Orthopedics - Oleksa A.P. 2006

Neurogenic Deformities of the Musculoskeletal System
Paralytic Valgus Foot

Valgus FOOT develops gradually As a result of paralysis of the tibial Muscles, while the function of the peroneal muscles remains preserved. It can be combined with Flatfoot, equinus, and calcaneal deformities. Paralytic flatfoot with valgus deformity of the foot is the most common presentation (Fig. 376).

The foot rapidly shifts laterally due to the tension of the peroneal muscles and the triceps surae, which also acts as a pronator when the foot deviates sideways. This deformity not only severely impairs gait but also causes pain in the ankle joint.

Although patients are prescribed corrective orthopedic footwear, preventing the progression of the deformity is practically impossible.

In such cases, adolescents and adults require Surgical Treatment—M.I. Kuslik's semilunar metatarsal resection of the foot with transposition of the tendon of the peroneus longus Muscle and the extensor hallucis longus to the medial border of the foot (for supination). Before surgery, the width and shape of the wedge base should be determined from foot radiographs in order to correct flatfoot and abduction of the distal foot.

If only the tibialis anterior muscle remains paralyzed, a tendon transposition of the peroneus longus to the navicular bone is performed by routing it through a tunnel between the BONES OF THE lower leg to its anterior surface. The tendon is fixed subperiosteally into a notch on the navicular bone, maintaining the foot at a 90° angle relative to the lower leg.

If both the anterior and posterior tibial muscles are paralyzed, T.S. Zatsepin transplanted the tendons of both peroneal muscles in a similar manner to the area of the navicular bone. If the peroneal muscles are also impaired in such paralysis, the peroneus longus and the extensor hallucis longus are transferred in the region of the navicular bone.

Following surgery, a circular split plaster cast is applied, which is replaced after suture removal.

Rehabilitation treatment is initiated in three to four weeks.

It should be noted that N. Nefedyeva (1960) points out a recurrence of foot deformity in the vast majority of operated patients. This prompted orthopedists (M.I. Kuslik, 1958; P. Bertrand, 1961; L.Ye. Rukhman, 1961) to employ combined surgeries and prolong comprehensive rehabilitation.

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Fig. 376. Paralytic Flat-valgus foot.

In our clinic (I.L. Zaichenko, O.K. Skorokhod) during the 1950s, Grice's operation was widely used in children and adolescents.

Surgical technique. Under anesthesia, through an dorsolateral incision of the Tissues of the foot, the sinus tarsi is exposed, cleaned of fat, and the ligaments between the talus and calcaneus, as well as between the navicular and talus bones, are sectioned, which allows these bones to be placed in a normal position. Because the sinus tarsi has enlarged, it is wedged with an autologous bone graft to prevent recurrent bone displacement.

Simultaneously, during the operation, the Achilles tendon is lengthened in a standard manner, and transposition of the peroneus longus or brevis together with the extensor hallucis longus to the navicular bone is performed, as described previously. The plaster cast is removed in two to three months, depending on the patient's age.

In children, the surgery is performed in two stages: arthrodesis is performed first, followed by muscle tendon transposition several weeks later.

The Grice operation ensures foot balance, especially when combined with muscle transfers.

In paralytic drop foot, arthrorisis is sometimes used to limit its flexion (Fig. 377). Such Procedures are performed extremely rarely in other joints.

Fig. 377. Posterior arthrorisis of the ankle joint.

Toupet, who proposed this operation in 1920, believed that preserving 5–10° of movement in the ankle joint was sufficient for its function. To limit foot drop (equinus), a posterior arthrorisis is performed; to limit its extension, an anterior arthrorisis is used.

Putti used a periosteal autograft for anterior arthrorisis. Campbell also harvested cancellous bone for transplantation from the calcaneus. Most orthopedists used an autograft harvested from the tibial crest.

If necessary, Boychev's anteroposterior arthrorisis can be performed (Fig. 378) in cases of foot instability (pes flacidans). Through anterior and posterior incisions, he exposed the talus and impacted an autograft through a tunnel within it, projecting by 1 cm on both sides.

To limit supination or pronation of the foot, lateral arthrorisis is performed. To limit supination, Del Torto in 1927 proposed impacting an autograft into the talus beneath the medial malleolus.

To limit paralytic pes plano-valgus, E.K. Nikiforova (1968) suggests performing a lateral arthrorisis by turning down a pedicled bone flap from the lateral malleolus, which abuts against the calcaneus.

Sometimes foot arthrorisis is combined with other procedures, such as triple arthrodesis, when there is lateral deviation of the heel, etc.

Fig. 378. Schematic diagram of arthrorisis of the ankle joint according to B. Boychev.

In flaccid foot (pes flacidans), arthrodesis is performed in the ankle and Chopart joints (quadruple arthrodesis). The most widespread Procedure is the Oppel-Lorthioir operation with metal rod fixation according to Zatsepin, as it yields the most encouraging outcomes.

The surgery involves removing the articular Cartilage from all surfaces of the talus and the mortise of the ankle joint. Afterwards, the talus is returned to its anatomical position and wedged with cancellous bone harvested from the tibial metaphysis or the iliac wing. If available, a preserved cancellous allograft can be used. To achieve complete immobilization of the foot in a slight equinus position (100–110°), osteosynthesis is performed by driving a Bogdanov rod into the sole, passing through the calcaneus and talus into the Tibia.

Postoperatively, a plaster boot is applied for 3–3.5 months. If a transarticular rod has been driven in, the plaster cast is removed after 2–2.5 months.

However, triple arthrodesis of the foot—namely arthrodesis between the talocalcaneal, talonavicular, and calcaneocuboid joints—is most commonly used in clinical practice. This procedure provides reliable foot stabilization and, when necessary, can be combined with muscle transposition as mentioned above.

In paralysis of the toe extensors, Lambrinudi's procedure is performed (Fig. 379), which consists of establishing ankylosis in the subtalar and calcaneocuboid joints with wedge resection of the talar HEAD and the articular surface of the navicular bone. The resected surfaces of these bones are adapted and fixed postoperatively with a plaster boot cast for 3.5–4 months.

Following these surgeries, the patient must wear orthopedic footwear for one year.

Arthrodesis of the knee and hip joints is performed extremely rarely, typically in cases combining paralytic with dysplastic or static deformities.

Since a paralyzed lower limb lags in growth during childhood and becomes shortened, resulting in pelvic tilt and spinal curvature, timely limb-lengthening surgery using the Ilizarov method (osteotomy and hardware distraction) is necessary.

Paralytic deformities of the upper limbs are less common than those of the lower limbs (5.7% according to Abdugafarov, 1961) and present with diverse Clinical Features. Paralysis of the shoulder girdle muscles is the most frequent sequela of poliomyelitis. As a result, the patient cannot abduct, elevate, or retropulse the arm. If Innervation of the pectoralis major muscle is preserved, an adduction contracture of the shoulder develops along with slight medial rotation.

When the biceps brachii is paralyzed, a hanging arm is observed because the patient cannot flex the forearm at the elbow. In triceps brachii paralysis, the patient can flex and extend the arm, as it drops passively under its own weight during extension. If the radial nerve (n.radialis) remains affected, the hand assumes a flexed posture due to paralysis of the m.extensor carpi radialis, and the patient loses The ability to abduct the thumb and extend the fingers. Long-standing paralytic contracture eventually evolves into arthrogenic contracture.

Fig. 379. Schematic diagram of Lambrinudi's procedure.

In paralysis of the muscles innervated by the ulnar nerve, the patient cannot spread the fingers or flex them at the metacarpophalangeal joints. When the median nerve is affected, the hand flattens with semi-flexed fingers, resembling an "ape hand".

In total paralysis of the upper limb, it hangs passively, muscles are severely atrophied, and glenohumeral subluxation occurs due to stretching of the Joint Capsule under the limb's weight.

The treatment of upper limb paralysis shares the same Conservative Methods applied to lower limb muscle paralysis. It is crucial to apply them systematically over a prolonged period, immobilizing the limb in a mid-physiological position to prevent overstretching of the paralyzed muscles, which would otherwise significantly hinder functional recovery.

If the deltoid muscle remains paralyzed, Hildebrand's procedure of transferring and suturing the craniolateral portion of the pectoralis major muscle on a neurovascular pedicle to the deltoid is performed. Postoperatively, the patient regains some ability to abduct and anteverted the arm.

To enable shoulder abduction, Hoffa suggested transplanting a portion of the trapezius muscle onto the posterior half of the deltoid. L.V. Koltsova (1961), while transposing these muscles, simultaneously reinforced the anterior wall of the joint capsule and achieved satisfactory results. However, due to the technical complexity of these procedures, shoulder arthrodesis at 60° of abduction is often performed instead of muscle transposition in deltoid paralysis, which restores two-thirds of the normal shoulder range of motion provided the scapular muscles are intact.

Surgical technique. Under anesthesia, an epaulet incision of the tissues is made, including the deltoid muscle, 2–3 cm distal to its insertion. The exposed joint capsule is incised, and the tendon of the long head of the biceps and the humeral head are dislocated. Articular cartilage is excised from both the humeral head and glenoid surfaces, and they are adapted after joint reduction. With the shoulder set in slight abduction (60°), it is fixed with a rod, Kirschner wires, an L-shaped plate, or bone grafts according to Kuslik. If the biceps tendon had to be incised during surgery, it is sutured. The incised tissues are closed in layers, and a thoracobrachial bandage is applied.

In recent years, hardware methods of rigid shoulder fixation have been adopted, allowing for movement in other JOINTS OF THE arm starting from the postoperative period.

In biceps brachii paralysis, transposition of the lateral part of the triceps brachii is performed by suturing it to the biceps above the cubital fossa. This enables forearm flexion at the elbow joint following 3–4 weeks of limb immobilization.

If the extensors or flexors of the fingers are paralyzed, tendon transfer procedures using muscles that retain their innervation to the tendons of paralyzed muscles are performed. Given the Variability of these paralyses, the surgical plan must be tailored accordingly.

For a drop wrist, the best outcomes are achieved following wrist arthrodesis. Because ankylosis in this joint develops slowly, it is essential during surgery to stabilize it with a Bogdanov rod driven from the third metacarpal bone into the radius, or even to bridge the joint with a bone graft.

Paralytic Scoliosis sometimes develops following poliomyelitis, particularly progressing during rapid growth spurts in children. During conservative management of poliomyelitis sequelae, preventing scoliosis is essential but extremely difficult to achieve, despite The Use of plaster beds, corrective braces, massage, and balneotherapy.

The primary treatment method for paralytic scoliosis is surgical intervention, which involves applying spinal axis-correcting fixators (such as Rodnyansky's device) during the child's growth period, followed by stabilizing osteoplastic procedures after growth is complete.

Rodnyansky's surgical technique. The patient is placed in a prone position with spinal traction. Under general anesthesia, two linear incisions are made along the PROJECTION OF THE spinous processes of the neutral thoracic and lumbar vertebrae. The spinous processes are stripped of muscles using a raspatory in both wounds, and toothed, sharp "combs" are secured to both sides of their base. Then, using a special instrument, muscles are separated from the spinous processes along the convex side of the spine to create a tunnel connecting both wounds. A long, rigid metal plate is passed through this tunnel and connected to the upper "comb". Afterwards, the lower part of the plate is passed through a special metal loop-"earring" attached to the lower "comb".

Thus, the plate, fixed at the top, is able to move within the loop as the child grows, continuously supporting the spinal axis by pressing against the lateral side of the spinous processes. During surgery, It is important to perform Blood transfusions, ensure hemostasis, and drain the wound for 24–48 hours.

Technique of spinodesis (posterior spinal fusion). Under general anesthesia, with the patient in the prone position, a linear Skin incision is made along the projection of the spinous processes in the curved region of the spine. The spinous processes and vertebral arches are subperiosteally exposed, accompanied by decortication of their smooth surfaces.

On the convex side of the spine, an autograft is placed into this bed and secured with cerclage wire, while a strong bone allograft is placed on the concave side. To ensure more stable fixation of the corrected spinal axis, a Kazmin distractor is applied prior to bone grafting, which is subsequently removed once the grafts have fused and remodeled.

It is crucial that the grafts are sufficiently long to span the primary curve and make contact with adjacent neutral vertebrae. Following wound healing, patients are sometimes prescribed a removable brace for the duration of graft consolidation.

The data presented above do not exhaust the information regarding the treatment of orthopedic deformities resulting from poliomyelitis, as the mosaic pattern of paralysis necessitates individualized solutions for each specific patient.