Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

General Comments

This manuscript addresses a clinically relevant and unresolved question regarding the management of incomplete intertrochanteric fractures in older patients. The authors’ attempt to compare operative and conservative treatment and to evaluate immediate full weight-bearing is timely. The observation that no secondary displacement was identified among the conservatively managed patients may also provide potentially useful clinical information in an area where the available evidence remains limited.

However, this recommendation is not based simply on the number of revisions required. Rather, the cohort structure, data presentation, statistical analyses, and principal conclusions would all need to be fundamentally reconstructed before the findings could be interpreted reliably.

The main concerns are as follows.

Major Comments

1. The study population and cohort structure cannot be determined from the manuscript

The manuscript appears to include two cohorts:

1. Forty-two patients with MRI-diagnosed incomplete intertrochanteric fractures, including 10 conservatively treated and 32 surgically treated patients.
2. Thirty-two patients with greater trochanteric fractures without medial calcar cortical disruption on CT, including 22 patients permitted full weight-bearing and 10 prescribed restricted weight-bearing.

It is unclear whether the CT cohort is completely separate from, partially overlaps with, or is included within the MRI cohort. The Abstract describes only 42 patients and refers to “MRI- or CT-confirmed” fractures, whereas the Results introduce the CT cohort as an additional population.

If the cohorts overlap, the CT cohort cannot be presented as an independent dataset supporting the MRI findings, and the possibility of non-independence and double counting must be addressed. If the cohorts are separate, the Abstract, title, Methods, Results, and Conclusions would all require substantial restructuring.

Any future manuscript based on this dataset would require a STROBE-compliant participant flow diagram showing the total number screened, imaging modalities performed, overlap between MRI and CT populations, exclusions and reasons, final numbers in each analysis, and the number available at each follow-up point.

2. Several numerical inconsistencies raise concerns regarding data integrity and denominators

The reported data contain several internal inconsistencies.

The operative group in Tables 1 and 2 includes 32 patients, has a mean age of 87.2 years, and has 0% protected weight-bearing. In Table 3, the CT cohort also includes 32 patients, the full weight-bearing subgroup has a mean age of 87.2 years, but 10 patients are classified as receiving protected or restricted weight-bearing. These findings cannot be reconciled without clarification of the cohort structure.

The reported female proportion of 65.7% in a group of 32 patients is also not mathematically compatible with that denominator. The numerator and denominator should both be verified.

In addition, the reported 1-year mortality rates differ substantially between the MRI and CT analyses. The method of mortality ascertainment, completeness of follow-up, and any loss to follow-up should be reported.

These issues require verification from the original patient-level data rather than correction by narrative revision alone.

3. The inclusion criteria are internally contradictory

The Methods list “patients who were managed conservatively” as an inclusion criterion, yet the principal cohort includes 32 surgically treated patients.

The eligibility criteria for the MRI and CT cohorts should be separately defined. The manuscript should clearly distinguish:

• the imaging definition of an incomplete intertrochanteric fracture;
• general study eligibility criteria;
• criteria for recommending surgery;
• reasons for selecting conservative treatment; and
• criteria used to prescribe full versus restricted weight-bearing.

4. The “greater than 50% intertrochanteric involvement” criterion is not reproducible

The greater-than-50% threshold is central to the study, but its measurement is not described.

The manuscript should specify:

• the MRI sequence and imaging plane used;
• the anatomical reference points;
• whether the measurement represents linear extension, area, or another parameter;
• the number and expertise of image reviewers;
• whether reviewers were blinded;
• how disagreement was resolved; and
• interobserver reliability.

The actual distribution of the measured percentages should also be reported, as this variable is stated to have been collected.

Furthermore, the manuscript appears to use the extent of bone marrow edema and the extent of the fracture line interchangeably. These are not necessarily equivalent. Reactive marrow edema and hemorrhage may extend beyond the actual fracture line. The authors must clarify whether the 50% criterion refers to the fracture line, marrow edema, or a combination of both.

The use of a single case report as support for this defining threshold is also insufficient.

5. Fracture morphology is inadequately characterized

No recognized fracture classification is applied to the study population. The AO/OTA classification should be reported where applicable.

If these incomplete or occult fracture patterns cannot be reliably categorized using conventional AO/OTA 31-A subtypes, that limitation should be stated explicitly. In that case, standardized morphological variables should be reported, including lateral wall involvement, medial calcar continuity, cortical extension, and posteromedial involvement.

Without this information, the study population cannot be meaningfully compared with other published series.

6. Treatment allocation is subject to substantial confounding by indication

The manuscript indicates that surgery was routinely recommended for fractures with greater than 50% involvement and that conservatively managed patients were primarily those who declined surgery. Therefore, treatment allocation was not based on a standardized comparative protocol.

The conservative group also had a higher Charlson Comorbidity Index. Comorbidity burden is related to treatment selection, mobility, rehabilitation potential, length of stay, and mortality.

Nevertheless, the Abstract states that outcomes were comparable “after adjustment for comorbidity burden,” although no adjusted analysis is described in the Methods or Results. This statement must be removed unless a prespecified and clearly reported adjusted analysis was actually performed.

Given the very small sample, meaningful multivariable adjustment may not be feasible. If so, the findings should be presented descriptively, without claims of comparative effectiveness, equivalence, or noninferiority.

7. The statistical analyses and reported p-values require complete re-verification

Several statistical methods are inappropriate for the sample size and data type.

Categorical outcomes with small cell counts, including mortality, should generally be assessed using Fisher’s exact test rather than the chi-square test. MFAC is an ordinal measure and should not automatically be analyzed as a normally distributed continuous variable using means and t-tests.

In addition, several reported p-values do not appear reproducible from the presented summary statistics using conventional independent-samples tests. For example, approximate recalculation yields p values of approximately 0.07 for the Charlson Comorbidity Index and 0.20 for length of stay, rather than the values reported in the manuscript. These approximations may differ slightly from analyses using the raw data because of rounding or the choice of statistical test. Nevertheless, all results should be independently rechecked from the original dataset.

Effect estimates and 95% confidence intervals should be reported. In this underpowered study, a nonsignificant result must not be interpreted as evidence of equivalence.

8. The definitions and assessment of union and secondary displacement are insufficient

Radiographic union at 3 months is defined as bridging callus assessed by “experienced orthopaedic surgeons,” but the number of assessors, blinding, independent review, disagreement resolution, and interobserver reliability are not reported.

This is particularly important because these incomplete or occult fractures may not have had a clearly visible fracture line on the initial radiograph. The validity of assessing union solely by bridging callus on a 3-month radiograph therefore requires justification.

Secondary displacement is a principal outcome supporting the full weight-bearing conclusion, yet it has no operational definition and is not included as a separate outcome in Tables 2 or 3. The manuscript should specify whether displacement was defined by fracture gap or step-off, change in neck–shaft angle, greater trochanter migration, new medial cortical discontinuity, or progression to a complete fracture.

The imaging follow-up schedule for conservatively managed patients is also unclear. If no intermediate radiographs were obtained, a fracture that displaced early and subsequently united in the displaced position could have been classified simply as united at 3 months. Therefore, the current study cannot distinguish absence of displacement from absence of detection.

9. The study does not establish the safety of immediate full weight-bearing

Only six patients in the MRI-defined conservative cohort were permitted immediate full weight-bearing. Even with zero observed displacement events, the exact binomial Clopper–Pearson upper 95% confidence limit is approximately 46%. For the CT full weight-bearing group of 22 patients, the corresponding upper limit is approximately 15%.

Therefore, a clinically substantial risk cannot be excluded despite the absence of observed events.

The statement that restricted weight-bearing is unnecessary and does not meaningfully reduce risk is not supported, particularly because only four conservatively managed MRI patients received protected weight-bearing.

The findings may suggest the feasibility of immediate full weight-bearing in a carefully selected group. They do not establish its safety.

10. The MRI and CT populations should not be treated as equivalent disease entities

The MRI cohort was defined by greater than 50% marrow edema or intertrochanteric involvement without medial calcar cortical disruption. The CT cohort was defined by a greater trochanteric fracture without visible medial calcar cortical disruption.

These definitions are not interchangeable. The absence of calcar disruption on CT does not determine the extent of intertrochanteric fracture propagation and does not establish that the CT cohort had the same morphology as the MRI cohort.

Evidence from another study suggesting that many such patients would show marrow edema on MRI cannot be used to retrospectively classify the current CT cohort. Unless paired CT and MRI data are available in the same patients, the two cohorts should be analyzed and interpreted separately.

11. The conclusion that CT may replace MRI is not supported

The study did not compare CT and MRI diagnostic accuracy, management decisions, or clinical outcomes within the same patients. There was no reference standard, index-test comparison, or diagnostic accuracy analysis.

Moreover, the CT cohort was selected specifically for the absence of medial calcar cortical disruption. Therefore, favorable outcomes in this preselected CT-negative group cannot demonstrate that CT is sufficient to exclude clinically important fracture extension. The reasoning is circular because patients with the CT feature proposed as reassuring were selected precisely on the basis of that feature.

The statement that outcomes were acceptable “regardless of the extent of marrow edema involvement” is also unsupported because the MRI cohort included only patients with greater than 50% involvement and had no lower-extension comparison group.

Any future manuscript should limit the conclusion to the hypothesis that cortical continuity on CT may be clinically relevant in treatment selection. It should not suggest that CT is equivalent to or can replace MRI.

12. The principal conclusions and novelty claims exceed the evidence

The current manuscript suggests that:

• conservative treatment is comparable to surgery;
• restricted weight-bearing is unnecessary;
• immediate full weight-bearing is safe;
• early full weight-bearing reduces bed-rest complications; and
• CT may substitute for MRI.

None of these conclusions can be established by the present design. This was not an equivalence or noninferiority study, bed-rest complications were not measured, treatment allocation was confounded, and the imaging modalities were not directly compared.

The novelty statement also conflicts with Reference 10, which is itself a retrospective cohort study comparing surgical and conservative treatment of greater trochanteric fractures with occult intertrochanteric extension.

The novelty claim should either be removed or rewritten to identify a genuinely distinct and supportable contribution.

Additional Reporting Issues

The limitations section is incomplete and should acknowledge the uncertainty regarding cohort overlap, treatment-selection bias, limited validity of the radiographic outcomes, lack of standardized imaging follow-up, use of discharge MFAC as the principal functional outcome, and the very small number of conservatively managed patients accrued over a 10-year period.

The reference list and citation support should also be comprehensively checked. Several references are incomplete or do not adequately support the statements for which they are cited.

Terminology should be standardized throughout the manuscript. “Incomplete intertrochanteric fracture,” “incomplete trochanteric fracture,” “greater trochanteric fracture with intertrochanteric extension,” and “TOF fracture” should not be used interchangeably unless the authors explicitly define them as the same entity.

Professional English-language editing is also required.

Recommendation

Reject

The clinical question is important, and the underlying dataset may still have value. However, the cohort structure, original data, statistical analyses, imaging definitions, and interpretation would need to be fundamentally reconstructed. These changes exceed the scope of a conventional revision.

A future manuscript based on a single, clearly defined and non-overlapping cohort, with verified denominators, reproducible imaging criteria, validated outcome definitions, and appropriately cautious descriptive conclusions could be considered as a new submission.

Comments on the Quality of English Language

The manuscript would benefit from comprehensive professional English-language editing. Numerous grammatical errors, awkward expressions, inconsistent terminology, and several incomplete sentences are present throughout the Introduction, Methods, Results, and Discussion. These language issues occasionally obscure the intended meaning and should be corrected in any future submission.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

As an orthopedic surgeon who frequently encounters proximal femoral fractures in elderly patients in clinical practice, I consider the topic of this manuscript to be significant and clinically relevant. Incomplete intertrochanteric fractures represent a challenge in decision-making between operative and conservative management, particularly regarding the safety of early mobilization and full weight-bearing. The authors have addressed a current and insufficiently investigated issue with potential implications for everyday orthopedic practice. The study is methodologically well designed as a retrospective cohort analysis comparing conservatively and surgically treated patients. The authors evaluated relevant clinical and radiological outcomes, including fracture union, secondary displacement, functional mobility, length of hospital stay, and mortality. The results suggest that, in carefully selected patients, conservative treatment with the possibility of early full weight-bearing may achieve satisfactory outcomes comparable to those of surgically treated patients. The discussion is appropriately linked to previous studies and highlights the importance of avoiding prolonged immobilization in geriatric patients.

Suggestions:

• The main limitation of the study is the small number of patients in the conservative treatment group (10 patients), which limits the statistical power of the analysis. I recommend that the authors further emphasize this limitation in the conclusion and avoid overinterpretation of the results.
• The retrospective design of the study and the lack of randomization represent potential sources of selection bias. The authors should provide a more detailed explanation of the criteria used to determine the choice between conservative and operative treatment.
• It would be beneficial to provide a more detailed description of fracture characteristics, including the extent of intertrochanteric involvement, integrity of the medial cortex, bone quality, and other radiological factors that may influence fracture stability.
• The conclusion should be formulated more cautiously. The results support conservative management in carefully selected patients with stable incomplete fractures; however, they do not provide sufficient evidence to recommend a change in the current standard treatment algorithm.
• The inclusion of longer-term functional outcomes (6–12 months) is recommended, including return to previous activity level, quality of life assessment, and late complications.

 

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

The comparison of rehabilitation outcomes between surgical and conservative treatment of incomplete intertrochanteric fractures of the proximal femur is an important and clinically relevant research topic. In particular, it is important to determine whether conservative treatment can provide satisfactory rehabilitation outcomes in elderly and frail patients with comorbidities, for whom surgical intervention may pose substantial risks. However, several methodological and reporting issues should be addressed.

1. Please clearly indicate the study design in the title by specifying that this is a retrospective cohort study.
2. Please provide an appropriate reference for the statement in lines 41–43 that approximately 50% of fragility hip fractures are intertrochanteric fractures.
3. Figure 2 appears to show an isolated greater trochanteric fracture. However, according to the definition provided in the Methods section, the study evaluates incomplete intertrochanteric fractures, in which the fracture line extends into the intertrochanteric region. I therefore suggest replacing Figure 2 with a more representative CT or MRI image of an incomplete intertrochanteric fracture. Alternatively, the Methods section should be revised so that the diagnostic definition corresponds to the fracture shown in the figure and to the fractures actually included in the study.
4. Lines 91–92: Please describe the conservative treatment protocol in greater detail. Protected weight-bearing should be defined more precisely, including the permitted proportion of body weight or the specific instructions given to patients. The authors should also provide a clear timeline for early mobilization and physiotherapy, describe the specific rehabilitation procedures used, and explain the pain-management protocol, including the types of analgesic or other interventions administered.
5. The Modified Functional Ambulation Classification (MFAC), which was used as one of the secondary outcome measures, should be described in sufficient detail. Please explain the scoring system, the individual categories, the interpretation of the scores, and the time points at which the assessments were performed.
6. The surgical procedures should be described in greater detail. The manuscript currently states only that cephalomedullary nail fixation was used. Please clarify whether this was the only surgical technique used in all surgically treated patients. The authors should also specify the surgical approach, the timing of surgery, any relevant intraoperative variations, and the postoperative weight-bearing and rehabilitation protocol.
7. The definition of the study groups is unclear. The Abstract and Methods section suggest that the study concerns incomplete intertrochanteric fractures, whereas the The Results section appears to present two distinct fracture groups: patients with incomplete intertrochanteric fractures and patients with isolated greater trochanteric fractures. The Methods section should therefore be substantially revised to clearly define both study groups, describe the diagnostic criteria used for each fracture type, and explain how patients were allocated to the groups.
8. The title should be revised to accurately reflect the fracture types investigated and, as already noted, clearly specify the study design. The Abstract and Methods should also be rewritten to ensure that the group definitions, treatment protocols, and outcome measures are clearly and consistently presented.
9. In Table 3, all abbreviations should be defined in the table legend, even if they have already been explained in the main text.
10. The manuscript would benefit from professional English-language editing. Several expressions should be revised to improve clarity and scientific style. Terms such as “operative,” “operation,” “OAH,” and “bony union” should be reviewed and replaced with more precise and contextually appropriate terminology where necessary. Terminology should also be used consistently throughout the manuscript.

Comments on the Quality of English Language

1. The manuscript would benefit from professional English-language editing. Several expressions should be revised to improve clarity and scientific style. Terms such as “operative,” “operation,” “OAH,” and “bony union” should be reviewed and replaced with more precise and contextually appropriate terminology where necessary. Terminology should also be used consistently throughout the manuscript.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Comments to Authors

Thank you for the authors’ careful revision of the manuscript. The removal of the separate CT-based cohort has substantially clarified the scope of the analysis. The manuscript has also been improved by withdrawing the previous priority claim, more appropriately positioning the study in relation to the work of Katsuyama et al. [10], providing a definition and reference for the MFAC, applying the Mann–Whitney U test to ordinal data, and adding secondary displacement as an explicit outcome in the table.

However, the two issues that were central to my first-round review—numerical consistency of the reported data and complete re-verification of the statistical analyses—do not yet appear to have been fully resolved. In addition, several inconsistencies have been introduced or become apparent during the revision process. Most of the remaining issues do not require a new study or substantially new analyses, but rather careful reconciliation of the source data with the revised manuscript and clearer description of the methods.

Major Comment 1 — Previous Comments #2 and #7: Numerical and statistical verification remains incomplete

1-1. The numerical information in the response letter and the revised manuscript is inconsistent.
The response letter states that 21 of 32 patients (65.625%) in the operative group were female, whereas revised Table 1 reports “65.7% (11)”. Because this discrepancy occurs in the same item specifically raised in the first-round review, after the authors stated that the “primary data was revisited,” it should be clarified as a priority. Please verify the value against the source data and ensure consistency among Table 1, the main text, and the response letter.

1-2. The reported p-value for the Charlson Comorbidity Index cannot be reproduced from the summary statistics presented in the table.
The Methods state that continuous variables were compared using an independent-samples t-test. Using the summary statistics as reported in Table 1 (7.5 ± 1.9, n = 10 vs. 6.0 ± 1.4, n = 32), an equal-variance t-test yields approximately p = 0.010, whereas Welch’s t-test yields approximately p = 0.039. Although calculations based on the raw data may differ somewhat because of rounding of the reported means and standard deviations, the discrepancy from the reported p = 0.21 appears too large to be explained by rounding alone. As this variable is relevant to assessment of baseline comparability between groups, please recheck the analysis and report the correct value.

1-3. Please provide a concise audit of the numerical values that changed during the revision.
Several values have changed between versions, including age (85.8 to 86.1 years), CCI (7.3 to 7.5 in the conservative group and the SD from 1.7 to 1.4 in the operative group), and length of stay (25.0 ± 12.6 to 31.6 ± 16.4 days). Changes following re-analysis are entirely reasonable; however, it would be helpful for the response letter to briefly identify which values were corrected and to confirm that all revised values have been consistently propagated through the Abstract, main text, and tables.

1-4. The denominator for the 3-month union rate remains unclear.
Table 2 reports one death within 3 months in each treatment group while simultaneously reporting a 100% radiographic union rate at 3 months in both groups. These findings are not necessarily contradictory, but the denominators need to be explicitly stated. Please clarify: (1) how many patients in each group actually underwent 3-month radiographic assessment; (2) whether patients who died before that assessment were included or excluded from the union denominator; and (3) the denominator and assessment time point used for the reported 0% secondary displacement rate.

1-5. Please verify that the statistical tests actually applied are consistent with the revised Methods.
Section 2.4 states that Fisher’s exact test was used when cell counts were inadequate. However, the reported 3-month mortality comparison (1/10 vs. 1/32, p = 0.36) appears more consistent with an uncorrected chi-square calculation, whereas Fisher’s exact test gives a value of approximately 0.42. Similarly, if the operative female count is confirmed to be 21 as stated in the response letter, the reported p = 0.88 for sex distribution does not appear reproducible from that contingency table using either chi-square or Fisher’s exact testing. These differences do not change the overall clinical interpretation, but the Methods and Results should be internally consistent.

Major Comment 2 — Previous Comments #1 and #3: Construction of the comparative cohort remains incompletely defined

Removal of the separate CT cohort has substantially clarified the study population. However, the revised Methods still do not fully establish how the final comparative cohort of 42 patients was constructed.

The inclusion criteria list “patients who were managed conservatively” as criterion 3, followed immediately by the statement that these patients were “matched” with a cohort of geriatric patients with a similar injury who were managed surgically.

Please clarify whether the 32 surgically treated patients represented all consecutive surgical patients meeting the same clinical and imaging criteria during the study period, or whether they were separately selected as comparators. If formal matching was performed, the matching variables, matching ratio, and matching procedure should be described. If formal matching was not performed, the term “matched” should be removed or replaced with a more accurate description.

Major Comment 3 — Previous Comments #4 and #5: MRI diagnostic criteria and fracture characterization

3-1. Operational definition of “>50% involvement.”
The addition of the T2-weighted coronal plane and the experience level of the reviewing specialist has improved the description. Please further clarify how the degree of intertrochanteric involvement was actually determined—for example, which image plane or slice was used and whether the estimate was based on linear extension, area, or another criterion. Please also state how many readers performed the assessment.

3-2. There is an internal inconsistency in the description of the imaging review.
Section 2.1 states that the images were reviewed by a specialist in orthopaedics and traumatology, whereas Section 2.3 states that the MRI reports were reviewed to confirm fracture characteristics. Please clarify whether eligibility and fracture characterization were based on direct review of the MRI images, review of the radiology reports, or both, and revise the Methods accordingly.

3-3. Quantitative information regarding intertrochanteric extension.
I agree with the authors that conventional AO/OTA 31-A subtyping may not be readily applicable to these incomplete fractures, and the absence of a standardized classification has now been appropriately acknowledged as a limitation. I have no further request regarding AO/OTA classification itself.

However, Section 2.3 states that the “percentage of intertrochanteric extension” was collected. If these percentages were quantitatively recorded, please provide an appropriate descriptive summary by treatment group. If no quantitative measurements were actually recorded, please revise the Data Collection section so that it does not imply that continuous measurements of extension were available.

Major Comment 4 — Previous Comment #6: Confounding by indication and baseline comparability

4-1. The revised Methods state that conservative treatment was considered not only when patients refused surgery but also when patients were considered unfit for surgery. The Limitations section, however, focuses primarily on treatment refusal. Patients being medically unfit for surgery represent an important source of confounding by indication and should be explicitly acknowledged in the Discussion.

4-2. If re-verification under Major Comment 1 confirms a statistically meaningful difference in comorbidity burden between the groups, the broad statement in Section 4.1 that the baseline characteristics were “comparable” should be revised. Any observed baseline imbalance should be reported accurately and its implications for interpretation of the treatment comparison should be discussed.

4-3. Section 4.1 also states that pre-injury mobility was comparable between the two groups, although these data are not presented in Table 1 despite being listed as a collected variable in Section 2.3. Please either provide the corresponding data or remove this statement.

Major Comment 5 — Previous Comments #8, #9, and #11: Outcome definitions and strength of interpretation

5-1. Outcome definitions (Previous Comment #8).
The addition of definitions for fracture union and secondary displacement, as well as the inclusion of secondary displacement in Table 2, represents a clear improvement. Two points remain to be clarified.

First, secondary displacement is defined in terms of fracture gap, step-off, or change in neck–shaft angle, but no quantitative threshold is provided. Please specify the threshold used for each parameter, if one was prespecified.

Second, the definition of fracture union combines radiographic findings (bridging callus or trabeculae) with clinical resolution of localized pain. Please clarify whether both criteria were required, whether either criterion alone was sufficient, and how discordant cases were classified.

5-2. Immediate full weight-bearing (Previous Comment #9).
The Conclusions section in the main manuscript has been appropriately moderated. However, the strength of the interpretation remains somewhat inconsistent in two other locations.

First, the Abstract still states that “conservative management with early mobilization and immediate FWB produced radiographic bone union with no secondary displacement.” Only six conservatively treated patients underwent immediate FWB. Please state this number explicitly and align the wording with the more cautious tone used in the main Conclusions. The Abstract Conclusions could also be shortened, as the same concept is currently expressed more than once.

Second, Section 4.2 states that “restricted weight-bearing may be unnecessary,” whereas the Limitations section appropriately acknowledges that only six patients underwent immediate FWB and that the risk of secondary displacement cannot therefore be excluded. Please harmonize the strength of these statements.

5-3. MRI-related discussion (Previous Comment #11).
Removal of the CT cohort and deletion of the conclusion that CT might substitute for MRI were appropriate revisions. Nevertheless, some unsupported implications remain in Section 4.3.

The section title (“The arguable necessity for MRI in the investigation of occult hip fractures”) and the concluding statement that, “Including the current study, emerging evidence suggests that MRI may lead to overdiagnosis or surgical treatment...” continue to imply that the present study provides evidence regarding the diagnostic value of MRI. However, all patients in the current analysis were diagnosed by MRI, and there was no comparison between imaging modalities. The present study therefore cannot directly support that inference.

In addition, the statement that conservative treatment yielded acceptable outcomes “regardless of extent of marrow edema involvement” is not supported by the present cohort, which included only fractures with more than 50% intertrochanteric involvement.

Please either remove Section 4.3 or shorten it to a literature-based discussion that does not present the current study as evidence for MRI overdiagnosis or for outcomes irrespective of the extent of marrow edema.

Major Comment 6 — Issues requiring verification following the revision

6-1. The ethics approval number has changed between manuscript versions.
The original version listed CRE Ref No. 2025.909, whereas the revised manuscript lists 2018.161, without explanation in the response letter. Please verify the correct approval number against the original ethics documentation and briefly explain this correction in the response letter.

6-2. Newly described use of a spica brace.
The revised Methods now define conservative management as early mobilization “with or without immobilization with a spica brace.” Please report how many conservatively treated patients used a spica brace and whether brace use overlapped with the immediate-FWB subgroup. This information is relevant to interpretation of the immediate weight-bearing results.

Adequately Addressed

Previous Comment #10 regarding separation of the MRI and CT populations and Previous Comment #12 regarding the novelty/priority claim and moderation of the conclusions have been adequately addressed. I have no further requests regarding these points.

Minor Comments

1. The newly added seven-category MFAC description is presented in a tabular format and would be more appropriately labeled as a Table rather than “Figure 2.” Please renumber subsequent tables/figures accordingly.
2. The formatting of revised Table 1 appears disrupted in several places, particularly the row alignment and spacing, and should be corrected for readability.
3. As the CT-based cohort has been removed and CT is no longer used as part of the study methods or results, please review whether “CT” remains necessary in the Abbreviations section. If retained, the correct term is “computed tomography,” not “computer tomography.”
4. The p = 1.00 shown for 100% union in both groups provides little additional information and may be omitted.
5. The manuscript would benefit from minor language editing for grammar and subject–verb agreement; for example, in Section 4.2, “immediate FWB offer clinical benefits” should read “immediate FWB offers clinical benefits.”

Comments on the Quality of English Language

The manuscript would benefit from comprehensive professional English-language editing. Numerous grammatical errors, awkward expressions, inconsistent terminology, and several incomplete sentences are present throughout the Introduction, Methods, Results, and Discussion. These language issues occasionally obscure the intended meaning and should be corrected in any future submission.

Author Response

Please see the attachment.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you to the authors for the additional clarifications and the revisions made.

Author Response

Thank you for your time and consideration.