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.

Keywords: DDH; History; Pediatric orthopedics.

Fig. 1

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

Fig. 2

Drawings demonstrating the concept of the Ortolani and Barlow maneuver

Fig. 3

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

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

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

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

Fig. 7

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

Fig. 8

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

Fig. 9

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

Fig. 10

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

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

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