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Poliomyelitis

Poliomyelitis
Objectives
  1. Describe the pathophysiology of poliomyelitis
  2. Discuss the role of vaccination on the present geographic distribution of poliomyelitis
  3. Describe orthopaedic problems associated with poliomyelitis
  4. Discuss a treatment approach for orthopaedic problems secondary to poliomyelitis
  5. Discuss post-polio syndrome

Discussion
Poliomyelitis continues to be a scourge in many countries, despite the goal of the World Health Organization to have eliminated poliomyelitis by the year 2000. Vaccines are of proven effectiveness, and the disease is now so rare in the United States that many residents will complete training without treating anyone with poliomyelitis. However, especially in countries in wartime situations, large numbers of children remain unvaccinated, and contract the disease. Faulty handling of vaccine can be another cause of children acquiring the disease.

The poliovirus is contracted by oral-fecal contamination, is rapidly absorbed through the gastrointestinal tract, and attacks the anterior motorneruon horn cells of the spinal cord. The lumbar and cervical regions are particularly predispose, with the quadriceps, anterior tibial, medial hamstrings, hip flexors, most commonly affected. After the acute inflammatory response resolves, muscles innervated by anterior horn cells which were damaged but not destroyed will regain strength. The acute phase of the disease is very painful, in unvaccinated infants it usually occurs at about 1 year of age. Immobilization during the acute phase can contribute to contracture.

Recovery of function can occur up to 2 years after infection, although most is complete by 6 months. Physical therapy and orthotic support are mainstays of treatment during this phase.

Chronic residuals are common after poliomyelitis. Muscle imbalance results in contracture and deformity, weakness in loss of function and joint stability. Knee flexion contractures are common. Virtually all joints have been affected. Principles of treatment include using available motors for tendon transfers when feasible, stabilization of flail joints by orthotics, arthrodesis, or osteotomy when function will be improved, and correction of contracture, especially about the knee. Scoliosis occurs in about 1/3 of patients, usually in those with more severe residual effects.

At this time, treatment for poliomyelitis is most needed in countries with fewer resources, so a major emphasis in surgical treatment is avoiding the necessity for expensive equipment. Effective procedures requiring little equipment, such as the O' Donoghue tibial osteotomy, are seldom if ever performed in the United States at present, but are still useful in many settings around the world.

Postpolio syndrome affects older patients, sometimes decades after their acute illness. It is basically a fatigue or overuse syndrome involving muscle groups which have been used to compensate for weakness. Many patients who recovered from their acute and recovery phase with a great deal of will. Unfortunately, this does not always carry over for a lifetime, the consequences of this are well described by Mulder.

The necessary knowledge base for treating poliomyelitis is very much geographically determined at present. However, a basic knowledge of the disease process and treatment are a large part of the historic development of orthopaedic surgery as a specialty, and should be considered a necessary part of the knowledge base of any orthopedic surgeon.

References
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  2. Valente F, Otten M, Balbina F, Van de Weerdt R, Chezzi C, Eriki P, et al. Massive outbreak of poliomyelitis caused by type-3 wild poliovirus in Angola in 1999. Bulletin of the World Health Organization 2000;78(3):339-46.
  3. Anonymous. Outbreak of poliomyelitis--Kunduz, Afghanistan, 1999. MMWR Morbidity & Mortality Weekly Report 1999;48(34):761-2.
  4. El-Said NS. Osteotomy of the tibia for correction of complex deformity. Journal of Bone & Joint Surgery - British Volume 1999;81(5):780-2.
  5. Sutter RW, Chudaiberdiev YK, Vaphakulov SH, Tursunova D, Oblapenko G, Iskandarov TI. A large outbreak of poliomyelitis following temporary cessation of vaccination in Samarkand, Uzbekistan, 1993-1994. Journal of Infectious Diseases 1997;175(Suppl 1):S82-5.
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  7. Mulder DW. Clinical observations on acute poliomyelitis. Annals of the New York Academy of Sciences 1995;753:1-10.
  8. Lee DY, Choi IH, Chung CY, Ahn JH, Steel HH. Triple innominate osteotomy for hip stabilisation and transiliac leg lengthening after poliomyelitis. Journal of Bone & Joint Surgery - British Volume 1993;75(6):858-64.
  9. Lee DY, Choi IH, Chung CY, Shim JS. A modified Wagner technique for femoral lengthening in skeletally mature patients with poliomyelitis. International Orthopaedics 1993;17(3):154-7.
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  11. Helou S, Pilliard D, Taussig G. [Flexion of the knee in poliomyelitis. Results and indications for femoral and tibial osteotomies]. International Orthopaedics 1988;12(2):125-34.
  12. Lau JH, Parker JC, Hsu LC, Leong JC. Paralytic hip instability in poliomyelitis. Journal of Bone & Joint Surgery - British Volume 1986;68(4):528-33.
  13. Kumar K, Kapahtia NK. The pattern of muscle involvement in poliomyelitis of the upper limb. International Orthopaedics 1986;10(1):11-5.
  14. Dao QS, Zhang YF, Yang QM, Guo BF. Free gracilis transfer in the treatment of gluteus medius paralysis after poliomyelitis. Journal of Reconstructive Microsurgery 1985;1(3):241-4.
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  16. Parekh PK. Flexion contractures of the knee following poliomyelitis. International Orthopaedics 1983;7(3):165-72.
  17. Leong JC, Wilding K, Mok CK, Ma A, Chow SP, Yau AC. Surgical treatment of scoliosis following poliomyelitis. A review of one hundred and ten cases. Journal of Bone & Joint Surgery - American Volume 1981;63(5):726-40.
  18. Mitchell GP. Posterior displacement osteotomy of the calcaneus. Journal of Bone & Joint Surgery - British Volume 1977;59(2):233-5.
  19. Mestikawy M, Zeier FG. Tendon transfers for poliomyelitis of the lower limb in Guinean children. Clinical Orthopaedics & Related Research 1971;75:188-94.
  20. Thompson GH. Neuromuscular disorders. In: Morrissy RT, Weinstein SL, editors. Pediatric Orthopaedics. Philadelphia: Lippincott-Raven Press; 1996. p. 537-77.

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