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Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
Total knee replacement (tkr) Surgery
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Total knee replacement (tkr) Surgery

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MedicYatra provides the safe & best Total knee replacement(tkr) treatment and surgery at its affiliate & trusted hospitals & clinics in various metro cities of India, like Mumbai, Delhi, Bangalore, …

MedicYatra provides the safe & best Total knee replacement(tkr) treatment and surgery at its affiliate & trusted hospitals & clinics in various metro cities of India, like Mumbai, Delhi, Bangalore, Chennai, Pune etc.Our Associate Board certified doctors are extensively trained and vastly experienced and have performed hundreds of such cases at our state of the art JCI accredited hospitals & Clinics. Our aim is to provide you the best of the services at the most affordable costs. Don't forget to say hi at info@medicyatra.com

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  • In today’s talk we will discuss brief anatomy of the knee joint, and then about the common knee problems that may lead to tka surgery. I will talk about brief history of TKR. then we will discuss how tkr is performed. At the end I will show u few cases of TKR done in our unit during the last one year. But first, lets review the anatomy of the knee joint
  • The bony anatomy of the knee joint includes the distal femur, the proximal tibia and the patella. The knee joint is a tricompartmental joint and consists of a patellofemoral articulation and medial and lateral femorotibial articulations.
  • The knee joint has no inherent stability rather it is provided by the surrounding ligaments and muscles.The ligaments about the knee include the collateral ligaments and the cruciate ligaments.the medial and lateral cpllateral ligaments prevent valgus and varus stresses, respectively. The anterior and posterior cruciate ligaments prevent anterior and posterior tibial traslation on the femur and secondary restraint to rotation. Fibrocartilagenous medial and lateral meniscus provides stability and shock absorption , especially with axial loading.
  • Knee motion during normal gait is more complex than simple flexion and extension. It occurs in abduction adduction, internal and external rotation and obviously the flexion and extension
  • The most common conditions that can lead to TKR are osteoarthritis which may be primary and secodary and the rheumatoid arthritis. Arthritic conditions can be classified as non inflammatory and inflammatory types. The classic type of non-inflammatory diseases are primary osteoarthritis and pot traumatic arthritis. The classic type of inflammatory arthritis is rheumatoid arthritis. The other types include gout, arthritis of psoriasis, ankylosing spondylitis etc.
  • Here is some epidemiological data regarding osteoarthritis of the knee. AGE>it is more prevalent in advancing age. About 80% of people above 75 years of age have radiographic evidence of osteoarthritis. SEX> The disease is equally common among men and women up to age 45-55 years. After age 55 years, the disease becomes more common in women b/c of post menopausal changes.
  • Here are some risk factors for knee OA. It is more common in old age and obese people are more prone to develop OA. As I mentioned in the previous slide it is more common in female especially in the post menopausal age. Trauma is a recognized factor involved in knee arthritis especially young male.
  • Pain> is the usual presenting complaint of patients suffering from OA. usually starts insidiously and with passage of time increases in severity, initially aggravated by activity and releived by rest but later on patient has pain at rest as wel. the patient has difficulty in performing his daily activities like climbing stairs and squating. Stiffness> characteristically it occurs after period of inactivity. Swelling> may be intermittent( with effusion of acutr flare) or continous ( large osteophytes and capsular thickening. Deformity> deformaty may be present which is due to contractures or joint instability. Crepitus may be felt in the joint.
  • The radiograph of a knee with osteoarthritis demonstrate joint space narrowing, subchondral sclerosis with or whith out cysts, osteophyte formation. The radiological features depend upon the stage of involvement.
  • Nonpharmacologic interventions are the cornerstones of osteoarthritis (OA) therapy. Patient’s education > educate the patient to avoid aggravating stress to the affected joint and use assistive devices during walking. Weight loss > Encourage obese patients to lose weight, thus relieving stress on the affected knees. Physical therapy > Osteoarthritis of the knee may result in disuse atrophy of the thigh muscles. Instruct the patient to perform muscle-strengthening exercises. Occupatonal therapy > Occupational adjustments may be necessary. Steroid > usually during effusion and acute synovitis, no more than 3-4 per year otherwise it will destroy the cartilage, it inhibs PG, it has only short term results . Glucosamine sulphate > Thought to stimulate chondrocytes to make proteoglycans.Thought to possibly inhibit cartilage catabolic enzymatic. hyaloronic acid > Intra-articular injections of hyaluronic acid (HA) are approved as symptomatic therapy of osteoarthritis in the knee. Prescribe as a series of 3 or 5 injections (depending on the product). Each injection is administered one week apart.
  • Factors associated with good outcome: i- normal limb alignment ii- history of mechanical symptoms iii- minimal radiographic degenerative findings iv- short duration of sumptoms. Factors associated with poor outcome: i- varus or valgus malalignment ii- severe radiographic findings iii- previous surgeries iv- chronic symptoms
  • The aim is to correct the deformity and bring the limb towards the normal mechanical axis so that the force is equally distributed through the knee compartments. Indications for osteotomy Age less than 60 years Unicompartmental arthritis 10 to 15 degrees of varus deformity on weightbearing radiographs Preoperative motion arc of at least 90 degrees   Flexion contracture less than 15 degrees Ability and motivation to effectively and safely perform rehabilitation. Osteotomy can lessen the pain, although it can lead to more challenging surgery later if the patient requires arthroplasty
  • Perform this procedure when all other modalities of treatment are ineffective and the patient cannot perform his or her daily activities despite maximal therapy. Uni comp> only the diseased portion of the joint is resurfaced.
  • 1860- fergussen reported performing a resection arthroplasty of the knee for arthritis Few years later- verneuil performed first interposition arthroplasty using join capsule. Other substances were subsequently tried including muscle, fascia an fat. 1940-but these designs had problems with loosening and persistent pain. 1950s-These implants failed to account for the complexities of knee motion and consequently had high failure rates from aseptic loosening. They were also associated with unacceptably high rates of postoperative infection.
  • In 1971, Gunston importantly recognized that the knee does not rotate on a single axis like a hinge, but rather the femoral condyles roll and glide on the tibia with multiple instant centers of rotation. His polycentric knee replacement had early success with its improved kinematics over hinged implants but was unsuccessful because of inadequate fixation of the prosthesis to bone. In 1973 total condylar prosthesis was designed by Insall at the hospital for special surgery and this desighn is basically the model used today
  • There are 2 broad categories of implants design used for TKR
  • Un-constrained> most common type, used for un complicated knee problems, artificial components inserted into the knee are not linked to each other, have no stability built into the system, relyes on the person’s own ligaments and muscles.
  • Constrained> rarely used as a first choice, knee joint linked with a hinge, used when knee is highly unstable, useful in severly damaged knees, it is not expected to last as long as other types.
  • Unicondylar> replaces only half of the knee joint when damage is limited to one side of the knee,
  • 1-Cobalt-chrome alloy femoral component replacing femoral condyles and the patella trochlea. Cobalt-chrome alloy or titanium tibial tray affixed to the upper tibia. UHMWPE tibial bearing component fixed into the tibial tray. UHMWPE patella component
  • When the quality of life is such that they are willing to undertake the risks of major surgery. Any arthritic disorder of the knee that is nonresponsive to the usual nonoperative treatment, when the patient’s pain is such that he or she can no longer accomplish his or her required activities of daily living. Before surgery is considered, conservative treatment measures should be exhausted. Destruction of knee> Significant arthritis involving all three compartments of the knee but occasionally may be indicated with only unicompartmental or bicompartmental involvement
  • Old age> b/c tkr has a finite expected survival that is adversely affected by activity level, it generaly is indicated in olger patients with more sedentary life styles. It is preferable that pts undergoing TKA have a remaining life expectancy of b/w 20 and 30 years so that the need for repeat arthroplasty for a failed TKA will be minimal . Young pts> tka may be indicated in a young age group but the pt must understand the limitations of the procedure, be willing to modify his or her life style to prolong the life of the prosthesis and be willing to risk the loer success rate in a revision arthroplasty. Deformity> deformity can become the principle indication for arthroplasty in pts with moderate arthritis and variable levels of pain when the progression of deformity begins to threaten the expected outcome of an anticipated arthroplasty. Intervening before this degree of deformity is present allows the use of a prosthesis that has a more favorable expected survival.
  • Remember that TKR surgery is elective it is not an emergency so the patient’s condition should be optimized before embarking on surgery. A detailed medical history should be obtained to prevent potential complications that can be life threatening or limb threatening. b/c most pts undergoing TKR are elderly, comorbid diseases must be considered. Examination> end stage arthritis may be associated with flexion contractures, varus or valgus angulations. All of these mal alignments must be taken into consideration when planning for TKR. Rule out and evaluate for potential serious vascular disease in the lower extremity. assessment of the skin is also important in TKR
  • The mechanical axis of the lower limb is an imaginary line through which the weight of the body passes. It runs from the center of the hip to the center of the ankle through the middle of the knee. This is altered in the presence of deformity and must be reconstituted at surgery, which protects the prosthesis from eccentric loading and early failure
  • This is a vedio clip showing how TKR is performed. The pt is lying in supine position and properly draped. Mid line skin incision is made. Knee joint is opened through parapatellar dissection and the patella retacted to lateral side. U can see the diseased medial femoral condyle which is completely denuded of the cartilage. Femur is being prepared for proper cut. This is a assembly with predetermined level of femoral cut. U can see the ossicilating saw cutting yhe distal portion of the femur. Similarly the femoral condyles are cut anterorly and posterorly according to the shape of the implant to be inserted later on. This is the trail component inserted. Now the proximal portion of the tibia is being removed an the trial components inserted.
  • Post operative physical therapy and rehabilitation greatly influence the outcome of TKR. ROM exercises are performed post operatively with or with out the assistance of CPM. CPM assist in obtaining knee flexion more quickly and thus decreasing the hospital stay.
  • Various studies shows varying results but most of them have 95% survival rate at 15 years
  • Here you can appreciate the deformities in the knee joints
  • Here you can see the disuse atrophy of the quadrecips muscle and the range of flexion
  • These are the radiographs of this patient which shows the classical findings of OA.
  • Transcript

    • 1. Email: enquiry@medicyatra.com .Copyright @ Forever Medic Online Pvt. Ltd
    • 2. Email: enquiry@medicyatra.comoverview Anatomy of the knee joint Common conditions leading to TKR Evolution of TKR Total knee replacement Our own data Copyright @ Forever Medic Online Pvt. Ltd
    • 3. Email: enquiry@medicyatra.comAnatomy Of The Knee Joint Three bones and three compartment Copyright @ Forever Medic Online Pvt. Ltd
    • 4. Email: enquiry@medicyatra.com Knee Stabilizers Midial Lateral Anterior Posterior Rotatory Copyright @ Forever Medic Online Pvt. Ltd
    • 5. Email: enquiry@medicyatra.com. Copyright @ Forever Medic Online Pvt. Ltd
    • 6. Email: enquiry@medicyatra.comCommon Conditions That Lead To TKR OSTEOARTHRITIS Primary (idiopathic) Secondary Post traumatic arthritis RHEUMATOID ARTHRITIS Copyright @ Forever Medic Online Pvt. Ltd
    • 7. Email: enquiry@medicyatra.comKnee Arthritis Far more common than hip OA in asian population Age: 80% above 75 years Sex: Equal in both sexes upto 45-55 years After 55 years more common in female Copyright @ Forever Medic Online Pvt. Ltd
    • 8. Email: enquiry@medicyatra.comRisk Factors Of Osteoarthritis  Increasing age  Obesity  Female sex  Trauma  Infection  Repetitive occupational trauma Copyright @ Forever Medic Online Pvt. Ltd
    • 9. Email: enquiry@medicyatra.comClinical Features Of Osteoarthritis Depends upon stage of involvement I. Pain II. Loss of function III. Stiffness IV. Swelling V. Deformity VI. Crepitus Copyright @ Forever Medic Online Pvt. Ltd
    • 10. Email: enquiry@medicyatra.comRadiological Features Copyright @ Forever Medic Online Pvt. Ltd
    • 11. Email: enquiry@medicyatra.comNon Operative Treatment Non pharmacologic therapy  Patient’s education  Use of assistive devices  Weight loss  Physical therapy  Occupational therapy Pharmacologic therapy  NSAIDS  Glucosamine sulphate  Intra articular Corticoteroids  Intra articular Hyaluronic acid Copyright @ Forever Medic Online Pvt. Ltd
    • 12. Email: enquiry@medicyatra.comOperative Treatment  Arthroscopy  Osteotomy  Knee replacement surgery Copyright @ Forever Medic Online Pvt. Ltd
    • 13. Email: enquiry@medicyatra.comArthroscopic Debridement Copyright @ Forever Medic Online Pvt. Ltd
    • 14. Email: enquiry@medicyatra.comOsteotomy Copyright @ Forever Medic Online Pvt. Ltd
    • 15. Email: enquiry@medicyatra.comKnee Replacement Partial knee replacement Total knee replacement Copyright @ Forever Medic Online Pvt. Ltd
    • 16. Email: enquiry@medicyatra.comEvolution of TKR Fergussen(1860) resection arthroplasty Verneuil performed first interposition arthroplasty 1940s- first artificial implants were tried when molds were fitted in the femoral condyle 1950s- combined femoral and tibial articular surface replacement appeared as simple hinges Copyright @ Forever Medic Online Pvt. Ltd
    • 17. Email: enquiry@medicyatra.comEvolution of TKR (cont) Frank Gunston(1971), developed a metal on plastic knee replacement. John Insall(1973), designed what has become the prototype for current total knee replacements. This was a prosthesis made of three components which would resurface all three surfaces of the knee - the femur, tibia and patella Copyright @ Forever Medic Online Pvt. Ltd
    • 18. Email: enquiry@medicyatra.comClassification of ImplantsDesign  Unconstrained  Cruciate retaining  Cruciate substituting  Mobile bearing knees  Constrained (Hinged) Copyright @ Forever Medic Online Pvt. Ltd
    • 19. Email: enquiry@medicyatra.comUn constrained TKR Copyright @ Forever Medic Online Pvt. Ltd
    • 20. Email: enquiry@medicyatra.comConstrained TKR Copyright @ Forever Medic Online Pvt. Ltd
    • 21. Email: enquiry@medicyatra.comUni condylar TKR Copyright @ Forever Medic Online Pvt. Ltd
    • 22. Email: enquiry@medicyatra.comTotal Knee Replacement Today Large variety is available Majority of TKR today are condylar replacements which consist of the following  Cobalt-chrome alloy femoral component  Cobalt-chrome alloy or titanium tibial tray  UHMWPE tibial bearing component  UHMWPE patella component Copyright @ Forever Medic Online Pvt. Ltd
    • 23. Email: enquiry@medicyatra.comWho Is A Candidate For TKR Quality of life severely affected Daily pain Restriction of ordinary activities Evidence of significant radiographic changes of the knee Copyright @ Forever Medic Online Pvt. Ltd
    • 24. Email: enquiry@medicyatra.comWhat Is The Time For Replacement Old age with more sedentary life style Young patients who have limited function Progressive deformity Other treatment modalities have failed TKR should be done before things get out of hand and the patient experiences a severe decrease in ROM, deformity, contracture, joint instability or muscle atrophy Copyright @ Forever Medic Online Pvt. Ltd
    • 25. Email: enquiry@medicyatra.comEvaluation Of Patient Before Surgery A Complete Medical History Thorough Physical Examination Laboratory Work-up Anesthesia Assessment Copyright @ Forever Medic Online Pvt. Ltd 25
    • 26. Email: enquiry@medicyatra.comRecommended Preoperative Radiographs inKnee Replacement Surgery1. Standing full-length anteroposterior radiograph from hip to ankle3. Lateral knee x ray4. Merchant’s view Copyright @ Forever Medic Online Pvt. Ltd
    • 27. Email: enquiry@medicyatra.comGoal of TKR  Pain relief  Restoration of normal limb alignment  Restoration of a functional range of motion Copyright @ Forever Medic Online Pvt. Ltd
    • 28. Email: enquiry@medicyatra.comSuccessful Results Depends upon:  Precise surgical technique  Sound implant design  Appropriate material  Patient compliance with rehabilitation Copyright @ Forever Medic Online Pvt. Ltd
    • 29. Email: enquiry@medicyatra.comTechnical Goals Of Knee Replacement SurgeryO The restoration of mechanical alignment,o Preservation (or restoration) of the joint line, Balanced Ligamentst Maintaining or restoring a normal Q angle. Copyright @ Forever Medic Online Pvt. Ltd
    • 30. Email: enquiry@medicyatra.com Mechanical AlignmentTKA aims at restoring themechanical axis of the lowerlimb by: Sequential soft tissue releases Correction of bone defects by grafts or prosthetic augments Copyright @ Forever Medic Online Pvt. Ltd
    • 31. Email: enquiry@medicyatra.com4. Ligament Balancing a. Coronal Plane  For varus deformities’  For valgus deformities b. Sagittal Plane  Flexion contractures  Extension contractures Copyright @ Forever Medic Online Pvt. Ltd
    • 32. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 33. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 34. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 35. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 36. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 37. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 38. Email: enquiry@medicyatra.comProcedure Copyright @ Forever Medic Online Pvt. Ltd
    • 39. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 40. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 41. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 42. Email: enquiry@medicyatra.comPost Operative Rehabilitation Rapid post-operative mobilization Range of motion exercises started CPM Passive extension by placing pillow under foot Flexion- by dangling the legs over the side of bed Muscle strengthening exercises Weight bearing is allowed on first post op day Copyright @ Forever Medic Online Pvt. Ltd
    • 43. Email: enquiry@medicyatra.comProsthesis Survival Different studies shows different results Ranawat et al (Clin Orthop Relat Res ) 95% at 15 years 91% at 21 years Gill and Joshi (Am J Knee Surg) 96% at 15 years 82% at 23 years Font-Rodriguez (Clin Orthop Relat Res ) 98% at 14 years Copyright @ Forever Medic Online Pvt. Ltd
    • 44. Email: enquiry@medicyatra.comWard Data Total no of TKR done in last one year: 8 cases Gender: Male ……. 5 cases Female….. 3 cases Age range: 40…….65 years Cause for which TKR done: Osteoarthritis Bilateral/Unilateral: Single case for which bilateral knee replacement was done. Copyright @ Forever Medic Online Pvt. Ltd
    • 45. Email: enquiry@medicyatra.comCase 1 Copyright @ Forever Medic Online Pvt. Ltd
    • 46. Email: enquiry@medicyatra.comv Copyright @ Forever Medic Online Pvt. Ltd
    • 47. Email: enquiry@medicyatra.comCase 1 Copyright @ Forever Medic Online Pvt. Ltd
    • 48. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 49. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 50. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 51. Email: enquiry@medicyatra.comCase 2 Copyright @ Forever Medic Online Pvt. Ltd
    • 52. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 53. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 54. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 55. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 56. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 57. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 58. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 59. Email: enquiry@medicyatra.comCase 3 Copyright @ Forever Medic Online Pvt. Ltd
    • 60. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 61. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 62. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 63. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 64. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 65. Email: enquiry@medicyatra.comCase 5 Copyright @ Forever Medic Online Pvt. Ltd
    • 66. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 67. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 68. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 69. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 70. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 71. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 72. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 73. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 74. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 75. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 76. Email: enquiry@medicyatra.comCopyright @ Forever Medic Online Pvt. Ltd
    • 77. Email: enquiry@medicyatra.com ThanksCopyright @ Forever Medic Online Pvt. Ltd

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