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The natural history of hip deformity in myelomeningocele
N S Broughton1, M B Menelaus, W G Cole
1Department of Orthopaedics, Royal Children's Hospital, Victoria, Australia.
Insights
Hip dislocation and flexion contractures in children with myelomeningocele are not significantly linked to muscle imbalance. Management strategies should shift focus from restoring muscle balance to other factors.
Area of Science:
- Pediatric Orthopedics
- Neuroscience
- Developmental Biology
Background:
- Myelomeningocele, a complex birth defect, often leads to significant orthopedic challenges, particularly affecting hip development and stability.
- Hip dislocation and flexion contractures are common complications in children with myelomeningocele, impacting mobility and quality of life.
- The role of muscle imbalance in the pathogenesis of hip deformities in this population has been a long-standing focus of clinical management.
Purpose of the Study:
- To investigate the correlation between neurosegmental level, muscle imbalance, and the incidence of hip dislocation and flexion contractures in children with myelomeningocele.
- To re-evaluate the significance of muscle balance in the management of hip abnormalities in pediatric myelomeningocele patients.
- To determine if hip dislocation or flexion deformity occurs even in the absence of significant muscle imbalance.
Main Methods:
- Retrospective review of 3184 pelvic radiographs from 802 children with myelomeningocele.
- Analysis of hip dislocation incidence based on neurosegmental levels (thoracic to sacral).
- Assessment of hip flexion contractures in children aged 9-11 years in relation to neurosegmental levels and muscle imbalance.
Main Results:
- Hip dislocation occurred by age 11 in a significant percentage of children, varying by neurosegmental level (e.g., 36% for L3 vs. 1% for sacral levels).
- Hip dislocation was observed even in cases with maximal muscle imbalance, indicating it is not an inevitable outcome of imbalance.
- Average hip flexion contractures were notably greater in children with higher neurosegmental levels (thoracic, L1/2) compared to lower levels (L4, L5, sacral).
Conclusions:
- Muscle imbalance is not a primary driver for the development of hip flexion deformity or dislocation in children with myelomeningocele.
- Hip deformities, including dislocation and flexion contractures, frequently occur independently of muscle imbalance.
- Clinical management of hip issues in pediatric myelomeningocele should de-emphasize restoring muscle balance as the principal therapeutic goal.
Abstract:
We studied 1061 children with myelomeningocele, reviewing 3184 pelvic radiographs from 802 patients. Hip dislocation had occurred by the age of 11 years in 28% of children with a thoracic neurosegmental level, 30% of those with an L1/2 level, 36% of L3, 22% of L4, 7% of L5 and only 1% of those with sacral levels. Hip dislocation was not inevitable even when there was maximal muscle imbalance about the hip. The average hip flexion contracture in children aged 9 to 11 years was significantly greater in those with thoracic (22 degrees) and L1/2 (33 degrees) levels than in those with L4 (9 degrees), L5 (5 degrees) or sacral (4 degrees) levels. Our findings indicate that muscle imbalance is not a significant factor in the production of flexion deformity or dislocation of the hip; both are commonly seen in the absence of imbalance. The restoration of muscle balance should no longer be considered to be the principal aim of the management of the hip in children with myelomeningocele.