Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2018;-:-------

ORIGINAL RESEARCH

Are Seating Systems With a Medial Knee Support

Really Helpful for Hip Displacement in Children With
Spastic Cerebral Palsy GMFCS IV and V?
In Soo Kim, MD,a Donghwi Park, MD,b Jin Young Ko, MD,c Ju Seok Ryu, MD, PhDa,c
From the aDepartment of Rehabilitation Medicine, Seoul National University Hospital, Seoul, South Korea; bDepartment of Rehabilitation
Medicine, Daegu Fatima Hospital, Daegu, South Korea; and cDepartment of Rehabilitation Medicine, Seoul National University Bundang
Hospital, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-do, South Korea.

Abstract
Objective: To evaluate whether medial knee support (MKS) in seating systems aggravates hip displacement in children with cerebral palsy (CP).
Design: Retrospective chart review.
Setting: Rehabilitation department of tertiary university hospital.
Participants: Children with CP (NZ76) using seating systems (intervention group, nZ42; mean age 6.86y) and using regular wheelchairs
(control group, nZ34; mean age 8.15y).
Interventions: The intervention group was provided with a seating system with MKS. We enrolled children who did not use a seating system in
the control group, retrospectively.
Main Outcome Measures: By radiographic images, Reimer’s migration index (MI), lateral center edge angle (CEA), and femur neck shaft angle
(NSA) were measured. We compared the demographic data, clinical variables, and radiographs between the 2 groups.
Results: In the intervention group, there was a significant deterioration in the MI, from 26.89% to 44.18% after using the system (P<.001). The
progression of MI was 14.72% and 7.82% per year in the intervention and control groups, respectively (PZ.016).
Conclusion: We should consider the possibility that seating systems with MKS may exacerbate hip displacement in children with CP.
Archives of Physical Medicine and Rehabilitation 2018;-:-------
ª 2018 by the American Congress of Rehabilitation Medicine

Cerebral palsy (CP) is a heterogeneous group of permanent dis-
orders that hinders the control of posture and movement due to
nonprogressive damages in the fetal or infant brain.1 It is one of
the most common causes of early childhood disability, and its
symptoms and signs are highly diverse.2 In children with CP,
many musculoskeletal problems arise, causing motor weakness,
abnormal biomechanical alignment, spasticity, balance disorder,
and impaired sensory perception.3,4
The incidence of hip displacement ranks second highest among
all deformities in spastic CP, accounting for up to 28% of all re-
ported cases.5 The muscular imbalance around the hip musculature
causes progressive lateral dislocation of the femur from the
Supported by Basic Science Research Program through the National Research Foundation of
Korea (NRF) funded by the Ministry of Education (NRF-2016R1D1A1B03935130).
Disclosures: none.
acetabulum, due to hyperactivity in the adductors and flexors, as
well as relative weakness in the abductors and extensors. The
migration percentage shows a gradual deterioration of the severe
forms for children with CP, from 3.9% per year at Gross Motor
Function Classification System (GMFCS) level IV to 9.5% at level
V.6 Hip displacement may cause gait abnormalities, hip joint pains,
impaired sitting balance, problems with perineal sanitation, and
ulceration.5,7-9
Several positioning devices that support a child’s body posture
in standing, sitting, and/or lying have been proposed to prevent the
worsening of hip displacement. Use of standing equipment for
more than 1 hour/day with hips in abduction had reported positive
effects for children at risk for hip displacement.4 Diverse seating
systems and custom molded chairs have been developed to prevent
worsening of hip displacement with positive effects on mobility,
self-care, social function, nursing, and body positioning reported
for children with CP.10-12 With respect to seating systems, a

0003-9993/18/$36 - see front matter ª 2018 by the American Congress of Rehabilitation Medicine
https://doi.org/10.1016/j.apmr.2018.07.423
2 I.S. Kim et al
medial knee support (MKS) located between the 2 legs is often
recommended to maintain abducted hip posture to minimize hip
displacement (fig 1A, 1B).13,14 Using a MKS with a firm seat
cushion (as opposed to a sling seat) is thought to promote hip
abduction in sitting and to increase containment of the femoral
head in the acetabulum.15
In South Korea, service activities provided seating systems
with MKS to give various beneficial effects and prevent hip
displacement in children with CP. Onnuri R-bank was a project
that provided medical and/or surgical services to economically
challenged children with disabilities in rural areas. A team of
doctors, including physiatrists, orthopedic surgeons, and neuro-
surgeons, as well as paramedics visited the sites directly to pro-
vide care. Through this program, we have been providing seating
systemsa (see fig 1A) to children with disabilities in various
regions since 2010. We provided seating systems for free, and
physiatrists checked whether the seating system was suitable for
children. When the children grew up, they visited the outpatient
clinic to check, modify, and change the seating system to fit their
grown body; and old seating systems were recycled. When a
patient reached physical maturity, we provided a custom-molded
seating system (see fig 1B). In total, we provided 95 seating
systems at 7 different cities for a period of 5 years.
However, we think that these seating systems with MKS may
further aggravate hip displacement. In children with CP, spasticity
has been reported to be one cause of hip displacement.16 Spas-
ticity of hip adductors and flexors leads to scissoring of the thighs.
Subsequently, as MKS acts as a fulcrum, the characteristic
muscular imbalance transforms the force, causing hip displace-
ment. Moreover, flexed hip posture maintained while using the
seating systems could aggravate hip displacement. Although there
has been a study examining the progression of hip displacement
after using a custom-molded chair tailored to each patient, the
study was limited in providing accurate information regarding CP
due to the small number of patients included and wide variety of
diagnoses.12
The purpose of this study was to determine whether MKS in
seating systems may aggravate hip displacement in children with
CP. Our hypothesis is that the migration index progression is
greater in children with CP using MKS in seating systems than
children with CP using regular wheelchairs.
Methods
Subjects and demographic factors
A retrospective chart review was conducted on 42 children with CP
who used seating systems (intervention group) and 34 children with
CP (control group). The child’s functional level was assessed by
physiatrists, using the levels of the GMFCS.17,18 The intervention
group received seating systems through the R-bank project between
List of abbreviations:
CEA lateral center edge angle
CP cerebral palsy
GMFCS Gross Motor Function Classification System
MI Reimer’s migration index
MKS medial knee support
NSA femur neck shaft angle
January 2010 and May 2016. Inclusion criteria for the intervention
group included children who were diagnosed with spastic CP
(GMFCS levels IV and V), who underwent radiographic examina-
tion and who were provided a Squiggles, Mygo-I, or Mygo-II
seating device (see fig 1A, 1B). The seating system was equipped
with MKS, and children with CP were seated with their hips in
abduction and flexion. Mixed type was included if dominant type of
movement abnormality was spastic.1
Control subjects included children who attended Bundang
Seoul National University Hospital and were diagnosed with
spastic CP (GMFCS levels IV and V) but did not use any seating
systems during the same period. Control group were mainly or-
thopedic outpatients. They did not use seating systems because of
the lack of information about them. They used regular wheel-
chairs. A regular wheelchair consists of a sling seat and back, with
no lateral or MKS or lateral trunk support.
Medical information on sex, age, and GMFCS level of each
group was collected retrospectively. For the intervention group,
the time spent in sitting position was additionally analyzed before
and after they were provided with a seating system through
questionnaires. The following children were excluded: those with
a history of surgical treatment due to hip displacement, botulinum
toxin injection, or those without radiographic examination.
This study was conducted in conformance with the ethical
standards of the Declaration of Helsinki (1964) and was approved
by the Institutional Review Board of the Seoul National University
Bundang Hospital.
Radiographic measurements
In the intervention group, radiographs were achieved via a mobile
medical imaging machine. We photographed and examined chil-
dren in the intervention group every time we visited the area. In
the case of the control group, radiographic images were taken
every time the children visited the hospital. Follow-up routines
were based on revised guidelines for the Swedish CP program.16
Radiographic measurements and duration were calculated based
on the first and most recent radiographs.
Plain radiographic images of the pelvis and hip joints in the
anteroposterior direction were obtained with children in supine po-
sition and with the hips internally rotated by 30 degrees.19 The
radiographic parameters were digitally measured using standard
equipment in our Picture Archiving and Communication System.b
The radiographic parameters were as follows: Reimer’s migration
index (MI), lateral center edge angle (CEA), and femur neck shaft
angle (NSA).
MI is the percent of the femoral head that lies outside the
acetabulum. Generally, there are 2 methods to measure the
migration index: the classic method20 and the modified method.
We used the former because it is known to be have higher reli-
ability.21 This measurement was taken by identifying the Perkin’s
line and Hilgenreiner’s line, and then checking the amount of
femoral head that moved across the Perkin’s line laterally. It is
presented as a percentage (fig 1C). The CEA20 is the index of hip
displacement and a way to determine acetabular coverage. This
angle is formed between a perpendicular line of the femoral head
and the line communicating the most lateral margin of the
acetabular roof with the center of the femoral head (see fig 1C).
The NSA22 was measured to determine the coxa valga of the hip.
The angle is made up by 2 lines: one that connects the center of
the femur neck to the head, and another that is drawn through the
femur shaft midline (see fig 1C).
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Hip displacement after applying MKS for Spastic CP 3

Fig 1 (A) Mygo seating system, one of the modular seating systems offered to children with disabilities. (B) Molded seating systems were
provided when the children with disabilities were fully grown up. MKS is utilized in the 2 types of seating systems. (C) Antero-posterior radiograph
of the hip. MI, CEA, and NSA were calculated. H, Hilgenreiner’s line; P, Perkin’s line.

Statistical analysis
All statistical analyses were performed using SPSS software,
version 19.0.c To compare the differences between the 2 groups
with respect to the demographic factors (age, sex, duration,
GMFCS), initial assessment, or progression of radiographic
measurements, independent t tests or Mann-Whitney U tests
(if the assumptions of parametric statistical analysis were not
satisfied) were used. To assess changes of hip displacement
between before and after using the seating systems, radiographic
measurements were analyzed by Wilcoxon signed rank tests.
P value of less than .05 was considered statistically significant.
2 groups (table 1). The time spent in sitting position was
0.721.43 hours a day before using the seating system and
2.141.79 hours a day after using the seating system. The time
spent in sitting position was significantly increased after using the
seating system (t test, PZ.001).
Taking the side with the largest progression (the unfavorable
side), MI before using the seating system was 26.8917.10%.
After using the seating system, these significantly increased to
44.1821.74% (Wilcoxon signed ranks test: P<.001). CEA
decreased from 20.1516.23 to 2.8325.72 after using the
seating system (Wilcoxon signed ranks test: P<.001). However,
NSA was not significantly different after using the seating sys-
tem (table 2).

Results Progression of radiographic measurements

Changes of radiographic measurements in
intervention group
Sex, age, follow-up duration, GMFCS level, and initial radio-
graphic examinations were not significantly different between the
between intervention and control groups
The progression of MI was 14.7214.86% and 7.828.86% per year
in the intervention and control groups, respectively. There was a sta-
tistically significant difference between the 2 groups (Mann-Whitney
U, zZ-2.408, PZ.016). The progression of CEA was -15.4918.91

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4 I.S. Kim et al

Table 1 Demographic and clinical variables

Characteristics Intervention Control P Value
Number (men:women) 42 (24:18) 34 (18:16) .716
Age, y 6.863.88 8.153.90 .097
Duration (d) 482.02291.21 564.97645.36 .071
GMFCS in CP, V (%) 22 (52.4) 15 (44.1) .477
Initial Radiographic Measurements Between the Intervention and Control Groups
Intervention Control P Value
MI 26.8917.10 33.0223.47 .192
CEA 20.1516.23 14.4928.04 .208
NSA 154.8811.49 159.9210.71 .054
NOTE. Values are presented as mean  SD.

and -10.0913.29 per year in the intervention and control groups,
respectively. Although the progression of CEA was higher in the
intervention group, the difference was not statistically significant
(Mann-Whitney U, zZ-1.494, PZ.135). The change of NSA in the
intervention and control groups was not significantly different (see
table 2, Mann-Whitney U, zZ-0.331, PZ.741).
5.667.30% and 10.5810.09% per year, respectively. The
change of CEA and NSA was also measured according to
GMFCS, and is summarized in table 2. However, there were no
significant differences in MI, CEA, and NSA between the 2
groups divided by GMFCS.

Progression of radiographic measurements Discussion

according to GMFCS
In the intervention group, MI progression in GMFCS IV and V
were 11.5513.84% and 17.6015.48% per year, respectively. In
the control group, MI progression in GMFCS IV and V were
Our study showed that the use of seating systems with MKS in
children with CP may exacerbate hip displacement. Hip
displacement indexes (MI, CEA) were significantly different in
the intervention group when comparing before and after the use of

Table 2 Radiographic profiles in intervention and control groups

Changes of Radiographic Measurements in the Intervention Group (the Unfavorable Hip)
Radiographic Profiles Before Using Sitting Device After Using Sitting Device P Value
MI 26.8917.10 44.1821.74* <.001
CEA 20.1516.23 2.8325.72* <.001
NSA 154.8811.49 155.8010.04 .364
Progression of Radiographic Measurements Between the Intervention and Control Groups
Radiographic Profiles Intervention Progression (per y) Control Progression (per y) P Value
MI 14.7214.86 7.828.86* .016
CEA -15.4918.91 -10.0913.29 .135
NSA 1.849.07 -0.3412.15 .741
Annual Progression of Radiographic Measurements According to GMFCS
Intervention Control
Radiographic Profiles Progression (per y) n Progression (per y) n
MI
GMFCS IV 11.5513.84 20 5.667.30 19
GMFCS V 17.6015.48 22 10.5810.09 15
CEA
GMFCS IV -8.6613.86 20 -5.5812.29 19
GMFCS V -21.6920.97 22 -15.8012.63 15
NSA
GMFCS IV 0.276.46 20 -0.389.05 19
GMFCS V 3.2610.88 22 -0.2915.80 15
NOTE. Values are presented as mean  SD.
* P<.05.

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Hip displacement after applying MKS for Spastic CP 5

seating systems. Moreover, the MI progression rate per year was
significantly higher in the intervention group than in the con-
trol group.
In a previous report describing the natural history of hip
displacement in children with CP, the progression of MI per year
was shown to be 3.9% for GMFCS IV and 9.5% for GMFCS V.6
Our study showed a comparable migration progression rate as the
previous study in the control group (5.66% for GMFCS IV and
10.57% for GMFCS V). Contrastingly, in the intervention group,
we observed much higher rates for each category, 11.55% for
GMFCS IV and 17.60% for GMFCS V. These rates in our study
were much higher than those in the previously published study.6
A previous study evaluating musculoskeletal deformity before
and after using a custom-molded fitting chair for 2 years, showed
that the progression of MI per year was 1.45%, and the authors
noted that the seating systems played a role in preventing exces-
sive rapid progression of musculoskeletal deformity.12 However,
unlike our study, they did not mention the GMFCS levels, and not
all included children were diagnosed with CP, making it difficult
to accurately compare their results with ours.
Hip displacement in children with CP is caused by an imbal-
ance in the muscle tone, muscle length, and muscle force.20 The
spastic flexors and adductors often overwhelm the extensors and
abductors.23,24 One possible explanation for this study’s findings is
that the spasticity of the adductor muscles in sitting position lets
MKS, which lies between the legs in the seating system, serve as a
leverage (fig 2A). The adductor muscle group inserts into the
medial side of the femur, and the force acts in the direction of hip
dislocation through the third-class lever (fig 2B). In addition,
gracilis muscle inserts into the medial condyle of the tibia, and the
force is applied to the direction of hip dislocation through the first-
class lever (fig 2C). MKS acts as a fulcrum in the third-class lever,
where the force of the adductor muscle is transferred onto the hip
laterally and superiorly. As a result, the femur head moves in the
lateral and superior direction from the acetabulum, causing
displacement.
Another possible explanation might be that living in a seating
system, with a maintained flexed hip for an extended time, may also
influence hip displacement. However, little attention has been paid
to sustained positions affecting hip displacement in children with
CP, although adduction, internal rotation, and excessive flexion
have been shown to cause hip dislocation after total hip replace-
ment.25 When sitting for a long time, children with CP are kept in a
flexed hip position, which alone is known to induce hip displace-
ment. Moreover, it is also known that an internal rotation moment of
the hip increases when the hip is flexed.26 In the state of hip flexion,
several muscles showed an increase in the torque arm vector in the
direction of the adduction, flexion, and internal rotation.27 Hence, a

Fig 2 (A) Stronger adductor muscles have a moment in the direction of displacement of the femur head through leverage. When the adductor
muscles contract, it exerts a force toward the center of the chair (black arrow). This force causes the femur head to be dislocated from the hip
(empty white arrow). (B, C) MKS acts as a fulcrum in the lever, causing hip displacement. (D) In the flexed hip state, muscles showed an increase
in the torque arm vector in the direction of the adduction, flexion, and internal rotation. This force might destruct and flatten the superior and
posterior acetabulum in nonambulatory children with CP, eventually leading to hip displacement in the posterior direction.

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6 I.S. Kim et al
seating system that maintains a child in the state of hip flexion for an
extended time will likely induce hip displacement.
Children with CP have a higher incidence of severe osteopo-
rosis and valgus hip than the general population.28 Valgus hip
weakens the strength of the abductor muscles, and the hip
adductor muscles augment hip extension moment during the hip
flexion position.20,29,30 As a result, in nonambulatory children
with CP, the superior and posterior acetabulum may be flattened
and destroyed, further aggravating hip displacement (fig 2D).
Considering the above reasons, the use of seating systems with
MKS for an extended time may lead to an increased risk for
developing hip displacement. Interestingly, hip displacement in
children with CP using seating systems is different from that in the
general CP population. Generally, hip displacement occurs mostly
in the supero-lateral direction. The spastic adductors and flexors
tend to force the femoral head in the supero-lateral direction.5,8
Interestingly, some children with hip displacement were
observed in the posterior direction in the intervention group (see
fig 2D). In the literature regarding adults who have had hip
replacement, hip displacement has been classified into 3 types
dependent on its mechanical cause.31 Displacement toward the
dorsal (posterior) occurs when excessive adduction and internal
rotation positions are sustained in the flexed hip,31,32 which is
consistent with hip displacement in the posterior direction in the
intervention group.
To date, little attention has been paid to the influence of seating
systems or custom-molded chairs on hip displacement in children with
CP. In children with long-term use of these devices, it is important to
minimize risk for hip dislocation by conducting hip surveillance more
frequently than other children and using the appropriate medication
(such as botulinum toxin) for managing spasticity.4 Moreover, it is
important not to overdo hip abduction when using a seating system. It
may also be helpful to introduce a pelvic (and thigh) lateral supports to
stabilize the pelvis and hip position in sitting33 although we have yet to
find a study that examines how use of these components affect hip
dislocation. Further studies are needed to develop better ways to
prevent hip displacement in children with spastic CP who require long-
term use of seating systems.
In addition, young age is one identified risk factor for hip
displacement. There is no significant difference, but the average
age in the intervention group was about 1 year younger than that
in the control group (age; 6.86y for intervention, 8.15y for con-
trol). However, there was no difference in the risk of hip
displacement between the 2 groups because the initial migration
index, in addition to age, also affected the risk of hip displacement
(initial MI; 26.89% for intervention, 33.04% for control).34
Moreover, nonambulatory children with CP younger than the
age of 4 years have been reported to have a bigger hip migration
progression than older children.6 Since the majority of children in
the 2 groups were older than 4 years, the effect of age is thought to
be relatively small.
Despite the retrospective nature of this study, there was no
follow up loss of children in the intervention group as it was a
charity project.
Study limitations
There are several limitations in this study. Although significant
differences and changes were found, the sample may be sized too
small to generalize to other settings. In addition, there may be
factors not documented or collected that may influence the validity
of comparing these 2 groups because the study design is a
retrospective chart review. The spasticity, length, and power of the
muscles acting on the hip were not adequately evaluated due to the
retrospective nature of this study. The extent of hip displacement
varies depending on the intensity of spasticity of the hip muscles
although it is not known exactly what muscle activity has changed
and affected the hip after using MKS. Further experimental studies
on muscle activity or spasticity changes in hip musculature are
needed to confirm our observations.
Also, the seating systems that were provided to our interven-
tion group did not include lateral pelvic supports, and our results
may have been influenced by this configuration. Future work
should consider evaluating MKS use on hip displacement both
with and without the presence of lateral pelvic supports.
Conclusions
We should consider the possibility that seating systems with MKS
may exacerbate hip displacement. Future research should inves-
tigate the musculoskeletal characteristics in children using MKS
and identify the factors that exacerbate hip displacement.
Suppliers
a. Squiggles, Mygo-I, Mygo-II; Leckey.
b. PACS; Impax.
c. SPSS, Version 19.0.
Keywords
Cerebral palsy; Hip dislocation; Rehabilitation; Technology;
Wheelchair
Corresponding author
Ju Seok Ryu, MD, PhD, Department of Rehabilitation Medicine,
Seoul National University Bundang Hospital, Seoul National
University College of Medicine, 82 Gumi-ro 173 Beon-gil,
Bundang-gu, Seongnam-si, Gyeonggi-do, South Korea, 463-707.
E-mail address: jseok337@snu.ac.kr.
Acknowledgment
The authors thank the Medical Research Collaborating Center at
Seoul National University Bundang Hospital for statisti-
cal analyses.
References
1. Rosenbaum P, Paneth N, Leviton A, et al. A report: the definition and
classification of cerebral palsy April 2006. Dev Med Child Neurol
Suppl 2007;109:8-14.
2. Oskoui M, Coutinho F, Dykeman J, Jette N, Pringsheim T. An update
on the prevalence of cerebral palsy: a systematic review and meta-
analysis. Dev Med Child Neurol 2013;55:509-19.
3. Ofluoglu D. Orthotic management in cerebral palsy. Acta Orthop
Traumatol Turc 2004;43:165-72.
www.archives-pmr.org
Hip displacement after applying MKS for Spastic CP
4. Miller SD, Juricic M, Hesketh K, et al. Prevention of hip displacement
in children with cerebral palsy: a systematic review. Dev Med Child
Neurol 2017;59:1130-8.
5. Morrell DS, Pearson JM, Sauser DD. Progressive bone and joint ab-
normalities of the spine and lower extremities in cerebral palsy. Ra-
diographics 2002;22:257-68.
6. Terjesen T. The natural history of hip development in cerebral palsy.
Dev Med Child Neurol 2012;54:951-7.
7. Laplaza FJ, Root L. Femoral anteversion and neck-shaft angles in hip
instability in cerebral palsy. J Pediatr Orthop 1993;14:719-23.
8. Samilson RL, Tsou P, Aamoth G, Green WM. Dislocation and sub-
luxation of the hip in cerebral palsy: pathogenesis, natural history and
management. J Bone Joint Surg Am 1972;54:863-73.
9. Gajdosik CG, Cicirello N. Secondary conditions of the musculoskel-
etal system in adolescents and adults with cerebral palsy. Phys Occup
Ther Pediatr 2009;21:49-68.
10. Otensjo S, Carlberg EB, Volestad NK. The use and impact of assistive
devices and other environmental modifications on everyday activities
and care in young children with cerebral palsy. Disabil Rehabil 2005;
27:849-61.
11. Samaneein K, Riches P, Green P, Lees K. Assessment of forces imparted
on seating systems by children with special needs during daily living
activities. In: Proceedings of the Biomedical Engineering and Sciences
(IECBES), 2012 IEEE EMBS Conference on: IEEE; 2012. p 475-8.
12. Kim MO, Lee JH, Yu JY, et al. Changes of musculoskeletal deformity
in severely disabled children using the custom molded fitting chair.
Ann Rehabil Med 2013;37:33-40.
13. Morris C. Orthotic management of children with cerebral palsy.
J Prosthet Orthot 2002;14:150-8.
14. Pountney TE, Mandy A, Green E, Gard PR. Hip subluxation and
dislocation in cerebral palsyea prospective study on the effectiveness of
postural management programmes. Physiother Res Int 2009;14:116-27.
15. McDonald R, Surtees R. Changes in postural alignment when using
kneeblocks for children with severe motor disorders. Disabil Rehabil
Assist Technol 2007;2:287-91.
16. Hägglund G, Lauge-Pedersen H, Wagner P. Characteristics of children
with hip displacement in cerebral palsy. BMC Musculoskelet Disord
2007;8:101.
17. Palisano R, Rosenbaum P, Walter S, Russell D, Wood E, Galuppi B.
Development and reliability of a system to classify gross motor
function in children with cerebral palsy. Dev Med Child Neurol 1997;
39:214-23.
18. Palisano RJ, Rosenbaum P, Bartlett D, Livingston MH. Content val-
idity of the expanded and revised Gross Motor Function Classification
System. Dev Med Child Neurol 2008;50:744-50.
www.archives-pmr.org
7
19. Kay RM, Jaki KA, Skaggs DL. The effect of femoral rotation on
the projected femoral neck-shaft angle. J Pediatr Orthop 2000;20:
736-9.
20. Reimers J. The stability of the hip in children: a radiological study of
the results of muscle surgery in cerebral palsy. Acta Orthop Scand
Suppl 1980;184:1-100.
21. Kim SM, Sim EG, Lim SG, Park ES. Reliability of hip migration
index in children with cerebral palsy: the classic and modified
methods. Ann Rehabil Med 2012;36:33-8.
22. Chung CY, Lee KM, Park MS, Lee SH, Choi IH, Cho T-J. Validity
and reliability of measuring femoral anteversion and neck-shaft
angle in patients with cerebral palsy. J Bone Joint Surg Am
2010;92:1195-205.
23. Wiley ME, Damiano DL. Lower-extremity strength profiles in spastic
cerebral palsy. Dev Med Child Neurol 1998;40:100-7.
24. Flynn JM, Miller F. Management of hip disorders in patients with
cerebral palsy. J Am Acad Orthop Surg 2002;10:198-209.
25. Mccollum DE, Gray WJ. Dislocation after total hip arthroplasty.
Causes and prevention. Clin Orthop Relat Res 1990:159-70.
26. Delp SL, Hess WE, Hungerford DS, Jones LC. Variation of rotation
moment arms with hip flexion. J Biomech 1999;32:493-501.
27. Dostal WF, Andrews JG. A three-dimensional biomechanical model of
hip musculature. J Biomech 1981;14:803-12.
28. Finbråten A-K, Syversen U, Skranes J, Andersen G, Stevenson R,
Vik T. Bone mineral density and vitamin D status in ambulatory and
non-ambulatory children with cerebral palsy. Osteoporos Int 2015;26:
141-50.
29. Neumann DA. Kinesiology of the hip: a focus on muscular actions.
J Orthop Sports Phys Ther 2010;40:82-94.
30. Hoy MG, Zajac FE, Gordon ME. A musculoskeletal model of the
human lower extremity: the effect of muscle, tendon, and moment arm
on the moment-angle relationship of musculotendon actuators at the
hip, knee, and ankle. J Biomech 1990;23:157-69.
31. Dargel J, Oppermann J, Brüggemann G-P, Eysel P. Dislocation
following total hip replacement. Dtsch Arztebl Int 2014;111:884-90.
32. Woolson ST, Rahimtoola ZO. Risk factors for dislocation during the
first 3 months after primary total hip replacement. J Arthroplasty 1999;
14:662-8.
33. Reid D, Rigby P, Ryan S. Functional impact of a rigid pelvic stabilizer
on children with cerebral palsy who use wheelchairs: users’ and
caregivers’ perceptions. Pediatr Rehabil 1999;3:101-18.
34. Hermanson M, Hägglund G, Riad J, Rodby-Bousquet E,
Wagner P. Prediction of hip displacement in children with cerebral
palsy: development of the CPUP hip score. Bone Joint J 2015;97:
1441-4.