POST POLIO

RESIDUAL PARALYSIS
(PPRP)

DR.HARI PRASATH P
Introduction

Infectious disease characterized by

Asymmetric flaccid motor paralysis

• 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
Distribution

• Lower limb 92 %
• Trunk + LL 4%
• LL + UL 1.33 %
• Bilateral UL 0.67 %
• Trunk + UL + LL 2%
RESIDUAL PHASE OF POLIOMYELITIS

INTRODUCTION
• As the convalescent phase of poliomyelitis ends residual phase starts
• Even with intensive exercise programs it may not be possible to
restore the muscle power.
• Best can be achieved by elevation of grade of muscle power
• Therefore training individual for making good use of muscle at the
sub fatigue level is of importance.
Progressive deformities in residual
phase.
• Inaccessibility to medical care to majority of childrens have led to
large number of people with moderate to severe deformalities.
CAUSES OF PROGRESSIVE DEFORMITY
• MUSCLE IMBALANCE –
Flaccid paralysis is the main cause of functional loss and muscle
imbalance .when a muscle or a group of muscle is paralysed,the
opponent strong muscle pull the joints to their side.
• UNRELIEVED MUSCLE SPASM
Contractures of the paralysed muscles have a tendency for deforming
the joint in the direction of contracture. This can be prevented by
passive stretching and splinting.
• GROWTH
Bony growth depends upon the stimulus by active healthy stretching
around the growth plate , which is lacking in case of polio affected
childrens causing limb length inequality , attenuation of blood vessels
and reduced blood supply leading to reduced growth of the bone.
• GRAVITY AND POSTURE
- Gravity plays an important role in maintaining the posture and
deformity.
- Paralysed group of muscles are not in a position to maintain posture.
 HOW TO RECOGNIZE PARALYSIS
CAUSED BY POLIO
• Paralysis (muscle weakness):
• usually begins when the child is small, often during an illness
like a bad cold with fever and sometimes diarrhea

• Paralysis may affect any muscles of the body, but is most

common in the legs. Muscles most often affected are
described in following slides.

• Paralysis is of the ‘floppy’ type (not stiff). Some muscles may

be only partly weakened, others limp or floppy
• In time the affected limb may not be able to straighten all
the way, due to shortening, or ‘contractures’, of certain
muscles.

• The muscles and bones of the affected limb become thinner

than the other limb. The affected limb does not grow as fast,
and so is shorter.
• Unaffected arms or legs often become extra strong to
make up for parts that are weak.

• Knee jerks and other tendon reflexes in the affected

limb are reduced or absent
SECONDARY PROBLEMS TO LOOK
FOR WITH POLIO
• By secondary problems, we mean further disabilities or
complications that can appear after, and because of, the
original disability.

• The paralysis does not get worse with time. However,

secondary problems like contractures, curve of the
backbone and dislocations may occur
CONTRACTURES OF JOINTS
OTHER COMMON
DEFORMITIES
• Weight bearing (supporting the body’s weight) on weak
joints can cause deformities.
OTHER COMMON
DEFORMITIES
Evaluation of polio

• Step 1:-
• child and family History
• watch the child move about.
• Observe carefully which parts of the body seem strong,
and which seem weak.
• Look for any differences between one side of the body
and the other—such as differences in the length or
thickness of the legs.
• any obvious deformities, or joints that do not seem to
straighten all the way
• If the child walks, what is unusual about the way
child does it?
• Does child dip forward or to one side
• Does child help support one leg with hand
• Is one hip lower than the other Or one shoulder

• Does child have a hump back, a sway back, or a

sideways curve of the back.
• Step 2:-

• Range-of-motion testing

• Muscle testing

• Check for deformities:

• Contractures,dislocations (hip, knee, foot, shoulder, elbow);
difference in leg length; tilt of hips; and curve or abnormal
shape of the back.
Muscle power grading

• Grade 0 total paralysis (no contraction palpated)

• Grade 1 evidence of slight contractility but no joint movement

• Grade 2 complete range of motion with gravity eliminated

• Grade 3 complete range of motion against gravity

• Grade 4 complete range of motion against some resistance

• Grade 5 complete range of motion against maximal resistance

Deformities

• Vary according to degree of muscle imbalance, or if patient presented

in early phase or late phase.
• Early stage
• Child is febrile with rigidity of neck and tender muscles.
• Asymmetric involvement
• Most Severely Paralysed Muscle
- Tibialis Anterior

• Most common muscle Paralysed -

- Quadriceps femoris

• Most commonly involved muscles in Upper Limb

- Deltoid
• Late stage:

• Paralysis may result into wasting weakness

• The common deformity at hip is flexion-abduction-

external rotation

• The common deformity at knee is flexion,in severe

cases tripledeformity comprising of
flexion,posterior sublaxation and external rotation.

• At foot equino varus is commonest others may be

equino valgus calcaneo valgus and calcaneo varus
• The limbs may become short.

• With time deformities becomes permanent due to contracture

of soft tissue

• Mal development of bones in deformed position

Differential diagnosis of post
polio paralysis
Management

• Management starts with diagnosis & accurate

muscle charting (assessing power & deformities)

• Discussion of expectations

• Assessment resources

• Family support
Deformity correction

• Mainly lower limb

• Aim for walking with or without orthosis by getting straight limb with
plantigrade foot
• Methods
• Reconstructive surgery
• Physiotherapy
• Orthosis
Reconstructive surgery

• Correction of deformities

• Improving the function (transfer of a tendon or muscle, removal of

deforming force)

• Stabilizing paralyzed joints (arthrodesis)

 Why surgeries are done in Polio?
• Balancing of power

• Stabilization of joints

• 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 be inserted in the sheath of another tendon or it should
be passed 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

ARTHRODESIS

• Most efficient method for permanent stabilization of a joint

• A relaxed or flail joint is stabilized by restricting its range of

motion.

• 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
when to operate

• wait for atleast 1 1/2 years after paralytic attack

• Tendon transfers done in skeletally immature
• Extra articular arthrodesis 3-8 years
• Tendon transfer around ankle and foot after 10yr of age
can be supplimented by arthrodesis to correct the
deformity
• Triple arthrodesis >10-11 years
• Ankle arthrodesis >18 years
Hip deformities

• Paralysis of the muscles around the hip can cause severe

impairment

• Flexion and abduction contractures of the hip.

• Paralysis of the gluteus maximus and medius muscles.
• Paralytic hip dislocation
Iliotibial band contracture

• The iliotibial band contracture produces flexion deformities

of the hip and knee on the same side.

• Spasm of the hamstrings, hip flexors, tensor fasciae

latae,and hip abductors is common during the acute and
convalescent stages of poliomyelitis.
Iliotibial band contracture

• Straight-leg raising usually is limited.

• The patient assumes the frog position, with the knees and
hips flexed and the extremities completely externally
rotated. When this position is maintained for even a few
weeks, secondary soft tissue contractures occur; a
permanent deformity develops
Iliotibial band contracture
deformities
• Flexion, abduction, and external rotation contracture of the hip.

• The iliotibial band lies lateral and anterior to the hip joint, and its contracture can cause
flexion and abduction deformity. The hip is externally rotated for comfort and, if not
corrected, the external rotators of the hip contract and contribute to a fixed deformity
Iliotibial band contracture
deformities
• Genu valgum and flexion contracture of the knee:

• With growth, the contracted iliotibial band acts as a taut

bowstring across the knee joint and gradually abducts and
flexes the tibia
Iliotibial band contracture
deformities
• Limb-length discrepancy:

• Although the exact mechanism has not been clearly

defined and may be related more to the loss of
neurological and muscle function, a contracted iliotibial
band on one side may be associated with considerable
shortening of that extremity after years of growth.
Iliotibial band contracture
deformities
• External tibial torsion, with or without knee joint
subluxation:

• Because of its lateral attachment distally, the iliotibial

band gradually rotates the tibia and fibula externally on
the femur; this rotation may be increased if the short
head of the biceps is strong. When the deformity
becomes extreme, the lateral tibial condyle subluxates on
the lateral femoral condyle and the head of the fibula lies
in the popliteal space.
Iliotibial band contracture
deformities
• Secondary ankle and foot deformities:

• With external torsion of the tibia, the axes of the ankle

and knee joints are malaligned, causing structural
changes that may require surgical correction.
Iliotibial band contracture
deformities
• Pelvic obliquity:
• When the iliotibial band is contracted, and the patient is
supine with the hip in abduction and flexion, the pelvis
may remain at a right angle to the long axis of the spine

• When the patient stands,the affected extremity is brought

into the weight-bearing position (parallel to the vertical
axis of the trunk), the pelvis assumes an oblique position
The iliac crest is low on the contracted side and high on
the opposite side.
• The trunk muscles on the affected side lengthen, and the
muscles on the opposite side contract. An associated lumbar
scoliosis can develop. If not corrected, the two contralateral
contractures (the band on the affected side and the trunk
muscles on the unaffected side) hold the pelvis in this
oblique position until skeletal changes fix the deformity
Iliotibial band contracture
deformities
• Increased lumbar lordosis:

• Bilateral flexion contractures of the hip pull the proximal

part of the pelvis anteriorly; for the trunk to assume an
upright position, a compensatory increase in lumbar
lordosis must develop.
Conservative Treatment

• It can be minimized or prevented in the early convalescent

stage of poliomyelitis
• The patient should be placed in bed with the hips in neutral
rotation,slight abduction,and no flexion
• All joints must be carried through a full range of passive
motion several times daily.
• The hips must be stretched in extension, adduction, and
internal rotation.
• knee roll is used to prevent a genu recurvatum deformity
Surgery

• For abduction and external rotation contractures, a complete release

of the hip muscles (Ober-Yount procedure) is indicated
Ober-Yount procedure

• Iliopsoas tendon, sartorius, rectus femorus, tensor fasciae

latae, gluteus medius and minimus
COMPLETE RELEASE OF MUSCLES
FROM ILIAC WING AND TRANSFER
OF CREST OF ILIUM
PARALYSIS OF THE
GLUTEUS MAXIMUS AND MEDIUS
• Paralysis result in unstable hip and an unsightly and fatiguing
limp.

• During weight bearing on the affected side when the gluteus

medius alone is paralyzed, the trunk sways toward the
affected side and the pelvis elevates on the opposite side
(the “compensated” Trendelenburg gait).

• When the gluteus maximus alone is paralyzed, the body

lurches backward
Trendelenburg test

• When a normal person bears weight on one extremity and

flexes the other at the hip, the pelvis is held on a horizontal
plane and the gluteal folds are on the same level
• when the gluteal muscles are impaired, and weight is borne
on the affected side, the level of the pelvis on the normal
side drops lower than that on the affected side.

• when the gluteal paralysis is severe, the test cannot be made

because balance on the disabled extremity is impossible
Treatment

• POSTERIOR TRANSFER OF THE ILIOPSOAS FOR PARALYSIS OF

THE GLUTEUS MEDIUS AND MAXIMUS MUSCLES
PARALYTIC DISLOCATION OF THE
HIP
• If a child contracts limbs in poliomyelitis before age of 2
years, and the gluteal muscles become paralyzed but the
flexors and adductors of the hip do not, the child may
develop a paralytic dislocation of hip

• Dislocation also can develop because of fixed pelvic

obliquity,in which the contralateral hip is held in marked
abduction,usually by a tight iliotibial band or a structural
scoliosis
Treatment

• Reduction of the hip in young children often can be achieved

by simple abduction, sometimes aided by open adductor
tenotomy and traction

• If the hip cannot be reduced by traction, open reduction and

adductor tenotomy may be required,

• In combination with primary femoral shortening, varus

derotation osteotomy of the femur, and appropriate
acetabular reconstructions
Knee deformities

• The disabilities caused by paralysis of the muscles acting

across the knee joint

• Flexion contracture of the knee

• Quadriceps paralysis.
• Genu recurvatum
• Flail knee
Flexion contracture of the knee

• Flexion contracture of the knee can be caused by a

contracture of the iliotibial band.

• Iliotibial band also causes genu valgum and an external

rotation deformity of the tibia on the femur.

• Flexion contracture also can be caused by paralysis of the

quadriceps muscle when the hamstrings are normal or only
partially paralyzed.
Treatment

• <15 – 20* contracture:

• Posterior hamstring lengthening and capsulotomy.
• 20-70* contracture:
• supracondylar extension osteotomy of the femur
• >70* knee flexion contracture:
• Division of the iliotibial band and hamstring
tendons,combined with posterior capsulotomy.

• Skeletal traction after surgery is maintained through a pin

in the distal tibia; a second pin in the proximal tibia pulls
anteriorly to avoid posterior subluxation of the tibia.

• Long-term use of a long-leg brace may be required to

allow the joint to remodel.
Paralysis of the quadriceps
muscle
• Set of four muscles rectus femorus along with 3 vastus
muscles.

• Quadriceps act as the great extensor muscle of the knee.

• Paralysis of the quadriceps muscle causes severe disability of

knee.

• The knee may be extremely unstable especially if there is

even a mild fixed flexion contracture.
Treatment

• TRANSFER OF BICEPS FEMORIS AND SEMITENDINOSUS

TENDONS
GENU RECURVATUM

• In genu recurvatum the knee is hyperextended

• Genu recurvatum from poliomyelitis is of two types

• Lack of power in the quadriceps

• The hamstrings and the gastrocnemius-soleus muscles

weakness.
GENU RECURVATUM

• Lack of power in the quadriceps:

• The quadriceps lacks the power to lock the knee in
extension; the hamstrings and gastrocnemiussoleus
usually are normal

• The hamstrings and the gastrocnemius-soleus muscles

weakness:
• These muscle weakness causes hyperextension of the
knee often followed by stretching of the posterior
capsular ligament.
 GENU RECURVATUM
• The pressures of weight bearing and gravity cause changes in
the tibial condyles and in the proximal third of the tibial shaft.

• The condyles become elongated posteriorly

• Their anterior margins are depressed compared with their

posterior margins

• The angle of their articular surfaces to the long axis of the tibia
which is normally 90 degrees becomes more acute.
GENU RECURVATUM

• The angle of their articular surfaces to the long axis of the

tibia which is normally 90 degrees becomes more acute.

• The proximal third of the tibial shaft bows posteriorly

• Partial subluxation of the tibia may gradually occur.

Treatment

• Closing wedge osteotomy for genu recurvatum.

• TRIPLE TENODESIS FOR GENU RECURVATUM
FLAIL KNEE

• The knee is unstable in all directions.

• Muscle power sufficient to overcome this instability is

unavailable for tendon transfer.

• Treatment :
• Locking knee long leg knee brace.
• Knee arthrodesis
 Foot and ankle
• Most dependent parts of the body subjected to significant
amount of deforming forces.
• Deformities includes:-
- equinus
- equino varus
- equino valgus
- calcaneous
- cavovarus
- claw toes
- dorsal bunion
 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 muscle

• 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
• Treatment:

• 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
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
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

• Treatment:
• Radical plantar release
• Tenodesis
• In older pt mid foot wedge resection may be required
• ANKLE ARTHRODESIS