Polio and orthopaedics – A surgeon’s look back

We are now five years post the COVID-19 epidemic, but it recalls a comparison with another epidemic: polio in the 20th century.

Diseases and epidemics have always been part of human history. Poliomyelitis, however, was a disease where orthopaedic surgeons were intimately involved. Polio, like COVID-19, could be fatal, but unlike COVID, polio often caused lasting effects on patients’ extremities and spine.

Fears we faced with COVID echoed the public fear of polio in the last century. If you were growing up in the early 1950s, your parents might have kept you away from gatherings, playgrounds, and swimming pools. There was no cure for polio, only treatment. Today, there are relatively few practicing orthopaedists who lived through the polio epidemic and remember the musculoskeletal damage it caused. So, it makes sense to recall the role orthopaedic surgeons played in treating polio patients.

My father was a community orthopaedic surgeon in Jersey City, New Jersey. As a prominent surgeon in the community, he was able to obtain one of the first doses of the Salk polio vaccine. I remember him coming up to my room, syringe with a big needle in hand, telling me I had to have this injection. At five years old, I wasn’t too happy. But as I grew older, I began to understand what the injection was and why it was given. Looking around town, you almost always saw someone disabled by the disease. And many of these people ended up in my father’s office.

The first reported polio outbreak in the United States, 123 cases, occurred in Vermont in 1894. By the summer of 1916, there were multiple cases in a part of Brooklyn. The disease spread to adjacent areas, leading to 6,000 deaths in the U.S. that summer, with 2,000 in New York alone. By then, the viral origins of the disease had become known.

Over the succeeding decades, the number of cases in the U.S. climbed steadily. Most were recorded in the summer among children and adolescents. In 1952, there were 57,628 reported polio cases in the U.S. Of those patients, 21,269 had mild, disabling paralysis, but 3,145 patients died from the disease.

The first polio vaccine, developed by Jonas Salk, MD, at the University of Pittsburgh, changed all that.

The Salk vaccine, consisting of an injectable but inactivated virus, was first given in the U.S. in 1955. The results were startling.

By 1957, there were only 5,600 polio cases in the U.S., and by 1961, only 161.

The Sabin vaccine, introduced in 1960, consisted of live virus given orally in a sugar cube. The ease of inoculation made its use widespread both in the U.S. and Europe. In fact, one song in the 1964 hit movie “Mary Poppins” — “Just A Spoonful of Sugar Makes the Medicine Go Down” — was based on the Sabin vaccine.

Notwithstanding the declining rates of transmission and infection, there was a need for reconstruction and rehabilitation for those who survived the disease. Orthopaedists sought to restore function in people with flaccid paralysis, contractures, and fixed deformities such as equinus and cavus deformities of the foot and ankle. We learned much from the procedures performed at that time. Multiple operative approaches emerged to address these challenges, each targeting different aspects of deformity, muscle imbalance, and functional loss.

Tendon transfers
Commonly used tendon transfer procedures included:

• Steindler flexorplasty to restore flexion to the elbow when the biceps are paralyzed. This involves transfer of the origins of the pronator teres, FCR, FDS, and FCU to the forearm;
• anterior transfer of the triceps, also used to restore elbow flexion;
• trapezius transfer for deltoid paralysis;
• pronator teres transfer to ECRB to restore wrist extension;
• anterior transfer of the posterior tibial tendon to supply dorsiflexion to the foot and ankle; and
• hamstring transfer to quadriceps to strengthen knee extension.

Arthrodesis
In contrast to today, when arthrodesis is usually performed for pain relief, arthrodesis in the polio era was done mostly to stabilize an otherwise flaccid joint. Some of the most common fusions were:

• triple arthrodesis of the subtalar, talonavicular, and calcaneocuboid joints. The Lambrinudi procedure, with osteotomy of the talus, was sometimes used for an equinus deformity;
• subtalar arthrodesis — the Grice Green extra-articular arthrodesis was among the most popular;
• tibiotalar fusion for an unstable ankle; and
• shoulder arthrodesis, which was sometimes performed to stabilize a flail upper extremity.

Epiphysiodesis and leg lengthening
Leg length discrepancy was common in the polio era, particularly in the lower extremity. If paralysis affected one leg but not the other, there could be a significant functional difference and gait abnormality. Epiphysiodesis, the surgical closure of the growth plates of the femur and tibia, is a technique that was used in adolescent polio patients to limit the discrepancy. It was up to the surgeon to predict the amount of anticipated growth and schedule the right time for surgery.

Procedures for leg lengthening also evolved to treat the discrepancies that were present at skeletal maturity to give the patient a more functional gait. Early techniques centered on an osteotomy followed by gradual lengthening with an adjustable fixator. While newer techniques such as Ilizarov have come along, orthopaedics benefited greatly from the polio experience.

In addition to surgery, there were advances in orthotics and bracing, as many people needed durable lower extremity braces that would last a lifetime. Orthopaedists also devised new physical therapy protocols and came to understand how good rehabilitation led to better results.

While polio has been eradicated in most parts of the world, pockets of the disease remain in Afghanistan and Pakistan. Beyond this, there are still adult polio patients worldwide who developed the disease before vaccination and now need reconstruction. This was brought home to me by a recent patient, a scientist who had emigrated from India. She had a long-standing ankle fusion that had fractured through the talus. She had a shorter leg with a weakened hyperextending knee, and the repeated stress had caused her fracture. Fortunately, the fracture healed after realignment and internal fixation.

As time passes, institutional memory about the polio epidemic fades. It is important for us as orthopaedic surgeons to have some knowledge of the disease and its consequences.

Many young parents want to know why the vaccine is necessary as well as the vaccination sequence and when each dose should be given. Modern vaccines use an inactivated virus. The American Academy of Pediatrics and the Centers for Disease Control recommend a total of four doses given at two months, four months, six to 18 months, and four to six years. There is also a “catch-up schedule” if doses are missed.

We should remember the lessons of the polio experience. As orthopaedic surgeons, we are in a unique position to share our knowledge of events from the past and help guide our patients towards the future.

Stuart J. Fischer, MD, FAAOS, is an orthopaedic surgeon in private practice in Watchung, New Jersey. He serves on the AAOS Committee on Ethics and Outside Interests, AAOS Adult Reconstruction-Hip Program Committee, and the AAOS Digital Health Task Force. Dr. Fischer is also a member of the AAOS Now Editorial Board.