Dynamic, Over-Valgus Correction Without Osteotomy for Nonunion of Subtrochanteric Hip Fractures Using a Dynamic Hip Screw^†

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Valgus correction with a dynamic hip screw is a useful technique for a nonunion of a subtrochanteric hip fracture. This zone is well vascularized, so just dynamic mechanical compression at the fracture site is needed. This variation in the technique makes surgery easier to perform. Although this study has clinical application value and provides a new diagnostic and therapeutic method for the treatment of postoperative bone nonunion after subtrochanteric fracture of the femur, there are still some problems that need to be further solved.

1.      This study included only three patients, and the age gap was large, so it is recommended that the number of cases be increased.

2.      Quantitative analysis of patients' osteoporosis and BMI values are recommended to be added to describe patients' general conditions.

3.      The patients were followed up for 6 and 10 months and it is recommended to extend the follow-up period.

4.      How soon after this type of revision surgery is it recommended that the patient have the endoprosthesis removed?

5.      It is recommended that the discussion section be further analyzed around postoperative biomechanics and other directions.

Author Response

1. This study included only three patients, and the age gap was large, so it is recommended that the number of cases be increased.
Reply: We have added two more patients. It is a non-frequent injury. Another patient only had 10 months of follow-up.

2. Quantitative analysis of patients' osteoporosis and BMI values are recommended to be added to describe patients' general conditions.
Reply:  Except for one, our patients are all at high risk of suffering osteoporosis because they involve a hip fracture in the elderly, so BMD was not necessary to be recorded.

3. The patients were followed up for 6 and 10 months, and it is recommended that the follow-up period be extended.
Reply: All patients had at least 12 months of follow-up

4. How soon after this revision surgery is it recommended that the patient have the endoprosthesis removed?
Reply:  It is not necessary if there are no major complications, like infection or implant failure.

5.  It is recommended that the discussion section be further analyzed around postoperative biomechanics and other directions.
Reply: Done!

Reviewer 2 Report

Comments and Suggestions for Authors

 The current manuscript is focused on " Dynamic valgus correction for nonunion of subtrochanteric hip fractures". There are several concerns which i think are important to consider before any further possible review, following "Major revisions".
1. The work is ambiguous and the specific knowledge contributions is not clear. How does this work differ from or improve upon other similar studies? Authors are advised that more detailed comparative analysis of prior studies as table to further highlight and strengthen the knowledge gap.
2. The improvements in Harris hip scores are notable, but are they statistically significant? Would performing a statistical test (e.g., paired t-test or ANOVA) between pre- and post-surgery data strengthen the results?
3. The paper does not mention any postoperative complications like infections, hardware failure, during the 12-month follow-up period?
4. The results should be compared qualitatively to the literature. Could a quantitative comparison table summarizing outcomes (e.g., union rates, Harris scores) from this study versus published studies improve the readers' understanding of the technique’s relative effectiveness?
5. Please add more in-depth discussions of results, with schematics and numerical modelling/equations.

6. Figures like Figure 6 (showing the application of plates and screws) provide valuable insights into the surgical process. However, could annotations (e.g., indicating critical steps in the procedure) improve clarity for readers? Would adding high-resolution images of fracture healing (e.g., X-rays at different follow-up stages) give more visual proof of success?

 

7. In conclusions, the work findings should be totally unique with several points of key results each with an indepth reasoning, not just to report these results. The conclusion could expand upon the broader implications of the findings. 

Comments on the Quality of English Language

needs an extensive improvement.

Author Response

1. The work is ambiguous and the specific knowledge contributions is not clear. How does this work differ from or improve upon other similar studies? Authors are advised that more detailed comparative analysis of prior studies as table to further highlight and strengthen the knowledge gap.
Reply： It is clear now in the new paper. I think that we have established several differences from previous studies. Our paper is unique and is the only one that has described, to date, dynamic fixation in subtrochanteric nonunion. It is very easy to perform, and we are convinced it will be a game-changer in this type of injury.

2. The improvements in Harris hip scores are notable, but are they statistically significant? Would performing a statistical test (e.g., paired t-test or ANOVA) between pre- and post-surgery data strengthen the results?
Reply： we think it will not strengthen the results. There are very few patients. It would be interesting if there were a comparative control group.

 

3. The paper does not mention any postoperative complications like infections, hardware failure, during the 12-month follow-up period?
Reply： Fortunately, no major complications have been described. It is a very small series, and complications are expected when the number of patients increases. Only one case was near the cutout, but it was not finally produced.

4. The results should be compared qualitatively to the literature. Could a quantitative comparison table summarizing outcomes (e.g., union rates, Harris scores) from this study versus published studies improve the readers' understanding of the technique’s relative effectiveness?
Reply： Done. We cannot compare it to any dynamic fixation. This is the first time it has been described. We have added a table. It is also difficult to compare our results because the number of patients is very small. Despite these results are amazing.

5. Please add more in-depth discussions of results, with schematics and numerical modelling/equations.
Reply：We have improved our previous discussion

6. Figures like Figure 6 (showing the application of plates and screws) provide valuable insights into the surgical process. However, could annotations (e.g., indicating critical steps in the procedure) improve clarity for readers? Would adding high-resolution images of fracture healing (e.g., X-rays at different follow-up stages) give more visual proof of success?
Reply： We think figures and Surgical Procedures are now much improved.

7. In conclusions, the work findings should be totally unique with several points of key results each with an indepth reasoning, not just to report these results. The conclusion could expand upon the broader implications of the findings.
Reply： We have tried to clarify all the advantages of this new technique. The most critical key, dynamic fixation, offers benefits that we think are now clear enough in the discussion. We have tried to explain even complex biomechanical aspects of bone union and fixation.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I have no further questions except for the small sample size of patients.

Author Response

Reply：

We believe that the paper has been improved. We have revised all the sections from the title to the conclusions. Unfortunately, to date, we only have five patients. Your comments have been of great help to improve the paper. We would like you to review the paper again so that we can improve it if necessary. We have included better figures for a better understanding of the novelty of our technique. We understand that some parts can be challenging to understand, as we have added many details about the biomechanics of bone consolidation and surgical implants.

We are convinced this technique will revolutionize the treatment of one of the orthopedic surgeons' most complicated pathologies.

Best regards.

Reviewer 2 Report

Comments and Suggestions for Authors

This work is focussed on Dynamic valgus correction for nonunion of subtrochanteric hip fractures. I can see that authors have significantly revised the manuscript. However, there are several concerns making it necessary minor revisions. 

1: The abstract should be concise and limited to a single paragraph. It is recommended to focus on summarizing the key findings and improvements clearly and effectively. And Conlcusions also need to be further refined and polished with specific quantitative results with an indepth reasoning and justifications.

2: The provided keywords are insufficient and lack relevance. It is advised to add more 2 to 3 high-quality keywords that accurately represent the core themes of the manuscript to enhance discoverability.

3: The introduction section requires significant improvement as it currently lacks depth and clarity. Adding a detailed table or section summarizing the literature survey is highly recommended. This should include:

• Existing challenges in the field.
• The originality and novelty of this work.
• Clear differentiation from already published studies.

Comments on the Quality of English Language

Minor editing needed.

Author Response

1: The abstract should be concise and limited to a single paragraph. It is recommended to focus on summarizing the key findings and improvements clearly and effectively. And Conlcusions also need to be further refined and polished with specific quantitative results with an indepth reasoning and justifications.

Reply

You are absolutely right. We have reviewed all sections of the paper, from the title to the conclusions.

 

2: The provided keywords are insufficient and lack relevance. It is advised to add more 2 to 3 high-quality keywords that accurately represent the core themes of the manuscript to enhance discoverability.

Reply

Done

 

3: The introduction section requires significant improvement as it currently lacks depth and clarity. Adding a detailed table or section summarizing the literature survey is highly recommended. This should include:

• Existing challenges in the field.
• The originality and novelty of this work.
• Clear differentiation from already published studies.

Reply

Indeed, the introduction was not clear. We believe we have improved it.  It is the basis for the understanding of the article. In the discussion we have included the table comparing our new technique with what has been published so far. We understand that with the new modifications introduced now, certain parts may be difficult to understand because they detail aspects of biomechanics that are difficult to understand if you are not an expert in the field.

Your comments have been very helpful to improve the article.

Author Response File: Author Response.pdf