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Vijayan S, Kyalakond H, Kulkarni MS, Aroor MN, Shetty S, Bhat V, Rao SK. Clinical outcome of anterior cruciate ligament reconstruction with modified transtibial and anteromedial portal. Musculoskelet Surg 2023; 107:37-45. [PMID: 34389922 PMCID: PMC10020253 DOI: 10.1007/s12306-021-00727-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
Arthroscopic ACL reconstruction is the current standard care of treatment for anterior cruciate ligament (ACL) injuries. Modified transtibial (mTT) and anteromedial portal (AMP) techniques aim at the anatomical placement of femoral tunnel. Controversy existed in the literature with regard to the outcome of these techniques. Hence, we designed a retrospective comparative study to analyse the clinical and functional outcomes of mTT and AMP techniques. We hypothesized that there would be no difference between the clinical and functional outcomes in mTT and AMP techniques. This retrospective observational study was conducted in consecutive patients who underwent arthroscopic ACL reconstruction using semitendinosus-gracilis (STG) quadrupled graft in our tertiary care centre with a minimum follow-up of two years. Out of 69 patients, 37 had undergone ACL reconstruction by mTT technique and remaining by AMP technique. All the patients were assessed clinically by anterior drawer, Lachman's, pivot shift and single-legged hop test. Lysholm Knee Scoring Scale and International Knee Documentation Committee (IKDC) subjective knee evaluation score were used for the functional status. Knee instability was assessed objectively by KT-1000 arthrometer. There was no statistically significant difference in baseline demographic characteristics between mTT and AMP groups. At the end of 2 years, no statistically significant difference was noted in the anterior drawer and Lachman's test. Though not significant, IKDC scores and Lysholm's scores showed a better outcome in the AMP group when compared to the mTT group. AMP group showed significantly better outcome with KT-1000 arthrometer. Based on the results obtained, we presume that overall both mTT and AMP have similar functional outcome. However, as AMP technique offers significantly improved subjective rotational stability on pivot shift test, better hop limb symmetry index and KT 1000 readings compared to mTT, we suggest AMP over mTT.
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Affiliation(s)
- S. Vijayan
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - H. Kyalakond
- grid.496653.b0000 0004 1805 6782Department of Orthopedics, BVVS S Nijalingappa Medical College and HSK Hospital and Research Centre, Navanagar, Bagalkot, Karnataka 587103 India
| | - M. S. Kulkarni
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - M. N. Aroor
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - S. Shetty
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
| | - V. Bhat
- grid.411639.80000 0001 0571 5193Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, Karnataka 576104 India
| | - S. K. Rao
- grid.465547.10000 0004 1765 924XDepartment of Orthopedics, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka 576104 India
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Yoon KH, Kim JH, Kwon YB, Kim EJ, Lee SH, Kim SG. A two-portal technique using a flexible reamer system is a safe and effective method for transportal anterior cruciate ligament reconstruction. Arch Orthop Trauma Surg 2020; 140:383-390. [PMID: 31970504 DOI: 10.1007/s00402-020-03343-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Indexed: 01/14/2023]
Abstract
INTRODUCTION A flexible reamer system (FRS) for transportal anterior cruciate ligament reconstruction (ACLR) has been developed to overcome the technical challenges of a rigid reamer system. The purpose of this study was to investigate the safety and effectiveness of the two-portal technique using an FRS by evaluating femoral tunnel geometry. METHODS This study included 30 patients (mean age 30 ± 12.1) who underwent transportal single-bundle ACLR. Operations were performed with the two-portal technique using an FRS. Three-dimensional computed tomography was performed for all patients 2 days after the operation. The femoral tunnel position, femoral graft bending angle, femoral tunnel length, and posterior wall breakage were evaluated. These radiologic outcomes were compared to previous literature-reported outcomes. RESULTS The mean distances (measured as a percentage) from the posterior wall and the intercondylar notch roof to the femoral tunnel center were 29.6 ± 5.5% and 20.1 ± 6.7%, respectively. The femoral graft bending angle (108.4° ± 6.9°) was similar to that associated with the traditional transportal technique using a rigid reamer system, but it was less acute than that associated with the three-portal technique using an FRS. The femoral tunnel length (32.8 ± 4.5 mm) was also similar to the results of the traditional transportal technique using a rigid reamer system, but it was shorter than that of three-portal technique using an FRS. The prevalence of posterior wall breakage was as low as the reported outcomes of the outside-in technique (2 cases, 6.6%). CONCLUSIONS The two-portal technique for transportal ACLR using an FRS can achieve comparable femoral graft bending angle and femoral tunnel length compared with the conventional three-portal technique using the rigid reamer system and had a low risk of posterior wall breakage. Therefore, the two-portal technique using the FRS can be considered a safe and effective method for transportal ACLR. LEVEL OF EVIDENCE Retrospective case series; level of evidence, 4.
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Affiliation(s)
- Kyoung Ho Yoon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Jae Ho Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Yoo Beom Kwon
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Eung Ju Kim
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang Hyeon Lee
- Department of Orthopaedic Surgery, Kyung Hee University Hospital, 23, Kyungheedae-ro, Dongdaemun-gu, Seoul, 02447, South Korea
| | - Sang-Gyun Kim
- Department of Orthopedic Surgery, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-Gu, Ansan-si, Gyeongki-do, 15355, South Korea.
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Nakamura K, Nakamura T, Horie M, Katagiri H, Otabe K, Nakagawa Y, Amemiya M, Sekiya I, Muneta T, Koga H. Anatomic femoral tunnel placement is difficult by the transtibial technique: comparison of three different femoral tunnel drilling techniques in double-bundle anterior cruciate ligament reconstructions. Knee Surg Sports Traumatol Arthrosc 2020; 28:584-593. [PMID: 31612263 DOI: 10.1007/s00167-019-05740-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 09/30/2019] [Indexed: 01/18/2023]
Abstract
PURPOSE To compare the position and direction of femoral and tibial tunnels for both the anteromedial bundle (AMB) and posterolateral bundle (PLB) among three different femoral tunnel drilling techniques, transtibial (TT), transportal (TP), and outside-in (OI) techniques, in anatomic double-bundle ACL reconstruction to clarify advantages and disadvantages of each technique. METHODS One-hundred and thirty-nine patients underwent primary ACL reconstruction with an autologous semitendinosus tendon in our institution between 2014 and 2016. Thirteen patients were excluded according to the exclusion criteria. Of the 126 patients, 98 patients agreed to be included in this study. Patients were then randomized into three groups according to the femoral tunnel drilling technique; the TT, TP, and OI groups. Femoral and tibial tunnel angles and positions were measured using three-dimensional computed tomography. RESULTS Of patients who agreed to be included in this study, eight patients (seven in TT and one in OI) were excluded since the femoral tunnel could not be created at the intended position. Eighty-six patients (29 in TT, 29 in TP, and 28 in OI) were included for the analyses. Tunnel angles, as well as tunnel lengths, had significant differences among different techniques depending on each technique's characteristics. In terms of tunnel position, femoral tunnel positions of both the AMB and PLB in the TT group were significantly higher than those in the TP group (AMB: p = 0.003, PLB: p = 0.001), and the PLB tunnel position in the TP group had significantly smaller vaciance than that in the TT group (p = 0.004) and OI group (0.002). CONCLUSIONS The femoral tunnel positions created by the TT technique were significantly higher, with larger variance, than the TP technique in double-bundle ACL reconstruction, although the positions seemed to be within anatomical footprint. In addition, there were several cases in which femoral tunnels could not be created at the intended position by the TT technique. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Kaori Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Tomomasa Nakamura
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masafumi Horie
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hiroki Katagiri
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Koji Otabe
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Yusuke Nakagawa
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Masaki Amemiya
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Ichiro Sekiya
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Takeshi Muneta
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Hideyuki Koga
- Department of Joint Surgery and Sports Medicine, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan. .,Department of Orthopaedic Surgery, Tokyo Medical and Dental University Hospital of Medicine, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan.
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Saito M, Nakajima A, Sonobe M, Takahashi H, Akatsu Y, Inaoka T, Iwasaki J, Morikawa T, Watanabe A, Aoki Y, Sasho T, Nakagawa K. Superior graft maturation after anatomical double-bundle anterior cruciate ligament reconstruction using the transtibial drilling technique compared to the transportal technique. Knee Surg Sports Traumatol Arthrosc 2019; 27:2468-2477. [PMID: 30374576 DOI: 10.1007/s00167-018-5240-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 10/17/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate and compare the femoral tunnel aperture position, graft bending angle and the magnetic resonance imaging (MRI) graft signal intensity after anatomical double-bundle anterior cruciate ligament (ACL) reconstruction between transtibial and transportal drilling techniques of the femoral tunnel. METHODS Eighty-seven patients who underwent anatomic double-bundle ACL reconstruction with hamstring tendon autograft between January 2012 and December 2014 were included in this retrospective study. Forty-one patients underwent reconstruction using a transportal technique (TP group) and 46 patients underwent reconstruction using a transtibial technique (TT group). The anteromedial (AM) femoral aperture position and the graft bending angle were assessed using transparent three-dimensional CT 2 weeks postoperatively. MRI assessment was performed with proton density-weighted images in an oblique coronal plane 6 and 12 months postoperatively. Signal/noise quotient was calculated for two specific graft sites (femoral tunnel site and mid-substance site). Femoral aperture position, the graft bending angle and signal/noise quotient were compared between the TP and TT groups. RESULTS There was no significant difference in the aperture position between the two groups. The graft bending angle of the AM tunnel in the axial plane was significantly greater in the TP group (p < 0.001). On the other hand, the TP group had a significantly more acute angle in the coronal plane (p < 0.001). There was no significant difference at either site in the signal/noise quotient of the graft between the two groups at 6 months. However, the TT group had a lower signal/noise quotient at 12 months at both sites (femoral aperture: p = 0.04, mid-substance: p = 0.004). CONCLUSION There was a significant difference in signal/noise quotient between the two drilling techniques 12 months postoperatively. There was no significant difference in femoral tunnel aperture position between the two groups. However, graft bending angle at the femoral tunnel aperture was significantly different between the two groups, indicating the possibility that graft bending angle is a factor that influences graft maturation. This indicates that the TT technique has an advantage over the TP technique in terms of graft maturation.
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Affiliation(s)
- Masahiko Saito
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan.
| | - Arata Nakajima
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Masato Sonobe
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Yorikazu Akatsu
- Department of Orthopaedic Surgery, Toho University Sakura Medical Center (Chiba), 564-1 Shimoshizu, Sakura, Chiba, 285-0841, Japan
| | - Tsutomu Inaoka
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
| | - Junichi Iwasaki
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Tsuguo Morikawa
- Department of Orthopaedic Surgery, Chiba Medical Center, 1-7-1 Minami-cho, Chuo-ku, Chiba, 260-0842, Japan
| | - Atsuya Watanabe
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Yasuchika Aoki
- Department of Orthopaedic Surgery, Eastern Chiba Medical Center, 3-6-2 Okayamadai, Tougane, Chiba, 283-8686, Japan
| | - Takahisa Sasho
- Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuou-ku, Chiba, 260-8670, Japan
| | - Koichi Nakagawa
- Department of Radiology, Toho University Sakura Medical Center (Chiba), Chiba, Japan
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Niki Y, Nagai K, Harato K, Suda Y, Nakamura M, Matsumoto M. Effects of femoral bone tunnel characteristics on graft-bending angle in double-bundle anterior cruciate ligament reconstruction: a comparison of the outside-in and transportal techniques. Knee Surg Sports Traumatol Arthrosc 2017; 25:1191-1198. [PMID: 26294057 DOI: 10.1007/s00167-015-3761-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 08/11/2015] [Indexed: 01/10/2023]
Abstract
PURPOSE Bone tunnel creation techniques influence the 3-dimensional (3D) position of bone tunnels and graft-bending angle in anterior cruciate ligament (ACL) reconstruction. This study assessed graft-bending angle and 3D characteristics of femoral bone tunnels and compared them between outside-in (OI) and transportal (TP) techniques. METHODS Participants comprised 64 patients who underwent anatomic double-bundle ACL reconstruction, allocated to OI and TP groups (n = 32 each). The graft orientation plane exhibiting the largest graft-bending angle at the femoral tunnel aperture with the knee in extension was reconstructed from CT data using 3D imaging software. In this plane, graft-bending angle was compared between the OI and TP techniques. RESULTS Although positionings of the intra-articular apertures of the femoral and tibial bone tunnels were similar, several spatial parameters of bone tunnels differed between techniques. Graft-bending angles of both anteromedial and posterolateral bundles were significantly more acute with the OI technique than with the TP technique. On coronal-plane CT, angle of the bone tunnel axis relative to the distal condylar axis correlated negatively with graft-bending angle, while in the axial plane, angle of the bone tunnel axis relative to the posterior condylar axis correlated positively with graft-bending angle. Lysholm score, pivot shift test, and anteroposterior laxity at >2.5-year follow-up demonstrated no significant differences between techniques. DISCUSSION Different bone tunnel directions in OI and TP techniques substantially affected graft-bending angle , despite similar positionings of the intra-articular apertures. Graft-bending angle with the OI technique was acute, but risk of posterior blowout of the lateral femoral condyle was decreased. Surgeons should create the femoral tunnel while considering an obtuse graft-bending angle without increasing the risk of posterior blowout. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yasuo Niki
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Katsuya Nagai
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Kengo Harato
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Yasunori Suda
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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Vaishya R, Agarwal AK, Ingole S, Vijay V. Current practice variations in the management of anterior cruciate ligament injuries in Delhi. J Clin Orthop Trauma 2016; 7:193-9. [PMID: 27489416 PMCID: PMC4949409 DOI: 10.1016/j.jcot.2015.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/27/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The aim of this study was to determine the current practices and preferences of the arthroscopic surgeons of Delhi in the diagnosis, treatment and rehabilitation of patients with anterior cruciate ligament (ACL) injury. METHODS It was a cross-sectional descriptive study conducted among arthroscopic surgeons of Delhi. A survey was conducted using a questionnaire that was sent either by e-mail or by direct contact to all sixty arthroscopic surgeons of Delhi. RESULTS Forty-eight (80%) surgeons responded to our questionnaire. Maximum participants (83.3%) used semitendinosus/gracilis tendon autograft for ACL reconstruction (ACLR) and only 2.1% were using bone-patellar-tendon-bone (BPTB) autograft. Most preferred method of graft fixation was an 'interference screw' on the tibial side and an 'endobutton' on the femoral side, which was preferred by 95.83% and 93.75% surgeons, respectively. Almost all respondents (97%) used a bio-absorbable interference screw for tibial side graft fixation. Postoperative bracing was advised for <3 weeks by 47.9% surgeons and for 3-6 weeks by 31.3%. The results were analysed using statistical analysis. CONCLUSION Surgeon preferences in ACLR differ considerably among the arthroscopic surgeons of Delhi. There is majority consensus for using Hamstring autograft (single bundle) with a suspensory fixation on the femoral side and an aperture fixation on the tibial side. Transportal technique of making the femoral tunnel and preservation of amputation stump were the preferred methods. However, differences exist over the timing of surgery, rehab after surgery, pain management, etc.
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Affiliation(s)
- Raju Vaishya
- Professor, Senior Consultant Orthopaedics, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Amit Kumar Agarwal
- Consultant Orthopaedics, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
- Corresponding author. Tel.: +91 9968578514.
| | - Sachin Ingole
- Orthopaedic Registrar, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
| | - Vipul Vijay
- Consultant Orthopaedics, Department of Orthopaedics and Joint Replacement Surgery, Indraprastha Apollo Hospitals, New Delhi 110076, India
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