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Objective: Poliomyelitis is a rare neuromuscular disease that can cause hip osteoarthritis on the contralateral side due to an abnormal mechanical weight-bearing state, making some residual poliomyelitis patients candidates for total hip arthroplasty (THA). The aim of this study was to investigate the clinical outcome of THA in the nonparalytic limbs of these patients compared with those of non-poliomyelitis patients., Methods: Patients treated between January 2007 and May 2021 were retrospectively identified in a single center arthroplasty database. Eight residual poliomyelitis cases that met the inclusion criteria were matched to non-poliomyelitis cases in a ratio of 1:2 based on age, sex, body mass index (BMI), age-adjusted Charlson comorbidity index (aCCI), surgeon, and operation date. The hip function, health-related quality of life, radiographic outcomes, and complications were analyzed with unpaired Student's t test, Mann-Whitney test, Fisher's exact test or analysis of covariance (ANCOVA). Survivorship analysis was determined using the Kaplan-Meier estimator analysis and Gehan-Breslow-Wilcoxon test., Results: After a mean follow-up of about 5 years, patients with residual poliomyelitis had worse postoperative mobility outcomes(P < 0.05), but there was no difference in total modified Harris hip score (mHHS) or European quality of life-visual analogue scale (EQ-VAS) between the two groups (P > 0.05). There was no difference in radiographic outcomes or complications between the two groups, and patients had similar postoperative satisfaction (P > 0.05). No readmission or reoperation occurred in the poliomyelitis group (P > 0.05), but the postoperative limb length discrepancy (LLD) in the residual poliomyelitis group was greater than that in the control group (P < 0.05)., Conclusion: Functional outcomes, health-related quality of life improvement were similarly significantly improved in the nonparalytic limb of residual poliomyelitis patients after THA compared with conventional osteoarthritis patients. However, the residual LLD and weak muscle strength of the affected side will still influence mobility, so residual poliomyelitis patients should be fully informed of this outcome before surgery., (© 2023 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Introduction: Total hip arthroplasty for poliomyelitis sequelae could be a technical challenge due to the higher risk for prosthetic dislocation and degenerative changes in the affected limbs. This study aimed to analyse the mid-term outcomes of primary total hip arthroplasty on the affected hip with standard prosthesis., Materials and Methods: From January 2008 to January 2018, 32 patients with poliomyelitis sequelae underwent total hip arthroplasty on the affected hip with standard prosthesis. Clinical and radiographical outcomes, complications, and prosthesis survival rates were evaluated., Results: After a mean follow-up of 7.9 (4.4-13.1) years, the Harris Hip Score, University of California Los Angeles activity level rating, and 12-item Short Form Health Survey Questionnaire scale score significantly improved. The abduction and flexion motions of the hip joint improved dramatically, and the visual analogue scale pain score decreased significantly. The leg length discrepancy was effectively corrected. During the follow-up, one patient experienced prosthetic dislocation, one underwent revision surgery due to acetabular component loosening, two had osteolysis, four had heterotopic ossification, two experienced transient sciatic nerve palsy, and one had intermuscular vein thrombosis. The prosthesis survival rate was 96.9% at 5 years postoperatively. No periprosthetic infection occurred., Conclusion: Total hip arthroplasty with standard prosthesis could be an effective treatment for hip arthropathy on the affected hip of patients with poliomyelitis sequelae, resulting in good clinical outcomes and few complications. Constrained liner and dual mobility articulation are not recommended unless the hip muscle strength of the abductor is < III., (© 2023. The Author(s).)

Background: We compared the clinical and radiographic outcomes of corrective surgery in patients with poliomyelitis-related spinal deformity (PSD) using 3 types of pelvic fixation and investigated the incidence and risk factors for complications., Methods: We reviewed the data from 42 patients with PSD who had undergone spinopelvic reconstruction at a single institution from 2000 to 2016. Of the 42 patients, 15 had been treated with the Galveston technique, 13 with iliac screw fixation, and 14 with S2-alar-iliac (S2AI) screw fixation. Demographic data, radiographic parameters, and complications were analyzed. Health-related quality of life was determined using Scoliosis Research Society (SRS) 22-item questionnaires and the Oswestry Disability Index scores., Results: After surgery, the correction rate of the main curve was 51.7%, 57.8%, and 52.1% in the 3 groups, with significant improvement in regional kyphosis, coronal balance, and pelvic obliquity (PO) (P < 0.05). The correction of PO was similar among the 3 types of pelvic fixation; however, the patients treated with S2AI fixation required significantly less operative time (P < 0.05) and blood loss (P < 0.006). The overall complication rate was 40.5%, with a major complication rate of 23.8%. Age at surgery (P = 0.006) and grade >2 SRS-Schwab osteotomy (P = 0.036) were significant risk factors for complications. Significant improvement was found in the SRS-22 and Oswestry Disability Index scores at the final follow-up examination in the 3 groups., Conclusions: The present study showed satisfactory correction of spinopelvic deformity for 42 patients with PSD. Compared with the Galveston technique and iliac screw fixation, the use of S2AI significantly decrease the operative time and estimated blood loss and obtained similar correction of PO. Patient age at surgery and grade >2 SRS-Schwab osteotomy were significant risk factors for complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aims: The aims of this study were to determine the clinical and radiographic outcomes, implant survivorship, and complications of patients with a history of poliomyelitis undergoing total hip arthroplasty (THA) in affected limbs and unaffected limbs of this same population., Patients and Methods: A retrospective review identified 51 patients (27 male and 24 female, 59 hips) with a mean age of 66 years (38 to 88) and with the history of poliomyelitis who underwent THA for degenerative arthritis between 1970 and 2012. Immigrant status, clinical outcomes, radiographic results, implant survival, and complications were recorded., Results: In all, 32 THAs (63%) were performed on an affected limb, while 27 (37%) were performed on an unaffected limb. The overall ten-year survivorship free from aseptic loosening, any revision, or any reoperation were 91% (95% CI 0.76 to 0.99), 91% (95% CI 0.64 to 0.97) and 87% (95% CI 0.61 to 0.95), respectively. There were no revisions for prosthetic joint infection. There were no significant differences in any of the above parameters if THA was on the affected or unaffected control limbs., Conclusion: Patients with a history of poliomyelitis who undergo THA on the affected or unaffected limbs have similar results with overall survivorship and complication rates to those reported results in patients undergoing THA for osteoarthritis. At long-term follow-up, previous clinical concerns about increased hip instability due to post-polio abductor weakness were not observed. Cite this article: Bone Joint J 2018;100-B:733-9.

The goal of orthopaedic treatment in chronic poliomyelitis is to address the functional impairments resulting from muscular imbalances and bony deformities. The most common knee deformity is a flexion contracture seen in the sagittal plane. Inappropriate or overcorrections of these deformities can have devastating long-term consequences. Revision surgery presents the surgeon with a complex and challenging case with very sparse published literature on revision techniques and osteotomy options. This report describes the successful use of a posterior closing wedge flexion osteotomy with plate fixation to correct a hyperextension deformity caused by a failed or overcorrected extension osteotomy in a 40-year-old man. In this patient, this flexion osteotomy led to complete deformity correction, resolution of symptoms, functional improvement, and return to work without restrictions. (Journal of Surgical Orthopaedic Advances 27(4):329-334, 2018).

Incapacitating articular sequelae in the hip joint have been described for patients with late effects of poliomyelitis. In these patients, total hip arthroplasty (THA) has been associated with a substantial rate of dislocation. This study was conducted to evaluate the long-term clinical and radiologic outcomes of unconstrained THA in this specific group of patients. The study included 6 patients with ipsilateral polio who underwent primary THA between 1985 and 2006. Patients with polio who underwent THA on the nonparalytic limb were excluded. Mean follow-up was 119.5 months (minimum, 84 months). Clinical outcomes were evaluated with the modified Harris Hip Score (mHHS) and the visual analog scale (VAS) pain score. Radiographs were examined to identify the cause of complications and determine the need for revision surgery. All patients showed significantly better functional results when preoperative and postoperative mHHS (67.58 vs 87.33, respectively; P=.002) and VAS pain score (7.66 vs 2, respectively; P=.0003) were compared. Although 2 cases of instability were diagnosed, only 1 patient needed acetabular revision as a result of component malpositioning. None of the patients had component loosening, osteolysis, or infection. Unconstrained THA in the affected limb of patients with poliomyelitis showed favorable long-term clinical results, with improved function and pain relief. Nevertheless, instability may be a more frequent complication in this group of patients compared with the general population. [Orthopedics. 2017; 40(2):e255-e261.]., (Copyright 2016, SLACK Incorporated.)

Background: We report our experience with outcomes of poliomyelitis in the Asian population., Methods: Sixteen total knee replacements in 14 patients with polio-affected knees were followed up for at least 18 months. Follow-up assessment included scoring with the American Knee Society Score (AKSS), Oxford knee score, and Short Form 36 Health Survey scores., Results: The mean AKSS improved from 25.59 preoperatively to 82.94 at 24 months, with greater improvement in the knee score. The mean Oxford knee score improved from 40.82 preoperatively to 20.53 at 24 months. The mean AKSS pain score rose from 2.35 to 47.66 at 24 months. The Short Form 36 Health Survey physical functioning and bodily pain scores improved for all patients., Conclusion: Primary total knee arthroplasty of poliomyelitis-affected limbs shows good outcomes, improving quality of life, and decreasing pain., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Many things cause leg asymmetry and sequelae seen after poliomyelitis infections are still a cause of leg deformities. In this study, lipofilling and liposuction combinations are performed on patients with poliomyelitis sequelae. Volume deficiency is not the only leg problem with polio sequelae, leg length is also a problem. For this reason, the length deficiency must be addressed in order to achieve the desired symmetry. The aim of this study is correcting limb asymmetry by a method addressing both limb length deficiency by heel raise and volume deficiency by injection of fat based on corrected limb length., Patients and Methods: From 2011 through 2013, 10 female patients who had unilateral leg atrophy as a result of paediatric polio infections were included in our study. All of the patients were treated with liposuction and lipofilling combinations. During planning, a ridge was placed under the affected leg in order to equalize the lengths of both legs. The fat injection sites on the affected leg were marked to mimic the unaffected leg., Results: All the patients stated that they were satisfied with the results. Transient hypoesthesia was seen in only one patient, but this was spontaneously resolved six months later., Conclusion: The study results indicate that the asymmetric fat injection procedure can be a good technique to use with patients who have polio sequelae, both with short legs and volume deformities., Level of Evidence: 4., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Complex regional pain syndrome (CRPS) is a painful and disabling syndrome in which the patient presents with neuropathic pain, edema, or vasomotor or pseudomotor abnormalities that are often refractory to treatment. Polio paralysis is caused by the damage or destruction of motor neurons in the spine, which lead to corresponding muscle paralysis. This report is a case report on the application of a pulsed radiofrequency (PRF) current to dorsal root ganglia (DRG) for the treatment of CRPS type 1 in an adolescent patient., Design: Single case report., Setting: Selcuk University Hospital., Patient: A 16-year-old girl who suffered from CRPS type 1 secondary to surgeries for the sequelae of poliomyelitis., Interventions: PRF current application to the lumbar 4 and lumbar 5 DRG., Outcome Measures: Pain reduction., Results: The patient had complete resolution of her symptoms, which was maintained at a 6-month follow-up., Conclusions: This case illustrates that PRF applied to lumbar 4 and lumbar 5 DRG may play a significant role in CRPS type 1 management after the surgical treatment of poliomyelitis sequelae in adolescent patients. Further randomized, controlled studies are needed to support this argument., (Wiley Periodicals, Inc.)

Although poliomyelitis is almost eradicated, as orthopaedic surgeons we occasionally encounter residual deformities in patients who suffered the disease in the past. An equino-varus deformity of the foot is the commonest deformity seen. In this report we present a 53 years old lady who had poliomyelitis as a child and presented with a painful, degenerate ankle and 12 degrees of varus deformity. CT confirmed advanced degenerative changes. The management options included realignment and fusion, supramalleolar ostoetomy or total ankle replacement. In view of the satisfactory active range of motion and advanced OA confirmed by CT scan we considered the option of total ankle replacement. To our knowledge this has never been reported before. At two and half years follow up the patient showed satisfactory functional results (AOFAS score 88/100) and high satisfaction. Plain radiographs revealed a well aligned joint with no evidence of loosening or osteolysis., (Copyright © 2009 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Study Design: This study was a retrospective chart review for patients undergoing operative treatment by Dr. Harvey Cushing at the Johns Hopkins Hospital between 1896 and 1912., Objective: To illustrate the early use of peripheral nerve anastomoses for the treatment of postpoliomyelitis paralysis., Summary of Background Data: At the turn of the 20th century, poliomyelitis was recognized as a disease of neurons; neurological surgeons sought to find a surgical cure for the paralysis occurring after the disease onset. Peripheral nerve anastomoses were an attractive option employed during this time., Methods: Following IRB approval, and through the courtesy of the Alan Mason Chesney Archives, the surgical records of the Johns Hopkins Hospital from 1896 to 1912 were reviewed. A single case of peripheral nerve anastomosis for the treatment of postpoliomyelitis paralysis was selected for further analysis., Results: Cushing performed a multiple peripheral nerve anastomoses in a 3-year-old girl. Although the patient experienced no postoperative complications, there was no improvement in her function at the time of discharge from the hospital, and no long-term follow-up was available., Conclusion: While unsuccessful, Cushing's use of peripheral nerve anastomoses to restore motor function in the pediatric patient described here demonstrates his commitment to pushing the boundaries of neurological surgery at the turn of the 20th century.

Background: Some patients with a functionally impaired lower limb choose to have an elective amputation, whereas others do not. Functional outcomes do not favor either type of treatment, making this a complex decision. The experiences of patients who have chosen elective amputation were analyzed to identify the key factors in this decision-making process., Methods: Patients from a tertiary care amputee clinic who had chosen to undergo elective amputation of a functionally impaired lower limb participated in the present study. A qualitative research design involved the use of one-on-one semi-structured interviews, which were audio recorded and transcribed. Narrative analysis was used by three researchers to provide triangulation. Recurrent key themes and patterns were described. Personal factors in the decision-making process were identified., Results: Factors that had the largest impact on the decision-making process were pain, function, and participation. Body image, self identity, and the opinions of others had little influence. Satisfaction with the surgical outcome was related to how closely the result matched the patient's expectations. Patients who were better informed prior to surgery had more realistic expectations about living with an amputation., Conclusions: The severity of pain and the desire for improved function are strong drivers for patients deciding to undergo elective amputation of a functionally impaired lower extremity. While patients do not want others' opinions, information regarding life with an amputation helps to set realistic expectations regarding outcome.

Leg discrepancy is common after poliomyelitis. Tibial lengthening is an effective way to solve this problem. It is believed lengthening over a tibial intramedullary nail can provide a more comfortable lengthening process than by the conventional technique. However, patients with sequelae of poliomyelitis typically have narrow intramedullary canals allowing limited space for inserting a tibial intramedullary nail and Kirschner wires. To overcome this problem, we tried using humeral nails instead of tibial nails in the lengthening procedure. In this study, we used humeral nails in 20 tibial lengthening procedures and compared the results with another group of patients who were treated with tibial lengthening over tibial intramedullary nails. The mean consolidation index, percentage of increase and external fixation index did not show significant differences between the two groups. However, less blood loss and shorter operating time were noted in the humeral nail group. More patients encountered difficulty with the inserted intramedullary nail in the tibial nail group procedure. The complications did not show a statistically significant difference between the two techniques on follow-up. In conclusion, we found the humeral nail lengthening technique was more suitable in leg discrepancy patients with sequelae of poliomyelitis.

The sequelae of poliomyelitis are the common causes of leg discrepancy. Tibial lengthening is an effective way to solve this problem but it is associated with a high rate of complications. In this study, we combined the use of humeral nail and external fixator in tibial lengthening with the purpose of reducing lengthening complications. Compared with the cases lengthened by a single-plane external fixator alone, this combined strategy was found to be beneficial in maintaining the tibial alignment. Therefore, it can be recommended as a good technique for tibial lengthening in patients with sequelae of poliomyelitis.

This article presents a case of a patient with degenerative hip disease in paralytic dislocation by poliomyelitis. Poliomyelitis is an acute infection disease caused by a group of neurotrophic viruses, which has a special affinity by the anterior horns cells of the spinal cord and for certain motor nuclei of the brain stem. Paralysis is a flaccid type and characteristically paralysis is asymmetrical. It is said that the joints of the affected limb by poliomyelitis are protected from the development of osteoarthritis. Hip dislocation in poliomyelitis is an acquired deformity caused by flaccid paralysis and the resulting muscular imbalance. In young children, when the gluteus maximus and medius muscles are paralyzed and the hip flexors and adductors are of normal strength, eventual luxation of the hip is almost inevitable. Hip osteoarthritis in a limb with poliomyelitis is an unusual entity because these limbs do not support excessive loads. In patients who present with the residual effects of poliomyelitis including degenerative disease and hip dysplastic, surgery is one of the most difficult challenges faced by reconstructive surgeons. In such cases, surgeons should attempt to optimize the component position and choice, surgical approach, and soft tissue tensioning because stability of the prosthesis can be problematic.

Between 1991 and 2001, 17 primary total knee arthroplasties were performed in 15 patients with limbs affected by poliomyelitis. Eight patients had a constrained condylar knee design, 8 a posterior stabilized design, and 1 a hinged design. Mean follow-up was 41.5 months. The mean Knee Society knee score improved from 45 preoperatively to 87 postoperative. Knee stability was obtained in all patients, including 4 patients with less than antigravity quadriceps strength. Radiologic evaluation showed satisfactory alignment with no signs of loosening. Complications included 1 case of deep venous thrombosis and 2 knees that required a manipulation for stiffness. Pain relief, functional improvement, and knee stability can be achieved after constrained total knee arthroplasty in patients with poliomyelitis despite impaired quadriceps strength, and osseous and soft tissue abnormalities.

A defective, normal or enhanced hemostasis has been reported in Duchenne muscular dystrophy (DMD). A retrospective analysis of intra-and postoperative (up to 36 h) estimated blood losses was performed in 156 patients undergoing spinal surgery for: DMD (n = 31), idiopathic scoliosis (IS) (n = 70), poliomyelitis (n = 10), cerebral palsy (CP) (n = 28), spinal muscular atrophy (SMA) (n = 17). Platelet aggregation and bleeding times were also investigated in DMD patients. Immunohistochemistry for dystrophin was performed in platelets, megakaryocytes and blood vessels of normal tissues. DMD patients showed significantly higher intraoperative estimated blood losses (DMD: 3495+/-890 ml; IS: 2269+/-804 ml; poliomyelitis: 2582+/-1252 ml; CP: 2071+/-683 ml; SMA: 2464+/-806 ml; P < 0.05), while postoperative blood losses were similar among different groups. Higher estimated blood losses in DMD were independent of the duration of surgery, body weight, gender, age, vertebral levels or preoperative Cobb angle. DMD children had significantly prolonged bleeding times, but retained normal platelet function. From control samples dystrophin was expressed in vascular smooth muscle cells, but not in platelets. DMD appears to be characterized by immediate bleeding during highly-invasive surgery and increased bleeding time without platelet abnormalities. Considering dystrophin expression in normal vascular smooth muscle cells, these results altogether suggest a selective defect of primary hemostasis in DMD, likely to be due to impaired vessel reactivity.

Objective: To investigate the relationship between the tibia callus diameter ratio (CDR) and prognosis during tibial distraction and the occurrence of late deformity or fracture., Methods: We measured tibial lengthening callus diameter and added up the cases of angular deformity and fracture in 68 cases from January 1996 to December 2001, to calculated callus diameter ratios and compare the relationship between the tibia callus diameter during tibial distraction and the occurrence of late callus angular deformity or fracture., Results: In 23 cases of CDR < 80%, 13 cases had new bone fracture, 21 cases had angular deformity > 5 degree. In 6 cases of 81% < CDR < 85%, there were 4 cases of angular deformity > 5 degree. In the other 39 cases of CDR > 85%, there were no fracture and angular deformity., Conclusion: When the CDR was > 85%, there were no angular deformity and fracture, but when the CDR was < 80%, the complications of fracture and angular deformity occur. CDR is a better alarming index for preventing the complications occurring in tibial lengthening.

A patient with no active elbow flexion because of poliomyelitis-like syndrome underwent functioning free muscle transfer for elbow flexion reconstruction in which a part of the ulnar nerve was used as a donor motor nerve. Fourteen months after surgery the patient had achieved 120 degrees of active elbow flexion against gravity without functional deficit of the donor ulnar nerve. A part of the ulnar nerve can be used as an alternative donor motor nerve for reconstruction of chronic C5-C6 (or C5-7) brachial plexus injury.

Death before maturity is the usual fate of the untreated crawling crippled child in developing countries. Most children with poliomyelitis, however, when upright and walking with supports or following surgery, are accepted by the community, educated by parents and relatives, and employable when they reach maturity. It is more economical to prevent 100 polio cases than to treat one hopelessly crippled child. It is often quicker to straighten 100 deformed limbs by simple subcutaneous surgeries than to treat a single patient with complicated procedures. It costs less for 100 crawling paralyzed children to walk in simple, locally made braces and clogs, than for 1 patient to be mobile in expensive imported appliances and boots. It is essential to educate or rehabilitate patients in addition to making them mobile. The final aim should be patients returned to their own village or town, accepted and integrated into their own communities, and earning their own living among their own friends. This chapter is discussed in further detail in both English and French in my Website, . This site also includes comprehensive information on both the manufacture of the simple appliances described and various surgical details. This information is also available on CD-ROM.

A new technique of shoulder fusion is presented using a posterior approach. After removal of the articular cartilage, a Rush pin is introduced from the spine of the scapula, through the glenoid into the medullary canal of the humerus. This is supplemented by tension-band wiring from the acromion to the neck of the humerus and a muscle pedicle graft attached to the acromion. A shoulder spica is applied for four to six weeks. Four patients with injuries to the upper brachial plexus and 14 with paralysis of the upper arm due to anterior poliomyelitis have been followed for three years. One of the 18 patients developed nonunion; she had removed her own cast prematurely. This method of fixation provides high shear resistance and low axial stiffness without deforming plastically. It does not affect bone growth in young patients, is effective in patients with osteoporosis, and gives a high rate of union.

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.

From 1977 to 1988, 166 patients with median nerve paralysis of varied aetiology underwent opponensplasty. In 50 of these the extensor indicis was used, and in 116 the flexor digitorum superficialis of the ring finger. An analysis of these hands showed that the EI opponensplasty was best in supple hands and FDS opponensplasty was more suitable for less pliable hands. There were fewer complications seen after FDS opponensplasty if the detachment of the donor tendon was done through a volar oblique incision rather than the conventional lateral incision.

Between 1983 and 1990 the authors examined 630 children who had suffered from poliomyelitis, mostly between the age of one and three, at an average age of 9 years 3 months. Half were unable to walk because of residual paralysis. Operation was carried out on 252 children. Most underwent soft tissue release at the hips, knees or tendo Achilles. Triple arthrodesis was carried out on 24. Calipers, produced locally, were used, and trunk bracing was not employed. The average duration of treatment was 3 months, with gradual achievement of correction. Vascular complications occurred in one leg, there were 5 paralyses of the sciatic nerve and 4 fractures of the upper tibia. One hundred children who were not able to walk before operation were reviewed. Sixty five were walking and able to go to school. The best results were achieved before the age of 12.

A patient with recurrent pernio of the right ankle for 21 years after surgery had a leukocytoclastic vasculitis localized in the area. We suggest that the various histologic descriptions of pernio in the literature and in this case represent different levels of severity of the disease.

Extension osteotomy of the proximal tibia was carried out in patients with quadriceps weakness after poliomyelitis in order to obtain a stable knee during the stance phase. Blood flow in the anterior and posterior tibial arteries was measured by Doppler sonography before, during and after operation. It was found that there was a correlation between the degree of extension of the knee after operation and a diminished blood flow. This probably explains some of the neurovascular complications reported in the literature after this procedure. We recommend that blood flow is monitored sonographically in the postoperative phase and that optimum extension is obtained gradually over a period of time in a hinged plaster cast.

Forty-four arthrodeses of the ankle were carried out between 1965 and 1984 in forty-three patients with post-traumatic osteoarthritis or poliomyelitis. Twenty-eight patients, one of whom had a bilateral arthrodesis, were followed up after an average of ten years. Twenty-four were satisfied and the patients with poliomyelitis were better than those with osteoarthritis. The condition of the tarsal joints before the operation influences the result, but the arthrodesis does not cause degenerative changes in these joints.

Biomechanical considerations of limb lengthening procedures are fundamental to their clinical outcome. The purpose of this study was to determine the relationships among force, stiffness, and distracted length in a patient whose leg was lengthened 50 mm with the Ilizarov procedure. A modified Ilizarov apparatus with force transducers in its three columns was surgically applied to the left tibia of an 11-year-old female patient after corticotomy of the proximal metaphysis. The leg was distracted 0.25 mm four times daily for 50 days, commencing six days after surgery. At approximately weekly intervals, forces at rest were recorded before and after distraction. Resting predistractional force magnitudes increased almost linearly during the first three weeks of lengthening, from 49 N to 223 N. The rate of increase slowed markedly thereafter with a further force increase of 11 N in the next three weeks. The stiffness of the limb, derived from the change in force accompanying the 0.25-mm change in length, increased by approximately 3.9%/mm of distracted length with 95% confidence limits of 6.8% and 0.9%. These results show marked differences from the nonlinearly increasing force-displacement relationship during in vitro limb distraction.

The authors compared somatosensory evoked potentials (SSEP) recorded in 16 patients with infantile cerebral paralysis (ICP), 16 patients with parkinsonism (P), 18 patients with torticollis (T), and 15 healthy individuals. Structural changes of SSEP were found in all patients with ICP and in most patients with P and T. The structural changes of SSEP in these patients were mainly associated with the absence or suppression of one or two components of SSEP of a healthy individual. It is assumed that one and the same pathological process underlies these three diseases, but it differs in the degree of manifestation in each one. Two groups of patients with parkinsonism which differed in age were distinguished, which represent, probably, two different pathological processes. Certain normalization of the muscular tonus and inhibition of hyperkinesia in most patients as the result of stereotaxic operation was not attended by normalization of the SSEP structure.

Three different distraction devices were investigated for the treatment of leg-length discrepancy caused by poliomyelitis in 144 patients. The average leg-length discrepancy was 5.2 cm and lengthening obtained 4.8 cm. For tibial leg-lengthening. Anderson's apparatus was used in 50 patients; an external fixator device (developed in Shafa Rehabilitation Hospital) was used in 40 patients; and the Wagner apparatus was used in 51 patients. The incidence of major complications was low in all 3 groups. The overall failure rate was 4%. There were no significant differences in the final results among the 3 groups. However, preference is given to the Wagner device because of its practical advantages.

Experience gained during 2 1/2 years' work as chief government surgeon for Nyanza Province, Kenya, is outlined. The wide variety of surgical conditions encountered and the problems posed in dealing with these by a chronic shortage of essential drugs, instruments, hospital facilities, and fully qualified staff are emphasised. It is suggested that at present the solution must lie in wider instruction in surgical techniques for general duties officers and clinical officers together with energetic community health, family planning, and preventive medicine programmes.

Strength and stability of the shoulder girdle affect function of the entire upper extremity. Isolated muscle weakness may be compensated for by adjacent muscles; however, profound weakness of the deltoid muscle, for example, affects not only placement of the extremity, but also strength and endurance of the forearm and hand. Orthotic substitutes for weakened muscles are not successful. If the muscle weakness is nonprogressive and stable, then surgical treatment will improve glenohumeral stability, increase endurance, and provide more uniform strength for many activities of daily living.

Muscle transplantation in deltoid paralysis in poliomyelitis has been practiced only sporadically and considered ineffective. Trapezius transfer to humeral shaft with fascia lata extension was performed to restore abduction power of the shoulder in 24 patients between 4--10 years of age. It is recommended that the muscle re-education program and bracing be continued for a sufficiently long time so that the muscle may develop enough strength to function. If a forward subluxation of the joint develops and persists, a Nicola procedure is effective. The functional results obtained in a follow-up of 1--3 years has been encouraging in these children, especially when the accessory muscles were not paralyzed.