Comparison between femoral block and PENG block in femoral neck fractures: A cohort study

Céline Allard; Emmanuel Pardo; Christophe de la Jonquière; Anne Wyniecki; Anne Soulier; Annibal Faddoul; Eileen S. Tsai; Francis Bonnet; Franck Verdonk

doi:10.1371/journal.pone.0252716

Peer Review History

Original SubmissionJanuary 11, 2021
25 Feb 2021 Decision Letter - Robert Jeenchen Chen, Editor PONE-D-21-01032 PAF study: Peng block in Emergency Arthroplasty of the Upper Extremity of the Femur : a before/after study PLOS ONE Dear Dr. Allard, 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. Please revise accordingly. Please submit your revised manuscript by Apr 11 2021 11:59PM. 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, Robert Jeenchen Chen, MD, MPH 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. Please amend either the title on the online submission form (via Edit Submission) or the title in the manuscript so that they are identical. 3. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ [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: Yes ****** 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: First, I would like to express sincere gratitude to get an opportunity to review the manuscript. The endeavor of the authors is appreciated, as the topic seems to be relevant and promising. The authors have compared PENG block with femoral nerve block for arthroplasty surgery in femoral neck fractures. However, there is some scope for its improvement. Specific concerns: 1. The title mentions about emergency arthroplasty. Why were such replacement surgery done in emergency basis? 2. It seems the terms ‘before and after’ to be inappropriate. I think it would be better to mention ‘comparison of two procedures’. 3. Kindly mention the principle of the PENG block. 4. Kindly provide Institutional Review Board reference number and date. 5. Was informed written consent taken from the participants of the study? 6. It would be better if study design were clearly mentioned in title, abstract and main text. Section wise comments 1. Kindly frame title such that it is accurate, informative, descriptive, succinct, simple and specific. The information from title is not convincing. a. The author may consider modifying the title. b. Title should contain design of the study. c. Kindly avoid abbreviations. d. The words ‘upper extremity’ in needs to be removed. Instead ‘neck of femur fracture would make more sense’. 2. Methods sections is supposed to be core of any study. Here, methods section contains inadequate information. For example, following components for methods section need to be well described. i. Details of Study design ii. Setting iii. Sample size estimation iv. Sampling technique v. Participant vi. Primary and secondary outcome variables with working definition vii. Intervention/issue of interest (exposure) viii. Comparison ix. Ethics and end point x. Statistical analysis 3. The discussion section needs to be described scientifically. Kindly frame it along the following lines: a. Main findings of the present study b. Comparison with other studies c. Implication and explanation of findings d. Strengths and limitations e. Conclusion, recommendation and future directions Reviewer #2: The research compared the efficacy and side effects of the “Pericapsular Nerve Group (PENG) Block” with those of the femoral block. The study is interesting and the result is encouraging and practical. The limit is the small scale of the sample. ****** 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:** Dr Satish Prasad Barnawal 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.0252716.r001
Revision 1
17 Mar 2021 Author Response Response to reviewers #1 and #2 � Reviewer #1 First, I would like to express sincere gratitude to get an opportunity to review the manuscript. The endeavor of the authors is appreciated, as the topic seems to be relevant and promising. The authors have compared PENG block with femoral nerve block for arthroplasty surgery in femoral neck fractures. However, there is some scope for its improvement. First of all, we would like to thank the Dr. Satish Prasad Barnawal for spending time to review our manuscript. It is a great honor to read his comments so that our work would be better after revising it. We hope that our changes would suit his expectations. Sincerely, Allard Céline, MD and Verdonk Franck, MD, PhD Specific concerns: 1. The title mentions about emergency arthroplasty. Why were such replacement surgery done in emergency basis? Our study concerns only arthrosplasties in the femoral neck fracture setting. So that, all surgeries were done in an emergency basis as delayed surgeries (>24 hours) have been associated with an increase in mortality and incidence of pneumonia, myocardial infarction, and pulmonary embolism at 30 days (1,2). 2. It seems the terms ‘before and after’ to be inappropriate. I think it would be better to mention ‘comparison of two procedures’. Accordingly to this comment, we corrected our manuscript title which is now “Comparison between femoral block and PENG block in femoral neck fractures : a cohort study”. 3. Kindly mention the principle of the PENG block. We added the principle of the PENG block in the material and methods section, “intervention” paragraph. “The PENG block is a diffusion block on the anterior surface of the hip joint capsule. The target nerve branches of this block are the articular branches of the femoral nerve, the obturator nerve and the accessory obturator nerve, leading to no quadricipital motor block. Using a curvilinear low-frequency ultrasound probe (5 MHz) placed in a transverse plane over the Anterior Inferior Iliac Spine (AIIS) and rotated to be aligned with the pubic ramus, a 80 mm RA needle is inserted to inject 20ml of ropivacaine 3.5 mg/ml. The landmarks of this block are externally the AIIS, internally the iliopubic eminence, the psoas tendon anteriorly and the pubic ramus posteriorly.” 4. Kindly provide Institutional Review Board reference number and date. We added a specific section to clarify this ethical point of utmost importance as “Regulatory and Ethical Aspects” in “Material and methods”, as following: “In accordance with French law on biomedical research, this observational data-based study obtained the approval of the Institutional Review Board “Comité d’Ethique de la Recherche en Anesthésie-Réanimation (CERAR, president Prof J.E. Bazin, May 6th 2020) under the reference number IRB 00010254 - 2020 – 078. In order to guarantee the security of personal data, the investigators collected and integrated the information anonymously into a secure database in accordance with the French Commission Nationale de l’Informatique et des Libertés (CNIL) MR-004 methodology, and registered in the Assistance Publique – Hôpitaux de Paris (AP-HP) processing register under the number 20200512144042.” 5. Was informed written consent taken from the participants of the study? Our study is observational and data-based. In accordance with the French law on biomedical research, all participants of the study as well as all patients from the Assistance Publique -Hôpitaux de Paris signed a consent for possible use of their hospitalization data, as it was done here. In addition, information was delivered through the hospital’s welcome booklet, and in all medical reports at the hospital discharge. To clarify this point to the readers of Plos One, we added this information in the “Regulatory and Ethical Aspects” section as following : “Patients consented via the websites of the institution (AP-HP and Hôpital Saint-Antoine) to the possible use of their data in research aimed towards improving the quality of care, and were informed about their rights and terms of objection. This information was also included for each patient in the hospital’s welcome booklet, which was given during administrative registration and presented at the end of the hospitalization reports.” 6. It would be better if study design were clearly mentioned in title, abstract and main text. We fully agree with Dr. Satish Prasad Barnawal’s comment. We changed the manuscript so that the study design is much well explained. This study is a cohort study : comparative and single-center. 7. Methods sections is supposed to be core of any study. Here, methods section contains inadequate information. Accordingly to the Dr. Satish Prasad Barnawal’s comment, we rewrite the methods to improve the manuscript quality. We added some subheadings so that the comprehension of section is clearer. 8. The discussion section needs to be described scientifically. We changed the discussion section to be more accurate by adding subheadings. � Reviewer #2 The research compared the efficacy and side effects of the “Pericapsular Nerve Group (PENG) Block” with those of the femoral block. The study is interesting and the result is encouraging and practical. The limit is the small scale of the sample. We would like to thank reviewer #2 for all the time spent to review our work. We hope that this revised version would suit his/her expectations. We fully agree with reviewer #2 that one of the limits of this study is the small sample of population. We found these results encouraging and will certainly conduct another prospective study with a more important number of patients to confirm the latter. Sincerely, Allard Céline, MD and Verdonk Franck, MD, PhD https://doi.org/10.1371/journal.pone.0252716.r002
11 Apr 2021 Decision Letter - Robert Jeenchen Chen, Editor PONE-D-21-01032R1 Comparison between femoral block and PENG block in femoral neck fractures: a cohort study PLOS ONE Dear Dr. Franck, 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. Please revise accordingly. Please submit your revised manuscript by May 26 2021 11:59PM. 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: All comments have been addressed Reviewer #4: (No Response) ******** 2. 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 #3: Yes Reviewer #4: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes Reviewer #4: Yes ****** 4. 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 #3: Yes Reviewer #4: Yes ****** 5. 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 #3: Yes Reviewer #4: No ****** 6. 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 #3: The article is of scientific interest and in line with the aims of the journal. The manuscript restates the authors guidelines and does not require a revision of the English language by a native speaker. The changes made after the reviews have certainly increased the quality of the article. I recommend its publication after minor revision. KEYWORDS In order to improve the visibility of the article, do not use keywords already present in the title. ABSTRACT Materials and methods: "42 patients were reviewed: 21 patients before (Femoral group) and 21 patients ..." delete all information relating to the included patients and move it to the results section. In the materials and methods section there should be only the inclusion and exclusion criteria and not information on the patients included. INTRODUCTION The introduction should be extended. MATERIALS AND METHODS "of 21 patients in each group (total number of 42 patients) was" move to the results section. Statistical analysis was adequately performed- RESULTS AND DISCUSSION The results are written very fluently and are adequately argued in the discussion. LIMITS Add the small number of patients. CONCLUSIONS Invite future studies that resolve the limitations expressed above. FIGURES The figures are of good quality. TABLES The tables are well made and adequately cover the text. REFERENCES The references are recent and the text is adequate. Reviewer #4: Comment on the manuscript Number PONE-D-21-01032R1 Comparison between femoral block and PENG block in femoral neck fractures: a cohort study The idea of the research is interesting for the readers of the journal. The authors compared the effect of 2 types of nerve block ( Femoral nerve block and Pericapsular Nerve Group Block) on the postoperative pain relief and recovery of patient who underwent hip replacement after fracture neck of femur. They used for this multiple parameters as mentioned in the study. They found no significant difference between both nerve blocks except in one parameter which is the quadriceps muscle strength. This parameter was for the advantage of the Pericapsular Nerve Group Block. The article submitted for me to review was the second version of the article. I acknowledge the improvements that the Authors did on the first version of the manuscript which has met most of the recommendations of the previous reviewers. In spite of this there is still a room for improvement. I have the following recommendation: • I recommend the authors lit the article being reviewed by an english language specialist. • Lines 38 and 88 and other locations: The Term “intermediate hip replacements” is strange and not known in orthopedic surgery. Did the authors mean hemi arthroplasty or bipolar arthroplasty? Please explain and I recommend to use the world wide known terminology. • Line 104: there is nothing called the upper extremity of the femur. Please Replace with fracture of the proximal femur. • The abbreviation IQR is repeatedly used in the article without mentioning what it does mean. This was mention under one of the tables. Please write it in full text at the first time to appear in the text. • Some spelling mistakes: - Line 71: PEricapsular should be "Pericapsular. - Line 90: Associated to …. Please replace using : Associated with . - Line 137: an experimented anesthesiologist please replace with experienced anesthesiologist I recommend to accept the article for publication after considering the previous recommendations. ****** 7. 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 #3: No Reviewer #4: Yes:** Dr. Ayman F. AbdelKawi, MD [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.0252716.r003
Revision 2
19 Apr 2021 Author Response Response to reviewers #3 and #4 � Reviewer #3 The article is of scientific interest and in line with the aims of the journal. The manuscript restates the authors guidelines and does not require a revision of the English language by a native speaker. The changes made after the reviews have certainly increased the quality of the article. I recommend its publication after minor revision. First of all, we would like to thank the reviewer #3 for spending time to review the new version of our manuscript. We hope that our changes would suit his expectations. Sincerely, Allard Céline, MD and Verdonk Franck, MD, PhD Specific concerns: 1. KEYWORDS In order to improve the visibility of the article, do not use keywords already present in the title. We deleted the keyword “PENG block” which already appear in the title. 2. ABSTRACT Materials and methods: "42 patients were reviewed: 21 patients before (Femoral group) and 21 patients ..." delete all information relating to the included patients and move it to the results section. In the materials and methods section there should be only the inclusion and exclusion criteria and not information on the patients included. We re-wrote this section so that this information appears in the section “results” and not in the “materials and methods” section. 3. INTRODUCTION The introduction should be extended. We added some information in the “introduction” paragraph. Line 54 “By 2050, it is estimated that more than 4.5 million patients worldwide per year will suffer a femoral neck fracture. (1)” Line 67 “even the “3-in-1” block which can theoretically block all the three nerves by only one injection does not often reach the territory of the obturator nerve (8).” 4. LIMITS Add the small number of patients. This limitation of the study is added in line 296 “Even if the sample size was statistically evaluated, another limitation of the study is the small number of patients.” 5. CONCLUSIONS Invite future studies that resolve the limitations expressed above. We added this sentence in the conclusion section in line 304 “Further studies with a prospective multicentric design and with a greater number of patients should be done to confirm these results.” � Reviewer #4 The idea of the research is interesting for the readers of the journal. The authors compared the effect of 2 types of nerve block (Femoral nerve block and Pericapsular Nerve Group Block) on the postoperative pain relief and recovery of patient who underwent hip replacement after fracture neck of femur. They used for this multiple parameters as mentioned in the study. They found no significant difference between both nerve blocks except in one parameter which is the quadriceps muscle strength. This parameter was for the advantage of the Pericapsular Nerve Group Block. The article submitted for me to review was the second version of the article. I acknowledge the improvements that the Authors did on the first version of the manuscript which has met most of the recommendations of the previous reviewers. In spite of this there is still a room for improvement. I have the following recommendation: • I recommend the authors lit the article being reviewed by an english language specialist. • Lines 38 and 88 and other locations: The Term “intermediate hip replacements” is strange and not known in orthopedic surgery. Did the authors mean hemi arthroplasty or bipolar arthroplasty? Please explain and I recommend to use the world wide known terminology. • Line 104: there is nothing called the upper extremity of the femur. Please Replace with fracture of the proximal femur. • The abbreviation IQR is repeatedly used in the article without mentioning what it does mean. This was mention under one of the tables. Please write it in full text at the first time to appear in the text. • Some spelling mistakes: - Line 71: PEricapsular should be "Pericapsular. - Line 90: Associated to …. Please replace using : Associated with . - Line 137: an experimented anesthesiologist please replace with experienced anesthesiologist We would like to thank Dr. Ayman F. AbdelKawi, MD for all the time spent to review our work. We changed our manuscript by respecting all his remarks and suggestions. We sent the manuscript to an English native speaker (Dr. Eileen Tsai) to check the language. We hope that it will now suit his expectations. Sincerely, Allard Céline, MD and Verdonk Franck, MD, PhD https://doi.org/10.1371/journal.pone.0252716.r004
13 May 2021 Decision Letter - Robert Jeenchen Chen, Editor PONE-D-21-01032R2 Comparison between femoral block and PENG block in femoral neck fractures: a cohort study PLOS ONE Dear Dr. Franck, 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. Please revise accordingly. Please submit your revised manuscript by Jun 27 2021 11:59PM. 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols. We look forward to receiving your revised manuscript. Kind regards, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Journal Requirements: Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: All comments have been addressed Reviewer #5: (No Response) ******** 2. 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 #3: Yes Reviewer #5: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes Reviewer #5: Yes ****** 4. 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 #3: Yes Reviewer #5: Yes ****** 5. 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 #3: Yes Reviewer #5: Yes ****** 6. 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 #3: I thank the authors for the corrections made. The work has been improved and is now acceptable for publication. Reviewer #5: This study was a before and after protocol, comparing the phase of femoral block to newly applied PENG block. The methods were simple. Simply, the authors showed non-inferiority of PENG regarding perioperative pain control, and the results seemed to be sound. I would address some minor comments. Minor comments #1. Regarding the inclusion criteria, I do not understand how the author managed those who the block was not sufficient, and the technique of analgesia was converted to other ways (general anesthesia or spinal?). #2. I understand that calculating sample size was so difficult. However, for me, a 30% decrease of morphine consumption in 48 hours seemed to be too large. Reference # 15 and # 16 would not generate the idea of 30% decrease. I do not have the impression that the effects of block last for 48 hours. The pain scores in the surgery or morphine consumption in OR or PACU would have some reason. #3. The authors showed that the MRC scale before discharge from RR was different. Please wrote the timing of MRC measurement in the result (line 221 to 224). How long the muscle weakness last would be a good discussion point. The description of ERAS in discussion seemed to be over-speculation. It can be deleted. #4. In the conclusions, the authors wrote that PENG provided “equivalent”. However, because of the small sample size, probably the description would be written in more mild way. #5. For me, the description of acknowledgment was too broad. Probably, a little more specific description would be favorable. #6. Regarding figure legends, the publishers will request the title of figure and the explanation. ****** 7. 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 #3: No Reviewer #5: 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.0252716.r005
Revision 3
16 May 2021 Author Response Response to reviewers #3 and #5 � Reviewer #3 I thank the authors for the corrections made. The work has been improved and is now acceptable for publication. Dear Reviewer #3, Thank you again for reviewing our work. We hope to work with you again soon. Sincerely yours, Dr. Céline ALLARD and Dr. Franck VERDONK � Reviewer #5 This study was a before and after protocol, comparing the phase of femoral block to newly applied PENG block. The methods were simple. Simply, the authors showed non-inferiority of PENG regarding perioperative pain control, and the results seemed to be sound. I would address some minor comments. Minor comments #1. Regarding the inclusion criteria, I do not understand how the author managed those who the block was not sufficient, and the technique of analgesia was converted to other ways (general anesthesia or spinal?). This study is a before and after protocol comparing two types of analgesic block -femoral block and PENG block- before a total hip arthroplasty (THA) or hemi arthroplasty (HA) both performed in emergency for hip fracture. Both analgesic blocks were performed in the pre-anesthesia room, right before entering the operating room. All surgeries were done under general anesthesia as written in the methods section. We made the decision, prior to data collection and analysis, to exclude patients operated under spinal anesthesia considering that spinal anesthesia will modify pain and muscle strength evaluation after the surgery, in addition to the potential systemic effect of local anesthetics and morphine in this setting. #2. I understand that calculating sample size was so difficult. However, for me, a 30% decrease of morphine consumption in 48 hours seemed to be too large. Reference # 15 and # 16 would not generate the idea of 30% decrease. I do not have the impression that the effects of block last for 48 hours. The pain scores in the surgery or morphine consumption in OR or PACU would have some reason. We totally agree with this comment. However, calculating sample size was very difficult because there is actually no study in the literature comparing morphine consumption after femoral block and another type of analgesic block. References #15 and #16 evoke the possibility of a 30% decrease in morphine consumption. We also agree with the reviewer that the effect of analgesic block may not last for more than 24 hours. The primary end point of this study was the cumulative morphine consumption at 48 hours after the surgery as one of the common endpoints in studies focusing on peri-operative medicine 1,2. That being said, the pain scores after surgery recorded in PACU didn’t show any significant difference between the two groups of patients. #3. The authors showed that the MRC scale before discharge from RR was different. Please wrote the timing of MRC measurement in the result (line 221 to 224). How long the muscle weakness last would be a good discussion point. The description of ERAS in discussion seemed to be over-speculation. It can be deleted. We thank the reviewer for his comment. We added this sentence in the methods section to explain when the MRC score was measured : “immediate postoperative mobility of the operated limb quadriceps as defined by the Medical Research Council (MRC) scale (17) before discharge from RR (2 hours after the end of surgery).” We deleted the paragraph concerning ERAS in the discussion and added this sentence concerning the duration of the muscle weakness after a femoral block : “In a previous study, Ghodki et al showed that only 13% of the 30 patients receiving femoral nerve block present a normal quadricipital motricity 12 hours after surgery and, more interestingly, that 17% of them still have muscle weakness 24 hours after surgery.” #4. In the conclusions, the authors wrote that PENG provided “equivalent”. However, because of the small sample size, probably the description would be written in more mild way. We modified the conclusion to address this comment : “In conclusion, in this study, PENG block may provide equivalent postoperative morphine consumption, compared to femoral block in patients operated on for femoral neck fractures.” #5. For me, the description of acknowledgment was too broad. Probably, a little more specific description would be favorable. We modified a bit the acknowledgment section : “We would like to thank all the anesthesiologists, surgeons, nurses and patients who participated in the realization of this work.” #6. Regarding figure legends, the publishers will request the title of figure and the explanation. The titles of the figures already are in the manuscript. The figures were uploaded separately in the Plos one online submission form, as it was asked. We added the explanation of the figure in the manuscript : “Explanation of the figure : box-plot diagram : the rectangle extends from the first quartile to the third quartile and is intersected by the median. The segments at the ends of the rectangle provide information on the extreme values.” https://doi.org/10.1371/journal.pone.0252716.r006
21 May 2021 Decision Letter - Robert Jeenchen Chen, Editor Comparison between femoral block and PENG block in femoral neck fractures: a cohort study PONE-D-21-01032R3 Dear Dr. Franck, 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, Robert Jeenchen Chen, MD, MPH Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #3: All comments have been addressed Reviewer #5: All comments have been addressed ******** 2. 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 #3: Yes Reviewer #5: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #3: Yes Reviewer #5: (No Response) ****** 4. 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 #3: Yes Reviewer #5: (No Response) ****** 5. 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 #3: Yes Reviewer #5: (No Response) ****** 6. 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 #3: (No Response) Reviewer #5: (No Response) ****** 7. 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 #3: No Reviewer #5: No https://doi.org/10.1371/journal.pone.0252716.r007
Formally Accepted
25 May 2021 Acceptance Letter - Robert Jeenchen Chen, Editor PONE-D-21-01032R3 Comparison between femoral block and PENG block in femoral neck fractures: a cohort study Dear Dr. Verdonk: 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. Robert Jeenchen Chen Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0252716.r008

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