polio,PPRP

1. PPRP OF FOOT AND ANKLE
by dr. giridhar boyapati
pg
dept. of orthopaedics

2. Foot and Ankle are the most dependent parts of the
body subjected to significant amount of deforming
forces
M.c deformities includes-
1. Claw toes
2. Cavus deformity and claw toes
3. Dorsal bunion
4. Talipes Equinus
5. Talipes Equino Varus
6. Talipes Equino Valgus
7. Talipes Calcaneus

3. PEABODY’S CLASSIFCATION
1. Limited extensor invertor insufficiency
2. Gross extensor invertor insufficiency
3. Evertor insufficiency
4. Triceps surae insufficiency

4. LIMITED EXTENSOR INVERTOR INSUFFICIENCY
- Tibialis Anterior muscle paralysis produces slowly
progressive deformity
1. Equinus
2. Cavus
3. Varying degree of plano values
Muscle power is redistributed by transferring the EHL tendon
to base of 1st metatarsal + plantar fasciotomy.

5. GROSS EXTENSOR INVERTOR INSUFFICIENCY
TYPE A
-Paralysis of Extensors of toes and Tibialis Anterior in the
presence of relatively normal Tibialis Posterior muscle. Produces
-Equinus
-Equino Valgus
• Transfer of Peroneus Longus to dorsum of 1st
cunieform bone.
• Talo-navicular arthrodesis is combined if deformity is
fixed.

6. TYPE B
Paralysis of both Tibialis Anterior & Tibialis
Posterior and toe extensors
Transfer of both Peroneals to dorsum of foot.
Hoke arthrodesis is combined in severe deformity

7. EVERTOR INSUFFICIENCY
Paralysis of Peroneal muscles producing
- Varus foot
• Deformity produce Slight to moderate impairment:
Transfer of EHL to base of 5th MT.
• Severe:- Tibialis anterior to cuboid
EHL to base of 5th MT

8. TRICEPS SURAE INSUFFICIENCY
Calcaneo-Varus deformity- Tibialis posterior,FHL are
transferred.
Calcaneo-Valgus deformity- both peroneals attached
to calcaneum
Calcaneo-Cavus in which both invertors and
overtures are strong. transfer of peroneals,tibialis
posterior tendons to calcaneus.

9. when to operate
1. wait for atleast 1 1/2 years after paralytic attack.
2. tendon transfers done in skeletally immature
3. Extra articular arthrodesis 3-8 years
4. Tendon transfer around ankle and foot after 10yr of age can be
supplimented by arthrodesis to correct the deformity
5. Triple arthrodesis >10-11 years
6. Ankle arthrodesis >18 years

10. PRE-OPERATIVE CONSIDERATIONS
AGE:
bony procedures after skeletal maturity.
tendon transfers better after 10 yrs
TYPE OF DEFORMITY:
static deformity require bony procedures
dynamic deformity require both tendon transfer and bony
procedures.

11. CLAW TOE
Hyperextension of MTP
and flexion of IP
Seen when long toe
extensors are used to
substitute dorsiflexion
of ankle

12. Treatment: For lateral 4 toes :
Procedure 1: division of extensor tendon by z-plasty
incision,dorsal capsulotomy of MTP joint.
Procedure 2:
Girdlestone- Taylor tendon transfor
Dorsolateral incision. Divide the long flexor tendon and suture
them to lateral side of proximal phalanx to extensor expansion.

14. Dickson and Diveley procedure
For insufficiency of the planter flexors of the ankle
-EHL tendon is divided proximal to IP joint.
-Proximal end is attached to taut flexor tendons.
-Distal part of extensor tendon sutured to soft tissues on
dorsum of proximal phalanx to assist maintain opposition of
raw surfaces of IP joint.
-Arthrodesis of interphalangeal joint.

16. Modified Jone’s procedure
Division of EHL proximal to IP joint
Proximal slip fixed to neck of 1st metatarsal
Distal slip fixed to soft tissues
Arthrodesis of IP joint by K wire fixation

18. CAVUS AND CLAW FOOT

19. Primary deformity is forefoot Equinus resulting in clawing of
toes.
Clawing disappear if mild cavus of short duration is
corrected.
In severe cavus large callosities or even ulcerations may
develop beneath the metatarsal heads.
Clawing may lead to dorsal dislocation of MTP joint
In severe cases all plantar stuctures may contract

20. MILD CAVUS WITH CLAWING
Conservative : metatarsal bar on the shoe, metatarsal pads.
Surgical measures:
Division PL tendon and imbricate to PB assuming that the
deformity is due to imbalance of Tibialis Anterior and PL.
Arthrodesis of all IP joints assuming clawing is caused by
disturbance of function of intrinsic muscles of foot.

21. MODERATE
young children : Steindler’s fasciotomy
older children : Dwyers calcaneal osteotomy.
Japas V osteotomy

22. SEVERE DEFORMITY
Steindler’s fasciotomy
stripping of fat and muscles from both superficial and
deep surfaces.
Transverse division of fascia close to calcanea
attachment.
Release of long plantar ligament extending from
calcaneus to cuboid.

24. Cole’s Anterior wedge osteotomy
indicated in cavus without various or calcaneus or
gross muscle imbalance.
Advantage : preserves mid tarsal and sub-talar joints
Disadvantage: shortens the dorm of foot.
Osteotomy of the navicular and cuboid and defect is closed by
elevating the forefoot.

26. Japas V osteotomy.
apex of v is proximal at highest point of cavus
lateral limb extends to cuboid
medial limb through intermediate cuneiform to medial border
of foot.
no bone is excised
proximal border of distal fragment is pressed plantarwards,
while metatarsal heads are elevated correcting the
deformity.

28. Hibb’s operation
EDL tendons is divided and proximal end is inserted to 3rd
cuneiform.
EHL tendon is divided and fixed to neck of 1st metatarsal.
Interphalangeal joint arthrodesis.

30. DORSAL BUNION
Shaft of 1st MT is
dorsiflexed and graet toe
is plantar flexed resulting
in prominent head of 1st
metatarsal. If severe may
result in subluxation of
MTP joint.

31. Pathogenesis :
Imbalance between TA and PL : normally TA raises the 1st
cuneiform and 1st MT and PL opposes this action. Unopposed
action of TA causes this deformity. Thus before the transfer of
PL, the effect of its loss on 1st MT must be considered. Every
transfer of PL should be accompanied with midline transfer of
TA to 3rd cuneform.
Weakness of Anterior and lateral compartment muscles.
unopposed action of posterior compartment muscles causes
excessive plantar flexion of great toe.

32. LAPIDUS TECHNIQUE
Wedge of bone is removed from metatarso-cuneform and
naviculo-cuneform joint.
If TA is overactive, transfer it to 2nd or 3rd cuneiform.
FHL is detached and brought dorsally and attached to 1st
metatarsal, converting it into a plantar flexor of metatarsal
rather than great toe.
Subcutaneous plantar tenotomy
capsulotomy of 1st MTP joint.

34. HAMMOND TECHNIQUE
any deforming tendon except
the FHL is divided and
transferred to dorsum of foot to
correct MT displacement.
Fusion of joint.

35. TALIPES EQUINUS

36. Commonest deformity
Planter flexors are stronger than dorsiflexors and tight TA.
If lateral imbalance is there Equinuovarus or Equinovalgus may
result.
MANAGEMENT :
1. No intervention : mild equinus
2 Conservative management: exercises, serial casting, orthosis
and molded shoe wear.
3 Surgical management:
a) soft tissue procedures
b) bony procedures

37. Contraindications for surgery in equinous foot.
In children : children who will never walk due to week
arms.
minimal deformity and child is managing well
Infection
In adults : Equinus foot is stabilizing n unstable foot.
Equinus foot is compensating for shortening.

38. Lengthening of Tendo-achillis
1. Percutaneous Tenotomy
2. Z- plasty
Tendon transfer
1. Anterior transfer of TP
2. Anterior transfer of PL, PB

39. Cambells Posterior bone block operation
Usually combined with triple arthrodesis to correct lateral
instability.
A mechanical bone block is constituted on posterior aspect
of talus and superior aspect of calcaneus in such a manner
that it will impinge on posterior lip of distal tibia and prevent
plantar flexion.
Dorsiflexion is preserved.
Complications: Recurrence of deformity, degenerative
arthritis, flattening of talus, ankylosis of ankle

41. LAMBRINUDI PROCEDURE
Talonavicular and Calcaneocuboid joint arthrodesis
Wedge of bone removed from distal and plantar parts of talus, so
that talus remains in equines but rest of foot is brought to
corrected position.
Complications : recurrent of deformity
residual deformity
degenerative tarsal athritis
pseudoarthrosis of talonavicular joint
flattening of talus

43. PANTALAR ARTHRODESIS
Surgical fusion of Tibio-talar, subtalar, talo-
navicular,calcaneo-cuboid joints.
Indications:
Calcaneous or Equinus deformity combined with lateral
instability of foot and whose leg muscles are strong enough
to control the foot and ankle.
Reccurance of deformity after post. bone block or
lambrinudis
Foot deformity with unstable knee due to quadriceps palsy.

44. Contraindications:
If full extension of knee is not possible
Insufficient hamstrings or triceps to prevent genu
recurvatum
When there is Equinus / Calcaneous deformity in addition to
unstable knee, whether pantalar arthrodesis will effectively
stabilize the knee may be determined before surgery by
applying a short leg walking cast.

46. TALIPES EQUINO VARUS

47. Deformity: equinus at ankle, inversion of heel at mid tarsal
joint, adduction of forefoot. Cavus and clawing may develop
in long standing cases.
Weak peroneals
Weak Tibialis anterior
Normal triceps surae
Equinus thus produced increases mechanical advantage of
TP which in turn encourages the fixation of hind foot
inversion and forefoot adduction and supination.Cavus and
clawing develop when toe extensors help to dorsiflex the
ankle.

48. Treatment:
Young children4-8 yrs:
Double bar brace with ankle stop
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)
Anterior transfer of medial half of tendo-calcaneous(
Caldwell)

49. Children >8yrs:
Steindlers fasciotomy
Triple arthrodesis
Anterior transfer of tibialis posterior
Modified jones procedure
When TP is weak TA is transferred laterally to midline.

50. TALIPES EQUINO VALGUS
Tibialis anterior and Tibialis
posterior are weak and
Peroneal longus and brevis
are strong and the triceps sure
is strong and contracted.
Triceps surae pulls the foot
into equinus and the
Peroneals into valgus.

51. Treatment: skeletally immature
Double bar brace with ankle stop
Shoe with an arch support and medial heel wedge
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
Modified Jones

52. TALIPES CAVOVARUS
Seen due to imbalance of
extrinsic muscles or by
unopposed short toe
flexors and other
intrinsic muscle

53. 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
EHL is transferred to the neck of neck of 1st MT

54. TALIPES CALCANEUS
Due to unopposed action of
dorsiflexors

55. Plantar fasciotomy ,intrinsic muscle release before
tendon transfer
Transfer of TP and PL and FHL tendons to calcaneous.
Green and Grice
Posterior transfer of TA ( Peabody )
When EHL and EDL strength is good, both tibials and
peroneials can be transferred posteriorly and EHL, EDL
transferred proximally to act as dorsiflexors of ankle.
If adequate muscles are not available, Tenodesis of
Tendoachiles to fibula is done ( Westin )

56. 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.
Radical plantar release
Tenodesis
In older pt mid foot wedge resection may be
required
ANKLE ARTHRODESIS

57. Indian Journal of Orthopaedics ,
October 2004, Vol 38: Number 4. p 226-232

61. THANK U