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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Early Bony Fixation and Soft Tissue Coverage in Type IIIB Open Proximal Tibia Fractures: A Cross-sectional Study
Correspondence Address :
Surendra Kumar,
Associate Professor, Department of Orthopaedics, BRD Medical College, Gorakhpur-273013, Uttar Pradesh, India.
E-mail: doctorsurendra82@gmail.com
Introduction: The tibia, the second largest bone in the human body, is largely enveloped by subcutaneous fat and skin, rendering it vulnerable to fractures and soft tissue injuries. This unique anatomical configuration contributes to a heightened susceptibility to open fractures. Notably, an aggressive treatment protocol involving radical debridement, internal fixation, and immediate or early soft tissue coverage with muscle flaps has demonstrated improved rates of bony union and reduced incidences of infection.
Aim: To assess the clinical outcomes of early bony fixation and soft tissue coverage in Type IIIB open proximal tibia fractures.
Materials and Methods: This cross-sectional observational study was conducted at the Department of Orthopaedics, BRD Medical College, in Gorakhpur, Uttar Pradesh, India. Total of 30 cases were enrolled between August 2021 and November 2022. The parameters assessed in the study encompassed patient demographics, including age and gender distribution, the aetiology of fractures, soft tissue coverage outcomes, time to bone union, knee joint movement postsurgery, and the incidence of complications such as superficial infections and chronic osteomyelitis. The analysis was conducted using Statistical Package for Social Sciences (SPSS) version 26.0, primarily employing descriptive statistics to present the results, with percentages and frequencies serving as the primary modes of representation.
Results: All cases of Gustilo-Anderson Type IIIB high-grade open tibial fractures were included in this study, with the majority of patients being males 26 (87%) aged between 20 to 40 years. Road traffic accidents accounted for 25 (83.3%), while falls from height were responsible in 5 (16.7%) cases. Assessment of soft tissue coverage revealed 73.33% with good healing, 20% with fair healing, and 6.67% with poor healing. The time to bone union varied, with 10% of cases showing non union. Postsurgery, most cases demonstrated knee joint movement of over 120° (86.67%) and a few cases with movement ranging between 90-120° (13.33%). The incidence of complications was relatively low, with 3 (10%) cases presenting superficial infections and 2 (6.7%) suffering from chronic osteomyelitis.
Conclusion: Early bony fixation and soft tissue coverage utilising the medial gastrocnemius flap, along with Split-Thickness Skin Grafting (STSG), demonstrate efficacy in treating high-grade open proximal tibia fractures (Gustilo-Anderson Type IIIB). This approach facilitates expedited bony union and contributes to a reduction in postoperative complications.
Flaps, Fractures, Injuries, Skin grafts
Tibia fractures are common due to their specific anatomy and vulnerable soft tissue covering, leading to an increased risk of soft tissue injuries and a high incidence of open tibial fractures. Historically, open tibia fractures were managed through repeated debridement, external fixation, and delayed soft tissue coverage, resulting in persistent complications (1),(2). Surgical interventions for open tibial fractures, without adequate attention to soft tissues, can result in deep infections, malunion, non union, implant failure, and may even jeopardize the limb, necessitating amputation. Improved outcomes in the surgical treatment of tibial fractures have been facilitated by the implementation of sterile surgical techniques and antibiotic prophylaxis. The outcome is significantly influenced by the injury mechanism, extent of comminution, and soft tissue condition (3),(4). The Gustilo open fracture classification system stands as the most widely employed system for categorising open fractures (5). Originating from the work of Ramón Gustilo and Anderson, it underwent subsequent refinement by Gustilo, Mendoza, and Williams (6). This classification relies on evaluating the energy imparted, the extent of soft tissue damage, and the level of contamination to determine the severity of the fracture. Advancing from Grade I to IIIC signifies escalating levels of energy in the injury, heightened damage to soft tissues and bones, and an increased likelihood of complications. It is crucial to note that a Gustilo score of grade 3C indicates not only bone and connective tissue damage but also vascular injury (6).
Successful treatment of open tibial fractures hinges upon achieving three critical goals: preventing infection, achieving bony union, and restoring preoperative function (7). The primary focus in managing open tibia fractures revolved around early soft tissue coverage, prompt union, and infection prevention. Godina M proposed the use of early free microvascular flaps to cover large contaminated wounds. An aggressive protocol, comprising radical debridement, internal fixation, and immediate or early soft tissue coverage with muscle flaps, has been reported to expedite union and lower infection rates (8). Early soft tissue coverage of Type III open tibial fractures significantly reduces the rates of infection, non union, and late amputation. Various options for closing soft tissue defects in open fractures include Split Skin Graft (SSG), fasciocutaneous flap, rotational muscle flap (with SSG), and free muscle flap (with SSG) (9). Non microvascular flaps are less technically demanding and can be used to cover the soft tissue defects in open tibial fractures. Typically, tissue defects in the proximal third of the tibia are managed with a gastrocnemius rotational flap in conjunction with STSG (10),(11). An orthopaedic surgeon, equipped with comprehensive knowledge of the local vascular anatomy, is well-suited to harvest an appropriate local or regional flap to cover exposed bone or metal in open tibia fractures. Given their extensive experience with extremity surgery, orthopaedic surgeons are ideally positioned to reconstruct soft tissue defects in these injuries as promptly as possible.
Considering these factors, the current study aim to evaluate the management of open proximal tibia fractures through early bony fixation and soft tissue coverage, utilising the medial gastrocnemius flap with STSG, while assessing both bone healing and functional outcomes.
A cross-sectional observational study was conducted at the Department of Orthopaedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India, which is a tertiary care teaching hospital. Over a period spanning from August 2021 to November 2022, 30 cases were enrolled in the study after obtaining informed consent from each participant. The study received ethical approval from the Institute’s Ethical Committee (IEC) (No. 51/CRC/2021 dated 27/08/21).
Inclusion criteria: Patients diagnosed with Gustilo-Anderson Grade IIIB fractures were included in the study.
Exclusion criteria: Patients who did not consent to surgical intervention, those with multiple injuries including head, abdominal, chest, and other limb injuries, as well as those falling under Gustilo-Anderson Grades I, II, IIIA, and IIIC (6) were excluded from the study.
Initial resuscitation involved administering intravenous fluids and immobilising the injured limb with a Thomas/Bohler’s brown splint, preceded by an assessment of distal neurovascular and soft tissue status in the emergency department. Concurrently, a thorough evaluation ruling out injuries to the head, thorax, and abdomen was conducted, followed by the classification of the wound using the Gustilo-Anderson classification (6) and the Ganga Hospital Open Injury Scoring System (12).
Post-resuscitation, wound irrigation with copious normal saline and debridement within the first six hours, along with the application of betadine-soaked dressings, was performed. Wound swabs were collected for culture and sensitivity testing, with broad-spectrum intravenous antibiotics initiated. Subsequent redebridement within 72 hours was performed as deemed necessary, ensuring complete removal of necrotic tissue. The application of the medial gastrocnemius muscle flap with STSG was the chosen surgical intervention for proximal third tibia fractures, following patient stabilisation.
Postoperatively, limb elevation was maintained to prevent oedema and graft failure. The initial wound inspection and dressing change occurred on the fourth postoperative day. Patients with definitive internal fixation were permitted partial weight-bearing from 4 to 6 weeks, followed by full weight-bearing as soon as radiological evidence of sound union appeared. Patients treated with an external fixator underwent removal of the fixator once the wound exhibited a healthy flap, followed by a subsequent secondary procedure involving definitive internal fixation using plates and intramedullary nails.
The first follow-up evaluation typically occurred between 4 to 6 weeks postoperatively, with subsequent regular follow-ups scheduled every 4 to 6 weeks until complete fracture union was achieved. Thus, the parameters included patient demographics, aetiology of fractures, soft tissue coverage outcomes, time to bone union, knee joint movement postsurgery, and the incidence of complications such as superficial infections and chronic osteomyelitis.
Statistical Analysis
The collected data were analysed using SPSS version 26.0. Descriptive statistics were employed to present the results, including percentages and frequencies to illustrate the outcomes.
The study comprised 30 cases of high-grade open tibial fractures (Gustilo-Anderson Type IIIB), with 87% being male and 13% female patients, predominantly within the age group of 20-40 years. The leading causes of these fractures were road traffic accidents, accounting for 25 (83.3%) cases, followed by falls from height, contributing to 5 (16.7%) cases.
The evaluation of soft tissue coverage outcomes is shown in (Table/Fig 1).
During the study, the time taken for bone union varied, with 5 (16.7%) cases demonstrating union around 30 and 34 weeks each, 7 (23.3%) at approximately 28 weeks, 4 (13.3%) at around 26 weeks, 3 (10%) at 32 and 36 weeks each, while 2 (6.7%) and 1 (3.3%) displayed union at 24 and 40 weeks, respectively (Table/Fig 2). Additionally, 3 (10%) of cases experienced non union during the study period.
Postsurgery, knee joint movement was assessed, revealing that 26 (86.7%) cases exhibited a range of movement exceeding 120°, whereas 4 (13.3%) cases displayed knee joint movement ranging between 90-120°. The majority of cases demonstrated favourable movement postsurgery during the study (Table/Fig 3).
Furthermore, the study noted that the majority of cases 25 (83.3%) did not experience any complications, while 3 (10%) cases presented with superficial infections, and 2 (6.7%) patients suffered from chronic osteomyelitis.
The findings of this study underscore the efficacy of early bony fixation and soft tissue coverage, utilising the medial gastrocnemius flap with STSG, in the management of high-grade open proximal tibia fractures (Gustilo-Anderson Type IIIB). These interventions demonstrated favourable outcomes, including expedited bone union, successful soft tissue healing, and improved knee joint mobility. Moreover, the low incidence of postoperative complications, coupled with the notable reduction in non union cases, highlights the effectiveness of the implemented approach in achieving the desired clinical outcomes.
Open tibial fractures are commonly associated with complex fracture patterns, limb-threatening soft tissue damage, and the potential for severe arterial haemorrhage. Karikalan T conducted a study involving 20 patients with Type IIIB open tibial fractures treated through skeletal stabilisation and soft tissue coverage, either via a fasciocutaneous flap or a myocutaneous flap. The study concluded that early soft tissue coverage is instrumental in promoting favourable bone healing and enhancing limb function (13). Similarly, present study findings align with this conclusion, emphasising that early soft tissue coverage, specifically through the utilisation of the myocutaneous flap, facilitates prompt bony union and early restoration of limb function.
In present sudy the functional outcomes of soft tissue coverage, primarily utilising the medial gastrocnemius flap, revealed that 22 (73.3%) cases exhibited a good functional outcome, 6 (20%) demonstrated a fair functional outcome, and 2 (6.7%) indicated a poor outcome. Most cases exhibited positive functional outcomes during follow-up. Comparative results from other studies are presented in (Table/Fig 4) (14),(15).
Sandhu KS et al., conducted a study on high-grade open tibial fractures, revealing a bone union rate of 50% of cases between 24-30 weeks (16), as indicated by other studies presented in (Table/Fig 5) (17),(18),(19). In contrast, present study demonstrated a more favourable outcome, with 60% of cases achieving bone union within the same timeframe of 24-30 weeks. This discrepancy underscores the potential variations in outcomes across different studies and reinforces the significance of individualised approaches in managing high-grade open tibial fractures.
Milner SA et al., conducted a study, reporting that 69% of cases had knee joint movement of more than 120°, with 31% showing movement between 90-120°. Another study by Weiss RJ et al., demonstrated that 80% of cases had knee joint movement of more than 120°, while 20% fell between 90-120° (20),(21). In comparison, present study revealed favourable outcomes, with 26 (86.7%) cases exhibiting knee joint movement exceeding 120° and 4 (13.3%) showing movement between 90-120°. This suggests that adherence to the established protocol and a one-year follow-up period contributed to notably positive results in terms of both bony union and functional outcomes.
Penn-Barwell JG et al., conducted a study where 22% of cases exhibited superficial infections, and 8% presented with deep infections. Similarly, Campion EM and Mackersie RC reported that 10% of cases showed superficial infections, and 12% presented with deep infections, specifically chronic osteomyelitis (22),(23). In contrast, present study revealed a notably lower incidence of complications, with approximately 3 (10%) cases presenting with superficial infections and 2 (6.7%) cases with chronic osteomyelitis. This suggests that the implemented approach in present study may contribute to a reduced risk of postoperative complications compared to some existing studies.
The success of this study and the achievement of satisfactory long-term outcomes are contingent upon diligent follow-up and comprehensive patient care. Notably, this study distinctive attributes, including its substantial sample size, rigorous authentication processes, and innovative approaches, contribute to its novelty within the field. Comparative studies within the existing literature are relatively scarce.
The available literature reviews have highlighted a significant gap concerning data on high-grade open proximal tibial fractures, specifically Gustilo-Anderson Type IIIB. This study plays a crucial role in addressing this gap, providing valuable insights into the management and outcomes of such fractures. The data generated not only contributes to the existing body of knowledge but also holds potential for guiding future research endeavours, particularly for young researchers. The findings of this study have the potential to benefit surgeons in refining their approaches and interventions, ultimately serving the broader community and advancing healthcare practices for the betterment of society.
Limitation(s)
The limitations observed during this study primarily include a comparatively smaller sample size, attributed to the unavailability of a larger number of cases, and the relatively short duration of the study, consequently leading to a limited follow-up period. A longer follow-up duration is essential for a more comprehensive assessment of the long-term outcomes associated with the use of the gastrocnemius flap for high-grade open tibial fractures. Additionally, while the descriptive analysis employed in this study provided valuable insights, future research endeavours employing inferential statistics and specific statistical tests would enhance the depth of understanding and contribute to a more rigorous evaluation of the data’s significance.
The study affirms that the approach of early bony fixation and soft tissue coverage, specifically utilising the medial gastrocnemius flap along with STSG, emerges as an efficacious strategy for the treatment of high-grade open tibial fractures (Gustilo-Anderson Type IIIB). The accessibility and ease of mobilisation of the gastrocnemius muscle, situated in close proximity to the proximal tibia, make it a practical choice for soft tissue coverage. The demonstrated success includes expedited bony union within a shorter timeframe, accompanied by a favourable reduction in postoperative complications.
DOI: 10.7860/JCDR/2023/66143.18818
Date of Submission: Jun 19, 2023
Date of Peer Review: Sep 11, 2023
Date of Acceptance: Nov 01, 2023
Date of Publishing: Dec 01, 2023
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jun 20, 2023
• Manual Googling: Sep 29, 2023
• iThenticate Software: Oct 27, 2023 (5%)
ETYMOLOGY: Author Origin
EMENDATIONS: 5
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