polio foot & ankle


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polio foot & ankle

  1. 1. POLIOMYELITIS OF FOOT AND ANKLE By Dr.tejaswi dussa Post graduate in ms ortho Gandhi hospital, secunderabad
  2. 2. INTRODUCTION • picarno viruses • -Virus mainly localized in anterior horn cells and certain brain stem motor nuclei • Clinical manifestations: 1. asymptomatic infection (90-95%) 2. abortive poliomyelitis 3. non paralytic polio myelitis 4. paralytic polio myelitis (1%) • Clinical course • Three stages - acute stage - convalescent stage - chronic stage
  3. 3. Acute stage • 7-10 days • superficial reflexes absent • deep tendon reflexes disappear when the muscle group is paralysed • Treatment- bed rest - Analgesics - Hot packs - Anatomical positioning of limbs to prevent flexion contracture - Gentle passive ROM exercises
  4. 4. Distribution • Lower limbs 92 % • Trunk + LL 4% • LL + UL • Bilateral UL • Trunk + UL + LL 1.33 % 0.67 % 2%
  5. 5. Convalescent stage • recovery phase • Varying degree of spontaneous recovery in muscle power takes place • > 80% return of strength - recovered muscles • < 30% of normal strength - paralysed muscle
  6. 6. • • • • • Treatment: Vigorous passive stretching exercises Wedging casts for mild –mod contractures Surgical release of tight fascia & aponeurosis Lengthening of tendons may be neccesory for contractures persisting longer than 6months • Orthoses used until further no recovery is antcipated
  7. 7. Chronic stage • Usually begins 24 months after the acute illness • This is the time for orthopedic intervention …………………………….X………………………………. • Most Severely Paralysed Muscle - Tibialis Anterior • Most common muscle Paralysed - Quadriceps femoris • Most commonly involved muscles in Upper Limb - Deltoid and Opponens
  8. 8. Causes of deformity in Polio • 1. muscle imbalance • 2. posture and gravity effect • 3. dynamics of activity • 4. dynamics of growth
  9. 9. Goals of treatment • • • • To achieve maximal functional activity Correction of significant muscle imbalances Preventing or correcting of limb deformties Static joint instability can be controlled by orthoses • Dynamic joint instability cannot be controlled by orthoses, that results in fixed deformities • Soft tissue surgeries such as tendon transfer should be done before the developement of fixed bony changes
  11. 11. Claw toes
  12. 12. Foot drop
  13. 13. equinovalgus
  14. 14. equinovarus
  15. 15. What surgeries are done in Polio? Balancing of power Stabilization procedures Correction of deformities Limb lengthening
  16. 16. TENDON TRANSFER • Tendon transfers are indicated when dynamic muscle imbalance results in a deformity • Surgery should be delayed until the maximal returns of the expected muscle strength has been achieved • Objectives of tendon transfer • To provide active motor power • To eliminate the deforming effect of a muscle • To improve stability by improving muscle balance
  17. 17. Criteria and selecting the tendon for transfer • Muscle to be transferred must be strong enough • Free end of transferred tendon should be attached as close as possible to the insertion of paralised tendon • A transferred tendon should be retained in its own sheath or should inserted in the sheath of another tendon or it should be pass through the subcutaneous fat
  18. 18. • Nerve supply and blood supply of transferred muscle must not be impaired • Joint must be in satisfactory position • Contracture must be released before tendon transfer • Transferred tendon must be securely attached to bone under tension slightly greater than normal • Agonists muscles are preferable to antagonists
  19. 19. • Phasic muscle transfer is preferable to nonphasic transfer • A nonphasic muscle should be trained by extensive physiotherapy before tranfer • the ideal muscle for tendon transfer would have the same phasic activity as the paralysed muscle , same size in cross section and of equal strength and could be placed in the proper relationship to the axis of the joint • Child with dynamic deformity an apropriate tendon transfer
  20. 20. ARTHRODESIS • Most efficient method for permanent stabilization of a joint • When the control of one or more joints • Bony procedures can be delayed until skeletal growth is complete • When the tendon transfer and arthrodesis is combined in the same operation the arthrodesis is performed first
  21. 21. PPRP OF FOOT AND ANKLE • Most dependent parts of the body sujected to significant amount of deforming forces • M.c deformities includes- equinus - equino varus - equino valgus - calcaneous - cavovarus - claw toes - dorsal bunion
  22. 22. PEABODY’S CLASSIFCATION 1. limited extensor invertor insufficiency 2. gross extensor invertor insufficiency 3. evertor insufficiency 4. triceps surae insufficiency
  23. 23. 1. LIMITED EXTENSOR INVERTOR INSUFFICIENCY - tibialis anterior paralysis - equinus and cavus - plano valgus • Transfer of EHL to base od 1st MT • If valgus deformity is fixed talonavicular arthrodesis is combined
  24. 24. 2. GROSS EXTENSOR INVERTOR INSUFFICIENCY TYPE A -paralysis of extensors of toes and tibialis anterior -equinus -equino valgus • Transfer of peroneus longus to dorsum of 1st cunieform bone • Talonavicular arthrodesis is combined if deformity is fixed
  25. 25. • TYPE B – paralysis of both tibialis anterior & tibialis posterior and toe extensors • Transfer of both peroneals to dorsum of foot • Hoke arthrodesis is combined in severe deformity
  26. 26. 3.EVERTOR INSUFFICIENCY paralysis of peroneal muscles - varus foot • Slight-mod impairement: EHL to base of 5th MT • Severe:-tibialis anterior to cuboid EHL to base of 5th MT
  27. 27. • 4.TRICEPS SURAE INSUFFICIENCY • Calcaneovarus deformity- tibialis posterior,FHL • calcaneovalgus deformity- both peroneals attached to calcaneum • calcaneocavus - transfer of peroneals,tibialis posterior
  28. 28. when to operate 1. wait for atleast 1 1/2 years after paralytic attack 2. tendon transfers done in skeletally immature 3. extra articular arthrodesis 3-8 years 4. tendon transfer around ankle and foot after 10yr of age can be supplimented by arthrodesis to correct the deformity 4. triple arthrodesis >10-11 years 5. ankle arthrodesis >18 years
  29. 29. CLAW TOE • Hyperextension of MTP and flexion of IP • Seen when long toe extensors are used to substitute dorsiflexion of ankle Treatment: For lateral toesdivision of extensor tendon by z-plasty incision,dorsal capsulotomy of MTP For great toeFHL transferred to prox.phalanx,IP joint arthrodesis (or) division of EHL ,proximal slip attached to neck of 1st MT,distal slip to soft tissues+ IP arthrodesis
  30. 30. Dorsal bunion • Shaft of 1st MT is dorsiflexed and graet toe is plantar flexed • Seen in muscle imbalance,m.c is between anterior tibial and peroneus longus muscle
  31. 31. Lapidus operation • remove abnormal bone from MT head • If anterior tibial is overactive- detach its tendon And transfer it to 2nd or 3rd cuneiform bone • remove the inferior wedge of bone from 1st metatarso cuneiform joint • bring the end of the FHL through the tunnel in 1st MT and anchor to the capsule over dorsum of MTP joint
  32. 32. • .
  33. 33. EQUINUS FOOT • • • • • • • • • • Anterior tibial muscle Peroneal and long toe extensor muscles Treatment: Serial stretching and cast Achilles tendon lengthening Posterior capsule release Posterior bone block of cambell Lambrinudi operation Pantalar arthrodesis
  34. 34. EQUINOVARUS DEFORMITY • Tibialis anterior • Long toe extensors and peroneal muscle
  35. 35. • Treatment: • Young children4-8 yrs: • 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) • • • • Children >8yrs: Triple arthrodesis Anterior transfer of tibialis posterior Modified jones procedure
  36. 36. EQUINO VALGUS DEFORMITY • Anterior and posterior muscle weakness with strong peroneals and gastroconemius-soleus muscle
  37. 37. • • • • • • Treatment: Skeletally immature: Repeated stretching and wedging cast TA lengthening Anterior transfer of peroneals Subtalar arthrodesis and anterior transfer of peroneals (Grice and green arthrodesis) • Skeletally mature : • TA lengthening • Triple arthrodesis followed by anterior transfer of peroneals
  38. 38. CAVOVARUS DEFORMITY • Seen due to imbalance of extrinsic muscles or by unopposed short toe flexors and other intrinsic muscle • • 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 • Extensor hallucis longus is transferred to the neck ofneck of 1st MT
  39. 39. CALCANEUS DEFORMITY • Gastroconemius-soleus muscle
  40. 40. Keeping in slight equinus position during acute stage of poliomyelitis • Plantar fasciotomy ,intrinsic muscle release before tendon transfer • Depends on residual strength of GS muscle • Transfer of peroneus brevis and tibialis posterior to the heel • Both peroneals trasfered for calcaneo valgus deformity • Posterior tibial and FHL can be transfered for cavovarus deformity • Anterior tibial tendon can be transferred posteriorly-DRENNAN TECHNIQUE
  41. 41. • For mild deformity –braces used • Tenodesis of achilles tendon to fibula • There is progressive equinous deformity with subsequent growth in pt with achilles tenodesis
  42. 42. Flail foot • All muscles paralised distal to the knee • Equinus deformity results because passive plantar flexion and • cavoequinus deformity because – intrinsic muscle may retain some function • Radical plantar release • tenodesis • In older pt mid foot wedge resection may be required • ANKLE ARTHRODESIS
  43. 43. ` THANK U