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International Journal of Research in Orthopaedics
Number of Followers: 1  

  This is an Open Access Journal Open Access journal
ISSN (Online) 2455-4510
Published by Medip Academy Homepage  [12 journals]
  • Management of open fractures of the lower limb during the COVID-19
           pandemic: are the standards of treatment being maintained' A study
           from a major trauma centre in England

    • Authors: Rajan Choudhary, Madhumita Gupta, Shahidul Huq, Wareth Maamoun
      Pages: 894 - 900
      Abstract: Background: Coronavirus disease 2019 (COVID 19) has created an immense strain on the NHS. During the height of the pandemic, trauma services were affected by redeployment, reduced theatre capacity and staff illness, and COVID BOAST guidelines were introduced.Methods: This retrospective study aimed to evaluate the standards of management of open fractures of the lower limb at a Major Trauma Centre in the United Kingdom during the COVID-19 pandemic and compare the same with the pre-pandemic period. Patient demographics, mechanism of injury, timing and mechanism of initial debridement and definitive soft tissue and skeletal fixation were noted. Outcomes including duration of hospital stay, 30 day and 1 year mortality were also assessed.Results: There was an overall 21% reduction in admissions with open lower limb fractures during the pandemic period with a 48% reduction during the first lockdown. There was a significant reduction in time taken from Emergency Department presentation to first debridement as well as a notable increase in operating outside of regular theatre hours. There was little difference in operative technique used for skeletal or soft tissue management at initial and definitive surgery, though fewer cases were performed as a two stage procedure. There was no difference in amputation rate in the two years. Length of stay was reduced from 21 days to 17, and 30 day mortality remained the same.Conclusions: Our study shows this Major Trauma Centre was able to provide a trauma service in accordance to the BOAST4 guidelines despite the increased pressures of the COVID-19 pandemic.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213232
      Issue No: Vol. 7, No. 5 (2021)
       
  • Clinical study of Masquelet technique in the treatment of osteomyelitis
           and bone defect

    • Authors: Bikash Neupane, Zhao Meng, Xu Sheng Kang, Prabha Paudel, Sagar Panthi, Zhao Xing, Zhang Jin Song
      Pages: 901 - 906
      Abstract: Background: The induced membrane technique, introduced by Masquelet in 1986 called Masquelet technique is universally preferred methods of treatment in bone defect either of any cause. Consists of two principle steps: first radical debridement and filling defect with polymethylmethacrylate (PMMA) spacer, this allows the formation of induction membrane. Secondly bone cement is removed and defect is filled with bone graft and stabilized with definitive fixation.Methods: This prospective observational study was carried out in the department of orthopedic surgery, Taihe Hospital affiliated to Hubei University of Medicine, Shiyan Hubei China from July 2018 to November 2019.Results: Total 32 patients observed and recorded for the analysis. The mean age 38.28±11.211 years. 20 (62.5%) male and 12 (37.5%) female, 13 (40.6%) had right, and 19 (59.4%) had left side injury. Tibia has the highest involvement 16 (50%), femur 10 (31.3%), calcaneus 3 (9.4%) radius, cuboid and ulna 1 (3.1%) each. For cause of defect osteomyelitis is found to have highest frequency of 11 (34.4%). The size of defect ranges from 3 to 20 cm with mean defect (6.91±4.489 cm). Duration of bone cement ranges from 4-20 weeks with mean of 8.75±3.379 weeks. The union time ranges from 4-14 months. With mean of 8.31±2.17 months. 18 (56.3%) have excellent results, 13 (40.6%) have good results, and 1 patient (3.1%) have satisfactory results.Conclusions: This study concludes that Masquelet technique as being the more appropriate, reliable and is a noble technique in the reconstruction of bone defect either of any cause with good functional result.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213374
      Issue No: Vol. 7, No. 5 (2021)
       
  • Prevalence of low back pain and associated factors among office workers in
           Kano city, Nigeria

    • Authors: Muhammad Nuhu Salihu, Mamman Muhammad Lawal, Abuhuraira Ado Musa, Yusuf Muhammad Abdullahi, Maryam Dahiru Umar, Oruche Chinyere Amaka, Jacob Jonah Addi, Faisal Muhammad
      Pages: 907 - 913
      Abstract: Background: Many studies across the globe have reported the prevalence of low back pain (LBP) among office workers. This study aimed to find out the prevalence of LBP and associated factors among office workers in Kano city, Nigeria.Methods: A cross-sectional type of study was conducted among the office workers in Kano metropolitan from September to December 2019. A total of 300 office workers were selected using a convenience sampling technique. The data was collected from the respondents by face-to-face interview technique using a semi-structured questionnaire and all the data collected were analyzed using statistical software (SPSS version 22.0).Results: In this study, the mean age of the respondents was 38.6±9.6 years and 72.7% of them were male. More than half (54.7%) of the respondents had a bachelor's degree and above. About 71.3% of the respondents had a familial history of LBP. About 68.0% of the respondents had suffered musculoskeletal disorder in the past and the majority (54.4%) mentioned they suffered hip pain. Only 33.7% of the respondents were maintaining the proper posture and 37.7% of the respondents were using an ergonomic chair.Conclusions: The findings of this study found a 65.3% prevalence of low back pain among the office workers in Kano metropolitan. Office workers should be encouraged to maintain proper postures at work and there is a need for more educational programs regarding the prevention measures of low back pain.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213375
      Issue No: Vol. 7, No. 5 (2021)
       
  • Comparison of spinal manipulation and short-wave diathermy on patients
           with chronic postural low back pain, in department of physical medicine at
           teaching hospital, Kandy, Sri Lanka

    • Authors: W. A. T. Nisansala, H. H. T. Shashikala, I. N. Aluthge, K. N. B. Illukkumbura, S. Sukirthan, J. M. K. B. Jayasekara
      Pages: 914 - 918
      Abstract: Background: Chronic postural low back pain (CPLBP) is one of the common health problems worldwide. The aim of the study was to compare the spinal manipulation (SM) and short-wave diathermy (SWD) in patients with CPLBP in department of physical medicine at teaching hospital, Kandy, Sri Lanka.Methods: Observational study was conducted. Patients diagnosed as CPLBP, who referred to the department of physical medicine (DPM), teaching hospital Kandy, were observed in the study (n=140). Seventy (70) patients were allocated for SWD and 70 for SM by the consultant. Two physiotherapists were routinely appointed for the treatments and SWD treatment by group 1 and SM was carried out by group 2. The two treatment sessions were continued once a week through four weeks. Outcomes were measured by numerical pain scale to compare with initial pain.Results: Group 1, SM consisted 39 females and 31 males, group 2, SWD 40 females and 30 males. After 4 sessions, the mean value of pain reduction from initial pain was significantly high (p<0.001) in SM group than the short-wave diathermy group in both genders. (Female: 6.410 (SM) and 4.625 (SWD), Male:6.710 (SM) and 4.333 (SWD). Further the mean values showed that there was a significant pain reduction during the initial treatment session than 2nd, 3rdand final sessions in both treatment groups.Conclusions: Pain reduction was more pronounced in the first treatment session in both methods. SM is more effective for the treatment of CPLBP irrespectively the age and gender when compare to the SWD in the study population. Therefore, SM could apply on CPLBP patients with higher effective treatment.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213376
      Issue No: Vol. 7, No. 5 (2021)
       
  • Evaluation of functional outcome of intertrochanteric femur fractures
           treated with proximal femoral locking compression plate

    • Authors: Maruti Bhujangrao Lingayat, Pratik P. Rathod
      Pages: 919 - 925
      Abstract: Background: The objective was to find out the clinical and functional outcome of intertrochanteric femur fractures treated with proximal femoral locking compression plate (PFLCP).Methods: The study was conducted on patients who underwent fixation of intertrochanteric femur fractures with PFLCP in department of orthopedics, GMCH, Aurangabad from January 2020 to January 2021. The patients were assessed clinically and functionally using Harris hip score and radiological evaluation at three, six and nine months.Results: At one year follow up, two patients had varus collapse, one had superficial infection and one had screw cut out. The mean Harris hip score at one month was 69.46 (52-76), at three months was 78.6 (58-88) and at nine months was 87.6 (64-96). The average operative time was 86.23 minutes (60-128 minutes), the average blood loss was 207.5 ml (170-250 ml) and the average time required for union was 15.16 weeks (10-24 weeks).Conclusions: Intertrochanteric fractures treated with PFLCP provided a strong angular stable construct and showed satisfactory outcomes.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213199
      Issue No: Vol. 7, No. 5 (2021)
       
  • Results of posterior decompression with non-instrumented lumbar fusion
           surgery in cases of degenerative lumbar canal stenosis presenting with
           neurogenic claudication in a tertiary care hospital

    • Authors: Maruti Bhujangrao Lingayat, Ansari Muqtadeer Abdul Aziz, Gaurav Balasaheb Mate, Sourabh Sahebrao Dhamale
      Pages: 926 - 931
      Abstract: Background: Degenerative lumbar canal stenosis remains an important public health problem in today’s date. With the overall average age of the world’s population rising steadily it is important to have an optimal treatment plan affordable to the masses. Non-instrumented fusion after decompression remains an important treatment option which is affordable to the masses and effectively treats the instability occurring due to degeneration process. This study aims to understand the results of such treatment in a tertiary care center catering to the masses.Methods: The study was conducted in 34 patients with diagnosed degenerative lumbar canal stenosis with neurogenic claudication who underwent decompressive laminectomy with a posterolateral strut graft posterolateral fusion from July 2018 to August 2020. Each patient was followed up for 12 months.Results: In the present study, a total of 34 patients with degenerative lumbar canal stenosis with neurogenic claudication were included. There were 18 male and 16 female patients. The pre-operative Swiss spinal stenosis Score was 61-80 (52.9%) and these scores improved to a majority of patients in the category of 21-40 (82.4%) at 1 year postoperatively. The average VAS score was 4.7±1.8 preoperatively while the average post op VAS score was 0.8±0.77.Conclusions: Non-instrumented fusion of the vertebrae with decompression has significantly improved results at 1 year follow up postoperatively and it is an excellent easy and cost-effective technique if used in a properly selected patient. Further studies are required to assess its long-term results.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213200
      Issue No: Vol. 7, No. 5 (2021)
       
  • Correlation of clinical and radiological outcome of distal radius
           fractures treated with volar plating

    • Authors: Rajath H. P. Gowda, Ravi M. Daddimani, Srinath K. Madhava Murthy
      Pages: 932 - 937
      Abstract: Background: Distal radius fractures are one of the most common injuries treated by an orthopaedic surgeon, accounting for approximately one sixth of all fractures. Due to increase in incidence of high velocity trauma, the injury is seen occurring in young patients more often. A displaced fracture deranges the wrist anatomy causing deformity and loss of function at the wrist joint. Open reduction and internal fixation with plate using a volar approach allows anatomical reduction of the fracture, stable fixation aiding in early mobilization.Methods: Our study was a hospital-based study conducted during the period June 2016 to November 2018. A total of 30 patients with distal radius fracture were treated with ORIF with a volar plate. They were followed up for a year and clinical and radiological outcomes were evaluated.Results: Among the 30 patients studied 25 were males and 5 were females with mean age of 36.23 years. According to Gartland and Werley demerit scoring system, 15 of them had excellent result at the end of one year. 13 Of them had good and 2 of them had fair results. Radiological assessment was done by Sarmiento’s modification of the Lind storm criteria and 15 of them had excellent results. 15 patients had good radiological outcome.Conclusions: From this study we conclude that ORIF with volar plating can provide good clinical and functional outcome in distal radius fractures. Anatomical reduction of the fracture fragments is the key in achieving good results.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20212813
      Issue No: Vol. 7, No. 5 (2021)
       
  • A prospective study to evaluate functional results of PHILOS locking plate
           system in management of proximal humerus fractures in adults

    • Authors: Satish R. Gawali, Venktesh D. Sonkawade, Pradeepkumar S. Nair, Gaurav B. Mate
      Pages: 938 - 943
      Abstract: Background: Various management options are available for management of proximal humerus fractures where PHILOS plating is one of them. But data available in literature on its use and efficacy in management of all types of proximal humerus fractures is still dicey. So, we through our study attempted to grow our knowledge regarding its functional results, complication rates, etc. for use in coming future.Methods: 30 patients with proximal humerus fractures classified on the basis of Neer’s classification were included in study who were operated from 2018 to 2020 at our institute. These patients were operated by PHILOS locking plate system with either delto-pectoral or trans-deltoid approach and they are followed up at regular intervals to assess them clinicoradiologicallly and functionally by Neer’s criteria.Results: In our study we found maximum incidence of these fracture between age group of 40-80 years (66.66%) with male to female ratio of 2:1 with 19 patients having left sided and 11 patients having right sided proximal humerus fracture. Complications were found in 11 patients (36.67%). Functional evaluation was carried out using Neer’s criteria at final follow up which came to excellent results in 3, satisfactory in 18, unsatisfactory in 7 and failure in 2 patients. Average time of fracture union was 12.62 weeks.Conclusions: PHILOS locking plate system serves good purpose in management of fractures of proximal humerus but requires trained faculty to do this operation who has detailed knowledge about shoulder anatomy and mechanism of injury to reduce complications associated with this type of modality.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20212768
      Issue No: Vol. 7, No. 5 (2021)
       
  • The prevalence of femoroacetabular impingement in asymptomatic hips in
           Indian population: a radiomorphometric analysis

    • Authors: Mohammed Fawas Namboodikandy, Jojo Inassi, Balaji Zacharia
      Pages: 944 - 947
      Abstract: Background: Femoroacetabular impingement (FAI) is a common cause of secondary osteoarthritis of the hip. There are no much studies about the occurrence of FAI in asymptomatic individuals in Indian population. Our objective was to find out the radiological prevalence of FAI in asymptomatic adult Indian population.Methods: A cross sectional study was carried out in our institution, which is a tertiary care centre, between September 2016 and September 2018 in which in which we studied radiographs of 1600 hips from 800 pelvic x-rays of asymptomatic patients.Results: Out of 1600 radiographs of the hips studied 1353 were found to be normal and the remaining 247(15.4%), had features of FAI. 61 hip radiographs (3.8%) showed cam lesions and 9.2 % showed pincer type of lesion.38 hips (2.4%) showed mixed type of FAI.Conclusions: Significant number of radiographs of asymptomatic patients showed features of FAI. Further long-term studies are needed to see the proportion of these patients with FAI progressing to secondary osteoarthritis of hip.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213177
      Issue No: Vol. 7, No. 5 (2021)
       
  • Ponseti method for treatment of idiopathic congenital talipes equinovarus
           at tertiary care center in India

    • Authors: Maruti B. Lingayat, Sourabh S. Dhamale, Gaurav B. Mate
      Pages: 948 - 952
      Abstract: Background: Different treatment methods were tried with variable success rates but Ponseti method of serial casting and manipulation stood apart due to better understanding of foot biomechanics and became accepted choice of treatment worldwide.Methods: 50 patients were enrolled in the study out of which 40 were available for final follow-up. We studied 40 cases during October 2018 to December 2020 at Government Medical College, Aurangabad. Out of 40 cases 31 were male and 9 were female. 25 were unilateral and 15 were bilateral. All cases were idiopathic. 4 inches Plaster of Paris (POP) bandages were cut into half and such 2 inches POP bandages were used for casting. Tenotomies were performed under controlled environment of Operation Theater with general anaesthesia. Number 12 surgical blade was used. Dennis-Browne splint was used for maintenance of correction.Results: Out of total 55 feet studied, 10 feet (18.18%) required tendo Achilles tenotomy and 45 feet (81.82%) were treated with casting alone. There were 8 cases of relapses (20%). All relapsed cases were treated with repeat casting as per Ponseti protocol and none of them required repeat tenotomy. Complications related to plaster were minimal and there were no incidence of rocker bottom deformity.Conclusions: We conclude that in a low income developing country like India where case load is very high; Ponseti method is effective, inexpensive form of treatment with minimal complications. Need for extensive soft tissue procedures vastly reduced with this method.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213176
      Issue No: Vol. 7, No. 5 (2021)
       
  • A prospective study of management of tibial plateau fractures by locking
           compression plate in adults

    • Authors: Satish R. Gawali, Pradeepkumar S. Nair, Venktesh D. Sonkawade
      Pages: 953 - 958
      Abstract: Background: Tibial plateau fractures are one of the most complex and disabling fractures of the knee. The tibial plateau is important in transmitting load through the knee. These fractures need a meticulous management protocol in order to minimize patient's disability in range of movement, stability and reducing the risk of documented complications. The aim of the present study is to study the outcome of tibial plateau fractures managed with a locked compression plate.Methods: This study was conducted at a tertiary-care medical college and hospital, Aurangabad specializing in post-graduate training, where all patients who underwent surgical treatment between September 2018 and October 2020 were included. Patients were assessed using the knee society score (KSS). These evaluations were done at 1, 3, 6, 9 and 12 months.Results: In our study we included 55 patients out of which we found union in 98% of patients with 83% of patients showing good flexion at knee joint (>110 degrees). 85% patients achieved union within 6 months. An excellent KSS grade was seen in 38.2% patients with another 43.6% showing good outcome. 4 patients showed infection and 1 showed non-union. A single case of malunion was seen in our study.Conclusions: Locked compression plates in tibial plateau fractures has revolutionized the way these fractures are managed. Anatomic reduction is of utmost importance. Early physiotherapy which plays key role in preventing knee stiffness, use of bone grafts and good fixation are important for successful outcome.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213175
      Issue No: Vol. 7, No. 5 (2021)
       
  • Short-term functional results of surgical management of fractures of
           olecranon process of ulna by locking hook plate

    • Authors: Maruti B. Lingayat, Altamash Patel, Chandrakant R. Thorat
      Pages: 959 - 963
      Abstract: Background: The aim was to study functional results of fixation of fractures of olecranon process of ulna by locking hook plate.Methods: The study was conducted on 30 patients who underwent fixation of olecranon fracture by locking hook plate in department of orthopaedics, GMCH Aurangabad from September 2018 to September 2020. Patients were assessed functionally using Mayo elbow performance score and radiologically using serial follow up radiographs of elbow.Results: At 2 year follow up of 30 patients of all types of olecranon fracture treated by locking hook plate, no patient had evidence of non-union or loss of reduction or any other major complications. In our study 21 patients (70%) showed excellent results, 6 patients (20%) showed good results and 3 patients (10%) showed fair results. None of the patients in our study showed poor results. 3 patients (10%) had superficial infection which were treated by adequate antibiotics after doing culture and sensitivity testing and 4 patients (13.33%) had symptomatic metal prominence which underwent implant removal after union of fracture.Conclusions: Fixation of all types of fractures of olecranon by locking hook plate is good alternative to other methods of fixation like tension band wiring, intramedullary fixation using screw tension band wiring which are used only in selected cases. In our study we conclude that locking hook plate is excellent modality of treatment for all types of fractures of olecranon, it gives excellent functional and radiological outcome with minimal complication and stable fixation of all types of fractures including transverse as well as comminuted fractures.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20212915
      Issue No: Vol. 7, No. 5 (2021)
       
  • A study on functional outcome following surgical fixation for lower spine
           injuries

    • Authors: M. Sivakumar, M. Ganesh Kumar
      Pages: 964 - 967
      Abstract: Background: Cervical spine injuries are one of the common causes of serious morbidity mortality following trauma. 6% of trauma patients have spine injuries of which >50% is contributed by a cervical spine injury. The aim of the study was to determine the functional outcome following surgical fixation for sub-axial cervical spine.Methods: this prospective study involving 17 patients who were all admitted with sub-axial cervical spine injuries and amenable to intervention in our department of orthopedics and traumatology, government Theni medical college, Tamil Nadu, India in the year 2019-2020. Duration of 6 months from December 2019 to may 2020.Results: Most of the injuries presented within 24 hours of injury. Most of the patients presented with an incomplete neurological deficit. C5-C6 subluxation with disc bulge was the most common spinal injury. 5 patients were operated on more than 2 levels. The rest of the patients were operated on at 2 levels.Conclusions: We consider that the anterior decompression and fusion with a locking compression plate is a viable procedure in sub-axial cervical spine injuries.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20212773
      Issue No: Vol. 7, No. 5 (2021)
       
  • Radiological and functional outcome of unstable intertrochanteric
           fractures treated with proximal femoral locking plate

    • Authors: Chanchal Kumar Singh, Juhi Deshpande
      Pages: 968 - 975
      Abstract: Background: Intertrochanteric fracture is a common orthopaedic injury sustained in elderly population because of osteoporosis and trivial fall. Life threatening systemic complications occur mainly due to immobility.Methods: We included 62 patients (40 males and 22 females) of unstable intertrochanteric fracture (AO 31 A2 and A3) attending Department of Orthopaedics. They were all subjected to surgical treatment with proximal femoral locking plate. Patients were followed up at 3rd, 6th and 12th month for outcomes variables i.e.; functional (Harris hip score, Palmer and Parker mobility score) and radiological outcomes (neck shaft angle, loss of reduction, union and implant related complications). Statistical analysis was done using Friedman’s test after calculating the data in terms of mean and median using SPSS 20 software.Results: Mean age of our patients was 64 years, 40 were males and 22 females. 50 patients sustained fracture due to trivial fall and 12 due to RTA. 35 out of 62 patients had medical co-morbidites. 26 patients needed open reduction of fracture and 36 were close reduced. 22 of patients had severe comminution (AO A 3 III type). Average blood loss was 254 ml. Mean degree of loss of reduction was 5 degrees in 6th month and 4 degrees in 12th month. Union was achieved in 48 out of 50 patients at 12th month.  Most of the patients achieved fair to good functional outcome scores at 12th month of follow up. We noticed difficulties in fracture reduction as well as complications related to implant.Conclusions: PFLP is an effective implant in comminuted intertrochanteric fractures with broken lateral wall. Complications can be minimised by following principles of locking plate meticulously.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213377
      Issue No: Vol. 7, No. 5 (2021)
       
  • Effect of Nucart VG (Boswellia serrata in combination with veg glucosamine
           sulphate) in comparison with glucosamine sulphate to improve quality of
           life of knee osteoarthritis patients: a randomized controlled trial

    • Authors: Vijay G. Goni, Mukesh Mishra, Sailee Kadam, Sharat S. Gandhi
      Pages: 976 - 985
      Abstract: Background: Boswellia serrata has been proved to be an effective and safe herb for the treatment of osteoarthritis (OA). This study aims at assessing the synergistic effect of this herb with vegetarian glucosamine sulphate, a nutritional supplement, on knee osteoarthritis using quality of life indicators.Methods: This was an open label, parallel group randomized trial of 12-week duration. Sixty-six subjects were equally randomized to two treatment arms: Boswellia serrata extract (600 mg) and glucosamine (750 mg) [Nucart VG]; and glucosamine sulphate (market comparator) 750 mg. Patients were administered 1 tablet twice-a-day post-meal for three months. Efficacy of treatment was measured on primary end-points like EuroQol-5D (EQ-5D) (health status indicator), visual analogue scale (VAS) and Western Ontario and McMaster Universities osteoarthritis index (WOMAC) scale (pain indicators), while safety was measured in terms of vital parameters. Both intention-to-treat (ITT) and per-protocol (PP) analyses were performed for comparing scores between the two groups.Results: The baseline characteristics of patients between two groups were insignificantly different (p>0.05). In ITT analysis, the health status (EQ-5D score) of patients in Nucart VG group improved significantly than the comparator group at follow up 2 (p=0.037) and showed further improvement at follow up 3 (p=0.012). The pain indicators i.e. VAS and WOMAC scores were significantly lower in Nucart VG group right from follow up 1 till follow up 3 (p<0.05). Similar were the observations during PP analysis.Conclusions: Nucart VG is beneficial for the treatment of mild to moderate knee OA, as inferred from the functional and health status assessment.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213378
      Issue No: Vol. 7, No. 5 (2021)
       
  • Evaluation of functional and clinical outcome of open reduction and
           internal fixation of Barton’s fracture of the wrist in a central
           hospital of Kashmir

    • Authors: Jawed A. Bhat, Faesal khurseed, Abdul H. Javaid
      Pages: 986 - 990
      Abstract: Background: Fractures of the distal end of radius continue to pose a management challenge. Defective alignment of extra articular as well as intra articular fractures result in a variety of complications like post traumatic arthritis, decreased in grip strength and endurance as well as limited range of motion and instability of carpus. The main aim of this study is to assess the functional results of open reduction and internal fixation in the treatment of volar Barton’s fracture.Methods: From December 2006 to December 2019, forty cases of volar Barton’s fracture were operated in Skims Medical College Hospital, Srinagar, Kashmir, however only 32 cases were included in the study group and 8 cases were lost to follow up. In the majority of our cases the injury was sustained as a result of road traffic accident followed by fall. Majority (24) of the cases were operated within one week of trauma, followed by six in two weeks and two in 3 weeks of time since injury.Results: Functional evaluation was done after a mean follow-up of 28.7 months. Fracture union was achieved within 8 to 12 weeks and excellent results were obtained in 18 cases and 10 cases were categorized as good followed by fair result in 4 cases. Median nerve compression was not observed in any case.Conclusions: Good to excellent result can be achieved after open reduction and internal fixation which restores joint congruity.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213379
      Issue No: Vol. 7, No. 5 (2021)
       
  • Outcome of posterior lumbar interbody fusion in low-grade
           spondylolisthesis

    • Authors: Vamshikrishna Chand Nimmagadda, Hiranya Kumar Seenappa, Karthik Narayanamurthy Mittemari, Rajashree Paidipati
      Pages: 991 - 995
      Abstract: Background: Spondylolisthesis is the slippage of all or part of one vertebra in relationship to a caudal vertebra, most commonly occurring in the lumbar spine. Fusion is the recommended treatment of choice. Posterior stabilization with posterior lumbar interbody fusion (PLIF) is an established procedure with good outcomes. To study functional and radiological outcomes of PLIF in grade 1 and 2 lumbar spondylolisthesis.Methods: This is a prospective study in 30 patients who underwent PLIF and followed up for one year. Functional outcomes were measured in terms of visual analogue scale (VAS) and the Modified Oswestry Disability Index (ODI), and the fusion was assessed on plain radiographs. Results: There was a significant improvement in VAS of low back pain (90.71%, p<0.001) and VAS of radiating (82.52%; p<0.001). The ODI scores were significantly improved (63.65%, p<0.001) at 1 year follow up. The fusion rate was 70%, and 56.66% patients reported excellent outcomes.Conclusions: Based on functional outcomes and the fusion rates of PLIF, we conclude that PLIF is a recommended and excellent surgical option in the management of low grade lumbar spondylolisthesis.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213380
      Issue No: Vol. 7, No. 5 (2021)
       
  • Functional outcome of displaced mid shaft clavicular fractures treated by
           plate fixation: a prospective observational study

    • Authors: Junaid Ebrahim, Abdul Asraf Variyathodi, Mohamed Shakeeb Kannan Thody Uppil Thody, Nithin Chandrasekharan
      Pages: 996 - 1000
      Abstract: Background: Clavicle fractures are one of the commonest injuries to the shoulder girdle. Traditionally these fractures are treated conservatively. This study was to assess the functional outcome of displaced mid shaft clavicular fractures treated with plate fixation.Methods: This was a single center prospective observational study conducted at department of orthopaedics M.E.S medical college Perinthalmanna between the period January 2018 to December 2018 in patients with displaced mid shaft clavicle fractures treated by plate fixation. Out of 51 patients 35 patients were males and 16 were females with mean age of 37.7 years (range 19-59). All patients included in this study were included under Allman group 1. All Patients were treated with plate fixation. Post op follow done at 1 1/2 ,3 and 6 months. During follow up clinical and radiological union were checked. Final functional outcome was assessed at 6 months follow up by Constant-Murley Score.Results: Out of 51 patients with displaced mid shaft clavicle fractures treated with plate fixation 43 patients (84.3%) showed excellent functional outcome 8 patients (15.7%) showed good functional outcome. None of the patients showed moderate or poor outcome. The radiological union was attained at 9.35 weeks. No complications in 83.4% of patients.Conclusions: Mid shaft clavicle fractures are more common in young males sustaining high energy trauma, and those fractures treated with plate fixation has a better functional outcome in terms of pain relief, activities of daily living and range of motion.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213381
      Issue No: Vol. 7, No. 5 (2021)
       
  • Comminuted olecranon fractures: locking compression plate fixation verses
           conventional plate fixation

    • Authors: Neetin P. Mahajan, Mrugank A. Narvekar, Lalkar L. Gadod, G. S. Prasanna Kumar
      Pages: 1001 - 1009
      Abstract: Background: A variable consensus exists on the optimal management strategies for olecranon fractures. Though the mechanical properties of the conventional plates and the locking plates used show no difference, pre-contoured locking plates provide a significant advantage over non-locking plates in unstable fractures. The aim of the study was to compare clinical and radiological outcomes in the management of the comminute olecranon fractures by anatomically pre-contoured locking compression plates and the conventional plates.Methods: The present study was a prospective study of 50 patients with comminuted olecranon fracture, with 25 patients each randomized into two groups, those that underwent fixation of the fracture using a pre-contoured locking compression plate (group LCP) and those fixed using a conventional plate (3.5 mm reconstruction plate) (group CP). Patients were followed up to 1 year with functional outcome assessed at each follow-up with Mayo elbow performance score.Results: The mean MEPS (LCP vs CP) at 1.5 (47 vs. 43.4) and 3 (67.4 vs 61.6) months follow up showed a statistically significant difference between the two groups, but the difference was not significant at 6 (86.4 vs 85.6) and 12 (88.4 vs 87) months. The time to union (4.3 months vs 5.0 months) was not significantly different between the groups. There were 11 complications in group LCP and 12 complications in group CP.Conclusions: In the present study, we suggest that the use of a pre-contoured locking compression plate provides better outcomes at earlier periods as compared to the conventional plate; thus, returning the patient to normal function at the earliest.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213382
      Issue No: Vol. 7, No. 5 (2021)
       
  • Functional outcome of distal humerus fractures treated by orthogonal
           locking compression plating: a short-term study

    • Authors: Shivakumar Jeyarajan, Dinesh Loganathan
      Pages: 1010 - 1014
      Abstract: Background: In Indian settings, the incidence of distal humeral fractures is associated with motor vehicle accidents and simple accidental falls. The treatment of these fractures continues to remain challenging due to anatomical factors. The present study was carried out to evaluate the functional outcome of distal humerus fractures treated with bicolumn locking compression plates applied orthogonally.Methods: This prospective study was carried out among 15 patients who were diagnosed with fracture of distal humerus. A detailed clinical examination and radiological assessment were done to evaluate the fracture pattern. In complex articular fractures, Chevron V shaped olecranon osteotomy was done. In other cases, routine approaches like TRAP, paratricipital or Triceps splitting approach were used.Results: The most common type of fracture observed was C2 (53.4%) and was associated with fracture of distal radius (26.6%) followed by fracture metacarpals (13.2%). Olecranon osteotomy was the most common surgical approach (40%). Majority of the participants in both the age groups equally showed excellent and good outcomes (42.8% and 37.5% respectively) while males showed excellent outcomes (55.6%) compared to females (16.7%).Conclusions: It is inferred that distal humerus fractures with intraarticular extension can be successfully treated with locking compression plates applied orthogonally. However, a long-term follow-up and a larger sample study is needed to further validate our findings.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213383
      Issue No: Vol. 7, No. 5 (2021)
       
  • Knowledge and awareness of orthopaedic surgeons about radiation hazards in
           operation theatres

    • Authors: Manik Sehgal, Bhanu Awasthi, Saloni Sood, Sunil Raina, Rubinder Kaur, Sarvesh Singh, Punit Katoch
      Pages: 1015 - 1020
      Abstract: Background: Due to increase in geriatric orthopaedic patients minimally invasive soft tissue and orthopaedic surgeries are gaining. But such procedures have increased the surgeon’s dependence on fluoroscopy which has exposed them to ever increasing dosage of ionising radiations (both direct and scattered).Methods: The study was carried out among medical professionals attending annual north zone conference of orthopaedics using a pre-designed questionnaire on a non-probability sample of 200 orthopedicians.  Questionnaires contained 11 MCQs.Results: 62% of the surgeons believed that hands receive maximum amount of C-arm radiations followed by thyroid (25%). 9% of surgeons have answered eyes and 4% say gonads. 31% of surgeons believe that 100 mSv is allowable annual effective whole-body dose of radiation. 15% believe it to be 500 msv. Majority (37%) of the surgeons had no idea on the allowable annual effective whole-body dose of radiation. 30% of surgeons believe that allowable annual effective dose of radiation for hands is 50 msv. Further 23% of the surgeons believe it to be 100 msv. 50% have no idea about this.Conclusions: All orthopaedic residents and surgeons should have more information and knowledge about ionising radiation. Special courses and workshops can be arranged at local, regional and national levels in this regard. 
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213384
      Issue No: Vol. 7, No. 5 (2021)
       
  • A prospective study of retrograde nailing for distal third femoral shaft
           fractures

    • Authors: Nikil Sanaba Paramesh, Pradeep Kumar Munirathnaiah
      Pages: 1021 - 1025
      Abstract: Background: To evaluate the postoperative knee range of motion and results of unreamed retrograde nailing for distal third femoral shaft fractures.Methods: Between June 2019 and June 2021 inclusive, a consecutive series of 20 patients who underwent retrograde nailing were prospectively evaluated. Outcome measures were union time, initiation of weight bearing, deformity and shortening, functional length of the nail, knee function assessed using a modified knee society knee score. Correlations between union time and other variables were also studied.Results: In these patients 18 (90%) of the 20 fractures achieved union, of which 4 underwent dynamisation; the mean union time for the other 18 fractures was 3.1 months. Angular malalignment was present in 2 patients and shortening in 3 others. There was negligible correlation between union time and variables of nail-canal diameter mismatch, functional length of nail, fracture geometry, or initiation of partial weight bearing ambulation. Knee flexion of more than 100 degrees was achieved in 19 patients. 14 patients had anterior knee pain and 7 had instability in early phases of ambulation. By the end of one year, excellent or good scores for pain and function were recorded in 95% and 86% respectively of the 20 patients.Conclusions: In view of such favourable union rates and no significant deterioration in overall knee joint function, at best retrograde nailing is a reliable alternative in the management of selected complicated fractures of the distal femoral shaft.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213385
      Issue No: Vol. 7, No. 5 (2021)
       
  • Chronic patellofemoral instability and pain treated effectively by
           anteromedial tibial tubercle transfer (Fulkerson osteotomy) with or
           without medial patellofemoral ligament reconstruction

    • Authors: John Mukhopadhaya, Arvind Gupta, Amit K. Sinha, Janki S. Bhadani
      Pages: 1026 - 1031
      Abstract: Background-Chronic patellar instability (subluxation and dislocation) and pain is a debilitating knee condition that frequently involves young, active patients. Bony malalignment and soft tissue injury (torn or stretched MPFL) is considered as a surgical indication for distal realignment in the form of Anteromedial tibial tubercle transfer(Fulkerson osteotomy) with or without MPFL reconstruction that effectively prevents the patella from tracking laterally and thus unloads the lateral patella while making the patellofemoral joint more congruous , stable and pain free.Materials and method - It is a prospective study of 22 patients of chronic patellar instability and pain. Follow up ranged from 24 to 36(average 30) months. Preoperative assessment included clinical examination, Lysholm, IKDC score and Radiological examination (X-ray, CT scan and MRI). 18 patients with history of dislocation and pain having bony malalignment and torn MPFL were treated with Fulkerson osteotomy and MPFL reconstruction and 4 patients with history of subluxation and pain having bony malalignment only were treated with Fulkerson osteotomy alone. Patients were followed up with the help of X-rays at regular interval and the clinical outcome was measured using scoring system. Results-There was a significant improvement in postoperative assessment with regards to scoring system (Lysholm and IKDC) and knee pain. Union at osteotomy site for all patients was seen. None of the patients had further episode of dislocation or subluxation. Pain at femoral site of MPFL reconstruction in 2 cases persisted for 3 months followed by resolution of their symptoms. One of our patients had profuse swelling at the site of operation postoperatively which was treated with Rest, Ice Pack, Compression and Limb elevation. Out of 22 patients undertaken infection at osteotomy site was seen in 1 patient for which implant removal was done from osteotomy site after union. Conclusion-Anteromedial Tibial tuberosity osteotomy and MPFL reconstruction is a successful procedure to treat patellofemoral pain and instability.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213163
      Issue No: Vol. 7, No. 5 (2021)
       
  • Accessory medial cuneiform bone in a child: unreported site and review of
           literature

    • Authors: Waleed Saqer, Atul Bandi, Salman Hasan, Maged Mostafa, Ahmed Refaat Khamis
      Pages: 1032 - 1034
      Abstract: Accessory ossicles of the foot are not uncommon finding in foot radiographs which has confused radiologists and orthopedic surgeons from time immemorial. Occasionally these bones are symptomatic, hindering daily activities of patients. We present a case report of an eleven years old girl with a symptomatic accessory medial cuneiform on the dorsal aspect of left foot. The child was evaluated radiologically and after a trial of failed conservative treatment, she was operated upon. Intraoperatively a superficial nerve on dorsum of this accessory ossicle was found, and the extra bone was excised. This accessory bone was found to be related to medial cuneiform bone at its dorsal and distal surface making to suggest its name as "Os cuneo-I metatarsale-I dorsale". Detailed radiological evaluation is mandatory for identification and exact anatomical localization of the extra bone before proceeding to excision, when non operative treatment fails to relieve the symptoms. 
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213386
      Issue No: Vol. 7, No. 5 (2021)
       
  • Fracture union in extra articular distal tibia fracture after definitive
           delta frame external fixation in COVID 19 pandemic: a case report

    • Authors: Neetin P. Mahajan, Prasanna Kumar G.S., Tushar Chandrakant Patil, Pramod K. Bagimani
      Pages: 1035 - 1038
      Abstract: Distal tibia fractures account for 10% of lower limb fractures. Mode of trauma also determines the fate of soft tissue recovery. In low energy fractures soft tissue show better healing whereas fractures due to high energy trauma show high chances of soft tissue complications like poor soft tissue coverage, wound infection and necrosis. We presented a 50 years old male case of extra articular left distal tibia fibula open fracture managed by delta frame external fixator with fibular K wiring used as a definitive management with good fracture healing and range of motion 5 months postoperative. Ankle spanning external fixation is a good modality of surgical management of extra articular compound distal tibia fractures as both temporary and definitive surgical fixation.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213387
      Issue No: Vol. 7, No. 5 (2021)
       
  • Novel technique of removal of broken intra-medullary nail from femur with
           secondary DCS plating

    • Authors: Neetin Pralhad Mahajan, Kartik Prashant Pande, Pramod K. Bagimani
      Pages: 1039 - 1042
      Abstract: Femoral shaft fractures are one of the commonest fractures of the lower limb which are frequently operated with intramedullary nailing which enables immediate post-operative mobilization of the patient. There could be various causes of nail breakage – some of the notable being weight bearing over the non-union of the femur shaft, or a re-trauma over the operated limb causing both the implant and the nail to be broken. There are various methods of removal of the broken implant the commonest being the use of T-reamer technique. However not always can this be used due to varied intra-operative obstacles in different cases as described in this case below. We have a 35 year old male patient who was brought to us 2 hours after an alleged history of slip and fall following which he had sustained right sided subtrochanteric femur fracture with a broken implant – intramedullary interlock nail. The patient is a previously operated case of right sided femur shaft fracture with interlocking nailing done 15 years back. The patient was operated with – broken implant removal on the right side along with a secondary DCS plating with bone grafting for the subtrochanteric femur fracture. Intra operative period was met with a certain number of challenges and difficulties in view of a 15 year old implant for removal which was successfully with removed with DCS plating done. As is obvious with the above case, it would be quite imperative to say that older the implant, more difficult it becomes for its removal.  
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213388
      Issue No: Vol. 7, No. 5 (2021)
       
  • Nora’s lesion: bizarre parosteal osteochondromatous proliferation in
           right foot: a case report

    • Authors: Shikhar Yadav, Divya G., Jithin Mohan, Joice Varghese
      Pages: 1043 - 1046
      Abstract: Nora’s lesion is a benign lesion involving mainly the proximal phalanges, metatarsals or metacarpals in the hands and feet. It may be easily confused with a malignant entity and was first identified and reported by Nora et al. in 1983. We present a case of a 12 years old female with complains of a swelling over the right foot noticed 4 months ago. Plain radiograph revealed heterotrophic calcification over the dorso-lateral aspect of the head of the first metatarsal. MRI scan of the foot was suggestive of a benign pathology with a differential of bizarre parosteal osteochondromatous proliferation (BPOP) or an osteochondroma. The patient was managed with excision biopsy and lesion was excised along with the pseudo-capsule and adjoining periosteum. Cortex appeared normal and wound was washed with hydrogen peroxide and incision closed. Histopathology report was suggestive of Nora’s lesion. One year follow up of the patient showed no recurrence. BPOP proliferation is a benign lesion however differentials need to be kept in mind and treatment with excision of the lesion along with the pseudo-capsule and periosteal tissue beneath the lesion has low rates of recurrence.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213389
      Issue No: Vol. 7, No. 5 (2021)
       
  • Delayed fracture union in a case of vitamin D dependent rickets associated
           with pulmonary tuberculosis - a case report

    • Authors: Neetin P. Mahajan, Prasanna Kumar G.S., Tushar C. Patil, Kevin A. Jain
      Pages: 1047 - 1050
      Abstract: Rickets is a defect of bone mineralization caused by vitamin D deficiency, seen most significantly at growth plates that result in radiological bony abnormalities like metaphyseal flaring and cupping, physeal widening with focal and generalised osteomalacia. Here we present a rare case of 7 years old male, a case of vitamin D3 deficiency rickets in a known case of multi drug resistant pulmonary tuberculosis.  The patient had suffered left proximal fibular fracture following trivial fall 1.5 month back and had delayed bony union leading to difficulty in walking and pain. The patient was treated with oral vitamin D supplementation. In vitamin D deficiency rickets, there is decreased bone mineralization leading to weak bones and delayed fracture healing in children. Low serum vitamin D levels also caused decreased immunity with increased susceptibility to respiratory infections like pulmonary tuberculosis. Appropriate treatment with injectable or oral vitamin D3 with adequate exposure of sunlight and proper nutrition is the best modality of treatment. 
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213390
      Issue No: Vol. 7, No. 5 (2021)
       
  • Open posteromedial dislocation of ankle without associated fractures

    • Authors: Saipramod Yadlapalli, Bezawada Paparao, Guruvardhan Kumar Venkata Kotha, Praveen Elaprolu
      Pages: 1051 - 1054
      Abstract: Dislocation of ankle without associated malleoli or talar fractures is a rare presentation. There is no established standard treatment for this condition. Most of them are treated by immediate reduction followed by immobilisation for 6-9 weeks. Majority of them recover without any complications. Here we reported a case of 33 year old man who was injured due to fall from a height, His ankle was deformed with a laceration over lateral side of ankle. Plain radiograph revealed posteromedial tibiotalar dislocation without any associated fractures. Immediate reduction and suturing was performed. At 5 months postoperative review patient was able to perform his daily routine without any instability or complaints.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213391
      Issue No: Vol. 7, No. 5 (2021)
       
  • Open tibial fracture with severe soft tissue injury and bone loss managed
           with ipsilateral fibular transport and its complications: a case report

    • Authors: John Mukhopadhaya, Arvind Gupta, Amit K. Sinha
      Pages: 1055 - 1061
      Abstract: Massive segmental bone defects of tibia present as a challenging task to manage specially when associated with extensive soft tissue injury. A 30 year old male presented to Paras HMRI hospital, Patna, post road traffic accident with Gustilo Anderson 3B comminuted open tibia shaft fracture and with an external fixator in situ with a grossly inflamed and infected wound. Initially patient was managed with serial wound debridement and skin grafting was done early to obtain adequate soft tissue coverage. The patient then underwent application of Ilizarov external fixator with plan of one level fibular osteotomy for ipsilateral fibular transport. With good outcome of the procedure clinically and radiologically, Ilizarov fixator was removed after time duration of about 1.3 years and limb was immobilized in plaster of Paris (POP) cast which was removed after 8 weeks. Within 1 month of removal of POP cast the patient presented to hospital again with complaints of pain and instability when his leg was run over by his child’s bicycle while playing. Diagnosed as fracture of proximal (transported) fibula he was managed then with locking plates; one of which was used as an internal fixator and the other as external fixator which was outside the body and acted as a support to the operated limb. After about 1 year the external locking plate was removed and patient was able to bear weight on his extremities. Despite various modalities to treat massive tibial gap, fibular transport procedure with Ilizarov external fixator seems to be the most viable option.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213162
      Issue No: Vol. 7, No. 5 (2021)
       
  • Systemic enzyme therapy with trypsin, bromelain and rutoside in the
           management of arthritis: an overview

    • Authors: Abhay P. Kulkarni, Himanshu A. Bendrey
      Pages: 1062 - 1069
      Abstract: Chronic arthritis, including osteoarthritis and rheumatoid arthritis, is a growing major public health problem leading to disability and reduced quality of life. Analgesic and anti-inflammatory drugs form the mainstay of treatment for chronic arthritis. The protracted use of the conventional medications for their management is fraught with shortcomings, including safety concerns. Proteolytic enzymes and antioxidant combinations have been used empirically, since ages, in many of these conditions. There is a growing body of evidence indicating the beneficial effects exerted by the individual ingredients and their combinations on the pathophysiology of arthritis. The analgesic, anti-inflammatory, anti-edematous, anti-thrombotic and anti-oxidant properties of these substances have been demonstrated in multiple in vitro and animal models. Furthermore, the therapeutic use of proteolytic enzyme-antioxidant combination is also supported by clinical trials in arthritis and related disorders. Such studies have mostly been carried out on preparations consisting of combinations of trypsin, bromelain and rutoside. The results of various studies (placebo-controlled and comparisons with nonsteroidal anti-inflammatory (NSAIDs) drugs) in patients with arthritis suggest that oral therapy with such enzyme-antioxidant combination produces improvement in all major clinical parameters like swelling, pain and joint stiffness and have comparable efficacy to NSAIDs. Some clinical studies also evaluated their effect on biochemical markers like cytokines, interferons and prostaglandins and reported remarkable improvements. The overall data also indicates that the tolerability of the enzyme-antioxidant combination is better than conventional therapies.
      PubDate: 2021-08-25
      DOI: 10.18203/issn.2455-4510.IntJResOrthop20213392
      Issue No: Vol. 7, No. 5 (2021)
       
 
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