Comparative Evaluation of Closed Versus Open Reduction Techniques in Straddle Fractures: A Retrospective Analysis of 69 Patients

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Although CRF offers the advantage of being a minimally invasive surgery, ORF ensures precise reduction and secure fixation. The optimal surgical approach, whether employing CRF or ORF, to achieve superior osteosynthesis outcomes remains uncertain. This study aimed to compare the perioperative characteristics of the two methods and identify an optimal treatment approach tailored to each clinical indication. Methods We performed a retrospective analysis of patients with pelvic ring injuries at a single trauma center admitted between 2016 and 2021. Among this cohort, 69 patients with straddle fractures, with or without posterior pelvic ring injuries, were identified. The patients were categorized into two groups based on the treatment protocol: the CRF and ORF groups. Preoperative conditions, intraoperative features, and radiological outcomes were systematically compared and analyzed. Results A total of 69 patients with 138 superior pubic rami fractures underwent surgical treatment using either closed (57 superior pubic rami) or open (81 superior pubic rami) methods. Application of CRF significantly prevented fractures in Nakatani zone I (P = 0.003). ORF was employed for segmental fractures of the pubic ramus (P = 0.03) and fractures with greater displacement in the axial plane (P = 0.03). Additionally, ORF resulted in a more symmetric pelvic reduction according to the Lefaivre criteria (P = 0.003). Conclusion Both CRF and ORF demonstrated the ability to achieve satisfactory radiological outcomes in straddle fractures. The use of an established treatment protocol can assist surgeons in making informed decisions regarding the optimal treatment approach. Level of Evidence Therapeutic III Straddle fracture pelvic ring injury osteosynthesis treatment protocol radiological outcome Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction The management of pelvic ring injuries presents a complex challenge for orthopedic surgeons. The initial focus in acute management is on the resuscitation process and stabilization of the pelvic ring, which enables subsequent administration of post-injury medical and surgical care. Following this, prioritized interventions involve definitive reconstruction of the affected systems. In pelvic surgery, prioritizing the treatment of posterior pelvic ring injuries takes precedence because maintaining stability in the posterior pelvic ring is essential [ 1 – 3 ]. While osteosynthesis of the anterior pelvic ring is generally regarded as less critical compared to its posterior counterpart, suboptimal reduction quality and stability may contribute to a reduction in the functional performance of patients [ 4 – 8 ]. Anatomically, the anterior pelvic ring is supported by four pubic rami connected by the pubic symphysis, situated in the middle of the body. Dunn and Morris were the first to describe a fracture pattern involving these four pubic rami, which they termed a “straddle fracture” [ 9 ]. Straddle fractures typically occur due to high-energy trauma, encompassing scenarios such as motor vehicle accidents, falls from considerable heights, and crush injuries [ 3 ]. The profound force exerted on the pelvis during these traumatic events can result in various fractures, such as separation of the pubic symphysis, disruption of the sacroiliac joint, and fractures affecting the ilium or acetabulum [ 10 , 11 ]. Each fracture type within the straddle spectrum adds a layer of complexity to the overall clinical picture. A multidisciplinary approach plays a pivotal role in understanding the intricate landscape of straddle fractures. The decision between conservative and operative treatments is contingent upon various factors, including patient needs, pain management considerations, and the intricate nature of other concurrent pelvic fractures [ 10 ]. The optimal strategy for operative treatment, either closed reduction and fixation (CRF) or open reduction and fixation (ORF), to achieve superior osteosynthesis outcomes remains uncertain [ 12 – 14 ]. In this retrospective investigation, our objective was to evaluate the surgical outcomes following osteosynthesis for straddle fractures. Furthermore, by conducting a comparative analysis of variables across distinct treatments (CRF or ORF) and various implants, we aimed to identify an optimal treatment approach tailored to each specific clinical indication. Materials and Methods Study design and participants Between 2016 and 2021, we conducted a retrospective examination of consecutive patients who presented with pelvic ring injuries at a single trauma center. The inclusion criteria predominantly focused on straddle fractures, whether with or without involvement of the posterior pelvic ring, resulting from high-energy trauma, with comprehensive radiological and functional follow-ups lasting at least 12 months. Patients below 18 years of age and those diagnosed with pathological or fragility fractures of the pelvis were excluded from this study. Ultimately, a total of 69 patients were included in the analysis with the aim to evaluate the surgical outcomes following osteosynthesis for straddle fractures. This study was approved by the Institutional Review Board of our hospital (approval number: 202400382B0). Resuscitation and preoperative protocol Comprehensive triage protocols and resuscitation measures were implemented for individuals presenting with pelvic ring injuries in the emergency department (ED). In cases where patients were deemed non-responsive to the initial resuscitation efforts, transarterial embolization emerged as the primary hemostatic intervention. Following stabilization, patients were subsequently transferred either to the standard ward or the intensive care unit to continue acute care. Osteosynthesis procedures were performed at the earliest feasible juncture, contingent upon the patient's medical condition. Initially, standard pelvic X-ray examinations encompassing anteroposterior (AP), inlet, outlet, iliac oblique, and obturator oblique views were conducted in the ED. Subsequently, multiplanar fine-cut computed tomography (CT) was employed for image assessment, enabling quantification of fracture displacement and comprehensive assessment of injuries to the sacroiliac joint and pubic symphysis. If a pelvic binder was applied during the initial image evaluation, the X-rays were systematically repeated before surgery to address potential under classification. For the categorization of pelvic ring injuries, we utilized the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification [ 15 ]. Specifically, the Nakatani classification was employed to classify fractures occurring in the pubic ramus into zones I, II, and III [ 14 ]. Operative procedure The patient received general anesthesia and was positioned on the radiolucent table (Modular Table System©; Mizuho OSI, California, USA) throughout the entire surgical procedure. Evaluation under anesthesia (EUA) was required for patients with preoperatively ambiguous fracture classification. The decision on whether to perform osteosynthesis on the ventral or dorsal pelvic ring first was guided by the fracture pattern observed after EUA. Typically, surgical intervention was performed on the ventral pelvic ring when a solitary straddle fracture was present. For patients classified with lateral compression injury lacking substantial internal rotational deformity, the surgical procedure also began with the ventral pelvic ring. Conversely, in cases presenting with significant lateral compression injury, sacroiliac joint diastasis, and vertical instability of the pelvis, priority was given to the reduction and fixation of the dorsal pelvic ring. The decision between closed or open reduction was based on the location, pattern, and displacement of the superior pubic ramus fracture, as illustrated in Fig. 1 . Closed reduction with an intramedullary screw (7.0 mm cannulated screw system; Syntec Technology Co., Hsinchu, Taiwan) or nail (titanium elastic nail; DePuy Synthes, Paoli, PA, USA) could be executed through either an antegrade or retrograde approach, considering concurrent torso injuries and surgical feasibility (Fig. 2 ). In specific scenarios, such as blunt abdominal injury requiring exploratory laparotomy, bladder or urethral injuries requiring tube cystostomy, and open fractures with inadequate soft tissue coverage, tailored surgical techniques were employed. These techniques included external fixation or anterior superior internal fixation (ASIF), utilizing subcutaneous plates or screw-rod instrumentation osteosynthesis (Fig. 3 ). Patients requiring plate osteosynthesis (DePuy Synthes, Paoli, PA, USA) for superior pubic rami fractures underwent open reduction, which necessitated a Pfannenstiel incision. The preferred approach was to utilize a single plate spanning the ventral pelvic ring (known as a smile plate) during osteosynthesis. In certain scenarios, such as obesity, concomitant pubis symphysis diastasis, and challenges encountered in plate application, two or three individual plates were employed (Fig. 4 ). Ensuring that the lateral end of the plate terminates approximately at the acetabulum is crucial, regardless of whether a single plate or two plates are used. This allows for the engagement of at least two screws. Postoperative protocol Image assessments Day 1 after the surgical procedure, a series of five pelvic X-rays and CT scans were scheduled for evaluation. Various assessment parameters were employed to appraise the quality of osteosynthesis. The evaluation of pelvic symmetry in both vertical and horizontal dimensions from the AP X-ray utilized the Matta/Tonetta criteria and Lefaivre criteria [ 16 , 17 ]. Additionally, the reduction quality of the pelvic ring injuries was assessed by examining the inlet and outlet ratios [ 18 ]. CT scans were performed to quantify the residual fracture gap of the pubic rami fractures. Radiographic follow-ups, including AP, inlet, and outlet views, were conducted after hospital discharge and continued until the 12-week post-surgery. These assessments aimed to scrutinize the persistent stability of the pelvic ring and the effectiveness of the applied implants. Rehabilitation execution Following the initial surgical procedure, the patients were permitted to engage in rehabilitative exercises, including maneuvers such as turning around, assuming a sitting position, and performing hip and lower joint stretching exercises while in bed. Wheelchair assistance was recommended because of bilateral injuries. The transition to a standing position was advised 4 weeks post-surgery, followed by crutch- or walker-assisted ambulation. Generally, weight-bearing without protective measures was sanctioned 12 weeks post-surgery. Routine prophylaxis for venous thromboembolism was consistently administered using mechanical compression socks contingent on the absence of contraindications [ 19 ]. Mechanical prophylaxis was continued until the patient achieved unrestricted ambulation, typically at approximately 12 weeks postinjury. There was no standard prophylactic protocol for heterotopic ossification (HO). In cases where HO was suspected, patients were prescribed indomethacin at a dosage of 400 mg, administered orally (os) four times a day (q.i.d). Statistical analysis Categorical data were analyzed using the chi-square test, while between-group comparisons of numerical data were conducted using the Mann–Whitney test. Statistical significance was set at P < 0.05. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) 26.0 program for Windows (IBM SPSS Statistics for Windows, Version 26.0; IBM Corp, Armonk, NY). Results Table 1 presents the demographic distribution of all patients enrolled in the cohort. Of the total, 75% (52 out of 69) were transferred from other medical facilities. Among the patients, 12.5% (8 out of 69) had stable pelvic ring injuries, while the remaining 87.5% presented with partial or complete pelvic ring injuries. Table 1. Demographic distribution of enrolled 69 patients with straddle fractures Patient Number (n) Male:Female 69 26:43 Age (mean ± SD) 40.1 ± 17.9 Transferred from other hospital (n) 52 Injury mechanism (n) Motor vehicle collision Pedestrian injury Fall from height Crushing injury Others 45 7 6 9 2 Injury severity score (median, IQR) 17, 17.5 New injury severity score (median, IQR) 22, 20.5 Closed fracture : Open fracture 61:8 AO classification Type A Type B Type C 8 39 22 Location of posterior pelvic ring injury (n) Sacral fracture (n) Sacroiliac joint injury (n) 42 27 Pubic symphysis diastasis (n) 11 [Insert Table 1 ] The 69 patients were further categorized for detailed analysis, resulting in a total of 138 pubic rami fractures. Based on the reduction methods employed, they were stratified into one group undergoing CRF and the other undergoing ORF. Table 2 illustrates the comparisons of the selected variables. The analysis revealed that factors such as the proximity of the fracture to Zone I by the Nakatani classification and the orientation of the fracture line towards the segmental configuration were significant determinants for the choice of reduction and fixation methods (P = 0.003 and P = 0.03, respectively). Table 2. Comparisons between the closed reduction and open reduction treatments for a straddle fracture CRF group ORF group P value Pubic rami number 57 81 Fracture type Type A Type B Type C 0 39 18 16 39 26 0.33 Posterior pelvic ring injury† Yes No 1 24 9 29 0.05 Dennis classification (Sacral fracture) Zone I Zone II Zone III 12 16 2 18 26 0 0.93 Pubic symphysis diastasis Yes No 10 47 12 69 0.66 Nakatani classification Zone I Zone II Zone III Combined zones 1 37 16 3 21 41 15 4 0.003* Fracture line orientation Simple Segmental 48 9 59 22 0.03* Implant choices Screw Nail ASIF Ex-Fix Hybrid Plate 17 17 14 6 3 0 5 3 0 0 0 73 Approach for posterior pelvic ring injury Closed reduction Open reduction 43 12 37 26 0.24 Complications Surgical site infection (n) Implant loss (n) 1 4 7 8 0.09 0.56 †bilateral CRF or bilateral ORF *Statistical significance CRF: closed reduction and fixation; ORF: open reduction and fixation [Insert Table 2 ] Table 3 presents the outcomes of the imaging assessments conducted using X-rays and CT scans. When CT scans were used to quantify preoperative gaps in pubic ramus fractures across the axial, coronal, and sagittal planes, a notable reduction in the fracture gap was specifically observed in the axial plane for the ORIF group (P = 0.03). No discernible differences were observed in individuals who underwent either CRF or ORF methods when comparing X-rays immediately post-osteosynthesis and at the 3-month follow-up. Upon comparing various parameters between the two treatment modalities, the pelvis exhibited a significantly symmetrical outcome according to the Lefaivre criteria both immediately post-osteosynthesis and at the 3-month evaluation (P = 0.003 and P = 0.001, respectively). Table 3. Image assessments and comparison between the closed reduction and open reduction treatments Parameters Interval† CRF group ORF group P value Preoperative evaluation from computed tomography scan Fracture gap (mm) Axial Coronal Sagittal 8.9 ± 8.9 8.0 ± 7.5 6.6 ± 8.7 12.3 ± 9.0 10.1 ± 8.4 7.1 ± 7.4 0.03* 0.13 0.29 Postoperative X-ray assessments Matta (mm) Immediate 3.4 ± 3.2 4.0 ± 4.7 0.42 3 months follow-up 3.8 ± 3.8 3.9 ± 5.0 0.88 P value 0.09 0.22 Lefaivre (mm) Immediate 9.2 ± 6.6 6.1 ± 5.6 0.003* 3 months follow-up 9.1 ± 6.1 6.1 ± 5.6 0.001* P value 0.77 0.08 Inlet ratio Immediate 1.09 ± 0.07 1.11 ± 0.12 0.28 3 months follow-up 1.09 ± 0.08 1.10 ± 0.12 0.93 P value 0.66 0.05 Outlet ratio Immediate 1.10 ± 0.09 1.07 ± 0.08 0.05 3 months follow up 1.10 ± 0.10 1.07 ± 0.10 0.06 P value 0.56 0.67 CRF: closed reduction and fixation; ORF: open reduction and fixation. †Interval refers to the interval between th e index surgery and the image study *Statistical significance. [Insert Table 3 ] Discussion This study evaluated the clinical efficacy of the prescribed treatment protocols for straddle fractures. In instances where comparable complication rates were observed between CRF and ORF treatments, our findings indicate that ORF treatment might be clinically effective, particularly in cases where the fracture is situated proximally in relation to Nakatani zone 1 and exhibits a segmental pattern with over 10 mm displacement. Additionally, applying ORF to straddle fractures resulted in a more symmetric pelvic reduction. Closed reduction using an external fixator may be considered feasible under specific circumstances for anterior pelvic ring fractures [ 20 ]. Additionally, the utilization of ASIF methods such as pre-contoured subcutaneous approaches, anterior pelvic rod-screw systems, and INFIX may confer potential benefits in mitigating the risk of surgical site infections and facilitating straightforward application [ 21 – 23 ]. However, the conventional standard for addressing anterior pelvic ring instability involves internal fixation for stabilization. Utilizing intramedullary screw fixation for closed reduction of pubic ramus fractures represents a minimally invasive and effective surgical intervention. Various modified surgical approaches have been developed to enhance the precision of screw placement [ 12 , 13 , 24 ]. A Level 1 trauma center reported a comparably low failure rate [ 25 ]. Despite the advocacy for specific surgical techniques to facilitate accurate implant placement, inherent limitations persist [ 14 , 25 , 26 ]. Furthermore, improper selection of screw entry points may pose a risk of injury to the reproductive organs [ 27 ]. In situations where closed maneuvers are not feasible or are unsuccessful, open reduction is theoretically considered a viable alternative. However, the efficacy of CRF with intramedullary implants may be compromised in certain instances. The reported failure rates of CRF with intramedullary screws in addressing anterior pelvic ring injuries vary between 4.9% and 15% [ 14 , 25 , 26 ]. The initial displacement of the pubic ramus fracture contributes to such failures. Our surgical observations using an open approach revealed that an increased degree of displacement or comminution in pubic rami fractures corresponds to an elevated likelihood of disruption of the ligamentous structures along the pectineal line, colloquially referred to as the pectineal ligament. This ligament significantly contributes to maintaining stability in the anterior pelvic ring and is recognized as a secondary stabilizer [ 28 ]. Consequently, CRF failure may be attributed to disruption of the pectineal ligament, a condition discernible through the degree of pubic ramus displacement. Accordingly, we established a criterion of 10 mm displacement, serving as a threshold to determine the appropriateness of employing either a closed or open method for stabilizing staddle fractures. One imperative consideration involves the application of plate osteosynthesis to address this particular concern effectively. Preventing early fixation failure after osteosynthesis is of paramount importance. Lodde et al. conducted a biomechanical investigation comparing fracture displacement after the application of intramedullary screws and anterior plates [ 11 ]. Following 5000 loading cycles, the plate group exhibited greater displacement than the screw group. Nevertheless, it was observed that the plate length was insufficient, potentially leading to shorter screw lengths when the plate terminated in Nakatani Zone III. We advocate the selection of a plate of adequate length, spanning bilaterally across the acetabulum and enabling the engagement of at least two bicortical screws. A higher osseous density proximal to the acetabulum permits the use of longer screws ranging from 40 to 50 mm, in contrast to those conventionally employed in the pubic region. Despite eight instances of screw loosening in the ORF group, all occurrences were localized to the pubic region, with extended screws around the pubic symphysis and within the supra-acetabular area, maintaining secure fixation. In addition, when evaluating the displacement of pubic ramus fractures to ascertain the appropriateness of open reduction, factors such as age and fracture location influence the choice of procedural intervention. Fracture sites close to the pubic symphysis within Nakatani zone I or extending into the symphysis pose constraints on the use of closed reduction with intramedullary due to limitations like implant loosening and the potential loss of fracture reduction [ 14 , 25 , 29 ]. No instances of failed CRF were observed in cases where fractures were located in Nakatani zone I, as these cases predominantly underwent ORF following the established treatment protocol. It is worth noting that four fixation failures were documented in cases where the fractures were positioned in Nakatani zone II, with three of these instances involving female patients of advanced age who used intramedullary nails rather than screws. A pure straddle fracture is categorized as a stable pelvic ring injury, and conservative management is generally effective. The primary objective of treatment is to alleviate pain and expedite the restoration of functional capacity. Employing a closed reduction maneuver is preferred over an open approach to mitigate anatomical trauma. The necessity for open reduction in the presence of posterior pelvic ring injury remains controversial [ 3 , 10 , 11 , 13 , 29 , 30 ]. Clinical and biomechanical studies have provided evidence that a closed reduction method coupled with intramedullary implant fixation imparts sufficient strength even in the context of posterior pelvic ring injury [ 11 , 30 ]. Our observations indicated a correlation between a more severe and displaced posterior pelvic ring injury and a similarly displaced straddle fracture, indicative of a disrupted pectineal ligament. Although no statistical significance was demonstrated between the bilateral closed reduction with intramedullary fixation group and the bilateral open reduction with plate osteosynthesis group in the presence of posterior pelvic ring injury, a greater number of patients in our study underwent osteosynthesis via ORF. Although diligent efforts were made to mitigate bias, certain limitations persisted in our study. Firstly, a retrospective review and analysis of medical records were conducted. Despite the existence of a treatment protocol, the ultimate course of treatment is subject to various factors, including concomitant injuries, availability of surgical instruments and implants, and surgeon discretion. Additionally, the analysis categorized patients into CRIF and ORIF groups; however, it is important to recognize that some patients might have undergone ORIF at one site and CRIF at another. Furthermore, the absence of reported functional outcomes is noteworthy, with only nine straddle fracture patients lacking posterior pelvic ring injuries. The reported functional outcomes may have been influenced by the presence of more severe unstable pelvic ring injuries. Conclusion A straddle fracture may manifest either as a standalone injury within the pelvic ring or in conjunction with a posterior pelvic ring injury. In instances where surgical intervention is necessary, both closed and open reduction methods contribute to bone union. Open reduction yields a more symmetrical pelvis compared with the outcome using closed reduction. Opting for ORF becomes particularly advantageous when the fracture exhibits greater displacement and proximity to, or penetration of, the pubic symphysis, resulting in improved radiological outcomes. Abbreviations AO = Arbeitsgemeinschaft für Osteosynthesefragen AP = anteroposterior ASIF = anterior superior internal fixation CRF = closed reduction and fixation CT = computed tomography ED = emergency department EUA = evaluation under anesthesia HO = heterotopic ossification ORF = open reduction and fixation Declarations Ethics Approval and Consent to Participate: This retrospective chart review study involving human participants was conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Institutional Review Board (IRB NO: 202400382B0) of Chang Gung Memorial Hospital, Taoyuan City, Taiwan. Informed consent was waived by the Institutional Review Board (IRB NO: 202400382B0) of Chang Gung Memorial Hospital, Taoyuan City, Taiwan due to the retrospective nature of the study. Consent for Publication: Not applicable. Availability of Data and Materials: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing Interests: The authors declare that they have no competing interests. Authors' Contributions: Conceptualization: Y.-H. Y., C.-Y. L., and I-J. C.; Investigation: Y.-H. H. and Y.-C. C.; Writing: Y.-H. Y.; Writing-review and supervision: Y.-H. Y. All the authors have read and approved the final manuscript. Source of Funding: The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. 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Luksameearunothai K, Amin RM, Shafiq B, Hasenboehler EA. Distance Between Reproductive Structures and the Insertion Point of the Retrograde Pubic Ramus Screw. J Orthop Trauma. 2020;34(11):578-82. Osterhoff G, Reise R, Riemer E, Höch A, Fakler JKM, Heyde CE, et al. The pectineal ligament is a secondary stabilizer in anterior pelvic ring fractures - a biomechanical study. Injury. 2022;53(2):334-8. Rommens PM, Graafen M, Arand C, Mehling I, Hofmann A, Wagner D. Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws. Injury. 2020;51(2):340-6. McLachlin S, Lesieur M, Stephen D, Kreder H, Whyne C. Biomechanical analysis of anterior ring fixation of the ramus in type C pelvis fractures. Eur J Trauma Emerg Surg. 2018;44(2):185-90. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4245291","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":289988455,"identity":"980da3e8-fc9d-4ac7-b39b-063c8df4f7b2","order_by":0,"name":"Yi-Hsun Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIiWNgGAWjYDACdjApwcMm//gAiCFDWAszmLSQ42dISwDrJVZLhbFkQ44BiEVYC38z87PHvG0SiRsOnPn86kaNBQ8D++GjG/BpkTjMZm4M1nKwd5t1zjGgw3jS0m7gteYwg5k0WMth3m3GOWxALRI8Zni1yB9m/wbRcoznmXHOPyK0GBzmAdtiLNnDw/w4t40ILYaHecok55yTkOOXYDNjzu0DRhAhv8gdb98m8aasjodNgvnx55xvdXL87IeP4fc+EDBB44JNAkwSUg4CjD8gNPMHYlSPglEwCkbByAMASyRA6aVyFLMAAAAASUVORK5CYII=","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Yi-Hsun","middleName":"","lastName":"Yu","suffix":""},{"id":289988458,"identity":"305b83b3-cc85-43fd-afa8-cecb1d5828b1","order_by":1,"name":"Chih-Yang Lai","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chih-Yang","middleName":"","lastName":"Lai","suffix":""},{"id":289988459,"identity":"6cbd5e9e-6068-45f1-a7ab-d288fd20bef3","order_by":2,"name":"I-Jung Chen","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"I-Jung","middleName":"","lastName":"Chen","suffix":""},{"id":289988460,"identity":"f17006ad-e945-4081-8475-f8f1c3c1c654","order_by":3,"name":"Yung-Heng Hsu","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yung-Heng","middleName":"","lastName":"Hsu","suffix":""},{"id":289988461,"identity":"8a1e22c0-1d20-4d0e-ae60-a85831f38c17","order_by":4,"name":"Ying-Chao Chou","email":"","orcid":"","institution":"Chang Gung Memorial Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ying-Chao","middleName":"","lastName":"Chou","suffix":""}],"badges":[],"createdAt":"2024-04-10 05:45:00","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4245291/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4245291/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":54995283,"identity":"6712cb65-3a66-491a-8e12-3991738f01b8","added_by":"auto","created_at":"2024-04-19 17:54:10","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":236312,"visible":true,"origin":"","legend":"\u003cp\u003eTreatment flow chart for the straddle fracture. a: Nakatani classification; b: the largest distance measured from the CT scan; CR: closed reduction; OR: open reduction.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4245291/v1/e00b6b1911229f49ec38fc47.png"},{"id":54995286,"identity":"9cdfadb0-27be-4f2b-a574-1f4cf9179b6d","added_by":"auto","created_at":"2024-04-19 17:54:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":5457755,"visible":true,"origin":"","legend":"\u003cp\u003eDepictions of closed reduction techniques utilizing intramedullary fixation devices are presented. (A) and (B) illustrate a straddle injury managed with the application of bilateral intramedullary screws. (C) and (D) depicts the management of a straddle fracture employing bilateral intramedullary titanium nails for stabilization.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4245291/v1/a5c854f266249bb02d8b7a7c.png"},{"id":54995285,"identity":"120ff89c-fe27-4982-9f71-bd787874260c","added_by":"auto","created_at":"2024-04-19 17:54:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3310285,"visible":true,"origin":"","legend":"\u003cp\u003eSchematic illustrations of different fixations under closed reduction for a straddle fracture. (A) external fixation. (B) pedicle-rod system. (C) subcutaneous locking plate.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4245291/v1/35d64532cdab4815955ecb4b.png"},{"id":54995284,"identity":"dfde78a3-c01a-4c35-8bff-4c9faca62fe9","added_by":"auto","created_at":"2024-04-19 17:54:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":4894999,"visible":true,"origin":"","legend":"\u003cp\u003eRepresentative diagrams of two types of plate osteosynthesis under open reduction for the straddle fracture. (A) and (B) bilateral separate plates. (C) and (D) smile plates.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4245291/v1/1aed931cc884b3955b21312d.png"},{"id":54997975,"identity":"3bc19152-ab6b-4e9d-9511-710be8d304b9","added_by":"auto","created_at":"2024-04-19 18:18:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4451778,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4245291/v1/3d125a98-c2d9-446c-bdcd-cc776c7783dc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Comparative Evaluation of Closed Versus Open Reduction Techniques in Straddle Fractures: A Retrospective Analysis of 69 Patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe management of pelvic ring injuries presents a complex challenge for orthopedic surgeons. The initial focus in acute management is on the resuscitation process and stabilization of the pelvic ring, which enables subsequent administration of post-injury medical and surgical care. Following this, prioritized interventions involve definitive reconstruction of the affected systems.\u003c/p\u003e \u003cp\u003eIn pelvic surgery, prioritizing the treatment of posterior pelvic ring injuries takes precedence because maintaining stability in the posterior pelvic ring is essential [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While osteosynthesis of the anterior pelvic ring is generally regarded as less critical compared to its posterior counterpart, suboptimal reduction quality and stability may contribute to a reduction in the functional performance of patients [\u003cspan additionalcitationids=\"CR5 CR6 CR7\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnatomically, the anterior pelvic ring is supported by four pubic rami connected by the pubic symphysis, situated in the middle of the body. Dunn and Morris were the first to describe a fracture pattern involving these four pubic rami, which they termed a \u0026ldquo;straddle fracture\u0026rdquo; [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Straddle fractures typically occur due to high-energy trauma, encompassing scenarios such as motor vehicle accidents, falls from considerable heights, and crush injuries [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The profound force exerted on the pelvis during these traumatic events can result in various fractures, such as separation of the pubic symphysis, disruption of the sacroiliac joint, and fractures affecting the ilium or acetabulum [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Each fracture type within the straddle spectrum adds a layer of complexity to the overall clinical picture.\u003c/p\u003e \u003cp\u003eA multidisciplinary approach plays a pivotal role in understanding the intricate landscape of straddle fractures. The decision between conservative and operative treatments is contingent upon various factors, including patient needs, pain management considerations, and the intricate nature of other concurrent pelvic fractures [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The optimal strategy for operative treatment, either closed reduction and fixation (CRF) or open reduction and fixation (ORF), to achieve superior osteosynthesis outcomes remains uncertain [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this retrospective investigation, our objective was to evaluate the surgical outcomes following osteosynthesis for straddle fractures. Furthermore, by conducting a comparative analysis of variables across distinct treatments (CRF or ORF) and various implants, we aimed to identify an optimal treatment approach tailored to each specific clinical indication.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and participants\u003c/h2\u003e \u003cp\u003eBetween 2016 and 2021, we conducted a retrospective examination of consecutive patients who presented with pelvic ring injuries at a single trauma center. The inclusion criteria predominantly focused on straddle fractures, whether with or without involvement of the posterior pelvic ring, resulting from high-energy trauma, with comprehensive radiological and functional follow-ups lasting at least 12 months. Patients below 18 years of age and those diagnosed with pathological or fragility fractures of the pelvis were excluded from this study. Ultimately, a total of 69 patients were included in the analysis with the aim to evaluate the surgical outcomes following osteosynthesis for straddle fractures. This study was approved by the Institutional Review Board of our hospital (approval number: 202400382B0).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eResuscitation and preoperative protocol\u003c/h2\u003e \u003cp\u003eComprehensive triage protocols and resuscitation measures were implemented for individuals presenting with pelvic ring injuries in the emergency department (ED). In cases where patients were deemed non-responsive to the initial resuscitation efforts, transarterial embolization emerged as the primary hemostatic intervention. Following stabilization, patients were subsequently transferred either to the standard ward or the intensive care unit to continue acute care. Osteosynthesis procedures were performed at the earliest feasible juncture, contingent upon the patient's medical condition.\u003c/p\u003e \u003cp\u003eInitially, standard pelvic X-ray examinations encompassing anteroposterior (AP), inlet, outlet, iliac oblique, and obturator oblique views were conducted in the ED. Subsequently, multiplanar fine-cut computed tomography (CT) was employed for image assessment, enabling quantification of fracture displacement and comprehensive assessment of injuries to the sacroiliac joint and pubic symphysis. If a pelvic binder was applied during the initial image evaluation, the X-rays were systematically repeated before surgery to address potential under classification.\u003c/p\u003e \u003cp\u003eFor the categorization of pelvic ring injuries, we utilized the Arbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen (AO) classification [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Specifically, the Nakatani classification was employed to classify fractures occurring in the pubic ramus into zones I, II, and III [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eOperative procedure\u003c/h2\u003e \u003cp\u003eThe patient received general anesthesia and was positioned on the radiolucent table (Modular Table System\u0026copy;; Mizuho OSI, California, USA) throughout the entire surgical procedure. Evaluation under anesthesia (EUA) was required for patients with preoperatively ambiguous fracture classification. The decision on whether to perform osteosynthesis on the ventral or dorsal pelvic ring first was guided by the fracture pattern observed after EUA. Typically, surgical intervention was performed on the ventral pelvic ring when a solitary straddle fracture was present. For patients classified with lateral compression injury lacking substantial internal rotational deformity, the surgical procedure also began with the ventral pelvic ring. Conversely, in cases presenting with significant lateral compression injury, sacroiliac joint diastasis, and vertical instability of the pelvis, priority was given to the reduction and fixation of the dorsal pelvic ring.\u003c/p\u003e \u003cp\u003eThe decision between closed or open reduction was based on the location, pattern, and displacement of the superior pubic ramus fracture, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Closed reduction with an intramedullary screw (7.0 mm cannulated screw system; Syntec Technology Co., Hsinchu, Taiwan) or nail (titanium elastic nail; DePuy Synthes, Paoli, PA, USA) could be executed through either an antegrade or retrograde approach, considering concurrent torso injuries and surgical feasibility (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn specific scenarios, such as blunt abdominal injury requiring exploratory laparotomy, bladder or urethral injuries requiring tube cystostomy, and open fractures with inadequate soft tissue coverage, tailored surgical techniques were employed. These techniques included external fixation or anterior superior internal fixation (ASIF), utilizing subcutaneous plates or screw-rod instrumentation osteosynthesis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePatients requiring plate osteosynthesis (DePuy Synthes, Paoli, PA, USA) for superior pubic rami fractures underwent open reduction, which necessitated a Pfannenstiel incision. The preferred approach was to utilize a single plate spanning the ventral pelvic ring (known as a smile plate) during osteosynthesis. In certain scenarios, such as obesity, concomitant pubis symphysis diastasis, and challenges encountered in plate application, two or three individual plates were employed (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Ensuring that the lateral end of the plate terminates approximately at the acetabulum is crucial, regardless of whether a single plate or two plates are used. This allows for the engagement of at least two screws.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperative protocol\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eImage assessments\u003c/h2\u003e \u003cp\u003eDay 1 after the surgical procedure, a series of five pelvic X-rays and CT scans were scheduled for evaluation. Various assessment parameters were employed to appraise the quality of osteosynthesis. The evaluation of pelvic symmetry in both vertical and horizontal dimensions from the AP X-ray utilized the Matta/Tonetta criteria and Lefaivre criteria [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Additionally, the reduction quality of the pelvic ring injuries was assessed by examining the inlet and outlet ratios [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. CT scans were performed to quantify the residual fracture gap of the pubic rami fractures. Radiographic follow-ups, including AP, inlet, and outlet views, were conducted after hospital discharge and continued until the 12-week post-surgery. These assessments aimed to scrutinize the persistent stability of the pelvic ring and the effectiveness of the applied implants.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eRehabilitation execution\u003c/h2\u003e \u003cp\u003eFollowing the initial surgical procedure, the patients were permitted to engage in rehabilitative exercises, including maneuvers such as turning around, assuming a sitting position, and performing hip and lower joint stretching exercises while in bed. Wheelchair assistance was recommended because of bilateral injuries. The transition to a standing position was advised 4 weeks post-surgery, followed by crutch- or walker-assisted ambulation. Generally, weight-bearing without protective measures was sanctioned 12 weeks post-surgery.\u003c/p\u003e \u003cp\u003eRoutine prophylaxis for venous thromboembolism was consistently administered using mechanical compression socks contingent on the absence of contraindications [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Mechanical prophylaxis was continued until the patient achieved unrestricted ambulation, typically at approximately 12 weeks postinjury. There was no standard prophylactic protocol for heterotopic ossification (HO). In cases where HO was suspected, patients were prescribed indomethacin at a dosage of 400 mg, administered orally (os) four times a day (q.i.d).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eCategorical data were analyzed using the chi-square test, while between-group comparisons of numerical data were conducted using the Mann\u0026ndash;Whitney test. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) 26.0 program for Windows (IBM SPSS Statistics for Windows, Version 26.0; IBM Corp, Armonk, NY).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e presents the demographic distribution of all patients enrolled in the cohort. Of the total, 75% (52 out of 69) were transferred from other medical facilities. Among the patients, 12.5% (8 out of 69) had stable pelvic ring injuries, while the remaining 87.5% presented with partial or complete pelvic ring injuries.\u003c/p\u003e\n\u003cp\u003eTable 1. Demographic distribution of enrolled 69 patients with straddle fractures\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003ePatient Number (n)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; Male:Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003cp\u003e26:43\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eAge (mean\u0026nbsp;\u0026plusmn;\u0026nbsp;SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e40.1\u0026nbsp;\u0026plusmn;\u0026nbsp;17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eTransferred from other hospital (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eInjury mechanism (n)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Motor vehicle collision\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Pedestrian injury\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Fall from height\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Crushing injury\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eInjury severity score (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e17, 17.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eNew injury severity score (median, IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e22, 20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eClosed fracture : Open fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e61:8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eAO classification\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Type A\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Type B\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; Type C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003eLocation of posterior pelvic ring injury (n)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Sacral fracture (n)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Sacroiliac joint injury (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"54.611211573236886%\" valign=\"top\"\u003e\n \u003cp\u003ePubic symphysis diastasis (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"45.388788426763114%\" valign=\"top\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cdiv\u003e\u003cbr\u003e\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n \u003ch2\u003e[Insert Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e]\u003c/h2\u003e\n \u003cp\u003eThe 69 patients were further categorized for detailed analysis, resulting in a total of 138 pubic rami fractures. Based on the reduction methods employed, they were stratified into one group undergoing CRF and the other undergoing ORF. Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the comparisons of the selected variables. The analysis revealed that factors such as the proximity of the fracture to Zone I by the Nakatani classification and the orientation of the fracture line towards the segmental configuration were significant determinants for the choice of reduction and fixation methods (P\u0026thinsp;=\u0026thinsp;0.003 and P\u0026thinsp;=\u0026thinsp;0.03, respectively).\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003eTable 2. Comparisons between the closed reduction and open reduction treatments for a straddle fracture\u0026nbsp;\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003eCRF group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003eORF group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003ePubic rami number\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eFracture type\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Type A\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Type B\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Type C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003ePosterior pelvic ring injury\u0026dagger;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eDennis classification (Sacral fracture)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Zone I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Zone II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Zone III\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003ePubic symphysis diastasis\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eNakatani classification\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Zone I\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Zone II\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Zone III\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Combined zones\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eFracture line orientation\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Simple\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Segmental\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.03*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eImplant choices\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Screw\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Nail\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;ASIF\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Ex-Fix\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Hybrid\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Plate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eApproach for posterior pelvic ring injury\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Closed reduction\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Open reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"42.67631103074141%\" valign=\"top\"\u003e\n \u003cp\u003eComplications\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Surgical site infection (n)\u003c/p\u003e\n \u003cp\u003eImplant loss (n)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"22.24231464737794%\" valign=\"top\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"12.839059674502712%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003e\u0026dagger;bilateral CRF or bilateral ORF\u003c/p\u003e\n \u003cp\u003e*Statistical significance\u003c/p\u003e\n \u003cp\u003eCRF: closed reduction and fixation; ORF: open reduction and fixation\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003e[Insert Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e]\u003c/h2\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e presents the outcomes of the imaging assessments conducted using X-rays and CT scans. When CT scans were used to quantify preoperative gaps in pubic ramus fractures across the axial, coronal, and sagittal planes, a notable reduction in the fracture gap was specifically observed in the axial plane for the ORIF group (P\u0026thinsp;=\u0026thinsp;0.03). No discernible differences were observed in individuals who underwent either CRF or ORF methods when comparing X-rays immediately post-osteosynthesis and at the 3-month follow-up. Upon comparing various parameters between the two treatment modalities, the pelvis exhibited a significantly symmetrical outcome according to the Lefaivre criteria both immediately post-osteosynthesis and at the 3-month evaluation (P\u0026thinsp;=\u0026thinsp;0.003 and P\u0026thinsp;=\u0026thinsp;0.001, respectively).\u003c/p\u003e\n \u003cdiv\u003e\n \u003cp\u003eTable 3. Image assessments and comparison between the closed reduction and open reduction treatments\u0026nbsp;\u003c/p\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\n \u003cp\u003eParameters\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eInterval\u0026dagger;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003eCRF group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003eORF group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003ePreoperative evaluation from computed tomography scan\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\n \u003cp\u003eFracture gap (mm)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Axial\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Coronal\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Sagittal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e8.9\u0026nbsp;\u0026plusmn;\u0026nbsp;8.9\u003c/p\u003e\n \u003cp\u003e8.0\u0026nbsp;\u0026plusmn; 7.5\u003c/p\u003e\n \u003cp\u003e6.6\u0026nbsp;\u0026plusmn; 8.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e12.3\u0026nbsp;\u0026plusmn; 9.0\u003c/p\u003e\n \u003cp\u003e10.1\u0026nbsp;\u0026plusmn; 8.4\u003c/p\u003e\n \u003cp\u003e7.1\u0026nbsp;\u0026plusmn; 7.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.03*\u003c/p\u003e\n \u003cp\u003e0.13\u003c/p\u003e\n \u003cp\u003e0.29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" colspan=\"5\" valign=\"top\"\u003e\n \u003cp\u003ePostoperative X-ray assessments\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\n \u003cp\u003eMatta (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e3.4\u0026nbsp;\u0026plusmn;\u0026nbsp;3.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e4.0\u0026nbsp;\u0026plusmn; 4.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.42\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003e3 months follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e3.8\u0026nbsp;\u0026plusmn; 3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e3.9\u0026nbsp;\u0026plusmn; 5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.88\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\n \u003cp\u003eLefaivre (mm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e9.2\u0026nbsp;\u0026plusmn; 6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e6.1\u0026nbsp;\u0026plusmn; 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.003*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003e3 months follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e9.1\u0026nbsp;\u0026plusmn; 6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e6.1\u0026nbsp;\u0026plusmn; 5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.001*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\n \u003cp\u003eInlet ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.09\u0026nbsp;\u0026plusmn; 0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.11\u0026nbsp;\u0026plusmn; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003e3 months follow-up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.09\u0026nbsp;\u0026plusmn;\u0026nbsp;0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.10\u0026nbsp;\u0026plusmn; 0.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.93\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\n \u003cp\u003eOutlet ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eImmediate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.10\u0026nbsp;\u0026plusmn; 0.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u0026nbsp;\u0026plusmn; 0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003e3 months follow up\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.10\u0026nbsp;\u0026plusmn; 0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e1.07\u0026nbsp;\u0026plusmn; 0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"24.90974729241877%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.981949458483754%\" valign=\"top\"\u003e\n \u003cp\u003eP value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.03610108303249%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003cp\u003eCRF: closed reduction and fixation; ORF: open reduction and fixation.\u003c/p\u003e\n \u003cp\u003e\u0026dagger;Interval refers to the interval between th\u003c/p\u003e\n \u003cp\u003ee index surgery and the image study\u003c/p\u003e\n \u003cp\u003e*Statistical significance.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003e[Insert Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e]\u003c/h2\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the clinical efficacy of the prescribed treatment protocols for straddle fractures. In instances where comparable complication rates were observed between CRF and ORF treatments, our findings indicate that ORF treatment might be clinically effective, particularly in cases where the fracture is situated proximally in relation to Nakatani zone 1 and exhibits a segmental pattern with over 10 mm displacement. Additionally, applying ORF to straddle fractures resulted in a more symmetric pelvic reduction.\u003c/p\u003e \u003cp\u003eClosed reduction using an external fixator may be considered feasible under specific circumstances for anterior pelvic ring fractures [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Additionally, the utilization of ASIF methods such as pre-contoured subcutaneous approaches, anterior pelvic rod-screw systems, and INFIX may confer potential benefits in mitigating the risk of surgical site infections and facilitating straightforward application [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. However, the conventional standard for addressing anterior pelvic ring instability involves internal fixation for stabilization. Utilizing intramedullary screw fixation for closed reduction of pubic ramus fractures represents a minimally invasive and effective surgical intervention. Various modified surgical approaches have been developed to enhance the precision of screw placement [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. A Level 1 trauma center reported a comparably low failure rate [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Despite the advocacy for specific surgical techniques to facilitate accurate implant placement, inherent limitations persist [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Furthermore, improper selection of screw entry points may pose a risk of injury to the reproductive organs [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. In situations where closed maneuvers are not feasible or are unsuccessful, open reduction is theoretically considered a viable alternative.\u003c/p\u003e \u003cp\u003eHowever, the efficacy of CRF with intramedullary implants may be compromised in certain instances. The reported failure rates of CRF with intramedullary screws in addressing anterior pelvic ring injuries vary between 4.9% and 15% [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The initial displacement of the pubic ramus fracture contributes to such failures. Our surgical observations using an open approach revealed that an increased degree of displacement or comminution in pubic rami fractures corresponds to an elevated likelihood of disruption of the ligamentous structures along the pectineal line, colloquially referred to as the pectineal ligament. This ligament significantly contributes to maintaining stability in the anterior pelvic ring and is recognized as a secondary stabilizer [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Consequently, CRF failure may be attributed to disruption of the pectineal ligament, a condition discernible through the degree of pubic ramus displacement. Accordingly, we established a criterion of 10 mm displacement, serving as a threshold to determine the appropriateness of employing either a closed or open method for stabilizing staddle fractures. One imperative consideration involves the application of plate osteosynthesis to address this particular concern effectively.\u003c/p\u003e \u003cp\u003ePreventing early fixation failure after osteosynthesis is of paramount importance. Lodde et al. conducted a biomechanical investigation comparing fracture displacement after the application of intramedullary screws and anterior plates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Following 5000 loading cycles, the plate group exhibited greater displacement than the screw group. Nevertheless, it was observed that the plate length was insufficient, potentially leading to shorter screw lengths when the plate terminated in Nakatani Zone III. We advocate the selection of a plate of adequate length, spanning bilaterally across the acetabulum and enabling the engagement of at least two bicortical screws. A higher osseous density proximal to the acetabulum permits the use of longer screws ranging from 40 to 50 mm, in contrast to those conventionally employed in the pubic region. Despite eight instances of screw loosening in the ORF group, all occurrences were localized to the pubic region, with extended screws around the pubic symphysis and within the supra-acetabular area, maintaining secure fixation.\u003c/p\u003e \u003cp\u003eIn addition, when evaluating the displacement of pubic ramus fractures to ascertain the appropriateness of open reduction, factors such as age and fracture location influence the choice of procedural intervention. Fracture sites close to the pubic symphysis within Nakatani zone I or extending into the symphysis pose constraints on the use of closed reduction with intramedullary due to limitations like implant loosening and the potential loss of fracture reduction [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. No instances of failed CRF were observed in cases where fractures were located in Nakatani zone I, as these cases predominantly underwent ORF following the established treatment protocol. It is worth noting that four fixation failures were documented in cases where the fractures were positioned in Nakatani zone II, with three of these instances involving female patients of advanced age who used intramedullary nails rather than screws.\u003c/p\u003e \u003cp\u003eA pure straddle fracture is categorized as a stable pelvic ring injury, and conservative management is generally effective. The primary objective of treatment is to alleviate pain and expedite the restoration of functional capacity. Employing a closed reduction maneuver is preferred over an open approach to mitigate anatomical trauma. The necessity for open reduction in the presence of posterior pelvic ring injury remains controversial [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClinical and biomechanical studies have provided evidence that a closed reduction method coupled with intramedullary implant fixation imparts sufficient strength even in the context of posterior pelvic ring injury [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Our observations indicated a correlation between a more severe and displaced posterior pelvic ring injury and a similarly displaced straddle fracture, indicative of a disrupted pectineal ligament. Although no statistical significance was demonstrated between the bilateral closed reduction with intramedullary fixation group and the bilateral open reduction with plate osteosynthesis group in the presence of posterior pelvic ring injury, a greater number of patients in our study underwent osteosynthesis via ORF.\u003c/p\u003e \u003cp\u003eAlthough diligent efforts were made to mitigate bias, certain limitations persisted in our study. Firstly, a retrospective review and analysis of medical records were conducted. Despite the existence of a treatment protocol, the ultimate course of treatment is subject to various factors, including concomitant injuries, availability of surgical instruments and implants, and surgeon discretion. Additionally, the analysis categorized patients into CRIF and ORIF groups; however, it is important to recognize that some patients might have undergone ORIF at one site and CRIF at another. Furthermore, the absence of reported functional outcomes is noteworthy, with only nine straddle fracture patients lacking posterior pelvic ring injuries. The reported functional outcomes may have been influenced by the presence of more severe unstable pelvic ring injuries.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eA straddle fracture may manifest either as a standalone injury within the pelvic ring or in conjunction with a posterior pelvic ring injury. In instances where surgical intervention is necessary, both closed and open reduction methods contribute to bone union. Open reduction yields a more symmetrical pelvis compared with the outcome using closed reduction. Opting for ORF becomes particularly advantageous when the fracture exhibits greater displacement and proximity to, or penetration of, the pubic symphysis, resulting in improved radiological outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAO = Arbeitsgemeinschaft f\u0026uuml;r Osteosynthesefragen\u003c/p\u003e\n\u003cp\u003eAP = anteroposterior\u003c/p\u003e\n\u003cp\u003eASIF = anterior superior internal fixation\u003c/p\u003e\n\u003cp\u003eCRF = closed reduction and fixation\u003c/p\u003e\n\u003cp\u003eCT = computed tomography\u003c/p\u003e\n\u003cp\u003eED = emergency department\u003c/p\u003e\n\u003cp\u003eEUA = evaluation under anesthesia\u003c/p\u003e\n\u003cp\u003eHO = heterotopic ossification\u003c/p\u003e\n\u003cp\u003eORF = open reduction and fixation\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate:\u0026nbsp;\u003c/strong\u003eThis retrospective chart review study involving human participants was conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study protocol was approved by the Institutional Review Board (IRB NO:\u0026nbsp;202400382B0) of Chang Gung Memorial Hospital, Taoyuan City, Taiwan. Informed consent was waived by the Institutional Review Board (IRB NO:\u0026nbsp;202400382B0) of Chang Gung Memorial Hospital, Taoyuan City, Taiwan due to the retrospective nature of the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication: Not applicable.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; Contributions:\u0026nbsp;\u003c/strong\u003eConceptualization: Y.-H. Y., C.-Y. L., and I-J. C.; Investigation: Y.-H. H. and Y.-C. C.; Writing: Y.-H. Y.; Writing-review and supervision: Y.-H. Y. All the authors have read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSource of Funding:\u0026nbsp;\u003c/strong\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSimonian PT, Routt ML Jr. Biomechanics of pelvic fixation. Orthop Clin North Am. 1997;28(3):351-67. \u003c/li\u003e\n\u003cli\u003eKim WY. Treatment of Unstable Pelvic Ring Injuries. Hip Pelvis. 2014; doi:10.5371/hp.2014.26.2.79. \u003c/li\u003e\n\u003cli\u003eYu YH, Tsai PJ, Liu CH, Chen IJ, Hsu YH, Chou YC, et al. 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The pectineal ligament is a secondary stabilizer in anterior pelvic ring fractures - a biomechanical study. Injury. 2022;53(2):334-8. \u003c/li\u003e\n\u003cli\u003eRommens PM, Graafen M, Arand C, Mehling I, Hofmann A, Wagner D. Minimal-invasive stabilization of anterior pelvic ring fractures with retrograde transpubic screws. Injury. 2020;51(2):340-6. \u003c/li\u003e\n\u003cli\u003eMcLachlin S, Lesieur M, Stephen D, Kreder H, Whyne C. Biomechanical analysis of anterior ring fixation of the ramus in type C pelvis fractures. Eur J Trauma Emerg Surg. 2018;44(2):185-90. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Straddle fracture, pelvic ring injury, osteosynthesis, treatment protocol, radiological outcome","lastPublishedDoi":"10.21203/rs.3.rs-4245291/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4245291/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eOsteosynthesis techniques for addressing straddle fractures include closed reduction and fixation (CRF) and open reduction and fixation (ORF). Although CRF offers the advantage of being a minimally invasive surgery, ORF ensures precise reduction and secure fixation. The optimal surgical approach, whether employing CRF or ORF, to achieve superior osteosynthesis outcomes remains uncertain. This study aimed to compare the perioperative characteristics of the two methods and identify an optimal treatment approach tailored to each clinical indication.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed a retrospective analysis of patients with pelvic ring injuries at a single trauma center admitted between 2016 and 2021. Among this cohort, 69 patients with straddle fractures, with or without posterior pelvic ring injuries, were identified. The patients were categorized into two groups based on the treatment protocol: the CRF and ORF groups. Preoperative conditions, intraoperative features, and radiological outcomes were systematically compared and analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 69 patients with 138 superior pubic rami fractures underwent surgical treatment using either closed (57 superior pubic rami) or open (81 superior pubic rami) methods. Application of CRF significantly prevented fractures in Nakatani zone I (P\u0026thinsp;=\u0026thinsp;0.003). ORF was employed for segmental fractures of the pubic ramus (P\u0026thinsp;=\u0026thinsp;0.03) and fractures with greater displacement in the axial plane (P\u0026thinsp;=\u0026thinsp;0.03). Additionally, ORF resulted in a more symmetric pelvic reduction according to the Lefaivre criteria (P\u0026thinsp;=\u0026thinsp;0.003).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eBoth CRF and ORF demonstrated the ability to achieve satisfactory radiological outcomes in straddle fractures. The use of an established treatment protocol can assist surgeons in making informed decisions regarding the optimal treatment approach.\u003c/p\u003e\u003ch2\u003eLevel of Evidence\u003c/h2\u003e \u003cp\u003eTherapeutic III\u003c/p\u003e","manuscriptTitle":"Comparative Evaluation of Closed Versus Open Reduction Techniques in Straddle Fractures: A Retrospective Analysis of 69 Patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-19 17:54:06","doi":"10.21203/rs.3.rs-4245291/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7831876f-c649-42d6-9338-f3d4b17f7e96","owner":[],"postedDate":"April 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-24T12:38:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-19 17:54:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4245291","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4245291","identity":"rs-4245291","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}