PrevalenceThe 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.

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.

Effect on LifestyleDDH 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.

ConclusionTo 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.

AcknowledgementsMuch thanks to Peter Szocs and many staff members of the Muzeul JudeteanSatu 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 Cited1. Dwek JR, Chung CB, and Sartoris DJ. 2002. Developmental dysplasia of the hip. In: Resnick D, editor. Diagnosis of Bone and Joint

Disorders. Fourth ed. Philadelphia: W.B. Saunders Company. p 4355-4381.2. Hartofilakidis G, Yiannakopoulos CK, and Babis GC. 2008. The morphologic variations of low and high hip dislocation. Clinical Orthopedics and Related

Research 466:820-824.3. Roberts CA, and Manchester K. 2005. The Archaeology of Disease. Ithaca, NY: Cornell University Press.4. Ortner DJ. 2003. Identification of Pathological Conditions in Human Skeletal Remains. New York: Academic Press.5. Eng JT. 2003. Bioarchaeological analysis of an agricultural population from late medieval Transylvania. American Journal of Physical

Anthropology Supplement 36:93.6. Sartoris DJ. 1995. Developmental dysplasia of the hip. In: Resnick D, editor. Diagnosis of Bone and Joint Disorders. 3rd ed. London: W.B.

Saunders. p 4067-4094.7. Peled E, Eidelman M, Katzman A, and Bialik V. Ibid.Neonatal incidence of hip dysplasia: ten years of experience.771-775.8. Kokavec M, and Bialik V. 2007. Developmental dysplasia of the hip: prevention and real incidence. Bratislavske Lekarske Listy 108(6):251-

254.9. Coleman S. 1968. Congenital dysplasia of the hip in Navajo infants. Clinical Orthopedics and Related Research 56:179-193.10.Rabin DL, Barnett CR, Arnold WD, Freiberger RH, and Brooks G. 1965. Untreated congenital hip disease. American Journal of Public Health

Nations 55(2):1-44.11.Forst J, Forst C, Forst R, and Heller KD. 1997. Pathogenetic relevance of the pregnancy hormone relaxin to inborn hip instability. Archives

of Orthopaedic and Trauma Surgery 116(4):209-212.12.Galloway J, Goldberg B, and Alpert J. 1999. Primary Care of Native American Patients: Diagnosis, Therapy, and Epidemiology. Boston:

Butterworth-Heinemann.13.Mahan ST, and Kasser JR. 2008. Does swaddling influence developmental dysplasia of the hip? Pediatrics 121(1):177-178.14.Cooperman D, Wallensten R, and Stulberg S. 1983. Acetabular dysplasia in the adult. Clin Orthop 175:79.15.Lievense AM, Bierma-Zeinstra SMA, Verhagen AP, Verhaar JAN, and Koes BW. 2004. Influence of hip dysplasia on the development of

osteoarthritis of the hip. Annals of the Rheumatic Diseases 63:621-626.

A case study of developmental dysplasia of the hip and hip dislocation in a post-Medieval Transylvanian population

Jacqueline T. Eng and Connor HagenDept. Anthropology, Western Michigan University

Developmental Dysplasia of the HipDevelopmental 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.

Today, doctors screen newborns for predisposition for DDH, but in the pre-modern 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 SampleIn 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.

Methods: Diagnosing DDHDoctor 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

Figure 3. Observations of hip joint, adult Bobald sub-sample only

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).

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 cribraorbitalia and antemortem loss of LM1 and RM1. The vertebrae also display some age and activity related changes, with slight to moderate vertebral osteophytosisof 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).

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.

Table 1. Modern rates of DDH 9,10

compared to Bobald Table 2. Risk factors for DDH

Figure 5. M3 adult female with affected left hip

Figure 4. M22 adolescent female with affected right hip (normal left acetabulum in center)

M oldova

Transylvania

Wallachia

OTTOMAN EMPIRE

Serbia

HUNGARY

CAREI

Cluj

Oradea

Debretin

Cernauti

Siret

Suceava

Baia

Satu Mare

Targu Mures

Alba Julia

Sibiu Brasov

Targul Putnel

Buzau

AradSeghedin

Orsova

Targa Jiu Targoviste

Severin

Calafat Turnu

Giurgiu

Nicopole

RusciucTurtucaia

Silistra

BucharestCalarasi Constanta

HarsovaTargul de Floci

Braila

Galati

Chilia

Ploiesti

Razgrad

Smederevo

Belgrade

Timisoara

Hotin

Iasi

Chisinau

VasluiCetatea Alba

Cahul

Tighina

Pitesti

The Black Sea

Som

es R

.

Danube R.

Tisza R.

ROMANIA

Figure 2. Map of region, circa AD 1500

Figure 1. Continuum of hip alignment A: Normal. B: Dysplasia. C: Subluxation. D: Luxation

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.