Orthopaedic Journal of M. P. Chapter https://ojmpc.com/index.php/ojmpc <p>Orthopaedic Journal of Madhya Pradesh Chapter (P-ISSN: <a href="https://portal.issn.org/resource/ISSN/2320-6993">2320-6993</a> | E-ISSN: <a href="https://portal.issn.org/resource/ISSN/2582-7243">2582-7243</a>) is official publication of Madhya Pradesh Chapter of Indian Orthopaedic Association. It was started in 1980 with Dr. P. K. Rai as the first editor of the journal. Subsequently Dr. H.K.T. Raza, Dr. Alok C Agrawal (twice), Dr. Sunil Rajan, Dr. A. Mukherjee and Dr. Ashish Gohiya were elected as editors of the journal. Currently Dr. Saurabh Jain is editor of the journal.</p> <p>The journal has both print and online versions and is publishes two issues in a year. It is an open access, free, peer reviewed journal without any article no processing fee for any of its authors. The journal allows free access (Open Access) to its contents to attract more readers and citations to published articles. It permits authors to self-archive final accepted version of the articles on any OAI-compliant institutional / subject-based repository. It is indexed with Index Copernicus with IC value of 71.64. The journal got P-ISSN 2320-6993 in 2013 under the editorship of Dr. Alok C Agrawal and in the year 2020 journal got E-ISSN 2582-7243 under the editorship of Dr. Saurabh Jain. The journal publishes editorial, review articles, original articles and case reports which are published free of charge and journal does not charge for submission, processing or publication of manuscripts and even for colour reproduction of photographs. The journal’s full text is available online at https://www.ojmpc.com.</p> M P Chpater of Indian Orthopaedic Association en-US Orthopaedic Journal of M. P. Chapter 2320-6993 What Lies In Future Orthopaedics https://ojmpc.com/index.php/ojmpc/article/view/128 <p>Predictions are difficult about future, but change is inevitable. Orthopaedics is also constantly changing and touching new horizons every day. Existing techniques are being systematically upgraded and new techniques are constantly being integrated into existing systems. Although, it cannot be predicted too much, about how orthopaedics will look tomorrow, but there are a few key trends that are becoming apparent. Hence we orthopaedians have to rise up to face the challenge and to keep up the pace.<br>Today, like other surgical fields, orthopaedics is also on minimal invasive path with precision, favouring day care and overnight procedures. Minimal invasive procedures have been already established in joint surgeries of knee and shoulder. But now arthroscopies of small joints like ankle, wrist, elbow etc are also regularly performed. Scopies are recently performed even for various tendinopathies and also for nerve decompression. Minimal invasive and endoscopic spinal procedures are increasingly done and the spectrum of diseases which can be treated endoscopically is day by day increasing, broadening their scope. Even various training programs and fellowships are being structured and dedicated to these minimal invasive surgeries. Knee replacements are also being performed as day care procedures with the help of micro-plasty and improved instrumentation. Thus minimal invasive surgery is the future prospective of orthopaedic surgery and the trend towards outpatient and minimal invasive procedures in diagnostic studies and imaging, hospital-based treatment and rehab programs will also continue as technologies advance.<br>Newer advances are made in the field of implant and metallurgy as well. Femoral neck plate system, PFNA-2, Fence plate, variable angle plates, patellar plates, locked nails for rami are some of the examples of newly available implants. But are these implants really useful and beneficial for our patients or it is just an industrial and market driven hype to use them, will be tested over time. Proximal femur plate, short PFN, surface hip replacement and metal on metal arthroplasty are some of the examples which failed as quickly as they arrived. Hence we as surgeons should be vigilant, aware and judicious, in use of these implant weighing all pro and cons and use the implant what suits our patients the best. <br>The weak link in implant surgery is the metal with which they are made. There has been continuous research for search of an ideal metal to be used in orthopaedics. Today, other than stainless steel implants, implants made of titanium, and other alloys are available. Recently developed biodegradable implants and carbon implants are particularly useful for intra-articular fractures, which avoids need for second surgery for removal and are also radio transparent. Prosthesis made of zirconium, oxinium or newer alloys like TiNbN or NiCo are advantageous as they are inert, better survival-ship, less corrosive and less wear. Smart implants of further generations will be self-protective by automatically responding to changes in the local environment.<br>Orthobiologics including stem cell therapies and platelet-rich plasma have revolutionized some the orthopaedics treatment protocols by enhancing regeneration and repair. They are of tremendous use in sports injury, tendinopathy, arthropathies and wound healing. They act by increasing the growth factors at the pathology site and thus delay in aging procedure. They are increasingly used for joint preservation. Other treatments like including recombinant growth factors, cell transplants, gene therapies, stem cell therapy, tissue-engineered products are the new evolving biologics markets.<br>Introduced about two decades ago, computer-assisted orthopaedic surgery (CAOS) has emerged as a new and independent area in orthopaedics and traumatology. With the advances in technologies and imaging modalities, surgeries are increasingly performed with computer navigation, computer assisted, patient specific instruments and by robotics. Computer assisted surgery in arthroplasy, scoliosis, pedicle insertion etc have increased accuracy. Further uses of robotics to perform these surgeries have added a new dimension to orthopaedic surgery. The spectrum is increasing day by day. These are more precise, accurate, user friendly, lesser risk, economical and with fewer complication, especially for complex joints, deformed bones and complicated cases. Use of hexapods with computer software’s has given precision and flexibility for rapid corrections of deformity with simultaneous correction in all the planes. Use of robotics and computer software based hexapods is being explored and expanding for traumatological applications as well. Artificial intelligence in orthopaedics is in its infancy, yet its use has been helpful. But robotic surgery and artificial intelligence with its transformative potential will revolutionise orthopaedics and become increasingly common and it will assist and enhance decision-making intra-operatively, as well as in the planning and recovery stages too. <br>Many recent advances have occurred not only inside the operating theatre, but also outside the hospital and clinic room, both before and after surgery,as well. Improved imaging and printing have helped surgeons to better delineate three dimensionally, to assess the pathology early and definitely, thus help in better treatment at early stage. Fluoroscopy-based navigation, intra-operative 3-D fluoroscopy, O-arm, 2-D or 3-D multiple Image Stitching, Image Fusion or Statistical Shape Modelling are some of the recent modalities which can overcome the common problems of viewing of small portion of the target structure in a single C-arm image due to the limited field of view as these newer modalities image the entire structure by creating a panoramic view and also allow for visualization of critical structures such as nerve roots or vascular structures during surgical navigation. These improved diagnostic capabilities with the recent advancement like low-dose X-ray imaging, cartilage imaging, diffusion tensor imaging, MR arthrography, and high-resolution ultrasound and enabling image-guided interventions with real-time MRI or CT fluoroscopy, molecular imaging with PET/CT, and optical imaging have added a new dimension to orthopaedic practice. It is expected that with the advent of the flat panel technology, the use of fluoro-CT as a virtual object generator will significantly grow.<br>Smart phones and computers have added a new tool as an armamentarium for both the surgeons as well patient. They are helpful in many ways and can help in literature review, knowledge updates, search on a certain topic, diagnosing, pre-operative planning of patients, deformity assessment, measurement and calculations, treatment progress and to evaluate the outcome. They can also help to communicate, collect data digitally, remote monitoring, peer or expert advice for getting a second opinion. Hence it is very much necessary for a surgeon to learn and operate on these smart phones smartly because new generations of mobile imaging systems, will soon be available. <br>Issues related to training, technical difficulty, and learning curve are commonly presumed to be major problems to the acceptance of new technology, but these are not supposed to be the barriers for surgeons. The barriers to adoption are more intrinsic to the technology itself, including intra-operative glitches, unreliable accuracy, frustration with intra-operative registration, and line-of-sight issues. Despite these possible challenges, the future for the orthopaedic field looks bright as it evolves. <br>Large numbers of newer modules covering a wide range of traumatological and orthopedic applications have been developed, validated in the laboratory and in clinical trials. Some of them are abandoned, because the anticipated benefit failed to be achieved or the technology proved to be unreliable or too complex to be used intra-operatively. Hence all these new techniques, procedures, technologies and devices need to be carefully evaluated first in the laboratory setting and then clinically and must be proved better in both short and long-term outcomes for our patients rather than just a market driven gimmick. <br>A planned multidisciplinary approach holds the key for future treatment amalgating together other disciplines as well. Despite the advantages of newer technologies, to the patient and the surgical team and increased accuracy, technology is yet to gain general acceptance among orthopaedic surgeons of all age.</p> Saurabh Jain Copyright (c) 2021 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 1 3 Micro-Endoscopic Tubular Minimal Invasive Spine Surgery - Overview https://ojmpc.com/index.php/ojmpc/article/view/129 <p>Damage to paraspinal muscles as by caused by conventional open posterior lumbar spinal surgery can lead to inferior clinical and functional results. Minimally invasive approach to lumbar spine by microscopic, endoscopic or micro-endoscopic techniques using specialised instruments via neuro-vascular planes using muscle splitting approach to accesses the pathological site can reduce or minimise these complications. MIS techniques have demonstrated less blood loss, less postoperative pain, decreased need of analgesics post operatively, faster rehabilitation, shorter hospital stays and lower infection rates as compared to open techniques. while achieving equally efficacious results.<br>A thorough knowledge of anatomy of posterior spinal structures and understanding of the instruments used in minimal invasive spine surgery is of paramount importance. This article focusses on the anatomy, history, basics, instrumentation and indications used in minimally invasive lumbar spine surgeries.</p> Raut S Asati S Patel A Ruparel S Kundnani V Chaddha R Copyright (c) 2021 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 4 9 Outcome of Modified Wiltse Paramedian Approach For Fusion Of Single Level Lower Lumbar Spinal Instability https://ojmpc.com/index.php/ojmpc/article/view/115 <p>In one way, conventional open posterior midline approach for pedicle screws fixation for<span class="Apple-converted-space">&nbsp; </span>lower lumbar pathology is usually associated with significant para spinal muscle damage and mobility and in other way , recently used minimally invasive percutaneous pedicle screw fixation techniques have higher radiation exposure . Thus in midway between two Modified Wiltse paramedian<span class="Apple-converted-space">&nbsp; </span>approach may still provide the muscle sparing with minimal morbidity and radiation safety. We retrospectively evaluated the outcome of 12 patients of single level of lumbar instability<span class="Apple-converted-space">&nbsp; </span>at L4-L5 or at L5-S1 which included 2 patients with L5 vertebral body burst fracture, 6 patients with L4L5 ishthmic spondylolisthesis and 4 patients with L5S1<span class="Apple-converted-space">&nbsp; </span>Ishthmic spondylolisthesis.<span class="Apple-converted-space">&nbsp; </span>There were 4 male patients and 8 female patients<span class="Apple-converted-space">&nbsp; </span>with age range from 16 years to 45 years ( mean age of 34.6 years). The procedure was completed with less than 150 ml estimated blood loss.<span class="Apple-converted-space">&nbsp; </span>The average C arm exposure was 10.5.The average length of post operative<span class="Apple-converted-space">&nbsp; </span>stay was 3.5 days. There was no intraoperative neurological complications. Stitches were removed at 14th postoperative day and followed monthly for three months and 3 monthly upto 1 year . The mean preoperative VAS score ( 8.3) improved to the mean postoperative VAS score (3.2) in 3rd post op day and 1.2<span class="Apple-converted-space">&nbsp; </span>by 1 year with no use of analgesic medications.</p> Pandey KK Peepra D Pawar S Copyright (c) 2020 Orthopaedic Journal of M. P. Chapter https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 10 14 Efficacy of Microscopic Posterior Cervical Laminectomy for Multilevel Compressive Cervical Myelopathy: A Long Term Analysis https://ojmpc.com/index.php/ojmpc/article/view/130 <p><strong>Background:</strong> Cervical spondylotic myelopathy and ossified posterior longitudinal ligament (OPLL) are the two most common causes of compressive multilevel cervical myelopathy. These may cause progressive neurological deterioration and require surgical treatment. There is no gold standard treatment available. Anterior surgery is associated with morbidity and complications in multilevel cases because of which posterior surgeries are preferred, which have shown good clinical outcomes. We determined the long-term efficacy of microscopic posterior cervical laminectomy for multilevel compressive cervical myelopathy.</p> <p><strong>Material &amp; Methods:</strong> We reviewed 110 patients with multilevel compressive cervical myelopathy who underwent posterior cervical laminectomy from January 2007 to December 2014. Patients with age ≥45 years, C2-C7 cobb’s angle ≥ 10º, compression at ≥3 levels and a minimum of 5 years follow-up were included in the study. Demographic data, pre‑ and post‑operative clinical parameters (visual analog scale [VAS], Nurick’s grading and modified Japanese orthopaedic association [mJOA] score), radiological parameters (C2-C7 Cobb’s Angle), peri-operative parameters, complications and recovery rate were evaluated.</p> <p><strong>Results:</strong> The mean age of the patients was 55.6 years (44-74) with M: F 68:42. The mean blood loss and mean operative time was 93.9 ml and 96.6 minutes. There was significant improvement (p&lt;0.05) in VAS (3.7±1.5 to 1.9±0.8), Nurick’s grading (3.3±0.9 to 1.8±0.6) and mJOA score (8.3±1.4 to 13.9±1.8). At final follow-up 61.8% patients’ maintained cervical lordosis, 21.8% changes to a straight spine and 16.3% became kyphotic. Intraoperatively 7 patients had a dural tear. 3 patients showed neurological deterioration postoperatively and 3 had unilateral C5 palsy which improved within 6 months period. 19% had an excellent outcome, 39% had good, 33.6% had fair and 8.1% patients had a poor outcome.</p> <p><strong>Conclusion:</strong> Microscopic posterior cervical laminectomy is the gold standard surgical procedure in patients with multilevel compressive cervical myelopathy with good recovery and clinical outcomes in properly selected patients. In long term it may causes progression of kyphosis, without any significant clinical affection.</p> Asati S Raut S Ruparel S Patel A Chaddha R Kundnani V Copyright (c) 2021 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 15 21 Analysis of Potential Bone Donors and Deferral Rates for Bone Bank in a Tertiary Care Hospital https://ojmpc.com/index.php/ojmpc/article/view/117 <p><strong>Background:</strong> Bone grafts are widely used in various orthopaedic procedures. Problems of limited availability of autograft and donor site complications can be overcome by use of allograft procured from the bone bank. The banks are underutilized due to high donor deferral rate. Hence this study is done to analyse the donor profile and donor deferral rate of our bone bank.</p> <p><strong>Material &amp; Methods:</strong> Donor deferral rate in pre-harvesting phase, intraoperative phase and post harvesting phase in 67 patients of fracture neck of femur undergoing hemi-replacement / total hip replacement (THR), osteoarthritis hip undergoing THR and osteoarthritis knee undergoing total knee replacement, who donated the bone was analysed.</p> <p><strong>Results:</strong> Overall donor deferral rate was 69% as 46 donors out of the total 67 were rejected and only 21 (31%) donors were eligible for use. 24 (35%) donors were rejected during the pre-harvesting stage; 1 (1.4%) donor was rejected intraoperatively, whereas 21 (31 %) donors were rejected during the post harvesting period.</p> <p><strong>Conclusion:</strong> High rate of donor deferral rate has led to donation losses and burden on limited resources. Awareness, effective trained staff, proper counselling and consent, improved serological testing and equipped bone banks can reduce donor rejection and meet the increasing demand for bone grafts.</p> SAURABH kumar Ahmer Zafar ANIL KUMAR JAIN ADITYA N AGGARWAL HIMANSHU BHAYANA ISH KUMAR DHAMMI Copyright (c) 2020 Orthopaedic Journal of M. P. Chapter https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 22 27 Surgical Management Of Acromioclavicular Joint Injuries By Ligament Reconstruction Using Mersilene Tape And Ethibond https://ojmpc.com/index.php/ojmpc/article/view/131 <p><strong>Background:</strong> Acromioclavicular (AC) injuries account for 9% to 12% of all shoulder injuries. Rockwood grade IV to VI AC injuries require surgical fixation, which can be done by Mersilene tape reconstruction, K-wire transfixation, hook plates, reconstruction using autografts, or suture anchors. But no gold standard procedure has been established till date. </p> <p><strong>Material &amp; Methods:</strong> 12 patients of AC joint disruption treated by surgical reconstruction using mersilene tape and ethibond suture were evaluated functionally using Visual analog scale (VAS) and Constant and Murley scores and radiological for re-displacement and fixation. </p> <p><strong>Results:</strong> The mean age in the group was 46.6 years (range 26 to 61), with male to female ratio of 3:1. Mean delay in surgery was 11 days (range 4 to 14 days), mean blood loss was 100 ml and mean duration of surgery was 54 min. The mean pre-operative VAS score improved from 6.41 to post-operative score of 2.68 and 1.25 at 6 and 12 months respectively. Constant Murley score improved from a mean pre-operative score of 51 to a post-operative score of 88.33 and 92.08 at 6 and 12 months respectively. At the final follow up all the patients had satisfactory results in terms of pain, cosmetic correction and movements and strength of the shoulder. The AC joint was clinically as well as radiologically stable in all the cases.</p> <p><strong>Conclusion:</strong> Anatomic reconstruction of AC joint disruption requires reconstruction of both coracoclavicular ligament as well as acromioclavicular ligament to achieve stability in both superior-inferior as well as antero-posterior plane, which can be achieved by mersilene tape fixation augmented by 5-0 ethibond suture leading to excellent results. </p> Patidar A Chauhan A Aggarwal A Singh V Sharma SK Copyright (c) 2021 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 28 32 The Correlation Of Various Anthropometric Measurements With Tibia Interlocking Nail Length Measured Intra-Operatively https://ojmpc.com/index.php/ojmpc/article/view/111 <p><strong>Background:</strong> A proper and accurate size of tibial nail insertion is necessary for better functional outcome and to prevent complications related to improper nail length. Various preoperative and intraoperative measures are used, with varied accuracy for nail size estimation. With aim to find out the best anthropometric measure correlating with the tibial nail length, we correlated various anthropometric measurements to actual size of tibial interlock nail used in 100 cases of tibial shaft fracture.</p> <p><strong>Material &amp; Methods</strong>: 5 anthropometric parameters were measured i.e. (1) distance from medial knee joint line to ankle joint line (K-A) (2) distance from medial knee joint line to medial malleolus (K-MM) (3) distance from tibial tuberosity to ankle joint (TT-A) (4) distance from tibial tuberosity to medial malleolus (TT-MM) (5) distance from tip of olecranon to 5th metacarpal head (O-MH) in 100 cases of tibial shaft fractures treated with interlocking nail and were correlated with the tibial nail size used.&nbsp;</p> <p><strong>Results</strong>: Mean size of nail used was 33.61±1.69 mm (range 28 to 36 mm). Mean of five anthropometric parameters for K-A, K-MM, TT-A, TT-MM and O-MH, were 35.61±1.59 (range 30 to 39 mm), 37.16 +1.36 (range 32 to 41.5 mm), 33.58 ± 1.79 (range 28 to 37 mm), 34.40 ± 1.21 (range 30 to 39 mm), and 33.10 ± 1.61 (range 28 to 36 mm) respectively.</p> <p><strong>Conclusion</strong>: All anthropometric parameters i.e. TT-A, TT-MM, K-A, K-MM and O-MH can be used for nail size prediction. O-MH was nearly accurate to the nail size as compared to other methods because of interpersonal variation in palpation of tibial tuberosity.</p> Dr.Ravi Kant Jain Dr.Mandar Deshpande Dr. Taha Bohra Dr. Neeraj Jain Dr. Mayank Gulve Copyright (c) 2020 Orthopaedic Journal of M. P. Chapter https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 33 36 Functional Outcome Of Bilateral Total Hip Arthroplasty by Posterolateral Approach: A Prospective Study in Indian Population https://ojmpc.com/index.php/ojmpc/article/view/132 <p><strong>Background</strong>: Total hip arthroplasty (THA) is the most widely accepted surgical procedure for the treatment of Avascular necrosis of femoral head, with favourable clinical outcomes having been reported in various studies. Most patients that undergo THA suffer from primary osteoarthritis. The posterolateral (Moore’s) approach to hip permits easy access with fewer tissue dissection and blood loss while raising the risk of neural injury and postoperative dislocation of the prosthesis.</p> <p><strong>Material and Methods</strong>: This longitudinal study was conducted on 50 arthritic hips (25 patient) operated by a single surgeon with Bilateral THA via posterolateral approach (Southern Moore’s approach). All patients with bilateral osteoarthritis of hip secondary to avascular necrosis of hip (grade III or IV) more than 18 years of age, patients with normal septic profile and patients who were willing to undergo total hip arthroplasty according to our protocol were included in the study. The patients were followed up at the end of 6 weeks, 3 months and six months postoperatively after bilateral THA.</p> <p><strong>Results</strong>: Among 25 patients in this study, 20 patients (80%) were males and 5 patients (20%) were females. All the patients were between 18 to 60 years of age. The most common etiology for AVN was idiopathic in 11 patients (44%) followed by Steroid abuse in 8 patients (32%).The most common complication encountered in our study was Limb length discrepancy (LLD) in 3 patients (12%) followed by Posterior Dislocation of hip in 2 patients (8%). The mean pre op HHS was 28.22 and 26.73 for right and left hip which improved significantly post operatively with HHS of 82.36 after 6 months post operatively which suggest excellent improvement in clinical outcome.</p> <p><strong>Conclusion</strong>: Uncemented bilateral THA can be used in patients with excellent to good functional outcome at midterm follow-up, high satisfaction rate and lower rate of complications. Longer follow-up and multi-centric studies with larger sample size are necessary to establish confirmatory results.</p> Choudhari P Jain N Jain S Chauhan R Copyright (c) 2020 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 37 41 Evaluation of Platelet Rich Plasma Therapy in Osteoarthritis Of Knee https://ojmpc.com/index.php/ojmpc/article/view/133 <p><strong>Background</strong>: Knee osteoarthritis (OA) is common entity in adults causing disability and decreased work productivity. Management of early OA is not established showing varied results of conservative and medical treatment. We evaluated the functional outcome of intra-articular injection of platelet rich plasma (PRP) for management of early stages of OA knee.</p> <p><strong>Material and Methods:</strong> 30 patients of OA knee, Kellgren type II or III, more than 40 years’ age, were treated with 4 ml of intra-articular autologous PRP injection and were assessed by improvement in functional outcome as seen by WOMAC and VAS score.</p> <p><strong>Results</strong>: The mean age was 54.17 ± 8.18 years (range 44 to 78 years). 14 (46.7%) were males and 16 (53.3%) were females. 11 (36.7%) patients had KL grade 2 and 19 (63.3%) patients had KL grade 3 osteoarthritis. The mean pre-procedural WOMAC score of 47.67 ± 6.50 improved to 23.70 ± 5.88, 23.57 ± 5.12 and 25.80 ± 5.69 at one, three and six months after the PRP injection, respectively. The mean pre-procedural VAS score of 5.37 ± 0.85, improved to 1.43 ± 1.04, 1.43 ± 0.63 and 1.73 ± 0.58 at one, three and six months after the PRP injection, respectively. Pain at injection site was seen in 1 (3.3%) patient and 1 (3.3%) patient developed superficial infection.</p> <p><strong>Conclusion</strong>: PRP therapy provides pain relief and improves the functional outcome in early stages of Osteoarthritis of Knee.</p> Banodha L Thareja S Copyright (c) 2021 https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 42 45 Neglected Cauda Equina Syndrome Due To Prolapsed Lumbar Intervertebral Disc In An Adolescent Patient: A Case Report And Review Of Literature https://ojmpc.com/index.php/ojmpc/article/view/113 <p>Lumbar disc herniation is very rare in children and adolescent age group. We report a rare case of two months old neglected case of post traumatic L4-L5 disc herniation causing cauda equina syndrome and bilateral foot drop in a 13-year-old patient. He was treated successfully with emergency L4 laminectomy and L4-L5 discectomy, and he recovered fully without any restricted activity. Cauda equina is a surgical emergency, which should be diagnosed and operated as early as possible for good results, even if the patient presents late.</p> Jeetesh Gawande P K Verma Shubham Mishra P K Lakhtakia Copyright (c) 2020 Orthopaedic Journal of M. P. Chapter https://creativecommons.org/licenses/by-nc-nd/4.0 2020-12-31 2020-12-31 27 1 46 49