Orthopedics - Oleksa A.P. 2006

Neurogenic deformities of the musculoskeletal system
Orthopedic deformities following poliomyelitis

Poliomyelitis (polyomyelitis acuta anterior, Heine-Medin disease, epidemic infantile paralysis) is an acute childhood infectious disease caused by a neurotropic virus.

The disease was first described by Heine (1840), and its infectious nature was pointed out by Medin (1890). Poliomyelitis is now very rare due to well-established Prevention — active immunization according to Salk.

The poliovirus is excreted in feces and can be found in wastewater. It enters a child's body through the nasopharynx and the Digestive System. According to modern concepts, the virus penetrates the Central Nervous system through axis cylinders, moving along peripheral nerves.

This neurotropic virus affects the Gray matter of the anterior horns of the Spinal Cord (75%), to a lesser extent the Cerebral Cortex AND Hypothalamus, as well as other Organs and systems.

Childhood (two to three years) is a predisposing factor for the disease, and children who have had their Tonsils removed or suffer from adenoids are more frequently affected. During epidemic outbreaks of poliomyelitis, adolescents and sometimes adults fall ill. Vitamin deficiency, prior trauma, or diseases that weaken The Immune System are also considered predisposing factors. Mild cases can occur, in which poliomyelitis may remain undiagnosed.

Clinically, the course of classical poliomyelitis is divided into four phases:

1) the initial or preparalytic phase;

2) the paralytic phase;

3) the recovery phase;

4) the residual phase (or phase of residual phenomena).

The incubation period is characterized by generalized weakness in the child, lethargy, and decreased appetite.

Following the incubation period, the disease begins with a sharp rise in body Temperature, general weakness, and headache — symptoms common to many childhood diseases, which is why it is diagnosed on the first day only during endemic outbreaks. On the second day, nuchal rigidity, drowsiness, and clouding of consciousness may appear. This is the preparalytic phase, which lasts 24-48 hours.

The paralytic phase begins on the 3rd–4th day of the illness with a drop in temperature and the appearance of flaccid paralysis. During different epidemics, the proportion of paralytic forms varies from 5 to 70%. This is explained by the existence of different clinical types of the disease:

— the abortive type, characterized by headaches, nuchal rigidity, nausea, and vomiting, but without paralysis;

— the non-paralytic (neurological) type, featuring manifestations similar to the abortive type, along with paresthesias and anesthesias, though still without paralysis;

— the spinal type, in which paralysis develops alongside the aforementioned manifestations.

The spinal type is observed most frequently and, as already mentioned, accounts for 70% of cases among poliomyelitis patients.

The localization and severity of paralysis depend on the levels and severity of damage to the anterior horns of the spinal cord; therefore, paralysis can involve both the upper and lower extremities, as well as the trunk. A hallmark of poliomyelitis is the patchy (mosaic) distribution of paralysis.

Involvement of the nuclei of the IX, X, and XI pairs of Cranial Nerves results in the bulbar form of poliomyelitis. Its clinical signs include dysarthria, dysphagia, loss of Reflexes, inability to cough up secretions, and respiratory paralysis, which can lead to the patient's death unless timely intubation and Artificial ventilation are provided. The bulbar form of poliomyelitis accounts for an average of 10–15% of cases (Nikiforova E.K., 1968).

The first phase and the beginning of the second phase should be considered the acute period of poliomyelitis. Patients complain of pain upon examination (during passive movements), and the spine becomes fixed; that is, the "spinal sign" (Chumakov I.P., Perisman I.M., Zatsepin T.S., 1953) and the "tripod sign" appear — when sitting in bed, the patient leans on their elbows to unload the spine and keep it fixed.

When paralysis develops, the abdominal and cremasteric reflexes disappear first. Paralysis may develop gradually over one to two weeks, but there are cases where it appears within a few hours.

Sometimes, mild paralysis occurs initially, and after a subsequent temperature spike, it becomes pronounced and more widespread. However, a mosaic pattern of paralysis is typical, meaning that individual Muscles, Muscle groups, or muscles of one or both lower and upper extremities are paralyzed. In severe cases, the trunk muscles are paralyzed.

During the acute period of poliomyelitis, muscle spasm is observed, resulting in contractures in almost 20% of patients, followed by muscle atrophy over time and sometimes degenerative changes with the replacement of fiber bundles by Connective Tissue.

The third phase is characterized by gradual recovery. The patient recovers, and muscle innervation and tissue trophism begin to restore. Some muscles resume function quite quickly because the ganglion Cells of the anterior horns do not die; rather, paralysis occurs due to their edema and inflammatory process.

Clinical practice shows that most muscles recover their function within two to three weeks, but some do so slowly over months or even two to three years. Some muscles remain permanently paralyzed.

At this stage, children still exhibit flaccid paralysis, muscle atrophy, and vasomotor disorders (such as hypothermia, edema, and cyanosis of the extremities).

The prolonged loss of function in specific muscle groups leads to neurogenic and secondary static orthopedic deformities.

Contractures develop As a result of the traction exerted by muscles that have retained or regained their innervation. Limited load-bearing on the extremities and trophic disorders cause delayed bone growth, limb shortening, and progressive deformity. The bones and their cortical layer in the paralyzed limb are thinner.

Pathological changes occur in the Ligamentous apparatus of the joints and in the paralyzed muscles. The muscles are atrophied, flaccid, and stretched. This state of specific muscle groups causes ligamentous laxity, which leads to excessive joint mobility, joint instability, and subluxations, making walking difficult or entirely impossible for patients.

Unilateral paralysis of the trunk muscles leads to Scoliosis. Children are deeply distressed by their physical disability and strive by all means to keep pace with their peers. Despite compensatory mechanisms, their gait remains impaired and results in secondary static deformities. Thus, compensatory adaptations are not always rational and therefore must be corrected by medical professionals in a timely manner.

Treatment. The treatment of poliomyelitis patients and its sequelae involves a comprehensive range of conservative and surgical measures. Conservative treatment is administered continuously from the very first days of the disease. It includes pharmacotherapy, physical therapy, functional treatment, orthopedic management, and sanatorium-resort therapy. In the acute phase of the illness, treatment is symptomatic and aims at preventing complications. Patients are prescribed a rational diet and medications (such as proserine, dibazol, B-group Vitamins, etc.). During this period, children are kept in an infectious disease hospital (for no longer than six weeks).

To prevent The Development of contractures and deformities during this period, corrective plaster splints are applied to the paralyzed extremities, which are removed during Therapeutic Exercises and massage; individually molded plaster beds are also utilized, or the patient is properly positioned on a firm spinal board.

Functional treatment is initiated from the moment paralysis appears and is conducted systematically throughout the entire recovery phase.

Two weeks after the onset of the disease, patients are prescribed a comprehensive physical therapy regimen (Various Forms of heat, moist hot packs, diathermy, Electrophoresis of potassium iodide, novocaine, muscle faradization, etc.), which is administered in alternating courses. The Scope of conservative treatment is determined individually and applied with caution.

It is crucial to prevent the onset of contractures in a timely manner and correct them using plaster casts to avoid The formation of permanent arthrogenic contractures. Paralysis in poliomyelitis tends to regress, and a significant number of muscles recover their function.

Once the child begins to walk, braces, corsets, lower extremity orthoses, and appropriate orthopedic footwear are prescribed to improve limb function and prevent secondary static orthopedic deformities (depending on the localization of the paralyzed and preserved muscle groups). Prosthetics are of great importance during the convalescent period of the disease.

Comprehensive conservative treatment is quite prolonged and requires effort and patience from both parents and medical staff. Children require supervision by a qualified orthopedist and neurologist.

During the recovery period, sanatorium-resort treatment is of great importance. As a rule, following poliomyelitis epidemics, specialized departments staffed with educators are established at health resorts (such as Yevpatoria and Odesa), where children receive general education alongside comprehensive conservative treatment.

In specialized schools, children can acquire a feasible profession that, despite permanent deformities, enables them to engage in socially useful labor.

Surgical treatment for the sequelae of poliomyelitis is performed after the recovery period has ended (4–5 years later), although there is little chance of restoring muscle innervation and function after two years of conservative treatment. F.R. Bogdanov (1957) points out that when treatment is administered within the first year, the percentage of patients with contractures and deformities is 55.3%, whereas within three years it rises to 87%.

The primary goal of surgical treatment is the correction of deformities and the improvement of the static-dynamic Functions of the extremities.

Clinical practice employs various types of reconstructive surgeries, which can be broadly divided into three groups: soft tissue Procedures, bone procedures, and joint procedures. However, in the majority of patients, these must be combined in a staged manner.

One of the main Surgical Methods of treatment is tendon-muscle plastic surgery, which proves to be the most effective.

Synergistic and antagonistic muscles can be utilized for grafting. The transferred muscle must not be kinked, but rather follow a straight course and be placed under slight tension. A healthy muscle can be transferred, and its distal tendon should be secured within a bone tunnel or beneath a bone bridge.

Taking these requirements into account, prior to surgery, it is necessary to examine the patient and evaluate the condition of the limb muscles using the universally accepted five-point scale.

A paralyzed muscle with completely absent function is graded 0 points; if There is a faint Muscle contraction perceptible only by Palpation, it is graded 1 point. A muscle that contracts but is unable to support a limb segment is graded 2 points, whereas a muscle capable of supporting it against gravity alone is graded 3 points.

A muscle is graded 4 points if it is capable of supporting the limb segment even when the examiner applies resistance by pushing against the segment in the opposite direction.

A healthy muscle is graded 5 points when its strength is equal to that of the corresponding muscle in the contralateral limb.

This method of muscle strength assessment is subjective and inaccurate compared to instrumental evaluation methods.

A muscle with a grade of "5" or "4" is suitable for transfer, as clinical observations indicate that a relocated muscle scores 1 point lower. Consequently, it is inadvisable to transfer a muscle graded 3 points.

To determine the sequence and optimal methods of surgical treatment, a thorough study of each patient's posture and gait biomechanics, The Nature of orthopedic deformations, electromyography, tonometry, as well as muscle excitability and strength is required.

The consequences of poliomyelitis most frequently (75%, according to F.R. Bogdanov, 1957) affect the lower extremities, presenting as unevenly distributed paralyses when a single limb is involved, or as asymmetrical ones when both limbs are affected. Total paralysis of both lower extremities is extremely rare (Fig. 366).

To eliminate hip contracture, tenomyotomy, tenomyofasciotomy, osteotomy, Wreden's metaplasia, and arthrodesis are employed.

In paralysis of the gluteus medius and minimus muscles and the absence of hip subluxation, the Gey-Groves operation is performed.

An incision of the Tissues is made along the lateral surface of the thigh from the greater trochanter to the level of the knee joint line. A full-length pedicled flap with its base at the trochanter is excised from the exposed fascia lata. Then, through a second incision in the back near the spinous processes above the wing of the ilium, the sacrospinalis muscle is exposed, and a tunnel connecting both incisions is created using a sponge forceps. The excised fascial flap is pulled through this tunnel and fixed as a taut loop to this muscle while the thigh is extended and abducted.

Instead of creating a window in the sacrospinalis muscle through which Gey-Groves pulls the flap, Chaklin suggests incising the edge of this muscle and suturing the free end of the fascia to it. Following the operation, with the thigh in the same position, a hip spica cast extending down to the opposite leg is applied for a period of one to two months. Afterward, massage and therapeutic exercises are administered. As Chaklin and Spitsyna note, following such operations, the leg no longer gives way, and the gait is improved.

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Fig. 366. Lower paraplegia following poliomyelitis.

Ginzburg, Dedova, and Movshovych introduced The Use of Dacron tapes during surgeries connecting the back or Abdominal muscles to the thigh.

For the same purpose, Lange performed philodesis, which involves passing a bundle of threads through a channel in the greater trochanter and through a soft tissue tunnel, after which this tensioned bundle is sutured to the incised sacrospinalis or latissimus dorsi muscle (Fig. 367).

Fig. 367. Schematic drawing of Lange's operations.

Fig. 368. Flexion-adduction contracture of the hip following poliomyelitis.

Surgeries for flexion, flexion-adduction, or abduction contractures are performed more frequently (Fig. 368).

If the hip flexion contracture is less than 150°, Rrukhman (1964) considers subspinal myotomy to be the optimal Procedure, whereas subtrochanteric femoral osteotomy is required when it is necessary to correct not only the flexion contracture, but also rotational, adduction, or abduction deformities. Flexion-adduction contracture can lead to subluxation or dislocation of the femoral HEAD.

If a 20–30° flexion contracture of the hip joint is caused by a flexion contracture of the knee, an attempt should first be made to correct it conservatively using serial hip spica casts changed every 10–12 days. If the contracture cannot be resolved within one to two months, the patient should then undergo surgery.

Hip flexion contracture is surgically corrected via a Z-shaped incision of the rectus femoris muscle, while the tensor fasciae latae and sartorius muscles are left untouched, as paralysis almost never occurs in them.

Additionally, in cases of flexion-adduction contracture near the pelvis, the tendons of the hip adductor muscles are transected. On the operating table, an attempt is made to maximally abduct the limb and secure it with a hip spica cast. If necessary, the leg can be further abducted progressively after a few days.

If soft tissue surgery fails to eliminate the contracture, subtrochanteric osteotomy must be performed.

Under anesthesia, the subtrochanteric region of the Femur is exposed via a lateral tissue incision. Osteotomy is performed below the lesser trochanter. Following tenotomy of the adductor muscles, the limb is abducted and placed in the correct position. If this is achieved, the bone fragments are fixed with internal hardware, the wound is closed, and a plaster cast is applied. If the leg cannot be properly abducted during surgery, a swallowtail-shaped notch is made in the femoral fragment, it is wedged into place, and metal fixation is omitted so that postoperative abduction can be progressively increased to the required level. After bone fusion, the cast is removed, and physical therapy, massage, and physical modalities are administered.

Paralytic subluxation or dislocation of the hip is very rare (Fig. 369) and significantly impairs the static-dynamic function of the limb. Subluxations and dislocations occur in children who contracted poliomyelitis before the complete Development of the acetabulum, especially its roof. Due to a shallow acetabulum and muscle imbalance that fails to keep the femoral head in place, subluxations and dislocations develop. Dislocations do not occur in adults. As with dysplastic dislocation, children develop anteversion and Coxa Valga, along with deformation of the femoral head.

Due to the ineffectiveness of conservative measures, children must be operated on as early as possible during the subluxation stage, before severe anatomical Changes in the joint occur. Therefore, such children require dynamic monitoring and timely surgical intervention.

These interventions consist of open reduction of the femoral head, sometimes supplemented by acetabular roof plasty.

Wreden's operations—suspending the head by the ligamentum teres to form an acetabular roof—are no longer used; instead, the same procedures as for dysplastic subluxations and dislocations are performed, namely derotational-varus osteotomies with reduction of the femoral head and creation of an acetabular roof. Occasionally, the detached greater trochanter is transposed according to Veau-Lamy into the subtrochanteric region, which successfully maintains the head in its proper position.

Among the numerous surgical options, none can guarantee reliable Stability of the hip joint along with the static and dynamic function of the lower extremity.

As for paralytic Disorders of the knee joint function, flexion contractures of the lower leg caused by paralysis of the quadriceps femoris are the most common. Flexion is brought about by antagonistic muscles that have retained or restored their innervation, as well as by the weight (mass) of the peripheral segment of the limb (passive mid-physiological position of the lower leg) when the patient is lying or sitting. Restoring the Innervation of the quadriceps and its strength is essential for knee stability and active lower leg extension. If conservative treatment fails to yield the desired results, surgical intervention becomes necessary, as such patients are forced to rely on knee-immobilizing braces and are unable to climb stairs.

Fig. 369. Radiograph of a paralytic dislocation of the femur.

If a flexion contracture persists for a long time, it becomes complicated by a posterior subluxation of the lower leg, most frequently accompanied by its valgus deviation and rotation due to the contraction of the tensor fasciae latae and biceps femoris muscles.

It should be noted that even if skeletal traction or serial plaster casts successfully correct the subluxation of the lower leg, maintaining this correction and preventing recurrence is extremely difficult, if not impossible.

In cases of a persistent flexion contracture of the knee without subluxation or dislocation, a tendon transfer procedure is performed—specifically, transferring a lower leg flexor tendon to the Patella to substitute for the paralyzed quadriceps.

Vreden R.R. suggested transferring the biceps femoris muscle to the patella from the lateral side, and the semitendinosus and gracilis muscles from the medial side. The muscles must be mobilized sufficiently to prevent kinking and then routed subcutaneously to the patella, where they are fixed subperiosteally into a notch.

Nove-Josserand and T.S. Zatsepin point out that the iliotibial tract, the muscle of which is spared by poliomyelitis, can be transplanted if necessary (Fig. 370).

M.V. Akatov isolates only the long head of the biceps femoris and transplants it simultaneously with the semitendinosus muscle onto the patella.

E.K. Nikiforova believes that at least two to three flexor muscles, and the fascia lata if necessary, must be transplanted to achieve a favorable surgical outcome.

Fig. 370. Schematic diagram of T.S. Zatsepin's operation for paralytic hip dislocation.

Fig. 371. Schematic diagram of anterior arthrorisis of the knee joint according to Vollenberg.

The semimembranosus muscle should never be transferred, as it reinforces the posterior wall of the Joint Capsule.

For knee contractures exceeding 130°, supra-tubercular osteotomy of the femur is performed, followed by the application of a plaster hip spica cast. Fixation of the fragments after osteotomy using metal hardware (an L-shaped plate) allows for early knee mobilization.

The patient begins walking in a supportive orthopedic brace, and full weight-bearing on the limb is permitted only after radiological confirmation of bone union in the femur. To prevent recurrence of the flexion contracture, patients are advised to use braces for one year following the surgery.

Paralysis of the lower leg flexors and extensors leads to joint laxity, ligamentous insufficiency, and overall knee instability. Patients are forced to use knee-immobilizing braces to prevent knee recurvatum.

Sometimes, an arthrorisis procedure is used According to the method of Vollenberg (Fig. 371) or Tavernier and Guilleminet (Fig. 372), which involves inserting a bone peg through the patella into the tibial tuberosity.

Fig. 372. Schematic diagram of anterior arthrorisis of the knee joint according to Tavernier-Guilleminet.

Following poliomyelitis, paralytic FOOT deformities are the ones most frequently requiring treatment. Depending on which muscles are paralyzed, these include: paralytic calcaneus foot, Clubfoot, equinus foot, valgus foot, and others.

Calcaneus foot develops as a result of paralysis of the gastrocnemius muscle while innervation of the foot extensors remains intact. Although it occurs less frequently (8.1%) than other paralytic foot deformities, it is a severe complication that disrupts gait and, when combined with valgus deviation, contributes to instability in the ankle joint. The patient steps on a vertically dropped heel, leading to the formation of a callus in the area of the calcaneal tuberosity. The arch of the foot is concave with a transverse Skin fold because the plantar muscles are contracted. The plantar aponeurosis also shortens, holding the foot in this position.

Among the various methods for measuring the degree of calcaneal drop (M. Kuslik, Hoff, Putti, etc.), the Olmos method is the simplest, determining this degree from a lateral radiograph of the foot (Fig. 373).

Thus, in calcaneus foot, the angle between the axes of the calcaneus and the talus changes—specifically, it increases—while the angle between the axes of the calcaneus and the first metatarsal bone decreases, which characterizes the height of the foot arch (Hradiusko N.A., 1959).

It is important to note that under METABOLISM/18.html">The Influence of static and dynamic loads, calcaneal foot deformity tends to progress, making timely initiation of treatment crucial.

Although the initial degree of foot deformity is amenable to correction using serial plaster casts, patients must subsequently wear orthopedic shoes to prevent recurrence and progression. However, this is practically unachievable in practice, which is why surgical intervention is necessary even for mild calcaneus foot deformity, as conservative treatment methods are essentially ineffective.

The scope of the surgery depends on the severity of the clinical manifestations of the deformity.

In grade I (according to N.A. Hradiusko), when paresis of the triceps surae muscle is present while the function of other muscles is preserved, the heel can be brought into a normal position and secured by transferring the tendons of the peroneus longus and tibialis posterior muscles into a tunnel created in the calcaneus, accompanied by simultaneous shortening of the Achilles tendon.

If the tibialis posterior muscle is paralyzed, the procedure is limited to The transfer of the peroneus longus muscle. For pes calcaneo-valgus, Kuslik suggested creating an oblique rather than a transverse tunnel in the calcaneus, through which the tendon of the peroneus longus muscle is passed along with simultaneous shortening of the Achilles tendon.

Following surgery, a plaster cast is applied from the tips of the toes to the mid-thigh with the foot in supination and slight flexion. After three to four weeks, the foot is brought into a normal position, and the plaster cast is removed after two to three months. The patient must wear orthopedic shoes for a year.

In grade II calcaneus foot, the heel is generally pronated; therefore, In addition to transferring the tendon of the peroneus longus muscle, a wedge-shaped osteotomy of the calcaneus or subtalar arthrodesis must be performed to restore it to the required position.

Fig. 373. Method for measuring the degree of calcaneal depression according to Olmos.

The angle between the axis of the Tibia and the dorsal surface of the foot should be 127–130°, i.e., in slight equinus, depending on the existing shortening. Following bone surgery, fixation of the foot is required for 2–3 months in children and 4–6 months in adults due to slowed reparative processes.

A wedge-shaped resection of the calcaneus, with the Base of the wedge positioned posteriorly, is performed as an independent procedure in cases of $m. gastrocnemius$ paresis with restored function of the other muscles. When necessary, it is sometimes supplemented by tenoplasty of the Achilles tendon.

If calcaneus foot is accompanied by instability in the ankle joint (pes flacidans) that impairs walking, an arthrodesis is performed. To achieve bony ankylosis after surgery, prolonged fixation (6–8 months) using a walking plaster cast is required. The use of external fixation devices may be complicated by suppuration at the pin or wire insertion sites. Patients must subsequently wear orthopedic shoes for a year.

In all cases of excessive foot excavation, any surgical procedure must be supplemented by a plantar aponeurotomy combined with forceful correction of the foot using the Ilizarov apparatus.