PRESENTATION ON POLIOMYELITIS DISCRIPTION

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Balance 17,900This image explains Böhler’s angle, which is an important radiographic measurement used to assess for calcaneal fractures on a lateral X-ray of the calcaneus.

How Böhler’s angle is measured:

Draw Line 1: from the highest point of the anterior process to the highest point of the posterior articular facet.

Draw Line 2: from the highest point of the posterior articular facet to the highest point of the posterior tuberosity.

The angle formed between these two lines is Böhler’s angle.

Normal values:

20° – 40° → Normal

< 20° → Suggests depression fracture of the calcaneus (often intra-articular).

Key point:

A reduced Böhler’s angle is a classic radiographic sign of calcaneal fracture.COMPARISON OF FUNCTIONAL OUTCOME OF THE RETROGRADE NAILING AND DISTAL FEMORAL LOCKING PLATE USING MINIMALLY INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS IN DISTAL FEMORAL COMPARISON OF FUNCTIONAL OUTCOME OF THE RETROGRADE NAILING AND DISTAL FEMORAL LOCKING PLATE USING MINIMALLY INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS IN DISTAL FEMORAL COMPARISON OF FUNCTIONAL OUTCOME OF THE RETROGRADE NAILING AND DISTAL FEMORAL LOCKING PLATE USING MINIMALLY INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS IN DISTAL FEMORAL COMPARISON OF FUNCTIONAL OUTCOME OF THE RETROGRADE NAILING AND DISTAL FEMORAL LOCKING PLATE USING MINIMALLY INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS IN DISTAL FEMORAL COMPARISON OF FUNCTIONAL OUTCOME OF THE RETROGRADE NAILING AND DISTAL FEMORAL LOCKING PLATE USING MINIMALLY INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS IN DISTAL FEMORAL This image explains Böhler’s angle, which is an important radiographic measurement used to assess for calcaneal fractures on a lateral X-ray of the calcaneus.

How Böhler’s angle is measured:

Draw Line 1: from the highest point of the anterior process to the highest point of the posterior articular facet.

Draw Line 2: from the highest point of the posterior articular facet to the highest point of the posterior tuberosity.

The angle formed between these two lines is Böhler’s angle.

Normal values:

20° – 40° → Normal

< 20° → Suggests depression fracture of the calcaneus (often intra-articular).

Key point:

A reduced Böhler’s angle is a classic radiographic sign of calcaneal fracture.This image explains Böhler’s angle, which is an important radiographic measurement used to assess for calcaneal fractures on a lateral X-ray of the calcaneus.

How Böhler’s angle is measured:

Draw Line 1: from the highest point of the anterior process to the highest point of the posterior articular facet.

Draw Line 2: from the highest point of the posterior articular facet to the highest point of the posterior tuberosity.

1. DR MUHAMMAD MOAZ BIN KHALID RESIDENT ORTHOPEDIC SURGERY ORTHOPAEDIC UNIT 2, SHL POLIOMYELITIS

2. OUTLINE Definition Epidemiology Post-polio syndrome Patterns of weakness Contractures Gait disturbance Treatment options Principles of fracture management Arthroplasty considerations

3. DEFINITION * Poliomyelitis (Polio) = polio “grey”, myelon “marrow” * Inflammation of the grey matter in the spinal cord * Ancient Egyptian stele (\~1400 BC) thought to depict polio * Caused by Poliovirus, a neurotropic enterovirus * Spread by faecal–oral route or by pharyngeal secretions * Invades CNS causing meningitis and myelitis * Viral replication in anterior horn motor neurons → cell death → acute flaccid weakness * Dorsal root involvement can occur * 90–95% of cases are asymptomatic * 0.1% of patients develop paralysis

4. PATHOLOGY Entry & Spread: Virus enters via oropharyngeal route → multiplies in lymph nodes of alimentary tract Spreads hematogenously → attacks anterior horn cells (esp. cervical & lumbar enlargements) Mechanism of Damage: Direct viral multiplication / toxic by-products Indirect effects: ischemia, edema, hemorrhage Wallerian degeneration within 3 days

5. Histopathology: Necrotic ganglion cells removed by macrophages & neutrophils Later: gliosis & neuroglial proliferation Ongoing disease activity reported even 20 yrs later

6. Muscle Paralysis: Weakness detectable if >60% motor neurons destroyed Lower limb > upper limb (2:1) Commonly affected: LE: quadriceps, glutei, anterior tibial, medial hamstrings, hip flexors UE: deltoid, triceps, pectoralis major Recovery Potential: Due to axonal sprouting of surviving motor units Recovery: greatest in first month , mostly complete by 6 months Minimal recovery possible up to 2 years Muscles paralyzed at 6 months → remain permanently paralyzed

7. CLINICAL COURSE

8. Acute stag e Lasts 7–10 days Up to 95% of anterior horn cells may be infected Range of symptoms From mild malaise to generalized encephalomyelitis with widespread paralysis Upper spinal cord involvement → diaphragmatic dysfunction & respiratory compromise (life-threatening) High index of suspicion needed in patients with shoulder involvement (due to proximity of anterior horn cells) Neurological signs Superficial reflexes → usually disappear first Deep tendon reflexes → disappear when the respective muscle group is paralyzed

9. Convalescent stage Begins 2 days after temperature returns to normal Duration: up to 2 years Anterior horn cell recovery ~ 50% survive the initial infection Muscle power improves spontaneously Rapid recovery: first 4 months Gradual improvement: thereafter Recovery expectations (Johnson’s criteria) Muscles with >80% return of strength → recover spontaneously, no specific therapy needed Muscles with <30% of normal strength at 3 months → considered permanently paralyzed

10. Treatment approach Same as acute stage Muscle strength assessment : Monthly for 6 months Then every 3 months Physical therapy Focus on muscle activity in normal patterns Develop maximal capability of individual muscles Management of contractures Mild/moderate contractures : vigorous passive stretching, wedging casts Persistent (>6 months) contractures : surgical release of fascia/aponeuroses, tendon lengthening Orthoses Used until no further recovery is anticipated

11. CHRONIC STAGE Begins ~24 months after the acute illness Overall goal Achieve maximal functional activity Manage long-term consequences of muscle imbalance Treatment goals Correct significant muscle imbalances Prevent or correct soft-tissue and bony deformities

12. Joint instability Static instability → usually controlled indefinitely with orthoses Dynamic instability → eventually progresses to fixed deformity (cannot be controlled with orthoses) Age considerations Young children : higher risk of bony deformity (due to growth potential) Adults : less prone to progressive deformity Surgical options Soft-tissue surgery (e.g., tendon transfers) → best performed in young children before fixed bony deformities develop Bony corrective procedures are usually delayed until skeletal growth is near completion

13. POSTPOLIO SYNDROME new progressive muscle weakness, often decades after infection 8-71 years post initial polio episode fatigue, pain in muscles or joints 20-30% of patients higher risk severe initial disease older age at diagnosis of acute infection if significant recovery from acute paralysis

14. HISTORY AND CLINICAL EXAMINATION • Age of the patient • Unilateral/ bilateral • Hip, knee and ankle deformities -presence and severity • Power of gluteus maximus, gastrosoleus, quadriceps, hamstrings • Limb length discrepancy • Compensatory mechanism adopted by patients • Requirement of patient

15. COMPENSATORY GAIT DISTURBANCES

16. Useful equinus deformity allowing stability of the knee. Heel contact lock the knee in extension. Knee recurvatum induced by an equinus deformity. Insufficient gluteus medius and swing of the shoulder on weight-bearing side. Locking the knee by anterior manual pressure.

17. HIP IN POLIO

18. HIP IN POLIO FLEXION AND ABDUCTION CONTRACTURES OF HIP PARALYSIS OF GLUTEUS MEDIUS AND MAXIMUS PARALYTIC HIP DISLOCATION

19. FLEXION AND ABDUCTION CONTRACTURES CONTRACTURE OF ILIOTIBIAL BAND ASSUME FROG POSITION UNABLE TO DO STRAIGHT LEG RAISE PREVENTION IS POSSIBLE WITH EARLY IDENTFICAITON, PHYSICAL THERPAY AND SPLINTAGE

20. Contracture of the iliotibial band can lead to multiple deformities involving the hip, knee, tibia, ankle, and pelvis. Flexion, abduction, and external rotation contracture of the hip Genu valgum and flexion contracture of the knee Limb-length discrepancy External tibial torsion ± knee joint subluxation Secondary ankle and foot deformities Pelvic obliquity

21. OBER AND YOUNT COMPLETE RELEASE OF HIP FLEXION, ABDUCTION, AND EXTERNAL ROTATION CONTRACTURE

22. CAMPBELL TECHNIQUE COMPLETE RELEASE OF MUSCLES FROM ILIAC WING AND TRANSFER OF CREST OF ILIUM

23. HIP IN POLIO FLEXION AND ABDUCTION CONTRACTURES OF HIP PARALYSIS OF GLUTEUS MEDIUS AND MAXIMUS PARALYTIC HIP DISLOCATION

24. SHARRARD PROCEDURE POSTERIOR TRANSFER OF THE ILIOPSOAS FOR PARALYSIS OF THE GLUTEUS MEDIUS AND MAXIMUS MUSCLES

25. HIP IN POLIO FLEXION AND ABDUCTION CONTRACTURES OF HIP PARALYSIS OF GLUTEUS MEDIUS AND MAXIMUS PRALYTIC HIP DISLOCATION

26. Paralytic Hip dislocation The goal is to reduce and restore muscle balance and correct any bony deformity. Closed reduction Open reduction Tenotomy (adductor) Proximal femoral shortening and rotational osteotomies Acetabular reconstruction Girdlestone procedure

27. Pelvic Obliquity True vs false Release of flexion and abduction contractures Stabilization of spine valgus osteotomy of adducted leg varus osteotomy of abducted leg

28. Limb length discrepancy • In polio → LLD is usually 4-7 cm at maturity. • Slow consolidation & high complications → need cautious planning. • Nail-assisted tibial lengthening is superior to the Ilizarov alone. • Combine lengthening and angular correction for best ambulatory results. • Leave slight shortening (residual discrepancy) to help swing clearance.

29. KNEE IN POLIO

30. KNEE IN POLIO The disabilities caused by paralysis of the muscles acting across the knee joint include (1) flexion contracture of the knee (2) quadriceps paralysis (3) genu recurvatum (4) flail knee

31. FLEXION CONTRACTURE ILIOTIBIAL BAND CONTRACTURE IT BAND RELEASE HAMSTRING LENGTHENING POSTERIOR CAPSULE RELEASE SUPRACONDYLAR OSTEOTOMY TRACTION BRACE QUADRICEP PARALYSIS SECOND STAGE SUPRACONDYLAR OSTEOTOMY

32. TRACTION

33. KNEE IN POLIO The disabilities caused by paralysis of the muscles acting across the knee joint include (1) flexion contracture of the knee (2) quadriceps paralysis (3) genu recurvatum (4) flail knee

34. QUADRICEP PARALYSIS Severe disability from quadriceps paralysis Tendon transfer options BICEP FEMORIS AND MEDIAL HAMSTRINGS Requirements for successful transfer Limitations of certain transfers SARTORIS AND TFL (WEAK) Role of gastrocnemius-soleus Prevention of genu recurvatum after hamstring transfer

35. KNEE IN POLIO The disabilities caused by paralysis of the muscles acting across the knee joint include (1) flexion contracture of the knee (2) quadriceps paralysis (3) genu recurvatum (4) flail knee

36. GENU RECURVATUM Lack of quadricep power vs Soft tissue relaxation( hamstring and Gastrocnemius) Structural changes in tibial condyles if una ble to lock knee due to weak quads ( disabling) Hyperextension instability Treatment Correction of skeletal deformity with hamstring transfer to patella Proximal tibial osteotomy (Irwin and Storen) Bracing Triple Tenodesis

37. KNEE IN POLIO The disabilities caused by paralysis of the muscles acting across the knee joint include (1) flexion contracture of the knee (2) quadriceps paralysis (3) genu recurvatum (4) flail knee

38. FLAIL KNEE INSUFFICIENT MUSCLE POWER, INSTABLE IN ALL DIRECTIONS OPTIONS BRACING ARTHRODESIS TIME FOR INTERVENTION ( AT WHAT AGE) DOES OCCUPATION AFFECT DECISION ? WHAT IF BOTH LEGS ARE INVOLVED TRIAL CYLINDER CAST BEFORE FUSION

39. KAFO

40. FOOT AND ANKLE IN POLIO

41. COMMON PROBLEMS DUE TO MUSCLE IMBALANCE CLAW TOES CAVOVARUS FOOT DORSAL BUNION TALIPES EQUINUS TALIPES EQUINOVARUS TALIPES EQUINOVALGUS TALIPES CALCANEUS FLAIL FOOT

42. MANAGEMENT OPTIONS TENDON TRANSFERS TENODESIS OSTEOTOMIES ( CALCANEAL, DILLWYN EVANS) TALECTOMY ARTHRODESIS (SUBTALAR, TIBIOTALAR, TRIPLE, PANTALAR ARTHRODESIS)

43. TALIPES EQUINOVARUS

44. AIM OF TENDON TRANSFER Restore lost muscle power by redirecting a functioning tendon to replace a paralyzed muscle Rebalance muscle forces around a joint to correct deformities (e.g., equinus, cavovarus foot) Improve stability of joints during stance and gait Enhance function of the limb → better walking, grasp, or movement depending on site Prevent progression of deformities caused by unopposed muscle action Reduce need for orthoses or at least simplify orthotic requirements Improve cosmesis and patient confidence by correcting abnormal postures

45. AIM OF ORTHOSES Provide stability to weak joints during stance and gait Prevent or correct deformities (soft tissue and bony) Assist weak muscles by substituting their lost function Improve mobility and gait efficiency → reduce energy expenditure while walking Relieve pain associated with instability or deformity Maintain functional alignment of joints and limbs Facilitate rehabilitation by allowing early ambulation and training Delay or avoid surgery in certain cases Enhance independence and quality of life

46. GOOD TO HAVE FOLLOWING MILD ABDUCTION IN PRESENCE OF GLUTEUS MEDIUS WEAKNESS MILD RECURVATUM DEFORMITY OF KNEE MILD EQUINES DEFORMITY

47. FURTHER STUDY

48. REFERENCES CAMPBELL OPERATIVE ORTHOPEDICS Genêt, F., Schnitzler, A., Mathieu, S., Autret, K., Théfenne, L., Dizien, O., & Maldjian, A. (2010). Orthotic devices and gait in polio patients. Annals of physical and rehabilitation medicine, 53(1), 51–59. https://doi.org/10.1016/j.rehab.2009.11.005 Joseph, B., & Watts, H. (2015). Polio revisited: reviving knowledge and skills to meet the challenge of resurgence. Journal of children's orthopaedics, 9(5), 325–338. https://doi.org/10.1007/s11832-015-0678-4 https://www.youtube.com/watch?v=3Q0eCmyECjc