equinovalgus

Dr. Arun Reddy
II Year orthopaedics
KIMS, Narketpally
DEFORMITIES IN LOWER LIMBS
 Foot and ankle deformities
 Knee deformities
 Hip deformities
DEFORMITIES IN UPPER LIMB
 Shoulder deformities
 Elbow deformities
 Forearm deformities
Motor involvement
Lower limbs
Trunk + LL
Trunk + UL + LL
92%
04%
02%
 Lower limbs are the commonest to be involved.
 May be associted with trunk deformities, like
kyphosis ,scoliosis, kyphoscoliosis.
 Mainly deformities are evident in chronic stage of
polio
This is the time for orthopaedic intervention
Most severly paralysed muscle – tibialis anterior
Functional disabilities:
 Loss of power in muscles
 Deformities
 Instability of joints
 Limb length discrepancy
 Flail limbs
Cause of deformity:
 Imbalance of muscle power
 Gravity pull effect
 Bad posture of limb or joint
 Vary according to degree of muscle imbalance.
Rational Management
 Evaluation of patient before surgery
 Prevention as well as correction of contractures and
deformities
 Restoration of muscle balance
 Limb length equality
 Ambulation and rehabilitation
Evaluation of patient before
surgery
 Power of muscle testing (muscle charting)
 Identification of deformities
 Functional assessment
 Family support
Basic techniques of management:
 Soft tissue release
 Tendon lengthening and tendon transfers
 Bone procedures
a) osteotomies
b) arthrodesis
Tendon transfer
 Tendon transfers are indicated when dynamic muscle
imbalance results in a deformity.
 Surgery should be delayed until the maximal return of
the expected muscle strength has been achieved.
Objectives of tendon transfer:
 To provide active motor power
 To eliminate the deforming effect of 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 paralysed tendon.
 A transferred tendon should be retained in its own
sheath or should inserted in the sheath of another
tendon or it should be pass through the subcutaneous
fat.
 Nerve supply and blood supply of transferred muscle
must not be impaired.
Criteria and selecting the tendon
for transfer
 Joint must be in a functional position.
 Contracture must be released before tendon transfer.
 Transferred tendon must be securely attached under
tension slightly greater than normal.
 Agonists muscles are preferable to antagonists.
Arthrodesis:
 Most efficient for permanent stabilization of joint.
 When the control of one or more joints.
 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 ½ yrs after paralytic attack
 Tendon transfer done in skeletally immature
 Extra articular arthrodesis 3-8 yrs
 Tendon transfer around ankle & foot after 10 yrs of age
can be supplemented by arthrodesis to correct the
deformity.
 Triple arthrodesis >10 yrs
 Ankle arthrodesis >18 yrs
Deformities of foot and ankle
 Most dependent parts of the body are subjected to
significant amount of deforming forces.
 Most common defomities include- equinus
- equino varus
- equino valgus
- calcaneous
- cavovarus
- claw toes
- dorsal bunion
PEABODY’S classification
 Limited extensor invertor insufficiency
 Gross extensor invertor insufficiency
 Evertor insufficiency
 Triceps surae insufficiency
Limited extensor invertor
insufficiency
 Tibialis anterior paralysis
- equinus and cavus
- plano valgus
 Transfer of EHL to base of 1st MT
 Talo navicular arthrodesis is combined if valgus
defomity is fixed
Gross extensor invertor
insufficiency
TYPE A
 Paralysis of extensors of toe and tibialis anterior
- equinus
- equino valgus
 Transfer of peroneus longus to dorsum of 1st cunieform
bone.
 Talo navicular arthrodesis is combined if deformity is
fixed.
Gross extensor invertor
insufficiency
Type B:
Paralysis of both tibialis anterior and tibialis
posterior and toe extensors
Transfer of both peroneus to dorsum of foot
Hoke arthrodesis is combined in severe deformity
Evertor insufficiency
 Paralysis of peroneal muscles
- varus foot
 Slight- moderate impairement:
- EHL to base of 5th MT
 Severe: tibialis anterior to cuboid bone
- EHL to base of 5th MT
Triceps surae insufficiecy
Calcaneo cavus :
 >5yrs where power of
gastrosoleus is 0 or grade 1 with
normal tibialis anterior.
 Tibialis anterior muscle alone
or with peroneus longus
transferred to heel.
Triceps surae insufficiecy
If power of gastrosoleus 2 or 3, peroneus longus
tendon is translocated in to a groove on posterior
aspect of calcaneum.
 Calcaneovalgus defomity_ both peroneals
attached to calcaneum.
Claw toe
 Hyperextension of MTP & 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.
Dorsal bunion
 Shaft of 1st MT is dorsiflexed and great toe is plantar
flexed.
 Seen in muscle imbalance, most common is between
anterior tibialis and peroneus longus muscle.
Dorsal bunion
Lapidus operation:
 Remove abnormal bone from MT head
 If anterior tibial is overactive –detach its tendon and
transfer it to 2nd or 3rd cuneiform bone.
 Remove the inferior wedge of bone from 1st metatarso
cuneiform joint.
 Bring the end of the FHL through the tunnel in 1st MT
and anchor to the capsule over dorsum of MTP joint.
Dorsal bunion
Equinus foot
 Anterior tibial muscle
 Peroneal and long toe extensor muscles
 Treatment
a)Serial stretching and cast
b) Achilles tendon lengethening
c)Posterior capsule release
Posterior bone block of cambell
 Lambrinudi operation
 Plantar arthrodesis
Equinovarus defomity
 Tibialis anterior
 Long toe extensors and peroneals muscle
Equinovarus defomity
Treatment:
Young children 4-8yrs
 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
peroneus brevis (if tibialis posterior is weak).
Equinovarus defomity
Children>8yrs:
Triple arthrodesis
Anterior transfer of tibialis
posterior
Modified Jones procedure
Triple arthrodesis
Equinovalgus defomity
 Anterior and posterior muscle weakness with strong
peroneals and gastrocnemius-soleus muscle.
Equinovalgus defomity
Treatment
Skeletally immature:
 Repeated stertching 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.
Cavo varus deformity :

>5and<12yrs dwyers or pandeys
calcaneal T osteotomy with transfer
of tibialis posterior to outer dorsum
of foot.
 Presently by functional distraction
of foot by JESS.
Flail foot : no power to transfer
 plantar arthrodesis a salvage
procedure sacrifies mobility for
stability.
KNEE DEFORMITIES
Flexion contracture of knee :
due to iliotibial band contracture
 15 to 20degree posterior hamstring lengthening and
capsulotomy.
 >70 division of iliotibial band and hamstring tendons
combined with posterior capsulotomy with post-op
double skeletal traction(proximal and distal) to avoid
posterior sublaxation of tibia.
 supra condylar osteotomy as a second stage procedure
Quadriceps paralysis
 Biceps and semitendinous transfer to patella
 For satisfactory results power of not only hamstrings
but also hip flexors ,gluteus maximus,and gastrosoleus
must be fair.
 Normal gastrosoleus function prevent genu
recurvatum.
Genu recurvatum
Is of two types
structural articular and bone
changes due to lack of power in
quadriceps.
II. due to paralysis of hamstrings and
gastrosoleus which causes stretch of
posterior soft tissue.
 prognosis is good in first type.
I.
Genu recurvatum
Treatment:
Irwin osteotomy of proximal tibia followed by
transfer of one or two hamstrings to patella.
II. <30 degrees brace in knee flexion
>30 degrees triple tendonosis ( medial head of
gastrocnemius, semitendinosus and gracilis ).
I.
Flail knee: no power to transfer
knee arthrodesis a salvage procedure.
Hip deformities
 M0st common
defomity is flexion
abduction, external
rotation contracture.
 Iliotibial band
contracture leads to
flexion and genu
valgum of knee with
external torsion of tibia.
Hip deformities
Treatment :
 Mild contracture :
percutaneous soft tissue
release(tenotomy).
Moderate contracture : division of shortened
iliotibial band,fascia lata,sartorius,rectus femoris.
 Severe contracture : excision of iliotibial band and
lateral intermuscular septum above knee (yount’s
procedure).
Upper limb deformities
Shoulder deformities:
Deltoid paralysis-a)complete paralysis
b)incomplete paralysis
Treatment :
 Transfer of insertion of trapezius on to the humeral head
for complete paralysis.
 Transfer of deltoid origin for partial paralysis
Paralysis of subscapularis and infraspinatus
Treatment:
Transfer of latissmus dorsi and teres major and
inserted to the tubercle of greater tuberosity.
Flail shoulder:
Shoulder fusion is beneficial with levator scapuli,
serratus anterior and medial scapular muscles with fair
power.
Serratus anterior useful for rotation of scapula.
Elbow deformity
Elbow flexion deformity is most common in polio due to
paralysis of biceps and brachialis.
Elbow deformity
 Steindler’s flexeroplasty- transfering common origin of
flexor muscles from medial epicondyle to distal
humerus, mostly preferd
(or)
 Anterior transfer of triceps tendon into radial
tuberosity
(or)
 Brooks- seddon transfer of pectoralis major tendon.
Forearm deformities

Pronation contracture
deformity
Total release of interrosseous
membrane and holding
correct position in a cast for
6-8 wks.
 Fixed supination deformity
Rerouting of biceps tendon
(zincolli technique).
THANK
U