Dear Dr. Heckman and Spratt,
Thank you for your interest in our study. Here we response to your concerns as below.
We used AOFAS clinical rating system as the unique standard of the clinical outcomes as we introduced in the part of “The Materials and Methods (page 1571 left column, the third paragraph.” It was likely to have its limitation for the overall assessment of the outcome; however it has covered your concerns (e.g., residual pain, walking activities, range of subtalar movement, and the alignment of the ankle-hind-foot). Actually, as it is known, AOFAS clinical rating system has three sections: pain, function, and alignment.
The nurses, who had been trained to use the electronical system to evaluate these measurements, measured these five radiographic indexes three times at each visit, and the mean value was verified the final follow-up result. Furthermore, the accuracy of electronical system was proven by our study team before it was formally used to measure follow-up indexes. We think we had maximally avoided the measurement error and human errors.
These radiographic indexes were usually used for postsurgical clinical follow-up results. Although in 24 months and in 72 months the clinical AOFAS scores had no significant statistical differences, we think PRP + Allograft group had better radiographic findings than Allograft alone group. Compared with ordinary people, factory workers undertake more weight-bearing work. Meanwhile, this was an observed fact that these radiographic measurements mostly worsened after the plate was removed according to our follow-up. From our study, PRP + Allograft group can effectively reduce the loss of calcaneal height and deteriorated other measurements. It is beneficial for them. From this point of view, we made our recommendation. We also mentioned: “It is important to point out that in our study the finding of radiographic change did not lead to significant changes in clinical outcomes, as reflected in the AOFAS functional score” in the conclusion section (page 1574 right column, the third paragraph, line 13–16). Actually, we had frankly analyzed the possible reasons just as in the discussion part (page 1574 right column, the third paragraph and the fourth paragraph). If the excellent postsurgical reduction and recovery training in all three patient groups were not satisfactorily obtained, may be there would be significant changes in the clinical scores. That is, the deteriorated postsurgical measurements maybe lead to clinical outcome in the condition of good rather than excellent reduction or excellent recovery training. So we think we had demonstrated the results. By the way, we are still investigating the long-term follow-up and multiple clinical evaluation scores systems are used in our study.