The unstable hip and mid-lumbar myelomeningocele

Abstract

We reviewed 55 patients with mid-lumbar myelomeningocele (L3 and L4) first seen over a 17-year period from 1970 to 1986 and followed up for an average of ten years. We assessed a number of factors which might affect hip stability and ability to walk, recording the natural history of clinical and radiological hip deformity. Two-thirds of the hips had become dislocated or subluxed by the end of the first year of life, involving 86% of hips in patients with an L3 level and 45% of those with an L4 level. All the hips that developed instability secondary to muscle imbalance did so within the first year. The neurological level was the most significant determinant of walking ability: all patients with L4 neurological levels could walk but only one-third of those with L3 lesions could do so. Hip stability, intelligence quotient and fixed deformity did not influence walking ability.

Pre-school follow-up of a cohort of children with myelomeningocele in Cape Town, South Africa

“…A major factor in mid-lumbar (L3 and L4) lesions is hip instability, which results in delay in ambulation and a need for orthopaedic surgery. This has been reported by Asher & Olson 5 and locally by Fraser et al 16 Children in Cape Town are ambulant earlier than rural children, possibly because of delays in orthopaedic surgery or poor maintenance of appliances used for ambulation. Intelligence appeared to play a signi® cant role in ambulation in this study, a factor previously found not to affect ambulation in mid-lumbar lesions.…”

“…Intelligence appeared to play a signi® cant role in ambulation in this study, a factor previously found not to affect ambulation in mid-lumbar lesions. 16 Thirty-® ve (44%) of the children were continent at 5 years of age, 25 with intermittent catheterization and ten without assistance.…”

The influence of spasticity in the lower limb muscles on gait pattern in children with sacral to mid-lumbar myelomeningocele: a gait analysis study

“…Studies have shown that most patients with sacral and low lumbar neurological lesions retain their functional walking ability regardless of associated spinal deformities [17,31,43,44]. In our study, there were two subjects with fused spines.…”

The orthopaedic management of myelomeningocele

“…[6] Only 33% of L3 patients can walk, and then usually with ankle-foot orthoses (AFOs) and crutches, but all L4 patients are ambulatory. [7] The better walking potential of L4 patients is due to the presence of medial hamstrings that account for a third of hip extension strength. In myelomeningocele patients, unlike in those with cerebral palsy, an unstable hip does not result in painful arthritis.…”