PONE-D-24-23964Better accuracy of robotic-assisted total knee arthroplasty compared to conventional technique in patients with failed high tibial osteotomyPLOS ONE

Dear Dr. Nam,

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

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

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: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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: Yes

Reviewer #2: Yes

Reviewer #3: No

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5. Review Comments to the Author

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

Reviewer #1: 

Dear Authors, I had the opportunity to read your article, which has a clearly defined objective of comparing robot-assisted TKA with conventional TKA in patients with failed HTO. The methodological structure of the study is well articulated, with details on patient selection, inclusion criteria, and procedures performed. The results are clearly presented, with statistically significant differences well highlighted. The detailed description of the surgical procedures for both techniques (robotic and conventional) is useful for understanding the operational differences. This implies that the physician must necessarily provide appropriate information to the patient about the potential risks, benefits, and specific advantages of one procedure versus the other. In this context, I would suggest an important work that I recommend citing in your references (https://doi.org/10.1016/j.jflm.2024.102674), which clearly states that in conducting a thorough informed consent process, physicians have the professional duty to present and initiate a discussion on the risks, benefits, and possible alternatives to a given procedure. Illustrating and discussing possible alternatives is a fundamental element of the disclosure process; patients may not be able to assess risks in abstract terms and would therefore need to rely on a comparative framework to make a truly informed decision. Addressing these discussion elements in detail would certainly contribute to making the article more comprehensive, which is advisable, given that the article, while presenting quality and strengths, needs appropriate elaborations. The inclusion of details such as the measurement of the mechanical axis, alignment, and ligament balancing provides an in-depth view of the methods used. The results showing greater accuracy in mechanical axis and component positioning in the robotic group are well supported by statistical data. The discussion on the importance of alignment and ligament balancing for implant longevity and patient satisfaction is well-argued. In light of these elements—very representative and entirely agreeable—there are some areas that need appropriate elaborations. In this regard, although the study used a specific robotic system, no detailed information is provided on which system was used. It would be useful to know the type of robotic system employed to better understand the results and their generalizability. The lack of clinical follow-up data is a significant limitation. Additional information on long-term clinical outcomes could strengthen the conclusions. The fact that the study is single-center and retrospective is another limitation. Multicenter and prospective studies could provide more robust and generalizable results. The use of simple radiographs instead of postoperative CT scans to measure the accuracy of component positioning is a methodological choice that could be discussed more thoroughly. CT scans provide more precise and detailed measurements, although they may increase costs for patients. The mention of intraclass correlation coefficients between the measurements of the two observers is positive, but details on how these coefficients were calculated and interpreted are lacking. More details on these statistical aspects could better clarify the validity of the measurements. It is evident that the surgeon's competence and experience in performing the procedures can significantly influence the results. In conclusion, the article provides a useful comparison between robot-assisted TKA and conventional TKA in patients with failed HTO, highlighting the benefits of robotic assistance in terms of precision and alignment. However, further studies with long-term clinical follow-ups, use of postoperative CT scans, and involvement of multiple centers are necessary to confirm and generalize these results. Elaboration on methodological and statistical details would further strengthen the study.

Reviewer #2: 

First of all, congratulations on the good results of TKR in HTO failure patients using robots.

Let me point out a few things.

1. Please describe exactly what the definition of failure in HTO

2. It is unclear whether the advantages of robot surgery in the Ligament balance and the advantages of robot surgery in the valgus state of the tibia due to HTO are advantageous in holding the guide over conventional or in the positioning of the tibial component. Describe the advantages of an accurate robot in this regard

3. This result does not include clinical results but only radiologic results, such as mechanical axis and component slope. The discussion mentions the long-term follow-up results, but this does not appear appropriate. Please correct it.

4. The analysis of the advantages of robotic surgery in the discussion is not clear. Describe exactly and accureately the advantages of robot-assisted surgery over conventional techniques.

Reviewer #3: 

We would like to thank the authors for attempting to evaluate robotic technique in TKA, especially after conversion due to HTO.

However, the adequacy of statistical analysis based on tele-radiographs, which do not take into account the possibility of rotational imaging (the gold standard - multispiral computed tomography) due to the human factor and leading to conclusions on the scale of a degree, raises great doubts about their correctness.

At the same time, the simple assessment of the mechanical axis deviation does not give any insight into the clinical-functional results, which were not evaluated using appropriate scales (example KSS, WOMAC, etc.), which casts doubt on the scientific value of the work, while the number of patients in a methodologically correct approach would allow valuable conclusions to be drawn.

The "Aim of the study" is missing in the materials and methods of the main manuscript. The "Discussion" block comes after the "Results", but there are no "Conclusions", which is probably an editing error. The English language needs to be double-checked by a native speaker.

The reference list needs to be supplemented with current sources, 14 out of 23 references are older than 10 years, including publications that have only museum value in 2024...

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Reviewer #1: Yes: Giuseppe Basile

Reviewer #2: No

Reviewer #3: No

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Better accuracy of robotic-assisted total knee arthroplasty compared to conventional technique in patients with failed high tibial osteotomy

PONE-D-24-23964R1

Dear Dr. Nam,

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.

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Kind regards,

Gennaro Pipino, Md

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thanks to the authors for sending us this paper. All the reviewers interviewed gave unanimous feedback on the quality of your work. Congratulations on the work done. It is ready for publication

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 #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 #3: Yes

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

Reviewer #1: Yes

Reviewer #3: 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

Reviewer #3: Yes

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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 #3: Yes

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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: Dear Authors, I have read your additions, finding them entirely consistent and in accordance with my expectations. I consider your work interesting. The purpose is clear and respected. I believe that the information provided is to be considered entirely sufficient and represents useful elements to encourage the development of new scientific work.

Reviewer #3: Thanks a lot to the team of authors for the work done and increasing the value of the findings of the paper materials.

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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.

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: Giuseppe Basile

Reviewer #3: No

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