Treatment versus non-treatment of hip dislocations in ambulatory patients with myelomeningocele

Orthopedic management of myelomeningocele with a multidisciplinary approach: a systematic review of the literature

Background

Myelomeningocele (MMC) is the most common and severe form of spina bifida and imposes a significant burden on patients and the healthcare system. Recently, the multidisciplinary management of MMC has become popular. Herein, we aimed to review the orthopedic management, outcomes, and complications of the of patients with MMC eyeing a multidisciplinary approach.

Methods

We searched PubMed and EMBASE to find relevant studies published before August 2020. All studies that included clinical management of MMC patients and published earlier than 2000 were considered for review on the condition that they reported at least one orthopedic intervention and the rate of complications. We excluded review articles, case reports, case series, letters, commentaries, editorials, and conference abstracts. The primary and secondary goals of our review were to report the outcomes and complication rates of multidisciplinary management for MMC patients.

Results

Twenty-six studies included data for the management of 229,791 patients with MMC and were selected. Sixteen studies reported multidisciplinary management in addition to orthopedic management. From those, 11 (42.31%) included urologic management, 13 (50%) neurosurgical management, 11 (42.31%) neurologic management, and 5 (19.23%) gastrointestinal management. All studies included postnatal operations and related management. No randomized clinical trial was found in our search.

Conclusion

Orthopedic approaches play a key role in MMC management by alleviating spinal deformities, particularly scoliosis, and hip, foot, and ankle complications. However, the most appropriate management, whether surgical or non-surgical, may vary for different patients, given disease severity and the age of patients.

Graphical abstract

Hip Status and Long-term Functional Outcomes in Spina Bifida

BACKGROUND

Nearly 50% of individuals with myelomeningocele will develop a dislocated hip by skeletal maturity. The purpose of this study was to determine the influence of hip status on functional outcomes in a cohort of adult patients with myelomeningocele.

METHODS

Patients with a diagnosis of myelomeningocele >18 years were prospectively enrolled over a 12-month period. Neurological level of involvement was obtained from chart review and interview. Clinical examination included hip range of motion and leg-length discrepancy. Reimer's migration index was calculated from a current anteroposterior pelvic radiograph. All subjects completed the VR-12 and the NIH PROMIS outcomes measures for pain interference and physical function. The χ, the Pearson correlation coefficients, and linear regression models were applied to evaluate the influence of hip status on functional outcomes.

RESULTS

In total, 31 patients (average age 31, range 19 to 49) were included. Eight thoracic, 9 lumbar, and 14 sacral level patients participated. Twenty had bilaterally located hips, 5 had a unilateral subluxation or dislocation, and 6 had bilaterally subluxated or dislocated hips. In univariate analysis, patients with bilaterally located hips performed better in lower extremity function than those with unilateral subluxation/dislocation (36.7 vs. 26.0; P=0.03) but worse in pain interference than those with bilateral subluxation/dislocation (52.0 vs. 43.3; P=0.03). After controlling for neurological level, there was no statistically significant difference in the VR-12 mental (P=0.32) or physical component summary (P=0.32) scores, nor in the PROMIS lower extremity function (P=0.26) or pain interference scores (P=0.33) between groups. Decreased extension and abduction were indirectly correlated with VR-12 mental component scores (P=0.0038, 0.0032). Leg-length discrepancy was not associated with any outcome measure.

CONCLUSIONS

Long-term outcomes are not associated with hip status in adult patients with myelomeningocele. Functional outcomes are more closely correlated with neurological level and hip range of motion. These results suggest efforts to keep myelomeningocele hips reduced are likely without functional benefit and should be avoided in favor of maintaining motion with contracture release as needed.

LEVEL OF EVIDENCE

Level III.

The relationship between the level of lesion and progression in Reimer's index of spina bifida patients

AIM

We aimed to evaluate the influence of the lesion level and acetabular displasia on the progression of hip dislocation in patients with spina bifida.

MATERIAL AND METHOD

Two hundred twelve hips of 106 cases with spina bifida were evaluated both clinically and radiologically. Their vertebral level of lesions, clinical examinations, radiological migration index, and acetabulum terms were noted and were evaluated in terms of their relations with the level of lesion-migration and dysplasia. Data analysis method was evaluated using SPSS 22.0 program.

RESULTS

Deficiency of acetabulum was present in 33 % of the cases with spina bifida. Dysplastic floor was found to be as equally important as the level of lesion in the progression of hip dislocation (p = 0.002). Progression and dislocation incidences were observed to be higher in the thoracic level (p = 0.008). Reimer's progression index was seen to be a reliable way of assesment.

CONCLUSION

The development of hip dislocation and progression are not solely connected with muscle imbalance. Encountered more frequently in these cases, acetabular dysplasia is a factor that is as important as the level of lesion in the formation of hip dislocation and progression. Hip dislocation is associated with more progression in the higher level lesions. Reimer's index is a reliable assessment criteria.

Prenatal diagnosis and assessment of congenital spinal anomalies: Review for prenatal counseling

The last two decades have seen continuous advances in prenatal ultrasonography and in utero magnetic resonance imaging. These technologies have increasingly enabled the identification of various spinal pathologies during early stages of gestation. The purpose of this paper is to review the range of fetal spine anomalies and their management, with the goal of improving the clinician’s ability to counsel expectant parents prenatally.

Who needs surgery for pediatric myelomeningocele? A retrospective study and literature review

INTRODUCTION

Children with myelomeningocele (MMC) are usually subjected to multiple surgeries. However, the number and type of surgeries are not the same in every patient with MMC over time. This report summarizes the surgical interventions in a cohort of several ages.

MATERIALS AND METHODS

Data on all of the patients with MMC, aged from 1 year and 10 months to 21 years and 11 months, were retrospectively reviewed at the Dona Estefânia Hospital in Lisbon, Portugal. Data were collected by chart review and individual interviews. The factors analyzed were demographics, ambulatory status, neurological level of involvement, shunt status, Arnold-Chiari malformation type II, surgical history, and occurrence of fracture. The surgical interventions were categorized as neurosurgical, orthopedic, urinary, ulcer repair and others.

RESULTS

A total of 84 alive were eligible and enrolled. The average age was 14 years and six months. A total of 59 patients received shunts (all but one ventriculoperitoneal). In the study group, the 84 patients required 663 surgeries. Neurosurgical interventions were the most frequent surgical procedure and predominated during the first 2 years of life. Surgical interventions related to shunts were the most common neurosurgical interventions. Orthopedic surgeries were more frequent in the age group 6-12 years. Urological surgeries were done mainly after 6 years of age. Surgical repair of pressure ulcers was more common after 12 years of age.

CONCLUSIONS

Our study brings to light the complexity of this condition, with multiple surgeries among patients with MMC.

Past and current use of walking measures for children with spina bifida: a systematic review

OBJECTIVES

To describe walking measurement in children with spina bifida and to identify patterns in the use of walking measures in this population.

DATA SOURCES

Seven medical databases-Medline, PubMed, Embase, Scopus, Web of Science, CINAHL, and AMED-were searched from the earliest known record until March 11, 2014. Search terms encompassed 3 themes: (1) children; (2) spina bifida; and (3) walking.

STUDY SELECTION

Articles were included if participants were children with spina bifida aged 1 to 17 years and if walking was measured. Articles were excluded if the assessment was restricted to kinematic, kinetic, or electromyographic analysis of walking. A total of 1751 abstracts were screened by 2 authors independently, and 109 articles were included in this review.

DATA EXTRACTION

Data were extracted using standardized forms. Extracted data included study and participant characteristics and details about the walking measures used, including psychometric properties. Two authors evaluated the methodological quality of articles using a previously published framework that considers sampling method, study design, and psychometric properties of the measures used.

DATA SYNTHESIS

Nineteen walking measures were identified. Ordinal-level rating scales (eg, Hoffer Functional Ambulation Scale) were most commonly used (57% of articles), followed by ratio-level, spatiotemporal measures, such as walking speed (18% of articles). Walking was measured for various reasons relevant to multiple health care disciplines. A machine learning analysis was used to identify patterns in the use of walking measures. The learned classifier predicted whether a spatiotemporal measure was used with 77.1% accuracy. A trend to use spatiotemporal measures in older children and those with lumbar and sacral spinal lesions was identified. Most articles were prospective studies that used samples of convenience and unblinded assessors. Few articles evaluated or considered the psychometric properties of the walking measures used.

CONCLUSIONS

Despite a demonstrated need to measure walking in children with spina bifida, few valid, reliable, and responsive measures have been established for this population.

Orthopedic management of spina bifida. Part I: hip, knee, and rotational deformities

Children with spina bifida develop a wide variety of congenital and acquired orthopedic deformities. Among these are hip deformities such as contracture, subluxation, or dislocation. Patients may also have problems with the knee joint, such as knee flexion or extension contracture, knee valgus deformity, or late knee instability and pain. In addition, rotational deformities of the lower extremities, either internal or external torsion, are common as well. This paper will review both the overall orthopedic care of a patient with spina bifida and provide a focused review of the diagnosis and management of the above deformities. In addition, this paper will review the incidence, etiology, classification, and prognosis of spina bifida. The use of gait analysis and orthoses will be covered as well. The forthcoming Part II will cover foot and ankle deformities in spina bifida.

Strategies of hip management in myelomeningocele: to do or not to do

Paralytic hip dislocation in myelomeningocele is common and can be a complicated problem. This review summarizes results of surgical techniques employed in this patient population in order to achieve and maintain reduction of paralytic hip dislocations. This review also examines the controversial question of whether or not hip surgery in patients with myelomeningocele provides improved functional results. Finally this paper suggest appropriate goals and recommendations for treatment of the paralytic hip dislocation in myelomeningocele.

Análise laboratorial de marcha na mielomeningocele de nível lombar baixo e instabilidade unilateral do quadril

Este estudo examina a influência da instabilidade unilateral do quadril sobre a marcha de pacientes portadores de mielomeningocele, nível lombar baixo e instabilidade unilateral do quadril. Foram estudados através da análise laboratorial de marcha, 20 pacientes deambuladores comunitários utilizando goteiras e muletas, com luxação ou subluxação unilateral do quadril. , Os pacientes foram sub divididos em dois grupos. Grupo 1 (10 pacientes) , que não apresentavam contraturas do quadril (flexão e/ou adução) ou as apresentavam de forma simétrica entre os lados; e Grupo 2 (10 pacientes), que apresentavam contraturas assimétricas de quadril A cinemática do quadril e da pelve foi analisada no sentido de se avaliar a simetria entre o lado envolvido e o oposto. Sete pacientes do Grupo 1 e 2 do Grupo 2 apresentaram marcha simétrica. Marcha assimétrica foi encontrada em 3 pacientes do Grupo 1 e 7 pacientes do Grupo 2. A assimetria na marcha relacionou-se principalmente com a presença de contraturas de quadril unilaterais ou bilaterais mas assimétricas. Demonstrou-se que a assimetria da marcha não pode ser atribuída somente à instabilidade do quadril, mas parece estar mais relacionada com presença de contraturas unilaterais ou assimétricas e cujo tratamento deveria ser o objetivo em detrimento de reduções cirúrgicas do quadril.

Orthopaedic care of children with spina bifida: you've come a long way, baby!

The prognosis of children born with spina bifida has dramatically changed in the past several decades. Children with spina bifida with appropriate medical care can now expect to live into adulthood. Orthopaedic care of children with spina bifida has evolved to increase function, promote long-term mobility, and improve overall health. This article looks at current orthopaedic treatment against the backdrop of historical care. Treatment of the foot, knee, hip, and spine are reviewed, as well as neurologic implications. Issues of ambulation, orthotics, assistive devices, and insensate skin are addressed.

Long-term follow-up of Chiari pelvic osteotomy in myelomeningocele

The management of hip instability in myelomeningocele patients is controversial. The purpose of this study is to review our long-term results of isolated Chiari osteotomies in the treatment of hip instability in children with myelomeningocele. Between 1975 and 1988, 11 patients underwent 13 Chiari osteotomies for reducible hip subluxation or dislocation and acetabular deficiency. The patients returned for follow-up clinical examinations, interviews, and radiographs. The average age at the time of surgery was 9.4 years (range, 5-18). The average age at follow-up was 18 years (range, 13-23). The average follow-up was 11.4 years (range, 2-18). The mean preoperative center-edge (CE) angle was -38 degrees. The mean immediate postoperative CE angle was 41 degrees. At final follow-up, the mean CE angle was 4.6 degrees. Only three of the 10 hips had a normal CE angle of > or = 25 degrees. The Chiari osteotomy alone did not achieve long-term hip stability in the majority of patients. Several, if not most, of our patients may progress to frank dislocation with longer follow-up.

Dislocation of hip in myelomeningocele. The McKay hip stabilization

We reviewed the clinical and radiographic results of varus osteotomy of the proximal aspect of the femur and transfer of the adductor and external oblique muscles (the McKay procedure) in thirty-four children (sixty-six hips) who had an unstable hip secondary to a myelomeningocele at the middle or caudad lumbar level. the average age at the time of the operation was twenty months (range, seven to forty-two months). The average duration of follow-up was 10.9 years (range, 0.7 to 20.0 years). An open reduction was performed in ten hips. None of the children had had any previous operative treatment. The index operation helped to maintain the stability of thirty-seven of the fifty-one hips twenty-six children who remained neurologically stable: seventeen of nineteen hips that were at risk, two of three hips with acetabular dysplasia, fifteen of sixteen subluxated hips, one of three dislocated hips that had been previously reduced with a Pavlik harness, one of two dislocatable hips, and one of seven previously untreated dislocated hips. The index operation was not successful for one dislocated hip that had been treated with closed reduction and application of a spica cast. The operation was a success for eight of the fifteen hips in eight children who had a progressive loss of neurological function: three of five hips that were at risk, one hip with acetabular dysplasia, two of four subluxated hips, one of two that had been previously reduced with a Pavlik harness, and one dislocatable hip. Two dislocated hips redislocated. Initially the index operation was performed on all children who had a myelomeningocele at the third or fourth lumbar level. Recent data have shown that the hips in these children are not all at risk, and we now perform the operation only if there is documented instability of the hip.