[EXSCINDED]

PONE-D-19-21318

Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data

PLOS ONE

Dear Dr. med. Bakir,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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The authors put many hours in collecting data and preparing this interesting manuscript. The recommended therapeutic procedures for MCF as well as for SCJD are really very heterogenous, which underlines the importance of this study. However, in the present form it cannot be accepted for publication in POLS ONE. Please refer to the careful done reviwes for improvement. As pointed out by both reviewers, I believe that a native speaker could be of great linguistic help.

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Hans-Peter Simmen, M.D., Professor of Surgery

Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Partly

Reviewer #2: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

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Reviewer #1: Yes

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

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Reviewer #1: Yes

Reviewer #2: No

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear Autors

Thank you for submitting your paper to this journal.

You submit a scientific paper focusing on the frequency of medial clavicule injuries including medial clavicule fractures as well as dislocations of the sternoclaviular joint. Their cohort included a high number of patients (13588 MCF and 676 SCJD) and therefore the study could be very interresting and could bring up relevant differences between MCF and SCJD as well as between MCI and LCI. The severe problem with this data analysis is, that it is based on numbers related to ICD coding and OPS coding. We all know, that this may significantly falsify data, as coding is sometimes driven by financial and economic interrests. Although some conclusions seem to be logical, I would not take the data as realistic and meaningful. Over and/or undercoding as well as multicoding should be ruled out by looking at the charts and x-rays of the patients to avoid misinterpretation.

If the data are correct and doublechecked, the paper would contribute to a better understanding of shoulder girdle injuries. The paper is well written, the citations are correct and I only would suggest a few revisions.

Page 4 line 55: Change to: This has significant impact on Shoulder girdle kinematics as well as stability.

Page 4 line 60: The investigation focused primarily on the frequency and importance of MCI and comparing both variants as well as comparing MCI with other clavicle injuries concerning concomitant injuries and applied treatment strategies.

Page 5 line 80: chapter XIX is not clear for all readers of the journal.

Page 7 line 102: I would suggest to skip Fig I. The clarification in the text seems to be enough.

Page 8 line 129 to 149: this paragraph could possibly improve by rewriting and shortening by focusing on the relevant data. Why is it so important if the diagnosis is coded as the primary or secundary diagnosis keeping the uncertainty of coding in mind. Under this perspective also figure 5a and 5b could be revised.

Regarding the treatment options it seems very difficult to draw or follow relevant conclusions, as there is no detailed information on the type, classification and pattern of the injury. This should also be provided after analysing the charts and x-rays.

Concluding I want to emphysize, that in my opinion this paper would gain a lot of significance by correction of the data by checking the charts and the x-rays and improve the quality of the basic data to reduce this uncertainty.

Reviewer #2: The authors address the topic of medial clavicle injuries by using a nationwide database.

Abstract

Introduction

I have a little problem with the phrase “general idea”. Please rephrase this sentence into the hypothesis/research question/or the aim of this study.

Methods

Based on ICD-10 codes patients with medial clavicle fractures or SC joint dislocation were evaluated. This methodology could be adequate depending on the research question.

Results

The results section of the abstract need major revision: I recommend English correction by a native speaker. “A significant difference between the both MCI only appears for concomitant head injuries (p=0.003)” This sentence appears incomplete: what groups were compared?

Conclusion

Major language correction, conclusion of MCI being rare with inhomogeneous treatment strategies

Manuscript

Intoduction

The first sentence states clavicle fractures to be a common complication of upper extremity injury. We believe that these fractures are not common complication of other injuries, but are common injuries by themselves. Further, the authors state epidemiologic data regarding such injuries in Germany were sparse and cite 6 articles. This seems inconsistence.

“MCI are quite important as they are the only articular joint of the upper extremity to the trunk” Technically speaking, the scapula-thoracic also serves as an articular joint of the upper extremity to the trunk. Please correct the sentence (e.g. one of the important….)

“This has significant impact on…”, “significant” usually followed by a p-value / a comparison. Please rephrase

I have problems with the last sentence of the Introduction: The investigation focused primarily on the role of MCI in their comparison -> to what? And in comparison to other clavicle injuries concerning concomitant injuries …. This phrase is hard to read. The reader would benefit from substantial revisions with the help of native speaker

Methods

According to the methodology of this article, the authors only evaluated ICD-10 diagnosis an OPS codes.

Please include a definition of shoulder girdle injuries relating to the clavicle

The time frame 2012-2014 should be included in the methods section

Please include inclusion and exclusion criteria: where only surgical treated injuries included, or all injuries (non-surgical treatment). What about genetic disorder, or oncological patients with diseases affecting the musculo-skeletal system: these patients might be subject to adopted treatment that might increase heterogeneity of treatment strategies.

Are multiple injured patients calculated multiple times? E.g. Patient with MCF and, pneumothorax and fracture of the ankle. How is this patient being handled?

Please define soft tissue injury

How where patients handled that were operated several different times due to MCI / MCF?

Results

Figures: Generally, please replace the ICD-10 code with the wording of the injury, eventhough it has been stated in the description, I believe the reader would benefit from stating the text in the graph, rather in the description. X = non valid (where there missing data? NAs?)

How many patients had only the injury to the medial part of the clavicle, or is there always a concomitant injury?

Line 129: Concerning the concomitant injuries in particular… This belongs to the methods section

Line 143: There are also some differences for main as well as for secondary diagnosis with special regard to…. -> Please revise this sentence; don’t use empty phrases such as “There are also some differences”

It appears the results section to be a collection of Figure and Table descriptions…

Discussion

Major English corrections needed

Line 186-187: The authors state that large cohort analysis are more precise: We highly disagree with this statement. The problem with big data analysis, especially when comparing groups has been discussed several times. Further, this study lacks substantial elements of epidemiologic studies: Table 1 approach, patients demographics etc. Citing an article regarding head injuries the authors state “specifying confidence intervals in these cases” to be avoided “as it makes relatively small differences significant and simulates a relationship that is purely statistically significant”. First, this statement holds true for all statistical tests, and tor the p-value. The alpha is arbitrary set at 0.05, and the statistical tests simulate a purely statistical significance. Second, the CI gives way more information than the p-value and should always be preferred.

Line 190: “Another potential bias…” what has been done to reduce this problem?

The discussion part appears disorganized. Usually, the main results are discussed point by point and one section is dedicated to strengths and limitations. The limitations of this study are discussed in lines 191ff, 228, 247ff, 255. Apparently the author included a “limitation-sentence” at the end of each paragraph. I would not recommend doing so: First, usually Strengths and limitations have one section; Second, with the authors approach, each paragraph/section loses weight, when ended by a “limitation-sentence”

Conclusion:

Line 266: “… the high trauma force which is often responsible for this entities”. I don’t find data in the authors article to support this conclusion. How was the trauma force measured/calculated? Have these data been included?

“on the other hand” empty phrase, discard

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Reviewer #1: No

Reviewer #2: No

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Shoulder girdle injuries involving the medial clavicle differ from lateral clavicle injuries with a focus on concomitant injuries and management strategies: A retrospective study based on nationwide routine data

PONE-D-19-21318R1

Dear Dr. Bakir,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

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With kind regards,

Hans-Peter Simmen, M.D., Professor of Surgery

Academic Editor

PLOS ONE

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