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Thank you for thoroughly addressing the reviewers’ comments. I have carefully reviewed your responses and the revised manuscript entitled "Knowledge, attitude, and practice of patients with knee osteoarthritis towards perioperative functional exercise after total knee arthroplasty: A cross-sectional study". I am pleased to recommend the manuscript for publication in PeerJ. We appreciate your choice to submit your work to our journal and look forward to receiving future submissions from your team. A/Prof Mike Climstein
[# PeerJ Staff Note - this decision was reviewed and approved by Jeremy Loenneke, a PeerJ Section Editor covering this Section #]
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors agree that they are relevant and useful.
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I am quite disappointed that the references suggested were removed by editorial staff, although they were proper, such as:
• https://pubmed.ncbi.nlm.nih.gov/32622358/
• https://pubmed.ncbi.nlm.nih.gov/29695173/
https://pubmed.ncbi.nlm.nih.gov/31755217/
**PeerJ Staff Note:** It is PeerJ policy that additional references suggested during the peer-review process should only be included if the authors are in agreement that they are relevant and useful.
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Please respond to all the comments in a suitable revision.
Review
Many thanks to the authors for having presented a so interesting cross-sectional study about “Knowledge attitude, and practice of patients with knee osteoarthritis towards perioperative functional exercise after total knee arthroplasty”.
Title and Abstract
The title of the study summarizes the main idea of the article, however, the authors of the article cleverly provides another alternative to the title: KAP towards post-TKA exercise, which in my opinion is to short and maybe failing to deliver the main idea. I suggest another title that is short but inclusive, for example: Knowledge, attitude and practice of patients towards post total knee arthroplasty rehabilitation exercise.
The abstract absolutely covers the main aspect of the work and can stand alone. It is well structured, and it contains the main information of the study, plus the explanation of the abbreviation of the words appearing repeatedly in the article.
Key words
- Cross-sectional study
- Knee osteoarthritis
- Perioperative functional exercise
- Total knee arthroplasty
All the keyword presented the are relevant
Background
The introduction provides a relevant information to the study and develop gradually the purpose of the article, from describing the basic terms and connecting them to the main problem that the article wants to present.
Lines 49-51: Knee osteoarthritis (OA) is a prevalent chronic joint disease characterized by the degradation of articular cartilage, resulting in pain, stiffness, and functional limitations (Knights et al. 2023; Roelofs & De Bari 2024; Steinmetz et al. 2023). Please add a few lines regarding the KOA physiopathology: primary and secondary.
References
The references relevant to the study and in the correct style. Many of the references are up to date, from the last 10 years, but it seems that the older articles are also important and contribute to the article's argument. Please, add those suggested previously.
Competing interest
No competing interests
Concerns
The paper does not seem to raise any concerns.
Tables and Figures
The author has provided clear and legible figures and tables. The number and quality of tables and figures are appropriate to transmit the main information of the paper.
Methods
The author of the article chose to divide this section into three paragraphs.: study design and participants, Questionnaire introduction and statistical analysis, providing in this way a much easier and flowing understanding of the methods that were used to develop the study, and containing more than enough information to possibly repeat the study.
However, under study design and participants, the authors give information about where and when the study took place and the inclusion and exclusion criteria, but do not give information about the group of patients examined as is customary in scientific articles.
Statistical analysis (under Methods)
The statistical analysis is appropriate to the study. It was performed by the same authors using STATA 17.0. They used several statistical methods to examine the study's many variables. The statistical analysis used in the research are well explained and repeatable.
Results
Also, this paragraph was divided in four groups by the authors: Demographic characteristics, Knowledge attitude practice and TSK scores, Spearman correlation analysis and Path analysis, doing so simplifies the reading and understanding the results of the study.
Discussion
The article presents a balanced view of recent work by active groups in the subject area. It makes a valuable contribution to some field by reinforcing the findings of previous studies. The content of the discussion communicates the main information of the paper; the importance of addressing patients fear and misperceptions, enhancing their knowledge and attitudes and motivating them to engage in rehabilitation programs. Please, add a few lines regarding the use of both solution for knee replacement and the quality of life of these patients after: uni-compartmental or total knee replacement.
The limitations of the study are recognized by the authors: small sample size and the inability to establish casual relationships between patient knowledge and other variable, because the cross-sectional study design. For the second limitation, the authors suggest the incorporation of longitudinal studies to exam the evolution of patient knowledge over time and the impact on the outcomes.
Conclusions (under Discussion)
The conclusion justified by the methods and the results. And provide a clear summary of the main idea.
None
Introduction should be improved. It should be explained that OA is a whole joint disease involving all joint tissues and not only cartilage degeneration as reported by the authors. OA is characterized by subchondral bone remodelling, meniscal degeneration, changes in the infrapatellar fat pad and inflammation of synovial membrane.
Risk factors for OA such as obesity, sex etc are lacking.
Line 268: What’s more should be not used in a scientific paper.
Lines 67-69: Reading this part, it seems that this survey is widely used in the literature and validated. However, in the methods it is reported that authors prepared the questionnaire. Please clarify.
Please submit the full questionnaire (in English) used as supplementary material.
Line 94: test used should be reported.
Line 123: please cite software used for the statistical analysis as suggested by the supplier.
Line 125: normality test should be added. Post hoc test used with ANOVA should be added.
Line 116: it is unclear what authors want to say. What did authors change? Could this change impact the results?
Table 1 should be check. In particular, the p-values need to be aligned.
Table 1: “Have you undergone total Knee arthroplasty?” this sentence is unclear as all patients had TKA. Please clarify.
Lines 211-216: First the authors reported that socio-economic factors impact the understanding of the patients and then that this point was supported by a study demonstrating the occupational and family factors influence compliance. This is unclear as understanding and compliance are not the same.
Lines 220-221: why? Why did patients have difficulties in understanding critical period of rehabilitation etc? How is this information communicated to patients?
Limitations of the study should be discussed.
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