Flexor tendon degeneration affects short-term outcomes of open trigger digit release

Mardhiyah Abdul Nasir; Tunku Sara Ahmad; Tze Hau Low; Cassidy Devarajooh; Jayaletchumi Gunasagaran

doi:10.1371/journal.pone.0286301

Peer Review History

Original SubmissionNovember 8, 2022
12 Jan 2023 Decision Letter - Lucinda Shen, Editor PONE-D-22-30862Flexor tendon degeneration affects short-term outcomes of open trigger finger releasePLOS ONE Dear Dr. Gunasagaran, 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 submit your revised manuscript by Feb 25 2023 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. 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Additional Editor Comments: The manuscript has been reviewed by 2 reviewers and their comments may be seen below. The reviewers have provided feedback on the manuscript, and have requested additional information to further clarify the study methodology. Specifically, they have raised questions about the number of surgeons who were involved in assessing the pictures used in the study. If multiple surgeons were involved, it would be beneficial for the readers to have more information on how any discrepancies were addressed, and what measures were taken to account for inter-rater variability. Additionally, the reviewers have suggested that providing more information on the Greens grading system used in the study would be useful for the readers' understanding and interpretation of the results. Could you please carefully revise the manuscript to address all comments raised? [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: No 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: No 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: The authors present an ambitious prospective study evaluating the effect of tendon degeneration on postoperative outcome following open trigger finger release. The manuscript requires an English revision. The introduction is short and on point. In the methods section, please specify at what age you considered patients to be adults. I would also suggest to add the specifics of the grading system by Green that you used, as not all readers will be familiar with it. Who performed the preoperative assessment and when was it performed? Did you use the English version or a translated version of the DASH? When analysing the pictures, did the two surgeons do it together? Or separately? If separately, how did you handle the cases where the surgeons disagreed? How did you define comorbidity? The authors have included several digits from the same patients, and this is a recurrent problem in hand surgical research - how to handle multiple digits from the same patients. Perhaps a small elaboration on this is the discussion would add to the manuscript - for example, it is more likely that a patient with diabetes is represented by more than one finger in the data set than a patient who is otherwise healthy. I would also suggest to add a regression analysis, to be able to adjust for confounding factors. Is the seen effect of tendon degeneration on ROM and DASH a true effect, or does age and comorbidity play a role? In the results section, I was very surprised to see that patients had on average 34 visits to the physio before surgery, and few patients had recieved corticosteroid injections beforehand. This differs quite substantially from my practice. Is it standard in your practice that patients have such an extensive treatment by physios before surgery? I am also curious of how you reason with corticosteroids, would a previous injection affect the appearance of the tendon? In the discussion, it is mentioned that sonographic assessment was made, however this is not specified in the methods- or is line 210-211 only referring to previous literature? Figure 4 is difficult to read and requires a higher pixel solution. Reviewer #2: This is a prospective study evaluating the correlation between flexor tendon degeneration and the outcome of open A1 pulley release for trigger digits treatment. I have some questions and comments regarding this study, as listed below: In general: - To be more specific, trigger digits refer to trigger thumb and trigger finger. Trigger fingers include the index, middle, ring, and small fingers. You can replace the term of trigger finger to trigger digits, or include the separate data of trigger fingers and trigger thumb. Introduction: - Line 49: The proximal part of the A2 pulley could also be a cause of trigger finger. (see: J Hand Surg Eur Vol, 2007, 32:521) Methods: - Line 81: It would be better to add the details of the grading of trigger finger by Green et al. in the text or a table. - Line 85: The position setting of the JAMAR® Hand Grip Dynamometer used for testing (first, second, third...) should be mentioned. Different position settings will yield different grip strength. - Line 94, 95: Did any of the patients undergo partial proximal A2 release? This should be clarified as the proximal A2 pulley release could be a key for some patients to achieve a complete triggering release. Results: - How about the correlation of tendon degeneration with the steroid injection? In addition, value to this study would be added if the outcomes of the patients with and without steroid injection could be presented and compared. Discussion: - Line 249, 250: “Initially, trigger finger may present as a painless clicking digit.” This is not completely true since many patients initially present with a painful digit. In addition, in the Green classification of trigger finger, grade 1 already includes “pain.” - You included 12 digits of grade 4, indicating the trigger status in the fixed flexion contracture preoperatively. This group of patients is unique, not only their preoperative flexion contracture, but also the postoperative high chance of residual flexion contracture. You can summarize the macroscopic finding of this group of patients which is an important information. However, the functional influence by this group of patients would cause study bias which you also need to clarify. ****** 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: Malin Zimmerman 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/. 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Revision 1
1 Mar 2023 Author Response Reviewer #1: The authors present an ambitious prospective study evaluating the effect of tendon degeneration on postoperative outcome following open trigger finger release. - The manuscript requires an English revision. > English revision had been done. The introduction is short and on point. - In the methods section, please specify at what age you considered patients to be adults. > More than 18 years old and above. This had been included. Line 80-81. - I would also suggest to add the specifics of the grading system by Green that you used, as not all readers will be familiar with it. > Green’s classification had been added. Line 101. - Who performed the preoperative assessment and when was it performed? > Orthopaedics registrars assisted by a research assistant performed the assessments prior to surgery at minor operating theatre. This had been added in manuscript. Line 86. - Did you use the English version or a translated version of the DASH? > English version. - When analysing the pictures, did the two surgeons do it together? Or separately? If separately, how did you handle the cases where the surgeons disagreed? > The analysis was done by 2 surgeons separately. Training was done for both surgeons prior to assessment so they could identify and quantify the severity of tendon degeneration features (Likert scale 5) in a reliable and consistent manner. In this study, the scores obtained were averaged. Line 132-135. - How did you define comorbidity? > Medical conditions diagnosed by a medical professional and patients are on treatment/ follow ups. - The authors have included several digits from the same patients, and this is a recurrent problem in hand surgical research - how to handle multiple digits from the same patients. Perhaps a small elaboration on this is the discussion would add to the manuscript - for example, it is more likely that a patient with diabetes is represented by more than one finger in the data set than a patient who is otherwise healthy. > In this study, the trigger digit is an idiopathic condition which affects all patients with varying degree of severity and number of digits involved. Thus, analysis was done based on number of digits involved. - I would also suggest to add a regression analysis, to be able to adjust for confounding factors. Is the seen effect of tendon degeneration on ROM and DASH a true effect, or does age and comorbidity play a role? > The objective of this study is to investigate the association between flexor tendon degeneration and outcome of open trigger digit release while looking at the improvement of pain, ROM MCPJ/ PIPJ, pinch/ grip strength and DASH score pre- and post-surgery. The objective of this study does not require regression analysis. From previous literatures, tendinopathies may affect the outcome of trigger release. Age and comorbidity that does not involve musculoskeletal system, do not affect pain, ROM and DASH score. Comorbidity which involves musculoskeletal system like neurological disorder and inflammatory arthritis were excluded from this study. - In the results section, I was very surprised to see that patients had on average 34 visits to the physio before surgery, and few patients had recieved corticosteroid injections beforehand. This differs quite substantially from my practice. Is it standard in your practice that patients have such an extensive treatment by physios before surgery? > Yes. In our centre, many patients refused surgery even after counselling of its benefits. They preferred physiotherapy and were seen weekly. From our data, there were 2 patients who had 50 sessions and 8 patients who had about 40 sessions. - I am also curious of how you reason with corticosteroids, would a previous injection affect the appearance of the tendon? > We identified 26 trigger digits which had steroid injections. Correlation between number of steroid injections with severity of tendon degeneration was done and included in manuscript. Line 196-202 (results) and line 283-290 (discussion). Table 4 had been revised too. - In the discussion, it is mentioned that sonographic assessment was made, however this is not specified in the methods- or is line 210-211 only referring to previous literature? > Yes. From previous literatures, there were 2 methods of describing flexor tendon degenerations; sonographically and histologically. We did not perform these 2 methods. We described the macroscopic features of tendon degeneration via intraoperative imagings. - Figure 4 is difficult to read and requires a higher pixel solution. > Higher pixel of Figure 4 had been included. Reviewer #2: This is a prospective study evaluating the correlation between flexor tendon degeneration and the outcome of open A1 pulley release for trigger digits treatment. I have some questions and comments regarding this study, as listed below: In general: - To be more specific, trigger digits refer to trigger thumb and trigger finger. Trigger fingers include the index, middle, ring, and small fingers. You can replace the term of trigger finger to trigger digits, or include the separate data of trigger fingers and trigger thumb. > The term trigger finger had been replaced with trigger digit. Introduction: - Line 49: The proximal part of the A2 pulley could also be a cause of trigger finger. (see: J Hand Surg Eur Vol, 2007, 32:521) > This information had been added and the reference is included. Line 52-53. Methods: - Line 81: It would be better to add the details of the grading of trigger finger by Green et al. in the text or a table. > A table had been added. Line 101. - Line 85: The position setting of the JAMAR® Hand Grip Dynamometer used for testing (first, second, third...) should be mentioned. Different position settings will yield different grip strength. > Description of positioning of JAMAR® Hand Grip Dynamometer had been included in manuscript. Line 94-100. - Line 94, 95: Did any of the patients undergo partial proximal A2 release? This should be clarified as the proximal A2 pulley release could be a key for some patients to achieve a complete triggering release. > None of our patients had proximal A2 pulley release because the triggering had completely resolved after A1 pulley release. This had been included in ‘Intraoperative Examination’. Line 121-122. Results: - How about the correlation of tendon degeneration with the steroid injection? In addition, value to this study would be added if the outcomes of the patients with and without steroid injection could be presented and compared. > We identified 26 trigger digits which had steroid injections. Correlation between number of steroid injections with severity of tendon degeneration was done and included in manuscript. Line 196-202 (results) and line 283-290 (discussion). Table 4 had been revised too. Discussion: - Line 249, 250: “Initially, trigger finger may present as a painless clicking digit.” This is not completely true since many patients initially present with a painful digit. In addition, in the Green classification of trigger finger, grade 1 already includes “pain.” > We had revised the statement. Line 275-277. - You included 12 digits of grade 4, indicating the trigger status in the fixed flexion contracture preoperatively. This group of patients is unique, not only their preoperative flexion contracture, but also the postoperative high chance of residual flexion contracture. You can summarize the macroscopic finding of this group of patients which is an important information. However, the functional influence by this group of patients would cause study bias which you also need to clarify. > We agree that grade IV trigger digit group is unique. We speculated that the flexor tendon degeneration would be severe in this group. However, there was no correlation between severity of flexor tendon degeneration with severity of trigger finger (grading). Thus, we felt there is no need for subgroup analysis. Attachments Attachment Submitted filename: Updated Response to reviewers PLOS1 FDS degen.docx https://doi.org/10.1371/journal.pone.0286301.r002
26 Apr 2023 Decision Letter - Emiliano Cè, Editor PONE-D-22-30862R1Flexor tendon degeneration affects short-term outcomes of open trigger digit releasePLOS ONE Dear Dr. Gunasagaran, 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. Dear Authors, one expert in the field revised your new manuscript version detecting some minor issues you should consider during the revision process. Please submit your revised manuscript by Jun 10 2023 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: https://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, Emiliano Cè 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 #1: (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 #1: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: 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 #1: 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 #1: 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 #1: Thank you for the revised manuscript. I only have a few small comments as follows: Please add to the manuscript that you used the English version of the DASH questionnaire. Please add your definition of comorbidity to the manuscript. Interesting results with the steroid injections. I would suggest to change the heading in Table 4 from "Number of steroid injections" to "previous steroid injection". Congratulations on a nice study! ****** 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 #1: Yes: Malin Zimmerman ******** [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.0286301.r003
Revision 2
3 May 2023 Author Response Reviewer #1: Thank you for the revised manuscript. I only have a few small comments as follows: Please add to the manuscript that you used the English version of the DASH questionnaire. This had been added at Line 92 and 149. Please add your definition of comorbidity to the manuscript. This had been added at Line 184. Interesting results with the steroid injections. I would suggest to change the heading in Table 4 from "Number of steroid injections" to "previous steroid injection". This had been changed in Table 4. Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0286301.r004
15 May 2023 Decision Letter - Emiliano Cè, Editor Flexor tendon degeneration affects short-term outcomes of open trigger digit release PONE-D-22-30862R2 Dear Dr. Gunasagaran, 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, Emiliano Cè 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 #1: 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 #1: (No Response) ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (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 #1: (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 #1: (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 #1: (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 #1: Yes: Malin Zimmerman ******** https://doi.org/10.1371/journal.pone.0286301.r005
Formally Accepted
18 May 2023 Acceptance Letter - Emiliano Cè, Editor PONE-D-22-30862R2 Flexor tendon degeneration affects short-term outcomes of open trigger digit release Dear Dr. Gunasagaran: 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 Professor Emiliano Cè Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0286301.r006

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