Collateral effect of COVID-19 on orthopedic and trauma surgery

Thomas M. Randau; Max Jaenisch; Henryk Haffer; Friederike Schömig; Adnan Kasapovic; Katharina Olejniczak; Johannes Flechtenmacher; Carsten Perka; Dieter C. Wirtz; Matthias Pumberger

doi:10.1371/journal.pone.0238759

Peer Review History

Original SubmissionJune 19, 2020
3 Aug 2020 Decision Letter - Hans-Peter Simmen, Editor Transfer Alert This paper was transferred from another journal. As a result, its full editorial history (including decision letters, peer reviews and author responses) may not be present. PONE-D-20-18877 Collateral Effect of COVID-19 on Orthopedic and Trauma Surgery PLOS ONE Dear Dr. Pumberger, 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. The reviewers made an effort to help you to improve your manuscript. Please follow their recommendations. Please submit your revised manuscript by 30 september, 2020. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Hans-Peter Simmen, M.D., Professor of Surgery Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. Thank you for stating in the text of your manuscript "The study protocol was reviewed and approved by the institutional ethics board (Approval No. #20/127)". Please also add this information to your ethics statement in the online submission form. In addition, in your ethics statement please state that this was an online anonymous survey. 3. Please include a summary table of any collected demographic data. 4. Please include a separate caption for each figure in your manuscript. 5.Thank you for stating the following in the Declaration of competing interests Section of your manuscript: [P. C. reports personal fees from Smith&Nephew, personal fees from Link, personal fees from DePuy/Synthes, personal fees from Aesculap, personal fees from Zimmer, outside the submitted work. W. D. C. has nothing to disclose.] We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [The author(s) received no specific funding for this work.] Additionally, because some of your funding information pertains to commercial funding, we ask you to provide an updated Competing Interests statement, declaring all sources of commercial funding. In your Competing Interests statement, please confirm that your commercial funding does not alter your adherence to PLOS ONE Editorial policies and criteria by including the following statement: "This does not alter our adherence to PLOS ONE policies on sharing data and materials.” as detailed online in our guide for authors http://journals.plos.org/plosone/s/competing-interests. If this statement is not true and your adherence to PLOS policies on sharing data and materials is altered, please explain how. Please include the updated Competing Interests Statement and Funding Statement in your cover letter. We will change the online submission form on your behalf. Please know it is PLOS ONE policy for corresponding authors to declare, on behalf of all authors, all potential competing interests for the purposes of transparency. PLOS defines a competing interest as anything that interferes with, or could reasonably be perceived as interfering with, the full and objective presentation, peer review, editorial decision-making, or publication of research or non-research articles submitted to one of the journals. Competing interests can be financial or non-financial, professional, or personal. Competing interests can arise in relationship to an organization or another person. Please follow this link to our website for more details on competing interests: http://journals.plos.org/plosone/s/competing-interests [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 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 authors, thank you for your interesting survey on the impact of COVID-19 on the german orthopaedic and trauma surgery. The development of the COVID-19 pandemia is nowadays well known and spread througout the media worldwide. Due to this background i would suggest to shorten the Introduction and focus on the development within germany as the base of your survey. The description of Table 1 is not fully conclusive, please reformulate clearer: "Descriptive analysis and data quality, as assessed by N, mean, standard deviation (SD), standard error of the mean (SEM), 95% confidence interval (95% CI), skewness, and kurtosis of all items where these analyses was sensibly possible." Reading your manuscript i was wondering if there is a positive correlation between the level of preparedness, resources, informedness and existing concerns. A further analysis of this context might lead to a better flow of information limiting concerns in the future. Reviewer #2: The authors present results of a questionnaire based survey among trauma and orthopaedic surgeons in private practices and hospitals in Germany regarding the impact of COVID-19. Abstract: - Please provide full text before using the abbreviation “PPE” Introduction: - Well done. Methods: - As only about half of the opened questionnaires have been returned, it would be interesting to know whether the sample analyzed was representative. Do you have demographic data of the unreturned questionnaires or could you estimate these numbers based on numbers of hospital and outpatient trauma/orthopaedic surgeons in Germany? - Supplementary Material (A) and (B) with the original questionnaire are missing. - Whereas the index questions are clearly described in the methods part, the different groups of surgeons (independent profile variables) are not mentioned. Please add this to the methods part. Partially the information can be found in Figure 2. However, it is not congruent to the variables used in Table 2. Results: - It would be informative to have a “Table 1“ giving crude numbers of baseline data for the different independent profile variables (hospital employed, working in a small unit etc) and each index question. - I am not sure whether the many numbers in Table 1 are easy to understand for the reader. It would be helpful to have an example for at least one predictor explained in text. E.g. “Reduction in outpatient clinic with a mean of 0.7673 means that …” - In general, the manuscript is methodologically sound, but very “technical” and therefore not easy to understand for the reader. I suggest to add legends for Figures 3 and Suppl. Figure 1, each containing an example that explains how to read the diagrams. Discussion: - Well done. ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes:** Carina Eva Maria Pothmann, MD Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0238759.r001
Revision 1
21 Aug 2020 Author Response We have addressed all comment of the editorial office and the reviewers, and hereby submit our point-by-point reply: 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. We have checked the style requirements and updated the style of the manuscript as needed. 2. Thank you for stating in the text of your manuscript "The study protocol was reviewed and approved by the institutional ethics board (Approval No. #20/127)". Please also add this information to your ethics statement in the online submission form. In addition, in your ethics statement please state that this was an online anonymous survey. We have completed the ethics statement in the online submission as required 3. Please include a summary table of any collected demographic data. No other demographic data than those already displayed in Figure 2 was collected. We therefore do not see any additional value in also providing this data as a table. However, if needed, the data can be included, we have uploaded it as supplemental Table 2 in the online submission system. 4. Please include a separate caption for each figure in your manuscript. We have included figure legends to figures 1-4 in the manuscript. 5. Please remove any funding-related text from the manuscript Done 5. ..let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [The author(s) received no specific funding for this work.] Still true. No adjustments necessary. Additionally, because some of your funding information pertains to commercial funding, we ask you to provide an updated Competing Interests statement, declaring all sources of commercial funding. Please include the updated Competing Interests Statement and Funding Statement in your cover letter. We will change the online submission form on your behalf. None of the funding received by individual authors pertains any competing interest related to the study. No commercial funding was received in relation to the study. We have deleted the competing interest section within the manuscript. The development of the COVID-19 pandemia is nowadays well known and spread througout the media worldwide. Due to this background i would suggest to shorten the Introduction and focus on the development within germany as the base of your survey. Only the first paragraph of 123 words relates to the pandemia in general, the rest of the introduction is already focused on the german development. We have further shortened the introduction to address the reviewers concerns. The description of Table 1 is not fully conclusive, please reformulate clearer: "Descriptive analysis and data quality, as assessed by N, mean, standard deviation (SD), standard error of the mean (SEM), 95% confidence interval (95% CI), skewness, and kurtosis of all items where these analyses was sensibly possible." We have modified Table 1 description to be clearer in its’ meaning: “SD, SEM and 95% CI was calculated only for those items measured on the 5-degree scale or Likert skale, as well as for the calculated indices. For dichotome or multiselect items, these calculations are not sensibly possible”. Reading your manuscript i was wondering if there is a positive correlation between the level of preparedness, resources, informedness and existing concerns. A further analysis of this context might lead to a better flow of information limiting concerns in the future. Figure 3 holds the information the reviewer is asking for, though hard to recognize. The lower right corner of the figure presents a correlation matrix between the calculated indices. It shows that “concern” (last line but one in the matrix) correlates strongly negative with “resources” and “informedness”, and positively with “depletion”, less positively also with “reduction”. On Page 10, “Correlations and regression”, we are pointing this out in the text. However, we agree that this point is worth pointing out in regard to future handling, and therefore now have picked this up in the discussions section: “We could show that the index “concern” had a strong negative correlation with the indices “informedness” and “resources”, so in future handling of the crisis, information and resources are the key factors to diminish healthcare professionals’ anxiety.” Please provide full text before using the abbreviation “PPE” The abbreviation was defined inthe abstract, as requested. As only about half of the opened questionnaires have been returned, it would be interesting to know whether the sample analyzed was representative. Do you have demographic data of the unreturned questionnaires or could you estimate these numbers based on numbers of hospital and outpatient trauma/orthopaedic surgeons in Germany? We have completed an analysis of the incomplete surveys, and have attached this to the submitted revision. The PDF “SupplData3_ Sample Size and selction bias” addresses the reviewers very good question. If needed, the data can also be included in the final manuscript as supplementary material. Supplementary Material (A) and (B) with the original questionnaire are missing. We have included the original and the translated questionnaire (originally referenced as “A”) as supplementary data 1 and 2 in the resubmission, as well as the table of index questions (originally “B”) as SupplTable1_Index questions. Whereas the index questions are clearly described in the methods part, the different groups of surgeons (independent profile variables) are not mentioned. Please add this to the methods part. Partially the information can be found in Figure 2. However, it is not congruent to the variables used in Table 2. With appending the original survey, the different groups of surgeons and professional levels are clearly defined. We see this as sufficient for the reader, and have added the original and translated survey as intended. Table 2 only lists those independent profile variables that were significant in the bivariate analysis, and is therefore not congruent with the figure 2, which is a mere summary of the answers given. It would be informative to have a “Table 1“ giving crude numbers of baseline data for the different independent profile variables (hospital employed, working in a small unit etc) and each index question. In this case we do not agree with the reviewer. Figure 1 and 2 are a graphical representation of the numbers, as the answers were given by the participants, an additional table with the numbers would not add any information to this. Should the editor decide that a table with numbers is beneficial rather than only figures, we can provide this. I am not sure whether the many numbers in Table 1 are easy to understand for the reader. It would be helpful to have an example for at least one predictor explained in text. E.g. “Reduction in outpatient clinic with a mean of 0.7673 means that …” We have added a paragraph to the results section, explaining how Likert scales transform into numerical values to be statistically analyzed, and how to grade this. We abstain from explaining Skewness, Kurtosis and other statistical measures, assuming the statistically inclined reader will be familiar and able to interpret. In general, the manuscript is methodologically sound, but very “technical” and therefore not easy to understand for the reader. I suggest to add legends for Figures 3 and Suppl. Figure 1, each containing an example that explains how to read the diagrams. We have added figure legends (see above), and included an example as suggested in Figure legend 3. We thereby see all issues raised by the reviewers as addressed and would very much appreciate our manuscript to be considered for publication. Attachments Attachment Submitted filename: Rebuttal_Letter.docx https://doi.org/10.1371/journal.pone.0238759.r002
25 Aug 2020 Decision Letter - Hans-Peter Simmen, Editor Collateral Effect of COVID-19 on Orthopedic and Trauma Surgery PONE-D-20-18877R1 Dear Dr. Pumberger, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Hans-Peter Simmen, M.D., Professor of Surgery Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0238759.r003
Formally Accepted
27 Aug 2020 Acceptance Letter - Hans-Peter Simmen, Editor PONE-D-20-18877R1 Collateral Effect of COVID-19 on Orthopedic and Trauma Surgery Dear Dr. Pumberger: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Hans-Peter Simmen Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0238759.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .