POLIOMYELITIS OF

FOOT AND ANKLE

By
Dr.tejaswi dussa
Post graduate in ms ortho
Gandhi hospital,
secunderabad
 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
 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
 Distribution
• Lower limbs 92 %
• Trunk + LL 4%
• LL + UL 1.33 %
• Bilateral UL 0.67 %
• Trunk + UL + LL 2%
 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
• 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
 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
Causes of deformity in Polio

• 1. muscle imbalance
• 2. posture and gravity effect
• 3. dynamics of activity
• 4. dynamics of growth
 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
FOOT AND ANKLE
oRTHOSIS
Claw toes
Foot drop
equinovalgus
equinovarus
What surgeries are done in Polio?
Balancing of power
Stabilization procedures
Correction of deformities
Limb lengthening
 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
 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
• 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
• 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
 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
 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
PEABODY’S CLASSIFCATION

1. limited extensor invertor insufficiency

2. gross extensor invertor insufficiency
3. evertor insufficiency
4. triceps surae insufficiency
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
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
• 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
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
• 4.TRICEPS SURAE INSUFFICIENCY
• Calcaneovarus deformity- tibialis
posterior,FHL
• calcaneovalgus deformity- both peroneals
attached to calcaneum
• calcaneocavus - transfer of
peroneals,tibialis posterior
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
 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
 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
 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
• .
 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
 EQUINOVARUS DEFORMITY
• Tibialis anterior
• Long toe extensors and peroneal muscle
• 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
 EQUINO VALGUS DEFORMITY
• Anterior and posterior
muscle weakness with
strong peroneals and
gastroconemius-soleus
muscle
• 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
 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
 CALCANEUS DEFORMITY
• Gastroconemius-soleus muscle
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
• For mild deformity –braces used
• Tenodesis of achilles tendon to fibula
• There is progressive equinous deformity with
subsequent growth in pt with achilles
tenodesis
 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
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