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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
Functional Outcomes of Quadriceps Tendon versus Hamstring Tendon Autograft using Suspensory Fixation at Femoral and Tibial Sites for Primary Anterior Cruciate Ligament Reconstruction: A Randomised Controlled Study
Correspondence Address :
Dr. Sandeep Naik,
Associate Professor, Department of Orthopaedics, 2nd Floor, BLDE’s Shri BM Patil Medical College and Research Centre, Vijayapur-586103, Karnataka, India.
E-mail: sandippkmc@gmail.com
Introduction: Arthroscopic Anterior Cruciate Ligament (ACL) reconstruction using hamstring tendon autografts is commonly used in day-to-day practice. Recently, the quadriceps tendon has been considered as a graft choice for primary ACL reconstruction due to its reliable graft size and resistance to rupture. The available literature comparing Quadriceps and Hamstring autografts in ACL reconstruction is limited. Therefore, the present study was conducted to compare the functional outcomes of these autografts using suspensory fixation at the femoral and tibial sites.
Aim: To compare the functional outcomes of quadriceps tendon versus hamstring tendon autografts for primary ACL reconstruction.
Materials and Methods: A randomised controlled study was conducted at Department of Orthopaedics, BLDE’s Shri BM Patil Medical College and Research Centre, Vijayapur, Karnataka, India, from January 2021 to April 2023. Thirty-four patients were included in the study and randomised into two groups: one group was operated with a quadriceps tendon graft, and the other group used a hamstring tendon autograft. Both groups underwent surgery using suspensory fixation, and postoperative rehabilitation was similar. Functional outcomes (assessed using Lysholm and International Knee Documentation Committee (IKDC) scores), return to preinjury activity, and complications were evaluated. Statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 20.0. The Mann-Whitney U test was applied to compare pre- and postoperative functional outcomes (Lysholm and IKDC scores) at 6, 12, and 24 months, with a significance level of p<0.05.
Results: Out of 34 patients, 27 (79%) were male and 7 (21%) were female. The follow-up period ranged from a minimum of 24 months to a maximum of 26 months. The mean Lysholm score in the hamstring group increased from 47 preoperatively to 92 at six months postoperatively, while in the quadriceps group, it increased from 46 preoperatively to 90 at six months postoperatively. The reliability and validity of the IKDC score for the hamstring group also increased from 46 preoperatively to 79 at six months, and for the quadriceps group, it increased from 44 preoperatively to 78 at six months. A total 31 of the cases (91%) returned to their preinjury activity, while 3 patients (9%) (2 from the hamstring group and 1 from the quadriceps group) experienced knee stiffness, which restricted their ability to squat and sit cross-legged. There were no significant differences in Lysholm and IKDC scores between the hamstring and quadriceps tendon autografts at 6, 12, and 24 months postoperatively.
Conclusion: Patients undergoing single bundle ACL reconstruction have comparable functional outcomes with either hamstring or quadriceps grafts at the end of the 2-year follow-up period, with no specific graft site complications. The soft tissue quadriceps tendon autograft can be considered as an equally viable option for graft selection.
Anterior cruciate ligament injuries, Autografts, Arthroscopy, Lysholm knee score
One of the ligaments in the knee joint that frequently ruptures is the ACL. Reconstruction has long been recognised as a treatment for instability and to prevent associated complications (1). Conservatively treated ACL tears may result in residual instability and pain due to knee instability itself or instability-related lesions such as Ramp lesion, bucket handle tears, and posterior horn longitudinal tears of the medial and lateral menisci, chondral defects, stenosis, and osteophytes at the intercondylar notch (2). Post-traumatic osteoarthritis of the knee is a common finding in chronic ACL tears. Arthroscopic ACL reconstruction using autografts is the standard practice (3). Allografts carry a risk of slower graft incorporation, higher rupture rates in some highly active young groups, non availability, and increased cost (4).
Bone-patellar tendon-bone graft has been considered the gold standard for ACL reconstruction due to its high strength, stiffness, ease of harvest, consistent graft size, and bone integration potential (5). However, complications such as patellar ligament rupture, patella fracture, or tibial tuberosity may occur intraoperatively (6). Postoperatively, common complaints of quadriceps weakness can lead to extension lag (7), problems with kneeling, and anterior knee pain, which have drawn attention to other graft options (8).
Hamstring tendon autograft is a common choice amongst surgeons due to its larger cross-sectional area and the maintenance of the extensor mechanism’s integrity (5). Moreover, the Hamstring tendon autograft has an elastic modulus similar to that of the native ACL, resulting in postoperative outcomes similar to the native ACL, with less anterior knee pain and stiffness (9). However, it may have a longer healing time and graft integration time within the bone tunnel, as well as hamstring weakness with compromised flexion and internal rotation (9).
In recent years, the soft tissue quadriceps tendon has been increasingly used as a graft choice for ACL reconstruction due to its reliable graft size. The Quadriceps tendon has the same width as the patellar tendon but a larger cross-sectional area, resistance to rupture, and can be harvested with a minimally invasive technique. It also has the ability to adjust in width as per the intraoperative requirement (10). Compared to the hamstring graft, it exhibits less laxity on pivot shift, and therefore lower failure rates compared to the hamstring graft have been claimed (11). However, some reported disadvantages include the need for an extra incision for graft harvest, which can lead to Quadriceps atrophy and weakness postoperatively, and in rare cases (<1%), donor site quadriceps tendon rupture (12).
Studies claim that the Quadriceps tendon as a graft tends to perform better or equally to the hamstring tendon in terms of functional outcomes and has fewer complications (11),(13),(14). The available literature comparing quadriceps and hamstring grafts in ACL reconstruction is limited. Hence, the present study aimed to compare the functional outcomes of these autografts using suspensory fixation at the femoral and tibial sites.
A randomised controlled study was conducted at Department of Orthopaedics, BLDE’s Shri BM Patil Medical College and Research Centre, Vijayapur, Karnataka, India from January 2021 to April 2023.
Sample size calculation: The sample size was calculated to detect a true difference in means between two groups with a power of 50% and a significance level of 5% (two-sided) (7). The estimated sample size was 34.
Ethical clearance was obtained from the Institutional Ethical Committee, BLDE (DU) Shri BM Patil Medical College, Vijayapur, Karnataka, India with approval number IEC/NO-11/21 (dated 22/01/2021). Informed and written consent was obtained from all participating patients.
Inclusion criteria: The study included patients aged 18 to 45 years with clinically and Magnetic Resonance Imaging (MRI)-confirmed ACL ruptures.
Exclusion criteria: Patients with ACL ruptures associated with meniscal injury requiring meniscectomy, multiligament knee injuries, open knee injuries, associated fractures around the knee joint, associated neurovascular injury, polytrauma, and patients medically unfit for surgery were excluded.
Procedure
A total of 42 patients were initially recruited, but eight patients did not meet the inclusion criteria, resulting in a final sample size of 34 patients. The subjects were randomised into two groups using the lottery method. Group A (17 patients) underwent ACL reconstruction using the quadriceps tendon, while Group B (17 patients) underwent ACL reconstruction using the Hamstrings tendon autograft. Both groups underwent ACL reconstruction with suspensory fixation on both the femoral and tibial sides. The postoperative rehabilitation protocol was the same for both groups.
Patient demographics, side of the injury, functional outcomes (measured by Lysholm (15) and IKDC (16) scores), return to preinjury activity, and complications were assessed. Follow-up evaluations were conducted for a minimum of 24 months and a maximum of 26 months. The Lysholm and IKDC scores were assessed preoperatively and postoperatively at 6, 12, and 24 months. The Lysholm scoring system evaluated patients’ perceptions of their own function and indications of instability, with scores ranging from 18excellent (91-100) to unsatisfactory (<65) (15). The IKDC scoring system assessed subjective assessment, symptoms, range of motion, and ligament inspection, with scores ranging from 0 (lowest level of function or highest level of symptoms) to 100 (highest level of function and lowest level of symptoms) (16).
Surgical technique:
(a) Graft harvest:
• For the hamstrings tendon autograft (Table/Fig 1)a,b,(Table/Fig 2) (17), an oblique incision was made one finger breadth medial to the tibial tuberosity. The Sartorius fascia was incised, and the insertions of the gracilis and semitendinosus tendons were identified. Bands connecting the tendons were severed, and both tendons were stripped using a tendon stripper.
• For the soft tissue quadriceps tendon autograft (Table/Fig 3)a,b] (9), a mid-line incision ending at the superior pole of the patella was made. The anterior surface of the central portion of the quadriceps tendon was incised using a knife. The distal graft diameter would increase by 0.5 to 1 mm to prepare the graft for suture. A number 15-blade was used to extend the longitudinal incision distally to the superior pole of the patella. Deep dissection was avoided since only a partial thickness graft was to be harvested. After elevating 3 cm of the tendon, it was whipstitched using a looped suture. For most patients undergoing anatomic ACL restoration, a graft length of 7 cm was sufficient (18).
(b) ACL reconstruction (19),(20): A five-strand hamstrings graft and quadriceps graft were harvested with a diameter of 9 mm in all cases. Anatomical ACL reconstruction was performed by fixing the endobutton on the femoral side and the base plate on the tibial side.
The postoperative protocol and rehabilitation (19) were similar in both groups, including quadriceps strengthening, active Range of Motion (ROM) of 0-90 degrees, weight bearing as tolerated with crutches in the first two weeks, patella mobilisation, and ankle pumps. At four weeks, ROM of 0-120 degrees with full weight bearing using a stick was achieved. Full ROM (>130 degrees) and weight bearing without support were advised at six weeks. Further hamstrings strengthening, agility training, and sports-specific exercises were performed.
Statistical Analysis
The statistical analysis was conducted using the Statistical Package for Social Sciences (SPSS version 20.0). The Mann-Whitney U test was applied to compare functional outcomes (Lysholm and IKDC scores) preoperatively and postoperatively at 6, 12, and 24 months. A p-value <0.05 was considered statistically significant.
Out of 34 patients, 17 (50%) underwent surgery with Hamstrings tendon autografts, while the remaining 17 had quadriceps tendon autografts. Among them, 27 (79%) were male and 7 (21%) were female. A total of 16 patients (47%) sustained a left-sided injury, while 18 (53%) sustained a right-sided knee injury. The mean value of the Lysholm score in the Hamstrings group preoperatively was 47.06, which increased to 91.9 at six months postoperatively and 98.8 at 24 months. The IKDC score of the Hamstrings group also increased from 45.5 preoperatively to 79.2 at six months and 96.06 at 24 months. In the quadriceps group, the mean value of the Lysholm score preoperatively was 45.8, which increased to 90.2 at six months postoperatively and 99.1 at 24 months. The IKDC score of the Quadriceps group also increased from 43.8 preoperatively to 78 at six months and 96.2 at 24 months.
The Lysholm and IKDC scores for the Hamstrings and Quadriceps tendon autografts showed no significant difference (p>0.05) at 6, 12, and 24 months postoperatively (Table/Fig 4),(Table/Fig 5). All patients in the study had unsatisfactory outcomes preoperatively with a mean Lysholm score of 46.44. At six months postoperatively, 19 (56%) patients achieved excellent outcomes, 14 (41%) had good outcomes, and one (3%) patient had fair functional outcomes. At the one-year follow-up, all patients achieved excellent outcomes except for one with good functional outcomes. At the two-year follow-up, all patients scored excellent. A total of 31 (91%) cases returned to their preinjury activity. Three patients (two from the Hamstrings group and 1 from the Quadriceps group) still experienced knee stiffness, which restricted them from squatting and sitting cross-legged. Sixteen patients (47%) out of 34 returned to sports activity [Table/Fig-6,7], while the remaining 18 (53%) experienced mild pain and difficulty in cutting, accelerating, and sudden stops while running.
Complications: One patient from each group (Hamstrings and Quadriceps) had a superficial infection at the donor site, which was treated with intravenous antibiotics. Two patients from the Hamstrings group and one from the Quadriceps group complained of knee stiffness due to poor compliance with postoperative rehabilitation. Aggressive physiotherapy helped increase the range of movement from 10 to 80 degrees. Two patients, both from the Hamstrings group, reported numbness over the anteromedial aspect of the leg. None of the patients experienced severe early postoperative pain, unsatisfactory cosmetic appearance of the postoperative scar, implant or fixation failure requiring removal, or infection debridement.
A randomised controlled study was conducted to compare the functional outcomes of Quadriceps and Hamstrings tendon autografts in ACL reconstructions. No significant difference was observed between the two groups at a two-year follow-up. Out of 34 patients, 17 (50%) were operated on with the Hamstrings tendon, and the remaining 17 with Quadriceps tendon autograft. All patients in the study had unsatisfactory outcomes preoperatively (according to Lysholm scores). At six months postoperatively, 19 patients achieved excellent, 14 good, and one patient fair functional outcomes. At the one-year follow-up, all patients achieved excellent outcomes except for one with good functional outcomes. At the two-year follow-up, all patients scored excellent.
A similar study by Todor A et al., retrospectively followed-up with 72 patients (39 Quadriceps and 33 Hamstrings) for two years (21). Pomenta Bastidas MV et al., conducted a non-randomised comparative study including 52 patients (25 Quadriceps and 27 Hamstrings) with a minimum two-year follow-up (22). All patients who sustained sports-related injuries decided not to return to sports at the final follow-up. There was no significant difference in functional outcomes between Quadriceps and Hamstrings tendon autograft at the two-year follow-up based on Lysholm (p=0.563) or IKDC (p=0.567) scores in the present study. These findings were similar to the study by Todor A et al., which also concluded no significant difference in functional outcomes based on Lysholm scores (p=0.299) (21). Pomenta Bastidas MV et al., found no significant difference in IKDC scores (p=0.38) between both groups (22).
In the present study, two patients from each group were noted to have a superficial infection at the donor site. Three patients (two Hamstrings and one Quadriceps group) complained of restricted range of movement due to poor compliance with postoperative rehabilitation. Two patients from the Hamstrings group reported numbness over the anteromedial aspect of the leg. None of the patients reported unsatisfactory cosmetic appearance of the postoperative scar. There were no cases of fixation failure at the tibial or femoral site at the end of two years, and no deep infections requiring debridement. Additionally, there were no implant or graft-related long-term complications requiring revision.
Todor A et al., reported five patients in the Quadriceps group with unsatisfactory results, while eight patients in the Hamstrings group reported mild numbness on the anteromedial aspect of the leg. None of their patients required revisions or reoperations (21). Pomenta Bastidas MV et al., found three patients requiring revision surgery, one from the Quadriceps group due to donor site infection, and the other two (one from each group) due to sports injury (22).
Hence, the findings of the present study were similar to other studies, which concluded that the soft tissue Quadriceps tendon provides comparable outcomes to Hamstrings tendon autograft in ACL reconstruction (21),(22).
Limitation(s)
The short duration of follow-up and reliance on subjective scores for assessment were potential limitations of the present study.
Patients undergoing single-bundle ACL reconstruction have comparable functional outcomes with either hamstrings or quadriceps grafts at the end of a 2-year follow-up, with no specific graft site complications. Hence, the soft tissue quadriceps autograft can be considered a reliable graft option for primary ACL reconstruction, similar to Hamstrings, in the future.
Doi: 10.7860/JCDR/2023/64284.18350
Date of Submission: Apr 04, 2023
Date of Peer Review: May 24, 2023
Date of Acceptance: Jul 05, 2023
Date of Publishing: Aug 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
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