Author's response to reviews Title:Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors Authors: Guntmar Gradl ([email protected]) Lukas K Postl ([email protected]) Josef Stolberg-Stolberg ([email protected]) Ulrich Lenze ([email protected]) Florian Pohlig ([email protected]) Hans Rechl ([email protected]) Rüdiger von Eisenhart-Rothe ([email protected]) Chlodwig Kirchhoff ([email protected]) Version:4Date:5 August 2015 Author's response to reviews: see over

Klinikum rechts der Isar

Klinikum rechts der Isar Anstalt des öffentlichen Rechts

Klinikum rechts der Isar – UC –· 81664 München

Klinik und Poliklinik für Unfallchirurgie Überregionales Traumazentrum Univ.-Prof. Dr. Peter Biberthaler Direktor

Dott. Umile Giuseppe Longo Section Editor BMC Musculoskeletal Disorders

München, 05.08.2015

Dear Doctor Longo,

Thank you very much for the kind consideration of our manuscript 1939370737141680 “Long-term functional outcome and quality of life following rotationplasty for treatment of malignant tumors”

I deeply appreciate the efforts of the reviewer Dr. Andreou to improve the final manuscript. I also want to explicitly thank the editor for recognizing the value of our data and not rejecting the manuscript on a previous stage. I finally fulfilled my duty as a senior author now and rewrote whole sections of the manuscript. Now I regard the manuscript being substantially improved complying with the requirements of BMC Musculoskeletal Disorders.

In the following I will explain the revisions giving a point-by-point response. Hence it is a privilege to resubmit the revised version.

Indexed overview of reviewers’ comments: Dimosthenis Andreou

1.

Technische Universität München

The article still has several grammatical and syntactical errors (e.g. line 46: " Vitality was 75.0 ± 12.8, social functioning, social functioning turned out to be 98.9 ± 3.6," lines 65-67: "In comparing treatment with endoprosthesis to major amputation or arthrodesis walking efficiency defined by energy consumption and musculoskeletal tumor society score (MSTS) are significantly better" lines 75-76: "The main hypothesis of this study was, that patients with rotationplasty show similar results in physical and psychical health according to the SF36v2 (The Short Form (36) Health Survey) than a representative German sample" etc.)

Ismaninger Straße 22 81675 München www.unfallchirurgie.mri.tum.de E-Mail: [email protected] Tel: (089) 41 40 – 21 26 Fax: (089) 41 40 – 48 90 www.trauma-muenchen,de Sprechstunden: BG Sprechstunde für Arbeits- und Wegeunfälle täglich, Spezialsprechstunden nach Fachgebiet. (089) 4140-7390 Montag (13-16 Uhr) Univ.- Prof. Dr. Biberthaler Privatsprechstunde, Schultertraumatologie, obere Extremität, Hüfte, Polytrauma Business Sprechstunde (16-18Uhr) Univ.- Prof. Dr. Biberthaler Dienstag (13-15 Uhr) Lt. OA PD Dr. Lucke / Gf. OA PD Dr. Huber-Wagner Wirbelsäule, Becken, Hüfte, Pseudarthrosen Mittwoch (9-12 Uhr) OA Dr. Neumaier FOA Dr. Sandmann Rekonstruktive Chirurgie, untere Extremität Donnerstag (13-16 Uhr) FOA PD Dr. Kirchhoff FOA Dr. Siebenlist Obere Extremität, Ellbogen Freitag (12-14 Uhr ) FOA Dr. Patrick Delhey Extremitätenrekonstruktion Freitag (14-16 Uhr) FOA Dr. Patrick Delhey Fixateur-Sprechstunde Mo - Do (9-12 und 14-16 Uhr), Frei nach Vereinbarung OA Dr. Deiler Traumatologische Handambulanz Interdisziplinäres Hand-Zentrum IHZ Vorstand: Univ.-Prof. Dr. Reiner Gradinger (Ärztlicher Direktor, Vorsitzender) Andreas Holzner (Stellv. Kaufmännischer Direktor) Anette Thoke-Colberg (Pflegedirektorin) Univ.-Prof. Dr. Peter Henningsen (Dekan) Bankverbindung: Bayer. Landesbank Girozentrale Kto-Nr. 20 272 BLZ 700 500 00 BIC: BYLADEMM IBAN: DE82 7005 0000 0000 0202 72 USt-IdNr. DE 129 52 3996

Klinikum rechts der Isar

and needs to be extensively edited by a native speaker. The reviewer is more than right. The whole manuscript has been extensively reedited and reviewed by a native speaker. Especially all mentioned mistakes have been eliminated.

2.

Lines 117-122: Unneccesarily repeated informations: "Twelve of these 23 patients were enrolled in the study. Nine patients could not be included as they were dead of diseasevat the time the study was performed. Two patients were lost for follow-up. There were 7 males, 5 females with a median age at treatment of 19 ± 10 years of age and a median age of 33 ± 11 years of age at the time of follow up. Two of the remaining eleven patients, were lost to follow up (8.7%) and nine patients died due the disease (39.1%). No excuses, the section has been rewritten and significantly condensed.

3.

Table 1: It is not reasonable to state percentages when the study included well under 100 patients - 12 in this case, as noted in the first comments to the authors. All percentages have been eliminated from the table. I feel sorry, that it has not been done in our last draft.

4.

Lines 141-142 read: "The results for the psychosocial outcome as measured by the SFv2-36 are also reported in Error! Reference source not found." This obviously needs to be corrected. For once it has not been our fault and “Error” appeared due to a hyperlink within Microsoft Word. However, it has been corrected.

5.

Line 144-145: "The mean age in our series was 33 ±11 years and in the representative German sample it was 48,9 ± 18,1 years of age." Decimals should be given with ".", not "," Commas have been replaced by dots.

6.

Line 145: "There were five female (41.7%) and six male persons (58.3%) in our series". What about the 12th study participant? The number “six” of course was wrong. However, at least the percentage (58.3%) has been accurately calculated. We corrected “six” to “seven”.

7.

Lines 155-156 read: ""±0.43, median 3, range 3-4) and gait 2.58 (SD ±0.95, median 3, range 0-4) (Error! Reference source not found.)." Again, this is due to a hyperlink, that now has been eliminated.

Technische Universität München

Klinikum rechts der Isar

8.

Lines 185-187: "Nevertheless, initiation of social and intimate contact, body image and sexuality are negatively affected in more than one third of patients with rotationplasty..." Does this sentence reflect the results of the authors or the conclusions of other studies? Have the authors examined these aspects in their patients? If not, why not? The sentence does not reflect our results. It is a citation of the work of Veenstra et al.

9.

Lines 198-203: It would be helpful, if the authors chose to state either percentage scores or the absolute MSTS scores throughout their manuscript, rather than alternately using both. We now use only MSTS percentage scores within the whole manuscript.

10.

Discussion: Should be edited to allow the reader to draw clear conclusions The whole discussion has been rewritten.

11.

Conclusions: The authors state that "rotationplasty remains a viable treatment option and salvage procedure in revision cases after tumor prostheses for patients with malignant bone tumors of the femur." This cannot be a conclusion of this study, as no patient described had a rotationsplasty as a salvage procedure. Of course the reviewer is right. We also rewrote the conclusions and eliminated this phrase.

12.

The reference list also needs to be edited, as the references are not presented in a homogeneous way. The reference list is created using EndNote. Usually during the upload of a manuscript the editorial manager reformats EndNote libraries. So, as an exception this has not been our fault.

13.

Table 1: What do the authors mean with "Borggreve Rotationplasty 10 (83.3%) Winkelmann Rotationplasty 2 (16.7%)" under treatment? This information is misleading and has been eliminated.

14.

Results: Did the synovial sarcoma patient underwent chemo- or radiation treatment? We added treatment information for this patient.

Technische Universität München

Klinikum rechts der Isar

15.

Line 162: "Flexion and Extension was normal" - of the neo-knee?

Thank you. We rewrote the clinical examination section as well and especially clarified this issue.

We hope that our revised manuscript now meets the criteria for publication in BMC Musculoskeletal Disorders.

Respectfully, Chlodwig Kirchhoff, MD

Technische Universität München