Modified musculofascial lengthening technique for submuscular ulnar nerve transposition in cubital tunnel syndrome

Sang-Pil So; Won Sun Lee; KiHyeok Ku; Young Ho Shin; Jae Kwang Kim

doi:10.1371/journal.pone.0318303

Peer Review History

Original SubmissionApril 3, 2024
21 Aug 2024 Decision Letter - Vanessa Carels, Editor PONE-D-24-12479Modified musculofascial lengthening technique for submuscular ulnar nerve transposition in cubital tunnel syndromePLOS ONE Dear Dr. Kim, 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 Oct 04 2024 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, Vanessa Carels Staff 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 [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: I Don't Know ****** 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: Thank you for your effort on the study. My comments: The introduction section is well-written. Materials and methods section: In surgical technique, please give data about if there was any restriction after 2 post-operative 2 weeks. What was your follow-up protocol after two weeks? What was the timing of post-operative clinical assessment? Did you recall the patients for a final follow-up or you assess the patients in rutin follow-up? If you have the clinical assessments in post-operative 3 and/or 6 months, it could be better adding them to see progression of clinical status. If you have that data please add it. The results section is well-written. Discussion section: In the first paragraph before reporting most important finding of your study, please give a brief information about ulnar nerve entrapment treatments. In this section, the most of the articles you cited are very old. You can site newer articles like: -Lanzetti RM, Astone A, Pace V, D'Abbondanza L, Braghiroli L, Lupariello D, Altissimi M, Vadalà A, Spoliti M, Topa D, Perugia D, Caraffa A. Neurolysis versus anterior transposition of the ulnar nerve in cubital tunnel syndrome: a 12 years single secondary specialist centre experience. Musculoskelet Surg. 2021 Apr;105(1):69-74 -Byun YS, Lee SU, Park IJ, Im JH, Hong SA. Comparison of in-situ release and submuscular anterior transposition of ulnar nerve for refractory cubital tunnel syndrome, previously treated with subfascial anterior transfer-A retrospective study of 24 cases. Injury. 2023 Dec;54(12):111061. -Liu CH, Wu SQ, Ke XB, Wang HL, Chen CX, Lai ZL, Zhuang ZY, Wu ZQ, Lin Q. Subcutaneous Versus Submuscular Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Medicine (Baltimore). 2015 Jul;94(29):e1207. -Ergen E, Ertem K, Karakaplan M, Kavak H, Aslantürk O. Review of Anterior Submuscular Transposition of Ulnar Nerve for Cubital Tunnel Syndrome. Niger J Clin Pract. 2021 Aug;24(8):1170-1173. Also there is no discussion about minimal invasive endoscopic techniques, it could be better to add one paragraph about that topic. -Morse LP, McGuire DT, Bain GI. Endoscopic ulnar nerve release and transposition. Tech Hand Up Extrem Surg. 2014 Mar;18(1):10-4. -Marcheix PS, Vergnenegre G, Chevalier C, Hardy J, Charissoux JL, Mabit C. Endoscopic ulnar nerve release at the elbow: Indications and outcomes. Orthop Traumatol Surg Res. 2016 Feb;102(1):41-5. -Smeraglia F, Del Buono A, Maffulli N. Endoscopic cubital tunnel release: a systematic review. Br Med Bull. 2015;116:155-63. Reviewer #2: This retrospective study evaluates 29 cubital tunnel syndrome operations using the flexor-pronator musculofascial lengthening technique combined with anterior submuscular transposition of the ulnar nerve. The authors focus on reporting the outcomes of this method. Introduction: Well-written. Materials and Methods: - Lines 82-84, ‘Surgical indications included objective sensory-motor changes and persistent symptoms after six months of conservative treatment.’ Do you perform electrodiagnostic examinations, such as electromyography (EMG) and nerve conduction studies (NCS), for these patients with cubital tunnel syndrome? Additionally, what does your conservative treatment entail? - Lines 95-96, ‘The medial intermuscular septum and arcade of Struthers were released proximally.’ How do you release the medial intermuscular septum, or do you resect it? - For the surgical procedures: Do you release the branch(es) of the ulnar nerve to the flexor carpi ulnaris (FCU) muscle to avoid kinking during anterior transposition? In Figure 3, it appears that the fascial septum between the flexor carpi ulnaris and the flexor-pronator muscles is very obvious after the musculofascial flap is harvested. Could this cause tenting and compression of the transposed ulnar nerve? - Line 146, 'the fifth finger' should be replaced with 'the little finger' or 'the small finger'. Results and discussion - In your study, the mean grip strength on the operated side improved from 10.7 kg to 13.1 kg. It appears that the grip strength is generally lower than that of the average population and what is reported in the literature. Could there be any reason for this? - In addition to observing improvements in intrinsic muscle atrophy, did you perform any physical examinations to test the function of the intrinsic muscles? - As you mentioned in the introduction (lines 54-56), submuscular transposition reduces intraneural ulnar nerve pressure. In your method, will the area of the proximal flap, the proximal-based fascial layer of the middle third of the flexor-pronator mass, cause increased intraneural ulnar nerve pressure, since this part involves only subfascial nerve transfer? Conclusion: I would consider this a modified musculofascial lengthening technique rather than a novel one. ****** 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: No 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.0318303.r001
Revision 1
7 Oct 2024 Author Response Response to REVIEWER 1 comment We would like to thank you for the opportunity to resubmit our revised manuscript. We would also like to express our gratitude to the reviewers for their positive feedback and helpful comments. The manuscript has benefited immensely from these insightful suggestions. We have improved the article based on the critiques and suggestions. Please, see below our comments to the critiques and our revised manuscript. We have provided point-by-point responses to each suggestion below. The changes are also highlighted in the revised manuscript. Reviewer #1: Thank you for your effort on the study. My comments: The introduction section is well-written. Materials and methods section: In surgical technique, please give data about if there was any restriction after 2 post-operative 2 weeks. � Page 4 (Lines 90): Following your comments, we added information about further restriction after postoperative two weeks (no further restriction). What was your follow-up protocol after two weeks? � We tried to follow-up the patients at postoperative two weeks, three months, 1 year, 2 years and 3 years. What was the timing of post-operative clinical assessment? Did you recall the patients for a final follow-up or you assess the patients in rutin follow-up? If you have the clinical assessments in post-operative 3 and/or 6 months, it could be better adding them to see progression of clinical status. If you have that data please add it. � We tried to follow-up patients as mentioned above, however, the number of patients followed-up at each time point was restricted and main focus point of this study was clinical outcomes at the final follow-up; therefore, the clinical assessment data at the final follow-up was utilized for the analysis of this study. The results section is well-written. Discussion section: In the first paragraph before reporting most important finding of your study, please give a brief information about ulnar nerve entrapment treatments. � Page 7 (Lines 155-157): Following your comments, we added possible surgical options for the cubital tunnel syndrome before reporting findings of our study. In this section, the most of the articles you cited are very old. You can site newer articles like: -Lanzetti RM, Astone A, Pace V, D'Abbondanza L, Braghiroli L, Lupariello D, Altissimi M, Vadalà A, Spoliti M, Topa D, Perugia D, Caraffa A. Neurolysis versus anterior transposition of the ulnar nerve in cubital tunnel syndrome: a 12 years single secondary specialist centre experience. Musculoskelet Surg. 2021 Apr;105(1):69-74 -Byun YS, Lee SU, Park IJ, Im JH, Hong SA. Comparison of in-situ release and submuscular anterior transposition of ulnar nerve for refractory cubital tunnel syndrome, previously treated with subfascial anterior transfer-A retrospective study of 24 cases. Injury. 2023 Dec;54(12):111061. -Liu CH, Wu SQ, Ke XB, Wang HL, Chen CX, Lai ZL, Zhuang ZY, Wu ZQ, Lin Q. Subcutaneous Versus Submuscular Anterior Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis of Randomized Controlled Trials and Observational Studies. Medicine (Baltimore). 2015 Jul;94(29):e1207. -Ergen E, Ertem K, Karakaplan M, Kavak H, Aslantürk O. Review of Anterior Submuscular Transposition of Ulnar Nerve for Cubital Tunnel Syndrome. Niger J Clin Pract. 2021 Aug;24(8):1170-1173. � Page 7(Lines 157), Page 8 (Lines 175,177): we added newer articles mentioned above in our discussion section, following your comments. Also there is no discussion about minimal invasive endoscopic techniques, it could be better to add one paragraph about that topic. -Morse LP, McGuire DT, Bain GI. Endoscopic ulnar nerve release and transposition. Tech Hand Up Extrem Surg. 2014 Mar;18(1):10-4. -Marcheix PS, Vergnenegre G, Chevalier C, Hardy J, Charissoux JL, Mabit C. Endoscopic ulnar nerve release at the elbow: Indications and outcomes. Orthop Traumatol Surg Res. 2016 Feb;102(1):41-5. -Smeraglia F, Del Buono A, Maffulli N. Endoscopic cubital tunnel release: a systematic review. Br Med Bull. 2015;116:155-63. � Page 7 (Lines 167-168): we added a brief introduction regarding minimal invasive endoscopic release techniques in the discussion section following your comments. Response to REVIEWER 2 comment We would like to thank you for the opportunity to resubmit our revised manuscript. We would also like to express our gratitude to the reviewers for their positive feedback and helpful comments. The manuscript has benefited immensely from these insightful suggestions. We have improved the article based on the critiques and suggestions. Please, see below our comments to the critiques and our revised manuscript. We have provided point-by-point responses to each suggestion below. The changes are also highlighted in the revised manuscript. Reviewer #2: This retrospective study evaluates 29 cubital tunnel syndrome operations using the flexor-pronator musculofascial lengthening technique combined with anterior submuscular transposition of the ulnar nerve. The authors focus on reporting the outcomes of this method. Introduction: Well-written. Materials and Methods: - Lines 82-84, ‘Surgical indications included objective sensory-motor changes and persistent symptoms after six months of conservative treatment.’ Do you perform electrodiagnostic examinations, such as electromyography (EMG) and nerve conduction studies (NCS), for these patients with cubital tunnel syndrome? � Page 3 (Lines 60): Following your comments, we added “all included patients” to underline that we confirmed diagnosis (cubital tunnel syndrome) by EMG and NCS for all included patients. Conservative treatment included lifestyle modification, night extension splint and medication. Additionally, what does your conservative treatment entail? � Page 3 (Lines 63): We added detailed information of conservative treatment at the manuscript following your comments. Conservative treatment included lifestyle modification, night extension splint and medication. - Lines 95-96, ‘The medial intermuscular septum and arcade of Struthers were released proximally.’ How do you release the medial intermuscular septum, or do you resect it? � We simply released the medial intermuscular septum without further resection. - For the surgical procedures: Do you release the branch(es) of the ulnar nerve to the flexor carpi ulnaris (FCU) muscle to avoid kinking during anterior transposition? In Figure 3, it appears that the fascial septum between the flexor carpi ulnaris and the flexor-pronator muscles is very obvious after the musculofascial flap is harvested. Could this cause tenting and compression of the transposed ulnar nerve? � Page 4 (Line 77-78, 83-84): we added further detail of surgical procedure, following your comments. We release the FCU muscle branch of the ulnar nerve to prevent kinking of the ulnar nerve and therefore leading to the ease of anterior transposition. And, musculofascial lengthening was performed loosely; therefore not to tent or compress the transposed ulnar nerve. - Line 146, 'the fifth finger' should be replaced with 'the little finger' or 'the small finger'. � Page 5 (Lines 113): We replaced “the fifth finger” to “little finger”, following your comments. Results and discussion - In your study, the mean grip strength on the operated side improved from 10.7 kg to 13.1 kg. It appears that the grip strength is generally lower than that of the average population and what is reported in the literature. Could there be any reason for this? � Page 6 (Line 147-148), Page 8 (Lines 192-193): After your comment, we reviewed patients’ hand grip strength data again. We found that grip strength was originally measured by “kilograms”, however, there was error during data acquisition. Data was acquired and analyzed as grip strength measured by “pounds”; therefore, overall decrease of grip strength was made after conversion of unit (from pounds to kilograms). We re-analyzed grip strength data by “kilograms” and edited results and discussion section. Further, we added accurate P-values for each analysis. - In addition to observing improvements in intrinsic muscle atrophy, did you perform any physical examinations to test the function of the intrinsic muscles? � In our study, we did not perform specific physical examinations to test the function of the intrinsic muscles. While there are clinical methods to assess intrinsic muscle strength, such as manual muscle testing, these methods can be subjective and may lack the sensitivity needed for quantitative analysis in a research setting. We focused on objective measurements like grip strength, light touch perception, and static two-point discrimination, which provided reliable and reproducible data for evaluating the outcomes of our surgical technique. - As you mentioned in the introduction (lines 54-56), submuscular transposition reduces intraneural ulnar nerve pressure. In your method, will the area of the proximal flap, the proximal-based fascial layer of the middle third of the flexor-pronator mass, cause increased intraneural ulnar nerve pressure, since this part involves only subfascial nerve transfer? � As we mentioned at the materials and method section, musculofascial lengthening by loose suturing did not lead to increased intraneural ulnar nerve pressure. Conclusion: I would consider this a modified musculofascial lengthening technique rather than a novel one. � Page 8 (Line 205): We changed the phrase “novel musculofascial lengthening technique” to “modified musculofascial lengthening technique” following your comments. Attachments Attachment Submitted filename: Respone to Reviewers.docx https://doi.org/10.1371/journal.pone.0318303.r002
17 Oct 2024 Decision Letter - Emiliano Cè, Editor PONE-D-24-12479R1Modified musculofascial lengthening technique for submuscular ulnar nerve transposition in cubital tunnel syndromePLOS ONE Dear Dr. Kim, 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. ============================== ACADEMIC EDITOR: Dear Authors, your R1 manuscript version has been reviewed by one expert in the field that retrieved some minor issues you should consider during the revision process. Please submit your revised manuscript by Dec 01 2024 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 #2: 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: I Don't Know ****** 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 #2: 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 #2: 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 #2: The manuscript has undergone a thorough revision, and all questions and suggestions have been addressed well. I would recommend, if possible, that the authors include the results of tests for ulnar nerve intrinsic muscle function before and after surgery to demonstrate any recovery of ulnar intrinsic muscle function, such as Froment's test, the Crossed Finger test, and Wartenberg's sign. If this is not feasible, the authors should mention in the limitations section the absence of complete data from intrinsic muscle testing to demonstrate postoperative improvement. ****** 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 #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.0318303.r003
Revision 2
1 Jan 2025 Author Response Reviewer #2: The manuscript has undergone a thorough revision, and all questions and suggestions have been addressed well. I would recommend, if possible, that the authors include the results of tests for ulnar nerve intrinsic muscle function before and after surgery to demonstrate any recovery of ulnar intrinsic muscle function, such as Froment's test, the Crossed Finger test, and Wartenberg's sign. If this is not feasible, the authors should mention in the limitations section the absence of complete data from intrinsic muscle testing to demonstrate postoperative improvement. � Page 9 (Line 203-4): Thank you for your insightful suggestion. In our study, we did not perform specific physical examinations to test the function of the intrinsic muscles innervated by the ulnar nerve, such as Froment's sign, Crossed Finger test, and Wartenberg's sign. We acknowledge that this is a limitation of our study. We have now included a statement in the limitations section to address this point: Attachments Attachment Submitted filename: Respone to Reviewers.docx https://doi.org/10.1371/journal.pone.0318303.r004
14 Jan 2025 Decision Letter - Emiliano Cè, Editor Modified musculofascial lengthening technique for submuscular ulnar nerve transposition in cubital tunnel syndrome PONE-D-24-12479R2 Dear Dr. Kim, 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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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, Ph.D. 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 #2: 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: I Don't Know ****** 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 #2: 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 #2: 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 #2: The authors have made significant improvements to this manuscript after a series of revisions. I believe the manuscript is now qualified for acceptance. ****** 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 #2: No ******** https://doi.org/10.1371/journal.pone.0318303.r005
Formally Accepted
20 Jan 2025 Acceptance Letter - Emiliano Cè, Editor PONE-D-24-12479R2 PLOS ONE Dear Dr. Kim, I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now being handed over to our production team. At this stage, our production department will prepare your paper for publication. This includes ensuring the following: * All references, tables, and figures are properly cited * All relevant supporting information is included in the manuscript submission, * There are no issues that prevent the paper from being properly typeset If revisions are needed, the production department will contact you directly to resolve them. If no revisions are needed, you will receive an email when the publication date has been set. At this time, we do not offer pre-publication proofs to authors during production of the accepted work. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few weeks to review your paper and let you know the next and final steps. Lastly, 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 customercare@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 Prof. Emiliano Cè Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0318303.r006

Open letter on the publication of peer review reports

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

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

Learn more at ASAPbio .