The Natural History of Hip Deformity in Myelomeningocele

7/25/2019 The Natural History of Hip Deformity in Myelomeningocele

1/4

76 0 T H E JO U R N A L O F B O N E A N D JO IN T SU R G E R Y

THE NATURAL H ISTORY OF H IP DEFORM ITY IN

MYELOMEN INGOCELE

N IG E L S . B R O U G H T O N , M A L C O L M B . M E N E L A U S , W IL L IA M G . C O L E ,

D A V ID B . S H U R T L E FF

F rom th e R oya l C h ild ren s H osp ita l, M e lbo urne , A ustra lia an d the C h ild ren s H osp ita l an d M ed ica l

C en ter , S ea ttle , U SA

W estu d ied 1 06 1 child ren w ith

m y e lom en in goce le, rev iew ing

3 84 pe lv ic rad iog raph s from 80 2 pat i ents . H ip d islocat ion

had occurred by th e ag e o f

iu

years in 28 o f ch ild ren w ith

a tho ra cic n eu ro segm en ta l leve l, 3 0 o f those w ith an Lu

2

lev el, 36 o f L 3 , 2 2 of LA , 7 of L 5 an d on ly 1 of

th ose w ith sac ral levels . H ip d isloca tion w as not in ev ita b le

even w hen th ere w as m axim a l m u sc le im ba lance ab ou t the

h ip . T he averag e h ip flex io n con tra c tu re in ch ild ren aged 9

to

uu

year s w a s s ig n ifican tly g rea ter in th ose w ith tho ra cic

(22 {176 })n d L 1 /2 (3 3 {17 6})ev els than in tho se w ith LA (9 {1 76} ),5

(5 {176} )

r sacra l (4 {1 76 })evels .

O ur find ing s in d ica te tha t m usc le im ba lance is n o t a

s ign if ican t fac tor in th e prod uc tion of fle xio n d efo rm ity o r

d islo ca tion o f the hip;

both

a re co m m o nly seen in th e

abs ence of im ba lance . T he restora tion of m usc le ba lance

s hould no long er b e con s id ered to be th e pr in c ipa l a im of

th e m anagem en t o f th e h ip in ch i ld ren

with m yelom eningo-

cele .

J B on e Join t Surg [B r]

19 93 ; 75 -B

:760- 3 .

R ece ived 20 D ecem ber 1991

;

Accepteda fte r rev isio ns 22 Ap ril 1993

C h ild ren w ith m y elo m ening ocele com m only d eve lop

con tractu res o f th e h ip

;

som e m ay suffe r d is lo ca tio n , an d

th e n atu ra l h is to ry of th ese de form itie s is im p ortan t in

m anagem ent. S h arra rd (19 64 ) rep orted the d efo rm ities

p resen t a t th e age of o ne yea r in 1 83 ch ild ren w ith

m ye lo m eningo cele . H e foun d n o h ip d is loca tion s or

flex io n d efo rm ities in lim b s w ith no in ne rva tio n be lo w

T 12 and the re fo re n o ac tive m usc le s arou nd the h ip . In

h ip s w ith inn erva tion to L i and L 2 , h ip addu ctio n an d

N . S . B rou gh ton , F R C S, F R C S E d , FR A C S, C onsulta nt O rth opa ed ic

Surgeon

M . B .

M e ne lau s, M D , F R C S, F R A C S , Se nio r O rth op aed ic S urgeo n

W . 0.

C ole, M Sc, P hD , F R A C S , P rofessor o f O rtho pa edic S urg ery ,

Me l b o u r n e

D epar tm ent

o f O rth opa edics, R oya l C hildre ns H o spital, F le m ington

R oa d, Parkville , V icto ria 3 05 2, A ustralia .

D . B .

S hu rtle ff, M D, Profe sso r of Pa ediatrics

D ivisio n o f E m b ryo log y, T e rato lo gy an d C on ge nita l D e fec ts, U niver-

sity of W a shington S cho ol o f M e dic ine, C hild ren s H ospital an d

M ed ica l C enter, Se attle , W a shington 98 105 -03 71 , U SA .

C orrespon den ce sho uld be sen t to D r N . S . B rou ghton.

19 93 B ritish E dito ria l S ociety ofB on e an d Join t S urg ery

030 1-6 20 X /9 3/S 6S 3 $2 .00

flex ion co ntrac tu re s had deve lop ed , and m ost w ere

sub lu xed . H e co nsid ered th a t the se h ips w ou ld inev itab ly

d islo ca te by the age of five yea rs . M ost o f th e h ip s

inne rva ted to L 3 and L 4 h ad d isloca ted b y on e yea r and

he sta ted tha t the o th ers w o u ld do so w ith in ano th er year .

O f 27

h ips in ne rv ated to L5 , sev en w ere d isloca ted an d

12 w ere su b lu xed ; S ha rrard sta ted tha t the sub lux ed h ips

w o uld inev itab ly d isloca te b y the ag e of sev en y ea rs . H is

v iew w as tha t m uscle im ba lance cau sed co n trac tu re s an d

d islo ca tion s, and he su ggested th at th e re sto ratio n o f

m u scle ba lance arou nd th e h ip w ou ld p rev en t the se an d

im prove w a lk in g ab ility .

W e repor t a m uch larger study of th e d eve lopm en t

of h ip de fo rm ity in ch ild ren w ith m ye lom en in goce le ,

u sin g da ta co lle cted p rospec tive ly and b efo re any

op e ra tion , o ve r 17 yea rs in tw o cen tre s . A prev iou s pape r

from the sam e cen tre s has d iscu ssed th e p ro g ress ion o f

h ip f lex ion co n trac tu re (S hurtle ffe t a l 198 6) .

P A T IE N T S A N D M E T H O D S

O fthe to ta l s tud y grou p of 10 61 ch ild ren w ith m y elom en -

ing ocele, d etails o f

76 4

h av e been co llec ted by D B S from

S eattle , W A sin ce 19 71 , and 2 97 from M elbo urn e,

A u stra lia b y M B M sin ce 1 976 .

A t th e first a ttendance, a t any age , a sp ecia lly tra in ed

phy sio the rap ist reco rded th e range of m ovem en t in each

d irectio n a t each low er lim b jo in t, m usc le stren g th on th e

stan da rd in te rn atio na l scale fo r a ll m usc le s o f the low er

lim b s (D an ie ls and W orth ing ham 198 6), am b u la to ry

ab ility an d an y orth opaed ic ope ra tio ns o n the low er

lim b s. In terob se rv er d iffe rences in th e se m easu rem en ts

have been fou nd to be sm a ll (B a rtle tt e t a l 1 985 ).

T he neuro seg m ental leve l in each case w as assessed

by a m od if ic atio n o f S ha rra rd s c las sific a tion (T ab le I) ,

an d th ree ch ild ren w ith g ros s asym m etry o f leve l w ere

ex clu ded . A n ov era ll neu rosegm en ta l leve l fo r each ch ild

w as de te rm ined from a ll av ailab le a ssessm en ts in th e

kno w ledge th at m uscle s tren g th beco m es m o re con sis ten t

af te r th e age o ff ive y ea rs (M cD o na ld , J affe and S h urtle ff

198 6) . T h e d istrib u tion o f leve ls is sho w n in T ab le II .

A tota l o f 318 4 rad iog raphs o f 8 02 p atien ts w ere

a sse ssed and h ip s w ere ca teg o rised as d islo ca ted w hen

th ere w as n o area of con gru ity be tw een the fem ora l and

acetabu lar su rface s. A ll o bse rv atio ns re latin g to the


2/4

THORAC IC LEVEL

10 0

90

80

70

60

50

40

10 0

90

80

70

60

50

40

L 1/2

100

90

80

70

60

50

40

L3

I

I I I I I I I

0 2 4 6 8 10121416182022

A ge in yea rs

SACRAL LEVEL

100

90

80

70

60

50

40

, )n .

50

40

Cof l .

I I I I I I I I I I I U I I I I I I I I I I I I I I I I I I U I I

0 2 4 6 8 10121416182022 0 2 4 6 8 10121416182022 0 2 4 6 8 10121416182022

A ge in years Age in yea rs A ge in yea rs

T H E N A T U R A L H IS T O R Y O F H IP D E FO R M IT Y IN M Y E L O M E N IN G O C E L E

76

V O L. 75 -B , N o. 5 , S E PT E M BE R 1993

n a tu ra l h is to ry o f de fo rm ities w ere m ad e be fo re any h ip

operat ion .

D ata w ere sto red usin g the P a tien t D ata M anage -

m ent S ystem (IB M P C com pa tib le so ftw a re standa rd ised

b y th e In te rna tion a l M ye lody sp la sia S tud y G roup ) and

R -BA SE . Sta tist ica l ana ly sis w as by SP SS -X on a

m ain fram e co m pu ter o f th e U nive rsity o f M e lbou rn e

an d S P S S /P C . M eth ods in clu ded one -w ay an aly sis o f

va riance and m ultip le co m parisons by the T u key-H S D

test, d iffe ren ce o f m ean s by S tud en ts t- te st an d su rv iva l

cu rves and com pariso ns usin g L ee -D esu S ta tis tic .

RESULTS

H ip d is loca tion . T he propor tio n o f h ip s rem ain ing

un d isloca ted w as re la ted to age fo r each neurosegm en tal

leve l and is repo rted in the fo rm of su rv iva l cu rves to

ind ica te the ages at w h ich d islo ca tion o ccu rred . P e lv ic

rad io g rap hs w ere ava ilab le fo r m ost ch ild ren a t abo u t

tw o-y early in te rva ls , so m e as pa rt o f u ro lo g ica l in vesti-

ga tion s. B ecause o f the in te rva ls , the d iagno sis o f som e

d islo ca tion s w as d e lay ed and the cu rv es m ay be d isp laced

to the rig h t.

W hen ope ra tion s had been p erfo rm ed it w as

im po ssib le to de te rm in e w h eth er the h ip s w o u ld have

d islo ca ted w ithou t su rge ry . A ccord in g ly , w e g iv e tw o

curves fo r each neuroseg m en ta l lev el : on e is fo r the

ob served d is locatio n rate , th e o the r inc ludes d is locatio ns

an d h ips on w h ich an o pe ra tion has been pe rfo rm ed (F ig .

1 ). T he n atura l d is loca tion rate w itho u t the in flu en ce of

an y op era tio ns m u st lie be tw een these cu rv es. T hey sh ow

clea rly tha t pa tien ts w ith an L 3 neurosegm en ta l lev el

ten d to d isloca te ea r ly , w ith no m o re d isloca tio ns a fte r

the age o f th ree yea rs , w he rea s pa tien ts w ith tho rac ic

an d L l/2 lev els co n tinu ed to su ffe r h ip d isloca tions even

afte r the age of ten y ears (T ab le III). T he g raphs a lso

sho w th a t 42 % of the h ips w ith L 3 neurosegm en tal leve l,

67 %

w ith L 4 lev e l an d 80% w ith L 5 leve l neve r d isloca ted

or h ad op era tio ns pe rform ed on th em .

S ta tis tica l ana lysis o f the su rv iva l cu rves fo r d islo -

catio n o r op era tion , usin g L ee -D esu S tatis tic o n S P S S -X ,

sho w ed n o sig n if ican t d iffe ren ce be tw een th e cu rves fo r

tho rac ic, L i/2 and L 3 leve ls , bu t all th ree g rou ps h ad

sign ific an tly h ig he r d isloca tion rate s th an L 4 , L 5 and

sac ra l leve ls .

H ip

f lex ion con trac tu re . W e ca lcu lated the ave rag e h ip

flex io n con tractu re in un op era ted p a tien ts fo r each

neuroseg m en ta l leve l an d fo r tho se w ith n o lo ss fo r each

o f the ag e ca tego rie s 0 to 3 m o n ths , 9 to 15 m o n ths , an d 9

to 1 1 y ea rs . T he re su lts are show n in T ab le s IV , V an d

V I, w h ich in c lud e on ly on e read ing p er ch ild w ith in each

age catego ry , alth oug h o ne ch ild m ay app ea r in o ne , tw o

o r a ll th ree age ca tego ries . T h is m eans tha t th e sing le

o bse rv a tio ns a re no t independ en t an d cann o t b e co m -

p ared in term s of neu rosegm en tal lev els b etw een ag e

ca teg o ries , bu t on ly w ith in each age categ o ry . W e used

o ne -w ay ana lysis o f va riance an d T ukey -H S D m ultip le

com pariso n m eth ods .

H ip flex ion con trac tu re is com m o n in n orm a l

neon ate s (H offe r 19 80); w e foun d it in all n eu ro seg m en ta l

U I I I I U I I I I I

I 2 4

6 8 10121416182022

Age In yea rs

L4

10 0

)

2 4 6 8 10121416182022

Age In yea rs

L5

100

90

80

70

60

50

40

)A.

D is lo ca tion observed D isloca tion

o r o p er at io n

Fig . 1

H ip dis loc atio n rates in ch ildren w ith m ye lom en ing oc ele. R esu lts are for d if fere nt ne uro seg m e nta l lev els an d ex pre sse d a s percen tag es of hips n ot

d is loc ated at the var iou s ag es (see te xt).


3/4

L e v e l

Thoracic

L

L2

L3

L4

T able II. D istr ibu tion o f n eurose g-

m ental leve ls in 106 1 ch ild ren w ith

m yelom eningo ce le stu die d a t tw o

centres

L e v e l

Thoracic

Ll

L2

Seatt le

(n=764)

13 9

30

25

Me l b o u r n e

( n= 297)

71

14

L 3 60 2 7

L 4 1 86 8 6

L S 8 2 2 7

S 9 0 4 9

S2 76 12

A sym m etrical 2 1

N olo ss 7 4 3

T a ble I II. R e sults o fsu rvival a nalysis ofh ip dislo cation

in children w ith m yelo m en ing oc ele

T a b l e

IV .

A ve rag e hip flexion co ntrac-

ture in childre n w ith m y elo m e nin go cele

from b irth to a ge thre e m on ths

Percentage

L ev el N u m b er

ercen t ge

dis located

d islo ca ted or

o perate d on

A t 3 6 to 59 m on ths

T horacic 75 17 50

L /2

22 12 55

L 3 37

36 48

L 4 155

6 3

L S 4 4 7 17

S ac ral 77

1 2

A t 1 08 to 1 31 m o nth s

T h ora cic 28

28 59

L /2 13 30 75

L 3 1 9

36 50

L4

55 22 33

L S 1 7 7 20

S ac ral 30

1 2

L e v e l

Thoracic

Ll/2

L3

L4

L5

Sacral

N o loss

Nu m b e r

o f h ip s

12 8

54

39

20 5

82

11 8

28

T ab le V . A v erag e hip fle xio n co ntractu re

in c hildre n w ith m y elo m e nin goc ele from

9 to 15 m onths o f ag e

T ab le V I.

A ve rage hip f lexion co ntra c-

ture in children w ith m yelom enin go cele

fro m 9 to 11 yea rs of age

L e v e l

Thoracic

L1/2

L3

L4

LS

Sacral

N o loss

Nu m b e r

o f h ip s

87

36

31

18 4

82

11 8

38

L e v e l

Thoracic

L /2

L3

L4

LS

Sacral

N o loss

Nu m b e r

of h ips

6

l2

13

49

39

10 0

24

76 2

N . S . B R O U G H T O N , M . B . M E N E L A U S, W . G . C O L E , D . B . SH U R T L E F F

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

T ab le I. T h e a sse ssm en t of n eurose gm ental lev el in ch ild ren w ith

m ye lom en ing oce le m od ifie d fro m S harrard (19 64)

N o active m ov em en t at th e hip

Ilio pso as g rad e 2 or better

Ilio pso as , sarto riu s an d ad duc tors a ll g rade 3 o r be tte r

Q ua dric eps gra de 3 or better, a lso m ee t cri teria fo r L 2

M e dia l ham string s o r tib ia lis anterio r g rad e 3 o r be tte r

;

also

m eet cri teria for L 3

L 5 L a teral h am str ing s g rad e 3 o r be tter ; also m eet c rite ria fo r L 4

plus o ne of the fo llow ing th ree : g lu te us m edius grade 2 o r

be tter , perone us tertius gra de 4 or b ette r, t ib ialis po ster ior

g rad e 3 o r b ette r

5 T w o of the fo llow ing thre e : ga stro cne m ius/so le us grade 2 or

be tter , g lu teu s m edius grade 3 or b etter, g lu teu s m ax im us

grade 2 o r b ette r

;

also m eet cri teria for L S

S2 G a strocn em ius /so leus g rad e 3 o r be tte r and glu teus m ed ius a nd

glu teu s m axim u s g rad e 4 o r be tter , also m eet c rite ria fo r S i

N o loss A ll le g m uscle sha ve no rm a l s tren gth

H ip fl ex io n

c on trac ture (deg ree s)

M e a n

SD

2 1.3 1 2 0.5 7

2 6.4 3 17.14

3 2.2 1 16.49

2 8.5 1 15 .66

2 7.5 11.53

1 8.2 5 13.17

6.0 16.6

H ip

f lex ion

c ontrac ture (deg ree s)

Me a n SD

1 1.4 4 16 .63

9.6 4 14.63

7 .74 13.65

4 .92 9 .88

5 .98 12 .30

1.1 5 7.3 6

0 0 6 97

H ip Il ex io n

con tra ctu re (d egrees )

Me a n SD

22.16 2 1.4 4

3 2.9 1 10.54

11 23 15 59

9.48 17.47

5.3 8 10.22

3.5 3 8.7 6

-1 .25 7.1 0


4/4

T H E N A T U R A L H IST O R Y O F H IP D E FO R M IT Y IN M Y E L O M E N IN G O C E L E

76 3

V O L . 75 -B , N o. 5 , SE PT E M B E R 19 93

lev els o f ch ild ren w ith m y elo m en in goce le (T ab le IV ).

T h e av erage h ip flex ion con tractu res be tw een 9 an d 1 5

m o nths are sh ow n in T ab le V . T he th o rac ic g rou p has a

sign ific an tly h ig he r ave rag e than the L 4 ,

L 5, sac ral and

no lo ss g ro ups . T h e L l/2 g roup has a sig n if ican tly h igh e r

av erage th an th e sac ra l and n o loss g ro ups , bu t the re a re

no sign if ic an t d iffe rences b e tw een o th e r g rou ps.

B etw een 9 and 1 1 y ea rs th e av erage h ip flex ion

con tractu re s sh ow a s ig n if ican tly h ighe r ave rage fo r th e

tho rac ic g rou p than fo r the L 4 , L 5 an d sac ra l g rou ps

(T ab le V I). T h e L l/2 g rou p had a sign ifican tly h ig he r

ave rage than the L 3 , L 4 ,

L 5 , sacra l and no loss gro up s.

T h e L 4 gro up av e rag e w as sig n ifican tly h ighe r th an the

no loss g roup , bu t the re w ere no sign ific an t d iffe ren ces

be tw een th e o the r g roup s.

W e m ade a sp ec if ic ana lysis to d e term ine w heth er

the low er av erage h ip f lex ion con trac tu re in each of the

L 4, L 5 and sacra l group s at 9 to 15 m onth s w as due to

ex clu sion because o f p rev iou s su rge ry , and fo und tha t

th is w as no t the case . T he ave rag e h ip f lex ion co n trac tu re

in p atien ts w ho h ad su rge ry a t le ss than 1 5 m onth s w as

15 {176}or tho se w ith L 3 or m ore d istal neuro seg m enta l lev els

(n

=

20 ) and 2 9#{ 176 }or th ose w ith tho rac ic o r L l/2

n eu ro segm en ta l lev e ls (n

=

12) .

D I S C U S S I O N

T he d a ta w h ich w e h av e u sed have b een co llec ted by

ca refu lly -train ed p erso nne l to m in im ise in terob serve r

an d in traobserve r erro r (B artle tt e t a l 19 85

; B roug hton e t

al 1 98 9). O u r re su lts fro m th e stu dy o f 10 61 child ren o ve r

a pe rio d o f 2 2 yea rs in S ea ttle and 17 yea rs in M e lbo urn e

d iffe r from th ose o f S h arra rd (19 64) . H e stud ied 18 3

ch ild ren an d h is obse rva tions led h im to pos tu la te th at

m usc le im ba lance w as the cau se o f d islo ca tio n and

de fo rm ity o f the h ip .

F or le sion s a t th e th orac ic lev el w e found unexp ec -

ted ly h ig h ra te s o f d islo ca tion in the absence o f m u sc le

im ba lan ce. W e also foun d th at flex io n con trac tu re o f the

h ip w as co m m o n in pa tien ts w ith h igh -leve l le sion s : by

the age of 1 1 yea rs , in tho rac ic leve l p atien ts , the av erage

h ip flex ion con tractu re w as 2 2#{ 17 6}n

=

61 ). C hild ren w ith

ad duc to r an d flexo r pow er a sso cia ted w ith L i o r L 2 lev e ls

at the sam e age d id no t hav e a sig n ifican tly d ifferen t

av erage flex ion de fo rm ity than d id the th o rac ic leve l

gro up w ith n o m u sc le po w er at the h ip . B y th e ag e of 11

years , o n ly 30 % of the L l/2 g rou p of ch ild ren had

d islo cated h ips and

45

h ad been op era ted upo n , u sua lly

fo r p rog re ssive f lex ion d efo rm ity . T h is m eans tha t

25

had ne ith er d is lo cated n or b een o pe ra ted u pon .

In th e ch ild ren w ith an L 3 lev el, on ly 36 % o f h ips

had d isloca ted by the age of f ive yea rs an d th is num ber

d id no t inc rea se in late r life . In a ll, 42% of th e h ips o f

ch ild ren w ith th is lev el ne ithe r d islo ca ted n or had

operat ions.

In ch ild ren w ith L 4 neu roseg m en tal leve l le s ion s ,

w hich sh ou ld g iv e th e m ax im um m u sc le im b alance across

the h ip , 67 % of the h ip s ne ith er d is lo ca ted no r requ ired

ope ratio n . T h e av erage h ip flex io n con tractu re in th is

g roup at th e age of 1 1 y ea rs w as sign ific an tly le ss than

tha t in ch ild ren w ith fla il h ip s. In th e gro up w ith an L 5

neuro seg m enta l lev el on ly 7 % had dislocated b y th e age

of fiv e years , an d at the age o f 1 1 y ea rs , 80 % had n e ithe r

d islo ca ted n or had op era tio ns.

W e there fo re a gree w ith B eek er and Sch eers (198 6)

tha t h ip de fo rm ity and d isloca tion a re no t a s com m on as

w as firs t assum ed and th at the deve lop m en t o f th ese

abn orm alitie s can no t be p red icted o n th e b asis o f th e

leve l o f th e le sion . T h e concep t th a t m uscle im b alance is

respon sib le has been accep ted an d is repeated in m o st

tex t b oo ks (V and er B rin k 1 98 0). It also p rov ides th e

ra tiona le fo r m an ag em en t w h ich in clu des the co rrectio n

o f m usc le im ba lan ce . O ur re su lts ind ica te th a t the se

co ncep ts a re no long er va lid .

T he h igh in cidence of h ip d islocation and flex io n

con trac tu re in h ig h-lev el les io ns lead s us to h ypo th esise

th at com p lete ly pa ra ly sed h ips d isloca te sim p ly b ecause

th ey are no t k ep t in p lace by no rm a l m usc le ton e. In

add ition , bo th p ro lon ged sittin g and sp in al de fo rm ity

m ay en co urag e the deve lop m en t o f flex io n co n trac tu re

an d d isloca tion . T h is m eans th a t h ip de fo rm ity cann o t

b e p red ic ted fro m m u sc le im ba lance abo u t th e h ip , and

tha t p ro phy lactic surg ery to co rrec t m u sc le im b a lan ce is

illo g ica l. C h ild ren w ith m ye lom en in go ce le requ ire care -

fu l obse rva tion to de tect the d eve lopm en t o f d e fo rm ity

o r d is location ; it is n o t p ossib le to pred ic t th e sev erity o f

any d efo rm ity o r the occu rrence o f h ip d is locatio n .

N o ben efi ts in any form ha ve be en rece ived or w ill b e rec eiv ed fro m a

c om m e rcial pa rty rela ted d ire ctly or in direct ly to the su bje ct o f th is

ar t icle .

R E F E R E N C E S

Bartlet t

MD,

W olf L S , Sh urt lef f

DB,

Stabell

LT . H ip

f lex ion

con tra ctu res : a c om pa riso n of m ea surem ent m e tho ds. A rch P hys

MedRehab i l 1 98 5; 6 6: 62 0-5 .

B eeker T W ,

Scheers

M M . Th e

h ip jo in t in spin a bifida a cco m p anied

by m y elo m e nin go ce e : a re vie w of the c ase s of a sp ina b ifida te am .

N eu ro O rth op ed ic s 1 98 6; 2 :8 7-9 4.

B ro ug hto n N S ,

Brougham

D I, C ole W G ,

Me n e l a u s

M B.

R eliability of

radio lo gic al m e asu rem en ts in the assessm e nt of the ch ild s h ip .

J

BoneJointSurg[Br]

1 98 9; 7 l-B :6 -8 .

D a nie ls L , W o rth ing ham C . Muscle tes tin g: te chn iqu es of manu a l

examination .

P hila delphia : W B S au nde rs, 19 86.

H eife r M M .

Join t m otion in ne w b orn s.

C /in O rth op

1 98 0; 1 48 :9 4-6 .

M cD o n a l d

C M , Ja ife K M , Shur t leif D B . A ssessm ent of m uscle s tre ngth

in children w ith m eningo m y elo cele : acc ura cy an d stability of

m ea surem ents ov er tim e.

A rch P h ys M ed Reh ab il

1 98 6; 6 7:8 55 -6 1.

S harra rd W JW . P os te rio r ilio pso as transp lan ta tion in th e trea tm ent o f

p ara ly t ic d islo ca tion o f the h ip .

J B one Jo in t Su rg [B r] 1964 ; 46-

B

:426-44.

Shurt lei f DB,

Me n e l a u s

M B,

Stahell

LT ,

e t * 1 . N atu ra l h is to ry o f flex ion

deform ity of the hip in m ye lod ysp las ia .

J P aed ia tr O rthop

1 9 8 6 ;

6:666-73.

V a nde r B rink

KD.

M yelo m e nin go cele. In : E d m o nson A S , C ren sha w

A H , eds. C am pbe lls o pe rative or tho pa edics. 6th ed. S t . L ou is, T h e

C V M osb y C om pany , 1980 :1 620-3 7 .

Documents

The Natural History of Hip Deformity in Myelomeningocele