ANKLE AND FOOT DEFORMITIES IN polio.pptx

orthopaedics

1. ANKLE AND FOOT DEFORMITIES IN POLIO DR. THIRUNTHAIYAN Dept. of Orthopedics

2. INTRODUCTION Picarno virus family ( entero virus), ss RNA virus Virus mainly localized in anterior horn cells and certain brain stem motor nuclei. Affects the motor tracts , keeping sensory tracts intact Clinical manifestation – Asymptomatic infection ( 90-95%) Abortive poliomyelitis Non paralytic poliomyelitis Paralytic poliomyelitis ( 1%) 3 stages – Acute stage Convaslescent stage Chronic stage

3. Poliomyelitis ( polio) is a highly infectious viral disease mainly caused by 3 serotypes of human enteric polio virus, mainly affecting young children. Virus transmitted through contaminated food and water , multiplies in small intestine, and then invades nervous system . In Greek – “ polios ” means grey, ‘ myelos ’- medulla , ‘ itis ’- inflammation

4. Pathogenesis Polio infection – incubation period -3 -21 days , on average – 14 days Transmitted through both oral and feces routes Implantation and replication occurs in either the oropharyngeal and or in the instestine of mucosa. Enters the CNS from blood, spreads along the axons of peripheral nerves to CNS. Progress along the fibres of lower motor neurons spinal cord Destroys the anterior horn cells , producing flaccid paralysis. Ocassionally may produce myocarditis , lymphatic hyperplasia Usually of 2 types- spinal polio , bulbar polio

5. Acute Stage 7- 10 days Superficial reflexes absent Deep tendon reflex disappear when the muscle group is paralysed . Treatment- Bed rest Analgesics Hot packs Anatomical positioning of limbs to prevent felxion contractures Gentle passive ROM exercises.

6. Distribution Lower limbs- 92 % Trunk + LL- 4% LL+ UL- 1.3% Bilateral UL- 0.67% Trunk + UL+ LL – 2 %

7. Convalescent stage Recovery phase Varying degree of spontaneous recovery in muscle power takes place. >80% return of strength- recovered muscle <30% of strength- paralysed muscle Treatment- Passive stretching exercises Wedging casts for mild- moderate contractures Surgical release of tight fascia & aponeurosis Lengthening of tendons may be necessary for contractures persisting for >6 months Orthosis used until further recovery anticipated.

8. Chronic stage Usually begins 24 months after the acute illness This is the time for orthopaedic intervention Most severly paralysed muscle – T ibialis Anterior Most common muscle paralyzed- Quadriceps femoris Most commonly involved muscle in upper limb – Deltoids and Opponens

9. Causes of deformity in Polio Muscle imbalance Posture and gravity effect Dynamics of activity Dynamics of growth

10. Goals of treatment To achieve maximal functional stability Correction of significant muscle imbalance Preventing or correcting of limb deformities Static joint instability can be controlled by orthoses Dynamic joint instability cannot be controlled by orthoses and results in fixed deformities Soft tissue surgeries- such as tendon transfer should be done before the development of fixed bony changes

11. PPRP of foot and ankle Most dependent parts of the body subjected to significant amount of deforming forces m/c deformities include – Equinus Equino varus Equino valgus Calcaneus Cavo varus Claw toes Dorsal bunion

12. What surgeries are done in polio ? Balancing of power Stabilization procedures Correction of deformities Limb lengthening

13. Tendon Transfers Tendon transfers are indicated when dynamic muscle imbalance results in deformity Surgery should be delayed until 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

14. Criteria and selecting the tendon for transfer Muscles to be transferred must be strong enough Free end of transferred tendon should be attached as close as possible to the insertion of paralyzed tendon A transferred tendon should be retained in its own sheath or should inserted in the sheath of another tendon or it should be passed through the subcutaneous fat. Nerve supply and blood supply of transferred tendon must be intact Joint must be in satisfactory position Contractures must be released before the transfer . Agonist muscles preferred to antagonist Child with dynamic deformity- ideal candidate for tendon transfer

15. Arthrodesis M ost efficient method for permanent stabilization of a joint When the control of one or more joints is warranted Bony procedures can be delayed until skeletal growth is complete When the tendon transfer and arthrodesis is combined in same operation, the arthrodesis is performed first.

16. Treatment – children 4-8yrs - stretching of plantar fascia, TA lengthening, posterior capsulotomy , Anterior transfer of tibialis posterior Children > 8 years – Triple arthrodesis , Anterior transfer of tibialis posterior, modified Jones procedure

17. Treatment – Skeletally immature- repeated stretching, TA lengthening, anterior transfer of peroneals , subtalar arthrodesis ( GRICE & GREEN ARTHRODESIS) Skeletally mature- TA lengthening, Triple arthrodesis

18. Treatment – (keeping in equinus position during acute stage ) Plantar fasciotomy Transfer of peroneus brevis and tibialis posterior to heel - anterior tibial tendon transferred posteriorly – DRENNAN TECHNIQUE

19. TREATMENT – LAPIDUS operation – resection of head of 1 st MT, FHL transposed from plantar aspect to dorsal aspect.

20. Foot and ankle ORTHOSIS

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