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Poliomyelitis Treatment & Management

  • Author: Srinivasa Vidyadhara, MBBS, MS, DNB; Chief Editor: Jeffrey D Thomson, MD  more...
 
Updated: Feb 03, 2016
 

Approach Considerations

Treatment options for poliomyelitis include the following:

  • Release of joint contractures
  • Reestablishment of muscle balance around the joint to prevent deformities
  • Muscle transplantation to replace a paralyzed muscle
  • Stabilization of a relaxed or flail joint by means of (a) tenodesis, (b) fixation of ligaments, or (c) construction of artificial check ligaments
  • Arthrodesis
  • Limb lengthening [15]
  • Ilizarov techniques [16]
  • Joint replacement surgery

The surgeon managing the residual weakness of poliomyelitis and postpolio syndrome (PPS) must possess an understanding of the pathologic process in poliomyelitis, as well as the variations in the pattern of the disease in different parts of the body. Poliomyelitis causes a lower motor neuron disease unlike other types of neuromuscular paralysis. The neurologic problems and the pattern of paralysis following poliomyelitis are different from upper motor neuron paralysis or, indeed, lower motor neuron paralysis caused by other diseases.

Provocative poliomyelitis is paralysis following the administration of an intramuscular injection in children with acute viremia and indicates that (probably) muscle paralysis has been provoked by intramuscular injections. Unnecessary injection must be avoided in children during acute viremic states, and use of the oral polio vaccine should be encouraged.[17]

Knowledge of pathoanatomy before embarking on surgery is necessary. The mainstay of management remains physiotherapy and orthotic appliances.

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Nonsurgical Therapy

Acute stage

In the acute stage of poliomyelitis, treatment is mainly medical, involving the pediatric physicians. General supportive treatment for the pyrexia and irritation, prevention of secondary respiratory infection, and treatment of any respiratory paralysis are the main aspects of therapy.

The paralyzed legs are supported by plaster splints or pillows and sandbags to keep the hip joints in 5° of flexion and in neutral rotation. The knee joint is held at 5° of flexion, and the foot is supported in a 90° position. Splinting relieves pain and spasm and prevents the development of deformities.

Recovery stage

Treatment in the recovery stage is mainly by the orthopedics department, involving physiotherapy and splinting.

The aims of treatment are as follows:

  • To assist in the recovery of paralyzed muscles by remedial exercises
  • To prevent deformities by the use of orthotic devices

An assessment is first made of the extent of muscle paralysis by charting the power of various groups of muscles and grading them according to the international nomenclature (Medical Research Council grading) as follows:

  • 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

Total functional assessment of the limbs is made before planning treatment. This will include the following:

  • Charting the muscle power grades
  • Extent of contractures and deformities
  • Method of ambulation
  • Shortening of the limb

Efficient phsyiotherapy is the mainstay of the management of this stage of poliomyelitis; exercise therapy, hydrotherapy, and electrical stimulation of muscles are essential in the management of paralytic polio. (See the images below.)

Manipulation of deformities of the hip. Manipulation of deformities of the hip.
Manipulation of ankle and foot deformities. Manipulation of ankle and foot deformities.

Orthotic management

Appropriate orthotic appliances are prescribed to prevent deformities due to muscle imbalance (see the image below).

Orthotic treatment for deformities around the knee Orthotic treatment for deformities around the knee in poliomyelitis. (Click image to enlarge.)

The new international nomenclature for orthotic appliances describes the joints that are stabilized by the appliance (eg, the term "ankle-foot orthosis" replaces the term "below-knee appliances."[18, 19, 20, 21]

When the muscles controlling the hip and knee have normal power and the weakness is only in the dorsiflexors or plantar flexors of the ankle or invertors or evertors of the foot, the patient is prescribed an ankle-foot orthosis (below-knee orthosis or caliper). When quadriceps power is 2 or below, the knee must be stabilized, and hence, a knee-ankle-foot orthosis (full or above-knee caliper) is prescribed. If hip abduction power is poor (ie, <2), the appliance will include a pelvic band with a hip joint (hip-knee-ankle-foot orthosis) to prevent the lurching gluteus medius gait.

In the recovery stage, a child who starts with a full appliance with a pelvic band may be able to gradually manage with a shorter appliance and ultimately be able to discard it when the muscles fully recover because of intensive physiotherapy treatment.

Residual-paralysis stage

The final aim should be for patients to return home and be accepted and integrated into their communities. Because overuse weakness is frequently present in these patients, the role of slowly progressive, nonfatiguing exercise in their rehabilitation is emphasized. New muscle weakness of a mild-to-moderate degree responds well to a nonfatiguing exercise program and pacing of activity, with rest periods to avoid muscle overuse. Generalized fatigue may be treated with energy conservation, weight-loss programs, and lower-extremity orthoses.

An orthosis is a device that externally supports an existing body part, with the objective of supporting, correcting, or compensating for skeletal deformity or weakness. There are currently many various types of orthoses, and the range of devices available to the prescriber continues to increase with the advent of new materials such as carbon fiber, as well as advances in manufacturing techniques.[18, 19]

Orthoses are available for all parts of the body and aid in conservative and definitive treatment for many deformities. The thermoplastic leaf spring ankle-foot orthosis, or drop foot splint, is a good example of an orthosis commonly used. It assists dorsiflexion and uses three-point pressure to stabilize the ankle joint.

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Surgical Therapy

Hip and knee contractures of over 30°

In general, hip and knee contractures exceeding 30° will all require surgical treatment, unless one or both arms are weak in addition to bilateral lower-limb paralysis, making the use of crutches difficult or impossible. In a young child with fairly recent contractures, the most important single factor responsible for the deformity is a tight tensor fasciae latae and iliotibial band. In the older child or adult, however, other ligamentous and tendinous structures play an important part and must be divided as well.

The iliotibial band contracture produces flexion deformities of the hip and knee on the same side. Souttar’s release involves the soft-tissue release on the anterolateral aspect of the hip joint, whereby the tensor fasciae latae and gluteus maximus are released from their origins, as they contribute to the formation of the iliotibial band. Yount’s release involves reexcision of the thickened anterolateral fascia lata so that the knee contracture is better corrected. (See the image below.)

Surgical correction of a fixed flexion deformity o Surgical correction of a fixed flexion deformity of the knee and hip due to iliotibial band contracture by Souttar and Yount's release.

The subcutaneous method of division is very satisfactory for less severe contractures, provided that it is done correctly and as extensively as necessary. Care must be taken to avoid damaging the femoral and popliteal arteries, as well as the common peroneal nerve. The biceps, however, should always be divided under direct vision because of the risk of damaging the adjacent lateral popliteal nerve.

Tendon transfer to reestablish muscle power

In the selection of a tendon to transfer, the muscle should be sufficiently strong to supplement the power of a paralyzed muscle. The nerve and blood supply of the transferred muscle should be preserved in order to avoid iatrogenic weakness.

For efficiency, the transferred tendon should be securely attached (with tension) close to the insertion of a paralyzed tendon and should be routed in a direct line between its origin and the new insertion. The transferred tendon loses its power by one grade.

The transferred tendon should also be retained in its own sheath, avoiding tunnels in fascia or bone or an interosseous membrane to avoid adhesions.

The joint across which the muscle acts must be in a satisfactory position; all contracted structures must be released before the tendon transfer.

When possible, an agonist muscle, with the same range of excursion of its tendon, should be chosen.

Muscle transplantation to replace paralyzed muscle

In muscle transplant procedures, unlike tendon transfer procedures, both the origin and the insertion of a muscle are detached along with its neurovascular pedicle. This procedure is not as popular as tendon transfer, because of the difficulty in finding a normal muscle to transplant, donor-side morbidity, the technical difficulty of the procedure, and the shortage of microvascular surgeons in developing nations, where residual polio is still seen.

Stabilization of relaxed or flail joint

Tenodesis, fixation of ligaments, and construction of artificial check ligaments are used to restrict the range of movement or to eliminate abnormal motion of a joint. With few exceptions, these procedures have been discarded; deformity in the opposite direction may occur, and the tendon or artificial check ligaments may stretch with time. This technique can still be helpful in skeletally immature patients.

Arthrodesis

Arthrodesis is used to correct a deformity, relieve pain in arthritic joints, and reduce the number of joints a weak muscle is acting across. Arthrodesis is more popular than tenodesis. In skeletally immature patients, extra-articular arthrodeses can be performed, allowing continued growth of the skeleton.[22] (See the image below.)

Surgical correction of rigid foot deformities by o Surgical correction of rigid foot deformities by osteotomies and fusion.

Limb lengthening

Often, poliomyelitis is unilateral, causing limb-length inequality, which occasionally requires limb lengthening. In leg lengthening for patients with poliomyelitis, callus maturation is slow and patients tend to develop contractures despite physiotherapy, bracing, or joint fixation. Concomitant and secondary surgery are frequently required to treat associated problems or residual deformities. Lengthening along an intramedullary locked nail can significantly shorten the treatment time with relatively few complications.[15, 23]

Joint replacement surgery

In patients with postpolio residual deformities, joint replacement can be indicated. In one study, pain and knee scores improved following total knee arthroplasty in patients with a history of poliomyelitis and antigravity quadriceps strength, but there was less pain relief in patients with less than antigravity quadriceps strength.[24, 25]

Recurrence of instability and progressive functional deterioration are possible in all knees affected by poliomyelitis that have undergone total knee replacement, but they appear to occur more commonly in more severely affected knees.

Ilizarov techniques

There are many drawbacks to using conventional approaches for the treatment of complex foot deformities, such as the increased risk of neurovascular injury, soft-tissue injury, and shortening of the foot. An alternative approach that can eliminate these problems is the Ilizarov method. Pin-tract problems, contractures, residual deformity, and recurrence of deformity can complicate the Ilizarov method.[16]

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Management of Postpolio Syndrome

Many patients with PPS require revision of orthotic devices such as braces, canes, and crutches or may use new, lighter orthotic devices to treat new symptoms. Common issues include genu recurvatum, knee pain, back pain, degenerative arthritis, or arthralgia. Surgery for scoliosis or fractures may also be necessary to treat new conditions.[13, 26]

Nonsurgical treatments for PPS were examined in a 2015 Cochrane review by Koopman et al.[27] The reviewers concluded that intravenous immunoglobulin (IVIg), Iamotrigine, muscle-strengthening exercises and static magnetic fields may be beneficial but that at present, it is impossible to draw definite conclusions about their effectiveness.

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Complications

Mortality due to postpolio syndrome

With the exception of poliomyelitis patients with respiratory failure, long-term mortality following poliomyelitis appears to increase 20 years after recovery from the acute illness.[28]  Contracting severe paralytic poliomyelitis at a young age seems to increase long-term mortality.

Spinal deformity

Polio and PPS can result in paralytic spinal deformity. Godzik et al found that surgery had a high complication rate but also noted significant improvement in outcome scores.[29]

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Contributor Information and Disclosures
Author

Srinivasa Vidyadhara, MBBS, MS, DNB MS(Ortho), DNB(Ortho), FNB(Spine Surgery), MNAMS, Consultant, Department of Spine Surgery, Manipal Hospital, India

Srinivasa Vidyadhara, MBBS, MS, DNB is a member of the following medical societies: AO Foundation, Scoliosis Research Society

Disclosure: Nothing to disclose.

Coauthor(s)

Mundkur Sudhakar Shetty, MBBS, MS, MCh Senior Professor and Head of Orthopedic Department, Yenapoya Medical College and Hospitals, Mangalore

Mundkur Sudhakar Shetty, MBBS, MS, MCh is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Sharath K Rao, MBBS, MS, D'Ortho Professor and Head of Unit V, Department of Orthopedics, Kasturba Medical College Hospital, India

Sharath K Rao, MBBS, MS, D'Ortho is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Indian Medical Association

Disclosure: Nothing to disclose.

James J Gnanadoss, MBBS MS(Ortho), Professor and Head of Unit, Director, Department of Orthopedics and Spine Surgery, Mahatma Gandhi Medical College Hospital, India

James J Gnanadoss, MBBS is a member of the following medical societies: AO Foundation

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Paul E Di Cesare, MD 

Paul E Di Cesare, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey D Thomson, MD Associate Professor, Department of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Department of Pediatric Orthopedic Surgery, Associate Director of Clinical Affairs for the Department of Surgical Subspecialties, Connecticut Children’s Medical Center; President, Connecticut Children's Specialty Group

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

References
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The typical contractures of post-polio residual paralysis.
Manipulation of deformities of the hip.
Genu recurvatum deformity of the right knee.
Orthotic treatment for deformities around the knee in poliomyelitis. (Click image to enlarge.)
Surgical correction of a fixed flexion deformity of the knee and hip due to iliotibial band contracture by Souttar and Yount's release.
Manipulation of ankle and foot deformities.
Surgical correction of rigid foot deformities by osteotomies and fusion.
 
 
 
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