Summary: Nine patients with developmental dislocation of the hip who had no treatment other than observation were followed up for an average of 46 years. Seven of the 9 patients had bilateral hip dislocations. None of the hips developed avascular necrosis. Overall clinical and functional results were very satisfactory despite uniformly unsatisfactory radiographs. These patients achieved a better quality of life than have many patients of similar age who have undergone surgical treatments aimed at reducing such late-presenting hip dislocations.
Key Words: Developmental hip dislocation—Natural history—Untreated
The long-term follow-up and results of surgical treatment of developmental dislocation of the hip (DDH) have been considered by many authors (11,13–15). To date, however, few publications reviewed the natural history of DDH, as manifested in the untreated patient (12,18). Such information is of vital importance because at times older children with DDH have few if any signs or symptoms. Thus the orthopaedic surgeon may not be able to judge whether or not contemplated surgical treatment is superior to the natural history of the disease.
Management of these older children with unrecognized hip dislocations continues to be fraught with complications. Failure to achieve reduction, joint stiffness, avascular necrosis (AVN), deformity of the femoral head, and subluxation or redislocation are common sequelae after operative treatment (10,15). AVN, the most devastating of these hip complications, is said not even to occur in untreated patients (9,10,17,21). The purpose of this study was to describe the outcomes associated with DDH in a group of untreated individuals.
A retrospective chart and radiograph review was performed of 237 patients diagnosed with DDH from 1950 to 1975 at the Henry Ford Hospital. Nine patients, aged 9–60 years, were identified as having had no treatment other than observation. Information relative to clinical presentation, symptoms, physical function, and occupation was abstracted from each patient's chart. Information relative to femoral head size, pseudoacetabulum formation, degenerative joint disease, and trochanteric overgrowth was obtained via review of each patient's radiographs.
The study group was composed of eight women and one man. Seven patients experienced bilateral hip dislocations, whereas the other two patients had left hip dislocations. The patients' average age at most recent follow-up was 46 years (range, 16–60 years). The average age at which the diagnosis of DDH was made was 7 years (range, 3–16 years). Two aspects of the clinical history were similar in all 11 patients: (a) a waddling gait noted from earliest childhood, and (b) a normal childhood and young adult life (Fig. 1). Additional information on each patient is available in Table 1.
Physical examination of these patients revealed that all dislocated hips had fixed flexion contractures, but further flexion was normal. A significantly increased lumbar lordosis with protuberant abdomen compensatory to the hip-flexion deformity also was noted (Fig. 2). The hyperlordotic spine was associated with complaints of mechanical low back pain in five of the nine patients. External rotation and internal rotation of the dislocated hips was actually increased.
Regarding radiographic appearance, all dislocated hips were somewhat hypoplastic, but with round femoral heads (Fig. 3). They were high-riding and articulating in pseudoacetabuli or on the soft tissue adjacent to the ileum. Three of the nine patients developed early degenerative changes in both the femoral heads and pseudoacetabuli, but not before the fourth decade of life.