الفهرس 
Anatomy & Biomechanics of the HipOnly 14 pages are availabe for public view
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Abstract
Background: Aim of the Work: The aim of this work is to provide cumulative data about the efficacy and safety of triple innominate osteotomy in management of residual acetabular dysplasia in young adolescent patients. Methods: This review was done using standard methodology outlined in the Cochrane Handbook and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses Results: We found that; the total number of patients in all the included studies was 631 patients; while their average follow up time was (7.2 ± 4.6 years); with longest follow up time of 14.5 years. The average age of all patients was (12.67 ± 3.7 years); with youngest mean age of 7.5 years. Regarding Pre-operative assessment, the average CE angle was (10.4 ± 7.2) degrees, and the average HHS score was (77.7 ± 17.69) degrees. Regarding Post-operative sequel, the overall complications rate was (184/631) (29.1%), and the overall AVN rate was (123/631) (19.5%). Regarding 1ry efficacy outcome measures, Conclusion: Acetabular dysplasia is among the anatomical abnormalities seen in developmental dislocation of the hip (DDH). One of the goals of surgical treatment during childhood is to achieve optimal femoral head coverage by correcting this architectural flaw, thereby preventing osteoarthritis. Pelvic osteotomy is a treatment option in children and adolescents with residual acetabular dysplasia after developmental dislocation of the hip. Keywords: Triple Innominate Osteotomy, Residual Acetabular Dysplasia,. Adolescent Patients 2 INTRODUCTION Regarding the hip, acetabular dysplasia is by far the most frequent, most researched and most successfully treated disorder. It presents as an isolated form or as a prerequisite for subluxation or complete hip dislocation (Developmental Dysplasia of Hip). Insufficient femoral head coverage may develop even in cases of a well-developed acetabulum due to the changes on the femoral head (Legg-Calve-Perthes disease, avascular necrosis of femoral head) (Vukašinović et al., 2009a). The importance of early detection of the diseases lies in early staged treatment – preventive treatment, thus preventing the development of arthritis and preserving hip range of motion. There are different options of the non-operative treatment starting from the earliest age, while surgical treatment is considered only in cases of non-operative treatment failure or in patients with progressed disease. The triple pelvic osteotomy is the most effective surgical management of both dysplasia of the hip and secondary insufficient coverage of the femoral head. According to several authors, it is performed starting from the age of eight (Farsetti et al., 2019). The aim for performing the procedure is to achieve adequate coverage of femoral head and increase congruence of hip joint for preserving hip range of motion and delaying of degenerative changes (Farsetti et al., 2019). Some prerequisites must be fulfilled before surgery: the hip joint must be congruent, mobile (not stiff), not arthritic (Dungl et al., 2007). The triple pelvic osteotomy involves cutting of the pelvis in three places: pubic, ischial and iliac bone. According to the classic operating techniques it is done by three open incisions, and then adequately fixated, with an early start of rehabilitation then assisted weight bearing and walking is allowed. The triple pelvic osteotomy is nowadays considered as the most contemporary surgical treatment of disturbances regarding central positioning, coverage and hip containment in children older than eight years. Throughout the history other methods have been also used, most frequently the Salter pelvic osteotomy – isolated or combined with corrective femoral osteotomy, and the Chiari pelvic osteotomy (Li et al., 2012; Chen et al., 2018). The original triple pelvic osteotomy technique was published by Tonnis in 1979. Compared to the majority of other osteotomy techniques, the advantages of this triple osteotomy consist in the proximal osteotomy of the ischial bone, very close to the acetabulum. Since the osteotomies of the pubic and the iliac bone are also close to the 3 acetabulum, the anterolateral rotation is possible and performed much easier than in other osteotomies (Schmitz et al., 2019). The modification of the technique by Vladimirov (used in Egypt) consists of the anatomic access through two incisions (The first incision is to cut the ischial bone from a separate incision in the gluteofemoral fold, the second part of the operation is performed through a groin incision 8 to 12 cm long which gives an acceptable “bikini” scar for iliac pubic bones) thus sparing and allowing an easier and faster rehabilitation (Breidel et al., 2019; Millis et al., 2018). AIM OF THE WORK The aim of this work is to provide cumulative data about the efficacy and safety of triple innominate osteotomy in management of residual acetabular dysplasia in young adolescent patients. PATIENTS AND METHODS This review was done using standard methodology outlined in the Cochrane Handbook and reported the findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement guidelines (Liberati et al., 2009). Identification of studies: An initial search will be carried out using the PubMed, Cochrane library Ovid, Scopus & Google scholar using the following keywords: triple innominate osteotomy, residual acetabular dysplasia, adolescent, Review articles and bibliographies of each study identified will be searched for additional references that may contain further related studies. Personal contact with colleagues, collaborators and other trialists working in the field of Orthopedic surgery will be made to identify other published relevant studies, When two or more papers were based on an identical study, the paper will be used that principally investigated the outcome of Pre-operative assessment versus Post-operative assessment in residual acetabular dysplasia, adolescent patients, We will consider published, full text studies in English only. Moreover, no attempts were made to locate any unpublished studies nor non-English studies. Types of studies: The review will be restricted to clinical trials, and prospective comparative studies, which studied the outcome of Pre-operative assessment versus Post operative assessment of residual acetabular dysplasia, adolescent patients. Types of participants: Participants with residual acetabular dysplasia, young or adolescent patients. 4 Types of interventions: Pre-operative assessment versus Post-operative assessment of triple innominate osteotomy. Types of outcome measures: At least one of these outcome measures will be considered: Average CE angle “Center-Edge angle “(1ry efficacy outcome), average HHS score “Harris-Hip score “(1ry efficacy outcome), complications rate (2ry safety outcome), AVN rate “avascular necrosis” (2ry safety outcome). Inclusion criteria: English literature, journal articles, between 1990 until 2020, describing managements of residual acetabular dysplasia in young adolescent patients, human studies. Exclusion criteria: Articles describing adult patients, cadaver studies, animal studies. Methods of the review: Locating and selecting studies: Abstracts of articles identified using the above search strategy will be viewed, and articles that appear of fulfill the inclusion criteria will be retrieved in full, when there is a doubt, a second reviewer will assess the article and consensus will be reached. Data extraction: Using the following keywords: triple innominate osteotomy, residual acetabular dysplasia, adolescent, data will be independently extracted by two reviewers and cross-checked. Evidence of publication bias: Will be sought using the funnel plot method. A funnel plot is a simple scatter plot of the intervention effect estimates from individual studies against some measure of each study’s size or precision. RESULTS Table 1: Summary of patients and study characteristics: Author Number of patients Age (average years) Follow up time Total (average years) 1 Dungl et al., 2007 351 16.5 14.5 2 El-Tayeby, 2009 19 10.6 6 3 Vukašinović et al., 2009b 76 15.9 7.25 4 Vukasinovic et al., 2009a 30 10 NR 5 Camurcu et al., 2015 43 9.4 2.8 6 Li et al., 2018 28 7.5 1.85 7 Farsetti et al., 2019 58 16.8 12 8 Teplenky et al., 2020 26 14.7 5.9 #Studies were arranged according to publication year. --- NR: not reported. 5 Table 2: Summary of efficacy outcomes in all studies: Table 3: Summary of safety outcomes in all studies: N Author Secondary safety outcomes Complications rate AVN rate 1 Dungl et al., 2007 111 71 2 El-Tayeby, 2009 4 1 3 Vukašinović et al., 2009b 58 48 4 Vukasinovic et al., 2009a NR NR 5 Camurcu et al., 2015 0 0 6 Li et al., 2018 6 3 7 Farsetti et al., 2019 5 0 8 Teplenky et al., 2020 NR NR Table 4: Meta-analysis of (average CE angle) on Pre-operative assessment vs Pre-operative assessment – Mean difference: N Study Post-operative Pre operative Total SMD SE 95% CI t P value Weight (%) Fixed Random 1 Dungl et al., 2007 351 351 702 0.638 0.07 0.48 to 0.78 68.26 15.66 2 Vukašinović et al., 2009b 76 76 152 1.780 0.1 1.403 to 2.15 11.18 15.40 3 Vukasinovic et al., 2009a 30 30 60 1.153 0.2 0.601 to 1.7 5.36 15.08 4 Camurcu et al., 2015 43 43 86 5.265 0.45 4.36 to 6.16 1.97 14.11 5 Li et al., 2018 28 28 56 3.040 0.39 2.25 to 3.82 2.68 14.50 6 Farsetti et al., 2019 58 58 116 1.191 0.2 0.79 to 1.58 10.16 15.37 7 Teplenky et al., 2020 26 26 52 10.24 1.04 8.15 to 12.33 0.38 9.87 Total (fixed effects) 612 612 1224 1.041 0.06 0.916 to 1.16 16.3 < 0.0001), I2 (inconsistency) = 97.4% and SMD = 2.92. N Author Primary efficacy outcomes CE angle HHS score Pre operative assessment SD Post operative assessment SD Pre operative assessment SD Post operative assessment SD 1 Dungl et al., 2007 7.8 17 36 62 NR NR NR NR 2 El-Tayeby, 2009 NR NR NR NR NR NR NR NR 3 Vukašinović et al., 2009b 16.3 6.41 39.9 9.07 88.9 9.1 96.1 7.6 4 Vukasinovic et al., 2009a 20.4 3.18 37.83 5.37 76.73 8.38 94.5 4.33 5 Camurcu et al., 2015 0.37 7.8 23.7 6.2 53.09 25 86.9 23 6 Li et al., 2018 10.8 5.4 40.9 8.6 92.1 7.7 94 5.4 7 Farsetti et al., 2019 14 10 34 19 NR NR NR NR 8 Teplenky et al., 2020 3 0.2 28 1.6 NR NR NR NR 6 Table 5: Meta-analysis of (average HHS score) on Pre-operative assessment vs Pre-operative assessment – Mean difference: N Study Pre operative Post operative Total SMD SE 95% CI t P value Weight (%) Fixed Random 1 Vukašinović et al., 2009b 76 76 152 0.855 0.16 0.521 to 1.18 46.79 26.64 2 Vukasinovic et al., 2009a 30 30 60 2.630 0.35 1.929 to 3.33 10.86 23.03 3 Camurcu et al., 2015 43 43 86 1.395 0.23 0.920 to 1.87 23.36 25.43 4 Li et al., 2018 28 28 56 0.282 0.26 -0.249 to 0.81 18.98 24.91 Total (fixed effects) 177 177 354 1.065 0.11 0.838 to 1.29 9.22 < 0.0001), I2 (inconsistency) = 90.7% and SMD = 1.25. Table 6: Meta-analysis of (complications rate) - Proportion: N Study SD Proportion (%) 95% CI 1 Dungl et al., 2007 351 31.62 26.790 to 36.771 2 El-Tayeby, 2009 19 21.05 6.052 to 45.565 3 Vukašinović et al., 2009b 76 76.31 65.176 to 85.318 4 Camurcu et al., 2015 43 0.00 0.000 to 8.221 5 Li et al., 2018 28 21.42 8.296 to 40.953 6 Farsetti et al., 2019 58 8.62 2.859 to 18.983 Total (fixed effects) 575 30.14 26.440 to 34.061 Total (random effects) 575 23.62 6.391 to 47.42 Q test for heterogeneity = 134.4, (p < 0.0001), I2 (inconsistency) = 96.3%. Table 7: Meta-analysis of (AVN rate) - Proportion N Study SD Proportion (%) 95% CI 1 Dungl et al., 2007 351 20.228 16.150 to 24.817 2 El-Tayeby, 2009 19 5.263 0.133 to 26.028 3 Vukašinović et al., 2009b 76 63.158 51.314 to 73.942 4 Camurcu et al., 2015 43 0 0 to 8.221 5 Li et al., 2018 28 10.714 2.267 to 28.226 6 Farsetti et al., 2019 58 0 0 to 6.162 Total (fixed effects) 575 18.468 15.394 to 21.867 Total (random effects) 575 12.57 1.293 to 32.902 Q test for heterogeneity = 130.6 (p < 0.0001), I2 (inconsistency) = 96.2%. DISCUSSION The aim of this work is to provide cumulative data about the efficacy and safety of triple innominate osteotomy in management of residual acetabular dysplasia in young adolescent patients. The included studies published between 2007 and 2020. We found that; the total number of patients in all the included studies was 631 patients; while their average follow up time was (7.2 ± 4.6 years). Which came in agreement with Al-Ghamdi et al. (2012); El-Sayed et al. (2014); Li et al. (2018). 7 Al-Ghamdi et al., 2012 reported that, the study group consisted of 20 participants (21 hips), including 18 female and 2 males. The left hip was involved in 12 cases and the right hip was involved in 9 cases. The average follow-up was 87 months (range, 22 to 152 mo). El-Sayed et al., 2014 reported that, the postoperative follow-up period ranged from 24 month to 10 years, with a mean of 62 months (El-Sayed et al., 2014). Li et al., 2018 reported that, this study included a total of 28 hips in 27 patients, 20 with DDH (74.1%; one bilateral) and seven with LCPD (25.9%). Sixteen patients were female (59.3%) and 11 were male (40.7%). The right side was involved in 16 cases (57.1%), and the left side was involved in 12 (42.9%). The average age at the time of surgery was 7.6 ± 1.8 years (range 5–11.9). The mean follow-up period was 21.2 ± 9.8 months (range 12–53). The average age of all patients was (12.67 ± 3.7 years); with youngest mean age of 7.5 years. Which came in agreement with Farsetti et al. (2019); Li et al. (2012); Rampal et al. (2014). Farsetti et al., 2019 reported that, the average age of the patients was 28.5 years (range: 18–44 year). Li et al. 2012 reported that, the mean age at operation in group a (classical technique) was 22.7 years (8–34 years), whereas in group B (modified technique) it was 26.5 years (12– 46 years). Rampal et al., 2014 reported that, median age at surgery was 3 years (range, 1.1–12.2 years), and10 years (6.4–17.8) at end of follow-up. Sex ratio (M/F) was 1/14 pre-operatively. Regarding pre-operative assessment, the average CE angle was (10.4 ± 7.2) degrees, and the average HHS score was (77.7 ± 17.69) degrees. Which came in agreement with Morin et al. (2011); Al-Ghamdi et al. (2012); Klein et al. (2018); Farsetti et al. (2019); Kobayashi et al. (2017); Li et al. (2012); Li et al. (2018). Morin et al., 2011 reported that, the average CE angle was 29 (range 15–50). It was considered as normal in 18 hips, abnormal in one hip and borderline in 12 hips (Morin et al., 2011). Al-Ghamdi et al. (2012) reported that, the mean preoperative CEA was 2 degrees (SD 17) (the dislocated hips were not included in this analysis). The postoperative and follow-up mean CEA angles were 23 (SD 6) and 25 degrees (SD 12). Klein et al. (2018) reported that, evaluation Pre-operatively (Fig. 1), post-operatively, and at last follow-up, supine antero-posterior radiographs of the pelvis were used to measure the vertical-Centre edge angle (VCE) and the acetabular index (AI). The vertical-Centre 8 anterior angle (VCA) was measured at last follow-up on a Lequesne faux-profile radiograph. Pelvic remodeling was evaluated by comparing the VCE and AI values obtained post operatively and at last follow-up. Lateral overcorrection in the coronal plane was defined as AI ≤ 0◦and/or VCE ≥ 35◦. Anterior overcorrection in the sagittal plane was defined as VCA≥40◦. Acetabular retroversion in the coronal plane was defined as presence of the cross over sign (CO+). Farsetti et al. (2019) reported that, the CE angle improved from an average of 14° (range: 9°–19°) at diagnosis to an average of 34° (range: 26°–45°), with an average improvement of 20°. Kobayashi et al. (2017) reported that, the preoperative CEA in operative hips was smaller than those in contralateral hips (operated hips –0.76; contralateral hips 11 p < 0.001. Li et al. (2012) reported that, in postoperative measurement, the mean postoperative Sharp’s angle was 40.961 (34.3–45.41) in group A and 32.231 (22.8–451) in group B. The mean postoperative CE angle in group A and group B was 24.311(7.6–35.51) and 36.411 (29–51.31), respectively. Li et al. (2018) reported that, prior to surgery, 85.7% of hips (6/7) were graded as Herring C, and 14.3% (1/7) were graded as grade B. Prior to surgery, the mean AI and CEA were 19.4° ± 5.3° and 19.1° ± 12.6°, respectively. Regarding Post-operative sequel, the overall complications rate was (184/631) (29.1%), and the overall AVN rate was (123/631) (19.5%). Which came in agreement with Al-Ghamdi et al. (2012) and Kobayashi et al. (2017). Al-Ghamdi et al. (2012) reported that, three patients developed AVN, of the 3, 2 healed with no significant residual deformity; however, the third had significant residual deformity with persistent subluxation and an extrusion index of 0.5 at final follow-up. There were no perioperative complications. None of the patients had subsequent procedures; however, 1 patient was awaiting a repeat pelvic osteotomy. Kobayashi et al. (2017) reported that, the proportion of avascular necrosis (AVN) in this study was relatively high AVN 43%, femoral head. We found 7 studies reported CE angle. The random-effects model of the meta analysis study showed highly significant increase in mean CE angle in Post-operative assessment compared to Pre-operative assessment (p < 0.0001). Which came in agreement with Al-Ghamdi et al. (2012)); Klein et al. (2018)); Farsetti et al. (2019); Nunley et al. (2011); Sankar (2013); Sankar and Zaltz (2020). 9 Al-Ghamdi et al. (2012) reported that, the mean preoperative CEA was 2 degrees (SD 17) (the dislocated hips were not included in this analysis). The postoperative and follow-up mean CEA angles were 23 (SD 6) and 25 degrees (SD 12), respectively (these values include all 20 patients). Comparisons were performed only on the non-dislocated hips and revealed that there was a significant difference between postoperative and preoperative CEA (mean difference, 22 degrees; P = 0.007). Similarly, follow-up versus preoperative CEA showed a significant difference in mean difference (23, P < 0.001). Postoperative versus follow-up CEA was no significant with a mean difference of 1 degree (P = 0.30). Klein et al. (2018) reported that, our results highlight the three-dimensional nature of acetabular overcorrection. We found overcorrection in the coronal plane in 27% (VCE ≥ 35◦) and 15% (IA ≤ 0◦) of hips, overcorrection in the sagittal plane in 46% of hips, and acetabular retroversion in 46% of hips. Overcorrection in more than one plane was uncommon, per-haps because redirection of the acetabulum, although theoretically done in the antero-lateral direction, occurs chiefly in the coronal and sagittal planes. Others have also assessed the radiological outcomes in the coronal plane after osteotomy to redirect the acetabulum. Farsetti et al. (2019) reported that, the difference between the preoperative and postoperative values of the Wiberg angle was statistically significant (P < 0.001). According to Tönnis, the preoperative osteoarthritis was classified as grade 0 (absent) in all our cases, whereas at follow-up, it progressed to grade 1 in nine cases and grade 2 in the two cases with a poor result. Nunley et al. (2011) reported that, the mean Harris hip scores improved from 66.4 points (range, 44 to 100 points) preoperatively to 91.7 points (range, 39 to 100 points; p < 0.001) at the time of the most recent follow-up (at a mean of 29.2 months). Sankar (2013) reported that, at a mean follow-up of 12 years, the lateral CE angle had improved from 5.6 to 29.2 degrees and the acetabular index had decreased from 30.2 to 2.8 degrees. Sankar and Zaltz (2020) reported that, at a mean follow-up of 3.0 ± 2.2 years, all radiographic measures of acetabular dysplasia including the LCEA, AI, and MP were significantly improved. We found 4 studies reported HHS score. The random-effects model of the meta analysis study showed highly significant increase in mean HHS score in Post-operative assessment compared to Pre-operative assessment (p = 0.002). Which came in agreement with Farsetti et al. (2019). 10 Farsetti et al. (2019) reported that, according to the Harris hip scoring system, 16 excellent results, 32 good results, eight fair results, and two poor results were obtained. Thirty-eight patients were completely pain free; 14 patients reported slight hip pain that did not interfere with their daily activities; only two patients reported moderate pain when walking. In one of these patients, there was a painful snapping of the hip in flexion and adduction that limited daily life and sport activities. Eight patients had a positive. I 2 (inconsistency) was 96.3%; with highly significant Q test for heterogeneity (p < 0.0001); so random-effects model was chosen to assess post-operative sequel; with overall (complications rate) = 23.6%. Which came in agreement with Farsetti et al. (2019); Li et al. (2018); Morin et al. (2011). Farsetti et al. (2019) reported that, there were five complications; in one case, the CT scan with 3D reconstruction showed marked anterior prominence of the acetabulum, with deficient posterior coverage of the femoral head. Four patients showed an asymptomatic nonunion of the ischium. No neurovascular complications, wound infections, or thromboembolism were observed. Although the screws were removed in all patients, in six cases, it was difficult to remove the titanium cannulated screws owing to partial osteo integration. Li et al. (2018) reported that, Minor complications were recorded in seven patients (25.9%): three patients developed asymptomatic non-unions (10.7%) of the ischial osteotomy, and four had a transient dysesthesia in the territory of the lateral cutaneous nerve. Morin et al. (2011) reported that, Complications occurred in 12 out of 23 patients. Postoperative minor complications occurred in nine patients and included fractures around the knee, transient stiffness, superficial sepsis around the K-wire and premature partial closure of the Y cartilage. Postoperative major complication occurred in five patients and included AVN of the femoral head, displacement of the innominate osteotomy, with residual subluxation. In these cases, it was necessary to complete later on the treatment programme with a femoral osteotomy in one case and a triple pelvic osteotomy in the other case. I 2 (inconsistency) was 96.2%; with highly significant Q test for heterogeneity (p < 0.0001); so random-effects model was chosen to assess post-operative sequel; with overall (AVN rate) = 12.5%. Which came in agreement with El-Sayed et al. (2014). El-Sayed et al. (2014) reported that, AVN was detected in nine cases during the follow-up period. It was noted that one of those patients had had preoperative signs of AVN. They were classified according to the Bucholz–Ogden classification into 3, 2, 2, and 2, for types I, II, III, and IV, respectively. There was no statistically significant incidence of AVN 11 between the different types of osteotomies used. However, there was a statistically significant correlation between the younger age group of patients (A) and the incidence of AVN. CONCLUSION Acetabular dysplasia is among the anatomical abnormalities seen in developmental dislocation of the hip (DDH). One of the goals of surgical treatment during childhood is to achieve optimal femoral head coverage by correcting this architectural flaw, thereby preventing osteoarthritis. Pelvic osteotomy is a treatment option in children and adolescents with residual acetabular dysplasia after developmental dislocation of the hip. 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