The National Ribat University

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1 بسم هللا الرحمن الرحيم The National Ribat University Faculty of Graduate Studies and Scientific Research Measurements of Acetabular Angle among Sudanese Population in Omdurman Teaching Hospital (march to June 2015) Research submitted for partial fulfilment for requirement of MSc in human and clinical anatomy By: yousif Abdallah yousif adam Supervisor: Prof. Tahir Osman Ali

2 Dedication To the soul of my father, To my family.

3 Acknowledgement I would like to thank department of human anatomy in the National Ribat University for conducting this great program, special thanks to prof. Tahir the chief of program. I would like to thank those who help at finishing this job. Special thanks to Dr. Nora Fathallah.

4 List of abbreviation DDH REF IVU developmental dysplasia of the hip References intravenous program

5 List of figures Figure number Figure title Figure (4.1) Figure (4.2) Figure (4.3) Figure (4.4 ) gender distribution degree of acetabular angle in age groups types of pelvic x-ray used in the study different age groups included in the study and their percentages

6 List of tables Table number Table (4.1) Table (4.2) Table (4.3) Table (4.4) Table (4.5) Table (4.6) Table (4.7) Table title gender distribution value of acetabular angle in Sudanese male value of acetabular angle in Sudanese female degree of the acetabular angle in different age group the mean for age and mean for acetabular angle the degree of acetabular angle and their frequency degree of acetabular angle in group and gender

7 Abstract Introduction: acetabular angle is one of the most important osteometric measurements. It has very wide implications in clinical and medicolegal practice. Objective: to determine the acetabular angle in Sudanese population, to assess the sex influence, to compare these results with international results. Design: This is an observational descriptive cross-sectional hospital based study. Material and methods: This study was conducted at Omdurman Teaching Hospital during the period from March to June 2015, (107) of patients who came for plain pelvic x-ray or IVU are taken as study targets. Result: The mean of acetabular angle in males was (37.3) and in females was (35.2) with significant statistical difference. The maximum angle observed in male was 42 with 29 was the minimum. In females the maximum angle was 38 and 29 was the minimum. Conclusion: The anatomical difference in this study was significant. Sex influences geometrical measurements of the acetabulum; the male s angles are greater than that of females. In comparing the acetabular angle of both sexes in Sudanese subjects with others there was a high statistical significant racial variation.

8 CHAPTER (1) INTRODUCTION, Problem statement and OBJECTIVES

9 1. Introduction 1.1. Sex determination of skeleton: When the entire dead body is available sex can be determined in majority of cases by dissection. In mutilated it is easy to identify remains when the parts bearing sex characteristics are available such as uterus and its appendices, breast and prostate. When soft tissues of sexual characteristics are not available, the determination of sex must be based on bones. (4) Sex determination of human skeletal remains is more accurate and applicable on mature adult skeleton. The degree of accuracy is dependent on skeletal completeness. If complete skeleton is available the accuracy can be reached up to 100%. When the skeleton is incomplete the most reliable and accurate remains are the skull with 90% accuracy and bony pelvis with 95% accuracy. Using both, the skull and the bony pelvis remains accuracy can reach up to 98%. (4) The pelvis shows marked differences in sex than any other bone. These sexual characteristics are established early in development, but become apparent only on puberty (hormonal stimuli from pubertal ovary and active growth). The pelvic

10 parameters used in sex determination of skeletal remains are numerous. (4) 1.2. Identification of human skeletal remains: It is one of the most important investigations in forensic medicine and forensic anthropological studies. Many different skeletal remains had been used to help sex identification. One of the most frequently used and most accurate tools is the bony pelvis. (REF) There are many differences in osteometric and morphological studies comparing male and female bony pelvis. These differences are mostly related to physiology of female pelvic which has adapted to house the gravid uterus and facilitate easy passage of the baby during delivery. The diameters of female pelvis are larger that male pelvis. (REF) The different parts of the bony pelvis had been studied to find out these differences in both sexes and their significance in sex identification. One of the most parameters used are the shape and the contour of the articulated pelvis regarding the shape and diameters of the pelvic inlet and outlet. (REF) Other points that noticed to be different between the two groups are the acetabular angle, subpubic

11 angle (SPA), obturator foramen, ischial spine, and the ischiopubic index. (REF) A new method of arthrographic measurement: The acetabular cartilaginous angle (ACA), is used in order to find a simple, reliable, and reproducible measurement that can predict future acetabular development after successful closed reduction of developmental dysplasia of the hip (DDH),the study was conducted in Saudi arabia and the conclusion was Acetabular cartilaginous angle is considered a reliable measurement to identify hips with DDH that will need later acetabuloplasty after successful closed reduction and the acetabular index is important in monitoring acetabular development. (REF) 1.4. Geometric measurements of the acetabulum in adult Malawians: The study aimed to determine the acetabular depth as well as acetabular and centre edge angles; to assess the influence of sex, if any, in these geometric measurements; and to determine the prevalence of hip dysplasia in adult Malawian. The conclusion was that Sex influences geometrical measurements of the acetabulum. The prevalence of hip dysplasia with respect to centre edge angle was significantly higher in women than men and the prevalence for men

12 with respect to centre edge angle was significantly different when compared with Nigerian and Chinese men Radiologic Determination of Acetabular Index and Centre Edge Angle in Nigerian Population: This study was carried out to give a report on the average acetabula index and centre edge angle, its sexual dimorphism in South-South Nigerian population and to examine if there is racial differences in acetabular index and centre edge angle when compared to other races. The conclusion was the mean centre edge angle of males and females were ±5.53 and ±5.74. The female centre edge angle was significantly higher than that of the male centre edge angle. The mean acetabular angle of Sharp for males and females were ±4.04 and ±3.65. (11) 1.6. How should the acetabular angle of sharp be measured on pelvic radiograph: Four experienced orthopaedic surgeon measured the acetabular angle of sharp in 66 hips by using two methods, the classical method the lateral margin of the acetabular roof was used as landmark, the modified method the lateral margin of the sourcil was used as landmark and the

13 acetabular angle was 48.4 degrees and the mean for that was 44.8 degrees.(ref) 1.7. Role of ultrasound in measuring aceabular angle: Anew method of measuring acetabular angle by using ultrasound,normal acetabular roof are delineated as curvilinial hyperechoic lines on the screen,where as in dysplastic hips the the outlines of the acetabular roofs are shallower and more vertical the value elicited by ultrasound were in reasonably good agreement with those derived from roentgenography. The conclusion was that ultrasound is safe, handy and effective for measuring the acetabular angle. (1, 2, 3) This study concentrates on the acetabular angle measurement to notice the different values between both sexes among Sudanese population and if this difference, (if any) could be statistically significant Problem statement: Normal values in children The acetabular angle using Hilgenreiner's line should be less than 28 degrees at birth. The angle should become progressively narrower with age. Normal values in adults The normal range is 33 to 38 degrees. Angles above 47 degrees are seen in patients with acetabular dysplasia. A measurement between 39 and 46 degrees is indeterminate.

14 Additionally, having the center beam above or below the pubis can alter the measurment due to geometric distortion. However a 5 cm error in beam alignment only changes the measurement by 4º. This does highlight that these measurements should not be performed on an abdominal radiograph. In light of this situation the study aims to identify avarge normal range of acetabular angle amonge Sudanese population, those who come for pelvic X-ray in radiological department of Omdurman teaching hospital between March and june 2015 are taken as example.

15 1. Objectives: 1.1. General objectives: To assess the acetabular angle in Sudanese population Specific objectives: This research is undertaken to: 1- Determine the average acetabular angle in Sudanese males. 2- Determine the average acetabular angle in Sudanese females. 3- Identify if there is any significant difference in acetabular angle in Sudanese males and females subjects. 4- Compare the acetabular angle in Sudanese population with that of other populations.

16 CHAPTER (2) LITERATURE REVIEW

17 2. Literature Review 2.1. Definition: The acetabular angle is a radiographic measurement used when evaluating potential developmental dysplasia of the hip (DDH). It is most useful in patients who have started to ossify the epiphysis since ossification diminishes the usefulness of ultrasound. The angle is formed by a horizontal line connecting both triradiate cartilages (Hilgenreiner line) and a second line which extends along the acetabular roofs. In the adult, where the triradiate cartilages are fused and therefore unapparent, the inferior margin of the pelvic tear drop is used instead. This shifts the horizontal line inferiorly and changes the value of the angle Anatomy: The bony pelvis: The bony pelvis is formed of four bones that articulate together to enclose the pelvic cavity. The sacrum and the coccyx are in the midline posteriorly. Laterally there are the two hip bones that articulate in the midline anteriorly at the symyphysis pubis, and posteriorly the hip bone articulates with the sacrum at the sacroiliac joint. (1, 2, 3) The hip bone: Is formed of three bones, pubis, ischium and ilium fused at the acetabulum. The pubis and the ischium form together an incomplete bony wall of the pelvic cavity.

18 The pubis is formed of body, superior and inferior rami, the body of the pubis being more medial and triangular in shape. The two pubic rami project from the body laterally. The superior pubic ramus joins the ilium at the acetabulum and the inferior ramus joins the ischium and enclosed between the two rami is the obturator foramen. (1, 2, 3) The pubis: The right and left pubic bones join together at the midline with their symphyseal surfaces that are covered with hyaline cartilage to form a secondary cartilaginous joint (the symphysis pubis). The upper border of the body of the pubis is known as the pubic crest. it is marked laterally by a forward projection, the pubic tubercle. From the pubic tubercle diverge laterally two ridges, the upper one is the pectineal line which extends into the superior ramus and joins the arcuate line of the ilium.the lower one is the obturator crest, that passes to join the anterior margin of the acetabular notch. Between the two ridges is the iliopubic eminence. (1,2,3) The inner surface of the body of the pubis and the superior ramus are bares bone with no muscular attachment. The inner surface of the inferior pubic ramus gives attachment to the pelvic floor muscles. (2) The ischium: The ischium is an L-shaped bone formed of body, inferior ramus, ischial tuberosity and ischial spine.

19 The body is the center of the L-shaped bone that supports weight in sitting position. The inferior ramus of the ischium fuses with the inferior ramus of the pubis forming the ischiopubic ramus. The upper part of the body of the ischium joins the ilium and the pubis at the acetabulum. The ischial spine projects medially from the posterior border of the ischium forming an important anatomical land mark separating the greater and the lesser sciatic notches. In living these notches forms the greater and the lesser sciatic foramens. The ischial tuberosity is arugged prominence its posterior rough part gives attachment to the muscles of the posterior compartment of the thigh (the hamstring muscles). The inner surface of the body of the ischium is very gently concave and smooth giving attachment to the pelvic floor muscles. (1, 2, 3) The ilium: Is fan-shaped, its ala resembles the spread of a fan and its body represents the handle. The iliac fossa is a concavity in the ala of the ilium and forms part of the posterior abdominal wall. The ilium forms the superior two-thirds of the hip bone and the superior two-fifths of the acetabulum. The iliac crest is the superior margin of the ilium. It has external and internal lips. It ends anteriorlly in a rounded anterior superior iliac spine and end poteriorly in a sharp posterior superior iliac spine. (1, 2, 3) In the external lip of the iliac crest 5 cm posterior to the anterior superior iliac spine is the tubercle of the iliac crest.

20 The gluteal surface faces inferiorly in its posterior part and laterally and slightly downwards in front. It is bounded above by the iliac crest below by the upper acetabular border and by the anterior and posterior borders. It is rough and curved and marked by three gluteal lines, the anterior, the posterior and the inferior gluteal lines. (1,2,3) The acetabulum: Is a concave hemisphere with a deficient inferior margin (the acetabular notch). Its cavity is wider above than below. It articulates with the head of the femur ( the hip joint) the head of the femur being inside the acetabulum, but the articular surface of the acetabulum does not reach its floor ( the acetabular fossa no articualr surface). (1,2) The three parts of the hip bone meet. The pubis and the ilium meet at the anterior pole of the acetabulum (the iliopubic eminence) the ilium and the ischium meet just above the posterior pole of the acetabulum. (1,3) The pelvic outlet (inferior pelvic aperture): It is indented behind by the coccyx and the sacrum and bilaterally by the ischial tuberosity. Its perimeter consists of three wide arcs. Anteriorally is the subpubic arch. Posteriorally and laterally on both sides are the sciatic notches between the sacrum and ischial tuberosity. These are divided by the sacrotuberous and sacrospinous ligaments into greater and lesser sciatic foramina. (1,3)

21 Three measures are made for the pelvic outlet. The anteroposterior, the tranverse and the oblique diameters. (3) Growth of the hip bone: Development: The hip bone develops in cartilage with three primary ossification centers, one for each part of the bone. First to appear is the primary ossification centre of the ilium at the second month of fetal life. Then it is followed by that of the ischium at the third month, then pubis at the fourth month. At birth acetabulum is wholly cartilage. The three bones meet at the acetabulum in a Y-shape junction (cartilage). With age the ossification centers grow and enlarge tiil they fuse. The pubis and ischium fuse at age of seven years. (1) Ossification: 0ssification of the Y-shape cartilage begins at age of 12 years and is completed by 15 years of age. The hip bone is completely ossified at about 25 years. (1, 2, 3)

22 CHAPTER (3) MATERIALS AND METHODS

23 3. Materials and Methods 3.1. Study Design: This is an observational descriptive cross-sectional hospital based study Study Area and duration: The study was conducted at Omdurman teaching hospital during March to June Study Population: Study population includes patients referred to Omdurman teaching hospital for pelvic X-ray, Including plain pelvic X- rays, or X-rays of intravenous urogram (IVU) series Sample Size: All patients referred to Omdurman teaching hospital during the period march to june 2015 were included with a total of 107, (54 males and 53 females) Inclusion Criteria: All pelvic X rays that clearly shows the acetabular angle Exclusion criteria: All X- ray films that showed pelvic or lower limb fracture. All X-ray films with inappropriate alignment.

24 Patients with any pelvic or urological disease Data Collection: Data was collected from X-ray films and images of pelvic region taken from patients with no orthopedic or urological diseases. After that the X-ray films are printed out then the acetabular angle was measured by drawinga horizontal line connecting both triradiate cartilages (Hilgenreiner line) and a second line which extends along the acetabular roofs. Then the acetabular angle measured by using the goniometer. Data collection sheets were used to include the study variations and to record the results Data Analysis: Data was analyzed both, manually and with SPSS computer program version Data Management: Data was analyzed as mentioned above, then presented and described by using the text, tables and figures Ethical Considerations: Consents were delivered to the Radiology Department at Omdurman Teaching Hospital prior to data collection.

25 CHAPTER (4) RESULTS

26 4. Results One hundred and seven patients, who attended to omdurman teaching hospital and underwent pelvic X- rays, were included in this retrospective hospital based study. 54 of these patients were males (50.5%) and 53 were females (49.5%) as shown in table (4.1) and fig. (4.1) Figure 4.1.: showing gender distribution Male Female Table 4.1.: showing gender distribution Gender Frequency Percent Male Female Total

27 A fifty four male pelvic X-rays had been examined and acetabular angles were measured, it was found that the maximum degree of the acetabular angle was 42 and the minimum degree was 29, Mean angle was 37.3 and the standard deviation (SD) was 2.0 as shown in table (4.2), Table 4.2: Values of acetabular angle in Sudanese males. Sex N Range Mean SD Male After measuring the acetabular angle in the fifty three female pelvic X-rays it was found that, the maximum degree was 38 and the minimum degree was 29, with a mean value of 35.2 and SD of 2 as shown in table (4.3). Table 4.3: Values of the acetabular angle in Sudanese females. Sex n Range Mean SD Female

28 Table 4.4 showing the degree of the acetabular angle in difference age group. Degree of acetabular angle in group Angle degree Frequency Percent Total (62.6) of them were from (34) to (37) Angle from Anglefrom Anlge from Figure 4.2: showing the degree of the acetabular angle in different age groups.

29 Approximately Eighty four percent of the data were collected from plain pelvic x-rays and fifteen percent were from IVU 15.9 plain x-ray Series of IVU 84.1 Figure 4.3 showing the type of pelvic x-ray used in the study more than 45 years years years 0 Figure 4.4 showing the different age groups included in the study and their percentage.

30 Table 4.5 showing the mean and SD for age and acetabular angle. N Mean Std. Std. Error Deviation Mean Age Degree of acetabular angle Degree of acetabular angle Frequency Percent Total Table 4.6: showing the degree of the acetabular angle and its frequency. (Values (35),(36)and (37) are the commonest).

31 Table 4.7 showing the relation between degree of the acetabular angle and the gender (most of the degrees are between (34) to (37) in both sex). Degree of acetabular angle in group * Gender Degree of acetabular angle in group Gender Male Female Total Total

32 CHAPTER (5) DISCUSSION

33 5. Discussion The present study focuses on the presence of normal anatomical variation on the acetabular angle by analyzing pelvic X-rays of 107 subjects. The results were compared with some published studies discussing the same issue. Out of 107 patients 54 were males and 53 were females. The mean of acetabular angle in males was (37.3) and in females was (35.2) with significant statistical difference. The maximum angle observed in male was 42 with 29 being the minimum. In females the maximum angle observed was 38 and 29 was the minimum. (62.6%) of the the participant have the acetabular angle between (34) and (37) degree so this mean that the normal angle for the Sudanese in both sex is between these degrees. In the study the mean for age is about (42.1) with standard deviation (13) and the mean for degree of acetabular angle is (36) with standard deviation (2.2). The acetabular angle described by Sharp (1961) is one of the most common radiographic measurements used to assess acetabular dysplasia. Nakamura et al. (1989) reported a mean acetabular angle of 38 (S.D., 3.6 ) (males, 37.3 (S.D., 3.7 ); females, 38.6 (S.D., 3.4 )) among the Japanese population. Stulberg and Harris (1974) reported the mean acetabular angle of 32.2 in white males, whereas Harris (1986) reported 32.1 in white females. Han et al. (1998) reported the mean acetabular angle among Koreans to be 37.0 (S.D., 3.7 ) (males, 36.5 (S.D., 3.5 ); females, 37.5 (S.D., 3.8 )). In a Singaporean study by Umer et al. (2006), the mean acetabular angle was

34 39.46 (S.D., 6.04 ) (males, (S.D., 6.00 ); females, (S.D., 5.98 )). The mean Sharp angles for Egyptian men were 36 ±2.7 and for women were 38.8 ±2.4 (Tarek, 2011). (5, 6, 7, 8, 9) In study conducted in South Nigerian Population the total mean acetabular angle was ±3.85 The mean acetabular index for males was ±4.04 and ±3.65 for females, this almost similar to our result. (11) In study conducted in a Malawi population the mean of acetabular angles in men was more than in women (29.43 ), and this difference was significant (P<0.001), so that these values are lower from our result. (10) In this present study, the mean for degree of acetabular angle is (36), SD (2.2), the mean values is lower that of the Japanese, Singapore and Koreans population. But it is almost similar to the Egyptian, Nigerian population and higher than the Malawians population. All the studies showed that the acetabular angle is greater in male than in female with significant statistical difference. With some differences in measurement that may be referred to some extent to the ethnic differences in population of each geographic area. We can say that from this study in Sudanese population acetabular angle measures (37) degrees in males and in females. In conclusion the results from this study confirm the existence of regional and sexual variations in acetabular angle among populations of the different countries, age and sex. Those

35 significant variations allow their use in diagnosis of abnormalities and medico-legal identification of sex and race.

36 CHAPTER (6) CONCLUSION AND RECOMMENDATIONS

37 6.1. Conclusions The anatomical difference in the acetabular angle was significant in the present study. Sex influences geometrical measurements of the acetabulum. The male angles are greater than that of females. In comparing the acetabular angle of both sexes in Sudanese subjects with others, there was a high statistical significant racial variation.

38 6.2. Recommendations More elaborated studies should be done to study the acetabular angle in different ethnic groups in Sudan. Sample size should be as large as possible. Future study should determine the role of age in such research. Cooperative studies should be done with orthpaedics surgery and forensic medicine. Useful utilization of acetabular angle measurement In Forensic medicine to determine the sex of unknown skeletal remains. Useful utilization of acetabular angle measurement in clinical diagnosis in adult DDH.

39 CHAPTER (7) REFERENCES

40 7. References 1. Last R J. Lower limb. In: Last R J. editor. Anatomy regional and applied. 9 th ed. UK: Elsevier 1998; Gray H. Osteology. In: Williams P L, Warwick R. editors. Gray s anatomy. 36 th ed. UK: Churchill Livingstone 1980; Moore K L, Dalley A F. The pelvis. In: Agur M R, Moore B A, Sun B, Squd K H. editors. Clinically oriented anatomy. 5 th ed. London: Lippincott Williams and Wikins 1999; Heather W-H, Cheryl K, Anthony B F. Identification of human skeletal remains. Forensic Osteological Analysis chapter 3; Harris, W.H., Etiology of osteoarthritis of the hip. Clin. Orthop. Relat. R., 213: Han, C.D., J.H. Yoo, W.S. Lee and W.S. Choe, Radiographic parameters of acetabulum for dysplasia in Korean adults. Yonsei. Med. J., 39: Nakamura, S., S. Ninomiya and T. Nakamura, Primary osteoarthritis of the hip joint in Japan. Clin. Orthop. Relat. R., 241: Tarek, A.A., Hip morphologic measurements in an egyptian population. Orthopedics, 34(4): Umer, M., A. Thambyah, W.T.J. Tan and S. Das De, Acetabular morphometry for determining hip

41 dysplasia in the Singaporean population. J. Orthop. Surg., 14(1): B. C. Msamati, 2003, GEOMETRIC MEASUREMENTS OF THE ACETABULUM IN ADULT MALAWIANS, 15(1): J. Dairy Sci.,2013, Radiologic Determination of Acetabula Index and Centre Edge Angle in South Nigerian Population 3(3):

42 Appendix

43 بسم هللا الرحمن الرحيم The National Ribat University Faculty of Graduate Studies and Scientific Researches Data collection Sheet Date -Serial No. -Gender: Male Female - age -Type of X- ray: Plain -Series of IVU Degree of the acetabular angle : - Comments:

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