Prof. Anisuddin Bhatti's Lecture on Post Polio residual Palsy & Deformities part3 Upper limb. Acknowledged resource of text & photographs.

1. POST POLIO
DEFORMITY &
PARALYSIS
Par t.3
UPPER LIMB
Reconstructive Surgery
Anisuddin Bhatti
Professor, Dr. Ziauddin Hospital, Clifton
President Rt, Paeds Ortho Society Pakistan &
POA
Focal Person, Ponseti International, Pakistan
Ziauddin Hospital, Webinar Series
SUNDAY, 18th April 2021

2. EXPERTS
Prof. Imtiaz Hashmi
DZU KHI
Prof. Mehtab Pirwani
Karachi
Dr. M. Shoaib Khan
Peshawer

3. POSTPOLIO DEFORMITIES & RESIDUAL PARALYSIS
Before Embarking to Reconstructive surgery, it is
necessary to have detailed understanding &
knowledge of:
• Pathologic process
• Pathoanatomy of deformity
• Clinical Assessment
• Principles of Reconstructive Surgery
• Regional Deformities
• Management principles
• Case Discussion
Physiolone.com

4. DECISION MAKING
FACTORS
The most important factors that need attention
before embarking to reconstructive surgery
• Age of the patient,
• Functional assessment of limbs & spine
• Socioeconomic background.
• Radiographic examinations.

5. FUNCTIONAL ASSESMENT
1. Muscle Charting / power grades
2. Extent of contractures and
deformities
3. Ambulatory Status & Posture
4. LLD - Shortening of the limb
follow

6. EXTENT OF CONTRACTURES & DEFORMITIES
• Trendelenburg test
• Thomas test
• Ober / Yount’s test
• Ankle & Foot deformity
evaluation
• Pelvis & spinal curvatures
Slideshare
https://www.slideshare.net/AnisuddinBha
tti1/anis-bhatti-cp-2-clinical-assesment-
2020
Youtube https://youtu.be/IWLnWJ2P-3g
follow

7. AMBULATORY STATUS
• Observation of Gait /
Gait Lab Analysis
• Abductor Lurch
• Extensor Lurch
• Hand to Knee Gait
• The Calcaneus Gait
• Foot Drop Gait
• Short Limb Gait
Slide share
https://www.slideshare.net/AnisuddinBhatti1/4
anisbhatti-gait-disorders
youtube
https://youtu.be/96fZsU5SyYY
follow

8. PROGNOSTIC FACTORS
• i. Severity of initial paralysis
• ii. Diffuseness of its regional distribution
• Iii. Expectations & support
• Iv. Resources availibilty
• In general, the more extensive the paralysis in the
first 10 days of illness the more severe the ultimate
disability.

9. OPTIONS: RECONSTRUCTIVE SURGERY
1. Release of contractures : Fasciotomies &
Capsulotomies
II. Re-establishment of power by:
a) Tendon transfer to prevent deformities
b) Muscle transplantation: to replace a
paralyzed muscle
III. Stabilization of a relaxed or flail joint by:
(a) Tenodesis
(b) Construction of Bone block
Tenodesis of Achilles tendon to fibula
Posterior bone block

10. OPTIONS : RECONSTRUCTIVE SURGERY
IV. Correction of Deformities by
a) Osteotomies b) Arthrodesis
V. Limb lengthening (Ilizarov techniques to
release contracture & Limb Lengthening)
VI. Joint replacement surgery
VII. Correction of pelvic obliquity & Spine
deformity & stabilization

12. UPPER LIMB
RESIDUAL ALSYP & DEFORMITIES
Reconstructive Surgery
PART 3

13. SHOULDER
Before imbarking to Reconstructive surgery
Important to understand Biomechanis,
Assesment forParalysed muscles & availble substitute

14. SAHA’S 1967
BIOMECHANICAL CLASSIFICATION
OF SHOULDER GIRDLE MUSCLES
Prime Movers 1. Deltoid
2. Pectoralis Major
• Bulky muscles
• Act on long lever
• Clavicular head exert major
force for abduction
Steering Group:
Superior Sterer
Supra Spinatus • By virtue of their
insertions near articular
surface & Neck-shaft axis
• Steer the head on
Gelenoid Surface.
• Exert Stablizing force
• Have limited lifting force
Horizontal Anterior steerer Sub Scapularis
Horizontal Posterior Steerer Infra Spinatus
Teres Minor

15. Depressor Group:
Intermediate Group 1. Pectoralis Major
Sternal Head
2. Latissimus Dorsi
3. Teres Major
• Rotates Humeral
head during
elevation &
the head towards
later part.
• Also Exert week
steering force on
the head
SAHA’S 1967
BIOMECHANICAL CLASSIFICATION
OF SHOULDER GIRDLE MUSCLES

16. SAHA, 1967
PATTERN OF THE UPPER LIMB PARALYSIS
& SHOULDER JOINT SUBLUXATION
Group Muscles Involved Joint Subluxation
I
Serat. Ant, Levator Scap,
Rhomboids, Trapizius, Deltoid
Rotators
May or may not be present
II
Deltoid Anterior & mid part
rotators, other girdle musce
normal
May or may not be present
III
Same as II + elbow fexor palsy &
Supinator palsy
Often present
IV
Partial palsy of Trapizius,
Seratus,etc. GlenoHumeral
muscles of elbow, wrist &
Always resent
V
Flail upper limb Present

17. Rx: PPR Paralysis & Substitutes
Paralysed Muscle Action required Substitutes
Supra Spinatus Superior Glider 1. Levator Scapulae.
Preferable due to same
direction & length of
fibers.
2. Sternocliedomasto
d
3. Scaleneus anterior
/ medius
4. Scalenus Capitus

18. Rx: PPR Paralysis & Substitutes
Paralysed Muscle Action required Substitutes
Sub Scapularis Anterior Glider 1. Upper 2
of Seratus Ant.
2. Pectoralis Minor
3. Pectoralis Major
Whole /part
Infra Spinatus Posterior Glider, acting
from behind
1. Lati dorsi
2. Teres Major

19. DELTOID PALSY
TENDON AND MUSCLE TRANSFERS
Classic methods:
•Bateman Trapezius Transfer. Single muscle transfer,
without consideration to the functions of the steering muscles.
•Arthrodesis of the Shoulder
When there is, paralytic subluxation or dislocation of
shoulder with extensive paralysis of the scapulohumeral
muscles.

20. DELTOID PALSY:
BATEMAN TRAPEZIUS TRANSFER
• Spine of scapula osteotomised
near its base in obliquity distal
& lateral.
• Split atrohic deltoid
• Roughen deep surface of
acromion, spine &
corresponding area of humerus.
• Resect lateral end of clavicle.
• Anchor acromion to humerus
as far distaly as possible with 2-
3 screw.
Source; Campbell Operative Ortopaedics

21. DELTOID PALSY:
SAHA’S TRANSFER OF TRAPEZIUS
• Entire insertion of
Trapizius along with
attached lateral end of
clavicle, A-C joint &
Acromion & adjacent part
of scapular spine to be
anchored to lateral aspect
of humerus distal to
tuberosity by two screws.

22. PARTIAL DELTOID PALSY:
HARMON TRANSFER OF DELTOID
A.Posterior part of deltoid is
functioning, middle & anterior part
Paralyzed.
B.Posterior functioning part of
deltoid transferred over atrophic
anterior deltoid.
“Mechanism: Transferred posterior part of deltoid
overlying atrophic anterior part, when contracts, it
prevents anterior dislocation of shoulder and
exerts more direct abduction force than in its

23. ARTHRODESIS
PRE-REQUISITES
Followin a shoulder fusion the scapulothoracic
motion will serve as a substitute for
glenohumeral joint motion, hence following
Primary pre-requisites are very important to have:
• Normal motor strength of the trapezius and
serratus anterior
• Normal function of the hand
Best to delay Shoulder fusion until epiphyseal closure has taken
place. Source: Benjamin Josef

24. SHOULDER ARTHRODESIS
OPTIMUM POSITION
AAOS Recommendation
Most acceptable position:
• 500 of abduction,
• 200 of flexion,
• 250 of internal rotation.
This position is functional, that allows the
patient to reach the face and top of the
head with the elbow flexed.
Variation n females:
• 300 of abduction,
• 5-100 of flexion
• 450 of internal rotation
The lesser degree of abduction is
functionally compensated for by
fusing it in greater internal
rotation.
Caution: Shoulder should never be fused in external rotation
because the limb will be positioned in an awkward and functionally poor position.

25. OPTIMUM POSITION
VERY CRITICAL TO ACHIVE, FOR A GOOD FUNCTIONAL LIMB
Caution: Shoulder should never be fused in external rotation
because the limb will be positioned in an awkward and functionally poor position.
Sourse. Deborah Allen.
Orthobullet.com
Post Operative Splint
Source:
https://shoulderelbow.org/2017/06/23/shoulder-
fusion-arthrodesis/

26. SHOULDER ARTHRODESIS: Methods
Methods of fusion:
1. Intraarticular
2. Extra-articular
3. Combination of
above two
4. Compression
arthrodesis.

27. POST OPERATIVE OUTCOME WITH OPTIMAL POSITION
ACTA CHIRURGIAE ORTHOPAEDICAE ET
TRAUMATOLOGIAE ČECHOSL.,
78, 2011, p. 161 - 164
Source:
Arthrodesis for flail Shoulder
Benjamin Josef.
J. Children Orthop. Oct 2015.

28. PP RESIDUAL PARALYSIS
ELBOW AND FOREARM
MUSCLE AND TENDON
TRANSFERS TO
RESTORE
ELBOW FLEXION
Steindler’s FlxorPlasty
Clark’s Transfer of Part of Pectoralis Major
Brooks & Seddon Transfer of Pectoralis Major
Tendon
Bunnell’s Transfer of SCM muscle
Sipra’s transfer of Pectoralis Minoe
Bunnell & Carrll Anterior transfer of Triceps
Tendon
Hovanin’s Transfer of Lattisimus Dorsi

29. MUSCLE AND TENDON TRANSFERS TO RESTORE
ELBOW FLEXION
Flexorplasty: Bunnell modification of Steindler Anterior transfer of the triceps tendon
Bunnell and Carroll,

30. BROOKS & SEDDON TRANSFER
• Biceps origine detached
proximaly in groove,
Mobilised distaly to
tuberosity at Radius.
• Loop of Biceps tendon
Passed throud ditached
insertion of Pectoralis Major,
detached as close to bone
as possible
• Tendon Anchored througth
distal tendon of Biceps

31. HOVNANIAN TRANSFER OF LATI DORSI
A.Normal Anatomy of
Axila
B. Skin Incision
C. Origin & belly of
Lattisimus Dorsi
transferred to arm
Origin has been sutured
to biceps tendon and to
other suture distal to
elbow joint

32. POSTERIOR DELTOID TRANSFERS TO RESTORE
ELBOW EXTENSION
Triceps Paralysis Substitue Procedure
Requirment:
A good triceps is
essential, however,
to crutch walking
or to shifting the
body weight to
hands during such
activities as
moving from a
to a wheelchair.
Posterior Deltoid MOBERG’s
POSTERIOR
DELTOID
TRANSFER

33. SUPINATOR DEFORMITY
RESTORE PRONATION
Zancoli Rerouting Biceps tendon for
Supination Deromity
A. 1. Dorsal Skin Incision
2.Anterior incision to expose biceps
tendon & radial head
B. Exposure of introsseous membrane by
retracting dorsal muscles lateraly
C. Line at B shows Z-plasty incision to be
made in Biceps tendon. Introsseous
membrane divided at a.
D. At c. Biceps tendon divided by Z
plasty, distal segment has been
rerouted around radial neck medially,
and ends of tendon are sutured
together. Traction on tendon will
now pronate forearm as
indicated by arrow.

34. HAND & WRIST

35. COMMON PATTERN PPRP:
HAND & WRIST
Pattern Thumb Fingers Wrist
I Weak / Paralysed
Opposition & Abduction.
Normal long flexor ?
extensor
Weak Intrinsics,
Normal Long flexors /
Extensors
Normal flexors /
extensors
II Paralysed Intrinsic &
weak long flexors /
Exensors
Paralysed Intrinsics.
Weak long flexors /
Extensors
Normal / Weak
Extensors. Normal
Flexors ( at least FCU)
III Completely paralysed
except grade 1-2 power
in long flexor or extensor
Paralysed Intrinsic,
Partialy functioning long
flexors with grade 2-3
power in 1or 2 fingers
Wrist Drop

36. HAND
COMMON PATTERN
Pattern Paralysis
I Thenar muscle paralysis
Normal Thumb extensor & Flexor
Finger & Wrist motors also functional
II Thenar Paralysis
Weak thumb long flexors & extensors
Paralyzed finger intrinsics
Weak finger flexors
Normal wrist motors

37. Pattern I Palsy of Hand
• Thenar paralysis
• normal thumb extensor & Flexors
• Finger & Wrist normal Motors
Pattern II Palsy Hand
• Thenar paralysis
weak thumb long flexor &
extensor
• Paralysed finger inrinsic
weka finger flexor
• Normal wrist motors
Source: M. Sai Krishna. M.Pardhasaradhi

38. DEFORMITIES: WRIST & HAND
1. Flexion and ulnar deviation of wrist with or without
fixed contracture.
2. Volar subluxation of the midcarpal articulation
contributing to or the cause of the above
deformity.
3. Thumb web contracture
4. Trapeziometacarpal (or carpometacarpal) joint
contracture
5. MCP joint extension contracture of 2 or more

39. HAND & WRIST
RECONSTRUCTION FOR PATTERN I
OPPONENSPLASTY
Procedure oTansfers
Opponens Plasty oFlexor digitorum sublimis of the ring finger
opponensplasty
oExtensor carpi ulnaris (ECU) opponensplasty
oPalmaris longus (PL) opponensplasty
Hypothenar muscle
opponensplasty (Huber
1921)
Abductor digiti minimi
(ADM Transfer)
Palmaris longus transfer
to rerouted extensor pollicis
brevis

40. RECONSTRUCTION FOR PATTERN II PARALYSIS
RECONSTRUCTIN FOR THENAR MUSCLES PPARALYSIS
• Extensor indicis (El) opponensplasty is done if the
extensor indicis is at least grade 4 or the PL is
transferred to the rerouted distal EPS tendon,
alternatives as in pattern I.
• For Paralyzed Finger Intrinsics (Claw Fingers):
oPL
oECRL
oECRB

41. Poor Opposition of
Thumb, Opponence
Pollicis palsy.
Pulp to Pulp opposition
restored after
opponenspalsy with flexor
digitorum superficialis
transfer.
B e n j a m i n J o s e f . S O U R C E J . C H I L D R E N O R T H O P . O C T 2 0 1 5 .

42. RECONSTRUCTION FOR PATTERN III, PARALYSIS
1st Stage
• For thenar muscle paralysis, the
trapeziometacarpal arthrodesis for
intermetacarpal bone graft procedure is done to
maintain thumb in fixed palmar abduction.
• For the weak finger intrinsics (claw), volar
capsulodesis is done at the same stage.
• Followed by a 3 wks of plaster immobilization.

43. RECONSTRUCTION FOR PATTERN III PARALYSIS
2nd Stage To improve flexion of the fingers and thumb
• The FDP tendon slips are side-stitched or tenodesed to each other at the
distal forearm so that whatever available flexion power there is can be
evenly distributed for all fingers.
3rd Stage Drop Wrist
• When the pronator or a strong superficialis tendon is available, the transfer
of either of these to the ECRB tendon provides wrist extension.
• The available FCU or FCR can also be transferred to the EDC and EPL for
finger and thumb extension

44. REFERENCES & ACKNOWLEDGMENT
1. Current Concept Review Polio revisited. Benjamin Josef, Hugh Watts. J. Children Orthop. Oct 2015.
doi/10.1007/s/1832-015-0678-4.
2. Paralytic disorders Willium Warner, JH Beaty. CAMPBELL’s operative orthopaedics, 12th ed.ch 34
3. Post polio residual paralysis. Slide share. M. Sai Krishna. M.Pardhasaradhi. Andhra Medical College. India.
4. Post polio deformities: Mustafa KK, anisuddin Bhatti, et al. JPOA
5. Rehabilitation of PPRP/D. Moeed Kazi, Anisuddin BhattiJ Surg Pak. 1998(3):
6. Post polio syndrome. Anisuddin Bhatti. Med. Chanel. 1999(1)
7. Glenohumeral Arthrodesis in paralytic Shoulder., Anisuddin Bhatti. JCPSP.1999(4)
8. Post Polio Residual Paralysis. in Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for
Children, 5th Edition. Author: John Herring, eBook ISBN: 9781455737406, Saunders, 5th December 2013.
9. PHI's "Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors." © 1999
10. Poliomyelitis Treatment & Management. Srinivasa Vidyadhara, ed. Jeffrey D Thomson. Medscape

45. EXPERTS COMMENT

46. If, sum mun book mun. Let me reply urs un-asked questions
Q & A Participants vs Faculty

48. Thank you