Prof. Anisuddin Bhatti gave lectures to residents & Junior consultants on PostPolio Residual Paralysis part2 lower limb Reconstructive surgery on 17.04.202. Acknowledged for text and figures as such in reference list.

1. POST POLIO DEFORMITY &
RESIDUAL PARALYSIS: Part 2
Development of Regional Deformities &
Reconstructive Surgery
Anisuddin Bhatti
Professor, Dr. Ziauddin Hospital, Clifton
President Rt, Paeds Ortho Society Pakistan & POA
Focal Person, Ponseti International, Pakistan
Dr. Ziauddin University Hospital, Webinar Series
Saturday, 17th April 2021, 09:00-10:00

2. EXPERTS
Prof. Imtiaz Hashmi
Prof. Zamir A. Soomro
Dr. Fareedullah Khan Zimri

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 AND 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

11. DEVELOPMENT of
REGIONAL DEFORMITIES
&
RECONSTRUCTIVE SURGERY
AIM & OBJECTIVES:
• Patients to return home
• Patient be accepted and integrated into their
communities

12. I. Muscle imbalance:
Contracture of Flexion and
abduction muscles and Paralysis of
Gluteus maximus and Medius
muscles:
•Abductor Lurch / Trendlenburg
sign
•Paralytic dislocation of the hip
Hip Deformities - Causes
Source: J Children Orthop Oct
2015
Benjamin Josef.
Pelvic obliquity due to an
abduction contracture of one hip

13. II. Maintenance of a posture at
ease (Frog leg posture) during acute
and convalescent phase:
• Knees and hips remain flexed and
extremities completely externally
rotated.
• The secondary soft tissue & Iliotibial
band contracture leads to a
permanent deformity of FFC Hip &
Knee.
Cause of Hip deformities
Source Google.com.

14. ILIOTIBIAL BAND CONTRACTURE
Flexion, abduction, external rotation contracture of the
hip & Flexion deformity knee
• The Iliotibial band by virtue of its lateral & anterior position over the
hip joint, causes a flexion and abduction deformity.
• Due to position of comfort leg remain Externally rotated that, the
contracture of external rotators & contribute, further to a fixed
deformity.
• Due to attachements of Iliotibial band from iliac crest down to the
knee joint its its contracture produce double joint deformities: FFD
Hip & Knee.
Source Google.com.

15. ILIOTIBIAL BAND CONTRACTURE
Genu valgum and flexion contracture of the
knee
• With progressive growth, the contracted
iliotibial band (ITB) acts as a taut bowstring
across the knee joint, that gradually abducts
and flexes and cause FFC knee and Genu
valgus.
Genu
valgu
s

16. ILIOTIBIAL BAND CONTRACTURE
External tibial torsion, with or
without knee joint subluxation
• Due to ITB lateral attachment below knee &
its contracture gradually leads to external
tibia & fibula rotation.
• The externl rotation exaggerated by the
strog Biceps femoris
• When the deformity becomes extreme,
tibial condyle subluxates, rotates externaly,
thus head of fibula lies in the popliteal
Ext Tib
Torsion
Knee Subluxation
& FFC

17. ILIOTIBIAL BAND CONTRACTURE
Secondary Ankle and Foot deformities:
(Positional Pes Cavus / Cavo varus)
Results from ill fitted orthrosis that fails to
compensate external tibial torsion caused by
tight ITB.
Mechanism:
The axes of the knee and ankle joints do not occupy the same
horizontal plane in external torsion of the tibia.
When an above-knee orthosis manufactured with these joints
in the same horizontal plane is fitted to a limb with external
tibial torsion, the appliance will force the foot into varus
position so that the ankle is in line with the knee joint

18. ILIOTIBIAL BAND CONTRACTURE
Pelvic obliquity
• When the patient is supine, the iliotibial band contracture
keeps hip in abduction and flexion, the pelvis may remain at a
right angle to the long axis of the spine.
• When the patient stands , the affected extremity is brought
into the weight-bearing position (parallel to the vertical axis of
the trunk), the pelvis assumes an oblique position
On standing upright the iliac crest assumes a low
posture on contracted (Lt.) side and high on the
opposite (Rt) side. On long stading dislocation of
hip occures on other side

19. ILIOTIBIAL BAND CONTRACTURE
Pelvic obliquity:
On standing upright the iliac
crest assumes a low posture
on contracted (Lt.) side and
high on the opposite (Rt)
side. On long stading
dislocation of hip occures on
other side
Source: Campbell Orthop 12th Ed

20. ILIOTIBIAL BAND CONTRACTURE
Scoliosis
• The trunk muscles on the affected side lengthen, and the
muscles on the opposite side contract. An associated lumbar
scoliosis can develop.
• If not corrected, the two contralateral contractures (ITB band on
the affected side and the trunk muscles on the unaffected side)
hold the pelvis in this oblique position until skeletal changes fix
the deformity.
Increased lumbar lordosis
• Bilateral flexion contractures of the hip pull the proximal part of
the pelvis anteriorly; for the trunk to assume an upright position,
a compensatory increase in lumbar lordosis must develop
JaypeeDigital

21. DEFORMITIES CAUSED BY
ILIOTIBIAL BAND CONTRACTURE
• Pes Varus, valgus
• Pelvic obliquity
• Scoliosis
• Lumber lordosis
HIP Deformities:
• FFC
• FFC + Abduction +
External rotation
• Paralytic Dislocation
Knee Deformities:
FFC
FFC + Subluxation
External tibial torsion

22. HIP DEFORMITIES
RECONSTRUCTIVE SURGERY

23. SURGICAL RECONSTRUCTION
HIP AND KNEE CONTRACTURES
INDICATIONS FOR SURGERY:
• Hip and knee contractures
exceeding 30°
CONTRA INDICATIONS:
• Weakness of one or both arms in
addition to bilateral lower-limb
paralysis, making the use of
crutches difficult or impossible.
DECISION MAKING FACTORS:
• Age
• Severity of Contracture
oYoung child with recent
contracture : release Tight
tensor fasciae latae and Iliotibial
band,
oTeenage & Adolescent: Divide
additional ligamentous and
tendinous structures

24. RELEASE OF FFD HIP & KNEE:
Iliotibial band contracture
SOUTTAR’S SLIDE / CAMPBEL’S RELEASE
• Release of TFL and Gluteus maximus from from their origins
(anterolateral part of the hip) to correct hip FFD.
OBER-YOUNT PROCEDURE
Sartorius,TFL, Rectus femorus,Gluteus medius and minimus, Iliopsoas
tendon.
YOUNT’S RELEASE
Resection of the thickened anterolateral fascia latae, to correct knee
contracture. CAUTION:
Avoid damaging the femoral, popliteal arteries & common peroneal nerve.
Divide biceps under direct vision to avoid risk of damaging the adjacent lateral
popliteal nerve.

25. FFD HIP & KNEE:
ILIOTIBIAL BAND CONTRACTURE
Before & After SOUTTAR’S SLIDE , YOUNT’S
RELEASE. Source: M. Sai Krishna
Origin of Sartorius, TFL & G. Med released
+/- Resection of redundant iliac crest.
Source: Campbell Op Orthop
Campbell’s Slide for FFC Hip
Source: Tachdjian

26. PARALYSIS of
GLUTEUS MAXIMUS & MEDIUS
• Unstable hip and an unsightly and fatiguing
limp
• Gluteus Medius alone Palsy: Trendelenburg
Gait
• Gluteus maximus alone paralysis: Backward
lurch
Treatment
• Sharrards’ Posterior transfer of iliopsoas for
paralysis of the gluteus medius and maximus
muscles Trendelenburg Gait
Backward lurch

27. MUSCLE TRNSFER TO RESTORE DYNAMIC BALANCE @ HIP
PREVENT PELVIC OBLIQUITY & SUBLUXATIO
Age of Onset of
Paralysis
Principles
< 2 years • Early stage: Adductor tenotomy +/- OR
• Late Stage: IlioPsoas transfer @ the age 4-5 yrs.
• If Coxa Valga > 1500 , it is best to correct deformity
to FNS angle 1100 before IlioPsos transfer.
> 2yeras • IlioPsoas transfer may be postponed & Stability of
hip monitored periodically +/- without Adductor
tenotomy.
• When Coxa Valga exceed 1600 and femoral head
starts to subluxate laterally
• In patient <6yrs, PFVDR to reduce FNS angle to 1050.
• In older >6yrs pt. PFVDRO to reduce FNS angle to
0

28. PARALYSIS OF THE GLUTEUS MAXIMUS & MEDIUS
Treatment
Sharrards’ Posterior transfer of the iliopsoas
• Iliopsoas with lesser troch detached, Psoas &
Iliacus mobilzed, origin of ilacus freed fron
origin, hole made in Ilium.
• IlioPsoas is tendon passed from medial to
lateral through hole. IlioPsoas tendon with
lessor troch secured to greater troch with
screw.
Weisinger modification: IlioPsoas muscle +
Tendon redirected lateraly through Sciatic
Notch inserted into great troc.

29. VARUS
DEROTATION
INTERTROCH
FEMORAL
OSTEOTOMY
LLOYD ROBERT
TECHNIQUE

30. COBRA PLATE COMPRESSION
DISPLACEMENT OSTEOTOMY AD
DHS
HIP ARTHRODESIS
Position of hip fusion:
• Neutral abduction,
• External rotation of 0-300,
• Flexion 20-250
• Avoid abduction and
internal rotation
• This position is design to
minimize excessive lumbar
spine motion and opposite
knee motion which

31. KNEE DEFORMITIES

32. QUADRICEPS FEMORIS PARALYSIS
QUADRICEPS GAIT & GENU RECURVATUM
• With a Weak Quads, knee is stablized with Hand Knee gait
• Mild genu recurvatum: adequate strong triceps surae &
hamstring muscles. knee is stabilized by locking in
hyperextension.
• During stance phase, quadriceps weakness is compensated
by tilting trunk and center of gravity of the body forward.
Rx with bracing is sufficient to walk satisfactorily.
• The only functional disabilities are difficulty climbing steps
and running.
• Decompensation further leads to gross recurvatum
deformity with bony changes
Source: Benjamin Josef. J.
Children Orthop. Oct 2015.
Source: Bhatti ZHC March 2021.

33. QUADRICEPS FEMORIS PARALYSIS
Gross Genu Recurvatum
MUSCLE TRANSFER
Muscle transfer to restore knee extension
power:
Common:
• Biceps femoris
• Semitendinosus
Other:
• Sartorius
• Tensor fasciae latae, and
• Adductor longus
Transfer of biceps femoris and semitendinosus tendon

34. QUADRICEPS FEMORIS PARALYSIS
GENU RECURVATUM
with STRUCTURAL CHANGES
• With Wt bearing & Gravity, the proximal tibial shaft
bows posteriorly
• Partial subluxation of the tibia may gradually occur.
• There is frequently calcaneus deformity of foot.
Treatment
• Closing wedge osteotomy for genu recurvatum.
• Triple tenodesis for genu recurvatum
• Other Surgical methods of correcting genu recurvatum.
A . Irwin's technique. B. Modified dome osteotomy. C.
Open-up wedge osteotmy
A. Closing wedge tiabial osteotom
B. Prox. Tibail bow / sloped plateua
C. 5 months after CWO
Source: Campbel operative orthop

35. GENU RECURVATUM with STRUCTURAL CHANGES
Triple tenodesis for genu recurvatum

36. FFC KNEE
Cause: Contracture of the ITB & Quads Palsy with normal /
partialy paralysed hamstrings.
Treatment:
• <15 - 200 FFC Knee– Posterior hamstring lengthening and
capsulotomy.
• 20-700 FFC Knee – Supracondylar extension osteotomy of the
femur
• >700 FFC Knee – Division of ITB and hamstring tendons,
combined with posterior capsulotomy.
Post OP Care: Skeletal traction Two pins in the distal tibia &
proximal tibia to avoid posterior subluxation of the tibia.
• Long-term use of a long-leg brace for bone remodeling.
Supracondylar extension osteotomy
of the femur.
Source: Benjamin Josef. J. Children Orthop. Oct 2015.
Sourse: Campbell Op Orthop

37. FLAIL KNEE
• Knee is unstable in all directions.
• Insufficient muscle power for tendon transfer to
overcome this instability.
Treatment
• Locking knee long leg knee brace.
• Knee arthrodesis

38. FOOT AND ANKLE DEFORMITIES
1. Claw toes
2. Cavus deformity and claw toes
3. Dorsal bunion
4. Talipes Equinus
5. Talipes Equino Varus
6. Talipes Equino Valgus
7. Talipes Calcaneus
PEABODY’S CLASSIFCATION
1. Limited extensor invertor
insufficiency
2. Gross extensor invertor
insufficiency
3. Evertor insufficiency
4. Triceps surae insufficiency

39. PEABODY’S CLASSIFCATION
INVERTOR EXTENSOR INSUFFICIENCY
Limited extensor invertor insufficiency
• Tibialis Anterior muscle paralysis produces slowly
progressive deformity
1. Equinus 2. Cavus 3. Varying degree of plano
valgus
Treatment:
• Redistributed of muscle power by transferring the
EHL tendon to base of 1st metatarsal + plantar
fasciotomy.

40. PEABODY’S CLASSIFCATION
INVERTOR EXTENSOR INSUFFICIENCY
TYPE A: Gross extensor & invertor insufficiency
• Paralysis of Extensors of toes and Tibialis Anterior,
with relatively normal Tibialis Posterior muscle.
• Produces - Equinus – later Equino Valgus
Treatment:
• Transfer of Peroneus Longus to dorsum of 1st cunieform bone.
• Talo-navicular arthrodesis is combined if deformity is fixed.
TYPE B: Paralysis of both Tibialis Anterior & Tibialis Posterior and Toe
extensors
• Rx: Transfer of both Peroneals to dorsum of foot. Source: Benjamin Josef.
J. Children Orthop. Oct 2015.

41. PEABODY’S CLASSIFCATION
EVERTORS INSUFFICIENCY
Evertor insufficiency
Paralysis of Peroneal muscles producing:
• Varus foot
• Deformity produce Slight to moderate
impairment
Treatment:
• Mild Deformity: Transfer of EHL to base of 5th
MT.
• Severe Deformity: Tibialis anterior to cuboid, EHL
Source: M. Sai Krishna.

42. TALIPES EQUINUS
Mechanism:
• Planter flexors are stronger than
dorsiflexors and tight Tendo
Achilles.
• If associated lateral imbalance is
there Equinuovarus or
Equinovalgus may result.

43. Rx. TALIPES EQUINUS
• 1. No intervention : mild equinus
• 2. Conservative management: exercises, serial casting,
orthosis and molded shoe wear.
• 3 .SURGICAL MANAGEMENT:
a) soft tissue procedures to release contracture
b) bony procedures
• Cambells Posterior bone block operation
• Lambrinudi procedure
• Pantalar arthrodesis

44. CAMPBELLS POSTERIOR BONE BLOCK
Usually combined with Triple arthrodesis
To correct lateral instability as well
• Mechanical block created, posterior to talus , superior to
calcaneum, to impinge on posterior lip of distal tibia, to
prevent planter flexion.
• Dorsiflexion preserved
• COMPLICATIONS: Recurrence, OA, Talus flatening & Ankylosis of ankle
A. Bruce Gil

45. LAMBRINUDI PROCEDURE
TaloNavicular & CalneoCuboid Fussion.
• Wedge of bone resected from distal &
planter surface of Talus.
• Remaining Talus Wedged in trough
made in Navicular
• CalcaneoCuboid cartilage removed.
• Forefoot realinged in corrected position
COMPLICATIONS:
• Residual deformity, Degenerative Arthritis
• Pseudoarthrosis, Talus Flatening

46. TALIPES EQUINUS VARUS_TEV
Mechanism:
• Weakness of Peroneals & Tibialis anterior &
Normal triceps surae: (Lateral Imbalance).
• Equinus produced increases mechanical
advantage of TP which in turn encourages the
fixation of hind foot inversion and forefoot
adduction and supination.
• Cavus and clawing develop when toe
extensors help to dorsiflex the ankle.
Source: M. Sai Krishna.

47. Rx. TALIPES EQUINUS VARUS_TEV
Young
children
4-8 yrs
Early stage Coservative Rx. Operative Rx.
Double bar brace with ankle
stop •
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)
• Anterior transfer of medial
half of tendo-calcaneous(
Caldwell)

48. Rx. TALIPES EQUINUS VARUS _ TEV
Children
>8yrs:
Procedure
• Steindlers fasciotomy
• Triple arthrodesis
• Anterior transfer of tibialis
posterior
• Modified jones procedure
• When TP is weak TA is
transferred laterally to midline.

49. TRIPLE ARTHRODESIS
A. Oblique incision over
sinus tarsi to expose
Subtalar, TaloNavicular &
Calcanio cuboid Jts.
B. Cartilage & Cortical
bone removed,
appropriate wedges are
removes as nesseccary
C. Wedges necessary for
valgus deformity.
D. Wedges necessary for
varus defformity

50. SPLIT TRANSFER, TIB ANT
& POST TIB TRANSFER

51. TALIPES EQUINO VALGUS
Cause:
• Tibialis anterior and Tibialis posterior are weak and Peroneal longus and brevis are
strong and the triceps sure is strong and contracted. Triceps surae pulls the foot into
equinus and the Peroneals into valgus.
Skeletally immature – Treatment:
• Early Stage: Double bar brace with ankle stop • Shoe
with an arch support and medial heel wedge •
Repeated stretching and wedging cast
• TA lengthening
• Anterior transfer of peroneals
• Grice and Green arthrodesis Subtalar arthrodesis
and Anterior transfer of Peroneals Source: M. Sai Krishna. M.Pardhasaradhi

52. TALIPES EQUINO VALGUS
Skeletally mature :- Treatment:
•TA lengthening
•Triple arthrodesis followed by
anterior transfer of peroneals
•Modified Jones
Source: Benjamin Joseh

53. DILWYN-EVAN OPEN WEDGE GRICE-GREEN FUSION

54. TALIPES CAVO-VARUS
Cause:
• Imbalance of extrinsic muscles or by unopposed
short toe flexors and other intrinsic muscle
Rx.
• 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
• EHL is transferred to the neck of neck of 1st MT
Source: M. Sai Krishna. M.Pardhasaradhi

55. TALIPES CALCANEUS
Cause: Triceps Surae Weaknes with unopposed action of dorsiflexors
Rx.
• Plantar fasciotomy: Intrinsic muscle release before tendon transfer
• Transfer of TP and PL and FHL tendons to calcaneous.
• Green and Grice
• Posterior transfer of Tibialis Anterior ( Peabody )
• When EHL and EDL strength is good, both Tibials and Peroneials
can be transferred posteriorly and EHL, EDL transferred proximally
to act as dorsiflexors of ankle.
• If adequate muscles are not available:Tenodesis of
Tendoachiles to fibula is done ( Westin )
Source: M. Sai Krishna. i

56. CALCANEUS DEFORMITY
CALCANEAL TENODESIS WITH PEROPNIE

57. FLAIL FOOT
Cause:
• All muscles paralysed distal to the knee. Equinus
deformity results because passive plantar flexion and
Cavoequinus deformity because – intrinsic muscle may
retain some function.
Treatment:
• Radical plantar release
• Tenodesis
• In older pt mid foot wedge resection
may be required
• ANKLE ARTHRODESIS

58. CLAW TOES
Deformity: Hyperextension of MTP and flexion
of IP
Cause: long toe extensors substitutes
dorsiflexion of ankle
Treatment: For lateral 4 toes :
• Procedure I : division of extensor tendon by z-plasty
incision,dorsal capsulotomy of MTP joint.
• Procedure 2: Girdlestone- Taylor tendon transfer
Dorsolateral incision. Divide the long flexor tendon
and suture them to lateral side of proximal phalanx
to extensor expansion.
Girdlestone- Taylor tendon transfer

59. CLAW TOES
Girdlestone- Taylor tendon transfer Dorsolateral
incision. Divide the long flexor tendon and suture
them to lateral side of proximal phalanx to extensor
expansion.

60. CLAW TOES: BIG TOE
Rx. Great Toe: Dickson and
Diveley procedure.
• EHL tendon is divided
proximal to IP joint &
transferred to Flexor Hallucis
Longus tendon to taut flexor
tendons.
• Distal part of extensor tendon
sutured to soft tissues on
dorsum of proximal phalanx to
assist maintain opposition of
raw surfaces of IP joint.
• Arthrodesis of interphalangeal
joint.
Source: Slideshare.net

61. CLAW TOES: BIG TOE
Modified Jone’s procedure:
• Division of EHL proximal to IP
joint.
• Proximal slip fixed to neck of
1st metatarsal.
• Distal slip fixed to soft tissues.
• Arthrodesis of IP joint by K
wire fixation
Source: Slideshare.net

62. CAVUS AND CLAW FOOT
Primary deformity :
• Forefoot Equinus resulting in clawing of toes.
• Mild Clawing disappear if mild cavus of short duration is
corrected.
Sever Deformity:
• In severe cavus large callosities or even ulcerations may
develop beneath the metatarsal heads.
• Clawing may lead to dorsal dislocation of MTP joint.
• In severe cases all plantar stuctures may contract.

63. Rx. CAVUS AND CLAW FOOT
Rx.
Mild Deformity:
• Conservative : metatarsal bar on the shoe, metatarsal pads.
• Surgical measures:
oDivision PL tendon and imbricate to PB, considering that the
deformity is due to imbalance of Tibialis Anterior and PL.
oArthrodesis of all IP joints, considering that clawing is caused by
disturbance of function of intrinsic muscles of foot. mild cavus
with clawing

64. Rx. CAVUS AND CLAW FOOT
Rx.
Moderate Deformity:
• Young children :
o Steindler’s fasciotomy
• Older children :
o Dwyers calcaneal
osteotomy.
o Japas V osteotomy
Steindler’s fasciotomy • stripping of fat and muscles from both
superficial and deep surfaces. • Transverse division of fascia close to
calcaneal attachment. • Release of long plantar ligament extending
from calcaneus to cuboid.

65. CAVUS AND CLAW FOOT
SURGICAL PROCEDURES
Moderate / Sever Deformity
Cole’s Anterior wedge
osteotomy:
Indication:
Cavus without varus or calcaneus or
gross muscle imbalance.
Advantage : preserves mid tarsal and
sub-talar joints
Disadvantage: shortens the dorm of
foot.
Osteotomy of the navicular
and cuboid and defect is
closed by elevating the
forefoot.

66. CAVUS AND CLAW FOOT
SURGICAL PROCEDURES
Japas V osteotomy:
• Apex of “V” is proximal at highest point of
cavus
• Lateral limb extends to cuboid
• Medial limb through intermediate
cuneiform to medial border of foot.
• No bone is excised
• Proximal border of distal fragment is
pressed plantarwards, while metatarsal
heads are elevated correcting the
deformity.

67. CAVUS AND CLAW FOOT
SURGICAL PROCEDURES
Hibb’s operation:
• EDL tendons is divided
and proximal end is
inserted to 3rd cuneiform.
• EHL tendon is divided
and fixed to neck of 1st
metatarsal.
• Interphalangeal joint
arthrodesis.

68. DORSAL BUNION
• Shaft of 1st MT is dorsiflexed and great toe is plantar flexed
resulting in prominent head of 1st metatarsal. If severe may
result in subluxation of MTP joint.
Pathogenesis:
• Imbalance between Tib. A and PL: normally TA raises the 1st
cuneiform and 1st MT and PL opposes this action. Unopposed
action of Tib. A causes this deformity.
• Weakness of Anterior and lateral compartment muscles.
unopposed action of posterior compartment muscles causes
excessive plantar flexion of great toe.
Rx.
Transfer of PL & Midline transfer of TA to 3rd Cuniform
Before the transfer of PL, the effect of its loss on 1st MT must be considered. Every transfer of
PL should be accompanied with midline transfer of TA to 3rd cuneform.
Source: Slideshare.net

69. DORSAL BUNION
Rx: LAPIDUS TECHNIQUE
• Wedge of bone is removed from metatarso-
cuneform and naviculo-cuneform joint. •
• If Tib. A is overactive, transfer it to 2nd or 3rd
cuneiform. •
• FHL is detached and brought dorsally and
attached to 1st metatarsal, converting it into a
plantar flexor of metatarsal rather than great
toe.
• Subcutaneous plantar tenotomy
• capsulotomy of 1st MTP joint.
Source: Slideshare.net

70. DORSAL BUNIONUE
Hammond Techniq
• Any deforming tendon
except the FHL is divided
and transferred to dorsum
of foot to correct MT
displacement.
• Fusion of joint.

71. UPPER LIMB PARALYSIS &
DEFORMTIES
‫رڍن‬
‫آڱيان‬
‫رباب‬
‫وڃاعندي‬
‫ورھ‬
‫ٿياس‬ ‫بجانا‬ ‫بین‬ ‫آگے‬ ‫کے‬ ‫بھینس‬

73. ZOOM.COM
Anisuddin Bhatti Is Inviting You To A Scheduled Zoom Meeting
On 18th April 2021@ 12:00 -13:00
Topic: Post Polio Residual Paralysis & Deformities Par t Iii. Upper Limb
Time: This Is A Recurring Meeting Meet Anytime
Join Zoom Meeting
HTTPS://US04WEB.ZOOM.US/J/77449313684?PWD=MFJRC29
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MEETING ID: 774 4931 3684
PASSCODE: N535NP

74. CASE DISCUSSION
19 Years Old Female Known Case Of Poliomyelitis
H/O: Contractures and deformity of right leg for the last 17 years.
On examination:
Right knee FFD 90 degree
Hip FFD 90 degree
Abduction contracture 45 degree
Right leg Genu Valgum
LLD of ~11 cm
Distal neurovascular intact
Walks with Gluteal crutch
Xray revealed: Hypoplastic limb, contractures.
No dislocation.
Demand:
Release of contracture and brace able straight leg
Walk with the straight leg

75. DECISION MAKING CHART
Patient # xx yrs. FM, PPRP_xx yr. Walks xxxxxxx
AREA DEFORMITY DEFICIT SUBSTITUTE REMARKS
HIP
KNEE
ANKLE & FOOT
LLD
DIAGNOSIS
DEMAND
DECISION

76. Patient: 19 yrs. FM, PPRP_17 yr. Walks with gluteal Cructh, projected knee forward
Area Deformity Deficit Substitute Remarks
Hip FFC_Flx 900
Abduction 450
Glutie 3+, Abd 3+
Flexors 4
Iliopsoa, Rectus
abdominus
Not required, nearly
balanced power
Knee 900
Genu valgum
Quad 3+ Semitendinosis Not required, nearly
balanced power
Ankle & Foot None Controled All avaible Not required,
balanced power. No
deformity
LLD 11 cm, walks with gluteal crutch with Ugly posture of 90-90 HK contracture
Diagnosis Postural contracture Hip & Knee FFC 90-90, LLD 11cm, Balanced ankle power & no
deformity
Demand Elimination of contractures, Potural Stability & lengthening.
Decision Release of contratures: Hip_Campbells release + Knee_Z-Lengthening + Posterior
Capsulotomy. Followed by Shoe elevation
Stage 2: Limb Lengthening

77. FFC HIP & KNEE 90-900 CONTRACTURE

78. FFC HIP & KNEE 90-900 CONTRACTURE

79. HIP: Campbell’s Release
KNEE: Posterior Release

80. 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. Slideshare.com. Post polio residual paralysis. 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. Slideshare.com. Poliomyelitis Treatment & Management. Srinivasa Vidyadhara, ed. Jeffrey D Thomson.

82. EXPERTS COMMENTS

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

84. Thank you