Historical Aspects of DDH

Abstract

Background

Little was known about developmental dysplasia of the hip (DDH) in the early historical era. Symptoms such as limping were caused by a variety of disease processes, many of which were life threatening. It was not until the discovery of X-ray in 1896 that clear understanding of childhood hip conditions, including DDH, could evolve.

Methods

We reviewed available literature and distilled it into this summary of the history of our understanding of DDH.

Results

The development of non-operative methods relied on plaster of Paris cast reductions and later splints and harness systems leading to the Pavlik harness (1950’s). The development of ultrasound as a diagnostic technique made early diagnosis and treatment possible. Surgical approaches to DDH treatment required several key discoveries: invention of general anesthesia (1840s); development of sterilization techniques (1860–1880); discovery of X-ray (1890s); development of stainless steel (1920s); and the discovery of antibiotics (1930s). These surgical advances allowed the development of a remarkable variety of operations to treat DDH including open reduction techniques, and osteotomies of the acetabulum and proximal femur.

Conclusion

The path to accurate diagnosis and predictable treatment of DDH parallels the many advances that application of the scientific method has allowed in the specialty of orthopedic surgery. The development of academic centers that focus on research and education in childhood hip disorders, as well as a growing number of centers that focus on hip problems in adolescents and young adults, assure a continuous and changing “history” of this common childhood hip condition.

Introduction

The child’s hip has to last through a lifetime and even minor imperfections or abnormalities can lead to arthritis. Undiagnosed developmental dysplasia of the hip (DDH)—formerly known as CDH—(congenital dislocation of the hip) is a common cause of premature arthritis. Not much was known about the hip in the early historical era. In the days of Hippocrates, DDH was ignored, because the disease produced nothing more than a limp and many children limped because of more severe, and even life-threatening conditions, such as tuberculosis [1]. In contrast DDH did not threaten a child’s life and seldom caused pain. It was not until the development of the X-ray in 1896 by Roentgen, that doctors had much of an idea as to what they were treating when encountering a limping child. Accurate radiographic correlation of clinical findings has provided a clear understanding of DDH [as well as conditions such as Perthes disease and slipped capital femoral epiphysis (SCFE)]. Once Roentgen developed his radiograph, the diagnosis of DDH became much clearer and diseases such as SCFE and Perthes disease could now be differentiated from a dislocated hip (Fig. 1).

Fig. 1.

Wilhelm Roentgen in Wurzburg, Germany (1896). The first X-ray was of his wife’s hand (note ring)

Mercer Rang developed a timeline for the treatment of DDH which he published in his classic textbook, The Story of Orthopedics (1984) [2]. The timeline for pathology includes the following:

• 300BC—Hippocrates noted a joint dislocated in utero.

• 1564—Pare noted a shallow socket with stretched ligaments when doing a dissection.

• 1783—Palletta described the pathology of a hip in a 15-day-old child with a dislocation.

• 1826—Dupuytren wrote much about the changes seen in DDH.

• 1839—Gerrard Vrolik illustrated pathology of DDH in a book.

Rang also described the signs of DDH and when they were discovered. These were:

• 1742—Andry described the waddling gait and used a girdle to treat the child.

• 1864—Rosser described a test for neonatal instability.

• 1895—Trendelenburg described the sign of an abductor insufficiency when the child would stand on the leg where the hip was dislocated.

• Twentieth century—Le Damany and Ortolani describe special methods for diagnosis in infancy.

Pathologic Description in Congenital Dislocations of the Hip

Dupuytren in 1826 gave the best account of congenital dislocation of the hip in the modern Western literature. He considered its etiology and drew attention to the familial tendency of the condition. He mentioned that “the position of the lower extremities of the fetus is such that the thighs are very much bent on the bellies and the thigh bones continually press against the lower back part of the capsular ligaments”. He said that being in a fixed position for a prolonged time could cause the hip to dislocate and cause a new acetabulum, particularly if the child was from a family that had loose ligaments. He went on to describe all of the pathology, but not much on treatment. The earliest discussion of treatment began to be published in the European literature in the late nineteenth century.

The Evolution of Physical Diagnosis and Imaging

In the modern era, Le Damany in Rennes, France in 1912 began to perform an in-hospital physical examination of infants on a maternity ward to determine whether or not they had a dislocated hip. Thus, he was well ahead of Ortolani who developed his sign in the 1930s. Although infants could be found to have dislocatable hips at birth, the number of late diagnosis cases remained high, because the examination was not commonly performed.

Ortolani was an Italian surgeon and Professor of Pediatrics and Child Health at the Provincial Institute in Ferrara, Italy (1930s). In examining an infant, he noted that the DDH hip could be moved in and out of the acetabulum [3]. He then took an X-ray to demonstrate the dislocated hip.

The physical findings of the hip included Ortolani’s specific test of showing that a dislocated hip could be reduced back into the acetabulum by a physical maneuver. He described this as a “ridge sign” and not really a “click”—and some described this more as a “clunk” than a “click”. His method became widely known in 1937. This was the same sign that had been described earlier by Le Damany. It is not clear why Ortolani’s sign did not become widely used in the Northern parts of Europe and in North America, but likely it is related to the fact that writing in the Italian literature prevented it from being broadly disseminated. In 1962, Thomas Barlow of the UK described a provocative test in which one could examine an infant whose hip was in the socket and by adducting and pushing it posteriorly, could cause the hip to dislocate (Fig. 2). In the current era, a skillful examiner combines the Ortolani and Barlow methods when examining an infant for possible DDH.

Fig. 2.

Drawings demonstrating the concept of the Ortolani and Barlow maneuver

Development of Imaging

The brilliant development of technology that allowed one to examine the bones from “outside the body” came from Roentgen in Wurzburg Germany in 1896 and revolutionized our understanding of DDH. Radiologists soon developed specific imaging clues for clarifying the nature and severity of DDH including, Hilgenreiner’s line, Perkin’s line, and many others.

Another notable entrant that revolutionized the diagnosis and treatment of acetabular dysplasia was ultrasound. “Sonar”, as it was called by the military, was developed during war-time to detect submarines and became readily available to the medical community in the 1950s. Graf of Austria was among the first to use it for diagnosing DDH in infancy. This revolutionized the diagnosis and treatment of acetabular dysplasia, particularly non-operative treatment as it allows the physician to monitor the effectiveness of brace treatment on the stability of hip with serial, in office, ultrasounds.

Early Non-operative Treatment

In 1783, Giovanni Battista Palletta, the chief surgeon at the Ospedale Maggiore in Milan, gave the first anatomical description of a congenital dislocation of the hip, which was discovered during the post-mortem examination of an infant. In Paris, Dupuytren [4] studied and reported on the same phenomenon in older children and concluded that a dislocated hip could not be treated.

DDH in this historic era of medicine was largely ignored as it was not life threatening, was rarely painful, and did not impede a person’s ability to perform activities of daily living. Treatment for this condition was first well described by Charles Gabriel Pravaz in 1838 (Lyon) (Fig. 3). He described a method of applying traction that combined continuous traction with increasing abduction and pressure over the greater trochanter. This method allowed for the reduction of a dislocated hip in a small series of patients. This idea was expanded upon in Paris by Jules Guérin [5] who utilized preliminary traction along with a subcutaneous tenotomy, before performing a reduction maneuver. He also used his tenotomy knife to cut the superior capsule over the lateral wall of the ilium, creating adhesions in this area that he thought would encourage hip stability. Buckminster Brown of Boston, who had visited Guerin, took his method back the USA and reported a successful reduction in 1885.

Fig. 3.

Traction type treatment method developed by Pravaz in Lyon (1838)

Splint/Brace/Harness Reduction

The availability of closed reduction and plaster cast immobilization evolved in the late nineteenth century, even before X-ray diagnosis was available. Non-casting methods were not well described until early diagnosis became more common (due to the above described methods of Le Damany and Ortolani).

Various strapping methods and abduction pillows were developed once infantile diagnosis became common. Le Damany [6], Putti [7], Frejka [8], and von Rosen [9] all developed methods for infantile treatment using straps/pillows/splints. In 1958, Arnold Pavlik of Czechoslovakia (1902–1965) published a report of 1912 children with infantile DDH treated with a harness that allowed hyperflexion and controlled abduction, yet maintained constant movement (kicking) by the infant. Pavlik’s father was a horse harness maker and produced the first version, made of leather (Fig. 4). His method is now used throughout the world [10].

Fig. 4.

Arnold Pavlik, developer of the Pavlik harness. Czechoslovakia (1958). His father, who was a horse harness maker, made the early harnesses for him in leather (see photo). Current versions of the harness are made from modern materials

Most subsequent non-casting methods for infantile treatment utilize variations of Pavlik’s concept. Free kicking and motion, with flexion and abduction controlled by straps, allows a dynamic reduction and minimizes the avascular necrosis that was a common sequala of acute manipulative reduction plus a hip spica cast.

Evolution to Open Reduction

Formal, acute, manipulative reduction of DDH under general anesthesia was popularized by Agostino Paci (1845–1902) in Pisa in 1880. This concept was simultaneously popularized in Austria by Adolf Lorenz (1854–1946), with both claiming to be the originators of the concept.

Precursors to Modern Orthopedic Surgery

Several important discoveries paved the way for modern orthopedic surgery to develop, which in turn allowed predictable surgical treatment of DDH. The discovery of anesthesia in 1846 by a dentist in Boston, William Morton, was the first such discovery. Unfortunately for surgical patients of the era, the next important discovery, surgical sterilization, did not become popular until decades later. Joseph Lister, a surgeon from Glasgow was trying to solve the problem of surgical infection when he read the work of Louis Pasteur, a French scientist who developed an understanding of bacteria while trying to find a way to keep wine from souring. After visiting Pasteur in Paris, Lister further studied the bacterial foundation of infection and successfully applied the concept in his operating rooms in Glasgow. Lister traveled to Philadelphia in 1876 and stated, “I can open a joint with absolute certainty that no infection will occur.” Surgical antisepsis greatly decreased the morbidity and mortality rate of surgical procedures.

The next monumental discovery came from Germany when Wilhelm Roentgen described the X-ray in 1896. This discovery earned him the first Nobel Prize in physics and was the foundation for our understanding of a litany of orthopedic conditions and processes. The development of stainless steel in the 1920s was another important milestone for orthopedic surgery. Prior to the development of stainless steel, surgical implants were prone to corrosion, which led to poor clinical outcomes (Fig. 5). Finally, the discovery of antibiotics in the late 1930s rounded out the technological constellation that allowed safe, modern orthopedic surgical intervention.

Fig. 5.

The manufacturing of surgical grade stainless steel (1920s) allowed the development of modern hip implants which made children’s hip surgery more predictable

The first successful open reduction for DDH was described in Bologna by Alfonso Poggi in 1890 who performed the procedure in an adolescent girl. In 1896, Albert Hoffa of Germany developed an anterior approach for open reduction of a hip dislocation that became popular throughout Europe. As open reduction methods became more predictable, surgeons began to rigorously debate as to whether or not dislocated hips in children should be treated with closed or open reduction. Adolph Lorenz (Austria), a thought leader in this era, initially favored open reduction, but his dedication to open methods began to fade when he developed an allergic reaction to the carbolic acid, used to prevent surgical infections. He could no longer operate! He then became famous by traveling around the world demonstrating that children with DDH up to age 8 years could be treated with a “bloodless” closed reduction of the hip (Fig. 6). However, his stated results were not reproducible and many complications, particularly avascular necrosis, were documented when other surgeons tried to implement his technique.

Fig. 6.

Adolf Lorenz (1890s, Vienna) became world famous for his closed reduction techniques for DDH. In this figure, he demonstrated his methods for a large surgical audience in Chicago

In 1908, Karl Ludloff of Germany described a relatively blood-free, and very effective, open medial approach to open reduction of the hip for young children (up to age 2 years). Expert cast application technique was required to maintain reduction with this procedure as no capsulorrhaphy was performed. The approach was not universally accepted, with many centers preferring the typical anterior open reduction described by Poggi, which allowed some capsular repair.

As knowledge of acetabular dysplasia evolved, younger children tended to be treated with closed reduction, and older children were treated with open reduction. These older children were prone to residual subluxation and re-dislocation and surgeons began to develop bony osteotomies to be performed at the time of the open reduction to better stabilize the joint. Most of the early methods focused on the creation of a bony “shelf” at the edge of the acetabulum (Koenig, Hueter, Albee, Hey-Groves, and others). In the United Kingdom and North America (1960s), different methods for providing stability using bony osteotomies evolved. Edgar Somerville, in Oxford (1960s), discovered that a dislocated hip could be more easily reduced if the labrum was excised and a varus, derotational, shortening osteotomy of the proximal femur was performed. At the same time, Robert Salter, (Toronto), insisted that the labrum be left intact and performed a complete osteotomy above the acetabulum, “redirecting” the acetabulum to better cover the femoral head. In the USA Ponseti and Weinstein in Iowa performed important studies confirming the value of medial open reduction and always leaving the labrum intact.

Proximal Femoral Osteotomy

Somerville and Salter were not the first to combine an osteotomy with an open reduction. Franz Koenig [11] and Alfonso Poggi [12] both wrote about improving acetabular coverage using a shelf type acetabular osteotomy.

While an acetabuloplasty along with a closed reduction tended to have predictable results in children up to age 4 or 5 years, older children remained difficult to treat without the addition of a femoral shortening osteotomy. In 1928, Hey-Groves of England, reported a femoral osteotomy to aid in reduction. Omnredanne of France (1930s) was another early champion of femoral shorting in this population. Klisic of Yugoslavia popularized the method in the late 1960s (Fig. 7).

Fig. 7.

Prediag Klisic of Yugoslavia (1960s) was the first to demonstrate the efficacy of adding femoral shortening to surgical reduction in older children

Initially, orthopedic surgeons tended to reserve a femoral shortening osteotomy for children over age 4 or 5 years, but by the early twenty-first century most North American surgeons would consider combining a femoral shortening osteotomy with an acetabuloplasty for DDH reduction in children as young as age 2 years, particularly for high dislocations. Femoral shortening improves reduction stability but also reduces the risk of avascular necrosis. Also, the femoral shortening osteotomy has contributed significantly to the decline in use of pre-operative traction.

Twentieth Century Advances in Surgery to Correct Acetabular Dysplasia

As noted above, even in the late 1800s, surgeons were attempting to improve the size of the acetabulum when surgically treating DDH. These osteotomies were simple Shelf procedures or minimal bending procedures at the very edge of the acetabulum. They were not very effective. All this changed in the mid-twentieth century when unique procedures were developed to more completely correct acetabular dysplasia.

The first important advance was by Wiktor Dega (late 1950s) in Poland who described a bending acetabuloplasty that was “propped open” using triangular segments from the femur which he shortened as part of the hip reduction operation (Fig. 8). This was a bending type acetabuloplasty which did not extend into the sciatic notch [13].

Fig. 8.

Wiktor Dega of Poland (late 1950s) described a bending acetabuloplasty propped open by autograft taken from the femur

As Dega was describing his bending acetabuloplasty, Robert Salter was developing a complete redirectional pelvic osteotomy in an animal model. In the early 60 s, he began a very large series of clinical cases where older children with DDH had an open reduction plus his complete osteotomy which he described as being a “redirectional” procedure (Fig. 9) [14]. He emphasized that an acetabular osteotomy for hip dysplasia should not risk making the acetabulum smaller (as might occur with a “bending” procedure) but instead, it would be best to completely redirect the acetabulum. He held the osteotomy open using a triangular autograft taken from the ilium in the same surgical site. Because the osteotomy was complete, two k-wires were required to stabilize it. He developed a very large series of cases and his procedure became a world standard. Salter did not use a femoral osteotomy as part of his procedure but instead relied on a very comprehensive, specific capsulorrhaphy, which further stabilized the hip.

Fig. 9.

Robert Salter of Toronto (early 1960s) described the innominate osteotomy that has become a world standard

In the mid-1960s, Paul Pemberton of Salt Lake City, Utah, developed a bending osteotomy whose design was very similar to the one described by Dega [15]. The major difference was that he used a slightly curved, single, triangular bone graft taken from the iliac crest. This graft was inserted anterolaterally in the osteotomy site to hold the osteotomy open and thus cover the femoral head. This osteotomy is quite stable and fixation k-wires are usually not required. In many centers, the Pemberton procedure is used instead of the Salter procedure, because k-wires, which probably should be removed at a second operation, were not required (Fig. 10).

Fig. 10.

Paul Pemberton of Utah (1960s) developed a bending acetabular similar to the Dega

In San Diego (early 1990s), Mubarak and Wenger described an osteotomy for treating hip dysplasia in cerebral palsy that utilized a straight lateral osteotome insertion into the ilium with bending in a pure coronal plane [16]. The osteotomy was held open by three symmetrical triangular autografts taken from the adjacent ilium. This procedure was designed to focus correction on the posterosuperior acetabular deficiency that is common in cerebral palsy.

After experience with a large series of patients, it was noted that the osteotomy was extremely stable and never required pin fixation. The simplicity of the coronal plane osteotomy seemed easier to teach residents and trainees—as compared to the Pemberton procedure. Accordingly, Mubarak and Wenger modified their procedure for use in typical hip dysplasia in non-neuromuscular patients. They used three triangular grafts of varying sizes with the largest one used anteriorly [17], which is the location of the deficiency in typical DDH. This provided the same coverage as produced by the Salter and Pemberton procedures but was easier to perform and never requires k-wire fixation. They described this as the “modified” San Diego Acetabuloplasty (Fig. 11).

Fig. 11.

The San Diego acetabuloplasty was developed by Drs. Scott Mubarak (left) and Dennis Wenger (right) (1990s) to treat hip instability in patients with cerebral palsy. It was subsequently modified to treat DDH in typically developing patients

Treatment of Residual Hip Dysplasia—“Hip Preservation Surgery”

As surgical reduction of DDH became more predictable, many of the subsequent developments for DDH surgery relate to the treatment of residual dysplasia. These patients come in two groups. The first are children who had a mild dysplasia in infancy that was never diagnosed or treated, but never resolved. At an older age, they may develop a limp and also may begin to have hip pain with early signs of premature arthritis. The second group of patients, are DDH patients who were diagnosed and treated in early childhood, but did not achieve a perfect reduction and now, as a teenager or even an adult, present with residual hip dysplasia and pain.

It was noted above that many surgeons worked on developing methods to deepen the acetabulum, including Dega, Salter, Pemberton, and others. The same methods that were used to supplement and ensure reduction in a younger child, were now adapted to be used in older children and even adults. In the very recent years, the methods used to treat these patients has been entitled, “Hip Preservation Surgery”. The goal is to use native tissues to normalize the hip joint so that an early total hip replacement can be avoided.

The osteotomies used for residual dysplasia in teenagers and young adults include the Salter pelvic osteotomy, the triple innominate osteotomy (Steel) (Fig. 12), and more recently, the Bernese periacetabular osteotomy of Ganz [18, 19]. Each of these has a specific role for improving acetabular coverage so that the hip will have a prolonged lifespan. Also, as in young children for open reduction, a proximal femoral varus osteotomy can be added to insure full coverage of the femoral head (Fig. 13).

Fig. 12.

The triple innominate osteotomy was first described by Steel (Philadelphia, 1960s). This allows acetabular redirection in older children

Fig. 13.

The Bernese periacetabular osteotomy as described by Ganz (late 1980s). This osteotomy is very stable and suitable for both adolescents and young adults

Corrective surgery for residual hip dysplasia is generally successful, providing the femoral head is not massively deformed from early failed treatment or avascular necrosis. The Bernese PAO can be used in patients up to about age 35–40 years but following that age, it becomes less predictable in relieving hip pain. This older group of patients are more likely to be treated with a total hip replacement in advanced economies. It should be mentioned that hip fusion can still be used for children, teenagers, and young adults with significant residual DDH and severe hip pain, but with so much anatomical deformity that an acetabular and/or femoral osteotomy are not advised.

Summary

The history of DDH is a long, important, and successful story of all that has happened in children’s orthopedics. First, the condition had to be recognized. Then, non-operative treatment methods were applied as surgery could be safely performed only after the late nineteenth century. Since Roentgen’s discovery of the X-ray in 1896, advances in imaging technology have continued to revolutionize our understanding of orthopedic conditions, including DDH. Image intensifiers, computerized tomography scans, magnetic resonance imaging, as well as three-dimensional imaging have all advanced our understanding of how hips become deformed and how surgical management affects the hip. It is still widely accepted that diagnosis soon after birth, and treatment with a Pavlik harness or other device, is the best management scheme. Neo-natal diagnosis by ultrasound helps in achieving this goal. Finally, the development of academic centers that focus on teaching childhood hip disorders, as well as a growing number of centers that focus on hip problems in adolescents and young adults, assure a continuous and changing “history” of childhood hip disease.

Declarations

Conflict of interest

No external funding was received for this paper. This paper was supported by the Rady Children’s Hospital, San Diego Division of Orthopedics. Author JDB has nothing to disclose. Author DRW has the following disclosures: Rhino Pediatric Orthopedic Designs: Stock or stock options. Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties.

Ethical approval

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study, informed consent is not required.