Anatomical Reduction Rate Increased, Fluoroscopy Frequency Reduced: The Clinical Efficacy of the Modified Reduction Sequence in the Treatment of Acetabular Both-Column Fractures

Anatomical Reduction Rate Increased, Fluoroscopy Frequency Reduced: The Clinical Efficacy of the Modified Reduction Sequence in the Treatment of Acetabular Both-Column Fractures | 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 Anatomical Reduction Rate Increased, Fluoroscopy Frequency Reduced: The Clinical Efficacy of the Modified Reduction Sequence in the Treatment of Acetabular Both-Column Fractures Jianhua Zhang, Liqiang Zhang, Gaoxin Chen, Xingzhong Hu, Quanwei Ding, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8964418/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Hip acetabular fractures, especially complex both-column types, pose significant surgical challenges. Traditionally, the "anterior column first, posterior column second" reduction sequence has been widely adopted. However, a modified "posterior column first, anterior column second" sequence has been proposed to potentially improve surgical precision and outcomes. This study aimed to systematically compare the clinical efficacy and safety of these two reduction sequences in the surgical treatment of acetabular both-column fractures. Methods A retrospective analysis was conducted on 40 patients with acetabular both-column fractures treated between March 2023 and June 2025. Patients were divided into a modified group (n = 10), which underwent the "posterior column first, anterior column second" sequence, and a control group (n = 30), which received the traditional "anterior column first, posterior column second" sequence. Surgical parameters (operative time, fluoroscopy frequency, use of additional posterior approaches), fracture reduction quality (assessed via postoperative CT using the Matta criteria), early recovery (time to first ambulation), and hip function at 6 months (Merle d'Aubigné score) were compared. Results Baseline characteristics were comparable between groups ( P > 0.05). The modified group showed a non-significant trend toward shorter operative time (239.3 ± 109.3 min vs. 311.3 ± 83.6 min; P = 0.082) and earlier time to first ambulation (43.5 ± 3.5 days vs. 51.0 ± 15.2 days; P = 0.068). Intraoperative fluoroscopy frequency was significantly lower in the modified group (16.4 ± 2.1 times vs. 31.1 ± 3.7 times; P < 0.001). Although overall reduction quality distribution did not differ significantly ( P = 0.053), the modified group had a higher anatomical reduction rate (80.0% vs. 43.3%) and no unsatisfactory reductions. At 6 months, the modified group had significantly better Merle d'Aubigné scores (17.8 ± 0.4 vs. 16.5 ± 1.3; P = 0.001). Conclusions The modified "posterior column first" reduction sequence significantly reduces intraoperative radiation exposure and improves mid-term hip function in patients with acetabular both-column fractures. It also shows promising trends in shortening surgery time, increasing anatomical reduction rates, and facilitating earlier mobilization. These findings support the modified sequence as a safe and effective surgical strategy, particularly when the posterior column fragment is relatively intact. Further prospective, multicenter studies with larger samples are recommended to confirm these benefits and refine clinical indications. Acetabular fracture Both-column fracture Reduction sequence Ilioinguinal approach Retrospective study Merle d'Aubigné score Radiation exposure Figures Figure 1 Figure 2 Figure 3 Introduction Acetabular fractures represent one of the most challenging and complex injuries in the field of orthopedic trauma, typically resulting from high-energy mechanisms such as traffic accidents or falls from height[ 1 , 2 ]. Their intricate three-dimensional anatomy within the pelvic ring, coupled with the paramount importance of joint surface congruity and stability, renders the treatment process fraught with technical difficulties and prognostic uncertainty[ 3 ]. Within the Letournel-Judet classification system, both-column fractures are considered among the most complex types. Their fracture lines simultaneously involve the anterior and posterior columns of the acetabulum, often extending to the iliac wing and ischial tuberosity, leading to significant central displacement of the articular surface[ 4 ]. This makes surgical reduction and fixation exceptionally difficult, posing a severe test to the surgeon's anatomical knowledge, spatial imagination, and operative skills[ 5 ]. With the rapid development of modern society, the incidence of such high-energy injuries is on the rise. Therefore, continuously optimizing treatment strategies has become a persistent research focus in the field of trauma orthopedics[ 6 ]. Currently, for displaced acetabular both-column fractures, open reduction and internal fixation (ORIF) is widely recognized as the "gold standard" treatment[ 7 ]. Among the numerous available surgical approaches, the anterior ilioinguinal approach, due to its ability to provide extensive exposure of the anterior column, medial wall (quadrilateral plate), and even part of the posterior column while avoiding the disturbance to gluteal muscles and the sciatic nerve associated with posterior approaches, has become the mainstream choice for managing this type of fracture[ 8 , 9 ]. However, even after determining the surgical approach, significant academic disagreement persists regarding the sequence of reducing fracture fragments. Traditional surgical dogma and many classical texts advocate the "anterior column first, posterior column second" sequence[ 10 ]. The theoretical basis is that the anterior column is considered a key biomechanical strut of the pelvic ring, and prioritizing the restoration of its anatomical continuity can provide a stable anterior reference framework for subsequent posterior column reduction. This concept has been widely accepted and applied in clinical practice for many years[ 11 , 12 ]. Nonetheless, with the development of minimally invasive concepts, precision surgery, Enhanced Recovery After Surgery (ERAS) principles, as well as advancements in surgical instruments and intraoperative imaging technology, some clinicians and scholars have begun to re-evaluate the rationality and universality of this traditional sequence[ 13 , 14 ]. Clinical observations have revealed that in a considerable proportion of both-column fractures, the posterior column fragment is relatively large, morphologically intact, and with limited displacement, sometimes even maintaining partial connection with the sacroiliac joint[ 15 ]. In such cases, if the surgeon prioritizes handling and directly visualizes the reduction of the posterior column, not only is the operative field more direct and reduction assessment more precise, but it also establishes a solid, stable "posterior foundation" and "ultimate reference point" for the subsequent anterior column reduction[ 16 ]. This approach might align better with the biomechanical logic of pelvic ring reconstruction and could potentially simplify surgical steps and improve overall reduction accuracy. Although this modified concept is logically appealing, up to now, systematic and rigorous comparative studies on these two reduction sequences remain scarce. Particularly, there is a lack of well-designed clinical studies that can effectively control for potential confounding factors, leading to this technical controversy lingering at the level of empirical discussion, lacking high-level evidence-based medical support. To fill this knowledge gap and provide a more scientific basis for clinical decision-making, this study was designed as a retrospective case-control study. It aims to systematically compare the comprehensive clinical outcomes of the modified "posterior column first, anterior column second" reduction sequence with the traditional "anterior column first, posterior column second" sequence in treating acetabular both-column fractures. The primary outcome measures we focused on encompass surgical efficiency (operative time), patient and staff safety (intraoperative radiation exposure), the core determinant of technical success (radiographic reduction quality), and ultimate patient benefit (postoperative functional recovery). We hypothesized that the modified reduction sequence could significantly optimize the surgical process and reduce associated risks while ensuring or even improving reduction quality, ultimately translating into superior patient functional outcomes. Therefore, this study aims, through a retrospective cohort design, to systematically compare the differences between the modified "posterior column first, anterior column second" sequence and the traditional sequence in terms of surgical efficiency, radiation exposure, reduction quality, and postoperative functional recovery. The goal is to provide a more scientific and individualized basis for surgical strategy in clinical practice, promoting the systematization and refinement of acetabular fracture treatment. Materials and Methods Study Design and Ethics This study is a single-center, retrospective, case-control study. The study protocol was approved by the Institutional Review Board of our hospital (Approval No.: 2025-LW-YJ-003), and the requirement for informed consent was waived (due to the retrospective nature of data analysis, involving no new interventions, and with patient privacy information anonymized). The study was conducted in strict accordance with the principles of the Declaration of Helsinki. Study Subjects and Grouping Complete clinical data were retrospectively collected from patients with acetabular both-column fractures who were admitted to the Department of Trauma Orthopedics at our hospital and underwent surgical treatment between March 2023 and June 2025. Grouping Basis: Patients were grouped according to the fracture reduction sequence clearly documented in the surgical records. Modified Group (Experimental Group): Employed the "posterior column first, anterior column second" surgical sequence. Ten patients were included. Control Group (Traditional Group): Employed the traditional "anterior column first, posterior column second" surgical sequence. Thirty patients were included. Inclusion and Exclusion Criteria Inclusion Criteria: ① Age ≥ 18 years; ② No significant neurovascular injury in the affected lower limb preoperatively, with the ability to walk independently before injury; ③ Preoperative imaging (including anteroposterior/oblique pelvic radiographs, thin-slice CT scans, and 3D reconstructions) confirmed a diagnosis of "both-column fracture" according to the Letournel-Judet classification; ④ Closed fracture; ⑤ Underwent ORIF via a single anterior ilioinguinal approach; ⑥ Possessed complete surgical records, imaging data, and follow-up data for at least 6 months postoperatively. Exclusion Criteria: ① Age < 18 years; ② Concomitant severe unstable injuries to other parts of the ipsilateral or contralateral pelvic ring (e.g., sacrum, sacroiliac joint); ③ Pathological fracture or concurrent malignant tumor; ④ Previous history of ipsilateral hip surgery, femoral head necrosis, or severe osteoarthritis; ⑤ Concomitant multiple injuries affecting early rehabilitation, such as severe craniocerebral, thoracic, or abdominal organ injuries; ⑥ Lost to follow-up or with key information missing from clinical data. Surgical Method All surgeries were performed or directly supervised by the same group of senior attending surgeons with extensive experience in pelvic and acetabular trauma surgery at our hospital to ensure consistency and comparability of techniques. Preoperative Preparation and Positioning: All patients underwent general anesthesia. They were placed in the standard supine position with the affected hip elevated approximately 15°. Routine skin preparation and draping were performed. Surgical Approach: The standard ilioinguinal approach was used in all cases. The incision started at the junction of the middle and anterior third of the iliac crest, extended anteriorly along the iliac crest to the anterior superior iliac spine (ASIS), then turned medially, running parallel and about 2 cm above the inguinal ligament, and ended about 2 cm above the pubic symphysis. The skin, subcutaneous tissue, and superficial fascia were incised sequentially, with care taken to protect the lateral femoral cutaneous nerve. The lateral window (iliac fossa), middle window (between the femoral vascular sheath and the spermatic cord/round ligament), and medial window (pubic tubercle area) were opened sequentially to fully expose the internal plate of the iliac wing, pelvic brim, quadrilateral plate, superior pubic ramus, and part of the posterior column. Detailed Surgical Steps for the Modified Group (see Figure 1, 2, 3 for details): Exposure and Debridement: Priority was given to entering through the middle window. The fracture hematoma and impacted soft tissue in the greater sciatic notch area were carefully cleaned to fully expose the posterior column fracture ends, particularly the posterior part of the quadrilateral plate and the ischial spine region. Posterior Column Reduction and Temporary Fixation: Instruments such as periosteal elevators, pointed reduction forceps, or Farabeuf clamps were used to perform precise anatomical reduction of the posterior column fragment under direct vision. Reduction satisfaction was confirmed by palpating the continuity of the greater sciatic notch, observing the articular surface of the quadrilateral plate, and intraoperative fluoroscopy (Judet views). Temporary fixation was then achieved using 1.5-2.0 mm Kirschner wires or 3.5 mm cannulated screws. Anterior Column Reduction and Fixation: The anterior column fracture was then addressed. Via the lateral window and/or medial window, fractures of the iliac wing and pubic rami were reduced. Using the already stabilized posterior column as a reference, the anterior column fragment was precisely aligned with it. The anterior column was fixed using reconstruction plates or lag screws. Final Fixation and Closure: A pre-contoured long reconstruction plate was placed along the arcuate line, sequentially fixing the pubic portion, anterior acetabular column, and iliac fossa portion. Screws were directed toward the posterior column to achieve final stable fixation. The wound was thoroughly irrigated, a drain was placed, and the incision was closed in layers. Detailed Surgical Steps for the Control Group: Anterior Column Priority Reduction: The anterior column fracture (iliac wing, anterior inferior iliac spine region) was first reduced and fixed via the lateral window. Posterior Column Exploration and Reduction: The posterior column was then attempted to be exposed via the middle window. Due to obstruction by the anterior column plate and bone fragments, the posterior column was often in a semi-visualized or palpation-only state. Indirect reduction was performed using instruments, relying primarily on the surgeon's tactile feedback (finger palpation of the greater sciatic notch) and repeated intraoperative fluoroscopy to assess reduction quality. Posterior Column Fixation: Once reduction was deemed satisfactory, long lag screws were typically placed posteriorly through holes in the anterior column plate or via separate drilling to fix the posterior column. All patients underwent intraoperative fluoroscopic monitoring using a C-arm, but the timing and frequency of fluoroscopy were at the surgeon's discretion based on reduction needs. Postoperatively, prophylactic antibiotics were routinely administered for 24-48 hours, and drains were removed within 24-48 hours. Observation Indicators and Evaluation Criteria Baseline Data: Age, gender. Surgical-related Indicators: Operative Time: Total duration from skin incision to skin suture completion (minutes). Intraoperative Fluoroscopy Frequency: Total number of C-arm exposures recorded. Necessity of Combined Posterior Approach: Recorded whether an additional posterior approach (e.g., Kocher-Langenbeck) was required due to failed posterior column reduction or fixation difficulty. Radiographic Evaluation Indicators: Fracture Reduction Quality: Evaluated using thin-slice pelvic CT scans (slice thickness 1 mm) with multiplanar reconstruction (MPR) performed within 1 week postoperatively. Two senior radiologists, blinded to the group allocation, independently assessed the quality based on the internationally recognized Matta Radiographic Criteria: Anatomical Reduction: Fracture fragment displacement ≤ 1 mm. Satisfactory Reduction: Fracture fragment displacement 2 - 3 mm. Unsatisfactory Reduction: Fracture fragment displacement > 3 mm. In case of disagreement between the two assessors, consensus was reached through discussion or arbitration by a third senior radiologist. Postoperative Recovery and Functional Evaluation Indicators: Time to First Ambulation: Recorded as the postoperative day when the patient began standing and walking with partial weight-bearing (typically ≤15 kg) on the affected limb using a walker. Hip Function Score: Assessed at the 6-month postoperative outpatient follow-up using the Merle d'Aubigné-Postel Scoring System. This system evaluates three dimensions: pain (6 points), walking ability (6 points), and range of motion (6 points), with a total score of 18 points. Results are graded as: Excellent (18 points), Good (15-17 points), Fair (13-14 points), Poor (<13 points). Statistical Methods All statistical analyses were performed using IBM SPSS Statistics 26.0 software. Measurement data were first tested for normality using the Shapiro-Wilk test. Normally distributed measurement data are presented as mean ± standard deviation (x̄ ± s), and intergroup comparisons were made using the independent samples t-test. If variances were unequal (Levene's test for homogeneity of variances P <0.05), the adjusted t-test (Satterthwaite's method) was used. Non-normally distributed measurement data are presented as median (interquartile range) [M (IQR)], and intergroup comparisons were made using the non-parametric Mann-Whitney U test. Categorical data are presented as number (percentage) [n (%)], and intergroup comparisons were made using the Chi-square test (χ² test); when more than 20% of cells had an expected count less than 5, Fisher's exact test was used. For the intergroup comparison of reduction quality (a three-category ordinal variable), the Fisher-Freeman-Halton exact test was used due to small expected counts. All statistical tests were two-sided, with P <0.05 considered statistically significant. Results Patient Baseline Characteristics and Comparability Analysis A total of 40 eligible patients with acetabular both-column fractures were finally included in the study. The modified group consisted of 10 patients (9 males, 1 female), and the control group consisted of 30 patients (26 males, 4 females). As shown in Table 1 , comparative analysis of the baseline characteristics of the two groups revealed no significant differences in gender distribution ( P = 1.000) or age ( P = 0.828). Furthermore, there was no statistically significant difference between the groups in the necessity of a combined posterior approach, an indicator that may reflect the initial complexity or reduction difficulty of the fracture ( P = 0.556). These results indicate that the modified and control groups in this study had good comparability in terms of major demographic characteristics and one key indicator of surgical complexity, providing a relatively balanced basis for comparing subsequent surgical outcomes and functional prognosis. Comparison of Surgical-related Indicators The comparison results of surgical-related indicators are detailed in Table 1 . Regarding operative time, the mean operative time was (239.3 ± 109.3) minutes in the modified group and (311.3 ± 83.6) minutes in the control group. The operative time in the modified group was approximately 72 minutes shorter on average than in the control group, showing a trend towards reduced operative time. However, this difference did not reach statistical significance ( P = 0.082). In contrast, a highly significant difference was found between the groups in the key indicator of intraoperative fluoroscopy frequency . The mean fluoroscopy frequency was only (16.4 ± 2.1) times in the modified group, significantly lower than the (31.1 ± 3.7) times in the control group ( P < 0.001). This indicates that adopting the modified reduction sequence can substantially reduce intraoperative radiation exposure by approximately 47.3%. Comparison of Fracture Reduction Quality The results of fracture reduction quality assessed by postoperative CT are summarized in Table 1 . In the modified group, 80.0% (8/10) of patients achieved anatomical reduction, 20.0% (2/10) had satisfactory reduction, and none had unsatisfactory reduction. In the control group, 43.3% (13/30) achieved anatomical reduction, 46.7% (14/30) had satisfactory reduction, and 10.0% (3/30) had unsatisfactory reduction. Statistical analysis of the overall distribution of reduction quality between the two groups using the Fisher-Freeman-Halton exact test yielded a P-value of 0.053, which did not reach the conventional statistical significance threshold of less than 0.05. Nonetheless, the anatomical reduction rate was numerically higher in the modified group (80.0%) compared to the control group (43.3%). Moreover, cases of unsatisfactory reduction occurred in the control group but not in the modified group. This suggests that the modified sequence may have a potential advantage in achieving higher-precision anatomical reduction. Comparison of Postoperative Recovery and Functional Prognosis The comparison of postoperative recovery indicators is also presented in Table 1 . Regarding the time to first ambulation , the mean was (43.5 ± 3.5) days in the modified group and (51.0 ± 15.2) days in the control group. The modified group showed a trend towards earlier ambulation, but the intergroup difference did not reach statistical significance ( P = 0.068). For the core indicator evaluating hip function at 6 months postoperatively—the Merle d'Aubigné score —the modified group achieved significantly better results. The mean score was (17.8 ± 0.4) points in the modified group, significantly higher than the (16.5 ± 1.3) points in the control group, with the difference being highly statistically significant ( P = 0.001). This indicates that patients treated with the modified reduction sequence had significantly better comprehensive functional recovery status in terms of pain, walking ability, and range of motion of the hip at the mid-term postoperative follow-up compared to those treated with the traditional sequence. Discussion Through a retrospective case-control design, this study systematically evaluated the clinical application value of the modified "posterior column first, anterior column second" surgical sequence in treating complex acetabular both-column fractures. Our findings clearly demonstrate that compared to the traditional "anterior column first, posterior column second" sequence, the modified sequence shows significant advantages or positive trends in several important dimensions. Notably, it achieved highly statistically significant results in reducing intraoperative radiation exposure and improving patients' mid-term postoperative hip function . Simultaneously, the modified sequence also exhibited encouraging potential in shortening operative time , increasing the rate of anatomical reduction , and promoting earlier patient ambulation . Significant Optimization of Surgical Efficiency and Radiation Safety is one of the core highlights of this study. The mean operative time in the modified group was approximately 72 minutes shorter than in the control group (although P = 0.082 did not reach significance). This trend aligns with the logical advantages of the modified sequence. In the traditional sequence, the mechanical obstruction formed after anterior column fixation renders the posterior column area an "operational blind spot." Surgeons are forced to rely on tactile feedback and "blind" maneuvers, coupled with repeated, multi-angle intraoperative fluoroscopy to "guess" and verify the reduction, a process that inevitably consumes considerable time[ 17 , 18 ]. In contrast, the modified sequence eliminates this uncertainty by prioritizing direct visual reduction of the posterior column. The stabilization of the posterior column not only simplifies the subsequent alignment process for the anterior column but also reduces repeated adjustments due to suboptimal reduction, thereby achieving "streamlining and efficiency enhancement" in the surgical workflow. Even more striking is the remarkable reduction in intraoperative fluoroscopy frequency (modified group: 16.4 times vs. control group: 31.1 times, P < 0.001). This directly quantifies the substantial value of the modified sequence in lowering radiation exposure risks for both medical staff and patients. Against the backdrop of modern orthopedic surgery advocating the "ALARA" (As Low As Reasonably Achievable) radiation protection principle, this finding carries significant importance for occupational health and patient safety[ 19 ]. Reducing fluoroscopy frequency also implies fewer surgical interruptions, which helps maintain the surgical team's focus and the continuity of the operative rhythm. In-depth Interpretation of Reduction Quality warrants special attention. Although statistical testing showed no significant difference in the overall distribution of reduction quality between the groups ( P = 0.053), the clinical pattern of the data is suggestive. The modified group achieved a high anatomical reduction rate of 80%, with no cases of unsatisfactory reduction, whereas the control group had an anatomical reduction rate of only 43.3% and presented 3 cases (10%) of unsatisfactory reduction. The P-value approaching the threshold (0.053) might be related to the sample size of this study, particularly the small size of the modified group, which limits the statistical power (increasing the risk of Type II error). From a clinical practice perspective, achieving anatomical reduction is the ultimate goal in acetabular fracture surgery, as it is closely associated with a lower incidence of long-term post-traumatic arthritis and better preservation of joint function[ 20 , 21 ]. By establishing early anatomical alignment of the posterior column—the "load-bearing dome"—the modified sequence sets a "gold standard" reference for the precise reconstruction of the entire acetabulum. This is likely the key to technically achieving a higher anatomical reduction rate. The unsatisfactory reduction cases in the control group are probably related to the difficulty of achieving precise reduction of the posterior column under obstruction. Significant Improvement in Functional Prognosis is the most compelling finding of this study. At 6 months postoperatively, the Merle d'Aubigné score was significantly better in the modified group ( P = 0.001). This score difference holds clear clinical significance, meaning that patients in the modified group experienced better recovery in terms of pain relief, daily walking ability, and hip range of motion. Excellent postoperative function results from the combined effect of multiple factors: First, the higher anatomical reduction rate creates a near-ideal mechanical environment for articular cartilage, reducing abnormal contact stress and secondary inflammation[ 22 ]. Second, shorter operative time and potentially less tissue dissection may decrease the inflammatory response and soft tissue complication risks associated with the surgical trauma itself[ 23 ]. Finally, the trend towards earlier ambulation in the modified group (though not statistically significant) might also promote muscle strength recovery and joint proprioception reconstruction through early mobilization[ 24 ]. These factors together constitute a plausible pathway for the modified sequence to lead to better functional outcomes for patients. Examining from a broader Clinical and Academic Perspective , the findings of this study carry multiple implications. First, it challenges the established dogma regarding the reduction sequence for acetabular both-column fractures, providing empirical evidence for individualized and precise surgical strategies based on specific fracture morphology. Second, it resonates with the principles of ERAS by optimizing technical details to promote overall patient recovery. Third, it emphasizes the significant impact of intraoperative decisions (such as sequence selection) on long-term patient-reported outcomes. Of course, we must acknowledge the limitations of this study: the inherent selection bias of the retrospective design cannot be completely eliminated; the sample size, especially for the modified group, is small; and a more detailed subgroup analysis of factors potentially affecting reduction difficulty, such as comminution degree and osteoporosis, was not performed. Furthermore, the modified sequence likely demands higher anatomical knowledge and operative skills in the posterior column region from the surgeon, and its learning curve effect remains to be evaluated. Study Limitations Although this study has yielded some meaningful conclusions, it is essential to recognize its limitations, which may affect the interpretation and generalizability of the results: Inherent Bias of Retrospective Study Design This study is a retrospective analysis with all data derived from historical medical records. Grouping was based on established surgical sequences rather than random allocation, potentially introducing selection bias. For instance, surgeons might have chosen the reduction sequence based on the initial fracture morphology, complexity, or personal experience preference. This could mean that the two groups were not entirely balanced in terms of baseline fracture complexity, although no significant differences were found in our baseline comparison. Relatively Small Sample Size, Particularly in the Modified Group The modified group included only 10 patients, representing a limited sample size. A small sample size reduces statistical power and increases the risk of Type II error (false negative). This might be one reason why intergroup differences for indicators such as operative time ( P = 0.082) and reduction quality ( P = 0.053) did not reach conventional significance levels. The small sample size also limits the ability to perform more in-depth subgroup analyses (e.g., stratified by age, fracture comminution). Single-center Study All patients were from the same medical center, and surgeries were performed by the same group of surgeons. While this ensures technical consistency, it limits the external validity (generalizability) of the findings. It remains uncertain whether other centers or surgical teams could replicate these results using the same technique. Lack of Quantitative Assessment of Fracture Morphology Complexity This study did not employ more refined indicators such as "fracture comminution score" or "osteoporosis assessment" to quantify the initial difficulty of each case. Factors like the number of fragments and bone quality significantly influence reduction difficulty and final outcomes, and these potential confounding factors were not fully controlled. Relatively Short Follow-up Period The primary functional assessment point in this study was 6 months postoperatively. While suitable for observing early and mid-term functional recovery, this duration is insufficient to evaluate long-term complications of acetabular fracture surgery, such as post-traumatic arthritis, femoral head necrosis, or implant failure. The long-term benefits and safety of the modified sequence require confirmation through longer follow-up. Learning Curve Effect Not Assessed The "posterior column first" sequence may impose higher demands on the surgeon's familiarity with posterior column anatomy and operative techniques. This study did not analyze the learning curve associated with adopting this technique, making it impossible to determine if differences existed between early and later cases in terms of operative time and outcomes. Conclusion In conclusion, this retrospective case-control study demonstrates that in the surgical treatment of acetabular both-column fractures using a single anterior ilioinguinal approach, adopting the modified "posterior column first, anterior column second" surgical sequence, compared to the traditional sequence, can significantly reduce intraoperative fluoroscopy frequency (lowering radiation exposure) and significantly improve patients' hip function at 6 months postoperatively. Concurrently, this sequence also exhibits clear positive trends in shortening operative time, achieving a higher proportion of anatomical reductions, and promoting earlier patient mobilization. Therefore, this modified strategy represents a safe, effective, and multifaceted beneficial optimization of surgical technique. We recommend that clinicians actively consider adopting this reduction sequence when managing such complex fractures, especially when the posterior column fragment is relatively intact. In the future, more rigorous prospective, multi-center, large-sample studies, potentially combined with advanced technologies like artificial intelligence fracture analysis or intraoperative navigation, are needed to further validate and refine the applicable conditions and long-term efficacy of this strategy. Abbreviations ORIF Open reduction and internal fixation ERAS Enhanced Recovery After Surgery ASIS Anterior superior iliac spine MPR Multiplanar reconstruction Declarations Acknowledgments We appreciate the great help from the Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine. Author Contributions Conception and design of the research: Jiong Yang; Acquisition of data: Liqiang Zhang; Analysis and interpretation of the data: Gaoxin Chen, Xingzhong Hu; Statistical analysis: Jianhua Zhang, Quanwei Ding; Writing of the manuscript: Jianhua Zhang; Critical revision of the manuscript for intellectual content: Jiong Yang, Liqiang Zhang. All authors have read and agreed to the published version of the manuscript. Funding This research received no external funding. Data availability The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author. Ethics approval and consent to participate This study was conducted with approval from the Ethics Committee of the Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Approval No.: 2025-LW-YJ-003). The research was performed in strict accordance with the ethical principles outlined in the Declaration of Helsinki. Given the retrospective nature of the study, which involved no new interventions on patients, the requirement for obtaining informed consent was waived. All data analyses were conducted using anonymized patient information to ensure strict confidentiality and protect individual privacy. Clinical trial number Not applicable. Consent for publication Not applicable. Competing interests The authors declare that they have no competing interests. References Dyskin E, Hill BW, Torchia MT, Cole PA. A Survey of High- and Low-Energy Acetabular Fractures in Elderly Patients. Geriatr Orthop Surg Rehabil. 2019;10:2151459319870426. 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Fluoroscopically guided acetabular posterior column screw fixation via an anterior approach. Oper Orthop Traumatol. 2019;31(6):503–12. Kistler BJ, Sagi HC. Reduction of the posterior column in displaced acetabulum fractures through the anterior intrapelvic approach. J Orthop Trauma. 2015;29(Suppl 2):S14–9. Kaplan DJ, Patel JN, Liporace FA, Yoon RS. Intraoperative radiation safety in orthopaedics: a review of the ALARA (As low as reasonably achievable) principle. Patient Saf Surg. 2016;10:27. Cahueque M, Martínez M, Cobar A, Bregni M. Early reduction of acetabular fractures decreases the risk of post-traumatic hip osteoarthritis? J Clin Orthop Trauma. 2017;8(4):320–6. Bastian JD, Tannast M, Siebenrock KA, Keel MJ. Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach. Injury. 2013;44(12):1793–8. Sniderman J, Henry P. Articular reductions - how close is close enough? A narrative review. Injury. 2020;51(Suppl 2):S77–82. Aminsharifi A, Salehipoor M, Arasteh H. Systemic immunologic and inflammatory response after laparoscopic versus open nephrectomy: a prospective cohort trial. J Endourol. 2012;26(9):1231–6. Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015;29(9):844–54. Tables Table 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table1Comparisonofbaselinecharacteristicsandsurgicaloutcomesbetweenthemodifiedandcontrolgroups..docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 10 Mar, 2026 Reviews received at journal 08 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviewers agreed at journal 08 Mar, 2026 Reviews received at journal 03 Mar, 2026 Reviewers agreed at journal 03 Mar, 2026 Reviewers invited by journal 03 Mar, 2026 Editor invited by journal 02 Mar, 2026 Editor assigned by journal 02 Mar, 2026 Submission checks completed at journal 02 Mar, 2026 First submitted to journal 25 Feb, 2026 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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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-8964418","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":600255907,"identity":"5f4cb2d4-41d1-479a-8f3e-0006f4c71ef6","order_by":0,"name":"Jianhua Zhang","email":"","orcid":"","institution":"Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Fuyang TCM Hospital of Orthopedics Affiliated to Zhejiang Chinese Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Jianhua","middleName":"","lastName":"Zhang","suffix":""},{"id":600255908,"identity":"9e987539-094f-4b4e-96d4-a1d33cd550e3","order_by":1,"name":"Liqiang Zhang","email":"","orcid":"","institution":"Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Fuyang TCM Hospital of Orthopedics Affiliated to Zhejiang Chinese Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Liqiang","middleName":"","lastName":"Zhang","suffix":""},{"id":600255910,"identity":"1419bc53-bc3a-4626-8bfd-e70c62d4461b","order_by":2,"name":"Gaoxin Chen","email":"","orcid":"","institution":"Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Fuyang TCM Hospital of Orthopedics Affiliated to Zhejiang Chinese Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Gaoxin","middleName":"","lastName":"Chen","suffix":""},{"id":600255913,"identity":"0b47ac54-4b89-4fcc-8c14-fb5d5cfbcb1b","order_by":3,"name":"Xingzhong Hu","email":"","orcid":"","institution":"Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Fuyang TCM Hospital of Orthopedics Affiliated to Zhejiang Chinese Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Xingzhong","middleName":"","lastName":"Hu","suffix":""},{"id":600255920,"identity":"551317b3-2948-419e-860e-3429bc717858","order_by":4,"name":"Quanwei Ding","email":"","orcid":"","institution":"Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Fuyang TCM Hospital of Orthopedics Affiliated to Zhejiang Chinese Medical University)","correspondingAuthor":false,"prefix":"","firstName":"Quanwei","middleName":"","lastName":"Ding","suffix":""},{"id":600255922,"identity":"e3f24273-64fb-48bf-82e5-6d55b94dd103","order_by":5,"name":"Jiong Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA90lEQVRIiWNgGAWjYLACCQMgwd7YcPhPhYScPPFaeA4ffMBzxsLYsIF4q9KSDXjbKhIZDhBQaHD87OEXFgU2efIOOWYSkvMkEhgbmB8+uoFPy5m8NAsJg7RiwwNnzCQMt0nksTOwGRvn4NNyIMfMQMLgcOLGxh4zicRtEsWMDTxs0ni1nH8D1dLMYyZxcI5EYsMBQlpu5Bg/AGmZz8aWbNjYQIQWyRtvzICBnJa4gYf54GOGYxLGhs0E/MJ3Psf4s8Qfm8T58x82HGaoqZOTZ29++BifFoUDDGzSEuBwgAkx41EOAvINDMwfP0AYo2AUjIJRMAqwAwD+Yk+myWuu3QAAAABJRU5ErkJggg==","orcid":"","institution":"Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Fuyang TCM Hospital of Orthopedics Affiliated to Zhejiang Chinese Medical University)","correspondingAuthor":true,"prefix":"","firstName":"Jiong","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2026-02-25 07:23:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8964418/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8964418/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104258356,"identity":"fe24f896-6c7a-4dba-a331-9b58718a39f1","added_by":"auto","created_at":"2026-03-09 17:36:48","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":584038,"visible":true,"origin":"","legend":"\u003cp\u003eA. Anteroposterior radiograph of the pelvis shows typical imaging features of an acetabular both-column fracture. Fracture lines involve the iliac wing, anterior column, and posterior column, accompanied by central displacement of the acetabulum. B, C. Three-dimensional CT reconstruction of the pelvis clearly demonstrates the spatial distribution of the fracture lines, with separation of the anterior and posterior columns and obvious malalignment of the articular surface. D, E, F. Multiplanar CT reconstruction further delineates the direction and extent of fragment displacement, involvement of the quadrilateral plate, and provides precise anatomical guidance for surgical planning.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8964418/v1/69a9ff50b4c2cc60278082ff.png"},{"id":104258358,"identity":"d8ea72e8-6589-4846-a087-826ae05a317b","added_by":"auto","created_at":"2026-03-09 17:36:48","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":660071,"visible":true,"origin":"","legend":"\u003cp\u003eA. Anteroposterior radiograph of the pelvis reveals an acetabular both-column fracture, with fracture lines extending through the iliac wing, anterior column, and posterior column, accompanied by superomedial displacement of the acetabulum and asymmetry of the joint space. B. Three-dimensional CT reconstruction clearly illustrates anterior column fracture involvement of the anterior inferior iliac spine and pubic ramus, with posterior column fracture extending to the ischial tuberosity, resulting in overall separation of the acetabulum. C. Three-dimensional CT reconstruction further demonstrates posterior displacement of the posterior column fragment, separation of the acetabular roof, and loss of articular surface continuity. D. Axial CT image shows convergence of anterior and posterior column fracture lines at the quadrilateral plate, with obvious step-off deformity of the articular surface. E. Sagittal CT image reveals posterior displacement of the posterior column fragment and loss of integrity of the posterior acetabular wall. F. Coronal CT image (through the acetabular roof) displays displacement of the acetabular roof fragment, malalignment of the articular surface, suggesting a tendency toward central dislocation.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8964418/v1/ffc5e13e754d9e144f09eed6.png"},{"id":104404944,"identity":"4ddc656c-bf87-4037-b7b7-6b4412a02c5a","added_by":"auto","created_at":"2026-03-11 12:21:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":733401,"visible":true,"origin":"","legend":"\u003cp\u003eA. Postoperative anteroposterior radiograph of the pelvis shows satisfactory positioning of the internal fixation. The reconstruction plate conforms well along the arcuate line and pelvic brim, with restoration of fracture alignment and symmetry of the hip joint space. B, C. Postoperative three-dimensional CT reconstruction confirms anatomical reduction of fracture fragments. The internal fixation system adequately covers both the anterior and posterior columns, with restoration of acetabular morphology. D, E, F. Postoperative multiplanar CT reconstruction demonstrates well-aligned fracture lines, articular surface step-off \u0026lt;1 mm, restoration of the quadrilateral plate contour, and absence of intra-articular penetration by fixation screws.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8964418/v1/3a4caaaeeeb40586f2fd4c36.png"},{"id":104411107,"identity":"482f2f9d-4464-449c-ac3f-fa95c6850352","added_by":"auto","created_at":"2026-03-11 12:55:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3650392,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8964418/v1/2550c335-2b82-4b3d-8b7b-72e0cc58458d.pdf"},{"id":104258355,"identity":"6eb9b5e7-eec1-44f6-8978-9af9a005ddca","added_by":"auto","created_at":"2026-03-09 17:36:47","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":21231,"visible":true,"origin":"","legend":"","description":"","filename":"Table1Comparisonofbaselinecharacteristicsandsurgicaloutcomesbetweenthemodifiedandcontrolgroups..docx","url":"https://assets-eu.researchsquare.com/files/rs-8964418/v1/86558c48acd7e0cd727b1eef.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Anatomical Reduction Rate Increased, Fluoroscopy Frequency Reduced: The Clinical Efficacy of the Modified Reduction Sequence in the Treatment of Acetabular Both-Column Fractures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcetabular fractures represent one of the most challenging and complex injuries in the field of orthopedic trauma, typically resulting from high-energy mechanisms such as traffic accidents or falls from height[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Their intricate three-dimensional anatomy within the pelvic ring, coupled with the paramount importance of joint surface congruity and stability, renders the treatment process fraught with technical difficulties and prognostic uncertainty[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Within the Letournel-Judet classification system, both-column fractures are considered among the most complex types. Their fracture lines simultaneously involve the anterior and posterior columns of the acetabulum, often extending to the iliac wing and ischial tuberosity, leading to significant central displacement of the articular surface[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This makes surgical reduction and fixation exceptionally difficult, posing a severe test to the surgeon's anatomical knowledge, spatial imagination, and operative skills[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. With the rapid development of modern society, the incidence of such high-energy injuries is on the rise. Therefore, continuously optimizing treatment strategies has become a persistent research focus in the field of trauma orthopedics[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, for displaced acetabular both-column fractures, open reduction and internal fixation (ORIF) is widely recognized as the \"gold standard\" treatment[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Among the numerous available surgical approaches, the anterior ilioinguinal approach, due to its ability to provide extensive exposure of the anterior column, medial wall (quadrilateral plate), and even part of the posterior column while avoiding the disturbance to gluteal muscles and the sciatic nerve associated with posterior approaches, has become the mainstream choice for managing this type of fracture[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, even after determining the surgical approach, significant academic disagreement persists regarding the sequence of reducing fracture fragments. Traditional surgical dogma and many classical texts advocate the \"anterior column first, posterior column second\" sequence[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The theoretical basis is that the anterior column is considered a key biomechanical strut of the pelvic ring, and prioritizing the restoration of its anatomical continuity can provide a stable anterior reference framework for subsequent posterior column reduction. This concept has been widely accepted and applied in clinical practice for many years[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNonetheless, with the development of minimally invasive concepts, precision surgery, Enhanced Recovery After Surgery (ERAS) principles, as well as advancements in surgical instruments and intraoperative imaging technology, some clinicians and scholars have begun to re-evaluate the rationality and universality of this traditional sequence[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Clinical observations have revealed that in a considerable proportion of both-column fractures, the posterior column fragment is relatively large, morphologically intact, and with limited displacement, sometimes even maintaining partial connection with the sacroiliac joint[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In such cases, if the surgeon prioritizes handling and directly visualizes the reduction of the posterior column, not only is the operative field more direct and reduction assessment more precise, but it also establishes a solid, stable \"posterior foundation\" and \"ultimate reference point\" for the subsequent anterior column reduction[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This approach might align better with the biomechanical logic of pelvic ring reconstruction and could potentially simplify surgical steps and improve overall reduction accuracy. Although this modified concept is logically appealing, up to now, systematic and rigorous comparative studies on these two reduction sequences remain scarce. Particularly, there is a lack of well-designed clinical studies that can effectively control for potential confounding factors, leading to this technical controversy lingering at the level of empirical discussion, lacking high-level evidence-based medical support.\u003c/p\u003e \u003cp\u003eTo fill this knowledge gap and provide a more scientific basis for clinical decision-making, this study was designed as a retrospective case-control study. It aims to systematically compare the comprehensive clinical outcomes of the modified \"posterior column first, anterior column second\" reduction sequence with the traditional \"anterior column first, posterior column second\" sequence in treating acetabular both-column fractures. The primary outcome measures we focused on encompass surgical efficiency (operative time), patient and staff safety (intraoperative radiation exposure), the core determinant of technical success (radiographic reduction quality), and ultimate patient benefit (postoperative functional recovery). We hypothesized that the modified reduction sequence could significantly optimize the surgical process and reduce associated risks while ensuring or even improving reduction quality, ultimately translating into superior patient functional outcomes.\u003c/p\u003e \u003cp\u003eTherefore, this study aims, through a retrospective cohort design, to systematically compare the differences between the modified \"posterior column first, anterior column second\" sequence and the traditional sequence in terms of surgical efficiency, radiation exposure, reduction quality, and postoperative functional recovery. The goal is to provide a more scientific and individualized basis for surgical strategy in clinical practice, promoting the systematization and refinement of acetabular fracture treatment.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design and Ethics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is a single-center, retrospective, case-control study. The study protocol was approved by the Institutional Review Board of our hospital (Approval No.: 2025-LW-YJ-003), and the requirement for informed consent was waived (due to the retrospective nature of data analysis, involving no new interventions, and with patient privacy information anonymized). The study was conducted in strict accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Subjects and Grouping\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComplete clinical data were retrospectively collected from patients with acetabular both-column fractures who were admitted to the Department of Trauma Orthopedics at our hospital and underwent surgical treatment between March 2023 and June 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGrouping Basis:\u003c/strong\u003e Patients were grouped according to the fracture reduction sequence clearly documented in the surgical records.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eModified Group (Experimental Group):\u0026nbsp;\u003c/strong\u003eEmployed the \u0026quot;posterior column first, anterior column second\u0026quot; surgical sequence. Ten patients were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eControl Group (Traditional Group):\u0026nbsp;\u003c/strong\u003eEmployed the traditional \u0026quot;anterior column first, posterior column second\u0026quot; surgical sequence. Thirty patients were included.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria:\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;①\u0026nbsp;Age \u0026ge; 18 years;\u003cbr\u003e\u0026nbsp;②\u0026nbsp;No significant neurovascular injury in the affected lower limb preoperatively, with the ability to walk independently before injury;\u003cbr\u003e\u0026nbsp;③\u0026nbsp;Preoperative imaging (including anteroposterior/oblique pelvic radiographs, thin-slice CT scans, and 3D reconstructions) confirmed a diagnosis of \u0026quot;both-column fracture\u0026quot; according to the Letournel-Judet classification;\u003cbr\u003e\u0026nbsp;④\u0026nbsp;Closed fracture;\u003cbr\u003e\u0026nbsp;⑤\u0026nbsp;Underwent ORIF via a single anterior ilioinguinal approach;\u003cbr\u003e\u0026nbsp;⑥\u0026nbsp;Possessed complete surgical records, imaging data, and follow-up data for at least 6 months postoperatively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e①\u0026nbsp;Age \u0026lt; 18 years;\u003c/p\u003e\n\u003cp\u003e②\u0026nbsp;Concomitant severe unstable injuries to other parts of the ipsilateral or contralateral pelvic ring (e.g., sacrum, sacroiliac joint);\u003cbr\u003e\u0026nbsp;③\u0026nbsp;Pathological fracture or concurrent malignant tumor;\u003cbr\u003e\u0026nbsp;④\u0026nbsp;Previous history of ipsilateral hip surgery, femoral head necrosis, or severe osteoarthritis;\u003cbr\u003e\u0026nbsp;⑤\u0026nbsp;Concomitant multiple injuries affecting early rehabilitation, such as severe craniocerebral, thoracic, or abdominal organ injuries;\u003cbr\u003e\u0026nbsp;⑥\u0026nbsp;Lost to follow-up or with key information missing from clinical data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Method\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed or directly supervised by the same group of senior attending surgeons with extensive experience in pelvic and acetabular trauma surgery at our hospital to ensure consistency and comparability of techniques.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePreoperative Preparation and Positioning:\u0026nbsp;\u003c/strong\u003eAll patients underwent general anesthesia. They were placed in the standard supine position with the affected hip elevated approximately 15\u0026deg;. Routine skin preparation and draping were performed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical Approach:\u0026nbsp;\u003c/strong\u003eThe standard ilioinguinal approach was used in all cases. The incision started at the junction of the middle and anterior third of the iliac crest, extended anteriorly along the iliac crest to the anterior superior iliac spine (ASIS), then turned medially, running parallel and about 2 cm above the inguinal ligament, and ended about 2 cm above the pubic symphysis. The skin, subcutaneous tissue, and superficial fascia were incised sequentially, with care taken to protect the lateral femoral cutaneous nerve. The lateral window (iliac fossa), middle window (between the femoral vascular sheath and the spermatic cord/round ligament), and medial window (pubic tubercle area) were opened sequentially to fully expose the internal plate of the iliac wing, pelvic brim, quadrilateral plate, superior pubic ramus, and part of the posterior column.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDetailed Surgical Steps for the Modified Group (see Figure 1, 2, 3 for details):\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExposure and Debridement:\u0026nbsp;\u003c/strong\u003ePriority was given to entering through the middle window. The fracture hematoma and impacted soft tissue in the greater sciatic notch area were carefully cleaned to fully expose the posterior column fracture ends, particularly the posterior part of the quadrilateral plate and the ischial spine region.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePosterior Column Reduction and Temporary Fixation:\u0026nbsp;\u003c/strong\u003eInstruments such as periosteal elevators, pointed reduction forceps, or Farabeuf clamps were used to perform precise anatomical reduction of the posterior column fragment under direct vision. Reduction satisfaction was confirmed by palpating the continuity of the greater sciatic notch, observing the articular surface of the quadrilateral plate, and intraoperative fluoroscopy (Judet views). Temporary fixation was then achieved using 1.5-2.0 mm Kirschner wires or 3.5 mm cannulated screws.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnterior Column Reduction and Fixation:\u0026nbsp;\u003c/strong\u003eThe anterior column fracture was then addressed. Via the lateral window and/or medial window, fractures of the iliac wing and pubic rami were reduced. Using the already stabilized posterior column as a reference, the anterior column fragment was precisely aligned with it. The anterior column was fixed using reconstruction plates or lag screws.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFinal Fixation and Closure:\u0026nbsp;\u003c/strong\u003eA pre-contoured long reconstruction plate was placed along the arcuate line, sequentially fixing the pubic portion, anterior acetabular column, and iliac fossa portion. Screws were directed toward the posterior column to achieve final stable fixation. The wound was thoroughly irrigated, a drain was placed, and the incision was closed in layers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDetailed Surgical Steps for the Control Group:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnterior Column Priority Reduction:\u0026nbsp;\u003c/strong\u003eThe anterior column fracture (iliac wing, anterior inferior iliac spine region) was first reduced and fixed via the lateral window.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePosterior Column Exploration and Reduction:\u0026nbsp;\u003c/strong\u003eThe posterior column was then attempted to be exposed via the middle window. Due to obstruction by the anterior column plate and bone fragments, the posterior column was often in a semi-visualized or palpation-only state. Indirect reduction was performed using instruments, relying primarily on the surgeon\u0026apos;s tactile feedback (finger palpation of the greater sciatic notch) and repeated intraoperative fluoroscopy to assess reduction quality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePosterior Column Fixation:\u0026nbsp;\u003c/strong\u003eOnce reduction was deemed satisfactory, long lag screws were typically placed posteriorly through holes in the anterior column plate or via separate drilling to fix the posterior column.\u003c/p\u003e\n\u003cp\u003eAll patients underwent intraoperative fluoroscopic monitoring using a C-arm, but the timing and frequency of fluoroscopy were at the surgeon\u0026apos;s discretion based on reduction needs. Postoperatively, prophylactic antibiotics were routinely administered for 24-48 hours, and drains were removed within 24-48 hours.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObservation Indicators and Evaluation Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline Data:\u003c/strong\u003e Age, gender.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgical-related Indicators:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperative Time:\u0026nbsp;\u003c/strong\u003eTotal duration from skin incision to skin suture completion (minutes).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIntraoperative Fluoroscopy Frequency:\u003c/strong\u003e Total number of C-arm exposures recorded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNecessity of Combined Posterior Approach:\u0026nbsp;\u003c/strong\u003eRecorded whether an additional posterior approach (e.g., Kocher-Langenbeck) was required due to failed posterior column reduction or fixation difficulty.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRadiographic Evaluation Indicators:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFracture Reduction Quality:\u0026nbsp;\u003c/strong\u003eEvaluated using thin-slice pelvic CT scans (slice thickness 1 mm) with multiplanar reconstruction (MPR) performed within 1 week postoperatively. Two senior radiologists, blinded to the group allocation, independently assessed the quality based on the internationally recognized\u0026nbsp;Matta Radiographic Criteria:\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnatomical Reduction:\u0026nbsp;\u003c/strong\u003eFracture fragment displacement \u0026le; 1 mm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSatisfactory Reduction:\u0026nbsp;\u003c/strong\u003eFracture fragment displacement 2 - 3 mm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnsatisfactory Reduction:\u003c/strong\u003e Fracture fragment displacement \u0026gt; 3 mm.\u003c/p\u003e\n\u003cp\u003eIn case of disagreement between the two assessors, consensus was reached through discussion or arbitration by a third senior radiologist.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePostoperative Recovery and Functional Evaluation Indicators:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTime to First Ambulation:\u0026nbsp;\u003c/strong\u003eRecorded as the postoperative day when the patient began standing and walking with partial weight-bearing (typically \u0026le;15 kg) on the affected limb using a walker.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHip Function Score:\u0026nbsp;\u003c/strong\u003eAssessed at the 6-month postoperative outpatient follow-up using the\u0026nbsp;Merle d\u0026apos;Aubign\u0026eacute;-Postel Scoring System. This system evaluates three dimensions: pain (6 points), walking ability (6 points), and range of motion (6 points), with a total score of 18 points. Results are graded as: Excellent (18 points), Good (15-17 points), Fair (13-14 points), Poor (\u0026lt;13 points).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics 26.0 software. Measurement data were first tested for normality using the Shapiro-Wilk test. Normally distributed measurement data are presented as mean \u0026plusmn; standard deviation (x̄ \u0026plusmn; s), and intergroup comparisons were made using the independent samples t-test. If variances were unequal (Levene\u0026apos;s test for homogeneity of variances \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05), the adjusted t-test (Satterthwaite\u0026apos;s method) was used. Non-normally distributed measurement data are presented as median (interquartile range) [M (IQR)], and intergroup comparisons were made using the non-parametric Mann-Whitney U test. Categorical data are presented as number (percentage) [n (%)], and intergroup comparisons were made using the Chi-square test (\u0026chi;\u0026sup2; test); when more than 20% of cells had an expected count less than 5, Fisher\u0026apos;s exact test was used. For the intergroup comparison of reduction quality (a three-category ordinal variable), the Fisher-Freeman-Halton exact test was used due to small expected counts. All statistical tests were two-sided, with \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003ePatient Baseline Characteristics and Comparability Analysis\u003c/h2\u003e\n \u003cp\u003eA total of 40 eligible patients with acetabular both-column fractures were finally included in the study. The modified group consisted of 10 patients (9 males, 1 female), and the control group consisted of 30 patients (26 males, 4 females). As shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e, comparative analysis of the baseline characteristics of the two groups revealed no significant differences in gender distribution (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.000) or age (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.828). Furthermore, there was no statistically significant difference between the groups in the necessity of a combined posterior approach, an indicator that may reflect the initial complexity or reduction difficulty of the fracture (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.556). These results indicate that the modified and control groups in this study had good comparability in terms of major demographic characteristics and one key indicator of surgical complexity, providing a relatively balanced basis for comparing subsequent surgical outcomes and functional prognosis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003ch2\u003eComparison of Surgical-related Indicators\u003c/h2\u003e\n \u003cp\u003eThe comparison results of surgical-related indicators are detailed in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Regarding operative time, the mean operative time was (239.3\u0026thinsp;\u0026plusmn;\u0026thinsp;109.3) minutes in the modified group and (311.3\u0026thinsp;\u0026plusmn;\u0026thinsp;83.6) minutes in the control group. The operative time in the modified group was approximately 72 minutes shorter on average than in the control group, showing a trend towards reduced operative time. However, this difference did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.082). In contrast, a highly significant difference was found between the groups in the key indicator of \u003cstrong\u003eintraoperative fluoroscopy frequency\u003c/strong\u003e. The mean fluoroscopy frequency was only (16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1) times in the modified group, significantly lower than the (31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7) times in the control group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This indicates that adopting the modified reduction sequence can substantially reduce intraoperative radiation exposure by approximately 47.3%.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003ch2\u003eComparison of Fracture Reduction Quality\u003c/h2\u003e\n \u003cp\u003eThe results of fracture reduction quality assessed by postoperative CT are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. In the modified group, 80.0% (8/10) of patients achieved anatomical reduction, 20.0% (2/10) had satisfactory reduction, and none had unsatisfactory reduction. In the control group, 43.3% (13/30) achieved anatomical reduction, 46.7% (14/30) had satisfactory reduction, and 10.0% (3/30) had unsatisfactory reduction. Statistical analysis of the overall distribution of reduction quality between the two groups using the Fisher-Freeman-Halton exact test yielded a P-value of 0.053, which did not reach the conventional statistical significance threshold of less than 0.05. Nonetheless, the anatomical reduction rate was numerically higher in the modified group (80.0%) compared to the control group (43.3%). Moreover, cases of unsatisfactory reduction occurred in the control group but not in the modified group. This suggests that the modified sequence may have a potential advantage in achieving higher-precision anatomical reduction.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n \u003ch2\u003eComparison of Postoperative Recovery and Functional Prognosis\u003c/h2\u003e\n \u003cp\u003eThe comparison of postoperative recovery indicators is also presented in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. Regarding the \u003cstrong\u003etime to first ambulation\u003c/strong\u003e, the mean was (43.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5) days in the modified group and (51.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2) days in the control group. The modified group showed a trend towards earlier ambulation, but the intergroup difference did not reach statistical significance (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.068). For the core indicator evaluating hip function at 6 months postoperatively\u0026mdash;the \u003cstrong\u003eMerle d\u0026apos;Aubign\u0026eacute; score\u003c/strong\u003e\u0026mdash;the modified group achieved significantly better results. The mean score was (17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4) points in the modified group, significantly higher than the (16.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3) points in the control group, with the difference being highly statistically significant (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). This indicates that patients treated with the modified reduction sequence had significantly better comprehensive functional recovery status in terms of pain, walking ability, and range of motion of the hip at the mid-term postoperative follow-up compared to those treated with the traditional sequence.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThrough a retrospective case-control design, this study systematically evaluated the clinical application value of the modified \"posterior column first, anterior column second\" surgical sequence in treating complex acetabular both-column fractures. Our findings clearly demonstrate that compared to the traditional \"anterior column first, posterior column second\" sequence, the modified sequence shows significant advantages or positive trends in several important dimensions. Notably, it achieved highly statistically significant results in \u003cb\u003ereducing intraoperative radiation exposure\u003c/b\u003e and \u003cb\u003eimproving patients' mid-term postoperative hip function\u003c/b\u003e. Simultaneously, the modified sequence also exhibited encouraging potential in \u003cb\u003eshortening operative time\u003c/b\u003e, \u003cb\u003eincreasing the rate of anatomical reduction\u003c/b\u003e, and \u003cb\u003epromoting earlier patient ambulation\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSignificant Optimization of Surgical Efficiency and Radiation Safety\u003c/b\u003e is one of the core highlights of this study. The mean operative time in the modified group was approximately 72 minutes shorter than in the control group (although \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.082 did not reach significance). This trend aligns with the logical advantages of the modified sequence. In the traditional sequence, the mechanical obstruction formed after anterior column fixation renders the posterior column area an \"operational blind spot.\" Surgeons are forced to rely on tactile feedback and \"blind\" maneuvers, coupled with repeated, multi-angle intraoperative fluoroscopy to \"guess\" and verify the reduction, a process that inevitably consumes considerable time[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In contrast, the modified sequence eliminates this uncertainty by prioritizing direct visual reduction of the posterior column. The stabilization of the posterior column not only simplifies the subsequent alignment process for the anterior column but also reduces repeated adjustments due to suboptimal reduction, thereby achieving \"streamlining and efficiency enhancement\" in the surgical workflow. Even more striking is the remarkable reduction in intraoperative fluoroscopy frequency (modified group: 16.4 times vs. control group: 31.1 times, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). This directly quantifies the substantial value of the modified sequence in lowering radiation exposure risks for both medical staff and patients. Against the backdrop of modern orthopedic surgery advocating the \"ALARA\" (As Low As Reasonably Achievable) radiation protection principle, this finding carries significant importance for occupational health and patient safety[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Reducing fluoroscopy frequency also implies fewer surgical interruptions, which helps maintain the surgical team's focus and the continuity of the operative rhythm.\u003c/p\u003e \u003cp\u003e \u003cb\u003eIn-depth Interpretation of Reduction Quality\u003c/b\u003e warrants special attention. Although statistical testing showed no significant difference in the overall distribution of reduction quality between the groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.053), the clinical pattern of the data is suggestive. The modified group achieved a high anatomical reduction rate of 80%, with no cases of unsatisfactory reduction, whereas the control group had an anatomical reduction rate of only 43.3% and presented 3 cases (10%) of unsatisfactory reduction. The P-value approaching the threshold (0.053) might be related to the sample size of this study, particularly the small size of the modified group, which limits the statistical power (increasing the risk of Type II error). From a clinical practice perspective, achieving anatomical reduction is the ultimate goal in acetabular fracture surgery, as it is closely associated with a lower incidence of long-term post-traumatic arthritis and better preservation of joint function[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. By establishing early anatomical alignment of the posterior column\u0026mdash;the \"load-bearing dome\"\u0026mdash;the modified sequence sets a \"gold standard\" reference for the precise reconstruction of the entire acetabulum. This is likely the key to technically achieving a higher anatomical reduction rate. The unsatisfactory reduction cases in the control group are probably related to the difficulty of achieving precise reduction of the posterior column under obstruction.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSignificant Improvement in Functional Prognosis\u003c/b\u003e is the most compelling finding of this study. At 6 months postoperatively, the Merle d'Aubign\u0026eacute; score was significantly better in the modified group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001). This score difference holds clear clinical significance, meaning that patients in the modified group experienced better recovery in terms of pain relief, daily walking ability, and hip range of motion. Excellent postoperative function results from the combined effect of multiple factors: First, the higher anatomical reduction rate creates a near-ideal mechanical environment for articular cartilage, reducing abnormal contact stress and secondary inflammation[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Second, shorter operative time and potentially less tissue dissection may decrease the inflammatory response and soft tissue complication risks associated with the surgical trauma itself[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Finally, the trend towards earlier ambulation in the modified group (though not statistically significant) might also promote muscle strength recovery and joint proprioception reconstruction through early mobilization[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. These factors together constitute a plausible pathway for the modified sequence to lead to better functional outcomes for patients.\u003c/p\u003e \u003cp\u003eExamining from a broader \u003cb\u003eClinical and Academic Perspective\u003c/b\u003e, the findings of this study carry multiple implications. First, it challenges the established dogma regarding the reduction sequence for acetabular both-column fractures, providing empirical evidence for individualized and precise surgical strategies based on specific fracture morphology. Second, it resonates with the principles of ERAS by optimizing technical details to promote overall patient recovery. Third, it emphasizes the significant impact of intraoperative decisions (such as sequence selection) on long-term patient-reported outcomes. Of course, we must acknowledge the limitations of this study: the inherent selection bias of the retrospective design cannot be completely eliminated; the sample size, especially for the modified group, is small; and a more detailed subgroup analysis of factors potentially affecting reduction difficulty, such as comminution degree and osteoporosis, was not performed. Furthermore, the modified sequence likely demands higher anatomical knowledge and operative skills in the posterior column region from the surgeon, and its learning curve effect remains to be evaluated.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eStudy Limitations\u003c/h2\u003e \u003cp\u003eAlthough this study has yielded some meaningful conclusions, it is essential to recognize its limitations, which may affect the interpretation and generalizability of the results:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eInherent Bias of Retrospective Study Design\u003c/strong\u003e \u003cp\u003eThis study is a retrospective analysis with all data derived from historical medical records. Grouping was based on established surgical sequences rather than random allocation, potentially introducing selection bias. For instance, surgeons might have chosen the reduction sequence based on the initial fracture morphology, complexity, or personal experience preference. This could mean that the two groups were not entirely balanced in terms of baseline fracture complexity, although no significant differences were found in our baseline comparison.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRelatively Small Sample Size, Particularly in the Modified Group\u003c/strong\u003e \u003cp\u003eThe modified group included only 10 patients, representing a limited sample size. A small sample size reduces statistical power and increases the risk of Type II error (false negative). This might be one reason why intergroup differences for indicators such as operative time (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.082) and reduction quality (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.053) did not reach conventional significance levels. The small sample size also limits the ability to perform more in-depth subgroup analyses (e.g., stratified by age, fracture comminution).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSingle-center Study\u003c/strong\u003e \u003cp\u003eAll patients were from the same medical center, and surgeries were performed by the same group of surgeons. While this ensures technical consistency, it limits the external validity (generalizability) of the findings. It remains uncertain whether other centers or surgical teams could replicate these results using the same technique.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLack of Quantitative Assessment of Fracture Morphology Complexity\u003c/strong\u003e \u003cp\u003eThis study did not employ more refined indicators such as \"fracture comminution score\" or \"osteoporosis assessment\" to quantify the initial difficulty of each case. Factors like the number of fragments and bone quality significantly influence reduction difficulty and final outcomes, and these potential confounding factors were not fully controlled.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eRelatively Short Follow-up Period\u003c/strong\u003e \u003cp\u003eThe primary functional assessment point in this study was 6 months postoperatively. While suitable for observing early and mid-term functional recovery, this duration is insufficient to evaluate long-term complications of acetabular fracture surgery, such as post-traumatic arthritis, femoral head necrosis, or implant failure. The long-term benefits and safety of the modified sequence require confirmation through longer follow-up.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLearning Curve Effect Not Assessed\u003c/strong\u003e \u003cp\u003eThe \"posterior column first\" sequence may impose higher demands on the surgeon's familiarity with posterior column anatomy and operative techniques. This study did not analyze the learning curve associated with adopting this technique, making it impossible to determine if differences existed between early and later cases in terms of operative time and outcomes.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, this retrospective case-control study demonstrates that in the surgical treatment of acetabular both-column fractures using a single anterior ilioinguinal approach, adopting the modified \"posterior column first, anterior column second\" surgical sequence, compared to the traditional sequence, can significantly reduce intraoperative fluoroscopy frequency (lowering radiation exposure) and significantly improve patients' hip function at 6 months postoperatively. Concurrently, this sequence also exhibits clear positive trends in shortening operative time, achieving a higher proportion of anatomical reductions, and promoting earlier patient mobilization. Therefore, this modified strategy represents a safe, effective, and multifaceted beneficial optimization of surgical technique. We recommend that clinicians actively consider adopting this reduction sequence when managing such complex fractures, especially when the posterior column fragment is relatively intact. In the future, more rigorous prospective, multi-center, large-sample studies, potentially combined with advanced technologies like artificial intelligence fracture analysis or intraoperative navigation, are needed to further validate and refine the applicable conditions and long-term efficacy of this strategy.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2187%;\"\u003e\n \u003cp\u003eORIF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66.3539%;\"\u003e\n \u003cp\u003eOpen reduction and internal fixation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2187%;\"\u003e\n \u003cp\u003eERAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66.3539%;\"\u003e\n \u003cp\u003eEnhanced Recovery After Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2187%;\"\u003e\n \u003cp\u003eASIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66.3539%;\"\u003e\n \u003cp\u003eAnterior superior iliac spine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.2187%;\"\u003e\n \u003cp\u003eMPR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66.3539%;\"\u003e\n \u003cp\u003eMultiplanar reconstruction\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the great help from the Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConception and design of the research: Jiong Yang; Acquisition of data: Liqiang Zhang; Analysis and interpretation of the data: Gaoxin Chen, Xingzhong Hu; Statistical analysis: Jianhua Zhang, Quanwei Ding; Writing of the manuscript: Jianhua Zhang; Critical revision of the manuscript for intellectual content: Jiong Yang, Liqiang Zhang. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted with approval from the Ethics Committee of the Hangzhou Fuyang Hospital of Orthopedics of Traditional Chinese Medicine (Approval No.: 2025-LW-YJ-003). The research was performed in strict accordance with the ethical principles outlined in the Declaration of Helsinki. Given the retrospective nature of the study, which involved no new interventions on patients, the requirement for obtaining informed consent was waived. All data analyses were conducted using anonymized patient information to ensure strict confidentiality and protect individual privacy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDyskin E, Hill BW, Torchia MT, Cole PA. A Survey of High- and Low-Energy Acetabular Fractures in Elderly Patients. Geriatr Orthop Surg Rehabil. 2019;10:2151459319870426.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRinne PP, Laitinen MK, Huttunen T, Kannus P, Mattila VM. The incidence and trauma mechanisms of acetabular fractures: A nationwide study in Finland between 1997 and 2014. Injury. 2017;48(10):2157\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKleck CJ, Perry JM, Burger EL, Cain CM, Milligan K, Patel VV. Sacroiliac Joint Treatment Personalized to Individual Patient Anatomy Using 3-Dimensional Navigation. Orthopedics. 2016;39(2):89\u0026ndash;94.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScheinfeld MH, Dym AA, Spektor M, Avery LL, Dym RJ, Amanatullah DF. Acetabular fractures: what radiologists should know and how 3D CT can aid classification. Radiographics. 2015;35(2):555\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerkes MB, Little MT, Lazaro LE, Cymerman RM, Pardee NC, Helfet DL, et al. Intramedullary allograft fibula as a reduction and fixation tool for treatment of complex proximal humerus fractures with diaphyseal extension. J Orthop Trauma. 2014;28(3):e56\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoogervorst P, Shearer DW, Miclau T. The Burden of High-Energy Musculoskeletal Trauma in High-Income Countries. World J Surg. 2020;44(4):1033\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBriffa N, Pearce R, Hill AM, Bircher M. Outcomes of acetabular fracture fixation with ten years' follow-up. J Bone Joint Surg Br. 2011;93(2):229\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFensky F, Lehmann W, Ruecker A, Rueger JM. Ilioinguinal Approach: Indication and Technique. J Orthop Trauma. 2018;32(Suppl 1):S12\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSen RK, Tripathy SK, Aggarwal S, Goyal T, Mahapatra SK. Comminuted quadrilateral plate fracture fixation through the iliofemoral approach. Injury. 2013;44(2):266\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu GJ, Li ZJ, Ma JX, Zhang T, Fu X, Ma XL. Anterior versus posterior approach for treatment of thoracolumbar burst fractures: a meta-analysis. Eur Spine J. 2013;22(10):2176\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKumaran P, Wier J, Hasegawa I, Patterson JT, Gary JL. Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring? Eur J Orthop Surg Traumatol. 2024;34(6):3103\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWardle B, Eslick GD, Sunner P. Internal versus external fixation of the anterior component in unstable fractures of the pelvic ring: pooled results from a systematic review. Eur J Trauma Emerg Surg. 2016;42(5):635\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSarela AI. Minimally invasive surgery and enhanced recovery: Are we talking about apples and oranges? J Minim Access Surg. 2016;12(3):302\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteenhagen E. Enhanced Recovery After Surgery: It's Time to Change Practice! Nutr Clin Pract. 2016;31(1):18\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian S, Chen Y, Yin Y, Zhang R, Hou Z, Zhang Y. Morphological Characteristics of Posterior Wall Fragments Associated with Acetabular Both-column Fracture. Sci Rep. 2019;9(1):20164.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFourney DR, Abi-Said D, Rhines LD, Walsh GL, Lang FF, McCutcheon IE, et al. Simultaneous anterior-posterior approach to the thoracic and lumbar spine for the radical resection of tumors followed by reconstruction and stabilization. J Neurosurg. 2001;94(2 Suppl):232\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrappinger D, Schwendinger P, Lindtner RA. Fluoroscopically guided acetabular posterior column screw fixation via an anterior approach. Oper Orthop Traumatol. 2019;31(6):503\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKistler BJ, Sagi HC. Reduction of the posterior column in displaced acetabulum fractures through the anterior intrapelvic approach. J Orthop Trauma. 2015;29(Suppl 2):S14\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaplan DJ, Patel JN, Liporace FA, Yoon RS. Intraoperative radiation safety in orthopaedics: a review of the ALARA (As low as reasonably achievable) principle. Patient Saf Surg. 2016;10:27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCahueque M, Mart\u0026iacute;nez M, Cobar A, Bregni M. Early reduction of acetabular fractures decreases the risk of post-traumatic hip osteoarthritis? J Clin Orthop Trauma. 2017;8(4):320\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBastian JD, Tannast M, Siebenrock KA, Keel MJ. Mid-term results in relation to age and analysis of predictive factors after fixation of acetabular fractures using the modified Stoppa approach. Injury. 2013;44(12):1793\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSniderman J, Henry P. Articular reductions - how close is close enough? A narrative review. Injury. 2020;51(Suppl 2):S77\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAminsharifi A, Salehipoor M, Arasteh H. Systemic immunologic and inflammatory response after laparoscopic versus open nephrectomy: a prospective cohort trial. J Endourol. 2012;26(9):1231\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: a systematic review. Clin Rehabil. 2015;29(9):844\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Acetabular fracture, Both-column fracture, Reduction sequence, Ilioinguinal approach, Retrospective study, Merle d'Aubigné score, Radiation exposure","lastPublishedDoi":"10.21203/rs.3.rs-8964418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8964418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHip acetabular fractures, especially complex both-column types, pose significant surgical challenges. Traditionally, the \"anterior column first, posterior column second\" reduction sequence has been widely adopted. However, a modified \"posterior column first, anterior column second\" sequence has been proposed to potentially improve surgical precision and outcomes. This study aimed to systematically compare the clinical efficacy and safety of these two reduction sequences in the surgical treatment of acetabular both-column fractures.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 40 patients with acetabular both-column fractures treated between March 2023 and June 2025. Patients were divided into a modified group (n\u0026thinsp;=\u0026thinsp;10), which underwent the \"posterior column first, anterior column second\" sequence, and a control group (n\u0026thinsp;=\u0026thinsp;30), which received the traditional \"anterior column first, posterior column second\" sequence. Surgical parameters (operative time, fluoroscopy frequency, use of additional posterior approaches), fracture reduction quality (assessed via postoperative CT using the Matta criteria), early recovery (time to first ambulation), and hip function at 6 months (Merle d'Aubign\u0026eacute; score) were compared.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eBaseline characteristics were comparable between groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The modified group showed a non-significant trend toward shorter operative time (239.3\u0026thinsp;\u0026plusmn;\u0026thinsp;109.3 min vs. 311.3\u0026thinsp;\u0026plusmn;\u0026thinsp;83.6 min; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.082) and earlier time to first ambulation (43.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5 days vs. 51.0\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2 days; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.068). Intraoperative fluoroscopy frequency was significantly lower in the modified group (16.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 times vs. 31.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 times; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Although overall reduction quality distribution did not differ significantly (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.053), the modified group had a higher anatomical reduction rate (80.0% vs. 43.3%) and no unsatisfactory reductions. At 6 months, the modified group had significantly better Merle d'Aubign\u0026eacute; scores (17.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4 vs. 16.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe modified \"posterior column first\" reduction sequence significantly reduces intraoperative radiation exposure and improves mid-term hip function in patients with acetabular both-column fractures. It also shows promising trends in shortening surgery time, increasing anatomical reduction rates, and facilitating earlier mobilization. These findings support the modified sequence as a safe and effective surgical strategy, particularly when the posterior column fragment is relatively intact. Further prospective, multicenter studies with larger samples are recommended to confirm these benefits and refine clinical indications.\u003c/p\u003e","manuscriptTitle":"Anatomical Reduction Rate Increased, Fluoroscopy Frequency Reduced: The Clinical Efficacy of the Modified Reduction Sequence in the Treatment of Acetabular Both-Column Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-09 17:36:43","doi":"10.21203/rs.3.rs-8964418/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-10T10:09:55+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-08T16:15:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234847215134436917990677505677677053190","date":"2026-03-08T07:59:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"126132413419957926379518346925067388120","date":"2026-03-08T06:23:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-03T23:53:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196971220412817544486730535296015003669","date":"2026-03-03T22:06:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-03T19:10:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-02T15:38:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-02T11:15:10+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-02T11:13:38+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-02-25T07:05:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"60bf57b9-0adb-486a-bc96-ddd9e15bc1a2","owner":[],"postedDate":"March 9th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T09:40:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-09 17:36:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8964418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8964418","identity":"rs-8964418","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}