Enhancing Quality of Life After Partial Brachial Plexus Injury Combining Targeted Sensory Reinnervation and AI-Controlled User-Centered Prosthesis: A Case Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for presenting this interesting case. You have to be congratulated on your good results.

 

Nevertheless, this case study is a scientific manuscript and not an article for the interested lay press. The inclusion of citations by the patient, who is addressed by his name which is awkward, is inappropriate. Also the description of the prothesis is more an advertisment than a scientific presentation.

 

Please adapt your manuscript to other case studies published at MDPI to increase its scientific soundness. Also please make the surgical treatment more detailed - at which level did you amputate, what sensory nerves did you reroute etc.

Author Response

We would like to sincerely thank the Reviewer for the thoughtful and constructive comments, which have been extremely valuable for further improving the quality and scientific soundness of our manuscript. Please find our detailed responses below:

1. Patient citations and use of the patient’s name
   We respectfully acknowledge the Reviewer’s concern. Our intention in including selected direct patient quotations was to highlight the unique perspective of the individual undergoing this pioneering procedure. We firmly believe that, particularly in the context of case reports, integrating the patient’s authentic voice provides important qualitative insights that enrich the scientific narrative and convey the real-life impact of the surgical and prosthetic interventions. Such first-hand reports have also been recognized as valuable contributions in other medical journals. To address the Reviewer’s concern, we have carefully revised the manuscript to ensure that these statements are presented in a more neutral and scientific style, while still preserving their significance. We also replaced in the main text the patient’s name with a more neutral designation: “the patient”

2. Description of the prosthesis
   We agree that our initial description of the prosthesis may have been perceived as too detailed. We have now substantially revised and condensed this section, focusing exclusively on the scientific and technical aspects that are directly relevant for understanding the clinical outcome. The revised version avoids any wording that might be interpreted as promotional in nature and is now more aligned with the style of previously published MDPI case studies.

3. Adaptation to MDPI case study format
   We have carefully reviewed other case reports published in MDPI journals and revised our manuscript accordingly, improving its structure and ensuring greater consistency with accepted scientific standards.

4. Surgical technique – details
   As correctly noted by the Reviewer, this manuscript represents the first report of this novel surgical approach in the specific context of partial brachial plexus injury with elective amputation. The surgical technique has already been described in great detail by the first author in a separate publication (Gardetto et al., J Clin Med, 2025), which is cited in the text. To avoid unnecessary duplication, we had intentionally provided only a concise overview of the procedure here.

In summary, we have carefully revised the manuscript in line with the Reviewer’s valuable suggestions, which has substantially enhanced its scientific quality. We hope that the revised version is now clearer, more balanced, and more in keeping with MDPI’s case report standards, while still preserving the novel and patient-centered aspects that we consider essential for documenting this pioneering technique.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This paper presents a case study of the functional rehabilitation of a Paralympic athlete following an upper limb amputation. It highlights the effectiveness of combining advanced surgery (ulTSR) with an AI-controlled prosthesis (Adam's Hand).
While the paper is suitable as a case study, for publication in a journal such as Prosthesis, I believe the authors should add comparative data and technical details of the methodology used, which should be objectively validated.
Thus:
The present paper is based on a single patient and the results cannot be generalised or compared with other cases. Therefore, I believe the authors should include a sentence explicitly stating the limitations related to the sample size.
The paper mentions 'AI-controlled prosthesis' without providing technical details on the algorithm, control mode, sensor adaptability or software.
As this is a case study, it is understandable that it was conducted on a single patient. However, the paper does not describe the surgical procedure in sufficient detail for it to be replicated in other patients with similar pathologies. What technique was chosen, and why? Should essential steps and anatomical sketches be included?
Also, as there are no papers on AI in prosthetics or TSR in the bibliography, a comparative discussion should be added and at least three relevant, recent studies should be included in the list.

Author Response

We sincerely thank you for your thoughtful and constructive comments. We very much appreciate the time and expertise you devoted to carefully reviewing our manuscript and for providing such valuable suggestions. Your feedback has been instrumental in improving the clarity, rigor, and completeness of our work. Below we address each of your points in detail:

1. Limitation of a single case
   We fully agree with your observation that the present work is based on a single patient and therefore cannot be generalized. In the revised manuscript, we have added an explicit statement in the Colcusion to underline this limitation and to clearly state that the results should be interpreted within the context of a case study only. To further validate this approach, an international multicenter study is currently being prepared, in which a large cohort of patients will be evaluated over a three-year period. This effort aims to generate robust clinical evidence, and ultimately establish ulTSR as a standard technique for patients with partial brachial plexus injury.
2. Technical details of the AI-controlled prosthesis
   Thank you for highlighting the need for more methodological transparency. We have now expanded the description of the Adam’s Hand prosthesis to include the control algorithm, pattern recognition approach, sensor adaptability, and calibration procedure. 

3. 3. Description of the surgical procedure
   We acknowledge that a more detailed description of the ulTSR procedure is essential for reproducibility. In the revised version, we have enriched this section by specifying the rationale for the chosen technique, the surgical steps undertaken, and the relevant anatomical considerations. We would also like to emphasize that this surgical technique was recently published in detail by the first author (Gardetto et al., J Clin Med, 2025). To avoid redundancy, we provide here a concise description and refer the reader to that detailed publication for a comprehensive step-by-step account.

   4. Comparative discussion and references
   We appreciate your suggestion to situate our findings more firmly within the existing literature. We have now added a comparative discussion that relates our case to recent studies in the fields of AI in prosthetics and Targeted Sensory Reinnervation. At least three relevant, up-to-date references have been incorporated into the bibliography to broaden the scientific context of our work. At the same time, following the Editor’s request, we reduced the number of self-citations and streamlined the reference list to avoid redundancy. For this reason, some references authored by the author's that had been included in earlier drafts were removed.

   Once again, we are grateful for your valuable comments. We believe that the changes made in response to your review have significantly strengthened the manuscript. We hope that our revisions meet your expectations and we thank you warmly for helping us to improve the quality of this paper.

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Alexander Gardetto, in the manuscript entitled "Enhancing Quality of Life After Partial Brachial Plexus Injury Combining Targeted Sensory Reinnervation and AI-Controlled User-Centered Prosthesis: A Case Study," presented a case study of the rehabilitation journey of Riccardo, who underwent elective transradial amputation followed by advanced surgical and prosthetic interventions. They showed that ulTSR successfully restored meaningful sensory input, allowing intuitive and precise control of the prosthesis with minimal cognitive and muscular effort. However, some of the notes listed below were observed:

1. The manuscript contains many typos and spelling mistakes. They should be corrected.
2. The abstract should be reformulated in a convenient way, removing terms of objectives, methods, results, and conclusion.
3. The authors should reduce the keywords.
4. The introduction is weak. The authors should improve it by adding more examples of Targeted Sensory Reinnervation (ulTSR) with more references.
5. The subsection “3.1. Clinical Results” is weak. The authors provided general information. Technical and scientific information about the myoelectric, multi-articulating hand prosthesis is absent.
6. Numbers provided in Table 2 are not sufficient for comparison. The authors should provide control (reference) numbers for better comparison.
7. All provided paragraphs in the section “Discussion” are considered general. The authors should provide more scientific discussion.
8. The conclusion is so weak.

Author Response

We would like to sincerely thank the Reviewer for the careful and constructive comments on our manuscript entitled “Enhancing Quality of Life After Partial Brachial Plexus Injury Combining Targeted Sensory Reinnervation and AI-Controlled User-Centered Prosthesis: A Case Study.” We have carefully addressed each point and substantially revised our manuscript accordingly. Please find our detailed responses below.

1. Typos and spelling mistakes
   We carefully revised the entire manuscript, and the English language was thoroughly edited and corrected by our co-author Dr. Diane J. Atkins and her native-English-speaking team from Houston, USA. We are confident that the manuscript has now achieved the required linguistic quality.

2. Abstract structure
   We acknowledge the Reviewer’s comment. However, we would like to kindly clarify that the format of the abstract was written according to the specific requirements of the journal, which prescribes the subdivision into Background/Objectives, Methods, Results, and Conclusions. We have slightly reformulated and polished the abstract for clarity and conciseness, while maintaining adherence to the journal’s guidelines.

3. Keywords
   The number of keywords has been reduced, following the Reviewer’s advice.

4. Introduction
   The introduction has been strengthened with additional background information and new references on Targeted Sensory Reinnervation (ulTSR). We would like to emphasize that, to date, there is only one publication by the first author (Gardetto et al., 2025, J Clin Med) describing this specific surgical technique in detail. We also added information about the upcoming international multicenter study, scheduled to start in 2026 with leading Centers of Excellence in the USA, Europe, and Africa, which will further expand the clinical evidence in this field.

5. Section 3.1 “Clinical Results”
   We respectfully note that this manuscript is a case report. In Section 3.1, we intentionally summarized the essential clinical details of this individual patient in a concise way. More detailed data and outcomes are then reported in the following subsections (e.g., OPUS and DASH results) to provide objective and measurable information on functional recovery.

6. Table 2 – comparison numbers
   Table 2 has been revised for improved clarity. As this is a single case report, we provided outcome scores at two different follow-up time points (6 months and 18 months). These serve as intra-individual reference points and demonstrate significant improvement over time. We clarified this point in the text.

7. Discussion section
   The discussion has been substantially expanded and deepened. We now provide more detailed scientific context, including recent advances in myoelectric prosthetic control, AI-based algorithms, and sensory feedback integration. The role of ulTSR as a biological neural interface and its potential to replace more invasive approaches has also been more extensively discussed.

8. Conclusion
   The conclusion has been strengthened and extended. It now provides clearer take-home messages, underlining both the clinical relevance of ulTSR combined with advanced prosthetics and the broader implications for future multicenter clinical research.

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

thank you very much for your improvements of the manuscript and your elaborations. 

There are still some remarks of the surname of the patient in the demographics and legends. I would recommend to remove them.

The discussion has been significantly improved, congratulations!

Author Response

We would like to sincerely thank the Reviewer for the constructive feedback and for acknowledging the improvements made to the manuscript.

Concerning the remark regarding the surname of the patient in the demographics and legends, we have carefully revised the text and removed the surname in accordance with the Reviewer’s suggestion.

We also greatly appreciate the positive feedback on the discussion section. The Reviewer’s valuable comments have significantly contributed to further enhancing the quality and scientific rigor of our manuscript.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The authors made acceptable improvements to the manuscript.

Author Response

We sincerely thank the Reviewer for the thoughtful feedback and for acknowledging the improvements made to the manuscript. The Reviewer’s insights have been very helpful in further refining our work.

We remain committed to continuously improving the manuscript and will carefully consider any additional suggestions that may arise.

Author Response File: Author Response.pdf