ISSN 0972-978X 

 
 
 
 
 
 
 
 
 
 
 
 
  About COAA
 

 

 

 

 

 

 

ORIGINAL ARTICLE

Comparative Study Of Three X-Ray Methods For Assessment Of Curve Flexibility In Adolescent Idiopathic Scoliosis

 Qi Fei *,Yi-peng Wang *,Suo-mao Yuan,Yu Zhao,Gui-xing Qiu,Jian-xiong Shen,Jian-guo Zhang

* Department of Orthopedic surgery, Peking Union Medical College Hospital, China.

Address for Correspondence:

Yi-peng Wang,
Department of Orthopedic surgery, 
Peking Union Medical College Hospital, 
Chinese Academy of Medical Science& Peking Union Medical College, 
Beijing, 100730,China.

Tel: +8610-65296080, 
Fax: +8610-65296081, 
E-mail:  ypwang@medmail.com.cn

Abstract:

Objective: A prospective comparative evaluation of the commonly accepted radiologic techniques including supine lateral bending(SB),suspension traction(Tr), and fulcrum bending radiographs(fulcrum) to determine curve flexibility and predict surgical correction in adolescent idiopathic scoliosis (AIS).
Methods:A total of 68 consecutive patients with AIS according to inclusion and exclusion criteria who had surgical treatment were studied. Preoperative X-ray evaluation consisted of standing anteroposterior (AP) and lateral, Tr, SB, fulcrum radiographs. All curve types were single-curve and the PUMC classification were I a/ I b/ I c. These patients were divided into 4 groups according to the location and magnitude of the curves: moderate thoracic curve (19 cases, 400<COBB≤60°,severe thoracic curve (13 cases, COBB>60°), moderate lumbar curve (28 cases, 35°<COBB≤60°) and severe lumbar curve (8 cases, COBB>60°). The COBB angles were measured and the flexibility ratio was determined on each radiograph. The amount of correction obtained by all radiographic methods was compared with the amount of surgical correction by evaluating the differences from surgery as absolute values. Statistical differences were calculated with the comparison of the exact 95% confidence intervals for the mean.
Results:For the moderate thoracic curves, fulcrum provided the best amount of flexibility with significant difference from SB and Tr and no significant difference between %flexibility determined on fulcrum and surgical %correction was found. There were significant differences between %flexibility determined on each radiographs and surgical %correction in the remaining three groups. For the severe thoracic curves, fulcrum provided clearly better flexibility compared to Tr and SB, however with no significant difference between Tr and SB. For the moderate and severe lumbar curves, %flexibility obtained by fulcrum and SB were significantly different from Tr, but with no significant difference between fulcrum and SB.
Conclusions:Fulcrum can better assess flexibility and correction of thoracic curves in AIS but only predict those in moderate thoracic curves. Fulcrum and SB are similar with analyzing flexibility in lumbar curves.

J.Orthopaedics 2008;5(1)e2

 Keywords:
Idiopathic scoliosis; Flexibility; Radiography


Introduction:

Optimal balance over pelvis and the least number of fused segments have always been the major goal of surgical treatment for adolescent idiopathic scoliosis (AIS) 1-2. To achieve this goal, analysis and differentiation of various curve types and their response to corrective forces have been a source of concern to spine surgeons. Thus, preoperative evaluation of curve flexibility has become a crucial component of curve analysis, fusion level selection, correction prediction, and surgical decision making. There are three commonly used X-ray techniques including suspension traction radiograph (Tr)3, supine lateral bending radiograph (SB)3 and fulcrum bending radiograph (fulcrum)4 to determine curve flexibility and predict surgical correction in AIS. However, fewer prospective study results were reported. What’s more, the improved design of new generation implants and capacity to obtain more and more correction led spine surgeons to suspect the value of these accepted methods for assessing curve flexibility.

The purpose of this prospective study was to explore the value of three commonly accepted X-ray methods in flexibility evaluation and surgical correction prediction of AIS.

Material and Methods :  

Patients

General dataFrom October 2003 to August 2006, 68 adolescent idiopathic scoliosis (AIS) patients according to the inclusion and exclusion criteria were enrolled in this prospective clinical study at the Spine Center of Peking Union Medical College Hospital in Beijing , China . The inclusion criteria were designed as: a.) Diagnosed as AIS with aged from 11-18 years old; b.) Curve types were single-curve and the PUMC5 classification were I a/ I b/ I c; c.) Patients were divided into 4 groups according to the location and  magnitude of COBB angles oon standing anteroposterior (AP) films: moderate thoracic curve(40°<COBB≤60°), severe thoracic curve(COBB>60°), moderate lumbar curve(35°<COBB≤60°), and severe lumbar curve(COBB>60°); d.) The third-generation spinal segmental instrumentation systems  were used during surgery; e.) All patients in thoracic curve group and severe lumbar curve group underwent posterior spinal fusion (PSF) with segmental pedicle screws as the sole anchor, and patients in moderate lumbar curve group underwent anterior short-segmental anterior spinal fusion (ASF) with single solid rod and single vertebral screw constructs; f.) The criteria to determine the levels to be included in the arthrodesis in each group was identical according to PUMC classification5. The exclusion criteria were designed as: a.) Age younger than 10 years oldb.) Risser sign 0°; c.) A positive history of spinal surgery; d.)Patients suffered from surgery related complications or postoperative radiologic decompensation; e). Patients with moderate lumbar curve underwent PSF; f.) Lumbar/thoracolumbar kyphosis; g.) Patients with dissatisfied preoperative radiological data. All patients were divided into the following 4 groups.

1. Moderate thoracic curve group(40°<COBB≤60°: All 19 cases were females with the mean age of 14.6 years old (ranged from 11 to 17).The mean preoperative COBB angle on standing AP film was 44.79±4.65° (ranged from 40 to 50°). All curves were single-thoracic-curve (diagnosed as PUMC I a type) and underwent a PSF with segmental pedicle screws as the sole anchor. The distal instrumented level in all cases was 1 level proximal to stable vertebrae. The implants included 5 Mossmiami, 2 Isola, 3 CDH, 8 TSRH and 1 SSE.

2. Severe thoracic curve group(COBB>60°:There were 9 females and 4 males in this group with the mean age of 14.7 years old (ranged from 13 to 18). All curve types were PUMC I a. The mean preoperative COBB angle on standing AP film was 87.62±16.58° (ranged from 65 to 110°). The implants included 1 Mossmiami, 8 Isola, and 4 TSRH. The surgical technique and fusion level selection principle were similar to moderate thoracic curve group.

3. Moderate lumbar curve group (35°<COBB≤60°):There were 18 cases of PUMC I b type (4 males and 14 females) and 10 cases of PUMC I c type (1 male and 9 females) in this group with the mean age of 15.5 years old (ranged from 12 to 18). All curve types were single-lumbar/thoracolumbar-cuvre. The mean preoperative COBB angle on standing AP film was 43.29±7.32° (range from 35to 58°). Short-segmental anterior fusion level selection principle recommended by PUMC classification system5 was in reference to Hall's criteria5: a.) If the apex is a vertebra on the standing AP film, instrument one vertebral body above and below; if the apex is a disc, instrument 2 vertebral bodies above and below. b.) On convex bending film, the first disc space above and below the apex that opens up can be left unfused; on concave bending film, vertebral bodies below the apex should be parallel to the sacrum. If there is a discrepancy among the levels indicated in the aforementioned methods, the longest segment of instrumentation should always be selected. The implants included 4 Isola and 24 CDH.

4. Severe lumbar curve groupCOBB>60°:There were 3 males and 5 females in this group with the mean age of 16.4 years old (ranged from 14 to 18). All curve types were PUMC I b. The mean preoperative COBB angle on standing anteroposterior film was 69.50±9.80° (ranged from 61 to 88°). The surgical technique and fusion level selection principle were similar to thoracic curve group. The implants included 1 CDH, 2 Mossmiami, 2 Isola, and 3 TSRH.

Methods

All patients were eventually diagnosed as adolescent idiopathic scoliosis (AIS) through preoperative detailed case history collection, thorough physical and auxiliary examination. All patients received X-ray, myelography or simultaneous CTM, and MRI et al. The preoperative X-ray examination included standing AP and lateral radiographs, suspension traction radiographs (Tr), supine lateral bending radiographs (SB), fulcrum bending radiograph (fulcrum). Curves were identified as thoracic or lumbar/thoracolumbar, depending on the location of the apex of the deformity. All patients were single-curve. All structural curves were measured using the Cobb method, and flexibility ratio was determined on each radiograph (Tr/SB/fulcrum). %Flexibility on each radiograph= (preoperative COBB angle on standing AP film - preoperative COBB angle on Tr/SB/fulcrum film)/preoperative COBB angle on standing AP film. These radiographs were compared with the postoperative radiograph, which was made with the patient standing AP approximately 1 weeks postoperatively. The experienced surgeon (Qi Fei) measured the radiographs. The flexibility% determined on each radiograph was compared with the amount of surgical correction% by evaluating the differences from surgery as absolute values. Percentage surgical correction was calculated using the formula: %Correction = (preoperative COBB angle on standing AP film - postoperative COBB angle on standing AP film)/preoperative COBB angle on standing AP film. All patients in each study group were operated on by the same surgical team (Gui-xing Qiu and Yi-peng WANG), undergoing the same surgical procedures. The specific radiologic methods about Tr/SB/fulcrum were in reference to pertinent literature3-4.

Statistical methods

Patients’ preoperative and postoperative COBB angle on different X-ray methods, the flexibility% on each radiographic methods (Tr/SB/fulcrum) and surgical correction%, and respective COBB angle on three X-ray methods (Tr/SB/fulcrum)were compared and analyzed using SPSS 13.0 (SPSS, Inc., Chicago , IL ). A P value less than 0.05 would be considered statistically significant.

COBB angles after operation (Table 1).

In moderate thoracic curve group, the mean postoperative COBB angle on standing AP film was 9.11±5.83°, a statistical t test demonstrated no significant difference (p=0.076) compared to preoperative COBB angle on fulcrum film, but significant difference (p<0.01) compared to preoperative Tr/SB and standing AP film. In severe thoracic curve group, the mean postoperative COBB angle was 39.92±22.09° and there were significant differences (p<0.01) when compared to all preoperative films. In moderate lumbar curve group, the mean postoperative COBB angle was 6.18±4.52° and there were significant difference (p<0.01) when compared to preoperative Tr/fulcrum and standing AP film, also difference (p=0.013) compared to SB film. In severe lumbar curve group, the mean postoperative COBB angle was 24.0±5.33° and a statistical t test showed significant difference (p<0.01) when compared to preoperative Tr and standing AP film, also difference compared to fulcrum (p=0.021) or SB film(p=0.011 ).

Table 1. Preoperative and postoperative COBB angle x±s° in 4 groups

 

 

 

 

 

 

 

 

Table 2 .%Flexibility determined on Tr/SB/fulcrum film and surgical %correction 

In moderate thoracic curve group, a statistical t test demonstrated no significant difference (p=0.111) between %flexibility on fulcrum (75%) and surgical %correction(80%), however significant difference (p=0.000) between %flexibility on Tr and %correction, and difference (p=0.011) between %flexibility on SB and  %correction. The amount of %flexibility on fulcrum was larger than that on SB and Tr (p<0.01), %Flexibility on SB was larger than that on Tr (p<0.01). In severe thoracic curve group, there were significant differences (p<0.01) between %flexibility on Tr/SB/fulcrum and %correction (57%), but no significant difference of %flexibility (p=0.999) between SB and Tr. The amount of %flexibility on fulcrum was larger than that on SB (p=0.027) and Tr (p=0.003). In moderate lumbar curve group, a statistical t test demonstrated significant difference between %flexibility on Tr (44%, p<0.01)/fulcrum (76%, p<0.01)/SB (79%, p=0.019) and surgical %correction (86%). The amount of %flexibility on fulcrum and SB were larger than that on Tr (p<0.01), but no significant difference between fulcrum and SB (p=0.105). In severe lumbar curve group, there were significant difference between %flexibility on Tr (38%, p<0.01)/SB (47%, p<0.01)/fulcrum (53%, p=0.017) and %correction (67%). However, The amount of %flexibility on fulcrum was similar to that on SB (p=0.086), and %flexibility on SB was also similar to Tr (p=0.101).

Group                    cases             Flexibility(%)                                Correction(%)

Moderate thoracic       19       fulcrum(75%)>SB(63%)>Tr(50%)                 80%           

Severe thoracic           13        fulcrum(39%)>Tr(29.13%)>SB(29.12%)       57%  

Moderate lumbar        28       SB(79%)>fulcrum(76%)>Tr(44%)                  86%           

Severe lumbar              8        fulcrum(53%)>SB(47%)>Tr(38%)                  67%  

Fulcrumfulcrum bending radiograph, SBsupine lateral bending radiograph, Trsuspension traction radiograph.

Table 3. Comparison of preoperative COBB angle on different X-rayx±s°

Group                cases      X-ray       COBB angle95%CI             p value

Moderate thoracic       19      fulcrum      11.42±7.6, 7.76-15.09       fulcrumSB  0.012×

(40°<COBB≤60°)                     SB      16.47±10.14, 11.59-21.36    fulcrumTr  0.000×

                                     Tr       22.47±7.34, 18.94-26.01        SBTr  0.035×  

Severe thoracic         13      fulcrum     54.85±22.63, 41.17-68.25  fulcrumSB  0.011×

(COBB>60°)                        SB      63.38±22.72, 49.65-77.12   fulcrumTr  0.004×

                                    Tr      63.15±19.38, 51.44-74.87       SBTr  0.945  

Moderate lumbar        28      fulcrum     11.07±8.85, 7.64-14.5     fulcrumSB   0.083

(35°<COBB≤60°)                    SB       9.82±8.80, 6.41-13.23    fulcrumTr   0.000×

                                    Tr       24.96±10.74, 20.8-29.13      SBTr   0.000×  

Severe lumbar          8      fulcrum     32.88±10.56, 24.05-41.70    fulcrumSB  0.091

(COBB>60°)                       SB      36.88±10.95, 27.72-46.03    fulcrumTr  0.002×

                                   Tr      42.88±7.06, 36.97-48.78         SBTr  0.115

Fulcrumfulcrum bending radiographSBsupine lateral bending radiographTrsuspension traction radiograph, CI=confidence interval.

Discussion:

Preoperative assessment of spine flexibility in adolescent idiopathic scoliosis (AIS) is important to determine the levels to be included in the arthrodesis and the expected postoperative correction. There are many clinic accepted X-ray methods such as traction radiograph (Tr), supine side-bending radiograph (SB), fulcrum bending radiograph (fulcrum), push-prone radiograph6 (pushing), standing side-bending radiograph7, and supine traction radiographs under general anesthesia8 to be used for assessing flexibility and predicting surgical correction of AIS.

As the King classification theory for AIS was known and accepted, supine side-bending radiographs (SB) had been widely used to help in the preoperative evaluation, especially for selection of the fusion area. However, the development of current segmental spinal instrumentation systems, especially segmental pedicle screw constructs, have achieved more correction than would be expected from evaluation of traditional side-bending radiographs made with the patient supine9.So supine side-bending radiographs (SB) may fail to predict surgical correction. Although less frequently used than side-bending radiographs (SB), traction radiographs are also being used by some surgeons and centers for predicting the amount of postoperative correction, especially in patients who are less able to perform the side-bending radiographs (i.e., in patients with neuromuscular scoliosis or mental retardation). Winter and Lonstein10 reported that a traction view is more accurate for determining flexibility in curves more than 60°. However, whether traction shows higher flexibility in AIS curves is unknown or debatable.

Cheung and Luk4 first described “the fulcrum bending radiograph” for the assessment of spinal flexibility and compared the predictive value of the fulcrum bending radiograph with that of the supine lateral bending radiograph. They concluded that the fulcrum bending radiograph was always more predictive of the final correction. But few prospective comparative studies about fulcrum bending radiograph for assessing flexibility of AIS were reported. Push-prone radiograph8 (pushingwere also used by some scholars to assess flexibility of AIS. But the disadvantages included the difficulty in standardizing the force exerted on the apex of the curve and the physician’s excess exposure to radiation. The reproducibility of pushing is also not known. Recently Hamzaoglu A8 reported traction radiographs with the patient under general anesthesia may show much better flexibility, especially in more than 65° and rigid AIS curves. But in their study, the number of rigid and severe AIS cases were very small, and the surgeon were not be able to give the patient a definitive plan before surgery because the decision can only be finalized after seeing the traction radiographs with the patient under general anesthesia. What’s more, they used manual traction with maximum effort, which should be replaced by a more standard technique or method of traction to standardize the amount of force applied.

Now traction radiograph (Tr), supine side-bending radiographSB,and fulcrum bending radiographfulcrumwere best commonly used to assess the flexibility of AIS. However, these methods have been evaluated in relation to correction obtained with the Harrington distraction system and not with the newer, especially more rigid segmental pedical screws spinal instrumentation systems. To compare the value of the three X-ray methods and search an optimal method to analyze thoracic or lumbar curve flexibility and the curve response to surgical correction, we have started this prospective comparative study from 2003. We also want to know whether the three X-ray methods can predict surgical correction after the use of new segmental spinal instrumentation system especially including total pedicle screw instrumentation.

In our study, all AIS patients were single-curve and divided into moderate and severe thoracic/lumbar curve group according to PUMC classification system5 and the magnitude of COBB angle on preoperative AP films at the first time. Our goals were to standardize study object, discuss the value of Tr/SB/fulcrum radiographs for assessing thoracic or lumbar curve respectively, and avoid the interaction of double curves(PUMC II type) or three curves(PUMC III type) during preoperative X-ray examination.

Our practice in this study showed curve %flexibility and postoperative COBB angle were best assessed by fulcrum radiograph in moderate or severe thoracic curve group (Table 1-3). Especially in moderate thoracic curve group, there was no significant difference of the COBB angle between fulcrum radiographs and postoperative AP films (p=0.076), and also no significant difference between %flexibility determined on fulcrum radiographs and surgical %correction (p=0.111). These results indicated that the fulcrum radiograph for assessing flexibility of thoracic curve in AIS was superior to Tr/SB radiographs, and it even could predict surgical correction of moderate thoracic curve in AIS after undergoing a PSF with segmental pedicle screws as the sole anchor. Some reasons were considered to contributing to these results: a.) We found it was easy to center the fulcrum under the rib corresponding to the apex of the thoracic curve through identifying the position of “razor back deformity”; b.) It was easy to check that the shoulder is lifted off the X-ray table; c.) The fulcrum radiograph was easy to make and the bending force was passive and reproducible; d.) The amount of passive corrective force through the conduction of ribs was so powerful that it seemed to correspond well with the degree of correction that was obtained in thoracic curve with good flexibility(moderate thoracic curve) of AIS underwent a PSF with segmental pedicle screws as the sole anchor.

However, in moderate/severe lumbar curve group, no significant differences of the %flexibility and COBB angle measured between fulcrum and SB radiographs were found (Table 2-3, p>0.05). We considered the following reasons may result to the poor results of fulcrum radiograph for assessing flexibility and predicting %correction in lumbar curve group: a.) There are wide individual difference of fat and muscles distribution among childrenand the “razor back deformity” in lumbar curves was often not easy to be identified especially in moderate lumbar curves, so it was not easy to find the apex of the lumbar curve; b.) It was not easy to center the fulcrum under the apex of the lumbar curve because of the short size of lumbar vertebrae in children; c.) The passive corrective force was relatively poor because of lacking of the conduction of ribs.

The role of Tr radiograph for predicting flexibility and surgical correction demonstrated in this study was inferior to fulcrum/SB radiographs except no significant difference between Tr and SB (p=0.999, Table 2) in severe thoracic curve group. The suspension traction radiograph could not predict surgical %correction in all groups (p<0.01). The traction radiograph made with the patient suspending required active cooperation and effort by the patient, and the traction time had wide individual difference. Additionally, it also did not remove the muscle factor that affects clinical curve flexibility. These factors may result in the poor value of traction radiograph for analyzing curve flexibility and, at the same time, the curve response to surgical correction in AIS.

Moderate thoracolumbar/lumbar AIS was traditionally considered to be best indicated for instrumented anterior spinal fusion (ASF). ASF offered the benefit of improved curve correction and derotation while preserving more distal motion segments compared to the posterior approach. Our practice in this study demonstrated that the mean surgical %correction in moderate lumbar curve group was up to 86%, superior to %flexibility measured on Tr/SB/fulcrum radiographs (Table 2). The results showed all three traditional X-ray methods did not predict surgical correction of moderate lumbar AIS undergoing ASF.

Current segmental spinal instrumentation systems, especially segmental pedicle screw constructs, have been widely used and achieved more correction than the Harrington distraction system and previous third-degeneration spinal hook instrumentation systems11 12 13, especially in severe curves. In severe thoracic/lumbar curve group of this study, surgical %correction was 57% and 67% respectively, with significant difference from %flexibility measured on Tr/SB/fulcrum radiographs (Table 2, p<0.01). It indicates that better analysis of curve flexibility and consistent predictions of correction result require the development of new radiologic methods or techniques.

All above from this prospective study suggest that the fulcrum bending radiograph (Fulcrum) can better analyze curve flexibility and correction of thoracic curves in AIS compared to Tr/SB radiographs, but only predict surgical %correction in moderate thoracic curves. Fulcrum and SB are similar with predicting flexibility in lumbar curves. The new techniques are expected to emerge for adapting the development of new spinal instrumentation.

References:

  1. Kirk KL, Kuklo TR, Polly DW Jr. Traction versus side-bending radiographs: is the proximal thoracic curve the stiffer curve in double thoracic curves? Am J Orthop 2003;32: 284–288.

  2. Lenke LG, Betz RR, Harms J, Bridwell KH, Clements DH, Lowe TG, et al. Adolescent idiopathic scoliosis: a new classification to determine extent of spinal arthrodesis. J Bone Joint Surg(Am) 2001;83:1169-1181.

  3. Yu ZhaoGui-Xing Qiu, Jian-Xiong Shen. Evaluatian of imaging methods for predicting the correction of scoliosis. Clinical Journal of Rehabilitation 2004;26,5692-5694(In Chinese).

  4. Luk KDLu DSCheung KM, Wong YW. A prospective comparison of the coronal deformity correction in thoracic scoliosis using four different instrumentations and the fulcrum-bending radiograph. Spine 2004;29:560-563.

  5. Qiu G, Zhang J, Wang Y, Xu H, Zhang J, Weng X, et al. A new operative classification of idiopathic scoliosis:a Peking Union Medical College method. Spine 2005;30:1419-1426.

  6. Vedantam R, Lenke LG, Bridwell KH, Linville DL. Comparison of pushprone and lateral-bending radiographs for predicting postoperative coronal aligmnent in thoracolumbar and lumbar scoliotic curvel. Spine 2000;25:76-81.

  7. Klepps SJ, Lenke LG, Bridwell KH, Bassett GS, Whorton J.  Prospective comparison of flexibility radiographs in adolescent idiopathic scoliosis. Spine 2001;26:E74-79.

  8. Hamzaoglu A, Talu U, Tezer M, Mirzanli C, Domanic U, Goksan SB. Assessment of curve flexibility in adolescent idiopathic scoliosis. Spine 2005;30:1637-1642.

  9. Suk SI, Lee CK, Kim WJ, Chung YJ, Park YB. Segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis. Spine 1995;20:1399–1405.

  10. Winter RB, Lonstein JE. Idiopathic scoliosis. In: Rothman RH, Simeone FA,eds. The Spine. 3rd ed. Philadelphia , PA : Saunders;1992:411.

  11. Lee SM, Suk SI, Chung ER. Direct vertebral rotation: a new technique of three-dimensional deformity correction with segmental pedicle screw fixation in adolescent idiopathic scoliosis. Spine 2004;29:560–563.

  12. Suk SI, Lee SM, Chung ER, Kim JH, Kim SS. Selective thoracic fusion with segmental pedicle screw fixation in the treatment of thoracic idiopathic scoliosis: more than 5-year follow-up. Spine 2005;30:1602–1609.

  13. Storer SK, Vitale MG, Hyman JE, Lee FY, Choe JC, Roye DP Jr. Correction of adolescent idiopathic scoliosis using thoracic pedicle screw fixation versus hook constructs. J Ped Orthop 2005;25:415–419.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This is a peer reviewed paper 

Please cite as : Qi Fei : Comparative Study Of Three X-Ray Methods For Assessment Of Curve Flexibility In Adolescent Idiopathic Scoliosis

J.Orthopaedics 2008;5(1)e2

URL: http://www.jortho.org/2008/5/1/e2

ANNOUNCEMENTS

 


 

Arthrocon 2011


Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044

E-Mail:
anwarmh@gmail.com

 

Powered by
VirtualMedOnline

 

 

   
© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.