Medial pivot designs result in improved patient reported outcome measures and range of motion when compared to cruciate retaining total knee replacements: A systematic review and meta-analysis

Darren Puttock; Akhilesh Pradhan; Pip Divall; Amit Bishnoi; Arijit Ghosh; Seth O'Neill; Randeep Singh Aujla

doi:10.1371/journal.pone.0332548

Peer Review History

Original SubmissionJune 13, 2025
25 Sep 2025 Decision Letter - Sarah Jose, Editor Dear Dr. O'Neill, Please submit your revised manuscript by Nov 08 2025 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. 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, Sarah Jose, Ph.D. 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 2. We notice that Figure 1 is uploaded with the file type “Other”, to which you refer in your text on pages 10 and 11. Please amend the file type to “Figure”. If the figure is no longer to be included as part of the submission please remove all reference to it within the text. If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise. [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? Reviewer #1: Partly 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 Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: I thank the Editor for the invitation to review this manuscript. I was co-first author on the included Dowsey 2020 article and I wish to make it clear that my comments are in no way influenced by this - I make no specific comments regarding that article in terms of giving it any sort of special treatment. I believe this is a mostly methodologically sound review and a good fit for the journal, however I have a number of comments I believe need to be addressed prior to recommending acceptance for publication. - Could be made clearer in the Introduction re: when the most recent systematic reviews were published, to help justify this new review - AMPQQ acronym (and all acronyms, for that matter) needs to be defined at first use - Inclusion criteria included studies of high quality. Therefore, studies underwent critical appraisal then low quality studies were excluded? I do not recommend this approach. Essentially this constitutes a sensitivity analysis from the outset - - Related to this: critical appraisal should be in Results, not Methods. I understand why it is currently in the Methods section, but I disagree this methodological choice (i.e. using critical appraisal as part of the article screening process). A systematic review should include all relevant literature, and then the low quality studies can potentially be excluded in a sensitivity analysis but would still be included in the review overall. - Was forward and backward citation chasing conducted? - Has the search been re-run since July 2024? It has now been 12 months so this would be recommended. However, citation chasing may be a potentially acceptable alternative if conducted now to identify more recent publiations. - I recommend reporting prediction intervals and emphasising these over i-squared values when reporting on heterogeneity. Relevant references: Borenstein 2023 - Avoiding common mistakes in meta-analysis: Understanding the distinct roles of Q, I-squared,tau-squared, and the prediction interval in reporting heterogeneity; IntHout 2016 - Plea for routinely presenting prediction intervals in meta-analysis - Please provide more detail on the GRADE synthesis methodology, especially considering GRADE should be used to synthesise the entire body of evidence rather than each individual paper (which is what table 2 suggests) - Suggest using separate risk of bias tool for RCTs - Was there any plan for narrative synthesis, or only meta-analysis? Reviewer #2: Dear Authors, Thank you for submitting this interesting systematic review and meta-analysis.My suggestions to improve the article are as follows: 1. Discuss substantial clinical benefit, which was initially proposed by Glassman et al. for the PROMS as the absence of SCB in the selected studies is a limitation.The CORR study by Lyman et al : What Are the Minimal and Substantial Improvements in the HOOS and KOOS and JR Versions After Total Joint Replacement? Clin Orthop Relat Res. 2018 Dec;476(12):2432-2441 mentions (MCID) using distribution- and anchor-based approaches and the difference that can be considered a large improvement in joint health (substantial clinical benefit) using an anchor-based approach.Surprisingly this article is also missing from the references and the findings of this article are very relevant to this review. 2. A funnel plot is highly desirable to check for publication bias. Reviewer. ****** 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: Daniel Gould Reviewer #2: Yes: Prof. Roop Bhushan Kalia ******** [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.0332548.r001
Revision 1
1 Dec 2025 Author Response Response to Reviewers Dear reviewers, We sincerely thank you for your time and input reviewing our manuscript. We have considered all points raised and incorporated your valuable input into the revised version. Please see below our responses to each point raised. Reviewer 1: 1. Reviewer: Could be made clearer in the Introduction re: when the most recent systematic reviews were published, to help justify this new review Response: We thank you for this suggestion and have clarified the publications years of the quoted evidence accordingly. 2. Reviewer: AMPQQ acronym (and all acronyms, for that matter) needs to be defined at first use Response: Noted, thank you for highlighting this, AMQPP now defined within text. 3. Reviewer: Inclusion criteria included studies of high quality. Therefore, studies underwent critical appraisal then low quality studies were excluded? I do not recommend this approach. Essentially this constitutes a sensitivity analysis from the outset Response: Whilst we appreciate the concerns regarding the inclusion criteria, this approach was agreed with all authors within the group in order to draw conclusions only from robust, unbiased trials. Such an approach is common within this field and as such we feel this is acceptable. Although this does potentially constitute a sensitivity analysis, no study ended up being excluded on the basis of quality alone. 4. Reviewer: Related to this: critical appraisal should be in Results, not Methods. I understand why it is currently in the Methods section, but I disagree this methodological choice (i.e. using critical appraisal as part of the article screening process). A systematic review should include all relevant literature, and then the low quality studies can potentially be excluded in a sensitivity analysis but would still be included in the review overall. Response: Many thanks for highlighting this concern. Text and tables relative to critical appraisal of identified studies has been moved to the results to avoid confusion relating to our methodology. 5. Reviewer: Was forward and backward citation chasing conducted? Response: Yes, forward and backwards citation chasing was conducted. 6. Reviewer: Has the search been re-run since July 2024? It has now been 12 months so this would be recommended. Response: The search was repeated on 22/10/2025 and summarised in the PRISMA diagram. 25 new potentially eligible articles were retrieved, with 24 excluded on abstract screening. One article underwent full text screening however was excluded on the basis of data reporting methodology. 7. Reviewer: I recommend reporting prediction intervals and emphasising these over i-squared values when reporting on heterogeneity. Relevant references: Borenstein 2023 - Avoiding common mistakes in meta-analysis: Understanding the distinct roles of Q, I-squared,tau-squared, and the prediction interval in reporting heterogeneity; IntHout 2016 - Plea for routinely presenting prediction intervals in meta-analysis Response: Thank you for highlighting this to us, we have since calculated the prediction intervals and included these within the results section. Due to the fact that I2 is commonly used we have opted to also retain these within the manuscript but appreciate the merits of prediction intervals over I2 values, hence their inclusion. 8. Reviewer: Please provide more detail on the GRADE synthesis methodology, especially considering GRADE should be used to synthesise the entire body of evidence rather than each individual paper (which is what table 2 suggests) Response: The Grade synthesis used was determine the certainty of results obtained for each patient reported outcome measure utilised in the analysis. Decisions made regarding each domain were reached via discussion and analysis of each study by authors AP and DP. Where there was disagreement or uncertainty, an opinion from senior author RSA was sought. Table 2 demonstrates this process being conducted for each outcome measure individually and include information relating to the number of studies which included this measure as well as the number of patients for whom a result was obtained. Further information on this process added to manuscript as shown by tracked changes. 9. Reviewer: Suggest using separate risk of bias tool for RCTs Response: Thank you for this suggestion, risk of bias for included RCTs has been conducted using ROB2 tool and outlined within methods section. 10. Reviewer: Was there any plan for narrative synthesis, or only meta-analysis? Response: From the outset our plan was purely for meta-analysis. Reviewer 2: 1. Reviewer: Discuss substantial clinical benefit, which was initially proposed by Glassman et al. for the PROMS as the absence of SCB in the selected studies is a limitation.The CORR study by Lyman et al : What Are the Minimal and Substantial Improvements in the HOOS and KOOS and JR Versions After Total Joint Replacement? Clin Orthop Relat Res. 2018 Dec;476(12):2432-2441 mentions (MCID) using distribution- and anchor-based approaches and the difference that can be considered a large improvement in joint health (substantial clinical benefit) using an anchor-based approach.Surprisingly this article is also missing from the references and the findings of this article are very relevant to this review. Response: We would like to thank you for drawing this analysis method to our attention and agree its use and context is of value to this review and research area as a whole. Therefore a passage discussing substantial clinical benefit, its merits and potential use within the field has been added. 2. Reviewer: A funnel plot is highly desirable to check for publication bias. Response: Thank you for this suggestion, funnel plots have been added to the results section of the manuscript. Attachments Attachment Submitted filename: Response to Reviewers final.docx https://doi.org/10.1371/journal.pone.0332548.r002
14 Jan 2026 Decision Letter - Dimitrios Sokratis Komaris, Editor MEDIAL PIVOT DESIGNS RESULT IN IMPROVED PATIENT REPORTED OUTCOME MEASURES AND RANGE OF MOTION WHEN COMPARED TO CRUCIATE RETAINING TOTAL KNEE REPLACEMENTS: A SYSTEMATIC REVIEW AND META-ANALYSIS PONE-D-25-32016R1 Dear Dr. O'Neill, 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. For questions related to billing, please contact billing support . 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, Dimitrios Sokratis Komaris, Ph.D Academic Editor PLOS One Additional Editor Comments (optional): Reviewers' comments: Reviewer's Responses to Questions Comments to the Author Reviewer #1: All comments have been addressed Reviewer #3: All comments have been addressed ******** 2. Is the manuscript technically sound, and do the data support the conclusions??> Reviewer #1: Yes Reviewer #3: Yes ****** 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 Reviewer #1: Yes Reviewer #3: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #3: Yes ****** Reviewer #1: I thank the authors for their comprehenasive responses to reviewers' comments, and the accompanying thorough revisions to the manuscript. There are a some aspects of the approach to this review which I personally would have treated differently. However, the authors have provided sufficient responses to my queries and adequately justified their methodological approach. I feel the result is a manuscript that is now suitable for publication, despite not necessarily being the same as I would have written. The authors have provided an extensive discussion and drawn appropriate conclusions. The omission of a funnel plot from the original submission was, in my opinion, justified considering there were fewer than 10 studies included in the meta-analysis. However, I commend the authors on the inclusion of a funnel plot at the request of the other reviewer. I look forward to reading this review in its published form. Reviewer #3: The authors have adequately addressed the reviewers' questions from the first round. I have no further comments. ****** 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 #3: No ******** https://doi.org/10.1371/journal.pone.0332548.r003
Formally Accepted
Acceptance Letter - Dimitrios Sokratis Komaris, Editor PONE-D-25-32016R1 PLOS One Dear Dr. O'Neill, 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 You will receive further instructions from the production team, including instructions on how to review your proof when it is ready. Please keep in mind that we are working through a large volume of accepted articles, so please give us a few days 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. You will receive an invoice from PLOS for your publication fee after your manuscript has reached the completed accept phase. If you receive an email requesting payment before acceptance or for any other service, this may be a phishing scheme. Learn how to identify phishing emails and protect your accounts at https://explore.plos.org/phishing. 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 Dr. Dimitrios Sokratis Komaris Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0332548.r004

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 .