Post polio residual paralysis of lower limb

1. POST POLIO RESIDUAL PARALYSIS
OF LOWER LIMB

2. POLIOMYELITIS
•VIRAL INFECTION LOCALIZED IN THE ANTERIOR
HORN CELLSOF THE SPINAL CORD & CERTAIN BRAIN
STEM MOTOR NUCLEI.
•THE VIRUS,A MEMBER OF THE ENTEROVIRALGROUP
HAS 3 SUBTYPES -(BRUNHILDE,LANSING,LEON)
•OTHER MEMBERS-PRODUCE A PARALYTIC
SYNDROME MIMICKING POLIOMYELITIS

3. •ROUTE OF TRANSMISSION:
THROUGH GI TRACT & RESPIRATORY
TRACTHEMATOUGENOUSCNS

4. PATHOLOGY
THE ANTERIOR HORN CELLSOF THE SPINAL
CORD,ESPECIALLY LUMBAR & CERVICAL, DAMAGED-
-DIRECTLY: BY VIRAL MULTIPLICATION/ CYTOTOXIC
PRODUCTS OF VIRUS
-INDIRECTLY: ISCHEMIA, ODEMA, HAEMORRHAGE
IN SURROUNDING GLIAL TISSUES
HIGHER CENTRE CHANGES(MEDULLA, PONS, BASAL
GANGLIA,TEGMENTUM):PERIVASCULAR CUFFING,
LYMPHOID INFILTRATION, THROMBOSIS
-REVERSIBLE & TRANSITORY

5. •DESTRUCTION IN SPINAL CORD OCCURS
FOCALLY & WITHIN 3 DAYS-WALLERIAN
DEGENERATION IS EVIDENT
•AFTER 4 MONTHS-GLIOTIC TISSUE &
LYMPHOCYTIC CELLS FILL THE AREA OF
DESTROYED MOTOR CELLS
•WEAKNESS CLINICALLY DETECTABLE > 60%
MUSCLE INNERVATION DESTROYED
•PARALYSIS IN LL MUSCLES >> UL MUSCLES

6. CLINICAL COURSE
ACUTE STAGE:
•LASTS 7-10 DAYS
•SYSTEMIC STAGE
•PREPARALYTIC STAGE(CNS INVOLVEMENT)
•PARALYTIC STAGE-SPINAL-FLACCID PARALYSIS
FOCAL, ASYMMETRICAL
-BULBAR-ENCEPHALITIS
MEDULLARY RESPIRATORY CENTRE

7. TREATMENT OF ACUTE STAGE:
•BED REST
•ANALGESIC & HOT PACKS-MUSCLE PAIN
•ANATOMICAL POSITIONING TO PREVENT FLEXION
POSTURING & CONTRACTURES
•GENTLE PASSIVE RANGE OF MOTION EXCERCISES OF
ALL JOINTS DAILY SEVERAL TIMES
•SIGNS OF BULBAR POLIO

8. CONVALSCENT STAGE:
•BEGINS 2 DAYS AFTER TEMPERATURE COMES
DOWN, UPTO 2 YEARS
•MAXIMUM RECOVERY-1 MONTH & COMPLETE IN 6
MONTHS
•LIMITED AFTER 2 YEARS
•MUSCLES WITH >80% STRENGTH-SPONTANEOUS
RECOVERY
•<30% STRENGTH AT 3 MONTHS-CONSIDERED
PARALYSED

9. TREATMENT:
•ASSESSMENT OF STRENGTH MONTHLY FOR 6
MONTHS, & THEN 3-MONTHLY
•PHYSIOTHERAPY
•VIGOROUS PASSIVE EXCERCISES & WEDGING CASTS-
MILD/ MODERATE CONTRACTURES
•CONTRACTURES > 6 MONTHS-SURGICAL MEASURES

10. CHRONIC STAGE:
•24 MONTHS AFTER ILLNESS
•CORRECTION OF LONG TERM CONSEQUENCES
OF MUSCLE IMBALANCE
•PREVENTING/ CORRECTION OF SOFT TISSUE/
BONY DEFORMITIES

11. TENDON TRANSFERS
•TO PROVIDE MOTOR POWER TO REPLACE A
PARALYSED MUSCLE(s)
•TO ELIMINATE DEFORMING AFFECT OF A
MUSCLE WHEN IT ANTAGONIST IS PARALYSED
•TO IMPROVE STABILITY

12. ON SELECTING TENDONS:
•1.EQUAL IN POWER TO PARALYSED MUSCLE
•2. TENDON MUST PASS IN DIRECT LINE FROM IT
MUSCLE TO POINT OF INSERTION
•3. TO PRESERVE GLIDING, IT MUST PASS THROUGH S/C
TISSUE,ITS OWN/SHEATH OF PARALYSED MUSCLE
•4. MUST BE UNDER NORMAL PHYSIOLOGICAL TENSION
•5. ATTACHED CLOSE TO INSERTION OF PARALYSED
TENDON AS POSSIBLE
•6. NERVE & BLOOD SUPPLY PRESERVED
•7. AGONIST PREFERED TO ANTAGONISTS
•8. CONTRACTURES RELEASED & JOINT MOBILISED
•9. RANGE OF EXCURSION TO BE SIMILAR TO MUSCLE
BEING REPLACED

13. FOOT & ANKLE
•MOST DEPENDENT –SIGNIFICANT STRESS-
SUSCEPTIBLE TO DEFORMITIES FROM
PARALYSIS
•COMMON DEFORMITIES-CLAWTOES, CAVOVARUS,
DORSAL BUNION, TALIPES EQUINUS, TALIPES
EQUINOVARUS, TALIPESCAVOVARUS, TALIPES
EQUINOVALGUS, TALIPESCALCANEUS

14. •PLANTAR FLEXORS: TRICEPS SURAE
(GASTRONEMIUS+SOLEUS),TIBIALIS POSTERIOR,
FLEXOR HALLUCIS LONGUS, FLEXOR DIGITORUM
LONGUS
•DORSIFLEXORS: TIBIALIS ANTERIOR, EXT. HALLUCIS
LONGUS, EXT. DIGITORUM LONGUS,PERONEUS
TERITUS
•INVERTORS:ANTR. & POSTR. TIBIALIS, FHL
•EVERTORS: PERONEI (LONGUS,BREVIS,TERTIUS)

15. •<10 YRS-BONE RESECTIONS
CONTRAINDICATED (SKELETAL IMMATURITY)
•TENDON TRANSFERS ALLOWED, BUT BETTER >
10 YRS
•>10 YRS-1
ST
-STABILIZING BONE RESECTIONS
DONE, FOLLOWED BY TENDON TRANSFERS
•ONLY THEN, OTHER LOWER LIMB
DEFORMITIES CORRECTED, OR ELSE
RECURRENCE OF FOOT DEFORMITIES

16. PARALYSIS OF SPECIFIC MUSCLES-
TIBIALIS ANTERIOR
•LOSS OF DORSIFLEXION + INVERSIONEQUINUS &
CAVUS
•EXTENSORS OF TOES-OVERACTIVE TO REPLACE
TIB.ANTERIOR HYPEREXTENSION PROXIMAL
PHALANGES+DEPRESSION METATARSAL HEAD
•UNOPPOSED ACTION OF PERONEUS
LONGUS+ACTIVE TIB. POSTERIORCAVOVARUS
DEFORMITY

17. •CONSERVATIVE -PASSIVE STRETCHING & SERIAL
CASTING FOR EQUINUS CONTRACTURE
•SURGICAL-POSTERIOR ANKLE CAPSULOTOMY &
TENDOCALCANEUS LENGTHENING—COMBINED WITH
ANTERIORTRANSFER OF PERONEUS LONGUS (TO
BASE OF 2
ND
METATARSAL)
-CLAWTOE DEFORMITY-TRANSFER OF TOE EXTENSORS
FROM DISTAL PHALANGES INTO METATARSAL NECKS

18. TIBIALIS ANTERIOR & POSTERIOR
MUSCLES
•LOSS OF DORSI-& PLANTAR FLEXION +
INVERSION
•HINDFOOT & FOREFOOT EQUINOVALGUS
•DEFORMITY DEVELOPS RAPIDLY & BECOMES
FIXED AS TENDOCALCANEUS SHORTENS

19. •CONSERVATIVE:
SERIAL CASTING TO STRETCH TENDOCAL.
& TO PREVENT WEAKING OF TRICEPS SURAE
•SURGICAL: -
-ONE OF PERONEAL MUSCLES TRANSFERRED:
P. LONGUS (GREATER EXCURSION)ANTERIORLY
TO BASE OF 2
ND
METATARSAL TO REPLACE TIB.
ANTERIOR
-ONE OF TOE FLEXORS TO REPLACE TIB.
POSTERIOR

20. TIBIALIS POSTERIOR
•ISOLATED PARALYSIS-RARELOSS OF
INVERSION
•RESULTS IN HINDFOOT & FOREFOOT
EVERSION
•FHL & FDL USED FOR TRANSFERS

21. TIBIALIS ANTERIOR, TOE EXTENSOR &
PERONEAL MUSCLES
•LOSS OF DORSIFLEXION+ EVERSIONSEVERE EQUINOVARUS
+CAVUS DEFORMITY (UNOPPOSED ACTION OF TIB. POSTR. &
TRICEPS SURAE)
•TRT:
-SERIAL CASTING CAN BE TRIED
-LENGTHENING OF TENDOCALCANEUS
-SOFT TISSUE RELEASE OF FOREFOOT CAVUS DEFORMITY
-ANTERIOR TRANSFER OF TIB. POSTERIOR ,
-SUPPLEMENTED BY TRANSFER OF LONG TOE FLEXORS

22. PERONEAL MUSCLES
•ISOLATED PARALYSIS-RARELOSS OF EVERSION
•RESULTS IN SEVERE HINDFOOT VARUS DEFORMITY (UNOPPOSED
ACTION OF TIB. POSTERIOR)
TREATMENT:
•LATERAL TRANSFER OF TIB. ANTERIOR (FROM MED. CUNEIFORM &
BASE 1
ST
METARSAL BASE OF 2
ND
METATARSAL)
•CAN RESULT IN OVERACTIVITY OF
EHLHYPEREXTENSIONPAINFUL CALLUS BASE OF 1
ST
METATARSAL
•<5 YRS-LENGTHENING OF EHL TENDON
•>5 YRS-TRANSFER OF EHL TENDON TO 1
ST
METATARSAL NECK

23. TRICEPS SURAE MUSCLES
•STRONGEST PLANTAR FLEXOR OF FOOT
•LOSS OF PLANTAR FLEXION & UNOPPOSED
DORSIFLEXOR ACTIONPROGRESSIVE CALCANEAL
DEFORMITY
•REQUIRED FOR NORMAL FUNCTION OF LONG TOE
FLEXORS & EXTENSORS & TO INTRINSIC MUSCLES
OF FOOT

24. •PREVENTION: KEEPING FOOT IN SLIGHT
EQUINUS DURING A/C STAGE-PREVENTS
OVERSTRETCHING OF TRICEPS SURAE, & THE
POSITION MAINTAINED IN CONVALESCENT
STAGE
•IF TRICEPS SURAE WEAK—EARLY WALKING
DISCOURAGED

25. SURGICAL-IF PROGRESSIVE DEFORMITY-TENDON
TRANSFER
•MUSCLE SELECTED DEPENDS ON RESIDUAL
STRENGTH OF TRICEPS SURAE
•IF FAIR MOTOR STRENGTH-POSTERIOR
TRANSFER OF 2 OR 3 MUSCLES
•COMPLETE PARALYSES-AS MANY MUSCLES
POSSIBLE
•TIB. ANTERIOR TRANSFERED POSTERIORLY
(DRENNAN)

26. •IF INVERTORS & EVERTORS BALANCEDPURE
CALACANEOCAVUS DEFORMITY
•IF POSTERIOR TRANSFER OF ONLY ONE
SETINSTABILITY
•CALCANEOVALGUS –BOTH PERONEALS TRANSFERRED
TO HEEL
•CALCANEOVARUS—TIB. POSTERIOR+FHL TO HEEL
•RARELY,HAMSTRINGS USED TO REPLACE T. SURAE ,IF
NO INVERTORS / EVERTORS PRESENT FOR TRANSFER

27. FLAIL FOOT
•ALL MUSCLES DISTAL TO KNEE JOINT PARALYSED--->
EQUINUS DEFORMITY DUE TO PASSIVE PLANTAR
FLEXION
•INTRINSIC MUSCLES RETAIN FUNCTION--->
FOREFOOT EQUINUS / CAVOEQUINUS DEFORMITY
•TRT: RADICAL PLANTAR RELEASE /PLANTAR
NEURECTOMY
•IN OLDER –MIDFOOT WEDGE RESECTION (FOREFOOT
EQUINUS DEFORMITY)

28. DORSAL BUNION
•SHAFT OF 1
ST
METATARSAL-DORSIFLEXED
•GREATER TOE-PLANTAR FLEXED
•DEFORMITY PRESENT ONLY ON WEIGHT BEARING
•IF MUSCLE IMBALANCE NOT CORRECTED-IT BECOMES
FIXED
•EXOSTOSIS CAN DEVELOP ON DORSUM OF METATARSAL
HEAD
•WHEN FLEXION SEVERE ENOUGH-MP JOINT CAN
SUBLUXATE & DORSAL PART OF METATARSAL HEAD
CARTILAGE CAN DEGNERATE
•PLANTAR PART OF JOINT CAPSULE & FLEXOR HALLUCIS
BREVIS CAN CONTRACT

29. •COMMON IMBALANCE B/W TIB. ANTERIOR &
PERONEUS LONGUS
•TIB. ANTERIOR RAISES 1
ST
CUNEIFORM & BASE OF 1
ST
METATARSAL WHERE IT INSERTED MEDIALLY
•PERONEUS LONGUS, INSERTED LATERALLY BASE OF 1
ST
METATARSAL & MED. CUNEIFORM OPPOSES THIS
•WHEN PERONEUS L. WEAK/ PARALYSED-METATARSAL
STRONGLY DORSIFLEXEDGREAT TOE BECOMES
ACTIVELY PLANTAR FLEXED
(FOR A WEIGHT BEARING POINT ON MEDIAL SIDE OF
FOREFOOT & TO ASSIDT PUSH OFF IN WALKING)

30. •LAPIDUS & HAMMOND OBSERVED MANY DORSAL
BUNIONS DEVELOPED AFTER ILL ADVISED TENDON
TRANSFERS FOR RESIDUAL POLIOMYELITIS
•BEFORE ANY TRANSER, THE EFFECT OF ITS LOSS ON 1
ST
METATARSAL SHOULD BE CONSIDERED
•IF TIB ANTERIOR PARALYSED—TENDON OF P. LONGUS/
P. BREVIS SHOULD BE TO THE 3
RD
CUNEIFORM RATHER
THAN TO INSERTION OF TIB. ANTERIOR

32. BONY PROCEDURES(OSTEOTOMY &
ARTHRODESIS)
•OBJECTIVE: TO REDUCE NUMBER OF JOINTS THE
WEAKENED/ PARALYSED MUSCLES SHOULD
CONTROL
•STABILIZING PROCEDURES:
1.CALCANEAL OSTEOTOMY
2. EXTRAARTICULAR SUBTALAR ARTHRODESIS
3. TRIPLE ARTHRODESIS
4. ANKLE ARTHRODESIS
5. BONE BLOCKS TO LIMIT MOTION AT ANKLE JOINT

33. CALCANEAL OSTEOTOMY
•CORRECTION OF HINDFOOT VARUS OR VALGUS
DEFORMITY
•CAVOVARUS –IT IS COMBINED WITH RELEASE OF
INTRINSIC MUSCLES & PLANTAR FASCIA
•CALCANEOVARUS-COMBINED WITH POSTERIOR
DISPLACEMENT CALCANEAL OSTEOTOMY
•FIXED VALGUS DEFORMITY-MEDIAL DISPLACEMENT
OSTEOTOMY

34. DIILWYN-EVANS OSTEOTOMY
•FOR TALIPES CALCANEOVALGUS DEFORMITY
•LENGTHENS CALCANEUS BY TRANSVERSE
OSTEOTOMY OF CALCANEUS & INSERTION OF BONE
GRAFT TO OPEN A WEDGE & LENGTHEN LATERAL
BORDER OF FOOT

35. SUBTALAR ARTHRODESIS
•GRICE & GREEN:
•RESTORES HEIGHT OF MEDIAL LONGITUDINAL
ARCH
•WHEN VALGUS DEFORMITY LOCALISED TO
SUBTALAR JOINT & CALCANEUS CAN BE
MANIPULATED INTO NORMAL POSITION
BELOW TALUS

36. •DENNYSON &
FULFORD:
•SCREW INSERTED
ACROSS SUBTALAR
JOINT FOR INTERNAL
FIXATION & AN ILIAC
CREST GRAFT PLACED
IN SINUS TARSI.

37. TRIPLE ARTHRODESIS
•MOST EFFECTICE PROCEDURE IN STABILIZING FOOT
•FUSION OF SUBTALAR, CALCANEOCUBOID &
TALONAVICULAR JOINTS
•LIMITS MOTION TO PLANTAR FLEXION &
DORSIFLEXION
•INDICATED WHEN MOST OF WEAKNESS &
DEFORMITY ARE AT SUBTALAR & MIDTARSAL JOINTS

39. •RESERVED FOR SEVERE DEFORMITY IN CHILDREN 12
YEARS OR MORE
•EXACT TECHNIQUE DEPENDS ON TYPE OF
DEFORMITY
•COMPLICATIONS:
-PSEUDOARTHROSIS(TALONAVICULAR JT.)
-DEGENERATIVE ARTHRITIS(ADDITIONAL STRESS ON
ANKLE JT. DUE TO LOSS OF MOBILITY)
-AVN (EXCESS TALUS RESECTION)
-FOREFOOT DEFORMITY (MUSCLE IMBALANCE)

40. ANKLE ARTHRODESIS
•FLAIL FOOT
•RECURRENCE OF DEFORMITY AFTER TRIPLE
ARTHRODESIS

41. POSTERIOR BONE BLOCK(CAMPBELL’S)
•TO ELIMINATE ANKLE PLANTAR
FLEXION IN EQUINUS
DEFORMITY
•BONY BUTTRESS ON
POSTERIOR ASPECT OF TALUS
& SUPERIOR ASPECT OF
CALCANEUS
•IMPINGED TO POSTERIOR LIP
OF DISTAL TIBIA
•RARELY INDICATED
•REPLACED BY TENDON
TRANSFERS

42. TALIPES EQUINOVARUS
•EQUINUS DEFORMITY AT ANKLE
•INVERSION OF HEEL & MIDTARDAL JOINT
•ADDUCTION & SUPINATION OF FOREFOOT
IN LONG STANDING CASES-
•CAVUS DEFORMITY FOOT
•CLAWING TOES

43. •PERONEAL MUSCLES WEAKENED/ PARALYSED
•TIBIALIS ANTERIOR-NORMAL/ WEAKENED
•TIBIALIS POSTERIOR-NORMAL
•TRICEPS SURAE-CONTRACTED (MOTOR
IMBALANCE, GROWTH, GRAVITY, POSTURE)

44. TREATMENT:
•ANTERIOR TRANSFER OF TIBIALIS POSTERIOR-
AIDS ACTIVE DORSIFLEXION
•THE ENTIRE TENDON CAN BE TRANSFERRED
THROUGH INTEROSSEOUS MEMBRANE TO
MIDDLE CUNEIFORM
•OR, TENDON SPLIT WITH LATERAL HALF
TRANSFERRED TO CUBOID

46. TALIPES EQUINOVALGUS
•TIBIALIS ANTERIOR & TIBIALIS POSTERIOR
WEAK
•PERONEI STRONG, TRICEPS SURAE
CONTRACTED
•TRT: SUBTALAR ARTHRODESIS & ANTERIOR
TRANSFER OF PERONEUS LONGUS & BREVIS
•AFTER SKELETAL MATURITY-TRIPLE
ARTHRODESIS

47. TALIPES CAVOVARUS
•IMBALANCE OF EXTRINSIC MUSCLES OR
PERSISTENT FUNCTION OF SHORT TOE
FLEXORS & OTHER INTRINSIC MUSCLES WHEN
FOOT IS OTHERWISE FLAIL
•EXAGERATED LONGITUDINAL ARCH+ SLIGHT
FLEXION ON TOES
•PAINFUL CALLUSES ON PLANTAR ASPECT OF
METARSAL HEADS

48. TRT: PRESURRE RELIEVED BY METATARSAL
PADDING IN SOLE OF SHOE
•ARCH SUPPORT
•SURGICAL-
WEDGE OSTEOTOMY OF TARUS + STRIPPING
OF PLANTAR APONEUROSIS FROM PLANTAR
SURFACE OF CALCANEUS
-MUSCLE IMBALANCE-TOE EXTENSORS
TRANSFERRED TO NECKS OF METATARSALS
(ACTIVE DORSIFLEXION CREATED)

49. TALIPES CALCANEUS
•TRICEPS SURAE PARALYZED
•OTHER DORSIFLEXORS FUNCTIONAL
•RAPIDLY PROGRESSIVE DEFORMITY
TRT: EARLY TENDON TRANSFERS
•IF NO ADEQUATE MUSCLES-TENODESIS OF
TENDOCALCANEUS TO FIBULA (WESTIN)
•IN SKELETALLY MATURE FEET-1
ST
-PLANTAR
FASCIOTOMY + TRIPLE ARTHRODESIS
•6 WEEKS LATER-PERNEOUS LONGUS & BREVIS+
TIBIALIS POSTERIOR TRANSFERRED TO CALCANEUS

50. •IF EXT. DIGITORUM LONGUS FUNCTIONAL-
TRANSFER TO A CUNEIFORM
•TIBIALIS ANTERIOR TO CALCANEUS

51. KNEE
•DISABILITIES
•FLEXION CONTRACTURE OF KNEE
•QUADRICEPS PARALYSIS
•GENU RECURVATUM
•FLAIL KNEE

52. FLEXION CONTRACURE KNEE
•CONTRACTURE OF ILIOTIBIAL BAND
•PARALYSIS OF QUADRICEPS, WHEN HAMSTRINGS
NORMAL/PARTIALLY PARALYSED
•ILIOTIBIAL BAND CONTRACTURE-ALSO GENU
VALGUM
•BICEPS FEMORIS>MEDIAL HAMSTRINGS-GENU
VALGUM + EXTERNAL ROTATION DEFORMITY OF
TIBIA ON FEMUR

53. TREATMENT
•FLEXION CONRACTURES OF 15-20
O
–
POSTERIOR HAMSTRING LENGTHENING &
CAPSULOTOMY
•MORE SEVERE CONTRACTURES-
SUPRACONDYLAR EXTENSION OSTEOTOMY OF
FEMUR

54. •>70
o
-DEFORMITY OF ARTICULAR SURFACE OF
KNEE
•TENDENCY FOR POSTERIOR SUBLUXATION OF
TIBIA ON FEMUR
TRT: DIVISION OF ILIOTIBIAL BAND & HAMSTRING
TENDONS + POSTERIOR CAPSULOTOMY
•POSTOP-SKELETAL TRACTION GIVEN
•LONG TERM USE OF LONG LEG BRACE
•SUPRACONDYLAR OSTEOTOMY -2
ND
STAGE
PROCEDURE IN OLDER PATIENTS

55. QUADRICEPS PARALYSIS
•KNEE-VERY UNSTABLESEVERE DISABILITY
•TRT:TENDON TRANSFER IS REQUIRED –BICEPS
FEMORIS, SEMITENDINOSUS, SARTORIUS, TENSOR
FASCIA
•HAMSTRING TENDON-ONLY IF ANOTHER FLEXOR +
TRICEPS SURAE(ALSO ACTION AS KNEE FLEXOR) IS
FUNCTIONING. ALSO, HIP FLEXORS-GOOD FUNCTION

57. •GENU RECURVATUM AFTER HAMSTRING
TRANSFERS CAN BE KEPT TO MINIMUM IF-
•1. STRENGTH IN T. SURAE GOOD
•2.KNEE IS NOT IMMBOLISESD IN HYPEREXTENSION
AFTER SURGERY
•3. TALIPES EQUINUS, IF PRESENT, IS CORRECTED
BEFORE WEIGHT BEARING IS RESUMED
•4. PHYSICAL THERAPY IS BEGUN TO PROMOTE
ACTIVE KNEE EXTENSION

58. GENU RECURVATUM
•KNEE IN HYPEREXTENSION
•2 TYPES:
•-CAUSED BY STRUCTURAL, ARTICULAR & BONY
CHANGES DUE TO LACK OF POWER IN
QUADRICEPS
•-CAUSED BY RELAXATION OF SOFT TISSUES AT
POSTERIOR ASPECT OF KNEE

59. •1. QUADRICEPS LACKS POWER TO LOCK KNEE IN
EXTENSION
•HAMSTRINGS & T. SURAE-NORMAL
•PRESSURES OF WEIGHT BEARING & GRAVITY CAUSE
CHANGES IN TIBIAL CONDYLES-(ELONGATED
POSTERIORLY & DEPRESSED ANTERIOR MARGINS); &
ALSO, PROXIMAL TIBIAL SHAFT BOWS
POSTERIORLYPARTIAL SUBLUXATION OF TIBIA
TRT:
•SKELETAL DEFORMITY CORRECTED-OSTEOTOMY(IRWIN,
CAMPBELL)
•TRANSFER OF HAMSRINGS TO PATELLA

60. Campbell’s closing wedge osteotomy

61. •2.) HAMSTRINGS & T. SURAE WEAK
HYPEREXTENSION & WEAKING OF POSTERIOR
CAPSULE LIGAMENT
TRT:
•SOFT TISSUE OPERATIONS-TRIPLE TENODESIS
•PROLONGED BRACING OF KNEE IN FLEXION
PREVENTS AN INCREASE IN DEFORMITY IF IT IS <30
DEG.
•IF SEVERE-PERRY,O’BRIEN & HODGSON TENODESIS:

62. •-PROXIMAL ADVACEMENT OF POSTERIOR CAPSULE
OF KNEE WITH 20 DEG FLEXION
•-CONSTRUCTION OF A CHECKREIN IN MIDLINE USING
TENDONS OF SEMITENDINOSUS & GRACILIS
•-CREATION OF 2 DIAGONAL STRAPS POSTERIORLY
WITH BICEPS TENDON & ANTERIOR HALF OF
ILIOTIBIAL BAND

63. FLAIL KNEE
•KNEE UNSTABLE IN ALL DIRECTIONS
•NO MUSCLE POWER TO OVERCOME
DEFORMITY
TRT:LONG LEG BRACE WITH A LOCKING KNEE
JOINT
•OR, FUSION OF KNEE JOINT
•FUSION-SATISFACTORY GAIT BUT
INCONVENIENCE WHILE SITTING

64. HIP
DEFORMITIES-
•FLEXION & ABDUCTION CONTRACTURES
•PARALYSIS OF GLUTEUS MAXIMUS & MEDIUS
•PARALYTIC HIP DISLOCATION

65. FLEXION & ABDUCTION
CONTRACURES OF HIP
•ABDUCTION CONTRACTURE-MOST COMMON-
OCCURS ALONG WITH FLEXION & EXT. ROTATION
CONTRACTURES
•SPASM OF HAMSTRINGS, HIP FLEXORS, TENSOR
FASCIA LATAE, HIP ABDUCTORS-IN A/C &
CONVALESCENT STAGES
•PATIENT ASSUMES FROG LEG POSTION-IF
MAINTAINED FOR FEW WEEKSCONTRACTURES

66. •ILIOTIBIAL BAND CONTRACTURE RESULTS IN:
•1.FLEXION, ABDUCTION & EXTERNAL ROTATION
CONTRACTURE HIP
•2. GENU VALGUM & FLEXION CONTRACTURE KNEE
•3. LIMB LENGTH DISCREPANCY
•4. EXTERNAL TIBIAL TORSION / KNEE JOINT
SUBLUXATION
•5. SECONDARY ANKLE & FOOT DEFORMITIES
•6. PELVIC OBLIQUITY
•7. INCREASED LUMBAR LORDOSIS-B/L FLEXION
CONTRACTURES PULL PELVIC ANTERIORLY

67. •PELVIC OBLIQUITY-
•WHEN PATIENT STANDS & AFFECTED LIMB
BROUGHT TO WEIGHT BEARING POSITON-
PELVIC ASSUMES A OBLIQUE POSITION-ILIAC
CREST LOW ON CONTRACTED SIDE
•LATERAL THRUST PUSHSES PELVIC TO NORMAL
SIDE
•TRUNK MUSCLES ON AFFECTED SIDE
LENGTHEN, CONTRACT IN OPP. SIDELUMBAR
SCOLIOSIS

69. •PREVENTION IN EARLY STAGES:
•POSITION-HIPS IN NEUTRAL ROTATION,SLIGHT
ABDUCTION & NO FLEXION
•FULL RANGE OF MOVEMENT IN ALL JOINT
DAILY
•TO PREVENT EXT. ROTATION-A BAR SIMILAR TO
DENIS BROWNE SPLINT-TO HOLD FEET IN
SLIGHT INTERNAL ROTATION
•WATCH FOR CONTRACTURES & CORRECT
BEFORE AMBULATION

70. •SURGICAL:
•FOR ABDUCTION + ER CONTRACTURES-COMPLETE
RELEASE OF HIP MUSCLES (OBER YOUNT)
•SOUTTER’S RELEASE-RELEASE OF STRUCTURES
FROM ASIS
•SEVERE DEFORMITIES-RELEASE OF ALL MUSCLES
FROM ILIAC WING & TRANSFER OF CREST OF ILIUM
(CAMPBELL)

71. PARALYSIS OF GLUTEUS MAXIMUS &
MEDIUS MUSCLES
•RESULTS IN UNSTABLE HIP
•DURING WEIGHT BEARING ON AFFECTED SIDE-
WHEN GLUTEUS MEDIUS ALONE PARALYSED, TRUNK
SWAYS TOWARDS AFFECTED SIDE & PELVIS ON
OPPOSITE SIDE ELEVATES (“COMPENSATED”
TRENDELENBURG GAIT)
•GLUTEUS MAXIMUS –BODY LURCHES BACKWARD

72. •TRENDELENBERG TEST-
•NORMALON BEARING WEIGHT ON ONE
LIMB & FLEXED OTHER HIP, PELVIS HELD IN
HORIZONTAL, WITH GLUTEAL FOLDS AT SAME
LEVEL
•IF GLUTEAL MUSCLES AFFECTED-LEVEL OF
PELVIS ON NORMAL SIDE DROPS LOWER

73. •MGT:
•TRANSFER OF EXTERNAL OBLIQUETO GREATER TROCHANTER
FOR GL. MEDIUS PARALYSIS
•OTHER OPTION-ILIOPSOAS
-MUSTARD-ILIPSOAS TENDON TRANSFERED TO GREATER
TROCHNATER
-SHARRAD-ENTIRE ILIACUS TRANSFERRED POSTERIORLY
•ADV:
-HIP NOT FURTHER WEAKEND BY ELIMINIATING ILIOPSOAS AS HIP
FLEXOR
-POWER ADDED TO HIP BY TAKING MUSCLE FROM ABDOMINAL
WALL
-ACTS SYNERGESTICALLY(ILIOPSOAS-ANTAGONISTIC)
-ILIUM NOT VIOLATED

74. PARALYTIC DISLOCATION HIP
•POLIO<2 YRS, GLUTEAL MUSCLES PARALYSED BUT
FLEXORS & ADDUCTORS NORMALCHILD MAY
DEVELOP PARALYTIC DISLOCATION HIP
•ALSO, IF FIXED PELVIC OBLIQUITY IN CONTRALATERAL
ILIOTIBIAL BAND CONTRACTURE/ STRUCTURAL
SCOLIOSIS
•WEAKNESS OF ABDUCTOR MECHANISMRETARDS
GREATER TROCHANTER APOPHYSIS
GROWTHPROXIMAL FEMORAL CAPITAL EPIPHYSIS
GROWS AWAY FROM GREATER TROCHANTER
INCREASES VALGUS DEFORMITY OF FEMORAL NECK
& FEMORAL ANTEVERSIONHIP
UNSTABLESUBLUXATION

75. •TREATMENT:
•REDUCTION OF FEMORAL HEAD INTO ACETABULUM IN
DISLOCATIONS & RESTORATION OF MUSCLE BALANCE
•IF NOT REDUCED WITH TRACTION, OPEN REDUCTION
& ADDCUTION TENOTOMY WITH PRIMARY FEMORAL
SHORTENING, VARUD DEROTATION OSTEOTOMY OF
FEMUR & APPROPRIATE ACETABULAR
RECONSTRUCTION
•HIP ARTHRODESIS-LAST RESORT –FLAIL HIP

76. THANK YOU !!