PONE-D-23-14657Feasibility of Using Low-cost Markerless Motion Capture for Assessing Functional Outcomes after Lower Extremity Musculoskeletal Cancer SurgeryPLOS ONE

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Additional Editor Comments:

Specifically, Reviewers are asking more clarity and details at some stages of the manuscript. The manuscript and the usability of the propose system would also benefit from a clear definition of the equipment performances (accuracy and precision of MMC system -as taken from literature would be acceptable-, influence of depth sensor on keypoints tracking, robustness to presence of third subjects, ...).

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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

Reviewer #2: Partly

Reviewer #3: Yes

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

Reviewer #1: I Don't Know

Reviewer #2: Yes

Reviewer #3: Yes

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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

Reviewer #3: Yes

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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

Reviewer #3: Yes

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5. Review Comments to the Author

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

Reviewer #1: The authors used Markerless Motion Capture (MCC) to assess functional outcomes after sarcoma surgery in a cross section of 34 patients. The authors conclude that walking, single leg stance and kneeling assessment was feasible, acceptable and ‘clinically useful’.

This is an interesting technology that could have potential to improve our understanding of functional limitations after sarcoma surgery.

However, the manuscript fails to clearly communicate and interpret the study data. In addition, the study population is extremely heterogeneous (soft-tissue sarcoma, bone sarcoma, amputation, limb-salvage, all included). A more focused patient population would significantly improve the value of this study with respect to clinical relevance.

Abstract

� Line 73: (19-89) is this an age range, interquartile range? Standard deviation?

� Line 75: please clarify ‘clinically useful data’.

� What do the ‘*’s mean in the abstract?

� Overall, the abstract fails to connect the results of the analyses with the conclusions. What is the connection between the results and ‘novel knowledge’, ‘overcoming limitations’ and ‘guiding clinical management and rehabilitation’?

Introduction

� Line 123: Please clarify ‘inexpensive’. What costs specifically are reduced with the Microsoft Kinect?

� Overall, the rationale for the study is well explained and well supported by background information.

Methods

� Lines 138-139: Please clarify why a new paper is required from the data accessed, given the 2 previous publications.

� The pilot sample was one of convenience. That would exclude any statistical analysis. Therefore, statements such as ‘measures sensitive enough to significantly differentiate between tumour groups’, need further rationale/clarification. Same comment for lines 185-186.

� Lines 165-166: Please provide more information on the patient feedback survey.

� Lines 220-223: Statistical Analysis. Please clarify study power if stats were performed, with a sample size that was one of convenience.

Results

� Line 240: Please provide some information on the cohort that declined to participate.

� Line 251: Only 19 of 34 patients completed the survey. Please comment on this relatively poor response rate.

� Overall, the Results section is difficult to follow, with extensive technical jargon. If the data is meant to improve outcomes for orthopaedic oncology patients, the language should be appropriate for orthopaedic oncologists who treat them, not kinematic and kinetic specialists.

Discussion

� Lines 311-318: the study conclusions are strong, given that the data is not well interpreted for the reader. In addition, the low response rate weakens the ‘acceptability’ conclusions.

� Lines 401-425: This section, case studies, is the most useful for the clinician: how can this technology be used to improve patient outcomes?

� Overall, the Discussion is 3-4 X longer than appropriate. It is unfocused and disjointed. I suggest a complete rewrite.

Conclusions

� The conclusions are difficult to assess, given the lack of clear interpretation of study results.

Reviewer #2: I congratulate authors on this new and promising tool that could help in monitoring effectivity of targeted physical therapy for sarcoma patients. These are my comments to authors :

1. The study was performed only on patients who had a lower limb surgery. Could the authors elaborate if any ongoing studies involve the evaluation of patients following surgery for upper limb sarcomas or not and do they think MMC could be equally effective in this group of patients.

2. Although sample size was justified based on the study being a pilot study (looking at feasibility, safety and patient compliance), statistical conclusions regarding convergent and discriminant validities based on this sample size may lack sufficient power.

3. I suggest that in future continuing research, using healthy subjects as controls would be recommended.

4. Seven patients were included in amputation group. Could you confirm if all 7 patients had the same type of amputation or not. An above knee amputation may have a functional outcome different from a below knee amputation.

5. Although your study showed statistical significance in discriminating between Bone and soft tissue sarcomas as a matter of functional outcome, from clinical point of view , the difference in outcome would rely more on the extent of surgery and reconstruction rather than the primary diagnoses of the disease. The functional outcome may be the same in large sized sarcomas whether primarily affecting bone or soft tissues.

Reviewer #3: The manuscript presents an interesting markerless motion capture method to assess functional outcomes after sarcoma surgery. The work highlighted the feasibility of using markerless motion capture based on Kinect technology to assess impairments in patient movements. The study is relevant to be published in the journal.

However, in my opinion, I propose some suggestions that could improve this work.

It will be helpful to the reader if you could briefly describe the established sarcoma assessments TESS and MSTS (lines 91-92). I suggest to slightly elaborate the Introduction section (lines 117-121) to what concern the review of the current literature that use the Microsoft Kinect in movement analysis, adding also relevant recent works, e.g. from the last five years.

The overall presentation of results is clear. The Authors also identify the limitations of their study. I suggest to modify at line 517-518 “current covid 19 pandemic” with “pandemic conditions” in order to keep it more general.

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Reviewer #1: No

Reviewer #2: Yes: ahmed mohamed el ghoneimy

Reviewer #3: No

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Feasibility of Using Low-cost Markerless Motion Capture for Assessing Functional Outcomes after Lower Extremity Musculoskeletal Cancer Surgery

PONE-D-23-14657R1

Dear Dr. Furtado,

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.

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Kind regards,

Roberto Di Marco, PhD

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

Reviewer #2: All comments have been addressed

Reviewer #3: All comments have been addressed

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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

Reviewer #2: Yes

Reviewer #3: (No Response)

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: (No Response)

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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

Reviewer #2: Yes

Reviewer #3: (No Response)

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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

Reviewer #2: Yes

Reviewer #3: (No Response)

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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 addressing my comments. The paper is clearer with a more clinically relevant message and the data is well tied to conclusions.

Reviewer #2: Thank you for addressing most of the comments in revised manuscript . It can be premature or not clear how the outcomes of MMC can be scored or translated into recommendations that can be useful for monitoring post-operative rehabilitation programs and guiding patients and surgeons into expectations following different types of surgeries, but will be looking forward how the authors will address these issues in their future studies.

Reviewer #3: (No Response)

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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.

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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: Michelle Ghert

Reviewer #2: Yes: ahmed mohamed el ghoneimy

Reviewer #3: No

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