The following factors besides
spasm and contraction of the adductor muscles contribute to the occurrence of dislocations of the hip in
spastic paralysis:
Spasm and contraction of the iliopsoas muscle and enhanced valgus position and antetorsion. The author holds the opinion that in case of malformation of the proximal end of the femur, it is not only the indirect action of the
spastic musculature via the proximal femur-epiphyseal cartilage which is responsible for this phenomen in accordance with the law on functional adaption through longitudinal growth (Pauwels), but also the direct
traction of the iliopsoas tendon. A clue in this direction is the often very pronounced elongation or enlargement of the trochanter minor. The author demonstrates the pathogenetic importance of iliopsoas
contracture and malpositioning of the neck of the femur by means of analyses of the course in two patients. The following principles of treatment are postulated for
spastic dislocation of the hip: Elimination of the pathogenetic factors through myotenotomy of the adductor muscles and complete resection of the obturator nerve, with observation of strict aftertreatment criteria,
tenotomy of the iliopsoas, repositioning and
osteotomy with turning into varus.
Osteotomy without previous elimination of the pathogenetically acting muscular forces does not appear useful. Likewise, permanent re-positioning by means of muscle-relaxing operation cannot be sufficiently safe-guarded without additional
osteotomy once the dislocation has taken place. In twelve patients with
spastic dislocation of the hip, treated in accordance with these guidelines (two without
osteotomy) aged 6 6/12 and 19 5/12 years, a roentgenologically good result was obtained in half of the cases, whereas the functional result was satisfactory not only with these patients but also with part of the other patients. If surgical treatment is instituted early enough, and if the experiences described here are taken into consideration, it is to be expected that the results will be even more satisfactory. The corset supporting the seated patient, developed by us, has been found very useful during the aftertreatment stage. A definite stand is taken against the therapeutic nihilism which leaves treatment of
spastic dislocations to physiotherapy. It is also pointed out that indication for treatment is not represented only by the target of learning how to walk, but also by providing an overall improvement of the life situation of the patient, by either enabling him, or improving his ability, to sit or by "merely" improving the care of the perineum.