Discussion on Post polio Residual Paralysis

Post polio Residual Paralysis

Asymmetric patchy LMN type paralysis

Non progressive

No sensory loss

Prior acute paralytic illness, residual weakness and atrophy of muscles on neuromuscular examination and signs of  nerve damage on EMG

A period of partial or complete functional recovery after acute paralytic poliomyelitis followed by an interval of stable neuromuscular function

Symptoms persist for at least a year

Paralytic limbs colder than their counter parts

           

D/d

Myopathy

Neurlogical Disorder

Injury

Critical arc of motion in Foot

15 degrees PF/DF

Ideal age of tendon transfer and bony procdure in PPRP ?

Atleast 18 months after polio paralytic attack so that convalescent period is over and entered into residual stage

Tendon transfer in skeletally immature patients

Ideally after 5 years ( Child can be trained )

Results better after 10 – 11 years.

Tendon transfer should be supplemented with bony procedures (esp Arthrodesis  ) done before or along with tendon transfer.

Bony block procedures may be needed with tendon transfer to prevent opposite motion esp in children .

Cause – to prevent deformities

E.g. – tendon transfer to cause DF of ankle and posterior bony bock procedure to prevent new deformity.

Balance DF/PF before inversion and eversion .

PF strength to be gained first.

If no sufficient muscles for balance , do arthrodesis.

If inverstors and evertors not available , do triple arthrodesis so that only Planterflexor and dorsiflexors needed to balance.

Better to be too tight than to be too loose while doing tenodesis.

Transfer to midline if only plantar and dorsiflexors need blance .

Transfer medially and laterally if invertor and evertor needed.

            e.g. to gain DF and Eversion , transfer to dorsal tarsus and laterally to gain DF and    eversion .

Deformity progresses till bone and soft tissue growth caseses

Splint/passive stretch cant prevent development of a deformity but slows down .

Extra-articular arthrodesis done at 3-8 years

Triple arthrodesis done at 10-11 years.

Ankle arthrodesis done at 18 years.

Common deformity in polio foot ?

Equinovalgus – result of Tibialis Anterior Paralysis

Calcanecavovarus

Equinovarus

Aim of surgery in polio foot  ?

Stable foot

Plantigrade foot

No significant fixed deformity

Adequate muscle power >  3/5 in active dorsi and plantarflexors 

Peabody’s Classification of Polio foot

Limited Extensor / Invertor indufficiency

Gross Extensor – Invertor insufficiency

Evertor insufficiency

Triceps surae insufficiency

Management of Limited Extensor – invertor insufficiency

Deformity – Equinus and Cavus or Planvalgus

Due to Tibialis Anterior weakness

Treatment – EHL to base of Ist MT

                   Plantar Fasciotomy

                        +/- Peroneus teritius transfer to same site

Planovalgus – Long standing and fixed

                        Triple Arthrodesis

Fixed Equinus – TA lengthening

Management of Gross extensor – invertor insufficiency

Two types

Type A – Weak Tibialis Anterior , EHL , and EDL with a Normal Tibialis Posterior

Deformity – Equinus or Equinovalgus

Peroneus Longus to Ist cuneiform

            Or

Peroneus Brevis to dorsum midline (when TP and peroneus longus balance each other ) or Ist and 2^nd ray (when peroneus longus is stronger than TP )

Treatment of Type B

Transfer both peroneus longus and brevis to dorsum of foot

In both cases ,triple arthrodesis may be combined if bony deformities are fixed.

Evertor Insufficiency , how to manage this ?

Treatment depends on extent of weakness.

Mild

EHL – transfer to base of 5^th MT

Moderate

TA to cuboid

EHL to Ist MT

TA transferred more medially if TP also week so that it balances peroneal weakness .

Complete

TP to cuboid (Anterolateral aspect ) or lateral cuneiform

TA may be combined with any of above 

Treatment of Triceps Surae insufficiency

Calcaenus Deformity

Tibialis Anterior  to Calcaneus through interosseous membrane posteriorly along with EHL to dorsum of foot usually Ist MT base .

Calcaneovarus

(Peronei week and TP strong )

TP and FHL to calcaneum

Calcaneovalgus

TP week , strong peronei

TP and Peronei to calaneum

Triple Arthrodesis done if deformities uncorrectable and associated with bony deformities.

Triple Arthrodesis and its types

 minimizes number of joints paralyzed muscles have to stabilize.

Pre-requisites for TA

Angular deformities of knee and leg should be corrected immediately after this procedure otherwise there will be deformity reccurence .

Most important joint in tarsus – talonavicular hence a procedure should tackle this.

There should be a stable ankle joint without varus / vaglus otherwise reformity recurs.

If anterior structures around ankle are lax as in a forced PF X-ray , then either tendon transfer anteriorly to reinforce dorsiflexors or ankle arthrodesis should accompany TA .

Other CI

Unstable knee joint , painful OA Ankle ,Severe Trophic ulcers , age < 11 years

Position in Triple Arthrodesis

Hindfoot – Valgus – 50 Degrees

Tarsal Joint – 0-50 degrees abduction

Forefoot - < 100 degrees varus

Medial border of foot should be straight

Heel –5^th MT – same plantigrade plane , exact mid position .

Mild valgus – not harm , Varus Harmful ,

Incision – Kocher , Ollier , Anterolateral exposure to ankle +/- accessory medial incision over talonavicular joint

Types

Hoke

Subtalar arthrodesis with resection , reshaping and reimplantation of head and neck of talus with posterior displacement of foot less than in Dunn .

Dunn

Subtalr arthrodesis , Excision of navicular and part of head and neck of talus with posterior displacement which depends on amount of bony resection .

Shifts lever arm posteriorly helping plantarflexion of ankle.

Ryerson arthrodesis – Talonavicular , subtalar and cacaneocuboid  joint

Hindfoot varus correction by bony cuts  either side of Subtalr joint

Forefoot – varus /valgus and abduction /adduction correction from Talonavicular and Calcaneocuboid joint.

Useful when plantar flexors and dorsiflxors of ankle balance each other.

Lambrunidi – Similar to Ryerson except that break created in tarsal bones into which reshaped talar head and neck fitted to correct forefoot equinus.

Calcaneus remains in equinus at ankle but equinus deformity corrected at subtalar joint realigning rest of tarsus over talus , correction is achieved.

Stiffer , forster and Nachamie – dorsal cortex of  navicle excised . Inferior part of talar head and neck removed , Superior part of neck beaked into navicle and loacked along with attached soft tissues . Stapling don to fix it.

Complications –

Pseudoarthrosis of joint most common complication  and Talonavicular joint most commonly affected.

Residual deformities like supination of forefoot and varus/ valgus at hindfoot and midfoot

AVN talus

Varus /valgus at ankle

OA Ankle

Painful foor / pseudoarhtrosis

Callosities

Foot appearance after triple arthrodesis

Looks natural

No external rotation of long axis of foot when walking

No need for brace

Appears natural when bare

Weight evenly distributed over plantar surface

No pain

Controlled ankle joint motion

Toe Deformities

Deformities	MTP Joint	PIP Joint	DIP Joint
Hammer Toe	DF	PF	Neutral , or Extended
Mallet Toe	Neutral	Neutral	PF
Claw	DF	PF	PF
Curly	PF or Neutral	PF	PF

Clawaing Toes

Swing Phase – Ankle DFlexors weak , long toe extensors contract leading to clawing , More marked when TA contracted.

Stance Phase – Triceps surae – weak , long toe flexors contract during push off leading to clawing.

How does clawing present  ?

Pain on dorsum of PIP jt , impingement on shoes

Pain at tip of toes

Pain at MTP joint – due to synovitis following persistent hyperextension and istability

Callus / erythema over PIP joint

Callus or soft corn on medial broder of claw

Metatarsalgia or pressure on MT head

Treatment of clawing

Ist treat foot deformities

Then if toe clawing persist , treat for this

Swing Phase clawing

            Treat by restoring active DF

            Correct equinus

Stance phase Clawing

            Restore active PF

            Correct cavus

Indications

            Pain due to clawing

Contraindication

            Poor vascularity to toe and poor skin quality

Post operative

            Lamrunidi splint

            Its pads for toes and wires to hold toes

Surgery

Girdlestone Taylor procedure

            Long toe flexor transfer to dorsal expansion of extensor tendon

           

            So long toe extensors act as intrinsic muscles of foot to produce active PF of MTP joints       and extend IP joints.

More useful when clawing due to weakness of intrinsic muscles of foot

Mechanism of great toe clawing and treatment ?

Ankle DF – Weak , Normal long toe extensors

Treatment

A.     Modified Jones Procedure

            Attachment of EHL leading to Ist MT neck

            Arthrodesis of IP Joints

            EHL distal stump to soft tissue over dorsum of Proximal phalanx

            Clawing is caused by Tendoachilles contracture

B.     Dickson – Diveley Procedure

Caused by insufficiency of PF of ankle

Transfer of EHL to FHL around medial side of Ist MT head

Arthrodesis of IP joints

Stump of EHL to soft tissue over proximal phalanx

Difference between Jones and Modified Jones Procedure

In modified Jones

      Two incisions used

      IP Joints arthrodesis

      Excision of tendon sheath

Modified jones advantages

      Less chance of hypertrophic scar

      Less chance of pseudoarthrosis of IP Joint

      Regeneration of EHL less likely

Claw foot

Causes of foot with

      clawing of toes due to intrinsic tightness

      Equinus of forefoot – called cavus

Associations

      Mild and correctible

                  MT bar on shoes , MT Pad

      Mild not correctible

                  Preoneus longus to brevis

                  Arhtodesis of IP joints of all toes

      Moderate

                  Steindler’s fasciotomy

                  Dwyer’s clacaneal Osteotomy

                  Japas V osteotomy

      Severe

                  Anterior Tarsal wedge resection

                  Hoke / Dunn Triple Arthrodesis with TP transfer to dorsolateral tarsus

Steindler’s Fasciotomy

      Done for cavus deformity along with othe procedure or as a single operation.

Structures released are

      Platnar Fascia

      Extra –periosteal stripping of following muscles

                  Abductor Hallucis

                  Flexor Digitorum Brevis

                  Abductor Digiti Brevis

      Long plantar Ligament

                  If limb deformity not corrected , insert steinmen pin longitudinally into calcaneus from tip of heel

Apply corrective cast below knee

Japas Osteotomy ? Advantages

V shaped osteotomy of tarsus to correct cavus in children 6 years or older

No shortening , wideneing of foot . no bone is excised.

Apex of V – proximal and at highest point of cavus usually in navicle

One limb – through cuboid to lateral border of foot.

Other limb – through medial cuneiform to medial border of foot

Proximal border of distal fragment to depressed plantarward while MT heads elevated , thus lengthening plantar surface of foot

Plantar Fasciotomy should be done.

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