transverse just medial & distal to ASIS, extending laterally above
GT
• Divide ilio-psoas tendon, excise 1cm
• Sartorius origin detached from ASIS
• Rectus femoris origin detached from AIIS
• TFL divided from anterior to posterior
• Gluteus medius, minimus & short external rotators detached from insertion on
trochanter
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40. Ober -Yount procedure
• Sciatic nerve retracted , hip capsule opened from anterior to
posterior
• Hip spica cast applied with hip in full extension, 10deg abduction &
internal rotation
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41. Ober -Yount procedure
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Sartorius
Ilio-Psoas
Rectus femoris
TFL

42. Yount procedure
• Lateral longitudinal incision just proximal to femoral condyle
• Fascia lata exposed
• Ilio-tibial band & fascia lata divided anteriorly upto midline of
thigh, 2.5 cms proximal to patella, posteriorly upto biceps
tendon
• IT band & lat intermuscular septum of 5-8 cms long excised
• Post-operative care: cast removed at 2 weeks , long leg
brace with pelvic band applied with hip in same position
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43. Campbell technique
43

44. Campbell Technique
• For severe deformities
• Complete release of muscles from iliac wing & transfer of crest
of ilium
• Incision : skin along anterior 1/2 or 2/3 of iliac crest upto ASIS,
extended distally for 5-10 cms on anterior surface of thigh
• Superficial & deep fascia divided
• Origins of TFL, gluteus medius, minimus stripped
subperiosteally from wing of ilium to acetabulum
• Free proximal part of sartorius from TFL
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45. Campbell Technique
• With an osteotome, asis with origin of sartorius resected
• Anterior border of ilium denuded down to AIIS
• Free attachments of abdominal muscles from iliac crest
• Iliacus stripped subperiosteally
• Detach straight head of rectus from AIIS & reflected head from
anterior margin of acetabulum
• As result hip hyperextension without lordosis should be possible
• If not then divide capsule obliquely from proximal to distal +
tenotomy of Iliopsoas from LT
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46. Campbell Technique
• Redundant part of denuded ilium is resected
• Abdominal muscles sutured to edge of gluteal
muscles &TFL
• Superficial fascia on medial side of incision sutured
to deep fascia on lateral side to bring skin incision
2.5 cms posterior to rim of ilium
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47. Campbell technique
• In a child, all steps are followed except iliacus is not stripped
• A wedge of crest of ilium removed distal to physis from anterior to
posterior with apex as far as skin incision, base anterior & 2.5cms
in width
• Displace crest of ilium distally to contact main part of ilium , fix with
sutures
• Post-operative care: hip spica cast wit hip in hyperextension ,
10deg abduction for 3-4 weeks
• Cast removed & hip mobilised
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48. Campbell technique
A Origins of sartorius, tensor fasciae latae, and gluteus medius muscles are detached
from ilium. B Redundant part of ilium is resected.
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A B

49. Paralysis of gluteal
muscles
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50. Paralysis of gluteal muscles
• Weakness or paralysis of gluteus Maximus and medius
• Results in one of the most severe disabilities
• Paralysis causes unstable hip & unsightly, fatiguing limp
• If glut med alone is paralysed, during weight bearing-trunk sways
towards affected side, pelvis elevates on opposite side-
compensated trendelenburg gait
• If glut max alone is paralysed - body lurches backward
• Trendelenburg test is used to test strength of gluteal muscles
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51. 51

52. Ilio-Psoas transfer
• Ilio-psoas is the most effective muscle
• Innervation is different, often preserved in polio
• Has good power
• When transferred, acts in direct line to GT
• Although gluteal limp is reduced, normal balance is never restored
• If glutei are partially paralysed, reinforcement markedly improves
stability and gait
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53. Ilio-Psoas transfer
• When gluteus medius is chiefly involved & abductor power is the
chief requirement- MUSTARD PROCEDURE is done
• If both glutei are involved i.e both abduction & extension are weak-
SHARRARD PROCEDURE is done
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54. Sharrard procedure
Posterior transfer of the iliopsoas for paralysis of the gluteus medius and maximus muscles
Open adductor tenotomy should always precede iliopsoas transfer.
▪ Place the patient on the operating table slightly tilted toward the nonoperative side.
Through a transverse incision overlying the adductor longus, adductor muscles
exposed & divided
▪ lesser trochanter exposed and detached from femur, psoas muscle cleared as far
proximally as possible.
▪ second incision is given just below and parallel to the iliac crest.
▪ crest with the muscles of the abdominal wall detached and psoas muscle sheath
opened Locate the insertion of the muscle with a fingertip.
▪
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55. Sharrard procedure
▪ Through the first incision, LT grasped with a Kocher forceps and pulled
upwards, within the psoas sheath and into the upper operative area
▪ Expose sartorius muscle and divide it in its proximal half
▪ Direct head of the rectus femoris muscle divided at its origin,
reflected head of the rectus femoris muscle dissected free from the hip
capsule, and elevated posteriorly.
▪ If the hip is dislocated, capsule is opened anteriorly and laterally,
parallel to the labrum, excise the ligamentum teres, and remove any
hypertrophic pulvinar.
▪ Hip joint reduced
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56. Sharrard procedure
▪ A hole is made through the iliac wing just lateral to sacra-iliac
joint, make an oval with its long axis longitudinal, its width
slightly more than one third of that of the iliac wing, and its
length 1.5 times its width.
▪ Ilio-psoas tendon and the entire iliacus muscle passed
through the hole
▪ Posterolateral aspect of the greater trochanter identified,
corresponding anterior aspect of the greater trochanter
exposed
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57. Sharrard procedure
▪ With awls & burs and from anteriorly to posteriorly, hole is
made through the greater trochanter big enough to receive the
tendon.
▪ While the hip is held in abduction, extension, and neutral
rotation, pass the end of the tendon through the buttock and
from posteriorly to anteriorly through the tunnel in the greater
trochanter
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58. Sharrard procedure
▪ Psoas and lesser trochanter are secured to the greater
trochanter with sutures or a screw
▪ Origin of the iliacus muscle is sutured to the ilium, inferior to
the crest.
▪ For severe coxa valga or anteversion that requires more than
20 to 30 degrees of abduction for stability, a varus derotation
osteotomy with internal fixation can be performed before
insertion and suturing of the iliopsoas tendon in the GT
58

59. Sharrard procedure
▪ As an alternative, a “gutter,” or notch is cut into the posterior
lateral iliac crest rather than a window in the ilium.
▪ The muscle and its tendon can be redirected laterally through
the notch and inserted into the greater trochanter.
▪ This is technically simpler because the iliacus muscle is not
transferred to the outside of the pelvis.
POSTOPERATIVE CARE: The hip is immobilized for 6 weeks in
an abduction spica cast.
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60. Sharrard procedure
60

61. Mustard procedure
• Indicated when power of abduction must be improved
• Hip approached by smith-Petersen incision
• Origins of sartorius & rectus femoris removed
• Femoral vessels & nerve retracted medially
• ilio-psoas is divided at insertion along with LT
• Notch is cut in ilium between superior and inferior iliac spines
• Ilio-psoas is drawn through notch& attached to GT
• Hip is maintained in abduction for several weeks
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62. Mustard procedure
62

63. Mustard procedure
63

64. Paralytic dislocation of hip
‣ Paralyzed gluteal muscles with normal flexors and
adductors of the hip, the child may develop a paralytic
dislocation of the hip
‣ Combination of imbalance in muscle power, habitually
faulty postures, and growth is important in producing
deformity
‣ Dislocation also can develop because of fixed pelvic
obliquity, in which the hip is held in marked abduction,
usually by a tight iliotibial band or a structural scoliosis
64

65. Paralytic dislocation of hip
‣ Weakness of the abductor musculature retards the growth of
the greater trochanteric apophysis.
‣ The proximal femoral capital epiphysis continues to grow
away from the greater trochanter and increases the valgus
deformity of the femoral neck;
‣ Femoral anteversion also may be increased
‣ Hip becomes mechanically unstable and gradually subluxates
‣ Uneven pressure in the acetabulum causes an increased
obliquity in the acetabular roof.
65

66. Treatment
1. Reduction of dislocation:
Early: easily reduced by abduction
Later: by traction & abduction
Late: if contracture is severe—> adductor tenotomy with traction
If still irreducible—> skeletal traction continued till femoral
head is opp acetabulum, 30deg abduction & open reduction done
66

67. Treatment
2. Correction of muscle imbalance:
To restore abduction & extension by Iliopsoas transfer by
MUSTARD / SHARRARD procedure
3. Varus femoral osteotomy:
To correct valgus deformity
4. Acetabuloplasty :
To provide adequate roof & depth for stability by salter,
pemberton , chiari procedures
5.pelvic support osteotomy: rarely done
67

68. Paralytic dislocation of hip
Hip arthrodesis:
‣ Rarely is indicated
‣ Last alternative for treatment of a flail hip that requires
stabilisation or
‣ of an arthritic hip in a young adult that cannot be
corrected with total hip arthroplasty
‣ Girdlestone procedure is the final option for failed
correction of the dislocation
68

69. Flail hip
‣ Seen in extensive involvement of lower extremity with
complete lack of muscle power
‣ Requires multiple orthotic devices & support from upper
limbs
‣ Gait is lurching & unstable , poor endurance, lacks support
from contralateral limb
‣ Ambulation is impossible with weakness of upper limbs
69

70. Treatment of flail hip
• Arthrodesis of hip improves gait, stability, endurance and
eliminates need for external support
Principles:
‣ Hip fusion alone or combined with ankle fusion in slight equinus—>
good stability
‣ For hip fusion
a) good abdominal muscle power/ a strong opp glut med. providing
hip elevating power
b) knee ligaments should be sound
c) absence of flexion contracture of knee
‣ Fusion involves combined intra & extra articular fusion
supplemented by internal fixation
70

71. Treatment of flail hip
Best position is
1. Neutral rotation
2. No adduction
3. No abduction
4. 300 flexion
‣ In females & with shorter extremities 150 abduction
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72. REFERENCES
• Turek’s orthopaedics, 7th edition
• Campbell’s operative orthopaedics, 13th & 11th edition
• Internet
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73. Part-III of poliomyelitis- Surgical
management of deformities around knee
ankle & foot
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74. Thank you
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