A Study of Surgical Intervention in Fractures of Post-polio Residual Paralytic Lower Limb, Challenges Encountered, and Outcome Analysis

Abstract

Introduction:India is now a polio-free nation, but a huge load of ambulatory polio survivors present with challenging deformities and fractures to the present generation of orthopedic surgeons. These fractures are more challenging, because of the paralyzed, contracted shaft of femur fracture tissues, and inappropriate muscle forces, causing deformities. Also hypoplastic, osteoporotic, and less vascularized bone will influence the reduction maneuver, implant selection, fracture healing, and final outcome. We assess the outcome of surgical management of femoral and tibial fractures in the post-polio residual paralytic limb and the challenges encountered. Materials and methods: Out of 22 cases with 23 fractures analyzed, 2 cases were lost to follow-up and hence excluded and the remaining 20 patients were analyzed. Pre-injury deformity, range of movement, mode of ambulation (Vignos scoring), mode of injury, surgical technique, rehabilitation, and outcomes were assessed. Results: Minimum follow-up duration was 30 months; union was achieved by 18-24 weeks. We had one delayed union and one nonunion, which were managed with bone grafting. None of our patients had infection. A total of 16 patients regained their prefracture mobility; 4 patients developed hand to knee gait due to further weakness of the quadriceps muscle. Conclusion:In our series, femur was the most commonly fractured bone among the post-polio residual paralytic limbs. Fractures don't heel as readily as in normal bone. Conservative treatment has guarded prognosis. Decision of surgical treatment will be challenging. Pre-injury state, surgical planning, technique, and implant choice will be key factors with appropriate rehabilitation to have a satisfactory outcome.

Femur Shaft Fracture in a Polio Patient

“…Because of deformed bone, narrow medullary canal, and knee flexion deformity, access to correct entry point and nail insertion would be difficult. In addition, positioning of the patient over a fracture table for nailing and applying traction is difficult because of flexion deformity at knee [ 16 ]. Locked compression plates are one of the gold standard treatment options in distal femur fractures [ 17 ] which was also proved to be true in poliotic distal femur fractures [ 7 ].…”

“…Bony union and good functional outcomes were achieved with only one case showing delayed union [ 7 ]. Raju et al in 2020 in a study of surgical fixations and the encountered challenges seen in the lower limb fractures of polio patients concluded having only one non-union out of 20 patients [ 16 ]. Given poor soft-tissue envelope and hypovascularized bone in a poliotic limb, soft-tissue handling is the key to fracture union.…”