Prevalence and morphometry of the fabella in cadaveric and radiological studies: Is there a link to knee osteoarthritis?

Ebru Yolaçan; Nurcan Ercıktı; Barış Baykal; Uğur Bozlar; Necdet Kocabıyık; Mehmet Ali Güner; Necati Salman; Ayşe Özdemir; Mislina Utlu; Laçin Ramazanlı

doi:10.1371/journal.pone.0340399

Peer Review History

Original SubmissionSeptember 23, 2025
4 Nov 2025 Decision Letter - Srinivasa Rao Sirasanagandla, Editor PONE-D-25-50561-->-->PREVALENCE AND MORPHOMETRY OF THE FABELLA IN CADAVERIC AND RADIOLOGICAL STUDIES: IS THERE A LINK TO KNEE OSTEOARTHRITIS?-->-->PLOS ONE?> Dear Dr. YOLACAN, 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 Dec 19 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. 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You also have the option of uploading the data as Supporting Information files, but we would recommend depositing data directly to a data repository if possible. We will update your Data Availability statement on your behalf to reflect the information you provide. 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information . 6. 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. 7. 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 If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references.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. Additional Editor Comments: The manuscript is well written and clinically relevant. Consider adding the following published article on the Omani population in the table and discussion section. Al Matroushi OD, Sirasanagandla SR, Al Shabibi A, Al Obaidani A, Al Dhuhli H, Jaju S, Al Mushaiqri M. Radiological study of fabella in Omani subjects at a tertiary care center. Anatomy & Cell Biology. 2021 Sep 30;54(3):315-20. Correct the grammar and language throughout the manuscript. 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: 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 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: 1.Reference introduction first paragraph, If fabella is absent do you think the above functions are compromised? 2.In the literature, it is generally reported to be more common in Asia [5-7]. Current studies in the literature indicate that fabella is common in Asian countries. Merge these sentences 3.while the radiological part aimed to examine the prevalence of fabellae, lateralization pattern, genders distribution replace genders with gender 4. In the 2.1 section, In our study, 32 formaldehyde-fixed cadavers (6 six females, 26 males) and 3 three male specimens (How do you ascertain the sex by leg ) (2 two left legs, 1 one right leg) aged between 60 to 85 years were dissected in the anatomy 5. The right legs of both (two) female cadavers were amputated. 6. gastrocnemius muscle were palpated (identified) by dissection in the posterior region of the knee 7. The fabellae were decalcified in 20% EDTA solution for 8 (eight) days 8. It was determined that 2 (two) of these structures were muscular tissue 9. The prevalence of fabella in patients (patient) individuals did not differ significantly 10. Table 3 last column should be prevalence 11. In our work, due to comparing fabella measurements according to gender, the right fabella length (SI) was found to be 10.46±1.19 mm in males and 10.90 mm in females. Right fabella thickness (AP) was 4.23±1.42 mm in males and 3.95 mm in females. Left fabella SI was 10.83±0.68 mm in males and 12.45±1.39 mm in females; left fabella AP was 4.02±0.69 mm in males and 4.49±0.77 mm in females (n general females bone are said to be smaller than males. How would you justify the reason for high values in female 11. Table 4 last column should be prevalence Reviewer #2: Kindly got through the detailed review remarks and make necessary changes and resubmit Review report: PREVALENCE AND MORPHOMETRY OF THE FABELLA IN CADAVERIC AND RADIOLOGICAL STUDIES: IS THERE A LINK TO KNEE OSTEOARTHRITIS? The prevalence and morphometry of the fabella in a Turkish population, as well as any possible connections to osteoarthritis (OA), are discussed in this study that combines cadaveric, histological, and radiographic investigations. To improve readability, flow, and clarity, however, some small changes are required, particularly in the Introduction, Results, and Discussion sections. Minor terminology and statistical expression errors should be fixed, and certain phrases can be made shorter. Introduction: • Condense the repeated statements about fabella prevalence and Asian populations. • Clarify cultural reasoning: why the higher prevalence in Asian populations is thought to be associated with habitual kneeling and squatting postures and which may increase mechanical stimulation and ossification of the fabella.” • Last paragraph can be ended with more clearer research aim /objectives Results • Provide confidence intervals (if available) for key prevalence figures. • Add a brief linking statement before each table to improve flow, For example-Table 1 summarizes the distribution of fabella by sex. • Use table only legends when it is shown in the table (such as asterisks in table-2 used in the legend, but it is not shown in the content values) • In table -3, use of symbol % - should be in consistent with that of text. Generally it is used after number (eg. 14%.... ) Kindly check this Discussion Some paragraphs repeat details from the Results. Avoid repetition to make it concise and consider to condense to focus on interpretation. You may add a paragraph explicitly discussing possible biomechanical explanations for the lack of association between fabella and OA. ****** 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.] To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation. NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications. Attachments Attachment Submitted filename: PONE-D-25-50561.pdf Attachment Submitted filename: Review report_PLOS.docx https://doi.org/10.1371/journal.pone.0340399.r001
Revision 1
11 Dec 2025 Author Response Dear Editor, Manuscript Title: Prevalence and Morphometry of the Fabella in Cadaveric and Radiological Studies: Is There a Link to Knee Osteoarthritis? Corresponding Author: Ebru YOLAÇAN, MD Thank you for handling our manuscript and for forwarding it to the reviewers. Our point-by-point responses to the reviewers' comments are provided below. All changes and additions in the revised manuscript have been highlighted. In line with the editor’s recommendation, the study by Al Matroushi et al. (2021) (Ref.31) has also been incorporated into the relevant comparative table. Dear Reviewer #1 and Reviewer #2, Thank you for your valuable time and for your insightful and constructive critiques of our manuscript. In our commitment to improving the methodological rigor and clinical relevance of our study, we have carefully considered all of your suggestions and have implemented comprehensive revisions accordingly. Our point-by-point responses to your comments are presented below. Revisions made in response to Reviewer #1 are highlighted in yellow, and revisions made in response to Reviewer #2 are highlighted in light green. As we did not use line numbers in the revised manuscript, the changes have been indicated directly within the relevant sections using the specified highlight colors. CORRECTIONS: Authors’ response to Reviewer: 1 1. Reference introduction first paragraph, If fabella is absent do you think the above functions are compromised? Author’s Response: Dear Reviewer, thank you so much for your helpful question and feedback about what it means when the fabella is missing. We agree that this is an essential point that gives our results a lot of clinical context. We have completely rewritten our manuscript to address this point in response to your question. We didn't directly measure the fabella's function because our study was only on its prevalence and shape. We have now improved the Discussion section by adding a new paragraph that looks at what would happen if it is not present, based on a synthesis of the current literature. The new paragraph suggests that not having the fabellofibular complex could make the posterolateral stability less stable. It also says that losing its pulley-like action could make the gastrocnemius less mechanically efficient and more likely to get stressed by friction. We have backed up these theoretical statements by the right citations from the literature [1, 17, 40], which is very important. We also want to stress that the fabella is not always present in people, and that the body's compensatory mechanisms imply that this does not indicate that most people have functional failure. We think that adding this immediately addresses the interesting topic you mentioned and makes our article much more relevant to the conversation and the clinic. 2. In the literature, it is generally reported to be more common in Asia [5-7]. Current studies in the literature indicate that fabella is common in Asian countries. Merge these sentences Author’s Response: Thank you for this helpful suggestion. The two sentences have been merged to improve clarity and avoid repetition. The revised sentence now reads as follows: “In the literature, fabella prevalence is generally reported to be higher in Asian populations, and recent studies further support that it is particularly common in Asian countries [3, 5–7].” The change has been incorporated into the revised manuscript. 3. While the radiological part aimed to examine the prevalence of fabellae, lateralization pattern, genders distribution replace genders with gender Author’s Response: Thank you for pointing this out. The term “genders distribution” has been corrected to “gender distribution” in the revised manuscript. 4. In the 2.1 section, In our study, 32 formaldehyde-fixed cadavers (6 six females, 26 males) and 3 three male specimens (How do you ascertain the sex by leg ) (2 two left legs, 1 one right leg) aged between 60 to 85 years were dissected in the anatomy. Author’s Response: Thanks for these helpful suggestions. The suggested changes regarding the phrasing, numerical style, and terminology have been provided in the revised paper. As suggested, the words "six," "three," "two," and "one" have been changed, and the phrase "leg specimens" has been added to make things clearer. Your note also says that the age range has been changed to "aged 60 to 85 years." We would like to go into more information about how sex was determined for the isolated limb specimens in response to your question. The isolated lower-limb specimens individually did not determine sex. All of the bodies and limbs we have in our lab have identifying numbers attached to the auricle or great toe. These numbers match the official anatomical inventory records of the institution. These documents show the person's sex, age, year of body donation, and cause of death. Consequently, the sex of the three isolated lower-limb specimens was directly derived from these institutional data. Moreover, despite being classified as “leg samples,” the proximal soft tissues were well preserved to permit visibility of the genital region, offering a secondary anatomical confirmation that was entirely congruent with the inventory data. The study did not include any specimens whose sex was unknown or could not be determined. This explanation has now been added to the Materials and Methods section to make sure there is no confusion. All of the suggested changes have been made, and the new version shows these changes. Thanks again for your helpful feedback and thorough assessment. 5. The right legs of both (two) female cadavers were amputated. Author’s Response: We thank the reviewer for pointing this out. The sentence has been revised for clarity as suggested and now reads: "The right legs of two female cadavers were amputated." 6. gastrocnemius muscle were palpated (identified) by dissection in the posterior region of the knee Author’s Response: We thank the reviewer for this precise and accurate correction. The sentence has been rephrased as recommended and now reads: "The lateral and medial heads of the gastrocnemius muscle were identified by dissection in the posterior region of the knee and fibrocartilaginous structures were investigated." 7. The fabellae were decalcified in 20% EDTA solution for 8 (eight) days Author’s Response: The phrase has been corrected to ‘for eight days’ in accordance with the recommended numerical style, and consistency has been ensured throughout the manuscript. 8. It was determined that 2 (two) of these structures were muscular tissues Author’s Response: The expression has been revised as ‘two of these structures’ to maintain consistency in numerical style across the manuscript. 9. The prevalence of fabella in patients (patient) individuals did not differ significantly Author’s Response: The wording has been corrected to ‘in patient individuals’ in line with the reviewer’s recommendation. 10. Table 3 last column should be prevalence Author’s Response: Thank you for bringing this to our attention. The heading of the last column in Table 3 has been revised to ‘Prevalence’ as suggested. 11. In our work, due to comparing fabella measurements according to gender, the right fabella length (SI) was found to be 10.46±1.19 mm in males and 10.90 mm in females. Right fabella thickness (AP) was 4.23±1.42 mm in males and 3.95 mm in females. Left fabella SI was 10.83±0.68 mm in males and 12.45±1.39 mm in females; left fabella AP was 4.02±0.69 mm in males and 4.49±0.77 mm in females (n general females bone are said to be smaller than males. How would you justify the reason for high values in female Author’s Response: Thank you for this thoughtful observation. We carefully reviewed the sex-based morphometric data and provide the following clarification in the revised manuscript. Although some fabella measurements appeared slightly higher in females, these differences were not statistically significant (p> 0.05). We interpret these small discrepancies as the result of individual anatomical variation rather than true sexual dimorphism, particularly because our sample included only six female cadavers, which limits generalizability. Importantly, sesamoid bones such as the fabella do not follow the typical patterns of skeletal sexual dimorphism. Their presence, size, and ossification level are influenced much more strongly by local biomechanical loading, genetic predisposition, and tendon–muscle mechanics rather than by sex-related differences in overall bone size. As noted by Berthaume and Bull (ref. 15), the capacity to form a fabella is genetically determined, while its dimensions are shaped by environmental and mechanical stressors. Accordingly, the slightly higher measurements in females in our dataset likely reflect individual biomechanical variability combined with the small female sample size, rather than representing a biologically meaningful trend. We have added this explanation to the Discussion section to improve clarity. 12. Table 4 last column should be prevalence Author’s Response: Thank you for the correction. The last column of Table 4 has been revised and is now correctly labeled as “Prevalence.” The updated version is included in the revised manuscript. Authors’ response to Reviewer: 2 Introduction: Reviewer's Comment: Condense the repeated statements about fabella prevalence and Asian populations. Authors' Response: We thank the reviewer for this suggestion. As recommended, we have condensed the repeated statements regarding fabella prevalence in Asian populations into a single, more concise sentence in the Introduction/Discussion (as appropriate) to improve the flow and avoid redundancy. However, since our other reviewer also requested the same correction, it has been highlighted in yellow in the text. The revised text now states: "In the literature, fabella prevalence is generally reported to be higher in Asian populations, and recent studies further support that it is particularly common in Asian countries [3, 5-7]." Reviewer's Comment: Clarify cultural reasoning: why the higher prevalence in Asian populations is thought to be associated with habitual kneeling and squatting postures and which may increase mechanical stimulation and ossification of the fabella.” Authors' Response: Thank you for this valuable comment. In line with your suggestion, we have expanded upon the cultural and biomechanical rationale for the higher prevalence of the fabella in Asian populations and incorporated this explanation into the Introduction. In the revised text, we clarify that kneeling and squatting postures—common in many Asian societies—expose the fabellar region to sustained mechanical compression against the posterior aspect of the lateral femoral condyle. Furthermore, in accordance with Wolff's law, we state that such repetitive loading facilitates the ossification of the primordial cartilaginous template of the fabella. The relevant section has been highlighted in light green in the revised manuscript for your convenience. Reviewer's Comment: Last paragraph can be ended with more clearer research aim /objectives Authors' Response: We thank the reviewer for this valuable comment. As suggested, the final paragraph of the Introduction has been revised to state the research aims more clearly and explicitly. The new text now reads: "The purpose of this study was to (1) define the morphometric properties of the fabella via cadaveric dissection and (2) investigate its prevalence, lateralization pattern, gender distribution, and association with knee osteoarthritis using radiological examination in the Turkish population. This study aimed to address the lack of literature data on this subject specific to the Turkish population." We believe this revision provides a much clearer and more direct statement of the study's objectives. We thank the reviewer for the constructive feedback. Results Reviewer's Comment: Provide confidence intervals (if available) for key prevalence figures Authors' Response: In line with the recommendation, 95% confidence intervals (CIs) have now been calculated and added for all key prevalence values reported in the manuscript. The Results section has been updated accordingly and now includes the following figures: • Overall radiological prevalence: 36.5% (95% CI: 35.0%–38.0%) • Female prevalence: 35.6% (95% CI: 33.9%–37.3%) • Male prevalence: 39.5% (95% CI: 36.4%–42.6%) • Cadaveric prevalence: 18.4% (95% CI: 9.8%–30.0%) Additionally, as suggested, the 95% CI for the prevalence difference between the osteoarthritis and control groups has been incorporated into the Discussion section (OA – Control: 1.9%; 95% CI: –1.1% to 4.9%). Since this interval includes zero, it supports our conclusion that there is no statistically significant association between fabella presence and knee osteoarthritis. All confidence intervals have been incorporated into the revised manuscript and the corresponding additions have been highlighted for the reviewer’s convenience. Reviewer's Comment: Add a brief linking statement before each table to improve flow, For example-Table 1 summarizes the distribution of fabella by sex. Authors' Response: Thank you for your valuable feedback and for suggesting we add linking statements to improve the flow of the manuscript. We are pleased to inform you that we have already implemented this suggestion. As per your recommendation, we have added concise introductory sentences before each table to clearly signpost their content. The added statements are as follows: • Table 1 is now introduced with: "Table 1 summarizes the distribution of fabella by sex." • Table 2 is now introduced with: "Table 2 presents the distribution of unilateral and bilateral fabellae, as well as right- and left-sided occurrence, in patient and healthy individuals." • Table 3 is now introduced with: "Table 3 provides cadaver-based fabella prevalence values previously reported in the literature." • Table 4 is now introduced with: "Table 4 summarizes radiology-based prevalence values from different populations worldwide." We agree that these additions significantly enhance the readability and logical structure of the results section, and we thank you for this constructive comment. Reviewer's Comment: Use table only legends when it is shown in the table (such as asterisks in table-2 used in the legend, but it is not shown in the content values) Authors' Response: Thank you very much for pointing out the inconsistency in the legend of Table 2. Following your feedback, we conducted a thorough re-check of our statistical tables and their corresponding legends. You are correct. We identified that the legend for Table 2 contained a note referencing statistical symbols (such as * and *) that were not actually used in the table itself. To resolve this inconsistency, we have ensured the legend aligns precisely with the symbols used in the table by removing all explanations for symbols not present in the data presentation. Reviewer's Comment: In table -3, use of symbol % - should be in consistent with that of text. Generally it is used after number (eg. 14%.... ) Kindly check this Authors' Response: Thank you for your valuable comment regarding the "consistency in the use of the % symbol." As per your suggestion, we have reviewed Table 3 and corrected all values in the "Prevalence" column to ensure they consistently follow the number-first format (e.g., 27%) throughout the manuscript. Discussion Reviewer's Comment: Some paragraphs repeat details from the Results. Avoid repetition to make it concise and consider to condense to focus on interpretation. Authors' Response: We agree that some paragraphs in the Discussion section contained unnecessary repetitions of results. As suggested, we have thoroughly revised the Discussion to eliminate these redundancies. The focus has been shifted from re-stating the findings to providing a deeper interpretation of their significance. Reviewer's Comment: You may add a paragraph explicitly discussing possible biomechanical explanations for the lack of association between fabella and OA. Authors' Response: We appreciate your valuable feedback. In line with your comment, we have added a special paragraph Attachments Attachment Submitted filename: Response to reviewers.docx* https://doi.org/10.1371/journal.pone.0340399.r002
21 Dec 2025 Decision Letter - Srinivasa Rao Sirasanagandla, Editor Prevalence and Morphometry of the Fabella in Cadaveric and Radiological Studies: Is There a Link to Knee Osteoarthritis? PONE-D-25-50561R1 Dear Dr. Ebru YOLACAN, 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, Srinivasa Rao Sirasanagandla Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0340399.r003
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Acceptance Letter - Srinivasa Rao Sirasanagandla, Editor PONE-D-25-50561R1 PLOS One Dear Dr. Yolaçan, 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. Srinivasa Rao Sirasanagandla Academic Editor PLOS One https://doi.org/10.1371/journal.pone.0340399.r004

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