1. POST POLIO RESIDUAL PARALYSIS
OF LOWER LIMB

2. 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

3. • ROUTE OF TRANSMISSION:
THROUGH GI TRACT & RESPIRATORY
TRACTHEMATOUGENOUS CNS

4. 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

5. • 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

6. 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

7. 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

8. 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

9. 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

10. CHRONIC STAGE:
• 24 MONTHS AFTER ILLNESS
• CORRECTION OF LONG TERM CONSEQUENCES
OF MUSCLE IMBALANCE
• PREVENTING/ CORRECTION OF SOFT TISSUE/
BONY DEFORMITIES

11. 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

12. 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

13. 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

14. • 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)

15. • <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

16. 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. POSTERIORCAVOVARUS
DEFORMITY

17. • 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

18. TIBIALIS ANTERIOR & POSTERIOR
MUSCLES
• LOSS OF DORSI- & PLANTAR FLEXION +
INVERSION
• HINDFOOT & FOREFOOT EQUINOVALGUS
• DEFORMITY DEVELOPS RAPIDLY & BECOMES
FIXED AS TENDOCALCANEUS SHORTENS

19. • 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

20. TIBIALIS POSTERIOR
• ISOLATED PARALYSIS- RARELOSS OF
INVERSION
• RESULTS IN HINDFOOT & FOREFOOT
EVERSION
• FHL & FDL USED FOR TRANSFERS

21. TIBIALIS ANTERIOR, TOE EXTENSOR &
PERONEAL MUSCLES
• LOSS OF DORSIFLEXION+ EVERSIONSEVERE 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

22. PERONEAL MUSCLES
• ISOLATED PARALYSIS-RARELOSS 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
EHLHYPEREXTENSIONPAINFUL CALLUS BASE OF 1ST
METATARSAL
• <5 YRS-LENGTHENING OF EHL TENDON
• >5 YRS- TRANSFER OF EHL TENDON TO 1ST METATARSAL NECK

23. 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

24. • 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

25. 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)

26. • IF INVERTORS & EVERTORS BALANCEDPURE
CALACANEOCAVUS DEFORMITY
• IF POSTERIOR TRANSFER OF ONLY ONE
SETINSTABILITY
• 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

27. 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)

28. 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

29. • 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 DORSIFLEXEDGREAT TOE BECOMES
ACTIVELY PLANTAR FLEXED
(FOR A WEIGHT BEARING POINT ON MEDIAL SIDE OF
FOREFOOT & TO ASSIDT PUSH OFF IN WALKING)

30. • 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

32. BONY PROCEDURES(OSTEOTOMY &
ARTHRODESIS)
• OBJECTIVE: TO REDUCE NUMBER OF JOINTS THE
WEAKENED/ PARALYSED MUSCLES SHOULD
CONTROL
• STABILIZING PROCEDURES:
1.CALCANEAL OSTEOTOMY
2. EXTRAARTICULAR SUBTALAR ARTHRODESIS
3. TRIPLE ARTHRODESIS
4. ANKLE ARTHRODESIS
5. BONE BLOCKS TO LIMIT MOTION AT ANKLE JOINT

33. 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

34. 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

35. 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

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

37. 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

39. • 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)

40. ANKLE ARTHRODESIS
• FLAIL FOOT
• RECURRENCE OF DEFORMITY AFTER TRIPLE
ARTHRODESIS

41. 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

42. TALIPES EQUINOVARUS
• EQUINUS DEFORMITY AT ANKLE
• INVERSION OF HEEL & MIDTARDAL JOINT
• ADDUCTION & SUPINATION OF FOREFOOT
IN LONG STANDING CASES-
• CAVUS DEFORMITY FOOT
• CLAWING TOES

43. • PERONEAL MUSCLES WEAKENED/ PARALYSED
• TIBIALIS ANTERIOR- NORMAL/ WEAKENED
• TIBIALIS POSTERIOR-NORMAL
• TRICEPS SURAE-CONTRACTED (MOTOR
IMBALANCE, GROWTH, GRAVITY, POSTURE)

44. 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

46. 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

47. 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

48. 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)

49. 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

50. • IF EXT. DIGITORUM LONGUS FUNCTIONAL-
TRANSFER TO A CUNEIFORM
• TIBIALIS ANTERIOR TO CALCANEUS

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

52. 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

53. TREATMENT
• FLEXION CONRACTURES OF 15-20 O –
POSTERIOR HAMSTRING LENGTHENING &
CAPSULOTOMY
• MORE SEVERE CONTRACTURES-
SUPRACONDYLAR EXTENSION OSTEOTOMY OF
FEMUR

54. • >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

55. QUADRICEPS PARALYSIS
• KNEE-VERY UNSTABLESEVERE 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

57. • 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

58. 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

59. • 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
POSTERIORLYPARTIAL SUBLUXATION OF TIBIA
TRT:
• SKELETAL DEFORMITY CORRECTED- OSTEOTOMY(IRWIN,
CAMPBELL)
• TRANSFER OF HAMSRINGS TO PATELLA

60. Campbell’s closing wedge osteotomy

61. • 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:

62. • - 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

63. 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

64. HIP
DEFORMITIES-
• FLEXION & ABDUCTION CONTRACTURES
• PARALYSIS OF GLUTEUS MAXIMUS & MEDIUS
• PARALYTIC HIP DISLOCATION

65. 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 WEEKSCONTRACTURES

66. • 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

67. • 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. SIDELUMBAR
SCOLIOSIS

69. • 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

70. • 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)

71. 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

72. • TRENDELENBERG TEST-
• NORMALON 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

73. • 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

74. PARALYTIC DISLOCATION HIP
• POLIO<2 YRS, GLUTEAL MUSCLES PARALYSED BUT
FLEXORS & ADDUCTORS NORMALCHILD MAY
DEVELOP PARALYTIC DISLOCATION HIP
• ALSO, IF FIXED PELVIC OBLIQUITY IN CONTRALATERAL
ILIOTIBIAL BAND CONTRACTURE/ STRUCTURAL
SCOLIOSIS
• WEAKNESS OF ABDUCTOR MECHANISMRETARDS
GREATER TROCHANTER APOPHYSIS
GROWTHPROXIMAL FEMORAL CAPITAL EPIPHYSIS
GROWS AWAY FROM GREATER TROCHANTER
INCREASES VALGUS DEFORMITY OF FEMORAL NECK
& FEMORAL ANTEVERSIONHIP
UNSTABLESUBLUXATION

75. • 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

76. THANK YOU !!