Mid- to Long-Term Survival of Geriatric Patients with Primary Septic Arthritis of the Shoulder: A Retrospective Study over a Period of 20 Years

Round 1

Reviewer 1 Report

Abstract:

Lines 17-19: What is the outcome measure being evaluated in the Kaplan-meyer curve, repeat infection? Need for further surgery? Death? Please include this. Additionally what is meant by “germ spectrum” is this supposed to mean the types of bacteria isolated?

 

Introduction:

Line 35-36: please include the rates of septic arthritis specifically, so that the readers can understand the incidence of this issue.

Lines 41-43: quick relief is awkward wording, I would suggest saying “surgical debridement”

Line 47: the wording makes this seem as though bio-film formation causes hematogenous spread, which I don’t believe to be the case. Rather, bacteria that are capable of bio-film formation may also spread hematogenously.

 

Materials and Methods:

Line 104: “overview” is incorrect, should be “view” or “visualization.”

 

Results:

No issues

Discussion:

Lines 246-247: IS there any reason to hypothesize that those with osteoarthritis would have a different survivability compared to those without. I don’t understand why this was investigated. Please clarify in the introduction why this was something explored/considered. You discuss the theory of why those with osteoarthritis might get septic arthritis, but this paper didn’t look at this, it looked at the survivability in those that did develop septic arthritis.

Lines 259-260: please cite literature suggesting 204 surgeries is recommended, single event surgery is commonplace in many practices.

Lines 259-265: I think the higher mortality with multiple surgeries may be more representative of sicker patients with worse infections, thus predisposing them to higher morbidity and mortality rather than a result of having multiple surgeries. Correlation does not demonstrate causation.

 

The major limitation of this study is the lack of a control group. The survival curve may just be the standard survival curve for patients of this age cohort with these medical comorbidities regardless of having septic arthritis or not. For this study to have any impact there must be a comparison group of matched patients with similar ages/comorbidities, otherwise this is a basic correlation paper between septic arthritis and time of death. If this paper can include a comparison group than it would be significantly more impactful.

English was well done from a grammar standpoint, certain word choices and phrases were incorrect/not common. 

Author Response

Response to Reviewer:

Dear Reviewer,

Thank you very much for your time and effort put into reviewing of our manuscript. We appreciate the suggestions and requested changes during your review and try to keep up with the suggestions. Please find our detailed corrections below.

Abstract:

Question 1: Lines 17-19: What is the outcome measure being evaluated in the Kaplan-Meyer curve, repeat infection? Need for further surgery? Death? Please include this.

Response 1: The outcome measure demonstrated in the Kaplan-Meyer curves is death after diagnosis of infection in days. The sentence says: “Kaplan-Meyer curves were used for survival probability”. The definition is included in the text (line 18) now. We hope this statement helps to clarify this issue. Thank you for your suggestion.

Question 2 Additionally what is meant by “germ spectrum” is this supposed to mean the types of bacteria isolated?

Response 2: the term germ spectrum was used to describe the different types of bacteria isolated during the time of diagnosis. We changed the term to “types of bacteria” (line 23) instead of germ spectrum. Thank you very much for the hint.

Introduction:

Question 3: Line 35-36: please include the rates of septic arthritis specifically, so that the readers can understand the incidence of this issue.

Response 3: We included the specific rates of septic arthritis in the United Kingdom and Taiwan. (lines 34,35)

Question 4: Lines 41-43: quick relief is awkward wording, I would suggest saying “surgical debridement”

Response 4: Thank you very much for improving the writing. We changed it to “surgical debridement”. (line 42)

Question 5: Line 47: the wording makes this seem as though bio-film formation causes hematogenous spread, which I don’t believe to be the case. Rather, bacteria that are capable of bio-film formation may also spread hematogenously.

Response 5: You are perfectly correct. The sentence wasn’t understandable. I changed the sentence to: “(…) they can absent themselves from this state and cause hematogenous spread (…)”. (line 47, 48)

Materials and Methods:

Question 6 Line 104: “overview” is incorrect, should be “view” or “visualization.”

Response 6: Thank you for the improvement. We changed it just as you suggested. (line 104)

 

Results:

No issues

Discussion:

Question 7: Lines 246-247: Is there any reason to hypothesize that those with osteoarthritis would have a different survivability compared to those without. I don’t understand why this was investigated. Please clarify in the introduction why this was something explored/considered. You discuss the theory of why those with osteoarthritis might get septic arthritis, but this paper didn’t look at this, it looked at the survivability in those that did develop septic arthritis.

Response 7: We fully understand your point of view. Osteoarthritis is a predictive factor to get primary septic arthritis but doesn’t change the survival rate. We just deleted the section of Oeteoarthritis.

Question 8: Lines 259-260: please cite literature suggesting 2 surgeries is recommended, single event surgery is commonplace in many practices.

Response 8: We cited specific literature that suggests, more than one surgery is recommended depending on the severity of the disease and status of the patient. (line 237)

Point 9: Lines 259-265: I think the higher mortality with multiple surgeries may be more representative of sicker patients with worse infections, thus predisposing them to higher morbidity and mortality rather than a result of having multiple surgeries. Correlation does not demonstrate causation.

Response 9: Thank you very much for your feedback. We just deleted the last sentence of the paragraph. You are right that it cannot be stated this way.

Question  10: The major limitation of this study is the lack of a control group. The survival curve may just be the standard survival curve for patients of this age cohort with these medical comorbidities regardless of having septic arthritis or not. For this study to have any impact there must be a comparison group of matched patients with similar ages/comorbidities, otherwise this is a basic correlation paper between septic arthritis and time of death. If this paper can include a comparison group than it would be significantly more impactful.

Response 10: You are right that it is a fundamental limitation of this study. It is hard to establish a control group because it is hard to find patients at matching with comorbidities and diagnoses.

We tried to address the morbidity of the patients using the ASA classification.

The aim of the study was to demonstrate that patients with septic shoulder arthritis have a low survival rate. This could be due to the fact, that patients suffering from primary septic arthritis are suffering multimorbidy or that septic arthritis has a low survival probability by itself. But either way we could demonstrate that these patients need special attention during treatment as letality rises with comorbidity.

To clearly point out that limitation we implemented a section in the limitations.

 

Reviewer 2 Report

Good topic, but I have a few corrections.

Introduction

In the introduction, it would be better to present the prevalence of septic arthritis in the shoulder along with references.

 

Materials and Methods

 

In line 74-75, "joint lavage with microbiological sampling during surgery" is a more accurate test. Why did you conduct "joint aspiration in the emergency department" and why did you investigate? Performing cultures in the emergency room is not recommended, but in the operation room.

 

Lines 84-85 are duplicates mentioned in the introduction. Please delete either one.

 

It is helpful for readers to understand that all contents are presented in lines 87-88 or summarized in a table.

 

Replace lines 121-122 with the first line of 'material and methods'.

 

Results & limitation

Well organized.

 

 

 

Comments for author File: Comments.docx

Author Response

Response to Reviewer:

Dear Reviewer,

Thank you very much for your good review to the manuscript. We appreciate the good ideas and hints of the review and we try to keep up with the suggestions. The following are the responses to your stated points:

Good topic, but I have a few corrections.

Introduction

Point 1: In the introduction, it would be better to present the prevalence of septic arthritis in the shoulder along with references.

Response 1: We included the prevalence. It is quite difficult to give a better overview of the prevalence because of scarce data about this topic (lines 34-36).

Materials and Methods

Point 2: In line 74-75, "joint lavage with microbiological sampling during surgery" is a more accurate test. Why did you conduct "joint aspiration in the emergency department" and why did you investigate? Performing cultures in the emergency room is not recommended, but in the operation room.

Response 2: Thank you for your advice. We performed sampling in emergency department and in operating room. For analysis we used the type of bacteria from joint lavage during surgery. Joint aspiration in emergency was used to cover the diagnosis and to state the indication for operation. We discussed in the study group and came up with the idea to leave delete this passage, because this aspiration wasn’t used for the analysis of the study (line 76).

Point 3: Lines 84-85 are duplicates mentioned in the introduction. Please delete either one.

Response 3: Thank you for the feedback. We deleted this part in the first paragraph.

Point 4: It is helpful for readers to understand that all contents are presented in lines 87-88 or summarized in a table.

Response 4: Thank you for the hint. We fulfilled the definition of the ASA classification. You are perfectly right that it gives a better impression of the different stages in this classification (lines 83-90).

Point 5: Replace lines 121-122 with the first line of 'material and methods'.

Response 5: Thank you for your suggestion. We would prefer to keep the ethical approval at the end of the section material and methods. We hope that we got your suggestion right. If not we would appreciate your recommondation.

Results & limitation

Well organized.

Reviewer 3 Report

The research objective is to analyze the survival rates and germ spectrum of some patients treated for primary septic monoarthritis of the shoulder.

The abstract is written and structured appropriately. The introduction transposes the research into the topic and formulates the objective of the study at the end.

In the methodology section, the stages of the statistical research are presented, and the results are clearly described. In line 73 - it is not understood what it means (2).

The discussions interpret the research results and relate them to other results from the scientific literature. I have identified some drafting errors, for example line 217 - reference 24, as well as the following which are drafted as a superscript.

The limitations of the research are highlighted in a separate paragraph, due to an extensive presentation. The conclusions are concise and clear.

I congratulate the collective of authors for their research!

Author Response

Response to Reviewer:

Reviewer 3:

The research objective is to analyze the survival rates and germ spectrum of some patients treated for primary septic monoarthritis of the shoulder.

The abstract is written and structured appropriately. The introduction transposes the research into the topic and formulates the objective of the study at the end.

In the methodology section, the stages of the statistical research are presented, and the results are clearly described.

Point 1: In line 73 - it is not understood what it means (2).

Response 1: Thank you for your advice. We named the number of participants being excluded in the study. (line 73)

The discussions interpret the research results and relate them to other results from the scientific literature.

Point 2: I have identified some drafting errors, for example line 217 - reference 24, as well as the following which are drafted as a superscript.

Response 2: Thank you for your good hint. We changed it here and checked the manuscript for further drafting errors.

The limitations of the research are highlighted in a separate paragraph, due to an extensive presentation. The conclusions are concise and clear.

I congratulate the collective of authors for their research!