The Effect of Fracture Type on Restoration of Radiographic Parameters and Early Loss of Reduction in Surgical Treated Distal Radius Fractures

Round 1

Reviewer 1 Report

Thank you for asking me to review this paper. There is an excellent hypothesis worthy of exploration. The concerns I have a relevant to the lack of transparency with the methodology particularly pertaining to assumptions regarding the 'final ROM' and the time to radiological union. 

How long was followup? This was not clear in the methods. How many patients were lost to follow up. At what stage was 'final assessment made'. How were ROM assessed? Were they formally measured or 'eyeballed'? How accurate was data collected? 

In regards to time to fracture healing - what was the standard post of protocol for radiographic assessment. Did all patients receive a weekly XR post op? How can you report such precise weekly assessments of radiographic healing if this was not done? 

At what stage was the bridging plate removed. I find that in this group they regain less ROM, did you analyse this group separately?

Was time to full activity reported retrospectively by the patients or were they asked if at the time of review they had returned to full activity? The way this question was asked can distinctively change the answer, especially if routine followup is irregular. 

The premise of the paper is good. The large number of confounders make the results of the data concerningly inaccurate. 

On a formatting note, I would remove all the numbers of the results from the text if they are included in a table and emphasise the important aspects. It makes it very difficult to read. 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Dear authors,

Thank you for your submission. My comments are as follows:

- Could the mechanism as well as an open vs. closed fracture pattern be included or discussed in the demographics?

- What is the standard practise in this institution for follow-up? Is there a 'standard' practise? What prompted radiograph follow-up at 4 weeks post-op over the accepted 6 weeks post-op?

- Line 126 - "Table 2 summarizes the relationship between AO classification, restoration of parameters postoperatively, and early loss of reduction." Isn't this referring to table 3?

- Table 2 and 3 description need to be swapped.

- Could there be more analysis or discussion given to those patients in all fracture types who did not have restoration of parameters and their outcomes?

Good sentence structure and grammar.

Author Response

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Author Response File: Author Response.pdf

Reviewer 3 Report

The study by Sambhariya et al. investigates the effect of fracture type on restoration of radiographic parameters and early loss of reduction in surgical treated distal forearm fractures. The manuscript is well-written and easy to read. Below are some specific suggestions and comments for the authors.

Abstract:

·      AO should be introduced before being used in abbreviated form.

Introduction:

·      L42-44: Please add a reference for the statement.

Methods:

Why where patients with a previous ipsilateral distal forearm fracture excluded? Please comment.

·      Diagreement is misspelled.

Statistical analyses:

·      Please specify the alpha level used for “statistical significance”.

Results:

·      Please clarify how the number of fractures can exceed the number of included patients? Is it because some patients had multiple fractures?

·      For readers non-familiar with the OA classification system, it might be helpful to provide a illustrative figure with the different radiographs showing characteristics of A2-C3 fractures.

Discussion:

·      DASH should be introduced before being used in abbreviated form.

·      (p =0.164) remove extra space.

·      The Discussion should end with a conclusion, similar to the one stated in the abstract. It seems a bit odd the last paragraph is “future perspectives”. Alternatively, a short conclusion can be presented under a “Conclusion” subheading.

Minor typoes. Generally well-written.

Author Response

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Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Thank you for asking me to review this paper. The value in this paper is in demonstrating whether the pattern of fracture affects early loss of position. This is a very simple question which could be answered well with reproducibly and objective analysis of the radiological parameters. 

When starting to explore other outcomes such as ROM/time to union etc then the significant confounders make the data unreliable. 

It is not clear how long the follow up was for each group or in total. You excluded patients for < 6 weeks followup but how many were lost to follow up before return to function or union. I am very dubious regarding the reliability of a retrospective file analysis for patient return to full function unless there is a standardised PROMS that is administered every time the patient comes back. This is again not clear in the methodology and should be removed from the final results. There is a difference between a surgeon telling a patient he can return to full un restricted activity (is this what was documented) and the patient actually returning to activity. 

Likewise the bridge plates need to be analysed separately. How any had volar plates and how many didnt? Again I find it hard to believe that those that had only bridge plates in C3 patients had a return to normal anatomical parameters. 

Also you mentioned wires. Was there higher reoperation rate in the more complex fracture patterns? You havent mentioned complications.

Finally the data is full of holes which are significant and substantial flaws in your statistical analysis and void any conclusions in this paper. - why are there results for only 1 B1 Flexion but 2 for extension ??? and 7 for radiological parameters. There were 105 C2 patients but extension measured for 21 and radiographic healing for 83? yet there is no mention of patients lost to followup. 

Author Response

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Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for your additions. Nil further changes to add.

Author Response

We thank you for your constructive comments which we believe strengthened the quality our our revisions.

Reviewer 3 Report

My concerns have been addressed.