Single stage anterior cruciate ligament reconstruction and high tibial osteotomy

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BACKGROUND

Anterior cruciate ligament (ACL) injuries are a common clinical entity, especially among those committing sports activities [1]. ACL injuries are among the most common and debilitating injuries. Many patients successfully undergo ACL reconstruction; however, the incidence of long-term failure rate is high and mostly attributed to coronal versus sagittal osseous malalignment [2].

Furthermore, the increasing number of primary ACL reconstructions leads to a corresponding increase in the revision of failed ACL reconstruction surgeries. Also, because alignment of the lower limb weight-bearing axis plays an important part in ACL functioning, wedge high tibial osteotomy is extensively used to correct the varus lower limb alignment [1].

Coronal and sagittal plane knee malalignments increase the forces on the ACL grafts after ACL reconstruction (ACLR) [3]. PTS leads to increased force through the ACL and PTS exceeding 10.1 degrees increases the risk for ACL graft failure by 11-fold [4]. Moreover, varus and valgus alignment of the knee can lead to increased forces through the ACL or ACL graft compared with knees in neutral alignment [5]. In primary ACL reconstruction, steep PTS and excessive anterior tibial subluxation of the lateral compartment were associated with inferior graft outcomes [6].

Slope-reducing tibial osteotomies to correct bony malalignment are reported to significantly decrease the high tibial slope, the anterior tibial translation, and forces on the ACL graft [7]. Several slope-correcting osteotomies were proposed, with the most frequently used approach being either supra-tuberosity or trans-tuberosity approaches. Despite the satisfactory results, severe complications involving the extensor mechanism can occur [8].

Regrettably, a literature review to achieve definite international guidelines to enhance decision-making regarding the definition and evaluation of increased posterior tibial slope (PTS) and the role of wedge high tibial osteotomy during the revision anterior cruciate ligament reconstruction (ACLR) indicated the absence of a consensus for the definition of a cut-off value for pathological PTS [9].

AIM

This study aimed to evaluate the functional outcomes of single-stage ACL reconstruction with HTO in genu varum patients with ACL-deficient knees as judged by clinical and radiological assessments.

METHODS

Study design

This was a prospective, interventional case study.

Eligibility criteria

The enrollment criteria included deficient ACL with varus deformity and lateral thrust, medial compartment osteoarthritis, or associated meniscal injuries in patients younger than 40 years, the exclusion criteria included age older than 40 years; patients with findings suggestive of the presence of inflammatory arthritis, multi-ligamentous knee injury, or requirement for revision surgery for ACL reconstruction, an ASA grade of > II, and medical disorders exposing patients to further morbidities or mortality

Study setting

Orthopedic Surgery Department, Faculty of Medicine, Cairo University, in collaboration with Al-Haram Hospital.

Study duration

This prospective interventional case study continued from April 2018 to August 2020.

Intervention

Patients complaining of anterior knee instability secondary to ACL injury were evaluated based on their demographic and clinical data, clinical local knee examinations, and lab and radiologic workup to assess the inclusion and exclusion criteria.

Clinical Knee assessments

• Assessment of the knee range of motion (ROM)

Active and passive ROM of the knee was assessed for all patients during the supine position.

• Special Tests for ACL deficiency

– Lachman's test

The Lachmann test entailed the assessment of anteroposterior laxity in 20° flexion as judged by the approximate translation distance and graded as 1+ (< 5 mm), 2+ (5–10 mm), or 3+ (> 10 mm) [10].

– Anterior Drawer Test

It is performed to assess the relative displacement of each tibial condyle [11].

– Pivot Shift Test

The pivot shift phenomenon represents the subluxation-reduction of the tibia in the ACL-deficient knee. The pivot shift test is graded into 3 grades: Grade 1: glide, Grade 2: clunk, and Grade 3: pronounced clunk with momentary locking [12].

• Tests for Associated Injuries

The knee was examined for evidence of instability of the meniscal and collateral ligaments as well as injury to the posterior cruciate ligament. The collateral ligament laxity was examined with stress in the valgus or varus planes.

• Lysholm's score

The Lysholm score is a self-answered questionnaire to evaluate 8 items: limping, walking with support, locking, giving way, pain, swelling, climbing stairs, and squatting for a total score of 100. A score ≥ 91 is considered excellent, 82–90 is good, 60–81 is fair and a score ≤ 59 is poor.

Radiological workup

• Plain X-Ray

Anteroposterior standing (AP) and lateral radiographs of both knees were obtained to diagnose ACL avulsion and associated fractures. The varus deformity of the involved knee was assessed at the level of the knee joint by measuring the proximal medial tibial angle (PMTA) in longstanding film. Medial joint space was evaluated in the anteroposterior films to assess its reduction. The preoperative posterior tibial slope was determined through the lateral radiographs.

• MRI Assessment

MRI was used to ensure the ACL rupture and associated injuries, particularly the menisci, detection of ACL fiber discontinuity and change in ACL course, some secondary signs such as the bone bruise of the posterolateral tibial plateau and lateral femoral condyle, and estimation of the PCL angle.

Operative procedure

The procedure was performed undercover with broad-spectrum antibiotics and under spinal anesthesia. The patient was positioned supine, examination under anesthesia was conveyed, and then a tourniquet was applied high above the knee of the affected limb. Wiring of the osteotomy line under fluoroscopic guidance guidewire was placed in the subchondral bone parallel to the joint line and a second osteotomy guidewire was inserted posterior to the first. A lateral radiograph is obtained to double-check that the pins are in the correct plane with the joint line. The sartorius tendon is carefully incised in a parallel fashion to the gracilis and semitendinosus superior to the gracilis, and the overlying sartorius tendon was preserved to serve as a soft tissue cover for the harvest site. Semitendinosus and gracilis tendons were harvested for the hamstring autograft and prepared outside the field for ACL reconstruction.

The ST with GS tendons was folded in a double loop, and the free ends of the loop were tagged together with Ethibond suture No. 2, woven in an ascending and descending fashion to secure the loop ends firmly. An end button was attached to the graft, and this double loop was refolded again so that the tendons became quadrupled. The graft was suspended on a graft tensioner, and the end of the graft was sutured with Ethibond No. 2 for about 3 cm. Two Ethibond No. 2 wires were passed through the graft to be used for pulling on the graft.

An arthroscopic assessment was performed with special regard to menisci that were probed for the presence of tears, and if present meniscal repair or meniscectomy was done and small chondral lesions were treated by micro-fracture technique, and patients with large chondral lesions were excluded from this study. Then, using a 3-portal technique and an accessory anteromedial portal, the femoral footprint was visualized through the anteromedial portal and the notch was debrided, saving 1 to 2 mm of ACL fibers at both the tibial and femoral footprints.

A tibial guide was positioned on the anatomic tibial footprint of the ACL, drilled into the proximal tibia and a cannulated reamer was used to create tunnel-1. The stylite tip of the guide arm was put in the center of the footprint midway of the centers of both bundles of native ACL, the tibial tunnel entrance was through the graft harvest incision, 1.5 cm medial to the tuberosity and about 4 cm distal to the tibial articular surface, and the cannulated guide arm was passed, a guide pin was drilled through the cannulated guide arm, and after penetrating the joint, the guide was removed, and the tibial tunnel was reamed. The femoral tunnel was created in the lower third of the lateral notch. A guide pin was drilled through the femur till it passed through the skin of the thigh. A femoral guide was positioned on the anatomic femoral footprint of the ACL, and femoral tunnel drilling was done using a 4.5-mm cannulated reamer. The femoral tunnel length was determined by a depth gauge, under arthroscopic visualization, a rosette reamer was used to ream the femoral tunnel, and then a No. 2 Vicryl suture was passed through the tunnel using a guide pin leaving the looped tip inside the knee.

Opening Wedge High Tibial Osteotomy: using a freehand technique and C-arm, 2.5-mm guidewire was placed in the subchondral bone parallel to the joint line. Osteotomy started at the level of the upper half of the tibial tuberosity to isolate it. The saw was placed distal to the guidewires and passed approximately two-thirds of the way across the tibia avoiding penetrating the lateral cortex. Retractors were placed anterior and posterior between the periosteum and bone to protect the patellar tendon attachment and the neurovascular structures. Wide thin osteotomes are used to complete the osteotomy.

The osteotomy site was gradually opened using a lamina spreader or multiple osteotomes, a long diathermy cable was placed from the center of the femoral head to the center of the ankle to check the mechanical axis at the level of the knee and when the desired alignment was achieved, the Puddu plate was applied. Lastly, a grasper was passed through the tibial tunnel to bring out the stainless-steel wire loop, and the Ethibond No. 5 sutures of the prepared graft were passed using the stainless wire loop from the tibial tunnel to emerge outside the skin of the thigh. Pulling on the Ethibond sutures outside the thigh allowed the graft to pass through the tibial then the femoral tunnel and end button were set confirmed by the flipping mechanism. Drains were inserted and the wound was closed in layers.

PO care

Peripheral circulation and neurological assessments were performed and the patient was advised to use ice-therapy as much as tolerated. A broad-spectrum antibiotic was injected intravenously in a dose of 1 gm every 12 hours for 2–3 days, and anticoagulant therapy (Clexane 40 I.U) was started 12 hours after surgery. Analgesia was provided as intramuscular injection of pethidine 50–100 mg ampoule for 2–3 days and Diclofenac sodium 50 mg. tablets twice daily for one week starting from the second day. Dressings were changed and the wound was inspected after 24 hours, and the patient was discharged.

X-rays of the knee (AP and lateral views) were obtained after surgery. The peripheral circulation was ensured and then patients were placed in a hinged knee brace allowing full extension and flexion up to 60 degrees for 2 weeks, and allowing full extension and flexion up to 90 degrees for 4 weeks. After 6 weeks PO, the brace was removed and a full range of motion was allowed.

Case presentation

• Preoperative Radiological Assessment (Fig. 1, 2)
• Operative procedure (Fig. 3–11)
• PO Radiological Assessment (Fig. 12)

 

Fig. 1. Preoperative MRI showing the anterior cruciate ligament tear.

Рис. 1. Предоперационная МРТ, демонстрирующая разрыв передней крестообразной связки.

 

Fig. 2. Preoperative scannogram.

Рис. 2. Предоперационная сканограмма.

 

Fig. 3. Harvesting of semimembranosus & gracilis tendons for hamstring autograft.

Рис. 3. Забор сухожилий полуперепончатой и тонкой мышц для аутотрансплантата из сухожилий подколенных мышц.

 

Fig. 4. Insertion of the femoral guide pin.

Рис. 4. Введение направляющей спицы в бедренную кость.

 

Fig. 5. Arthroscopic view showing the Vicryl suture loop.

Рис. 5. Артроскопический вид петли из нити Vicryl.

 

Fig. 6. Isolation of tibial tuberosity.

Рис. 6. Выделение бугристости большеберцовой кости.

 

Fig. 7. Osteotomy of medial wall.

Рис. 7. Остеотомия медиальной стенки.

 

Fig. 8. Osteotomes separating the anterior and posterior cortices and advanced laterally within 1 cm of the lateral cortex.

Рис. 8. Остеотомы, разделяющие передний и задний кортикальные слои и продвигаемые латерально до уровня 1 см от латерального кортикального слоя.

 

Fig. 9. Lamina spreader to maintain the gap until complete the fixation.

Рис. 9. Расширитель Инге, используемый для удержания щели до завершения фиксации.

 

Fig. 10. Osteotomy gap fixation.

Рис. 10. Фиксация щели остеотомии.

 

Fig. 11. C-arm view intraoperative showing the fixation.

Рис. 11. Интраоперационное изображение C-arm, демонстрирующее фиксацию.

 

Fig. 12. Postoperative X-rays showing anterior cruciate ligament.

Рис. 12. Послеоперационные рентгенограммы, демонстрирующие реконструкцию передней крестообразной связки.

 

Ethics approval

Prior to commencement of the study ethical approval was obtained from the following ethical review board: Faculty of Medicine, Kasr El Ainy on 17/4/2018 with approval number: CMDRF132701.

Statistical analysis

The obtained results were analyzed using IBM® SPSS® Statistics (Version 22, 2015; Armonk, USA). Data were shown as numbers, percentages, mean, and standard deviation, and comparisons were conveyed by the Chi Square test and paired t-test to assess the significance between preoperative and postoperative findings. The optimum cut-off point for significance of a result is P = 0.05.

RESULTS

During the study duration, 39 male patients with ACL-deficient knees were evaluated for enrollment criteria; 4 patients were older than 40 years, 5 patients had multi-ligamentous knee injury, 3 patients had manifestations of inflammatory arthritis, two patients had coagulopathy, and two patients refused to sign the informed consent to participate in the study, and these 16 patients were excluded. Twenty-three patients who fulfilled the inclusion criteria and signed the informed consent were enrolled in the study. However, three patients were lost during follow-up and were also excluded from the study (Fig. 13). Patients' demographic and preoperative clinical data are shown in Table 1.

 

Fig. 13. Patients' flowsheet.

Рис. 13. Блок-схема включения пациентов в исследование.

 

Table 1. Preoperative data

Таблица 1. Дооперационные данные

Data			Findings
Age (years)			21.8 (±3)
Smoking	Not smokers		10 (50%)
	Ex-smokers		4 (20%)
	Current smokers		6 (30%)
Occupation	Employee		7 (35%)
	Manual workers		6 (30%)
	Farmers		4 (20%)
	Others		3 (15%)
Type of trauma	Pivoting non-contact		14 (70%)
	Contact		6 (30%)
Laterality	Affected side	Right	13 (65%)
		Left	7 (35%)
	Dominant side	Right	15 (75%)
		Left	5 (25%)
Associated meniscal injuries	Medial meniscal tear		7 (35%)
	Lateral meniscal tear		5 (25%)

 

The average operative time was 122 (±13) minutes and ranged from 100 to 145 minutes. The operative time was ≤ 120 minutes for 11 patients (55%) and was > 120 minutes for 9 patients (45%). The duration till bone union was < 3 months in 12 patients (60%) and was ≥ 3 months in 8 patients (40%) with an average duration of 2.79 (±0.9) months. During follow-up, PO complications were encountered in 4 patients (20%), but no patient required re-intervention. One patient had significant limb length discrepancy after varus correction; however, this problem can be resolved by adjustment of the height of the shoes. Two patients developed posterior pain over the hamstring tendon for more than 3 months and this pain was controlled by hamstring stretching exercises and was improved. One patient developed a superficial infection at the osteotomy site and was managed conservatively by broad-spectrum oral antibiotics till complete resolution (Table 2).

 

Table 2. Operative and Postoperative data

Таблица 2. Интраоперационные и послеоперационные данные

Items			Findings
Operative time (min)	Average (±SD)		122 (±13)
	Frequency	≤ 120	11 (55%)
		> 120	9 (45%)
Duration till bone union (month)	Average (±SD)		2.79 (±0.9)
	Frequency	< 3 months	12 (60%)
		≥ 3 months	8 (40%)
PO complications	Limb length discrepancy		1 (5%)
	PO pain		2 (10%)
	Osteotomy site infection		1 (5%)

 

At the end of the follow-up, subjective assessment using Lysholm score defined marvelous improvement as there were 4 patients with fair and 16 patients with poor grades preoperatively, while at the end of the follow-up, there were 11 patients (55%) had excellent, and 9 patients (45%) had good grading with significant differences between both evaluations. Moreover, the mean value of the Lysholm score was significantly (P < 0.001) higher at the end of the follow-up compared to that determined preoperatively (Table 3).

 

Table 3. Follow-up data

Таблица 3. Данные наблюдения

Items	Grading	Preoperative	Postoperative	P-value
Lysholm score	Excellent	0	11 (55%)	< 0.001
	Good	0	9 (45%)
	Fair	4 (20%)	0
	Poor	16 (80%)	0
	Mean (±SD)	39.8 (±9.5)	88.3 (±5.5)	< 0.001
IKDC score	Normal A	0	15 (75%)	< 0.001
	Nearly normal B	0	5 (25%)
	Abnormal C	6 (30%)	0
	Severely abnormal D	14 (70%)	0
Lachman test	Normal A	0	20 (100%)	< 0.001
	Nearly normal B	5 (25%)	0
	Abnormal C	12 (60%)	0
	Severely abnormal D	3 (15%)	0
Pivot shift	Normal A	0	16 (80%)	< 0.001
	Nearly normal B	0	4 (20%)
	Abnormal C	16 (80%)	0
	Severely abnormal D	4 (20%)	0
Effusion	Normal A	11 (55%)	15 (75%)	0.028
	Nearly normal B	3 (15%)	5 (25%)
	Abnormal C	6 (30%)	0
Lack of extension	Normal A	8 (40%)	20 (100%)	0.0002
	Nearly normal B	7 (35%)	0
	Abnormal C	5 (25%)	0
Lack of flexion	Normal A	13 (65%)	16 (80%)	0.288
	Nearly normal B	7 (35%)	4 (20%)
Degree of varus		8.5 (±3)	0.93 (±3)	< 0.001
Posterior tibial slope		9.2 (±1.37)	10.5 (±1.36)	0.0046

 

Objectively, patients' distribution according to the IKDC score, Lachman score, and scoring for the pivot shift improved significantly (P < 0.001) at the end of follow-up compared to preoperative distribution (Fig. 14). According to the presence of joint effusion, the frequencies of patients had normal A or nearly normal B increased and no patient had abnormal C at the end of follow-up with significantly (P = 0.028) higher frequencies compared to preoperative ones. Preoperatively, only 8 patients (40%) had normal A grades for lack of extension, 7 patients had nearly normal B and 5 patients had abnormal C grades for lack of extension. On the contrary, all patients were graded at the end of follow-up as normal A with a significant (P = 0.0002) difference versus the preoperative data. The frequency of patients had normal A lack of flexion grading was insignificantly (P = 0.288) increased after surgery than preoperatively (Fig. 15). Further, the degree of varus and the posterior tibial slope were dramatically improved after surgery with significant (P < 0.001 & 0.0046, respectively) at the end of follow-up versus the preoperative findings (Table 3, Fig. 16, 17).

 

Fig. 14. Patients' distribution at the end of follow-up compared to preoperative distribution according to the IKDC, Lachman, and Pivot shift scorings.

Рис. 14. Распределение пациентов в конце периода наблюдения по сравнению с дооперационным распределением по шкалам IKDC, Lachman и Pivot shift.

 

Fig. 15. Patients' distribution at the end of follow-up compared to preoperative distribution regarding the grading of the effusion and lack of extension and flexion.

Рис. 15. Распределение пациентов в конце периода наблюдения по сравнению с дооперационным распределением по степени выпота и дефицита разгибания и сгибания.

 

Fig. 16. The degree of varus determined at the end of follow-up compared to the preoperative measure.

Рис. 16. Степень варусной деформации в конце периода наблюдения по сравнению с дооперационным показателем.

 

Fig. 17. The degree of posterior tibial slope determined at the end of follow-up compared to the preoperative measure.

Рис. 17. Угол заднего наклона плато большеберцовой кости в конце периода наблюдения по сравнению с дооперационным показателем.

 

DISCUSSION

The applied combined ACL reconstruction and high tibial osteotomy (HTO) in genu varum patients with ACL-deficient knees provided marvelous subjective and objective outcomes. The degree of varus and the posterior tibial slope (PTS) were significantly improved at the end of the PO follow-up versus the preoperative findings. The obtained results supported the outcomes of previous studies where Ni et al. [13] reported improvements for patients with PTS and excessive anterior tibial translation and ACR repair failure after simultaneous slope-reducing high tibial osteotomy and ACL re-repair. Akoto et al. [14] also reported improved functional outcomes of patients who underwent revision ACL reconstruction and slope-correction osteotomy combined with lateral extra-articular tenodesis.

In a similar case series, Deng et al. [15] could achieve excellent functional outcomes with improved radiological results for patients with ACL tears with varus malalignment and increased PTS on the application of single-stage ACL reconstruction combined with biplanar HTO. In support of the appropriateness of HTO, Han et al. [16] documented the feasibility and effectiveness of HTO in the treatment of chronic multi-ligament knee injury associated with lower extremity malalignment and added that the procedure can restore normal lower extremity alignment and improve knee joint function.

In a comparative study, Weiler et al. [17] found HTO as anterior closed-wedge or medial open-wedge significantly reduces the tibial slope in patients with ACL insufficiency and a high tibial slope, especially the medial open-wedge. Jeong et al. [18] reported that arthroscopy and opening-wedge tibial osteotomy for the correction of varus malalignment in patients with previous ACL reconstruction is a safe, rapid procedure that reduces the intraoperative fluoroscopy shots and results in accurate and efficient correction of varus malalignment with good short-term clinical outcomes.

These findings align with multiple recent similar case studies; Deng et al. [15] evaluated the efficacy of modified HTO and ACL reconstruction in the treatment of a small sample of patients with ACL injuries, varus deformities, and increased PTS and documented significant short-term improvement. Also, Riveros et al. [19] documented that in complex cases involving tibial osteotomy and ACL reconstruction, the integration of patient-specific 3D-printed models into surgical planning may improve accuracy and efficiency in complex MAT procedures that involve tibial osteotomy and ACL reconstruction. Further, Wang et al. [6] found slope-reducing tibial osteotomy with ACL repair significantly mitigated the amount of anterior tibial subluxation, the incidence of graft roof impingement, and reduced the graft failure rate.

In support of the efficacy of the procedure entailing HTO and ACL reconstruction, Mayer et al. [20] documented that infra-tuberosity anterior closing wedge HTO for tibial slope correction did not lead to significant changes in patellar height.

Study limitations

The study presented a single-institute experience within a short duration which limited the sample size and may prevent generalization of the obtained results. The lack of normal cross-matched controls to provide radiographs for comparison is another limitation of the study. Further, the short-term follow-up and lack of description of the PO rehabilitation program are other limitations of the study.

Recommendations

Wider-scale multicenter controlled randomized studies are recommended to ensure the obtained results. Further, these studies are advised to follow up with the studied patients for longer durations, especially those in the active stage to confirm the stability of the results.

CONCLUSION

The provided procedure of single-stage ACL reconstruction with high tibial osteotomy in ACL deficient varus knees is a promising management policy for ACL injury in genu varum knee. The applied procedure is safe with few complications and short length of hospital stay and with satisfactory outcomes.

ADDITIONAL INFORMATION

Author contribution: Mohamed Nabil Salama: was responsible for the conceptualization, study design, and overall supervision of the project; Ahmed Samir Elkalyoby: handled data collection, conducted the literature review, and drafted the initial manuscript; Ahmed Essam Qandeel: contributed by performing data analysis, interpreting the results, and preparing visualizations; Mohamed Kamal Abdelaziz: revised the manuscript, provided critical intellectual input, and gave final approval. All authors reviewed and approved the final manuscript and accepted accountability for all aspects of the work.

Acknowledgements: The authors thank the patients for their participation in our study. Also, the authors thank the staff members of Be-Check for proofreading and adjusting the article.

Ethical approval: Prior to commencement of the study ethical approval was obtained from the following ethical review board: Faculty of Medicine, Kasr El Ainy on 17/4/2018 with approval number: CMDRF132701. Written informed consent was obtained from all participants for participating in the study and processing personal data.

Funding source: No funding.

Competing interests: The authors declare the absence of relationships, activities and interests (personal, professional or financial) related to third parties (commercial, non-profit, private), whose interests may be affected by the content of the article, as well as other relationships, activities and interests over the past three years, which must be reported.

Statement of originality: The authors did not use previously published information (text, data) to create this paper.

Generative AI: Generative AI technologies were not used for this article creation.

Data availability statement: All data obtained in this study are available in this article.

Provenance and peer-review: This paper was submitted to the journal on an initiative basis and reviewed according to the usual procedure. Two external reviewers, a member of the editorial board and the scientific editor of the publication participated in the review.

ДОПОЛНИТЕЛЬНАЯ ИНФОРМАЦИЯ

Вклад авторов. Мохамед Набиль Салама — определение концепции, дизайн исследования, общее руководство проектом; Ахмед Самир Элькалиоби — сбор данных, анализ литературных источников, написание черновика рукописи; Ахмед Эссам Кандил — анализ данных, интерпретация результатов, визуализация; Мохамед Камаль Абделазиз — пересмотр и редактирование рукописи. Все авторы одобрили рукопись (версию для публикации), а также согласились нести ответственность за все аспекты настоящей работы.

Благодарности. Авторы благодарят пациентов за участие в исследовании. Авторы также выражают благодарность сотрудникам Be-Check за корректуру и редактирование статьи.

Этическая экспертиза. До начала исследования было получено одобрение этического комитета медицинского факультета Каср Эль-Айни от 17.04.2018; номер одобрения — CMDRF132701. От всех участников исследования получено подписанное информированное добровольное согласие на участие в исследовании и обработку персональной информации.

Источники финансирования. Отсутствуют.

Раскрытие интересов. Авторы заявляют об отсутствии отношений, деятельности и интересов за последние три года, связанных с третьими лицами (коммерческими и некоммерческими организациями), интересы которых могут быть затронуты содержанием статьи.

Оригинальность. При проведении исследования и создании настоящей статьи авторы не использовали ранее полученные и опубликованные сведения (данные, текст).

Генеративный искусственный интеллект. При создании настоящей статьи технологии генеративного искусственного интеллекта не использовали.

Доступ к данным. Все данные, полученные в настоящем исследовании, представлены в статье.

Рассмотрение и рецензирование. Настоящая работа подана в журнал в инициативном порядке и рассмотрена по обычной процедуре. В рецензировании участвовали два внешних рецензента, член редакционной коллегии и научный редактор издания.

About the authors

Mohamed N. Salama

Kasr Al Aini Hospital, Cairo University

Author for correspondence.
Email: Dr.mo7amed.salama99@gmail.com
ORCID iD: 0009-0005-1925-9287

MD, Assistant Professor

Egypt, Cairo

Ahmed S. Elkalyoby

Kasr Al Aini Hospital, Cairo University

Email: fixerpaper2017@gmail.com

MD, Assistant Professor, Kasr Al Aini Hospital

Egypt, Cairo

Ahmed E. Qandeel

Kasr Al Aini Hospital, Cairo University

Email: essam.qandeel.a@gmail.com

MD, Assistant Professor

Egypt, Cairo

Mohamed K. Abdelaziz

Kasr Al Aini Hospital, Cairo University

Email: abdelaziz.mohamed@gmail.com

MD, Assistant Professor

Egypt, Cairo

References

Supplementary files