Prof. Anisuddin Bhatti, Paeds Orthop Surgeon delivered lecture on Post Polio paralysis and deformities Part 1 on Pathophysio and principles of treatment, through Dr. Ziauddin University Hospital Clifton Karachi webinar on googel.meet, on 3rd April 2021. Acknowledge for material taken from Research papers, slideshare and books as referred in reference list.

1. POST POLIO DEFORMITY & RESIDUAL PARALYSIS: part.1, pathophysiology & principles of reconstructive
surgery
By ANISUDDIN BHATTI. Dr. Ziauddin University Hospital, webinar series, 3rd April 2021, 09:00-10:00

2. POST POLIO DEFORMITY &
RESIDUAL PARALYSIS: PART.1
Pathophysiology & Principles of
Reconstructive Surgery
ANISUDDIN BHATTI
PROFESSOR, DR. ZIAUDDIN HOSPITAL, CLIFTON
PRESIDENT RT, PAEDS ORTHO SOCIETY PAKISTAN & POA
FOCAL PERSON, PONSETI INTERNATIONAL, PAKISTAN
DR. ZIAUDDIN UNIVERSITY HOSPITAL, WEBINAR SERIES
3RD APRIL 2021, 09:00-10:00

3. EXPERTS
Prof. Imtiaz Hashmi Prof. Zamir Soomro Dr. Fareedullah Khan Zimri

4. POSTPOLIO DEFORMITIES & RESIDUAL PARALYSIS
Before Embarking to Reconstructive surgery, it is
necessary to have detailed understanding & knowledge
of:
• Pathologic process
• Pathoanatomy of deformity
• Clinical Assessment
• Principles of Reconstructive Surgery
Lecture Part 2. Friday, 9th April 2021
• Regional Deformities
• Management principles
• Case Discussion
Physiolone.com

5. POLIOMYELITIS
1. Asymptomatic infection
2. Abortive poliomyelitis
3. Non paralytic polio myelitis
4. Paralytic polio myelitis
An infectious disease, that leads to a
lower motor neuron disease, manifest with
either of these 4 types:

6. COURSE OF DISEASE & DISTRIBUTION OF
RESIDUAL PARALYSIS
Distribution of Res. Palsy:
• Lower limb 92 %
• Trunk + LL 4 %
• LL + UL 1.33 %
• Bilateral UL 0.67 %
• Trunk+UL+LL 2 %
Disease Course:
1. Acute illness phase (l5 to 10
days), paralysis may occur.
2. Recovery phase (Convalescent
phase), a varying degree of
spontaneous recovery in
muscle power takes.
3. Residual phase, chronic & final
phase of residual paralysis.

7. POST POLIO RESIDUAL PARALYSIS
• Permenant, Asymmetric & Flaccid motor paralysis
With normal sensation.
• Asymmery & incompleteness in same & contralateral limb.
• These characteristics differentiate Poliomyelitis from
other lower motor neuron diseases and upper motor
paralysis as well.

8. DIFFERENTIAL DIAGNOSIS
POLIOMYELITIS Asymmetrical, LMN type, No Sensory loss, improves with time or
static
MYOPATHY Usually Symmetrical, LMND, No Sensory loss, Deteriorates with time.
Follows a specific pattern
SPINA BIFIDA Usually Symmetrical, LMND, Sensory + Motor loss, Deteriorates with
growth
NEUROPATHY Usually Bilateral, Sensory + Motor loss, Glove & Stocking’ pattern.
May Improve with treatment.
CEREBRAL PALSY UMN Type, Spasticity, Hyper reflexia, usually symmetrical, No sensory
loss, May deteriorate with growth

9. EXPLANTION:
Asymmetrical & Incomplete
• The asymmetrical and incomplete
paralysis is explained by the fact
that some muscles have a short
column of cells in the spinal cord
and others have long columns.
• Those with short columns develop
complete paralysis eg: tibialis anterior,
quadriceps femoris, deltoid, opponens pollicis

10. PROGRESSIVE DEFORMITIES
Causes
• Muscle imbalance
• Unrelieved muscle spasm
• Growth
• Gravity and posture
• Contractures
• Bony deformities
Inaccessibility to proper care, led to large number of affectees with moderate to severe
deformities

11. CAUSES OF PROGRESSIVE DEFORMITIES
UNRELIEVED MUSCLE SPASM
• Muscle spasm, a principal manifestation
in its early stage disesae
• Characterized by protective contraction
of the muscles to prevent a potentially
painful movement
GRAVITY AND POSTURE
• Inability of paralysed group of muscles
to maintain maintain posture.
• Inability to counter gravity forces
Palys an important role in
development of postural contractures
and deformity.

12. CAUSES OF PROGRESSIVE DEFORMITIES
Muscle Imbalance & Functional Loss
• Due to Asymmetrical & Flaccid
paralysis
• The strong opponent muscle pull the
joints to their side due to loss of
resistance from paralysed group.
Growth Attenuation
Flaccidity leads to Lacke of healthy
streching stimulus aroung growth plate that
leads to:
• Diminished oppositional & longitudinal
growth of bones… Limb length inequality
• Attenuation of blood vessels, reduced
blood supply
Muscle wasting & weakness
Diminished reflexes due to weakness

13. CAUSES OF PROGRESSIVE
DEFORMITIES
ANGULAR BONE DEFORMITIES
& SUBLUXATIONS
• The persistent Ilio Tibial Band
contractures, over the time
produce double FFD i.e FFD Hip
& Knee and Genu valgus
deformity & subsequent
subluxation at the knee.

14. THE MOST COMMON
MUSCLES PARALYSED
• Most Severely Paralysed
….Tibialis Anterior
• Most common muscle Paralysed
…. Quadriceps femoris
• Most commonly involved muscles
in Upper Limb …… Deltoid and
Opponens
http://sphweb.bumc.bu.edu/otlt/MPH-
Modules/PH/Polio/15.jpg

15. THE MOST COMMON
DEFORMITIES
• Hip: flexion-abduction- external
rotation.
• Knee: flexion & in severe cases
triple deformity comprising of
flexion, posterior sublaxation and
external rotation.
• Foot: Equino varus, Equino valgus
Calcaneo valgus and Calcaneo
varus.
https://www.google.com/url?samarpanphysioclini
c.com

16. WORSE PALSIES
Medcaretips.co
m
www.google.com/url?s
a=i&url=https%3A%2F
%2Flink.springer.com
Gluteal Max Lurch

17. OVER STRETCHED JOINTS & DISLOCATIONS
https://www.google.com/url?sa=i&url=https%3A%2F%2Fwww.slideshare.net

18. SPINAL DEFORMITIES
Weak Abdominal & spinal
Muscles.
• Curve Initialy
Compensatory, Later
Static.
• Curve may become so
sever to endanger
compromised lung &
Heart function

19. UNTREATED
POLIOMYELITIS
DEFORMITIES

20. TREATMENT
Acute & Recovery
Mainstay of Rx.. Physiotherapy and orthotics
i.e
“Preventive Orthopaedic Care”
To assist in the recovery of paralyzed
muscles by remedial exercises
To prevent deformities by the use of
orthotic devices.
Residual stage:
Mainstay of Rx: Surgical
Reconstruction
• to restore balanced
movements
• provide independence

21. PREVENTIVE ORTHOPAEDIC CARE
Emphasise to be given to:
• Slowly progressive non-fatiguing exercise to avoid
overuse weakness
• Pacing of activity, with rest periods to avoid muscle
overuse
• Energy conservation weight loss programs
• lower extremity orthoses to manage generalised Fatigue

22. PREVENTIVE ORTHOPAEDIC CARE
Acute stage & Recovery stage
Objectives:
• Splinting to relieve
pain and spasm and
prevent the
development of
deformities
Postural Positions:
Support the paralyzed legs with
plaster splints or pillows and
sandbags to keep:
• Hip joints in 5° of flexion and
in neutral rotation.
• Knee joint at 5° of flexion and
foot supported in a 90°
position

23. PREVENTIVE ORTHOPAEDIC CARE
RECOVERY STAGE: PHYSIOTHERAPY & ORTHOTICS
• Efficient Physiotherapy
• Exercise therapy
• Hydrotherapy
• Electrical stimulation of
muscles
https://www.google.com/url?s
a=i&url=https%3A%2F%2Fsa
marpanphysioclinic.com

24. RECOVERY STAGE_
Orthotics
to prevent deformities due to muscle
imbalance.
Weakness is only in the dorsiflexors or
plantar flexors of the ankle or invertor or
evertors of the foot
• AFO
When additional paralysis of quads:
• KAFO

25. KAFO /
AK CALIPER
KAFO or Above Knee
calliper is advised:
• When quadriceps
power is 2 or below

26. HKAFO & CALLIPER
To prevent the lurching gluteus
Medius gait, hip abduction power
<2:
• HKFO or long leg Calliper with a
pelvic band & a hip joint

27. FOOT DROP & WRIST DROP SPLINTS

28. WEANING OF ORTHOTICS
In recovery stage
• Gradual weaning off from full appliance once
patient is able to manage shorter appliance &
ultimately able to discard HKAFO with intensive
physiotherapy.

29. GENERAL PRINCIPLES OF Rx: RESIDUAL PARALYSIS
Non operative Rx
1. Strengthening of the
unaffected muscles,
stretching of the shortened
muscles.
2. Range of motion exercises of
joints
3. Appropriate use of orthosis
and splints, gait and walking
aids.
Surgical Rx
1. Early correction of deformities not
amenable to conservative line of
treatment by soft tissue release
procedures.
2. Restoring muscle balance by
tendon transfers.
3. Equalizing the leg length by
modification in the footwear /
lengthening

30. RECONSTRUCTIVE SURGERY
AIM & OBJECTIVES:
• Patients to return home
• Patient be accepted and integrated into their communities

31. MOST IMPORTANT PLANNING FACTORS
The most important factors that need attention before embarking to
reconstructive surgery
• Age of the patient,
• Functional assessment of limbs & spine
• Socioeconomic background.
• Radiographic examinations.
to know the status of the joints (subluxation/dislocation) to ascertain
stability of the joint

32. FUNCTIONAL ASSESMENT OF LIMB & SPINE
• Muscle Charting / power grades
o Lower & Upper limbs muscle power evaluation
o Spine & upper limb Muscle power evaluation
o Abdominal muscles Power evaluation
• Extent of contractures and deformities
• Ambulatory Status & Posture
• LLD - Shortening of the limb

33. MUSCLE POWER GRADING
MEDICAL RESEARCH COUNCIL GRADING
0 Complete paralysis
1 Slight flicker of contraction present
2 Muscle can move a joint only when gravity is
eliminated
3 Muscle can move a joint against gravity
4 Muscle can move a joint against gravity and
resistance
5 Full normal power

34. MSK CLINICAL EXAMINATION

35. EXTENT OF CONTRACTURES
AND DEFORMITIES
• Trendelenburg test
• Thomas test
• Ober / Yount’s test
• Ankle & Foot deformity
evaluation
• Pelvis & spinal curvatures
Slideshare
https://www.slideshare.net/AnisuddinBha
tti1/anis-bhatti-cp-2-clinical-assesment-
2020
Youtube https://youtu.be/IWLnWJ2P-3g
follow

36. TRENDELENBURG
TEST
• Cause: Disruption of the
osseo-muscular mechanism
between pelvis and femur
• Power: Weak abductors
• Fulcrum: acetabulo-
femoral articulation
defect
• Lever Arm: defective
lever system

37. HUGH OWEN
THOMAS TEST
To detect obscure flx
contracture hip

38. OTHER SIGNS FROM THOMAS TEST
• Contralateral hip flexes without knee extension- tight
Iliopsoas
• Hip Abducts during the test- tight Tensor Fascia Lata
• knee extension occurs- tight Rectus Femoris
• Lateral rotation of tibia- tight Biceps Femoris

39. OBER’S TEST
To detect abduction external rotation
contracture, tightness of Ilio tibial tract
• Knee Flex 90 degree
• Contralateral leg flexed & hold to stabilize
pelvis
• Modified test: Knee extension
• Knee touch to other leg Tst Negative
• Knee remains abducted test Positive

40. YOUNT’S TEST
YOUNT’s test
Contracture TFL, FFC Hip+Knee
Leg Abduction relaxes TFL, diminishes
FFC
To detect flexion deformity of left hip
and knee due to a contracted tenor
fascia lata muscle straddling across the
hip and knee joints.
Test:
by abduction the hip to relax tensor
fascia lata, the apparent flexion
deformity of both the hip and knee
diminishes

41. TIBIALIS & PERONEAL MUSCLE POWER TESTS
Peroneal Muscles
Tibialis Anterior
Tibialis Posterior

42. LEG LENGTH INEQUALITY
5 cm block underneath left leg squares pelvis, indicating TRUE difference
When the patient stands erect,
the pelvis is tilted due to
shortening of the left leg.
A block of 5 cm underneath the
left leg squares the pelvis,
indicating true deference in the
length of the legs.

43. LLD: APPARENT & TRUE LENGTHENING
Due to left leg abduction contracture, right leg is measured in same degree of abduction,
lengths are seen to be equal
Leg length inequality may be apparent only
Fixed adduction deformity at the hip causes
shortening, whereas fixed abduction causes
apparent lengthening
This child has a fixed abduction deformity of the
left hip caused by muscle contracture following
poliomyelitis. There is apparent lengthening of
the left leg.
When the right leg is measured in the same
degree of abduction as the left, the leg lengths
are seen to be equal.

44. LLD: BRYANT’S TRIANGLE
Assessment of relation b/w ant. Sup iliac spine & tip of G trochanter
base of triangle is a guideline to N-S angle, normally nearly isosceles triangle
Shortening may occur either above or below
the greater trochanter, i.e. in the femoral neck
and hip joint, or below it.
True Shortening indicated by diminished base of triangle.
Trochanter lies almost vertically below ASIS.
Can be measured by palpation by thumb+finger tips,
compared two sides simultaneously

45. AMBULATORY
STATUS
• Observation of Gait / Gait
Analysis
• Abductor Lurch
• Extensor Lurch
• Hand to Knee Gait
• The Calcaneus Gait
• Foot Drop Gait
• Short Limb Gait
Slide share
https://www.slideshare.net/AnisuddinBhatti1/4
anisbhatti-gait-disorders
youtube
https://youtu.be/96fZsU5SyYY
follow

46. PROGNOSTIC FACTORS
• i. Severity of initial paralysis
• ii. Diffuseness of its regional distribution
• Iii. Expectations & support
• Iv. Resources availibilty
• If total paralysis persists beyond the second month, significant recovery is
unlikely.
• If the initial paralysis is partial, prognosis is better.
• In general, the more extensive the paralysis in the first 10 days of illness
the more severe the ultimate disability.

47. OPTIONS: RECONSTRUCTIVE SURGERY
1. Release of contractures : Fasciotomies &
Capsulotomies
II. Re-establishment of power by:
a) Tendon transfer to prevent deformities
b) Muscle transplantation: to replace a paralyzed muscle
III. Stabilization of a relaxed or flail joint by:
(a) Tenodesis b) Fixation of
ligaments
c) Construction of artificial check ligaments
IV. Correction of Deformities by
a) Osteotomies b) Arthrodesis

48. OPTIONS: RECONSTRUCTIVE SURGERY
V. Limb lengthening (Ilizarov techniques to release
contracture & Limb Lengthening)
VI. Joint replacement surgery
VII. Correction of pelvic obliquity & Spine
deformity & stabilization

49. TENDON TRANSFER
To reestablish muscle power
PRINCIPLES FOR TENDON TRANSFER_1
1. Transferred Muscle should be sufficiently strong to supplement the power of a paralyzed
muscle.
2. Nerve vascular pedicle of transferred muscle should be preserved to avoid iatrogenic
weakness.
3. Transferred tendon should be securely attached (with tension) close to insertion of paralyzed
tendon & ensure that it will hold the part in optimal position.
4. Tendon should be routed in a direct line between its origin and the new insertion, without a
pully.
5. Transferred tendon loses its power by one grade, Recipient muscle should have minimum
power 2

50. TENDON TRANSFER
To reestablish muscle power
PRINCIPLES FOR TENDON TRANSFER_2
6. Transferring an Agonist muscle with same range of excursion shall be better than
antagonist
7. Preserve paratenon of transferred tendon.
8. Avoiding tunnels in fascia or bone or interosseous membrane to avoid adhesions.
9. Preferable to pass tendon beneath the deep fascia through tissues that permit free gliding rather
than subcutaneously
10. Correct contractures & deformities before tendon transfer.

51. MUSCLE TRANSPLANTATION
To replace paralyzed muscle
Muscle transplant procedures include detachment of both origin
and insertion of a muscle along with its neurovascular pedicle.
Not a popular procedure as tendon transfer, because of:
• Difficulty in finding a normal muscle to transplant,
• Donor-side morbidity
• Technical difficulty of the procedure
• Shortage of microvascular surgeons

52. STABILIZATION OF JOINT
Relaxed or flail joint
1. Tenodesis, fixation of ligaments and construction of artificial check
ligaments
OBJECTIVES:
• to restrict the range of movement or
• to eliminate abnormal motion of a joint.
COMPLICATIONS: deformity in the opposite direction tendon or artificial check
ligaments may stretch with time.
• This technique can still be helpful in skeletally immature patients.

53. STABILIZATION OF JOINT
Relaxed or flail joint
ARTHRODESIS
• to correct a deformity,
• reduce the number of joints a weak muscle is
acting across.
• relieve pain in arthritic joints
• Arthrodesis is more popular than tenodesis.
• In skeletally immature patients, extra-articular
arthrodesis & allowing continued growth of the
skeleton.
© 2019 Rajbhandari et al.
Combined Lambrinudi & Triple Fusion
https://www.google.com/Femedicine.medscape.com

54. TIMING / WHEN TO OPERATE
• Wait for atleast 1 ½ yrs after paralytic attack
• Tendon transfer done in skeletally immature
• Combined Tendon transfer Arthrodesis around ankle & foot after 10 yrs of
age
• Extra articular arthrodesis 3-8 yrs
• Triple arthrodesis >10 yrs
• Ankle arthrodesis >18 yrs

55. PRE-OPERATIVE EDUCATION & POST-OP CARE
PreOperative Education
• to teach to localize active contraction in the
muscle to be transferred.
• Continue active exercises postoperatively as
soon as the reaction to surgery and pain
have subsided.
• Muscle re-education delayed, when tendon
transfer is combined with arthrodesis, until
adequate bony union has taken place.
Postoperative Care and Training
• Plaster Support an overcorrected
position continued until the muscle
has assumed full function and there
is no tendency for the deformity to
recur.
• A bivalved cast or an orthosis to hold
the transferred tendon in a relaxed
position.

56. LIMB LENGTHENING
• Limb lengthening occasionally required in unilateral palsied
limb with a good stability & sometimes combined correction
deformity and lengthening.
• Since callus maturation is slow in PPRP, patients tend to re-
develop contractures despite physiotherapy, bracing, or joint
fixation.
• Lengthening along an intramedullary locked nail can
significantly shorten the treatment time with relatively few
complications

57. JOINT REPLACEMENT SURGERY
• Replacement may be indicated in few cases with PPRP
with antigravity quads strength
• Recurrence of instability and progressive functional
deterioration are possible in all knees that have
undergone total knee replacement, but they appear to
occur more commonly in more severely affected knees.

58. ILIZAROV TECHNIQUES:
DEFORMITY CORRECTION & FUSION
Increased Risk with
Conventional approaches:
oneurovascular injury,
osoft-tissue injury,
oshortening of the foot.
• An alternate approach with
Ilizarov method eliminates
above risk
Possible complication
with Ilizarov:
o Pin-tract problems,
o contractures,
o residual deformity,
o recurrence of
deformity

59. ILIZAROV TECHNIQUE
IN FOOT & ANKLE DEFORMITIES
Aims:
1. To achieve comprehensive correction
in minimum time
2. To minimize the energy expenditure
of walking and improve gait
3. To discard the caliper or to minimize
the extent of bracing.
Uses:
• Release contractures
• Correct deformities
• Fusion to stablize joints
• Simultaneous limb lengthening

60. DECISION MAKING: PPD
Patient # xx yrs. FM, PPRP_xx yr. Walks xxxxxxx
AREA DEFORMITY DEFICIT SUBSTITUTE REMARKS
HIP
KNEE
ANKLE & FOOT
LLD
DIAGNOSIS
DEMAND
DECISION

61. POST POLIO SYNDROME
What is postpolio syndrome
Refer: Post polio syndrome. Anisuddin Bhatti. Med. Chanel.
1999(1)

62. POST POLIO SYNDROME
• Development of a new weakness that appears in muscles previously
affected by the polio and/or muscles thought to be unaffected
originally [new weaknes]
• Usualy appear 20- 25 yrs after initial Poliomylitis
• Contracting severe paralytic poliomyelitis at a young age seems to
increase long-term morbidity …. & PPS

63. Rx POST POLIO SYNDROME
Nonsurgical treatments
• PPS often require revision of orthotic devices.
• Common issues include genu recurvatum, knee pain, back pain,
degenerative arthritis, or arthralgia.
• Intravenous immunoglobulin (IVIg), Iamotrigine, muscle-
strengthening exercises and static magnetic fields may be
beneficial. [Cochrane 2015)

64. Rx POST POLIO SYNDROME
Surgical Reconstruction:
• for scoliosis, worsening deformity or fractures may become
necessary to treat.
• Surgery had a high complication rate but also noted significant
improvement in outcome scores [Godzik et al].

65. LECTURE 2
REGIONAL DEFORMITIES &
RECONSTRUCTIVE SURGERY
FRIDAY, 9TH APRIL, 2021
EXPERTS: SAME

66. REFERENCES: ACKNOWLEDGMENT
1. Current Concept Review Polio revisited. Benjamin Josef, Hugh Watts. J. Children Orthop. Oct 2015. doi/10.1007/s/1832-015-
0678-4.
2. Post polio deformities: Mustafa KK, anisuddin Bhatti, et al. JPOA
3. Rehabilitation of PPRP/D. Moeed Kazi, Anisuddin BhattiJ Surg Pak. 1998(3):
4. Post polio syndrome. Anisuddin Bhatti. Med. Chanel. 1999(1)
5. Glenohumeral Arthrodesis in paralytic Shoulder., Anisuddin Bhatti. JCPSP.1999(4)
6. Post Polio Residual Paralysis. By Dr. M. Sai Krishna, Dr.M.Pardhasaradhi. Andhra Medical College. India.
7. Residual Deformities after Polio and Their Treatment. Arun pal Sigh. Bone & Joint. https://business.google.com
8. Tachdjian's Pediatric Orthopaedics: From the Texas Scottish Rite Hospital for Children, 5th Edition. Author: John Herring,
eBook ISBN: 9781455737406, Saunders, 5th December 2013.
9. Textbook of Orthopaedics and Trauma. GS Kulkarni. Jaypee Brothers 2008.
10. Campbell’s operative orthopaedics, 10th edition
11. PHI's "Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors." © 1999

67. FACULTY
DISCUSSION

68. If, sum mun book mun. Let me reply urs un-asked questions
Q & A Participants vs Faculty

70. Thank you