A case study of developmental dysplasia of the hip and hip dislocation in
a post-Medieval Transylvanian population
Jacqueline T. Eng and Connor Hagen
Dept. Anthropology, Western Michigan University
Developmental Dysplasia of the Hip
Developmental dysplasia of the hip (DDH) is an abnormal formation of the hip
joint in which the acetabulum and femoral head are misaligned. This condition
has also been called congenital dislocation of the hip, but DDH is a more fully
comprehensive term that emphasizes both the congenital and acquired aspects of
the progressive condition, which may or may not manifest as a complete
dislocation until later in development (Fig.1).1,2 DDH results in distinctive skeletal
changes that would have severely impacted the lifestyle of an afflicted individual
in ancient times.
Case 1: M22 (10220)
These are the nearly complete remains of an adolescent female about 15-16
years old at time of death. The right hip has a narrow, shallow opening at the
true acetabulum (as compared to the contralateral side) and associated with this,
an irregular and flattened right femoral head (Fig. 4).
Prevalence
The modern incidence has been reported between 10-20 per 1,000 live births,
with a bilateral condition in more than half of those affected, and left side more
common when it is unilateral.1,6 However, the real incidence has been known to
range from 4.4 to 52 percent because of varied diagnosis.7 There appears to be
geographic variation in the distribution of DDH, suggesting genetic and
environmental influences3 (Tab.1). Major high risk factors are listed in Table 2.
Table 1. Modern rates of DDH
compared to Bobald
9,10
Table 2. Risk factors for DDH
Figure 1. Continuum of hip alignment A: Normal. B: Dysplasia.
C: Subluxation. D: Luxation
Today, doctors screen newborns for predisposition for DDH, but in the premodern era, DDH would have likely gone undetected until it was too late to
treat.3 Since spontaneous reductions of such dislocations are unlikely, the
presence of DDH in archaeological samples more accurately represents actual
frequency than other joint fractures.4 This study looks a post-Medieval population
from Romania to document and discuss the prevalence of DDH in a skeletal
population.
Transylvania: Bobald Cemetery Sample
In 2001-2002, the Satu Mare County Museum excavated the cemetery of the
former village of Bobald, located near the modern town of Carei, situated in the
Hungarian Great Plain at the northwestern edge of Transylvania (Fig. 2). Analysis
of the funerary goods dates these burials to approximately AD 1550 to 1700.
Records indicate that the majority of the villagers at Bobald were Hungarian
peasants, subject to the Hungarian landlords, the counts of Károlyi.
Ho tin
Figure 4. M22 adolescent female with affected right hip (normal left acetabulum in center)
Case 2: M3 (20030)
These are the nearly complete remains an adult female who died in her early 40s.
The left hip has a false acetabulum superior to the true joint. Associated with this
condition, the left femoral head is somewhat flattened in shape, with an
indistinct fovea capitis, and the anterior surface is enlarged and lipped (Fig.5).
Likewise, the right femoral neck is robust, possibly owing to increased weight
borne on the right caused by the left hip displacement.
Other pathological conditions include moderate expression of healed cribra
orbitalia and antemortem loss of LM1 and RM1. The vertebrae also display some
age and activity related changes, with slight to moderate vertebral osteophytosis
of thoracic vertebrae and the sacral S1 surface, and Schmorl’s nodes that appear
on the inferior surface of T4 that get progressively larger down toward T8 (the
lowest preserved thoracic vertebra).
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Doctor Eng performed osteological analysis using protocols recommended by the
Global History of Health Project to obtain data on health status, including
evidence of pathological conditions.5 There was a minimum of 162 individuals,
with 68 people who had at least one portion of a hip joint present for observation
(that is, either an acetabulum or femoral head). Of those 68, subadults younger
than 15 years old accounted for 30 cases, and among the 38 adults, there were
16 males and 22 females. Two individuals showed evidence of DDH (Fig. 3),
which is recognizable in skeletal remains by: 1) a shallow, and incompletely
developed true acetabulum; 2) secondary (new) joint development, particularly
superior and lateral of the true acetabulum, and 3) potential flattening of femoral
head.1,3
DDH left untreated may predispose an individual to early degenerative hip
arthritis because of altered load on bones.14, 15 Not only is gait impaired, but DDH
may also cause considerable pain,3 and this may limit activities, possibly to the
detriment of the individuals affected and their families.
During the turbulent late and post-Medieval periods of constant warfare in the
Central European region, Transylvania was the least developed Hungarian
province economically and socially, in large part owing to the fact that peasants
struggled to meet feudal obligations, including the church tithe. Archival sources
give indications of the social and economic status of the villagers in Bobald who
practiced a combination of intensive agriculture and animal husbandry. According
to tax lists, the majority of the families owned enough land to feed their family
and to pay the taxes to their noble landlord, but about ten percent were under
this average, and a smaller number of families fell below even this status.
Families paid their taxes in the form of grain and several types of vegetables, as
well as taxes based on husbandry. Thus, any physical ailment would have
negatively impacted a peasant family in its ability to meet daily needs and taxes
for continued occupation of land.
Conclusion
Figure 5. M3 adult female with affected left hip
Both females suffered high hip dislocation. As seen in Figure 62 the adult M22
likely had a Type C1 high dislocation with development of the false acetablum,
while the adolescent M3 likely had a Type C2 high dislocation with no false
acetabulum, which results in deformity of the femur that is most marked among
all forms of DDH.
To date, 30% of the cemetery has been excavated and future excavations may
yield more observations of hips within this population, which will give a more
accurate representation of the prevalence of DDH. Current evidence suggests
that the frequency of DDH found in the Bobald collection is comparable to those
found in many modern groups, but the lack of medical treatment may have
meant that DDH was detrimental to maintaining a stable livelihood during the
period in which these two afflicted female villagers lived.
Acknowledgements
Much thanks to Peter Szocs and many staff members of the Muzeul Judetean
Satu Mare, Satu Mare, Romania, and to Jenny Eng and Kyle Jones for help with
figures. Funded by a National Science Foundation Graduate Research Fellowship
awarded to J.T. Eng.
Literature Cited
Figure 6. Types of high dislocation found in Fig.6A-F of Hartofilakidis et al.
(2008):823. A-C: Type C1 high dislocation with false acetabulum. D-F: Type
C2 high dislocation with no false acetabulum and free floating femoral head.
Figure 3. Observations of hip joint, adult Bobald sub-sample only
Effect on Lifestyle
Consta nta
Ra zgrad
Methods: Diagnosing DDH
In Bobald, there was a very large sample of hip joints for observation, likely a
factor of sampling during excavation. The incidence of 2.9 percent in the total
sample, or 5.3 percent of adults is comparable with some modern populations,
and not as high as found in others (Tab. 1). While there is no significant
difference between male and female frequencies in this small sample (Fisher’s
Exact Test, P=0.499), it is noteworthy that the only cases of DDH are found in
females of this collection.
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