Flexion Osteotomy in Genu Recurvatum Following Post-Polio Syndrome: Use of an Old Technique in a New Condition

Bagherifard, Abolfazle; Rahbar, Mohamad; Shahsavari, Ali; Moaiedfar, Mehdi; Bahrabadi, Mehrdad

doi:10.5812/soj.10530

Volume 4, Issue 2 (5-2017) JROS 2017, 4(2): 0-0 | Back to browse issues page

‎ 10.5812/soj.10530

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Bagherifard A, Rahbar M, Shahsavari A, Moaiedfar M, Bahrabadi M. Flexion Osteotomy in Genu Recurvatum Following Post-Polio Syndrome: Use of an Old Technique in a New Condition. JROS 2017; 4 (2)
URL: http://jros.iums.ac.ir/article-1-205-en.html

Flexion Osteotomy in Genu Recurvatum Following Post-Polio Syndrome: Use of an Old Technique in a New Condition

Abolfazle Bagherifard

¹, Mohamad Rahbar¹

, Ali Shahsavari¹

, Mehdi Moaiedfar¹

, Mehrdad Bahrabadi¹

1- Bone and Joint Reconstruction Research Center, Shafa Orthopedic Hospital, Iran University of Medical Sciences, Tehran, IR Iran

Keywords: Poliomyelitis, Osteotomy, Post-Polio Syndrome, Genu Recurvatum

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Abstract

Case Presentation: A 43-year-old woman with a history of supracondylar extension osteotomy of the left femur at the age of 22 was admitted to our hospital for a flexion contracture of the left knee due to poliomyelitis. She was able to walk without assistance for 20 years after the osteotomy until one year ago, when she started to experience progressive genu recurvatum. In the clinical and laboratory workup, she was diagnosed with PPS. Accordingly, we decided to perform supracondylar flexion osteotomy.

Copyright © 2017, Shafa Orthopedic Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Introduction

Post-polio syndrome (PPS) is the term used for the late manifestations of polio, occurring 30 to 40 years after the acute disease (1). Although PPS has been recognized for more than a century, it is more common today due to the epidemics of polio in previous decades (2). The manifestations of PPS include general, neurological, and musculoskeletal disorders. Fatigue is the most common general manifestation of PPS (3, 4).

Slowly progressive muscle weakness is the most important neurological manifestation, which is reported in most patients, and is more likely to occur in the muscle groups previously affected by poliomyelitis (5). Pain caused by joint instability is the main musculoskeletal problem in PPS (1). Weakness leads to the overstretching of the joints and pain (1), thereby increasing the risk of new deformities.

Genu recurvatum, when mild, confers knee stability due to the self-locking mechanism of the knee. With further hyperextension, the knee collapses posteriorly, as the center of gravity of the body passes anterior to the knee joint. This leads to increasing energy expenditure during walking due to increased vertical movements of the center of gravity of the body (6), as well as progressive genu recurvatum caused by chronic stretching of the posterior soft tissues of the knee (often painful) (7).

2. Case Presentation

The patient was a 43-year-old woman with a history of poliomyelitis at the age of 3. The diagnosis of poliomyelitis was established by careful review of the patient’s medical records. Due to the endemic course of poliomyelitis in Iran in previous decades, diagnosis in our case required great accuracy. The patient had suffered from progressive flexion contracture of the knee, resulting in limping during childhood; accordingly, she had undergone supracondylar extension osteotomy at the age of 22. She experienced functional recovery and could walk without a brace or crutches for 20 years after the surgery.

At the age of 42, the patient experienced progressive genu recurvatum, leading to her disability and loss of walking potential. She did not report any history of trauma and diabetes, collagen vascular disease, and polyneuropathy were ruled out through clinical and laboratory workup. In addition, there was no evidence of compression neuropathy due to the use of crutches. Neurological examination was performed by 2 neurologists in our institution. In addition, motor strength was assessed based on the scale developed by the medical research council (8). PPS was diagnosed, based on the criteria proposed by Jubelt and updated by the post-polio task force (1).

For the correction of genu recurvatum, we decided to perform supracondylar flexion osteotomy; this decision was made by a team of knee surgeons in our institute. After the induction of anesthesia, the passive range of motions in the knee was assessed (50°-0°-140°). During the operation, the genu recurvatum was corrected from 50º to 5º of hyperextension through opening up the osteotomy site. After this correction, we used a bone block allograft and a locking plate to fill and fix the osteotomy site, respectively.

After surgery, the patient used a knee immobilizer for 3 weeks and was non-weight-bearing for 3 months. In the final follow-up, she was able to walk without crutches or brace. The present study was approved by the ethics board of our center, and a written consent was obtained from the patient to publish the results of surgery.

3. Discussion

PPS may be a result of recovery from a polio attack. After the attack, nerve fibers sprout to innervate more muscle fibers than normal. These hyperfunctional motor neurons cannot meet the metabolic requirements of the sprouts, and consequently, slow deterioration of the terminals may gradually occur (9, 10). Also, weakness appears after an adequate number of nerve terminals are destroyed.

Genu recurvatum is a manifestation of PPS (7) and can be managed by conservative or surgical measures. The nonsurgical method of treatment is based on the use of a hinged leg orthosis, which can prevent the progression of genu recurvatum. This type of orthosis has many disadvantages, including its bulky design and feeling of discomfort when seated. It is also difficult to wear by patients with muscular weakness (11, 12).

Arthrodesis is a surgical method for the treatment of genu recurvatum. Also, anterior bone block technique is a method of treatment in paralytic genu recurvatum (13-15), which was first described by Campbell in 1918 (16). The graft has the same relationship with the tibia as the olecranon process with the ulna; the surgery is literally a conversion of the knee joint into an elbow (15). In this technique, the articular cartilage and anterior cortex are removed from the proximal half of the patella.

A transverse trough is made in the tibial plateau between the menisci, and the patella is placed within so that the articular surface of the patella faces the articular surface of the femoral condyles. The position of the patella is adjusted in a way that 5º hyperextension is allowed at the end of the procedure. The patella is fixed to the tibia by 2 crossed screws, and a long leg cast is used for 2 months (7).

Disadvantages of patella bone block include the possibility of patella fracture and recurrence of previous knee hyperextension due to the failure of bone block (7). It also disturbs the normal anatomy of the knee joint, making future reconstructions difficult. Two months of wearing a long leg cast, as recommended by the authors in bone block surgery (7), is another drawback of this technique, as it may further deteriorate the already weak muscles.

Supracondylar femoral flexion osteotomy is another method of treatment for genu recurvatum, which is commonly performed in primary poliomyelitis in the adolescent population with good results (17). However, to the best of our knowledge, this method has not been used in PPS in adult populations. In this technique, an open-wedge osteotomy is made in the supracondylar area of the femur, and an allograft is used to fill the resulting gap. Also, a plate is used to secure the osteotomy site at the end of surgery.

One of the advantages of supracondylar femoral flexion osteotomy is that there is no need for a long leg cast after surgery and rehabilitation can start very soon. This is very important considering the neuromuscular problems of these patients. In fact, use of a long leg cast in the healing process is associated with the severe loss of power in the already weak muscles. In addition, osteotomy restores the normal anatomy of the knee joint, preserves the bone stock, and relives stretching of the posterior soft tissue structures. This technique becomes even more valuable when the patient has a history of supracondylar extension osteotomy for the correction of flexion contracture, as in the present case.

Footnote

References

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Subject: Knee surgery
Received: 2019/09/9 | Accepted: 2017/05/15 | Published: 2017/05/15

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