Delay in Hip Reductions Due to the Advent of Rapid CT Scans in the Trauma Setting

Delay in Hip Reductions Due to the Advent of Rapid CT Scans in the Trauma Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Delay in Hip Reductions Due to the Advent of Rapid CT Scans in the Trauma Setting John Hwang, David Ahn, Caroline Preston, Michael S. Sirkin, Joseph D. Galloway, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7490310/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 02 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Introduction : With increasing reliance on computed tomography (CT) in trauma care, the use of anteroposterior (AP) pelvis radiographs has declined. This study examined whether omitting an initial AP pelvis film affects time to hip reduction and the need for additional CT imaging in patients with traumatic hip dislocations. Methods : We conducted a retrospective review at a Level I trauma center (2005–2016). Eligible patients were adults (>17 years) with native hip dislocations evaluated under the Advanced Trauma Life Support (ATLS) protocol. Patients with incomplete records or irreducible hips requiring operative reduction were excluded. Data collected included patient demographics, AP pelvis use, CT imaging, time to reduction, and presence of acetabular or proximal femur fractures. Results : The study cohort consisted of 50 patients, 76% male (n=38), with a mean age of 33 years (range, 18–68). High-energy motor vehicle accident or motorcycle crash accounted for 90% (n=45) of injuries, and 94% (n=47) were posterior dislocations. Associated fractures were present in 76% (n=38). Patients were divided into those who had no AP pelvis radiograph prior to CT scan (N-APP group, n=8; 16%) and those who obtained an initial AP pelvis radiograph on presentation (APP group, n=42; 84%). All patients in the N-APP group required an additional CT pelvis scan, while none in the APP group did. Average time to reduction was significantly shorter in the APP group compared with the N-APP group (69 vs 216 minutes, p<0.05). Conclusions : Obtaining an initial AP pelvis radiograph provides a rapid and reliable means of diagnosing hip dislocations. Adherence to ATLS guidelines by performing a pelvic film before CT shortens time to reduction and prevents unnecessary repeat CT imaging in adult patients with traumatic native hip dislocations. Hip Dislocation Trauma Diagnostic Imaging Perioperative Optimization Figures Figure 1 Introduction Traumatic dislocations of the hip often occur following high-energy trauma and require emergent care. These injuries are most seen in the setting of motor vehicle accidents [ 1 ]. Prognosis is variable, but obtaining a closed reduction as quickly as possible is ideal to decrease the chance of avascular necrosis of the femoral head and minimize the incidence of post-traumatic arthritis of the hip [ 2 ]. Historically, a dislocated hip is diagnosed on an AP pelvis x-ray performed as part of the Advanced Trauma Life Support (ATLS) protocol, with the ATLS algorithm mandating a pelvic radiograph during the initial assessment of the patient [ 3 ]. However, there is an increasing contingent of practitioners questioning the utility of plain film pelvic radiographs in the era of the readily available Computerized Tomography (CT) [ 4 ]. Current orthopaedic guidelines require a CT scan after reduction of a dislocated hip to evaluate for concentric reduction and intra-articular loose bodies [ 5 , 6 ]. In the situation of a hemodynamically stable patient without an obvious physical exam finding, the general surgery trauma literature advocates forgoing the initial AP pelvis to obtain the CT scan more quickly [ 7 ]. For these reasons, it is becoming a more common occurrence for the trauma CT to be performed before an AP pelvis is obtained. In the setting of a dislocated hip, foregoing the traditional ATLS protocol (i.e., AP pelvis radiograph), often results in the diagnosis being made on the CT scan. This then results in a delay in reduction, followed by a second CT scan to evaluate the joint. The clinical presentation of a patient with a hip dislocation is typically characteristic and should prompt an immediate AP pelvis film. The purpose of this study was to show that a substantial number of patients with hip dislocations do not receive an AP pelvis film prior to CT. We hypothesized that for patients with traumatic hip dislocations, a significant number were initially diagnosed on CT scan. Secondarily, we believe that by not performing an initial AP pelvic radiograph prior to a CT scan, these patients require additional CT scans and have an increased time to hip reduction. Methods Institutional review board approval was obtained prior to accessing the trauma database for the collection of patient information. Patients were searched for and selected from our institution's trauma database by ICD-9 and ICD-10 diagnosis codes for hip dislocation during the years 2005–2016. Inclusion criteria consisted of patients over the age of 17, initial evaluation with ATLS protocol (per hospital records), and native hip dislocation. Patients with incomplete medical records and irreducible hips that required reduction in the operating room were excluded from the study. Sixty-two patients were identified, and twenty-two patients were excluded because of incomplete medical records, irreducible hips in the emergency department, patients with prior hip arthroplasty, and pediatric patients. Patient demographics, including age and gender, were recorded. In addition, laterality of dislocation, mechanism of injury, and presence of associated fracture were identified. Next, a chart review was performed to assess whether the patient had an AP pelvis film prior to CT. The patients who did not obtain an AP pelvis radiograph prior to the CT scan were grouped in the No AP Pelvis (N-APP) group. The patients who obtained AP pelvis radiographs prior to a CT scan were grouped in the AP Pelvis (APP) group. Other information collected included the total number of CT pelvis scans each patient obtained on initial evaluation and the time from presentation until radiographic confirmation of hip reduction. Chi-squared analysis was utilized to compare the prevalence of additional CT scans performed in the N-APP group as compared to those in the APP group. Furthermore, a one-tailed T-test was used to determine whether a significant delay in time to radiographic confirmation of hip reduction between the two groups. A P value of < .05 was selected for the determination of statistical significance. Results There were 50 patients who sustained hip dislocations from 2005–2016 who met our inclusion and exclusion criteria. The group was predominantly male at 76%. Patient age ranged from 18 to 68, with an average age of 33. The predominant mechanism of injury was a high-energy motor vehicle accident or motorcycle crash, which together accounted for 90% of cases. The remaining cases were comprised of individuals who had fallen from heights or pedestrians who had been struck by motor vehicles. Fifty-five percent had an associated acetabular fracture. Three patients had anterior dislocations, while the remaining patients had posterior dislocations. There were eight patients (19%) who had CT scans while still dislocated without an initial AP pelvis film and who were grouped in the N-APP group. Of those eight patients in the N-APP group, 100% required an additional CT pelvis scan, while no patients in the APP group required additional CT pelvis scans (P < .05) (Table 1 ). Table 1 Patient demographics, injury characteristics, and CT utilization by group (APP vs N-APP). N-APP (8) APP (42) Total (50) p-value Gender Male 88% (7) 74% (31) 76% (38) .239 Female 12% (1) 26% (11) 24% (12) Laterality Right 88% (7) 67% (28) 70%(35) .406 Left 12% (1) 33% (14) 30% (15) Associated Fracture Yes 88% (7) 74% (31) 76% (38) .239 No 12% (1) 26% (11) 24% (12) Number of Pelvis CT 1 0% (0) 100% (42) 84% (42) .001 2 100% (8) 0% (0) 16% (8) The overall average time from presentation to the hospital to radiographic confirmation of hip reduction was 93 minutes. In the APP group average reduction time was 69 minutes (Standard Error − 4.8), while in the N-APP group, it was 216 minutes (Standard Error − 58.1), respectively (p = 0.039) (Fig. 1 ). In those that did not obtain an initial AP pelvic radiograph, there was an average of 2 hours and 27 minutes (216 minutes vs 69 minutes) delay in time to reduction (p < 0.05). Discussion Traumatic hip dislocation and fracture-dislocation occur following high-energy trauma, typically seen with motor vehicle accidents [ 1 ]. These injuries often occur following high-energy trauma, typically seen with motor vehicle accidents [ 1 ]. Due to the severity of these traumas, these patients present to the emergency department with other concomitant injuries that require ATLS management [ 8 – 10 ]. The traditional ATLS algorithm includes obtaining an emergent AP pelvis during the evaluation of these patients [ 3 ]. Recent studies in trauma and emergency medicine fields have suggested that the use of initial AP pelvis radiograph may be unnecessary with the advent and accessibility of CT imaging [ 4 , 7 , 11 ]. Conversely, orthopaedic literature continues to recommend a pelvis radiograph during initial management of the high-energy traumatized patients [ 12 , 13 ]. Urgent reduction of the hip dislocation continues to be recommended due to the high risk of avascular necrosis associated with this injury. In adults, the cervical arteries, which branch from the medial femoral circumflex artery, provide the main blood supply to the femoral head. Injury to these vessels could lead to avascular necrosis of the femoral head. With posterior dislocation, kinking or injury could occur to these vessels. A cadaveric study by Yue et al. examined six hips after they were forcefully dislocated posteriorly. The research found that there were filling defects in the circumflex arteries following dislocation [ 14 ]. A study performed in 1962 by Brav et al. found that 22% of patients who underwent reductions within 12 hours, as opposed to 52% of patients whose reductions were delayed greater than 12 hours, developed osteonecrosis [ 15 ]. A more recent retrospective study by Hougaard et al. found that, at the 5-year mark, 4% of those patients who underwent closed reduction within 6 hours, as opposed to 58% of patients whose reductions were delayed greater than 6 hours, developed osteonecrosis. In our study, approximately 1 in 5 patients (19%) with a hip dislocation did not have plain pelvis radiographs on initial evaluation, resulting not only in a delay in hip reduction but also an increased exposure to radiation. When comparing average times to hip reduction for the two groups, the N-APP group was found to have an increase of greater than two hours in average time to reduction when compared to that of the APP group. As these times were based on initial arrival to the emergency department, the actual time from injury to reduction would be greater than our current presented time, as we did not incorporate the time accrued prior to the patient arriving in the emergency department. For this reason, one could certainly deduce that the time to reduction was approached or surpassed 6 hours in the N-APP group (Average – 216 minutes), while those in the APP group (average – 69 minutes) were likely below this 6-hour threshold. Another complication associated with traumatic hip dislocations is post-traumatic arthritis. Post-traumatic arthritis is the most common complication, with rates as high as 48% [ 15 – 17 ]. Prolonged time to reduction can increase the risk of injury to the femoral head and the articular surface. Movement of patients during transportation to CT imaging prior to hip reduction, especially in those patients with unknown dislocations, can cause continued injury to the articular cartilage and further increase the risk of injury to the femoral head. While this is an area that is not yet fully understood, various studies have implied that increased radiation exposure poses a risk for radiation-induced carcinogenesis [ 18 – 20 ]. Currently, orthopaedic literature highly recommends CT scans following closed reduction of hip dislocations in order to evaluate for concentric reduction, loose bodies in the joint, and occult fractures [ 5 , 6 , 21 ]. Diagnosing and reducing hip dislocation during initial trauma management would prevent unnecessary radiation exposure, as the CT chest/abdomen/pelvis would be performed after the reduction. Our study found that 0% of those in the APP required additional CT scans, while 100% of those in the N-APP group required additional CT imaging. This additional CT scan results in increased radiation exposure. Our study demonstrates several limitations. First, although prior literature has established the consequences of delaying hip reductions, our study did not determine the clinical sequela of the delay in diagnosis within our population. Furthermore, the retrospective nature of our study did not allow us to consider possible other factors associated with the delay in reduction. Finally, this study is limited to one institution with a limited sample size. A larger data set would help strengthen the significance of our findings. Conclusion During initial management of traumatized patients, pelvis plain radiographs continue to be recommended for evaluation of hip dislocations. Our study demonstrates that those patients with traumatic hip dislocations who obtain an initial plain radiograph during initial evaluation can avoid delays in diagnosis, decrease time to reduction, lower patient cost, and minimize radiation exposure. Declarations Author Contribution All authors have contributed significantly to this manuscript. Study conception and design: JH, MS, JG, MCR, and MRA. Material preparation, data collection and analysis were performed by all authors. First draft of the manuscript: JH, MRA. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. References Rosenthal RE, Coker WL. Posterior fracture-dislocation of the hip: an epidemiologic review. J Trauma 1979;19:572-81. Kellam P, Ostrum RF. Systematic Review and Meta-Analysis of Avascular Necrosis and Posttraumatic Arthritis After Traumatic Hip Dislocation. J Orthop Trauma 2016;30:10-6. American College of Surgeons. Committee on Trauma. ATLS, advanced trauma life support program for doctors. 7th ed. Chicago, IL: American College of Surgeons; 2004. Kessel B, Sevi R, Jeroukhimov I, et al. Is routine portable pelvic X-ray in stable multiple trauma patients always justified in a high technology era? Injury 2007;38:559-63. Brooks RA, Ribbans WJ. Diagnosis and imaging studies of traumatic hip dislocations in the adult. Clin Orthop Relat Res 2000:15-23. Hougaard K, Lindequist S, Nielsen LB. Computerised tomography after posterior dislocation of the hip. J Bone Joint Surg Br 1987;69:556-7. Guillamondegui OD, Pryor JP, Gracias VH, Gupta R, Reilly PM, Schwab CW. Pelvic radiography in blunt trauma resuscitation: a diminishing role. J Trauma 2002;53:1043-7. Suraci AJ. Distribution and severity of injuries associated with hip dislocations secondary to motor vehicle accidents. J Trauma 1986;26:458-60. Marymont JV, Cotler HB, Harris JH, Jr., Miller-Crotchett P, Browner BD. Posterior hip dislocation associated with acute traumatic injury of the thoracic aorta: a previously unrecognized injury complex. J Orthop Trauma 1990;4:383-7. Epstein HC. Traumatic dislocations of the hip. Clin Orthop Relat Res 1973:116-42. Hilty MP, Behrendt I, Benneker LM, et al. Pelvic radiography in ATLS algorithms: A diminishing role? World J Emerg Surg 2008;3:11. Gibson PD, Adams MR, Koury KL, Shaath MK, Sirkin MS, Reilly MC. Inadvertent Reduction of Symphyseal Diastasis During Computed Tomography. J Orthop Trauma 2016;30:474-8. Foulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg 2010;18:199-209. Yue JJ, Wilber JH, Lipuma JP, et al. Posterior hip dislocations: a cadaveric angiographic study. J Orthop Trauma 1996;10:447-54. Brav EA. Traumatic dislocation of the hip. J Bone Joint Surg Am 1962;44:1115-34. Stewart MJ, Milford LW. Fracture-dislocation of the hip; an end-result study. J Bone Joint Surg Am 1954;36:315-42. Vecsei V, Schwendenwein E, Berger G. [Hip dislocation without bone injuries]. Orthopade 1997;26:317-26. Brenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A 2003;100:13761-6. Power SP, Moloney F, Twomey M, James K, O'Connor OJ, Maher MM. Computed tomography and patient risk: Facts, perceptions and uncertainties. World J Radiol 2016;8:902-15. Royal HD. Effects of low level radiation-what's new? Semin Nucl Med 2008;38:392-402. Court-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD. Rockwood and Green's fractures in adults. Eighth edition. ed. Philadelphia: Wolters Kluwer Health; 2015. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 02 Feb, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 09 Oct, 2025 Reviews received at journal 19 Sep, 2025 Reviewers agreed at journal 19 Sep, 2025 Reviews received at journal 17 Sep, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviewers invited by journal 16 Sep, 2025 Editor assigned by journal 30 Aug, 2025 Submission checks completed at journal 30 Aug, 2025 First submitted to journal 29 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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These injuries are most seen in the setting of motor vehicle accidents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Prognosis is variable, but obtaining a closed reduction as quickly as possible is ideal to decrease the chance of avascular necrosis of the femoral head and minimize the incidence of post-traumatic arthritis of the hip [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Historically, a dislocated hip is diagnosed on an AP pelvis x-ray performed as part of the Advanced Trauma Life Support (ATLS) protocol, with the ATLS algorithm mandating a pelvic radiograph during the initial assessment of the patient [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, there is an increasing contingent of practitioners questioning the utility of plain film pelvic radiographs in the era of the readily available Computerized Tomography (CT) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrent orthopaedic guidelines require a CT scan after reduction of a dislocated hip to evaluate for concentric reduction and intra-articular loose bodies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In the situation of a hemodynamically stable patient without an obvious physical exam finding, the general surgery trauma literature advocates forgoing the initial AP pelvis to obtain the CT scan more quickly [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. For these reasons, it is becoming a more common occurrence for the trauma CT to be performed before an AP pelvis is obtained. In the setting of a dislocated hip, foregoing the traditional ATLS protocol (i.e., AP pelvis radiograph), often results in the diagnosis being made on the CT scan. This then results in a delay in reduction, followed by a second CT scan to evaluate the joint.\u003c/p\u003e\u003cp\u003eThe clinical presentation of a patient with a hip dislocation is typically characteristic and should prompt an immediate AP pelvis film. The purpose of this study was to show that a substantial number of patients with hip dislocations do not receive an AP pelvis film prior to CT. We hypothesized that for patients with traumatic hip dislocations, a significant number were initially diagnosed on CT scan. Secondarily, we believe that by not performing an initial AP pelvic radiograph prior to a CT scan, these patients require additional CT scans and have an increased time to hip reduction.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eInstitutional review board approval was obtained prior to accessing the trauma database for the collection of patient information. Patients were searched for and selected from our institution's trauma database by ICD-9 and ICD-10 diagnosis codes for hip dislocation during the years 2005\u0026ndash;2016. Inclusion criteria consisted of patients over the age of 17, initial evaluation with ATLS protocol (per hospital records), and native hip dislocation. Patients with incomplete medical records and irreducible hips that required reduction in the operating room were excluded from the study. Sixty-two patients were identified, and twenty-two patients were excluded because of incomplete medical records, irreducible hips in the emergency department, patients with prior hip arthroplasty, and pediatric patients.\u003c/p\u003e\u003cp\u003ePatient demographics, including age and gender, were recorded. In addition, laterality of dislocation, mechanism of injury, and presence of associated fracture were identified. Next, a chart review was performed to assess whether the patient had an AP pelvis film prior to CT. The patients who did not obtain an AP pelvis radiograph prior to the CT scan were grouped in the No AP Pelvis (N-APP) group. The patients who obtained AP pelvis radiographs prior to a CT scan were grouped in the AP Pelvis (APP) group. Other information collected included the total number of CT pelvis scans each patient obtained on initial evaluation and the time from presentation until radiographic confirmation of hip reduction.\u003c/p\u003e\u003cp\u003eChi-squared analysis was utilized to compare the prevalence of additional CT scans performed in the N-APP group as compared to those in the APP group. Furthermore, a one-tailed T-test was used to determine whether a significant delay in time to radiographic confirmation of hip reduction between the two groups. A P value of \u0026lt;\u0026thinsp;.05 was selected for the determination of statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 50 patients who sustained hip dislocations from 2005\u0026ndash;2016 who met our inclusion and exclusion criteria. The group was predominantly male at 76%. Patient age ranged from 18 to 68, with an average age of 33. The predominant mechanism of injury was a high-energy motor vehicle accident or motorcycle crash, which together accounted for 90% of cases. The remaining cases were comprised of individuals who had fallen from heights or pedestrians who had been struck by motor vehicles. Fifty-five percent had an associated acetabular fracture. Three patients had anterior dislocations, while the remaining patients had posterior dislocations.\u003c/p\u003e\u003cp\u003eThere were eight patients (19%) who had CT scans while still dislocated without an initial AP pelvis film and who were grouped in the N-APP group. Of those eight patients in the N-APP group, 100% required an additional CT pelvis scan, while no patients in the APP group required additional CT pelvis scans (P\u0026thinsp;\u0026lt;\u0026thinsp;.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient demographics, injury characteristics, and CT utilization by group (APP vs N-APP).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN-APP (8)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAPP (42)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTotal (50)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88% (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74% (31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76% (38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.239\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12% (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26% (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24% (12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLaterality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eRight\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88% (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67% (28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70%(35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.406\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eLeft\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12% (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33% (14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30% (15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAssociated Fracture\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e88% (7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74% (31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e76% (38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.239\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eNo\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12% (1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26% (11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24% (12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNumber of Pelvis CT\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e1\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0% (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e100% (42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e84% (42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.001\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003e2\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e100% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0% (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e16% (8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe overall average time from presentation to the hospital to radiographic confirmation of hip reduction was 93 minutes. In the APP group average reduction time was 69 minutes (Standard Error \u0026minus;\u0026thinsp;4.8), while in the N-APP group, it was 216 minutes (Standard Error \u0026minus;\u0026thinsp;58.1), respectively (p\u0026thinsp;=\u0026thinsp;0.039) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In those that did not obtain an initial AP pelvic radiograph, there was an average of 2 hours and 27 minutes (216 minutes vs 69 minutes) delay in time to reduction (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTraumatic hip dislocation and fracture-dislocation occur following high-energy trauma, typically seen with motor vehicle accidents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. These injuries often occur following high-energy trauma, typically seen with motor vehicle accidents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Due to the severity of these traumas, these patients present to the emergency department with other concomitant injuries that require ATLS management [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The traditional ATLS algorithm includes obtaining an emergent AP pelvis during the evaluation of these patients [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Recent studies in trauma and emergency medicine fields have suggested that the use of initial AP pelvis radiograph may be unnecessary with the advent and accessibility of CT imaging [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Conversely, orthopaedic literature continues to recommend a pelvis radiograph during initial management of the high-energy traumatized patients [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eUrgent reduction of the hip dislocation continues to be recommended due to the high risk of avascular necrosis associated with this injury. In adults, the cervical arteries, which branch from the medial femoral circumflex artery, provide the main blood supply to the femoral head. Injury to these vessels could lead to avascular necrosis of the femoral head. With posterior dislocation, kinking or injury could occur to these vessels. A cadaveric study by Yue et al. examined six hips after they were forcefully dislocated posteriorly. The research found that there were filling defects in the circumflex arteries following dislocation [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA study performed in 1962 by Brav et al. found that 22% of patients who underwent reductions within 12 hours, as opposed to 52% of patients whose reductions were delayed greater than 12 hours, developed osteonecrosis [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. A more recent retrospective study by Hougaard et al. found that, at the 5-year mark, 4% of those patients who underwent closed reduction within 6 hours, as opposed to 58% of patients whose reductions were delayed greater than 6 hours, developed osteonecrosis.\u003c/p\u003e\u003cp\u003eIn our study, approximately 1 in 5 patients (19%) with a hip dislocation did not have plain pelvis radiographs on initial evaluation, resulting not only in a delay in hip reduction but also an increased exposure to radiation. When comparing average times to hip reduction for the two groups, the N-APP group was found to have an increase of greater than two hours in average time to reduction when compared to that of the APP group. As these times were based on initial arrival to the emergency department, the actual time from injury to reduction would be greater than our current presented time, as we did not incorporate the time accrued prior to the patient arriving in the emergency department. For this reason, one could certainly deduce that the time to reduction was approached or surpassed 6 hours in the N-APP group (Average \u0026ndash; 216 minutes), while those in the APP group (average \u0026ndash; 69 minutes) were likely below this 6-hour threshold.\u003c/p\u003e\u003cp\u003eAnother complication associated with traumatic hip dislocations is post-traumatic arthritis. Post-traumatic arthritis is the most common complication, with rates as high as 48% [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Prolonged time to reduction can increase the risk of injury to the femoral head and the articular surface. Movement of patients during transportation to CT imaging prior to hip reduction, especially in those patients with unknown dislocations, can cause continued injury to the articular cartilage and further increase the risk of injury to the femoral head.\u003c/p\u003e\u003cp\u003eWhile this is an area that is not yet fully understood, various studies have implied that increased radiation exposure poses a risk for radiation-induced carcinogenesis [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Currently, orthopaedic literature highly recommends CT scans following closed reduction of hip dislocations in order to evaluate for concentric reduction, loose bodies in the joint, and occult fractures [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Diagnosing and reducing hip dislocation during initial trauma management would prevent unnecessary radiation exposure, as the CT chest/abdomen/pelvis would be performed after the reduction. Our study found that 0% of those in the APP required additional CT scans, while 100% of those in the N-APP group required additional CT imaging. This additional CT scan results in increased radiation exposure.\u003c/p\u003e\u003cp\u003eOur study demonstrates several limitations. First, although prior literature has established the consequences of delaying hip reductions, our study did not determine the clinical sequela of the delay in diagnosis within our population. Furthermore, the retrospective nature of our study did not allow us to consider possible other factors associated with the delay in reduction. Finally, this study is limited to one institution with a limited sample size. A larger data set would help strengthen the significance of our findings.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eDuring initial management of traumatized patients, pelvis plain radiographs continue to be recommended for evaluation of hip dislocations. Our study demonstrates that those patients with traumatic hip dislocations who obtain an initial plain radiograph during initial evaluation can avoid delays in diagnosis, decrease time to reduction, lower patient cost, and minimize radiation exposure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors have contributed significantly to this manuscript. Study conception and design: JH, MS, JG, MCR, and MRA. Material preparation, data collection and analysis were performed by all authors. First draft of the manuscript: JH, MRA. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRosenthal RE, Coker WL. Posterior fracture-dislocation of the hip: an epidemiologic review. J Trauma 1979;19:572-81.\u003c/li\u003e\n\u003cli\u003eKellam P, Ostrum RF. 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J Orthop Trauma 2016;30:474-8.\u003c/li\u003e\n\u003cli\u003eFoulk DM, Mullis BH. Hip dislocation: evaluation and management. J Am Acad Orthop Surg 2010;18:199-209.\u003c/li\u003e\n\u003cli\u003eYue JJ, Wilber JH, Lipuma JP, et al. Posterior hip dislocations: a cadaveric angiographic study. J Orthop Trauma 1996;10:447-54.\u003c/li\u003e\n\u003cli\u003eBrav EA. Traumatic dislocation of the hip. J Bone Joint Surg Am 1962;44:1115-34.\u003c/li\u003e\n\u003cli\u003eStewart MJ, Milford LW. Fracture-dislocation of the hip; an end-result study. J Bone Joint Surg Am 1954;36:315-42.\u003c/li\u003e\n\u003cli\u003eVecsei V, Schwendenwein E, Berger G. [Hip dislocation without bone injuries]. Orthopade 1997;26:317-26.\u003c/li\u003e\n\u003cli\u003eBrenner DJ, Doll R, Goodhead DT, et al. Cancer risks attributable to low doses of ionizing radiation: assessing what we really know. Proc Natl Acad Sci U S A 2003;100:13761-6.\u003c/li\u003e\n\u003cli\u003ePower SP, Moloney F, Twomey M, James K, O\u0026apos;Connor OJ, Maher MM. Computed tomography and patient risk: Facts, perceptions and uncertainties. World J Radiol 2016;8:902-15.\u003c/li\u003e\n\u003cli\u003eRoyal HD. Effects of low level radiation-what\u0026apos;s new? Semin Nucl Med 2008;38:392-402.\u003c/li\u003e\n\u003cli\u003eCourt-Brown CM, Heckman JD, McQueen MM, Ricci WM, Tornetta P, McKee MD. Rockwood and Green\u0026apos;s fractures in adults. Eighth edition. ed. Philadelphia: Wolters Kluwer Health; 2015.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Hip Dislocation, Trauma, Diagnostic Imaging, Perioperative Optimization","lastPublishedDoi":"10.21203/rs.3.rs-7490310/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7490310/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: With increasing reliance on computed tomography (CT) in trauma care, the use of anteroposterior (AP) pelvis radiographs has declined. This study examined whether omitting an initial AP pelvis film affects time to hip reduction and the need for additional CT imaging in patients with traumatic hip dislocations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: We conducted a retrospective review at a Level I trauma center (2005–2016). Eligible patients were adults (\u0026gt;17 years) with native hip dislocations evaluated under the Advanced Trauma Life Support (ATLS) protocol. Patients with incomplete records or irreducible hips requiring operative reduction were excluded. Data collected included patient demographics, AP pelvis use, CT imaging, time to reduction, and presence of acetabular or proximal femur fractures.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: The study cohort consisted of 50 patients, 76% male (n=38), with a mean age of 33 years (range, 18–68). High-energy motor vehicle accident or motorcycle crash accounted for 90% (n=45) of injuries, and 94% (n=47) were posterior dislocations. Associated fractures were present in 76% (n=38). Patients were divided into those who had no AP pelvis radiograph prior to CT scan (N-APP group, n=8; 16%) and those who obtained an initial AP pelvis radiograph on presentation (APP group, n=42; 84%). All patients in the N-APP group required an additional CT pelvis scan, while none in the APP group did. Average time to reduction was significantly shorter in the APP group compared with the N-APP group (69 vs 216 minutes, p\u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Obtaining an initial AP pelvis radiograph provides a rapid and reliable means of diagnosing hip dislocations. Adherence to ATLS guidelines by performing a pelvic film before CT shortens time to reduction and prevents unnecessary repeat CT imaging in adult patients with traumatic native hip dislocations.\u003c/p\u003e","manuscriptTitle":"Delay in Hip Reductions Due to the Advent of Rapid CT Scans in the Trauma Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-25 11:41:08","doi":"10.21203/rs.3.rs-7490310/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-09T21:02:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T04:33:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"105303283780549509915512790078704926719","date":"2025-09-19T04:23:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-17T22:34:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298011130902397604468740460368548064895","date":"2025-09-17T19:41:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-16T20:02:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-30T14:47:14+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-30T14:45:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-08-29T16:17:21+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"e7579fc4-59ea-44d1-b7ee-ad3fff8c5b00","owner":[],"postedDate":"September 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T16:01:53+00:00","versionOfRecord":{"articleIdentity":"rs-7490310","link":"https://doi.org/10.1007/s00402-026-06192-9","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2026-02-02 15:58:34","publishedOnDateReadable":"February 2nd, 2026"},"versionCreatedAt":"2025-09-25 11:41:08","video":"","vorDoi":"10.1007/s00402-026-06192-9","vorDoiUrl":"https://doi.org/10.1007/s00402-026-06192-9","workflowStages":[]},"version":"v1","identity":"rs-7490310","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7490310","identity":"rs-7490310","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}