I am pleased that paleopathology is starting to interest also non paleopathologists and that our paper on hip dysplasia of Giovanna from Austria and of her daughter Anna (1) received comments by colleagues (2). However, the approach of paleopathology is very different from modern medicine, which deals with living patients, and for this reason it requires specific competences. With regard to the criticisms that have been made of the diagnosis, it should be said that the authors of the comment did not have the opportunity to directly observe and study the skeletal remains of Giovanna and Anna; their observations were limited to the radiological and macroscopic imagines found in literature and their comments are based purely on indirect documentation, which can be misleading.
In the original title reference was made to the Medici family because Giovanna was historically more famous at the Florentine court than in Vienna, but her origins are clearly stated as she is named Giovanna “from Austria”; Anna, as daughter of Francesco I, is a Medici to all effects. Therefore the reader cannot misinterpret the title.
As concerns the presence of hip dysplasia in the Medici, I wonder how they could have “researched the pathological conditions of the males in the Medici family” (2). In any case, no other cases of hip dysplasia, which however shows a predilection for the female sex, as highlighted in the original paper (1), were detected in the members of the Granducal line that I have studied so far (5).
The authors of the commentary demonstrate a poor knowledge of the literature concerning the paleopathological studies of the Medici. The lesions observed in the acetabular roofs of Giovanna had already been cited also in very preliminary reports (3, 4, 5), where an incomplete dislocation of the hip was diagnosed; references to Anna were absent in these papers because her skeletal remains had not yet been studied at that time. The paper cited by the authors of the commentary is based only on the radiological study (6) and the X-ray of Giovanna’s pelvis which was not carried out in a precise standard projection, owing to her pelvic deformity. These factors thus prevented a correct lecture, so that the lesions of Anna were not appreciable in the radiological image. Therefore, macroscopic observation remains the best method to diagnose acetabular dysplasia in skeletal remains.
Unlike modern medicine, which requires radiological examination to investigate bone lesions, in paleopathology the direct observation of the bone is possible and easy and, in many cases, the imaging techniques would not add any useful information. Furthermore, in the case of Giovanna and Anna, the absence of soft tissues does not allow to obtain a valuable image of the hip joints with the femur in connection. Therefore the request of the commentary’s authors to present X-rays or AP photos to illustrate the hip joint against the head of the femur is inconsistent. As clearly stated in the original paper (1), the defect is only in the acetabular roofs of both women, whereas no lesions are present neither in other parts of the acetabular cavities nor in the femoral heads.
However, to better clarify the diagnosis, a further image of the left acetabular cavity of both Giovanna and Anna is provided; the image clearly shows, from a lateral view, that the acetabular roofs are sloping (Fig. 1 A and B).
As clearly specified in the original paper, the reference to swaddling was only speculative (1), but this is considered an important, possible risk factor together with other ones listed in the paper.
The attempt to measure an abnormal angle of the acetabular roof, performed by the commentary’s  authors on an X-ray image with an “imaginary femoral head” in the very deformed pelvis of Giovanna, is purely imaginative and unfounded and therefore has not scientific value. In fact, it is self-evident that the deformity of the bones and the irregular projections, together with the absence of the femur head in connection, prevented any reliable measurements.
Finally, it is curious that the authors of the commentary criticise the identification of acetabular dysplasia, but do not provide any alternative diagnosis to explain the observed lesion.
In conclusions, the lesions of the acetabular roof of the pelvis of Giovanna and Anna are macroscopically evident, and the diagnosis of non severe developmental hip dysplasia is confirmed.

Lateral view of the left acetabular cavity of Giovanna (A) and Anna (B), with evident hip dysplasia (arrows)


  1. Giuffra V, Fornaciari G. Developmental hip dysplasia in the Medici family. Hip Int. 2013;23(1):108-9.
  2. Weisz M, Matucci-Cerinic M, Albury WR, Lippi D. Revealing the secrets of the Medici family – no proof as yet for hip dysplasia on "Developmental hip dysplasia in the Medici family”. Hip Int. 2013;23 (1):108-109.
  3. Fornaciari G, Vitiello A, Giusiani S, Giuffra V, Fornaciari A, Villari N. The Medici Project: first anthropological and paleopathological results of exploration of the Medici tombs in Florence. Med. Secoli 2007;19:521-44.
  4. Fornaciari G, Vitiello A, Giusiani S, Giuffra V, Fornaciari A. The “Medici Project”: first results of the explorations of the Medici tombs in Florence (15th-18th centuries). Paleopathol. Newsl. 2006;133:15-22.
  5. Fornaciari G. Il Progetto Medici: primi risultati dello studio paleopatologico dei Granduchi di Toscana (secoli XVI-XVIII). Archivio per l’Antropologia e la Etnologia. 2009;138:138-157.
  6. Villari N, Fornaciari G, Lippi D. Scenes from the past: the Medici Project: radiographic survey. Radiographics 2009;29(7):2101-14.