Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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On Aug 2018

Dr. Arundhathi. S
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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

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.
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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)
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.
On April 2011

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
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : TC01 - TC04 Full Version

Evaluation of Posterior Tibial Slope for Anterior Cruciate Ligament Tear and Meniscal Tear: A Cross-sectional Study

Published: January 1, 2023 | DOI:
Sathya Sabina Muthu, U Shrikrishna, Kayalvizhi Ravichandran

1. Lecturer, Department of Radiology, Amar Shanth Paramedical Institute, Tejasvini Hospital Group of Institutions, Mangaluru, Karnataka, India. 2. Professor, Department of Radiodiagnosis and Imaging, KS Hegde Medical Academy, Nitte Deemed to be University, Mangaluru, Karnataka, India. 3. Assistant Professor, Department of Radiodiagnosis and Imaging, KS Hegde Medical Academy, Nitte Deemed to be University, Mangaluru, Karnataka, India.

Correspondence Address :
Ms. Kayalvizhi Ravichandran,
Assistant Professor, Department of Radiodiagnosis and Imaging,
Mangaluru, Karnataka, India.


Introduction: The Posterior Tibial Slope (PTS) is an angle formed by the tibial plateau and supports the biomechanics of the knee joint. This slope is found to be a factor in differentiating ACL tear injuries. Earlier studies have shown the association of PTS with Anterior Cruciate Ligament (ACL) tears but have not evaluated the PTS values for different gradings.

Aim: To evaluate the PTS on X-ray and Magnetic Resonance Imaging (MRI), for patients with different grades of ACL tears, and patients identified with meniscal tears.

Materials and Methods: This cross-sectional study was conducted from April 2020 to March 2021 at the Department of Radiodiagnosis and Imaging, KS Hegde hospital, Mangaluru, Karnataka, India. A total of 30 patients were studied, in which 20 patients with ACL tears underwent both X-ray and MRI, while the 10 patients with meniscal tears were only subjected to MRI. The PTS was evaluated for different grades of ACL tears on X-ray and MRI by an experienced Radiologist. The number of patients with grade I, grade II, and grade III ACL tears were 7, 6 and 7, respectively. Paired t-test was used to evaluate the mean PTS for the identified grade of the ACL tear. One-way Analysis of Variance (ANOVA) and Bonferroni post hoc test was used to analyse the difference between grades of the ACL tear.

Results: The mean age of the study population was 32.50±16.363 years, and the male-to-female ratio was 4:1. Both right, as well as the left knee, were included in the study, and the left-to-right knee ratio was 3:2. There was a significant difference in PTS between Grades of ACL tears (p-value-0.001). The PTS was observed to increase as the severity of the ACL injury increased.The mean PTS value obtained on x-ray for grade I, grade II, and grade III ACL tears were 10.85±0.54, 14.18±0.62, and 16.46±1.56, respectively. While the mean PTS value obtained on MRI for grade I, grade II,and grade III ACL tears were 10.85±0.53, 14.19±0.60, and 16.47±1.55, respectively. There was no significant difference in the PTS measured for ACL tears between the X-ray and MRI (p-value>0.05). Further, the results did not show any difference of significance in the PTS measured on MRI between ACL tears and meniscal tears (p-value>0.05).

Conclusion: The PTS can be used as an aid in the identification of the severity of the ACL injury. The PTS could also be used as a tool to recognise the presence of ACL tears on X-ray and this could be an important prognostic factor towards the functional outcome.


Knee joint, Magnetic resonance imaging, X-rays

The day-to-day activities of everyday life are largely dependent on the lower limb. The knee joint, being a type of complex hinge joint in the body supports the various activities of everyday life. It has a vital role in weight-bearing and maintaining the position, whether standing or moving (1). The knee joint can be considered as two joints, a tibiofemoral joint, and a patellofemoral joint. The tibiofemoral joint is responsible for transmitting the weight of the body from the femur to the tibia and provides a hinge-like sagittal plane joint rotation accompanied by a small degree of tibial axial rotation (2).On the other hand, the primary function of the patellae is to act as a mechanical pulley for the quadriceps, when the patellae go through a change in the direction of the extension force throughout the knee range of motion (3). The knee joint has various ligaments that provide stability to the joint. The ligaments and menisci are often injured during heavy activities that cause strain to the knee joint. Early diagnosis and treatment are essential to prevent disability of the knee joint.

The articular surface of the tibial plateau forms posterior and inferior slopes about the longitudinal axis of an axial center and is known as the Posterior Tibial Slope (PTS) (4). This slope is found to vary in different studies according to age, gender, and ethnicity (5),(6). The Posterior Tibial Slope (PTS) is measured to assess its relationship to tibial translation, knee joint stability, and Anterior Cruciate Ligament (ACL) injuries (7). The knee biomechanics is largely affected by the Posterior Tibial Slope (PTS). The PTS is considered an indicator of ACL tears (5). Studies have shown that individuals with ACL injuries have a greater PTS than individuals with normal ACL (8),(9),(10). In addition, PTS plays an important role in the planning of surgical interventions such as tibial osteotomy, tibial osteoarthritis, and knee arthroplasty (4).

Many studies have proved that PTS can be a factor that influences the incidence of ACL tears (6),(9),(11). But to the best of authors’ knowledge, none of the earlier performed studies has evaluated the PTS for different Grades of ACL tears. Hence, this study would be a pioneer that has investigated the PTS for different grades of ACL tears on X-ray and MRI. This knowledge about PTS would improve the outcome of ACL tear treatment as PTS is a factor that influences the biomechanics of the knee.

This study has focussed on evaluating the measurements of the PTS for different grades of ACL tears on X-ray and Magnetic Resonance Imaging (MRI). Furthermore, the gender difference in PTS for ACL tears was evaluated and PTS for meniscal injuries was assessed, and compared it with the PTS measured for ACL injuries.

Material and Methods

A cross-sectional study was conducted in the Department of Radiodiagnosis and Imaging at KS Hegde hospital, Mangaluru, Karnataka, India, from April 2020 to March 2021. The study was initiated after obtaining ethical clearance from the Institutional Ethical Clearance Committee (INST.EC/044/2020-21). Informed written consent was obtained from the subjects included in the study. The patients with a history of knee pain or trauma were referred to the Department of Radiodiagnosis for performing an X-ray or MRI examination of the knee within the stipulated period of study duration form the sample population.

Inclusion and Exclusion criteria: The patients who had an X-ray and MRI performed of the same knee joint, within the age group of 18-60 years with ACL or meniscal tears were included in the study. The patients with a previous history of knee surgery, anatomical variations in the tibia, and other knee pathology were excluded from the study based on X-ray and MRI reports.

The PTS values needed for the study were measured prospectively on 30 samples diagnosed with ACL or meniscal tear. The ACL tears were classified into three grades as follows (8):

Grade I- Mild tear with the ACL fibers being intact and less than 10% of fibres torn,
Grade II - Partial tear with the ACL fibres being stretched and 10-50% of fibres torn,
Grade III - Complete tear with the ACL fibres being separated into two parts and more than 50% of fibres torn.

Study Procedure

The X-ray of the affected knee joint was performed using the digital radiography Agfa DX- D 600 system. A true lateral view was obtained of the knee under examination. The patient was positioned on the affected side with 45° flexion of the knee and sand bags were used to achieve adequate positioning of the patient. The X-ray image obtained was transferred to the PACS system where the measurements were conducted. The PTS was measured by considering the Proximal Tibial Anatomical Axis (PTAA). A reference line was drawn perpendicular to this tibial axis and a line tangent to the tibial plateau was drawn and the angle between the tangent and reference line was measured as the slope angle (Table/Fig 1).

The MRI examination of the same knee as referred by the orthopaedic department was conducted. The MRI study was performed on Siemens MAGNETOM Avanto 1.5 Tesla system. The study was initiated after ensuring that there were no metallic objects in the patient’s body, which is a major contraindication of MRI. The patient was placed supine with a feet-first orientation. The dedicated knee coil was placed over the knee joint under study. The study was performed by choosing the routine MRI knee protocol that consists of axial PDFS, coronal T1W, coronal T2W, coronal PDF, sagittal T2W, sagittal T1W, sagittal PDFS, and, axial T2W images. The diagnosis was performed by the radiologist of the Department of Radiodiagnosis and Imaging.

A single radiologist with more than 20 years of experience assessed both the X-ray as well as the MRI of the same knee. The patients identified with ACL injuries or meniscal injuries were selected as study samples and the images of these patients were transferred to the PACS system where the PTS measurements were conducted. The sagittal plane was chosen as the image of interest for evaluating the PTS on MRI. First, the MRI-longitudinal axis of the tibia was recognized by finding the MRI slice that exhibited the Posterior Cruciate Ligament (PCL) attachment and the intercondylar eminence. Then, the lateral plateau was identified and a tangent to it was drawn, and also a reference line perpendicular to the longitudinal axis was drawn. The PTS was then measured as the angle between the tangent and the reference line (Table/Fig 2). The PTS was measured for different grades of ACL tear on X-ray and MRI (Table/Fig 3).


The collected data were analysed using the Statistical Package for Social Sciences (SPSS) version 20.0 software. Paired t-test was used to evaluate the mean PTS for the identified grade of the ACL tear. One-way Analysis of Variance (ANOVA) and Bonferroni post hoc test was used to analyse the difference between grades of the ACL tear. While, Unpaired t-test was used to assess the PTS in males and females with ACL rupture and to compare the PTS data on X-ray with MRI for an ACL tear. The assessment of meniscal tear average values and its comparison with the PTS of ACL was performed using an unpaired t-test.


There were 20 patients identified with an ACL tear and had a mean age of 32.50 ±16.363 years. The number of male patients was 16 (80%) and the number of female patients was 4 (20%) with ACL injury (male-to-female ratio was 4:1). The study included 12 left knee cases (60%) and 8 (40%) right knee cases. There were 10 patients with a mean age of 32.9±14.185 with meniscal tears out of which five patients had a tear in the lateral meniscus and five patients had a tear in the medial meniscus. Both right, as well as the left knee, were included in the study, and the left-to-right knee ratio was 3:2.

The analysis for grade I ACL tear revealed no significant difference observed on X-ray and MRI for grade I ACL tear (p-value>0.05). The PTS observed did not differ significantly for grade II ACL tears on X-ray and MRI (p-value>0.05). The PTS data evaluation for grade III ACL tear showed no significant difference observed on X-ray and MRI for grade III ACL tear (p-value>0.05) (Table/Fig 4). The PTS for all grades of ACL tears in the results of the study was evaluated to be 13.81±2.61 on MRI and 13.83±2.70 on X-ray.

The results showed a significant difference in PTS on X-ray and also on MRI for intergrading analysis of ACL tear with p-value <0.05 (Table/Fig 5). There was no significant difference in PTS between males and females found with ACL tears (p-value>0.05) (Table/Fig 6).

There was no significant difference in PTS between medial meniscus tear and lateral meniscus tear cases (p-value >0.05) (Table/Fig 7). The PTS on MRI for ACL tear was observed to be 13.8230±2.61236 and for meniscal tear, it was observed to be 14.9250±1.89736. There was no significant difference in PTS between ACL tear and meniscal tear (p-value> 0.05) (Table/Fig 8).


One of the most frequently affected structures of the knee joint is the ACL and the meniscus. These are vital small structures of the complex knee joint that help in maintaining the stability of the joint. These structures mostly get injured during some traumatic non contact events. A factor that has been observed to be associated with ACL tears is the PTS. It is an angle formed anterioposteriorly by the tibial plateau in line with its longitudinal axis (2).

The study by Priono BH et al., revealed the PTS to be greater in ACL tear cases with an angle of 14.5±3.5 (11). The study performed by Todd MS et al., evaluated the relationship of PTS with ACL injuries on X-ray film and found the PTS to be higher in ACL injuries. The PTS in their study for ACL tears was 9.39±2.58 (12). And the investigation by Kumar R et al., showed the PTS to be 13.037±4.487 in the study group with ACL tears (13). The PTS observed in this study for ACL tears was quite similar to the results of Priono BH et al., and Kumar R et al., (12),(13).

Hudek R et al., in their study of evaluating the PTS on X-ray and MRI, found a difference in the PTS measured between X-ray and MRI of the same knee (10). Whereas, the results in the present study did not show any significant difference in PTS on X-ray and MRI of 3the identical knee. As per the present study, the PTS measured on MRI is reproducible on X-ray for different grades of ACL tears. This reproducibility could be used to identify the Grades of ACL tears on X-ray by measuring the PTS. The values measured could guide in identifying the grades on X-ray as the current study results showed the least PTS value for grade I ACL tear and the highest value for grade III ACL tear.

In the study performed by DePhllipo NN et al., and Panigrahi TK et al., the PTS values were not observed to differ significantly between males and females with ACL ruptures (9),(14). The observations in the present study were also similar to theirs as there was no difference of significance noted in PTS between males and females with ACL tears. This lack of significant difference in the present analysis could have occurred due to the unequal sample distribution that included 80% male cases and only 20% female cases. Similar gender distribution was observed in the study performed by Kumar R et al., which had 90% ACL tears in males and only 5% female cases with ACL injuries (13).

The investigation performed by Alici T et al., concerning the association of PTS and meniscal injury demonstrated that the PTS for the group with lateral meniscus injury was higher compared to the group with medial meniscus injury (15). The observations in the present study were also similar as the mean PTS for knees with lateral meniscus tears was greater than the knees with a medial meniscus tear. However, the difference observed between medial and lateral meniscus tears was not significant in the present study (p-value> 0.05). This study also attempted to compare the PTS obtained for ACL tear cases with the PTS obtained for meniscus tears but the analysis showed no significant difference. The lack of significance in our study could have occurred due to the lesser number of samples included with meniscal injuries than those with ACL tears.

The measurements of PTS were conducted by a single observer on all the images in the present study but the other investigations like the one performed by Kacmaz IE et al., have conducted the measurements by more than one observer and computed the data (16). As a future scope, the present study could be beneficial in identifying and recognising the severity of ACL tears present standard method of grading ACL tears. The additional MRI studies could be avoided in suspected cases of ACL tears by evaluating the PTS on X-ray and this would limit the cost as MRI is more expensive than X-ray. The knowledge of PTS could also serve as a guiding factor in the surgical procedures of the knee joint.


Small sample size and shorter duration are the main limitations of the study. The PTS for different categories of meniscal tears were not analysed in the present study and could be performed as a future investigation. The study did not analyse the PTS separately for the medial and lateral plateau of the tibia in this study and could be studied in the future.


The significant difference in PTS obtained among the different grades of ACL tears could aid in the identification of the severity of the ACL injury.The PTS could also be used as a tool to recognize the presence of ACL tears on x-ray and this could be an important prognostic factor towards the functional outcome.


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DOI and Others

DOI: 10.7860/JCDR/2023/58727.17268

Date of Submission: Jun 28, 2022
Date of Peer Review: Sep 16, 2022
Date of Acceptance: Nov 01, 2022
Date of Publishing: Jan 01, 2023

• 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 X-checker: Jun 30, 2022
• Manual Googling: Oct 26, 2022
• iThenticate Software: Oct 31, 2022 (17%)

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