Background

Poliomyelitis is first known to have occurred nearly 6000 years ago, as evidenced by the withered and deformed limbs of certain Egyptian mummies. Polio was epidemic in the United States and the world in the 20th century, especially in the 1940s and 1950s. It was not until the 1950s that a vaccine became available.

Since May 1988, when the World Health Assembly resolved to eradicate poliomyelitis, the estimated global incidence of polio has decreased by more than 99%, and three World Health Organization (WHO) regions (the Americas, the Western Pacific, and Europe) have been certified as polio-free. Since 1994, when the countries of the WHO South-East Asia Region (SEAR) began accelerating polio-eradication activities, substantial progress toward that goal has been made.

Problems remain due to the difficulties involved in extending immunization coverage to some regions (especially Africa), integrating new vaccines into routine immunization schedules, and securing sufficient funding for programs. Injection safety is also a major problem that should be resolved by utilization and proper disposal of single-use autodisabling syringes. The forthcoming availability of new vaccines and the action of the Global Alliance for Vaccines and Immunization hold reasonable hope for the future. Other problems remain, such as new conditions resembling polio paralysis caused by viral infection other than by poliovirus 2 and postpolio syndrome (PPS).

In developed countries, on the other hand, residual poliomyelitis is still occasionally seen in the elderly and immigrants.^{[1, 2, 3, 4, 5, 6, 7, 8]}

Transmission of wild poliovirus (WPV) continues in only three countries: Afghanistran, Pakistan, and Nigeria. WPV type 1 (WPV1) is the only circulating serotype. Starting in 2015, injectable trivalent inactivated poliovirus vaccine (IPV) has been introduced as a part of routine immunization program in place of oral polio vaccine (OPV).^[9]

Pathophysiology

Poliovirus is spread by the fecal-oral route and by aerosol droplets. The poliovirus is shed in oral secretions for several weeks and in the feces for several months. The poliovirus destroys the anterior horn cells in the spinal cord.

Etiology

Acute poliomyelitis is caused by small RNA viruses of the Enterovirus genus of the Picornaviridae family. The single-stranded RNA core is surrounded by a protein capsid without a lipid envelope, which makes poliovirus resistant to lipid solvents and makes it stable at a low pH. Three antigenically distinct strains are known, with type 1 accounting for 85% of cases of paralytic illnesses. Infection with one type does not protect from the other types; however, immunity to each of the three strains is lifelong.

Clinical Presentation

Paralytic disorders. Azar FM, Beaty JH, Canale ST, eds. Campbell’s Operative Orthopaedics. 13th ed. Philadelphia: Elsevier; 2017. Vol 2: 1304-91.
Centers for Disease Control and Prevention (CDC). Progress toward poliomyelitis eradication--India, January 2004-May 2005. MMWR Morb Mortal Wkly Rep. 2005 Jul 8. 54 (26):655-9. [Medline].
Lin KH, Lim YW. Post-poliomyelitis syndrome: case report and review of the literature. Ann Acad Med Singapore. 2005 Aug. 34 (7):447-9. [Medline].
Thompson KM, Duintjer Tebbens RJ. The case for cooperation in managing and maintaining the end of poliomyelitis: stockpile needs and coordinated OPV cessation. Medscape J Med. 2008. 10 (8):190. [Medline].
Jenkins HE, Aylward RB, Gasasira A, Donnelly CA, Abanida EA, Koleosho-Adelekan T, et al. Effectiveness of immunization against paralytic poliomyelitis in Nigeria. N Engl J Med. 2008 Oct 16. 359 (16):1666-74. [Medline].
Centers for Disease Control and Prevention (CDC). Progress toward poliomyelitis eradication--Pakistan and Afghanistan, 2007. MMWR Morb Mortal Wkly Rep. 2008 Mar 28. 57 (12):315-9. [Medline].
Rey M, Girard MP. The global eradication of poliomyelitis: progress and problems. Comp Immunol Microbiol Infect Dis. 2008 Mar. 31 (2-3):317-25. [Medline].
Centers for Disease Control and Prevention (CDC). Progress toward interruption of wild poliovirus transmission - worldwide, 2009. MMWR Morb Mortal Wkly Rep. 2010 May 14. 59 (18):545-50. [Medline].
Khan F, Datta SD, Quddus A, Vertefeuille JF, Burns CC, Jorba J, et al. Progress Toward Polio Eradication - Worldwide, January 2016-March 2018. MMWR Morb Mortal Wkly Rep. 2018 May 11. 67 (18):524-528. [Medline]. [Full Text].
Dutta A. Epidemiology of poliomyelitis--options and update. Vaccine. 2008 Oct 23. 26 (45):5767-73. [Medline].
Koh ES, Williams AJ, Povlsen B. Upper-limb pain in long-term poliomyelitis. QJM. 2002 Jun. 95 (6):389-95. [Medline].
Joseph B, Watts H. Polio revisited: reviving knowledge and skills to meet the challenge of resurgence. J Child Orthop. 2015 Oct. 9 (5):325-38. [Medline]. [Full Text].
Jubelt B. Post-Polio Syndrome. Curr Treat Options Neurol. 2004 Mar. 6 (2):87-93. [Medline].
Frustace SJ. Poliomyelitis: late and unusual sequelae. Am J Phys Med. 1987 Dec. 66 (6):328-37. [Medline].
Gonzalez H, Olsson T, Borg K. Management of postpolio syndrome. Lancet Neurol. 2010 Jun. 9 (6):634-42. [Medline].
Al-Shekhlee A, Katirji B. Electrodiagnostic features of acute paralytic poliomyelitis associated with West Nile virus infection. Muscle Nerve. 2004 Mar. 29 (3):376-80. [Medline].
Lo JK, Robinson LR. Postpolio syndrome and the late effects of poliomyelitis. Part 1. pathogenesis, biomechanical considerations, diagnosis, and investigations. Muscle Nerve. 2018 Dec. 58 (6):751-759. [Medline].
Mohammad AF, Khan KA, Galvin L, Hardiman O, O'Connell PG. High incidence of osteoporosis and fractures in an aging post-polio population. Eur Neurol. 2009. 62 (6):369-74. [Medline].
Wu CH, Huang SW, Lin YN, Wang CY, Liou TH, Chang KH. Adults with polio are at risk of hip fracture from middle age: A nationwide population-based cohort study. Injury. 2019 Mar. 50 (3):738-743. [Medline].
Sheth NP, Keenan MA. Orthopedic surgery considerations in post-polio syndrome. Am J Orthop (Belle Mead NJ). 2007 Jul. 36 (7):348-53. [Medline].
Emara KM, Khames A. Functional outcome after lengthening with and without deformity correction in polio patients. Int Orthop. 2008 Jun. 32 (3):403-7. [Medline].
Kocaoğlu M, Eralp L, Atalar AC, Bilen FE. Correction of complex foot deformities using the Ilizarov external fixator. J Foot Ankle Surg. 2002 Jan-Feb. 41 (1):30-9. [Medline].
Narayan A, Ganesan S, Shenoy UV, Narayanan E. Provocative poliomyelitis causing postpolio residual paralysis among select communities of two remote villages of North Karnataka in India: a community survey. Indian J Public Health. 2011 Oct-Dec. 55 (4):309-12. [Medline].
Watts HG. orthopedic techniques in the management of the residua of paralytic polio. Tech Orthop. 2005. 20 (2):179-89.
Brehm MA, Beelen A, Doorenbosch CA, Harlaar J, Nollet F. Effect of carbon-composite knee-ankle-foot orthoses on walking efficiency and gait in former polio patients. J Rehabil Med. 2007 Oct. 39 (8):651-7. [Medline].
Hachisuka K, Makino K, Wada F, Saeki S, Yoshimoto N, Arai M. Clinical application of carbon fibre reinforced plastic leg orthosis for polio survivors and its advantages and disadvantages. Prosthet Orthot Int. 2006 Aug. 30 (2):129-35. [Medline].
Andrysek J, Redekop S, Matsui NC, Kooy J, Hubbard S. A method to measure the accuracy of loads in knee-ankle-foot orthoses using conventional gait analysis, applied to persons with poliomyelitis. Arch Phys Med Rehabil. 2008 Jul. 89 (7):1372-9. [Medline].
Hwang S, Kang S, Cho K, Kim Y. Biomechanical effect of electromechanical knee-ankle-foot-orthosis on knee joint control in patients with poliomyelitis. Med Biol Eng Comput. 2008 Jun. 46 (6):541-9. [Medline].
Provelengios S, Papavasiliou KA, Kyrkos MJ, Sayegh FE, Kirkos JM, Kapetanos GA. The role of pantalar arthrodesis in the treatment of paralytic foot deformities. Surgical technique. J Bone Joint Surg Am. 2010 Mar. 92 Suppl 1 Pt 1:44-54. [Medline].
Chen D, Chen J, Jiang Y, Liu F. Tibial lengthening over humeral and tibial intramedullary nails in patients with sequelae of poliomyelitis: a comparative study. Int Orthop. 2011 Jun. 35 (6):935-40. [Medline].
Moran MC. Functional loss after total knee arthroplasty for poliomyelitis. Clin Orthop Relat Res. 1996 Feb. (323):243-6. [Medline].
Giori NJ, Lewallen DG. Total knee arthroplasty in limbs affected by poliomyelitis. J Bone Joint Surg Am. 2002 Jul. 84-A (7):1157-61. [Medline].
Prasad A, Donovan R, Ramachandran M, Dawson-Bowling S, Millington S, Bhumbra R, et al. Outcome of total knee arthroplasty in patients with poliomyelitis: A systematic review. EFORT Open Rev. 2018 Jun. 3 (6):358-362. [Medline]. [Full Text].
Rahman J, Hanna SA, Kayani B, Miles J, Pollock RC, Skinner JA, et al. Custom rotating hinge total knee arthroplasty in patients with poliomyelitis affected limbs. Int Orthop. 2015 May. 39 (5):833-8. [Medline].
DeDeugd CM, Perry KI, Trousdale WH, Taunton MJ, Lewallen DG, Abdel MP. Total hip arthroplasty in patients affected by poliomyelitis. Bone Joint J. 2018 Jun 1. 100-B (6):733-739. [Medline].
Sonekatsu M, Sonohata M, Kitajima M, Kawano S, Mawatari M. Total Hip Arthroplasty for Patients with Residual Poliomyelitis at a Mean Eight Years of Follow-up. Acta Med Okayama. 2018 Apr. 72 (2):203-210. [Medline]. [Full Text].
Sobrón FB, Martínez-Ayora Á, Cuervas-Mons M, Quevedo T, Laguna R, Vaquero J. Total Hip Arthroplasty in Patients of Post Polio Residual Paralysis: A Retrospective Case Series. Indian J Orthop. 2017 Jul-Aug. 51 (4):434-439. [Medline]. [Full Text].
Buttaro MA, Slullitel PA, García Mansilla AM, Carlucci S, Comba FM, Zanotti G, et al. Long-term Outcome of Unconstrained Primary Total Hip Arthroplasty in Ipsilateral Residual Poliomyelitis. Orthopedics. 2017 Mar 1. 40 (2):e255-e261. [Medline].
Werthel JD, Schoch B, Sperling JW, Cofield R, Elhassan BT. Shoulder arthroplasty for sequelae of poliomyelitis. J Shoulder Elbow Surg. 2016 May. 25 (5):791-6. [Medline].
Wu CC. Tibial lengthening with ankle arthrodesis in poliomyelitic patients with unilateral dysfunction of both knee extension and ankle dorsiflexion. Acta Orthop Traumatol Turc. 2016. 50 (3):284-90. [Medline]. [Full Text].
Wu CC. Combined tibial lengthening and ankle arthrodesis for patients with certain type of sequelae of poliomyelitis. J Orthop Surg (Hong Kong). 2017 Jan. 25 (1):2309499016684415. [Medline].
Kirienko A, Peccati A, Abdellatif I, Elbatrawy Y, Mostaf ZM, Necci V. Correction of poliomyelitis foot deformities with Ilizarov method. Strategies Trauma Limb Reconstr. 2011 Nov. 6 (3):107-20. [Medline]. [Full Text].
Gupta M, Jain VK, Upadhyaya GK, Arya RK. Comprehensive review of challenges associated with management of lower limb fractures in poliomyelitis patients. J Clin Orthop Trauma. 2016 Oct-Dec. 7 (4):276-281. [Medline]. [Full Text].
Wang WJ, Shi HF, Chen DY, Chen YX, Wang JF, Wang SF, et al. Distal femoral fractures in post-poliomyelitis patients treated with locking compression plates. Orthop Surg. 2013 May. 5 (2):118-23. [Medline].
Checa Betegón P, Valle Cruz J, García Coiradas J, Rodríguez González A, González Pérez A, Torrecilla Cifuentes E, et al. Fractures in patients with poliomyelitis: Past or current challenge?. Injury. 2020 Apr. 51 Suppl 1:S48-S54. [Medline].
Gellman YN, Khoury A, Liebergall M, Mosheiff R, Weil YA. Outcome of femoral fractures in poliomyelitis patients. Int Orthop. 2019 Nov. 43 (11):2607-2612. [Medline].
Li J, Hu Z, Tseng C, Zhao Z, Yuan Y, Zhu Z, et al. Radiographic and Clinical Outcomes of Surgical Correction of Poliomyelitis-Related Spinal Deformities: A Comparison Among Three Types of Pelvic Instrumentations. World Neurosurg. 2019 Feb. 122:e1111-e1119. [Medline].
Lo JK, Robinson LR. Post-polio syndrome and the late effects of poliomyelitis: Part 2. treatment, management, and prognosis. Muscle Nerve. 2018 Dec. 58 (6):760-769. [Medline].
Koopman FS, Beelen A, Gerrits KH, Bleijenberg G, Abma TA, de Visser M, et al. Exercise therapy and cognitive behavioural therapy to improve fatigue, daily activity performance and quality of life in postpoliomyelitis syndrome: the protocol of the FACTS-2-PPS trial. BMC Neurol. 2010 Jan 18. 10:8. [Medline]. [Full Text].
Koopman FS, Beelen A, Gilhus NE, de Visser M, Nollet F. Treatment for postpolio syndrome. Cochrane Database Syst Rev. 2015 May 18. 5:CD007818. [Medline].
Nielsen NM, Rostgaard K, Juel K, Askgaard D, Aaby P. Long-term mortality after poliomyelitis. Epidemiology. 2003 May. 14 (3):355-60. [Medline].
Godzik J, Lenke LG, Holekamp T, Sides B, Kelly MP. Complications and outcomes of complex spine reconstructions in poliomyelitis-associated spinal deformities: a single-institution experience. Spine (Phila Pa 1976). 2014 Jul 1. 39 (15):1211-6. [Medline].

Media Gallery

Typical contractures of postpolio residual paralysis.
Manipulation of deformities of hip.
Genu recurvatum deformity of right knee.
Orthotic treatment for deformities around knee in poliomyelitis. (Click image to enlarge.)
Surgical correction of fixed flexion deformity of knee and hip due to iliotibial band contracture by Soutter and Yount release.
Manipulation of ankle and foot deformities.
Surgical correction of rigid foot deformities by osteotomies and fusion.

of 7

Author

Ashish S Ranade, MBBS, MS, MRCS Consultant Orthopaedic Surgeon, Columbia Asia Hospital and Deenanath Mangeshkar Hospital, India

Ashish S Ranade, MBBS, MS, MRCS is a member of the following medical societies: Paediatric Orthopaedic Society of India

Disclosure: Nothing to disclose.

Coauthor(s)

Mohan V Belthur, MD, FRCSC, FRCS(Tr&Orth) Clinical Assistant Professor, Departments of Child Health, Orthopedics, and Pediatrics, University of Arizona College of Medicine; Staff Pediatric Orthopedic Surgeon, Center for Pediatric Orthopedics, Phoenix Children’s Hospital

Mohan V Belthur, MD, FRCSC, FRCS(Tr&Orth) is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Orthopaedic Surgeons, American College of Surgeons, AO Trauma, Limb Lengthening and Reconstruction Society, Paediatric Orthopaedic Society of India, Pediatric Orthopaedic Society of North America

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 Professor of Orthopedic Surgery, University of Connecticut School of Medicine; Director of Orthopedic Surgery, Connecticut Children’s Medical Center; Vice President of Medical Staff, Connecticut Children's Medical Center

Jeffrey D Thomson, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Pediatric Orthopaedic Society of North America, Scoliosis Research Society

Disclosure: Nothing to disclose.

Additional Contributors

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.

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

Srinivasa Vidyadhara, MBBS, DNB, MS(Orth), DNB(Orth), FNB(SpineSurg), MNAMS is a member of the following medical societies: AO Foundation, Scoliosis Research Society

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Poliomyelitis

Background

Pathophysiology

Etiology

References

Tables

Contributor Information and Disclosures

What would you like to print?