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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2012  |  Volume : 46  |  Issue : 3  |  Page : 326-332
Resistant clubfoot deformities managed by Ilizarov distraction histogenesis


1 Department of Orthopaedic Surgery and Traumatology (DOST), Liaquat University of Medical and Health Sciences Jamshoro, Sindh, Pakistan
2 Department of Orthopaedics, Isra University Hyderabad, Sindh, Pakistan

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Date of Web Publication18-May-2012
 

   Abstract 

Background: Resistant clubfoot deformities of the foot and ankle remain a difficult problem even for the most experienced surgeon. We report a series of neglected resistant clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis.
Materials and Methods: Twenty one patients with 27 feet having resistant clubfoot deformities were managed by Ilizarov distraction histogenesis from April 2005 to May 2008. The mean age was 12 years (range 8-20 years). A limited soft tissue dissection like percutaneous Achilles sheath tenotomy and plantar fasciotomy were done. Progressive correction of the deformities was achieved through the standard and simple Ilizarov frame construct setting. After removal of Ilizarov frame, a short leg walking cast was used for an additional 6 weeks, followed by an ankle foot orthrosis for 3 months.
Results: The mean followup period was 18.7 months (range 20-36 months). The mean duration of fixator application was 3.6 months (range 3-5 months). At the time of removal of the fixator, a plantigrade foot was achieved in 25 feet and gait was improved in all patients. There was residual varus hind foot deformity in two patients. Out of 27 feet, 3 (11.11%) were rated as excellent, 17 (62.96%) as good, 5 (18.51%) as fair, and 2 (7.40%) as poor according to Reinkerand Carpenter scale. Excellent and good results (74.07%) were considered satisfactory, while fair and poor results (25.92%) were considered unsatisfactory.
Conclusion: The short term clinical and functional results of resistant clubfoot deformities with Ilizarov's external fixator is promising and apparently a good option.

Keywords: Ilizarov frame, deformities, resistant clubfoot

How to cite this article:
Makhdoom A, Qureshi PA, Jokhio MF, Siddiqui KA. Resistant clubfoot deformities managed by Ilizarov distraction histogenesis . Indian J Orthop 2012;46:326-32

How to cite this URL:
Makhdoom A, Qureshi PA, Jokhio MF, Siddiqui KA. Resistant clubfoot deformities managed by Ilizarov distraction histogenesis . Indian J Orthop [serial online] 2012 [cited 2019 Dec 10];46:326-32. Available from: http://www.ijoonline.com/text.asp?2012/46/3/326/96385

   Introduction Top


The resistant and neglected clubfoot deformity presents a significant challenge. Several corrective procedures have been described, with the goal to provide a pain free, plantigrade foot. The Ilizarov method of external fixation and gradual distraction has been reported as an alternative to conventional techniques. Encouraging results are reported with this method. [1]

The Ilizarov's external fixator allows simultaneous correction of all the severe foot deformities associated with neglected clubfoot with minimal surgery, reducing risks of cutaneous or neurovascular complications and avoiding excessive shortening of the foot. [2] The external fixation remains an essential tool for future orthopedic surgeons. [3]

The Ilizarov method is being used increasingly to correct many orthopedic deformities. The frames required for ankle and foot deformity correction are among the most difficult to construct owing to the complexity of the deformities which must be corrected. [4] The application of Ilizarov frame is in two parts, one to the leg and one to the foot. First, a two-ring construct is applied to the leg. Each ring is fixed with two wires or one wire and one half pin. The foot construct consists of a half ring posteriorly and half ring anteriorly. [5] A half ring is fixed to the forefoot with 2 crossed olive wires, 1 traversing the 5 metatarsals and the other fixed to the medial 3 metatarsals medially to laterally. A half ring was applied to the hind foot with 2 crossed wires through the calcaneus, with a Shanz pin fixed to the calcaneus from posterior to anterior. The forefoot half ring was fixed to the hindfoot half ring by a medial rod on a hinge and connected to the distal tibial ring by a central dorsal rod on a universal hinge. Two dorsal rods were used on each side of the central hole of the forefoot half ring in patients with forefoot supination. [6] The Ilizarov technique has been suggested as an alternative to major surgery for the treatment of neglected or recurrent deformities in clubfoot. [7] Even in those patients in whom final corrective arthrodesis is necessary, this may be carried out with minimal bone resection, since the severe deformities of the foot and ankle have been corrected. [8] We report a series of neglected resistant clubfoot deformities treated by limited surgery and Ilizarov distraction histogenesis.


   Materials and Methods Top


We evaluated the results of this prospective study with Ilizarov's external fixation system in 21 patients with 27 feet without corrective osteotomies as treatment of neglected resistant clubfoot deformity, between April 2005 and May 2008. This study includes a resistant clubfeet (n=13) which were treated for the first time, already operated clubfeet by other methods (n=14), and also presented with multiple surgical scars (n=5).

All resistant clubfeet with common deformities like adduction or supination, or both, of the forefoot, short medial column and long lateral column, varus of the hind foot, and equinus of the ankle were included to decide the same surgical planning with Ilizarov in all patients because it permits simultaneous correction of these multiplanar deformities. Resistant clubfeet with non healing ulcers over the callosities on the dorsum of lateral column due to weight bearing were excluded from the study. Minimal soft tissue procedures for those were done below the age of 12 years depending upon their flexibility to correct the deformities without stress over the soft tissues with Ilizarov method during distraction and compression.

Gait of all patients like their walking pattern were assessed clinically through functional mobility scale [9] at the time of admission and every step was planned like physical assistance, bracing, and assistive devices to improve the speed, distance and efficiency while walking. They were also assessed for skin and soft tissue conditions, range of ankle and subtalar joint movement, levels of the particular deformity, limb shortening . The radiographs were obtained for standard anteroposterior and lateral views with and without weight bearing. The condition of ankle and other joints of foot, angles of individual deformities were assessed.

Operative procedure

The limb was painted and draped from foot to hip. Ilizarov frame was preassembled according to the deformity of foot as well as radiographs to correct without any stress over the related soft tissues.

Two full rings, mostly of 16 and 18 hole sizes, were assembled and connected with two rods and mounted over the tibia with one transverse wire and two 5 mm half pins with rancho cube system in each ring. One half ring was mounted to the calcaneus, using one plain wire and two shanz screws with rancho system. Another half ring with two plain crossed wires was applied through 1 st to 3 rd metatarsal and from 5 th to 2 nd or 3 rd metatarsal and connected with the rings applied over the tibia through the hinges, plates, and conical washers were also used wherever required. The calcaneal half ring had three connections to the lower ring of the tibia frame (posteriorly, medially, and laterally), while the forefoot half ring had two connections situated medially and laterally and sometimes only one connection situated centrally to the long axis of the foot. The hinges allow the rods to move without bending and also prevent the subluxation of joints during distraction.

Half ring over the calcaneus was used as a distractor or pusher and compression or pulling was achieved through the half ring over dorsum of the fore foot. Varus deformities of the heel were corrected through medial and lateral rods by compression and distraction method. These rods with hinges were applied in the rings fastened over the calcaneus and forefoot to increase or decrease the medial or lateral column according to the need of deformity correction. For correction of rotational like supination and pronation deformities, two frontal rods with hinges were applied in oblique directions connected with the ring in the forefoot and assembly over the leg and corrected accordingly. The sequence of deformities' correction was gradual distraction of medial column and compression of lateral column to correct the forefoot adduction, 1-2 mm/day, which was started on the 2 nd postoperative day. After correction of forefoot adduction supination, hind foot varus and finally equinus were corrected through the setting of the Ilizarov's external fixator. During distraction, tension over the soft tissues, neurovascular status, and improvement in the correction of the deformities were observed clinically, and radiologically dislocation or subluxation of tarsal and ankle joints was observed [Figure 1].
Figure 1: Ilizarov frame for ankle and foot with two full rings for leg, one half for calcaneum and one half for forefoot over the metatarsals

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After application of Ilizarov, a limited soft tissue dissection, percutaneous Achilles sheath tenotomy, and plantar fasciotomy were done for patients under 12 years and Achilles tendon lengthening was done for those above 12 years of age. Achilles tendon lengthening was performed in 9 (59.93%) feet, Achilles tendon sheath tenotomy in 8 (29.62%) feet, and planter fasciotomy in 6 (22.22%) feet.

Approximately 8΀-10΀ deformity was over corrected and this over lengthening of soft tissues avoided the recoil that could occur in the soft tissue after frame removal. All feet were also assessed radiologically as well as clinically every week during the followup period.

All patients were encouraged and weight bearing was allowed according to tolerance of the patients and their degree of correction. Adjustments were done by the surgeon and postgraduate students during stay in the hospital, and after discharge by either the patient himself/herself, and if the patient was a child, the family members were trained to move the nuts for compression, distraction, and lengthening through the markings. Care of pins was taken during their stay in the hospital, and patients and their attendants were trained to take care of pins by themselves after discharge. All the pins were cleaned with normal saline and dressed with sterilized dry gauzes initially after 24 hours than after 72 hours. Loose clamps, nuts, and bolts were tightened regularly in outpatient clinic initially weekly up to deformity correction, then fortnightly up to removal of the fixator. The fixator removal was decided after correction of all required deformities and the time needed for correction of the deformities was variable depending on the resistance and rigidity of the deformities. After complete correction, the distraction stopped and the Ilizarov was retained in a fixed position for a further period of 4-6 weeks. During this period, up to the removal, the patients were encouraged and allowed to bear full weight and improve the gait. Fixator was removed, all the pin wounds were washed, and aseptic dressings were done; a short leg walking plaster of paris (POP) cast was applied for 2 weeks, the patients were reviewed at the outpatient clinic after 2 weeks, and the POP cast was removed. The status of wounds was checked and again short leg walking cast was applied for 4 more weeks. The total time of the POP cast was 6 weeks after removal of the fixator, followed by an ankle foot orthrosis (AFO) for 3 months.


   Results Top


The mean age was 12 years (range 8-20 years). Eight feet were above the age of 15 years. There were 8 females and 13 males. The mean distraction time for deformity correction was 7.2 weeks (range 4-12 weeks). The mean duration of fixator application was 4.5 months (range 3-06 months). The mean followup period was 18.7 months (range 20-36 months). Ilizarov was removed after an average of 2.5 weeks (range 4-6 weeks) after correction of deformities. At the time of removal of fixator, a plantigrade foot was achieved in 25 feet and gait was improved in all patients. There was residual varus hind foot deformity in two patients

The correction of the deformity and function were assessed and the results were graded based on the Reinker and Carpenter scale as follows: Excellent: Painless, plantigrade foot with no functional limitations; good: Plantigrade foot in a patient able to ambulate long distances with mild pain; fair: Mild residual deformity, required bracing, and/or some functional limitations, but the patient leading an active life; and poor: Significant residual deformity, pain, and activity limitations.

Out of 27 feet, 3 (11.11%) were rated as excellent, 17 (62.96%) as good, 5 (18.51%) as fair, and 2 (7.40%) as poor. Excellent and good results (74.07%) were considered satisfactory, while fair and poor results (25.92%) were considered unsatisfactory. Thus, the Ilizarov technique gave satisfactory results in resistant club foot deformities that were difficult to treat by other conventional methods.

Superficial pin tract infection with hypergranulation over the Schanz screws were in 4 feet, and only superficial pin tract infection with watery discharge from the wires noted in 2 feet and were managed with regular dressings and short term 4 th generation oral cephalosporin. Loose wires were re-tensioned and infection settled after these reasonable measures.

Kinking of the skin with temporary edema over the callosities was noticed in 6 feet above the age of 15 years due to shortening of lateral column and resolved after 4-6 weeks after the deformity correction. Flexion deformities of toes developed due to increasing tension on the long flexor tendons during deformity correction and was controlled by toe slings, supports over forefoot, and insertion of Kwires. There were 8 feet above the age of 15 years, and the overall outcome was good in 5, fair in 2, and poor in 1 foot [Figure 2] and [Figure 3].
Figure 2A: (a) Preoperative clinical photograph of the feet, from the front of neglected congenital telepesequinovarus; (b) Preoperative clinical photograph of the same feet, from behind; (c) Preoperative lateral radiographs of both feet showing the deformity (d) Preoperative anteroposterior radiographs of both feet showing the deformity
Figure 2B: (a, b) Clinical photograph of the same patient showing application of Ilizarov and deformity correction; (c) Postoperative anteroposterior radiographs of the same patient showing fixator in situ
Figure 2C: (a, b) Clinical photograph of the same patient after removal of Ilizarov showing deformity correction (c, d) Followup photographs showing maintenance of correction


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Figure 3A: A 20-year old girl with right sided clubfoot (a) Preoperative clinical photograph of the feet from the front; (b) preoperative clinical photograph of the feet from the side; (c) preoperative clinical photograph from back; (d,e) preoperative lateral and anteroposterior radiograph of the right foot showing deformity
Figure 3B: (a, b) Clinical photograph of right foot from medial and lateral side showing ilizarov fixator in situ (c, d) Lateral and antero posterior view of right leg and (e) Antero posterior view of right foot showing ilizarov fixator in situ
Figure 3C: (a,b,c,d) Clinical photographs showing ilizarov in situ (e) Anteroposterior and lateral radiograph showing limb lengthening
Figure 3D: (a,b,c,d) Clinical photographs showing good correction (e, f) Lateral and antero posterior radiograph of foot at final followup showing correction


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   Discussion Top


Resistant clubfoot deformity is a multiplanar deformity. It also includes deformed feet with poor soft tissue coverage, relapsed or neglected cases. [10] The introduction of the Ilizarov technique to Italy in 1981 changed the concepts of the management of congenital and posttraumatic foot deformities. The technique allowed for a three dimensional approach to the foot without the need for additional wide surgical exposure [11] [Table 1]. Professor Ilizarov recognized that his technique could be used to treat foot pathologies such as clubfoot; physicians continue to expand the applications of the Ilizarov procedure in treating complex foot pathologies. [12] Complications were numerous but manageable, and for the most part, did not compromise overall patient satisfaction in this very difficult to treat clinical condition. [6] The technique, however, is difficult and should be performed by surgeons who are familiar with correction of pediatric foot and ankle deformities and are versed fully in Ilizarov fixation techniques. [13]
Table 1: Types of foot deformities (Catagni et al.)5


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Our study included 27 resistant clubfeet in patients with ages ranging from 8 to 20 years (mean 12 years) who underwent limited soft tissue dissection with Ilizarov distraction. Achilles tendon sheath tenotomy was performed in 8 (29.62%), plantar fasciotomy in 6 (22.22%), and Achilles tendon lengthening in 9 (59.93%) feet. Of the patients, 74.07% considered it as satisfactory, 3 (11.11%) as excellent, and 17 (62.96%) as good, while 25.92% considered it as unsatisfactory, 5 (18.51%) as fair, and 2 (7.40%) as poor. Gradual soft tissue compression and distraction with the setting of Ilizarov frame was used for correction of the deformities in all patients. The same evaluation criteria were used in all patients as the same principle was used in them.

Our results were compared with those of Ferreira et al., who reviewed 30 patients (38 feet) with a mean age of 19 years (range 5-39 years) with severe deformities and studied stiff feet associated with neglected clubfoot. A limited soft tissue dissection, Achilles tenotomy, and plantar fasciotomy were done. The device was used for 16 weeks on average, and after removal, a shortleg walking cast was used for an additional 6 weeks, followed by an AFO for 6 months.

Freedman in 2006 [1] conducted a review of 21 resistant clubfeet in 17 patients, who had undergone previous surgery, and were treated with Ilizarov's external fixation and gradual distraction by one of the two surgeons.

Amin Abdel-Razek Youssef Ahmed (2010) [12] included 18 feet in 13 children with ages ranging from 3 to 12 years (mean 5.5 years).Soft tissue distraction by Ilizarov was done in 12 feet, with elongation of the tendo achilles in 3 patients and midtarsal osteotomy in 3 patients, and the average followup period was 15.8 months. Of the patients, 72.2% considered it as satisfactory (2 excellent and 11 good) while 27.8% considered it to be unsatisfactory (4 fair and 1 poor). Franke et al. [13] succeeded to achieve plantigrade feet in all the feet with relapses in 3 feet in 8-15 years age group. They reported on 13 feet in 12 patients. Paley [14] treated 25 feet with complex foot deformities. Twenty two feet were plantigrade and three feet showed recurrence after 18 months of followup. El Barbary et al. [15] achieved satisfactory correction using an Ilizarov fixator for treatment of 66 relapsed or neglected club feet (40 months followup). Prem et al.[16] followed 19 feet managed by Ilizarov soft tissue distraction for 5-10 years postoperatively. They reported on 14 of 19 feet graded good or excellent and 13 of 14 children satisfied with the results of the treatment. Utukuri et al. [17] treated 26 resistant clubfeet in 23 children using Ilizarov technique. They reported unsatisfactory results of soft tissue and bony distraction with a recurrence rate of 70% for soft tissue distraction and 55% for bony distraction after a longer period of followup (47 months), but found that functional results (patient based outcomes) were better despite a poor surgical outcome.

Reinker and Carpenter [18] achieved excellent and good results in 21 of 23 feet treated by Ilizarov's external fixation. Nineteen feet had received one or more osteotomies at the time of Ilizarov's external fixation application; additional procedures were required during the course of treatment, including four percutaneous tendo Achilles lengthening, two first metatarso phalangeal joint fusions, and talectomy, ankle arthrodesis, Achilles tenodesis, and plantar arthrodesis in onecase.

Hosny [19] used the bloodless technique in treating 23 foot deformities in 22 patients without any real surgical incision; there was no need for soft tissue release or osteotomy, all patients had a plantigrade foot, and the results were rated as good in 20 and fair in 3 cases.

De La Huerta [20] reported on 12 feet in seven adults with the achievement of complete correction in all patients except three in whom mild adduction of the forefoot reoccurred [17] [Table 2].
Table 2: Comparison of surgical outcome in different studies surgeries with present study


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The average followup in our study was 18.7 months, and in situations like these, where the original foot and ankle deformities are so severe that the treatment option involves the use of an external fixator, minor or major recurrence of the deformities can be expected over time. As the followup time increases, further re-evaluation can reveal higher incidence of complications, some minor (stiff toes, callus, mild deformity recurrence) and others major (severe recurrence of the deformities, painful arthritis). It is easier to deal with the late complications than it was before the correction. Conventional surgical procedures, like osteotomies, limited arthrodesis, or soft tissue procedures, can be useful in order to correct residual mild deformities under safer conditions.

We conclude that the short term clinical and functional results of treating resistant clubfoot deformities with Ilizarov's external fixator are promising and apparently it is a good option.

 
   References Top

1.Freedman JA, Watts H, Otsuka NY. The Ilizarov method for the treatment of resistant clubfoot: Is it an effective solution? J Pediatr Orthop 2006;26:432-7.  Back to cited text no. 1
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2.Elomrani NF, Kasis AG, Tis JE, Saleh M. Outcome after foot and ankle deformity correction using circular external fixation. Foot Ankle Int 2005;26:1027-32.  Back to cited text no. 2
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3.Greisberg J. Recent innovations and future directions in external fixation of the foot and ankle. Foot Ankle Clin 2004;9:637-47.  Back to cited text no. 3
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4.Rosman M, Brown K. Preoperative Ilizarov frame construction for correction of ankle and foot deformities. J Pediatr Orthop 1991;11:238-40.  Back to cited text no. 4
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5.Catagni MA, Guerreschi F, Manzotti A, Knuth A.Treatment of foot deformities method using the Ilizarov. Foot Ankle Surg2000;6:207-37.  Back to cited text no. 5
    
6.Ahmed AA.The Use of the Ilizarov Method in Management of Relapsed Club Foot. Orthopedics 2010;33:881.  Back to cited text no. 6
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7.Choi IH, Yang MS, Chung CY, Cho TJ, Sohn YJ. Treatment of recurrent arthrogrypotic club foot in children by the Ilizarov method: A preliminary report. J Bone Joint Surg Br 2001;83:731-7.  Back to cited text no. 7
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8.Ferreira RC, Costo MT, Frizzo GG, da Fonseca Fitho FF.Correction of neglected clubfoot using the Ilizarov External Fixator. Foot Ankle Int 2006;27:266-73.  Back to cited text no. 8
    
9.Hugh Williamson Gait Laboratory, The Functional Mobility Scale (version 2), for children with cerebral palsy aged 4-18 years. The Royal Children's Hospital, Melbourne, Australia. 2004.  Back to cited text no. 9
    
10.Shalaby H, Hefny H. Correction of complex foot deformities using the V-osteotomy and the Ilizarov technique. Strategies Trauma Limb Reconstr 2007;2:21-30.  Back to cited text no. 10
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11.Catagni MA, Malzev V, Kirienko A. Congenital and acquired foot deformities. In: Bianchi MaiocchiD, Editor, Advances in Ilizarov Apparatus Assembly. Milan: Medical Plastic;1994. p.113-8.  Back to cited text no. 11
    
12.Friedman HE, Levitz S. A literature review of the Ilizarov technique and some applications for treating foot pathology. J Foot Ankle Surg 1994;33:30-6.  Back to cited text no. 12
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13.Franke J, Grill F, Hein G, Simon M. Correction of clubfoot relapse using Ilizarov's apparatus in children 8-15 years old. Arch Orthop Trauma Surg 1990;110:33-7.  Back to cited text no. 13
[PUBMED]    
14.Paley D. The correction of complex foot deformities using Ilizarov's distraction osteotomies. Clin Orthop Relat Res 1993;293:97-111.  Back to cited text no. 14
[PUBMED]    
15.El-Barbary H, Abdel Ghani H, Hegazy M. Correction of relapsed or neglected clubfoot using a simple Ilizarov frame. Int Orthop 2004;28:183-6.  Back to cited text no. 15
    
16.Prem H, Zenios M, Farrell R, Day JB. Soft tissue Ilizarov correction of congenital talipes equinovarus-5 to 10 years post surgery. J Pediatr Orthop 2007;27:220-4.  Back to cited text no. 16
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17.Utukuri MM, Ramachandran M, Hartley J, Hill RA. Patient-based outcomes after Ilizarov surgery in resistant clubfeet. J Pediatr Orthop B 2006;15:278-84.  Back to cited text no. 17
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18.Reinker KA, Carpenter CT. Ilizarov application in the pediatric foot. J Pediatr Orthop 1997;17:796-802.  Back to cited text no. 18
[PUBMED]  [FULLTEXT]  
19.Hosny GA. Correction of foot deformities by the Ilizarov method without corrective osteotomies or soft tissue release. J Pediatr Orthop B 2002;11:121-8.  Back to cited text no. 19
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20.De la Huerta F. Correction of the neglected clubfoot by the Ilizarov method. Clin Orthop Relat Res 1994;301:89-93.  Back to cited text no. 20
[PUBMED]    

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Correspondence Address:
Asadullah Makhdoom
Assistant Professor, Department of Orthopaedic Surgery and Traumatology (DOST), Liaquat University of Medical and Health Sciences Jamshoro, Sindh
Pakistan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5413.96385

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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]

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