Aims

Knowledge on total knee arthroplasties (TKAs) in patients with a history of poliomyelitis is limited. This study compared implant survivorship and clinical outcomes among affected and unaffected limbs in patients with sequelae of poliomyelitis undergoing TKAs.

A study of limb shortening after poliomyelitis in 225 children in whom paralysis was confined to one leg shows:

1. The paralysed leg became shorter than its fellow in 219 patients (97 per cent).

2. The discrepancy in leg length only once exceeded three and a half inches.

3. Both the tibia and the femur were shorter than their fellows in 171 out of 184 studied (93 per cent). In only one patient was the femur alone shortened.

4. Three patterns of progress of shortening are described. No evidence was found that reduction of shortening ever occurs.

5. It is impossible accurately to predict shortening. In general, the more severe the paralysis the greater the shortening, but there are notable exceptions.

6. No relationship could be found between the amount of shortening and the incidence of paralysis of any individual muscle-group.

7. There was no significant difference in leg shortening in adult life between those who had developed the disease in the first two years of life and those who had developed it later.

8. A cold blue limb is not more likely to undergo severe shortening.

9. When the paralysis was confined below the knee the greatest shortening seen was one and three-quarter inches. When muscles both above and below the knee were involved severe paralysis may produce shortening up to three and a half inches.

10. Lengthening of a paralysed leg can occur during the first two years after the onset of the disease, but this is always a temporary phase.

11. The cause of leg shortening is unknown. In only two patients in this series was there evidence of premature epiphysial fusion.

1. The results of a three-year study of recovery in 3,033 lower limb muscles and 1,905 upper limb muscles in 142 patients are presented.

2. The rate of recovery of partly paralysed muscles is the same in all muscles and muscle groups in the lower or upper limb. Clinical differences in the ability of individual muscles to recover depend upon the proportions of their number that remain permanently paralysed.

3. The rate of recovery is slowest in adults and most rapid in young children.

4. The amount of further recovery to be expected in a muscle can be predicted from a knowledge of its grade at any time after one month from the onset of the paralysis. Fourteen-fifteenths of the total amount of recovery takes place by the beginning of the twelfth month; with rare exceptions individual muscle recovery is complete after twenty-four months.

5. Ninety per cent of muscles that are still completely paralysed after six months remain permanently paralysed.

6. The prognosis of a completely paralysed muscle is related to the level of paralysis in muscles supplied by the same spinal segments.

7. Deterioration in power in a muscle is uncommon and, when it occurs, is associated with the presence of the strong opposing force of antagonist muscles or of gravity.

8. The application of these findings to the management of cases of paralytic acute anterior poliomyelitis is discussed.

We classified fixed pelvic obliquity in patients after poliomyelitis into two major types according to the level of the pelvis relative to the short leg. Each type was then divided into four subtypes according to the direction and severity of the scoliosis.

In 46 patients with type-I deformity the pelvis was lower and in nine with type II it was higher on the short-leg side. Subtype-A deformity was a straight spine with a compensatory angulation at the lower lumbar level, mainly at L4-L5, subtype B was a mild scoliosis with the convexity to the short-leg side, subtype C was a mild scoliosis with the convexity opposite the short-leg side, and subtype D was a moderate to severe paralytic scoliosis with the convexity to the short-leg side in type I and to the opposite side in type II.

A combination of surgical procedures improved the obliquity in most patients. These included lumbodorsal fasciotomy, abductor fasciotomy and stabilisation of the hip by triple innominate osteotomy with or without transiliac lengthening. In patients with type ID or type IID appropriate spinal fusion was usually necessary.

1. Methods of correcting flexion contractures of the knee following poliomyelitis fail if posterior subluxation of the tibia is allowed to occur.

2. Careful serial manipulations will give straight, congruous joints in younger patients. Posterior capsulotomy does not facilitate correction.

3. Supracondylar femoral osteotomy is indicated in children over fifteen and in adults, although sometimes arthrodesis of the knee is necessary.

1. A series of patients with respiratory paralysis after anterior poliomyelitis is reported.

2. The examination routine is described and its value discussed.

3. Details are given of methods of respiratory rehabilitation and of the various pitfalls encountered, with suggestions for their avoidance.

4. The rates of recovery of vital capacity (and percentage of the expected vital capacity) in adults and children are analysed and compared with the rates given by Sharrard for nonrespiratory individual muscles in treated patients. It is shown that during the first year treated patients tend to recover approximately 3 to 4 per cent of their expected vital capacity per month rather than to regain any definite proportion of their current vital capacity.

1. The distribution of the permanent paresis and paralysis in the muscles of 203 lower limbs affected by poliomyelitis is analysed and related to the destruction of motor nerve cells in the grey matter of the lumbo-sacral cord.

2. The tibialis anterior and tibialis posterior and the long muscles of the toes are more often paralysed than paretic; these muscles are innervated by short motor cell columns. Muscles such as the hip flexors and hip adductors that are more often paretic than paralysed are innervated by long cell columns.

3. Muscles innervated by the upper lumbar spinal segments are more frequently affected than those innervated by the sarcal segments. This agrees with the segmental incidence of motor cell destruction found in poliomyelitic spinal cords.

4. Each muscle or muscle group is associated in paralysis with other specific muscles. For instance, the long toe extensors with the peronei and the calf muscles (triceps surae) with the biceps femoris. Associated muscles are innervated by adjacent motor cell columns. The probability of recovery in a paralysed muscle can be determined by reference to the degree of involvement in its associated muscles.

5. The distribution of the paralysis in an individual lower limb is determined by the site and size of foci of motor cell destruction. The cell loss in certain common patterns of paralysis is described.

6. The practical application of these findings is discussed.

1. Three cases of poliomyelitis complicated by myositis ossificans are reported.

2. A search of the literature has failed to reveal any similar reported cases.

3. The cause is still obscure.

1. The results of posterior spinal fusion for paralytic scoliosis in 118 patients have been reviewed after growth had finished. The criteria for skeletal maturity were both clinical and radiological, with emphasis on ossification of the iliac apophyses.

2. The age of onset of anterior poliomyelitis and the age at which scoliosis was first noticed, as well as the extent of the muscle weakness and the curve patterns, all have a bearing on the severity of the deformity and the indication for operative treatment.

3. The method of treatment including operation is described and the complications detailed. The use of a tibial strut has now been abandoned and Harrington instrumentation has become routine.

4. There were five deaths in the series, three early and two late.

5. The difference in height, changes in respiratory function and eventual functional capacity have been analysed.

1. The treatment of contractures at the hip secondary to poliomyelitis by Soutter's muscle slide or by Yount's fasciotomy gives excellent results. So does high femoral osteotomy, but it is not superior to the other two and should therefore be kept in reserve as a supplementary operation for the completion of correction of a deformity so gross as not to be wholly remediable by division of the soft parts.

2. Subluxation of the hip occurs only if the paralysis comes on during the first eighteen months of life and is a product not of severe paralysis but of unbalanced and often slight weakness of muscles. Correction of the invariable valgus deformity of the femoral neck by osteotomy is followed by relapse; acetabuloplasty too is unreliable. The most promising remedy seems to be some form of acetabuloplasty combined with transplantation of an iliopsoas of adequate strength into the greater trochanter. The indications for arthrodesis are few, but the results of this operation are good.

3. In the few patients with abductor weakness and little else the dipping gait may be abolished by iliopsoas transplantation.

1. A method of correcting poliomyelitic lateral rotation deformity of the thigh by transplant of one or more of the hamstring muscles to the femur is described.

2. The results in seven cases are recorded.

3. Though it is emphasised that this is no more than a preliminary communication and the number of patients so treated is small, the satisfactory results suggest that the procedure is mechanically and physiologically sound.

1. Sixty feet operated upon either by triple or pantalar tarsal fusion for instability after poliomyelitis were re-examined ten to twenty-four years later.

2. After triple fusion with preservation of the ankle joint there was a striking absence of late osteoarthritis of the ankle, and only a low incidence of troublesome lateral instability of the ankle. The results were generally good provided the patient had reasonable power of extension of the knee.

3. Triple arthrodesis for completely flail foot in patients without active muscle control of the knee was often disappointing, so far as the limb as a whole was concerned, because of a persistent flexion deformity of the knee which usually necessitated the wearing of an appliance.

4. The results of pantalar arthrodesis for the flail foot were satisfactory. When this operation was performed (with the foot in slight equinus) in patients who lacked active extension of the knee it helped to stabilise the knee in walking by encouraging hyperextension.

Degenerative problems of the hip in patients with childhood and adult onset neuromuscular disorders can be challenging to treat. Many orthopaedic surgeons are reluctant to recommend total hip replacement (THR) for patients with underlying neuromuscular disorders due to the perceived increased risks of dislocation, implant loosening, and lack of information about the functional outcomes and potential benefits of these procedures in these patients. Modular femoral components and alternative bearings which facilitate the use of large femoral heads, constrained acetabular components and perhaps more importantly, a better understanding about the complications and outcomes of THR in the patient with neuromuscular disorders, make this option viable. This paper will review the current literature and our experience with THR in the more frequently encountered neuromuscular disorders.

Cite this article: Bone Joint J 2014;96-B(11 Suppl A):27–31.

1. A dynamic muscle-tendon transposition is described for supplementing the power of weak lateral abdominal muscles, and the details of the operative technique are given.

2. A clinical assessment of the results in a series of twenty-four patients is given.

3. The indications for the operation in poliomyelitis are suggested.

A carefully planned operation may be expected to check increasing deformity without doing harm, and to make subsequent bony stabilisation easier. In favourable cases it may be possible to restore muscle balance and stability, making further surgery unnecessary. A longer follow-up is necessary to determine to what extent this ideal can be achieved.