Pelvic Unlocking Closed Reduction Device for Treatment of Severe Traumas Combined with Pelvic Fractures

Pelvic Unlocking Closed Reduction Device for Treatment of Severe Traumas Combined with Pelvic 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 Pelvic Unlocking Closed Reduction Device for Treatment of Severe Traumas Combined with Pelvic Fractures Jie Chen, Zhuangzhuang Zhang, Yiping Weng, Zhongjie Yu, Yu Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4760232/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Oct, 2025 Read the published version in BMC Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Background Closed reduction and internal fixation is the key to early and minimally invasive treatment of pelvic fractures in patients with severe trauma. Although the pelvic unlocking closed reduction device has been promoted to a certain extent, the therapeutic effect and surgical strategy skills of which in treating severe traumas were not clarified in particularly. Our study was to explore the therapeutic effect and surgical strategy skills of the pelvic unlocking closed reduction device in treating severe traumas combined with pelvic fractures. Methods Data were retrospectively collected from 13 patients with severe traumas undergoing pelvic unlocking closed reduction for pelvic fractures in our hospital between July 2021 and December 2022. Seven males and six females aged 46.4 ± 16.7 years were involved. The operation time, times of fluoroscopy, and blood loss were recorded intraoperatively. Postoperative complications, and fracture healing time were recorded. The Matta and Majeed scales were used to evaluate fracture reduction and clinical efficacy respectively. Results The time from injury to surgery was 8.2 ± 3 (4–14) days. No wound infection, loosening or breakage of internal fixation, or loss of reduction occurred. The clinical healing time was 3.5 ± 0.7 (3–5) months. Three cases suffered paresthesia on unilateral anterolateral thigh. According to the postoperative imaging Matta scores, 12 cases were excellent and 1 case was good, with an excellent and good rate of 100%. At the last follow-up, the Majeed functional scores were excellent in all 13 cases. Conclusions For patients with severe trauma combined with pelvic fracture, the pelvic unlocking and reduction device can be used for minimally invasive internal fixation at an early stage as long as their vital signs are stable. This study summarized and proposed for the first time the 'turn-back order' reduction and internal fixation philosophy of 'posterior-ring unlocking - anterior ring to posterior ring reduction stabilization - posterior ring to anterior ring internal fixation placement' in pelvic closed reduction and internal fixation surgery. Pelvic fracture Closed reduction Trauma Internal fixation Figures Figure 1 Figure 2 Figure 3 Background Pelvic fractures often occur after high-energy injuries and are accompanied by hemodynamic instability, damage to abdominal organs, urinary system injury, and nervous system injury, leading to high disability and mortality rates [ 1 , 2 ]. It is necessary in the early stage to control bleeding, save lives, and handle combined injuries under the guidance of damage control surgery. Traditional open reduction internal fixation must be performed after the patient's conditions stabilize and the hematoma is organized, which is often 7 to 14 days after the injury. Such delay leads to high difficulty and risk in second-stage surgery, including selection of incisions, difficulty in fracture reduction, neurovascular injury, heterotopic ossification, and infection [ 3 , 4 ]. Recently, research on the anatomy and biomechanics of the pelvis and hip bone has further proceeded, and technologies such as the Starr pelvic external scaffold [ 5 , 6 ], the closed unlocking reduction concept [ 7 ], and the minimally invasive pelvic channel screw have well developed [ 8 ]. Thereby, pelvic fractures can be treated early and effectively through percutaneous minimally invasive fixation or limited open reduction fixation. The surgical time window can even be advanced to 48–72 hours after multiple injuries have been stabilized and resuscitated. The pelvic unlocking reduction device is a minimally invasive reduction system improved by Chen H et al. [ 7 ] based on the Starr frame. Relying on an integrated curing team and a trauma intensive care unit, our center has applied it to patients with severe trauma and calling for pelvic fracture therapy and has achieved good results. Here, data were retrospectively collected from patients with severe trauma and pelvic fractures who were treated with the pelvic unlocking reduction device in our hospital between July 2021 and December 2022. The therapeutic efficacy and surgical strategy skills in clinical application were explored. Methods 1. Inclusion and exclusion criteria Inclusion criteria were: 1) age > 18 years; 2) severe trauma (Abbreviated Injury Scale (AIS) ≥ 3 or Injury Severity Score (ISS) ≥ 16) [ 9 , 10 ] combined with pelvic fracture, with or without neurological damage; 3) minimally invasive fixation surgery using a pelvic unlocking reduction device. Exclusion criteria were: 1) disagreement to supracondylar traction therapy; 2) inability to tolerate surgery due to other diseases; 3) incomplete follow-up data, or follow-up time < 12 months. 2. Basic information According to the above inclusion and exclusion criteria, we retrospectively collected data from 13 patients with severe trauma undergoing early surgery of pelvic fractures using the pelvic unlocking reduction device at the Trauma Center of our hospital between July 2021 and December 2022. There were 7 males (53.8%) and 6 females (46.2%), with an average age of 46.4 ± 16.7 years. Five cases (38.5%) had traffic injuries, 5 cases (38.5%) fell from high, 2 cases (15.4%) were hurt by heavy objects, and 1 case (7.6%) was crushed. Tile classification of pelvic fractures was: 2 cases (15.4%) of type B2, 4 cases (30.7%) of type B3, 5 cases (38.5%) of type C1, and 2 cases (15.4%) of type C2. Two cases were complicated with isolateral lumbosacral nerve injurties; one case was manifested as impairment in sexual function and rectal bladder function, and the one was manifested as sacral nerve irritative pains. Two cases underwent cystostomy, and two cases received colostomy. Details were shown in Table 1 . Table 1 Demographic characteristics, injury mechanism, fracture classification, combined injuries, and AIS/ISS scores of patients Case NO. Gender Age (years) Mode of injury Type of pelvic fracture (Tile Classification) Neurology Associated injures AIS/ISS 1 Female 40 Traffic C1 Normal Femur fracture, fibular fracture 4/16 2 Male 51 Falling B2 Normal Rib fractures, pulmonary contusion, thoracic vertebrae fracture 4/32 3 Male 35 Falling B3 Normal Scapula fracture, pulmonary contusion 4/25 4 Female 37 Traffic B3 Normal Humerus fracture, clavicle fracture 4/16 5 Male 48 Falling B2 Normal Femur fracture, radius fracture 4/16 6 Female 25 Traffic C1 Normal Fibular fracture, pelvic effusion 4/20 7 Female 67 Traffic C2 Normal Lumbosacral transverse process fractures, urethral injuries, phalange fractures 4/29 8 Male 34 Crushing C2 Sexual function injury, rectal and bladder function injury Open perineal injury, urethral rupture 5/41 9 Male 69 Falling B3 Normal Mesenteric injury, urethral injury, lumbosacral transverse process fractures, rib fractures, pulmonary contusion, intertrochanteric femoral fracture, humeral fracture, ulnar olecranon fracture, clavicle fracture 4/41 10 Male 51 Heavy pound C1 Sacral nerve irritative pains Lumbosacral transverse process fractures 4/20 11 Female 18 Falling C1 Normal Traumatic pneumothorax, lumbar vertebral fracture, concussion 4/29 12 Female 59 Traffic B3 Normal Concussion, scalp laceration 4/20 13 Male 69 Heavy pound C1 Normal Traumatic pneumothorax, rib fractures, multiple lumbar fractures 4/36 3. Surgical strategy 3.1. Preoperative preparation 3.1.1 From admission to 1 day before surgery: Treatments included early and active treatment of hemorrhagic shock, rapid massive blood transfusion, pelvic stabilization (pelvic strap or sheet fixation, pelvic external fixator), and control of bleeding (interventional radioangiography embolization). Open wounds were completely debrided. Exploratory laparotomy + enterostomy + suprapubic cystostomy were performed in the case of combination with intestinal and urinary injuries. For vertically unstable pelvic ring injuries, femoral supracondylar traction was conducted on the injured side, with the traction weight being 7–8% of body weight. Surgery was performed immediately after vital signs stabilized. 3.1.2 From 1 day before surgery to surgery: The surgical plan was designed based on the fluoroscopic angle, screw placement angle, and screw placement length measured as per the patient's pelvic 3D CT. A good enema was required from each patient. The surgeon had years of experience in using open reduction internal fixation surgical technique, and provided sufficient technical support for possible accidents that may occur intraoperatively. 3.1.3 Basic equipment: The pelvic unlocking reduction device improved by Chen H's team (Shijiazhuang High-tech Zone Yicheng Technology Co., Ltd.) [ 7 ] was used here. A homemade wooden operating table was combined with a traction table (Fig. 1 A and B). Moreover, a 12-inch C-arm machine and professional fluoroscopy personnel were needed. 3.1.4 Sterilized sheets: The tested patient lay flat on the back, with the sacrum and coccyx elevated with a folded sheet. The assistant pulled up the skin of the lower limb on the sterilized side opposite to the operating table, so the sheet can be lain easily on the back of the surgical area. After the sheet was lain, sterile sutures were fixed on the skin, and a sterile film was used to cover the edges to completely separate the surgical area from the non-surgical area, which prevented contamination. The abdominal drainage tube was sealed with a sterile film, and the enterostomy bag was temporarily replaced with a sterile ostomy bag, The cystostomy tube was cut short, sealed with the skin and replaced later (Fig. 1 C). The lower limb on the traction side was disinfected to below the knee. 3.2 Surgical methods 3.2.1 The pelvic unlocking reduction device connected to the pelvis Insertion of half-threaded transverse screws above the acetabulum: The frontal image shows the inlet point of the screw and the lateral cortex of the ilium point to the hip of the acetabulum. The fluoroscopy direction was adjusted to the inlet point/mild obturator oblique position to clearly show the outlet point of the screw in the quadrangle. Insertion of LC-II half-threaded screw: The screw channel was displayed in three directions of fluoroscopy images. The Teepee image shows the inlet point of the LC-II screw: the iliac oblique view shows the screw channels at the inlet point of the anterior inferior iliac spine and above the greater sciatic notch. The down-the-wing image illustrates the route of the screw within the ilium is in between the internal and external iliac plates. 3.2.2 Intraoperative reduction and fixation The basic principle of controlling the pelvis with a reduction device is to first fix the stable pelvic side on the scaffold, then control the displaced side and the normal reduction side, and evaluate pelvic reduction using fluoroscopic monitoring. For bilateral pelvic injuries, the same reduction principle is used (during preoperative preparation, the upper body shall be fixed with straps to counter traction): the sacrum is the reference point of reduction, and the pelvis and sacrum on each side are reduced separately. The difference between bilateral and unilateral injuries is that once one side is reduced, the technique is then applied alternately to the other side. For lateral pelvic compressive fractures, the locked iliosacral joint and fracture end can be unlocked through traction using the acetabular half-threaded screws, and the vertical displacement and forward rotation displacement can be corrected in combination with skeletal traction through supracondyle of femur. The LC-II half-threaded screw was glided, through the connecting rod, onto the pelvic reduction frame to adjust the inversion, eversion, forward and backward displacement, and forward and backward rotation of the injured half pelvis. In addition to the acetabular screws and LC-II screws, more screws or some rods can be placed on the iliac crest to assist reduction when needed. The specific order of reduction and internal fixation will be elaborated in the discussion. The posterior ring was fixed with percutaneous iliosacral screws; the anterior ring was fixed with internal fixator (INFIX), symphysis pubis screws, symphysis pubis plate, and LC-II channel screws. A typical case is shown in Fig. 2 . 3.3. Postoperative processing Low-molecular-weight heparin anticoagulation is routinely used 12 hours after surgery to prevent deep vein thrombosis in lower limbs. The patients were observed for any intraoperative vascular nerve injury, and pelvic fluoroscopy and three-dimensional reconstruction CT were reexamined to evaluate fracture reduction and internal fixation. Active and passive lower limb flexion and extension exercises can be performed on bed on the first day after surgery. Based on the follow-up radiographs at 1, 2, and 3 months after surgery, the patient can gradually start walking with partial weight bearing until full weight bearing. Postoperative follow-up radiographs and neurological function examinations were performed regularly (1, 2, 3, 6, and 12 months) to evaluate fracture healing and neurological function recovery. 4. Therapeutic effect evaluation criteria 4.1 Fracture healing: Fracture healing was assessed based on imaging examinations during follow-up. X-ray fluoroscopy showed continuous callus passed through the blur fracture lines, which was assessed as fracture healing. 4.2 Pelvic fracture reduction was assessed using the Matta scoring system [ 11 ], where posterior pelvic ring displacement of ≤ 4 mm, 4–10 mm, 11–20 mm, and > 20 mm was considered as excellent, good, acceptable, and poor respectively. 4.3 Evaluation of clinical efficacy: The Majeed scoring system [ 12 ] was used to evaluate the clinical efficacy and the degree of improvement in neurological function from the aspects of pain (30 points), work (20 points), sitting (10 points), sexual function (4 points), and standing (36 points, including assisted walking, gait, and walking distance, each with 12 points). The full score is 100 points, of which 85–100, 70–84, 55–69, and < 55 points indicate excellent, good, acceptable, and poor respectively. 5. Statistical analysis Statistical analysis was conducted on SPSS 26.0. The measured data were examined via Shapiro-Wilk normality test. The age, time from injury to operation, operation time, intraoperative blood loss, times of fluoroscopy, fracture healing time, and follow-up time all conformed to the normal distribution and were expressed as (x ± s). The excellent and good rates of Matta score and Majeed score were expressed as number of cases (%). Results 1. Basic results All 13 patients successfully completed closed reduction and internal fixation with the pelvic unlocking and reduction device. The posterior ring was fixed with percutaneous iliosacral screws, and the anterior ring was fixed with INFIX, symphysis pubis plates, symphysis pubis screws, or LC-II screws depending on the situation. The time from injury to surgery was 8.2 ± 3 days, the surgery time was 172.3 ± 73.4 min, the intraoperative fluoroscopy was 101.5 ± 22.2 times, and the intraoperative blood loss was 52.7 ± 50.4 ml. The 13 patients were followed up for 12.9 ± 1 months (Table 2 ). Table 2 Intraoperative situation with the pelvic unlocking and reduction device Case NO. Duration from injury to surgery (days) Surgery time (min) Blood loss (ml) Times of fluoroscopy Surgical procedure for anterior pelvic ring Surgical procedure for posterior pelvic ring 1 14 245 50 116 INFIX Percutaneous iliosacral screw (S1,S2) 2 6 110 5 84 LC-II channel screw Percutaneous iliosacral screw (S1) 3 11 90 50 70 INFIX Percutaneous iliosacral screw (Double-sided S1) 4 8 115 50 86 INFIX Percutaneous iliosacral screw (S1) 5 7 260 50 95 INFIX Percutaneous iliosacral screw (S1,S2) 6 7 120 20 87 INFIX Percutaneous iliosacral screw (S1) 7 7 80 20 71 INFIX Percutaneous iliosacral screw (S1,S2) 8 14 195 100 130 INFIX + Symphysis pubis screw Percutaneous iliosacral screw (S2) 9 4 160 20 101 INFIX Percutaneous iliosacral screw (S1) 10 8 260 50 126 Symphysis pubis plate Percutaneous iliosacral screw (S2) 11 6 260 200 128 INFIX Percutaneous iliosacral screw (S1,S2) 12 8 100 20 96 INFIX Percutaneous iliosacral screw(S1) 13 7 245 50 130 Symphysis pubis screw Percutaneous iliosacral screw (S1,S2 through-fixation ) 2. Fracture healing and evaluation There was no postoperative wound infection, loosening or breakage of internal fixation, or loss of reduction in the 13 patients, and the clinical healing time was 3.5 ± 0.7 months. Among them, three cases (23.1%) developed unilateral anterolateral thigh paresthesia, which was considered to be injury to the lateral femoral cutaneous nerve. One case was relieved two weeks after surgery, and the other two cases were relieved when INFIX was removed after clinical healing. Two patients had lumbar sacral nerve symptoms before surgery. One patient's bladder function was recovered, but the sexual and rectal functions were not recovered at the last follow-up. The other patient's sacral nerve irritation symptoms were relieved after surgery. According to the postoperative imaging Matta score, 12 cases were excellent and 1 case was good, with an excellent and good rate of 100%. At the last follow-up, Majeed functional scores were excellent in all 13 cases. Details were shown in Table 3 . Table 3 Postoperative evaluation and fracture healing of patients Case NO. Healing time (months) Matta scores Majeed scores Duration of follow-up (months) Complications 1 3 Excellent Excellent 14 Unilateral anterolateral thigh paresthesia 2 3 Excellent Excellent 12 Nil 3 3 Excellent Excellent 12 Nil 4 3 Excellent Excellent 13 Nil 5 5 Excellent Excellent 12 Unilateral anterolateral thigh paresthesia 6 4 Good Excellent 13 Nil 7 4 Excellent Excellent 14 Nil 8 4 Excellent Excellent 13 Nil 9 3 Excellent Excellent 12 Nil 10 4 Excellent Excellent 14 Nil 11 3 Excellent Excellent 15 Unilateral anterolateral thigh paresthesia 12 3 Excellent Excellent 12 Nil 13 3 Excellent Excellent 12 Nil Discussion Treatment of pelvic fractures in patients with severe trauma usually involves internal fixation of the fracture after the condition stabilizes and the skin conditions for surgery are met. The waiting time for surgery is often more than 2 weeks. Especially, for old patients combined with rectal rupture, bladder rupture or severe soft tissue injury, the waiting time is further extended, and the opportunity for surgery may even be lost. Traditional open reduction and internal fixation (ORIF) treatment requires extensive dissection due to hematoma organization and scar formation at the fracture ends, which increases intraoperative bleeding and the risk of postoperative infection. Furthermore, the surgical assistant is required to manually control the stability of the healthy pelvis and the reduction of the injured pelvis. Even if the reduction is successful, it cannot be maintained until the internal fixation is completed. In this case, multiple repeated operations may be required, which increases the operation time and risk. Even when patients with severe trauma have reached the surgical window, they may still suffer from late functional disorders due to their inability to tolerate ORIF or the difficulty in reduction. Therefore, closed reduction and internal fixation is the key to early and minimally invasive treatment of pelvic fractures in patients with severe trauma. With the continuous development of the minimally invasive technology and surgical-assisted instruments, percutaneous screw fixation for treating acetabular and pelvic fractures has been increasingly popular worldwide and achieved good results [ 13 ]. The Well frame invented by Matta et al. [ 14 ] fixes the healthy pelvis to the operating table and completes closed reduction through traction. However, this method requires continuous traction and is not effective in correcting rotational displacement. Later, the Starr reduction frame designed by Lefaivre et al. [ 5 , 6 ] not only fixes the pelvis, but also uses relevant fixation pins to decrease and maintain the reduction position in multiple directions. Finally, various anterior and posterior ring percutaneous fixation techniques are used to fix fractures, marking a new era in the minimally invasive treatment of pelvic fractures. Recently, Chen H et al. [ 7 ] proposed a pelvic unlocking and reduction device using the improved Starr frame design based on the “unlocking and reduction concept”, which has been promoted to a certain extent in China [ 15 ]. Relying on the integrated rescue team and the support of the trauma intensive care unit, the trauma center of our hospital has applied this concept to patients with severe trauma who require early treatment of pelvic fractures. All the patients achieved clinical healing within the expected time, and the excellent rate of postoperative imaging evaluation and the last follow-up functional evaluation reached 100%, showing good clinical results. The AIS Committee defined patients with AIS ≥ 3 or ISS ≥ 16 as severe trauma patients. Among the 13 patients who successfully received surgeries, most of them had multiple injuries or multiple system injuries. The time from injury to surgery was 8.2 ± 3 days, the shortest time period was 4 days, and the intraoperative blood loss was 52.7 ± 50.4 ml. Compared with traditional open surgery, it greatly reduces the tolerance requirements for patients and advances the surgical window to about one week, leaving time for treating other combined injuries. Because closed reduction and internal fixation does not directly expose the fracture site, even if the patient undergoes colostomy or cystostomy in the surgical area, sterility can be maintained through local wound closure, reducing the risk of infection and making surgical contraindications possible. The operative time of this group was 172.3 ± 73.4 min, which is similar to the reported operative time of 169.4 min [ 16 ] and 167 min [ 17 ]. This treatment showed no significant time advantage over traditional pelvic surgery, but did not increase surgical risks. The number of intraoperative fluoroscopy in this group was 101.5 ± 22.2 times, indicating this surgery requires much time for fluoroscopy and has high fluoroscopy requirements. Therefore, preoperative intestinal preparation of patients is particularly important, and fluoroscopy examination is strongly recommended before sterilizing the drape to ensure that sufficiently clear images can be obtained. Our team treated a patient in the early stage where the enema was insufficient and the intraoperative fluoroscopy imaging was poor. Although the patient was reduced with a reduction device, percutaneous iliosacral screws cannot be inserted. Therefore, the patient was not included in this study. Three cases (23.1%) in this series developed lateral femoral cutaneous nerve injury, which was the only postoperative complication and had a high incidence. Similarly, Vaidya et al. [ 18 ] and Cole et al. [ 19 ] reported incidence of 32% and 4%, respectively. According to the data analysis of this group, the prolonged operation time at the LC-II nail placement site in one case resulted in edema and compression of surrounding tissues, which resolved spontaneously about 2 weeks after surgery. In the other two cases, the anterior ring INFIX was fixed too low because the patients were thin, causing compression on the nerves. The symptoms were relieved when the INFIX was removed after clinical healing. This study recommends that to install the anterior ring INFIX, the incision shall be appropriately enlarged to expose and release the pin tail. The key to closed pelvic reduction is to understand the fracture pattern and the direction of reduction force. The basic types of pelvic fracture displacement include upward displacement, inversion, eversion, and forward and backward rotation. High-energy injuries are often manifested as two or even three combinations, which complicate reduction. Hence, preoperative three-dimensional CT reconstruction is needed to analyze the displacement of the fracture ends, and is combined with intraoperative fluoroscopy to determine the closed reduction technique to be adopted during the operation. (Entrance site: the backward and forward displacement of the posterior ring combined with the iliosacral joint indicates the inversion or eversion of the pelvis; outlet site: the up displacement of the fracture end in the posterior ring, and the up and down displacement of the pubic symphysis indicate the backward or forward rotation of the injured pelvis)The pelvic unlocking and reduction system was used to stabilize the hemipelvis, control contralateral pelvic displacement, and reduce with the stable hemipelvis as the reference. Theoretically, for C3 type pelvic fractures, the axial skeleton cannot be stabilized indirectly by fixing unilateral hemipelvis. It is preferred to first reduce the easily reducible hemipelvic fracture, so that the C3 type pelvic fracture becomes a C1 type, and finally the C1 type pelvic fracture is treated using a reduction method [ 20 ]. The order of reduction and internal fixation between anterior and posterior pelvic rings has not been clarified in the literature, but the concept of unlocking and reducing the fracture ends of the posterior ring emphasized in the pelvic unlocking and reduction device has been gradually accepted. If the posterior ring is locked, the iliac fracture ends and iliosacral joint must first be unlocked laterally using the acetabular half-threaded screws. However, when there is no interlocking in the posterior ring, this study believes reduction of the anterior ring will help reduce the posterior ring, and reduction must be performed from the anterior ring to the posterior ring. In case of anterior ring pubic ramus fracture, the hinge effect of soft tissues at the fracture end can still be utilized to reduce inversion, eversion and up and down rotation in the anterior ring using the LC-II half-threaded screws. However, when the pubic symphysis in the anterior ring is completely separated, the soft tissue hinge is destroyed and reduction cannot be completed by manipulating the acetabular half-threaded screws and the LC-II half-threaded screws. Generally, Kirschner wires, point reduction forceps, etc. are first used to temporarily reduce and stabilize the anterior ring before reducing the posterior ring. During reduction of the posterior ring, femoral supracondylar traction depends on the inserted LC-II half-threaded screws as a pivot to correct the vertical displacement of the posterior ring, and the LC-II half-threaded screws are pulled in the anterior-posterior direction to correct the backward displacement of the posterior ring. Finally, the acetabular half-threaded screws are used to reduce the fracture end under compression. Because anatomical reduction of the posterior ring is crucial in these displaced injury patterns, first the posterior ring and then the anterior ring are fixed and placed after successful reduction. This study summarizes the reduction and internal fixation as a 'turn-back order' reduction and internal fixation of 'posterior ring unlocking - anterior ring to posterior ring reduction stabilization - posterior ring to anterior ring internal fixation placement'. A typical case is shown in Fig. 3 . Conclusions For patients with severe trauma and pelvic fracture, pelvic unlocking and reduction devices can be used for minimally invasive internal fixation treatment at an early stage as long as their vital signs are stable. This study summarizes and proposes for the first time the 'turn-back order' reduction and internal fixation philosophy of 'posterior-ring unlocking - anterior ring to posterior ring reduction stabilization - posterior ring to anterior ring internal fixation placement' in the closed pelvic reduction and internal fixation surgery. This study has some limitations. First, it is a retrospective study and lacks a control group with traditional surgery. Second, it is a single-center study with a small sample size, and presents the experience and conclusions that lack multi-center and large-sample verification. Abbreviations Abbreviated Injury Scale (AIS) Injury Severity Score (ISS) Internal fixator (INFIX) Open reduction and internal fixation (ORIF) Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of our hospital, and all subjects signed informed consent. Consent for publication The authors affirm that human research participants provided informed consent for publication of the images in Figure 1B,1C and 2I. Availability of data and materials The datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Author Contributions All authors contributed to the study conception and design. These surgeries were performed by Yu Zhang, Rongbin Sun, Yiping Weng, Jie Chen. Data collection and analysis were performed by Jie Chen and Zhuangzhuang Zhang. The first draft of the manuscript was written by Jie Chen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Acknowledgements: None. References Yoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg. 2014;76(2):380–5. Zhao JX, Zhang LC, Su XY, Zhao Z, Zhao YP, Sun GF, et al. Early Experience with Reduction of Unstable Pelvic Fracture Using a Computer-Aided Reduction Frame. Biomed Res Int. 2018;2018:7297635. Boudissa M, Francony F, Kerschbaumer G, Ruatti S, Milaire M, Merloz P, et al. Epidemiology and treatment of acetabular fractures in a level-1 trauma centre: Retrospective study of 414 patients over 10 years. 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Displaced posterior pelvic ring fractures treated with an unlocking closed reduction technique: Prognostic factors associated with closed reduction failure, reduction quality, and fixation failure. Injury. 2023;54(Suppl 2):S21–7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 07 Oct, 2025 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 02 Aug, 2024 Editor assigned by journal 01 Aug, 2024 Submission checks completed at journal 01 Aug, 2024 First submitted to journal 18 Jul, 2024 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-4760232","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":335308479,"identity":"2accf2b5-d692-4efa-b6e1-1319804defdf","order_by":0,"name":"Jie Chen","email":"","orcid":"","institution":"The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jie","middleName":"","lastName":"Chen","suffix":""},{"id":335308481,"identity":"86aff14d-3775-4343-aa51-b34da6f6bde8","order_by":1,"name":"Zhuangzhuang Zhang","email":"","orcid":"","institution":"The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhuangzhuang","middleName":"","lastName":"Zhang","suffix":""},{"id":335308482,"identity":"88b795a6-460c-441d-baa0-75488d646d65","order_by":2,"name":"Yiping Weng","email":"","orcid":"","institution":"The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yiping","middleName":"","lastName":"Weng","suffix":""},{"id":335308484,"identity":"ac55057a-06ee-4406-8979-4ef0955c237b","order_by":3,"name":"Zhongjie Yu","email":"","orcid":"","institution":"The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhongjie","middleName":"","lastName":"Yu","suffix":""},{"id":335308486,"identity":"14766604-66ac-48a7-b0a1-5325188c795e","order_by":4,"name":"Yu Zhang","email":"","orcid":"","institution":"The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yu","middleName":"","lastName":"Zhang","suffix":""},{"id":335308487,"identity":"23bfd2f9-129d-4b46-ba5c-f2d1226c36eb","order_by":5,"name":"Rongbin Sun","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzElEQVRIiWNgGAWjYJACZgYDMM34AMogXguzAQlaIIBNgijl5u29h18XFNxhkJ+Re6zyR8EdeQb2w0c34NMic+ZcmvUMg2cMBjfy0m7zGDwzbOBJS7uBT4uERI6ZMY/BYQYDIOM2g8FhxgYJHjPitMjPyDEr/GFw2J4YLcaPQVoYbuSYMQAZiYS18JwxY54BctiZN8bSQC3JbQT9wt5j/LngD9Bh7TmGH3/8OWzbz374GF4tDNDoqG+AcwkoBwHmD0QoGgWjYBSMgpEMACQBRAJAKQcxAAAAAElFTkSuQmCC","orcid":"","institution":"The Affiliated Changzhou No.2 People’s Hospital of Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Rongbin","middleName":"","lastName":"Sun","suffix":""}],"badges":[],"createdAt":"2024-07-18 05:59:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4760232/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4760232/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-025-03199-8","type":"published","date":"2025-10-07T15:57:43+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":64009566,"identity":"05564a08-33fe-4414-85b4-964677259f9b","added_by":"auto","created_at":"2024-09-04 23:18:12","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":467354,"visible":true,"origin":"","legend":"\u003cp\u003eA: Use of the pelvic unlocking and reduction device during surgery; B: Combination of a homemade wooden operating table and a traction table; C: Treatment of abdominal drainage tubes, colostomy tubes, and cystostomy tubes before disinfection.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4760232/v1/26da0c27eb6b6dd5b35dc709.png"},{"id":64009564,"identity":"7f1e4a23-4238-48b3-9007-ec364ae8d754","added_by":"auto","created_at":"2024-09-04 23:18:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":648941,"visible":true,"origin":"","legend":"\u003cp\u003eCase 1 A: C1 type fracture; B: Placement of bilateral acetabular half-threaded screws and LC-II half-threaded screws; C: Installation of the pelvic unlocking and reduction system to fix the pelvis at the uninjured side; D-E: After unlocking of the posterior ring, it is reduced through supracondylar traction and LC-II half-threaded screw traction; F-G: Rod support to further pressurize and reduce the iliosacral joint; H: Pelvic outlet and inlet radiographs after reduction showing S1 and S2 percutaneous iliosacral screws fix the posterior ring and INFIX screws fix the anterior ring; I: Full recovery of functions at the last follow-up.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4760232/v1/1464542fb4a4d4a171c1b6c4.png"},{"id":64009565,"identity":"7f62097b-05fc-45f7-9943-22818c06340c","added_by":"auto","created_at":"2024-09-04 23:18:12","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1118036,"visible":true,"origin":"","legend":"\u003cp\u003eCase 8 A: C2 fracture, pubic symphysis separation; B: Temporary reduction and fixation with Kirschner wires and point reduction forceps, acting as hinges; C: Unlocking of posterior ring fracture; D: Reduction of posterior ring fracture; E: Compressed fixation with percutaneous iliosacral screws; F: Anterior ring fixation with INFIX and pubic symphysis screws.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4760232/v1/4b246437213361a59f7d0d82.png"},{"id":93597672,"identity":"c7caac40-af71-497a-8c98-192324a225c9","added_by":"auto","created_at":"2025-10-15 14:19:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3699389,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4760232/v1/69507d7d-389b-453a-bbde-700240dc4638.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Pelvic Unlocking Closed Reduction Device for Treatment of Severe Traumas Combined with Pelvic Fractures","fulltext":[{"header":"Background","content":"\u003cp\u003ePelvic fractures often occur after high-energy injuries and are accompanied by hemodynamic instability, damage to abdominal organs, urinary system injury, and nervous system injury, leading to high disability and mortality rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is necessary in the early stage to control bleeding, save lives, and handle combined injuries under the guidance of damage control surgery. Traditional open reduction internal fixation must be performed after the patient's conditions stabilize and the hematoma is organized, which is often 7 to 14 days after the injury. Such delay leads to high difficulty and risk in second-stage surgery, including selection of incisions, difficulty in fracture reduction, neurovascular injury, heterotopic ossification, and infection [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Recently, research on the anatomy and biomechanics of the pelvis and hip bone has further proceeded, and technologies such as the Starr pelvic external scaffold [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], the closed unlocking reduction concept [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], and the minimally invasive pelvic channel screw have well developed [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Thereby, pelvic fractures can be treated early and effectively through percutaneous minimally invasive fixation or limited open reduction fixation. The surgical time window can even be advanced to 48–72 hours after multiple injuries have been stabilized and resuscitated. The pelvic unlocking reduction device is a minimally invasive reduction system improved by Chen H et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] based on the Starr frame. Relying on an integrated curing team and a trauma intensive care unit, our center has applied it to patients with severe trauma and calling for pelvic fracture therapy and has achieved good results. Here, data were retrospectively collected from patients with severe trauma and pelvic fractures who were treated with the pelvic unlocking reduction device in our hospital between July 2021 and December 2022. The therapeutic efficacy and surgical strategy skills in clinical application were explored.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e1. Inclusion and exclusion criteria\u003c/p\u003e\n\u003cp\u003eInclusion criteria were: 1) age\u0026thinsp;\u0026gt;\u0026thinsp;18 years; 2) severe trauma (Abbreviated Injury Scale (AIS)\u0026thinsp;\u0026ge;\u0026thinsp;3 or Injury Severity Score (ISS)\u0026thinsp;\u0026ge;\u0026thinsp;16) [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e] combined with pelvic fracture, with or without neurological damage; 3) minimally invasive fixation surgery using a pelvic unlocking reduction device.\u003c/p\u003e\n\u003cp\u003eExclusion criteria were: 1) disagreement to supracondylar traction therapy; 2) inability to tolerate surgery due to other diseases; 3) incomplete follow-up data, or follow-up time\u0026thinsp;\u0026lt;\u0026thinsp;12 months.\u003c/p\u003e\n\u003cp\u003e2. Basic information\u003c/p\u003e\n\u003cp\u003eAccording to the above inclusion and exclusion criteria, we retrospectively collected data from 13 patients with severe trauma undergoing early surgery of pelvic fractures using the pelvic unlocking reduction device at the Trauma Center of our hospital between July 2021 and December 2022. There were 7 males (53.8%) and 6 females (46.2%), with an average age of 46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 years. Five cases (38.5%) had traffic injuries, 5 cases (38.5%) fell from high, 2 cases (15.4%) were hurt by heavy objects, and 1 case (7.6%) was crushed.\u003c/p\u003e\n\u003cp\u003eTile classification of pelvic fractures was: 2 cases (15.4%) of type B2, 4 cases (30.7%) of type B3, 5 cases (38.5%) of type C1, and 2 cases (15.4%) of type C2. Two cases were complicated with isolateral lumbosacral nerve injurties; one case was manifested as impairment in sexual function and rectal bladder function, and the one was manifested as sacral nerve irritative pains. Two cases underwent cystostomy, and two cases received colostomy. Details were shown in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eDemographic characteristics, injury mechanism, fracture classification, combined injuries, and AIS/ISS scores of patients\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eCase NO.\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAge (years)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eMode of injury\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eType of pelvic fracture (Tile Classification)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNeurology\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAssociated injures\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAIS/ISS\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemur fracture, fibular fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eRib fractures, pulmonary contusion, thoracic vertebrae fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e35\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eScapula fracture, pulmonary contusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHumerus fracture, clavicle fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemur fracture, radius fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/16\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFibular fracture, pelvic effusion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLumbosacral transverse process fractures, urethral injuries, phalange fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCrushing\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSexual function injury, rectal and bladder function injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eOpen perineal injury, urethral rupture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5/41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMesenteric injury, urethral injury, lumbosacral transverse process fractures, rib fractures, pulmonary contusion, intertrochanteric femoral fracture, humeral fracture, ulnar olecranon fracture, clavicle fracture\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeavy pound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSacral nerve irritative pains\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLumbosacral transverse process fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFalling\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraumatic pneumothorax, lumbar vertebral fracture, concussion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraffic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eB3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eConcussion, scalp laceration\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHeavy pound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eC1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eNormal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTraumatic pneumothorax, rib fractures, multiple lumbar fractures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4/36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e3. Surgical strategy\u003c/p\u003e\n\u003cp\u003e3.1. Preoperative preparation\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e3.1.1 From admission to 1 day before surgery: Treatments included early and active treatment of hemorrhagic shock, rapid massive blood transfusion, pelvic stabilization (pelvic strap or sheet fixation, pelvic external fixator), and control of bleeding (interventional radioangiography embolization). Open wounds were completely debrided. Exploratory laparotomy\u0026thinsp;+\u0026thinsp;enterostomy\u0026thinsp;+\u0026thinsp;suprapubic cystostomy were performed in the case of combination with intestinal and urinary injuries. For vertically unstable pelvic ring injuries, femoral supracondylar traction was conducted on the injured side, with the traction weight being 7\u0026ndash;8% of body weight. Surgery was performed immediately after vital signs stabilized.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e3.1.2 From 1 day before surgery to surgery: The surgical plan was designed based on the fluoroscopic angle, screw placement angle, and screw placement length measured as per the patient\u0026apos;s pelvic 3D CT. A good enema was required from each patient. The surgeon had years of experience in using open reduction internal fixation surgical technique, and provided sufficient technical support for possible accidents that may occur intraoperatively.\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e3.1.3 Basic equipment: The pelvic unlocking reduction device improved by Chen H\u0026apos;s team (Shijiazhuang High-tech Zone Yicheng Technology Co., Ltd.) [\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e] was used here. A homemade wooden operating table was combined with a traction table (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA and B). Moreover, a 12-inch C-arm machine and professional fluoroscopy personnel were needed.\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e3.1.4 Sterilized sheets: The tested patient lay flat on the back, with the sacrum and coccyx elevated with a folded sheet. The assistant pulled up the skin of the lower limb on the sterilized side opposite to the operating table, so the sheet can be lain easily on the back of the surgical area. After the sheet was lain, sterile sutures were fixed on the skin, and a sterile film was used to cover the edges to completely separate the surgical area from the non-surgical area, which prevented contamination. The abdominal drainage tube was sealed with a sterile film, and the enterostomy bag was temporarily replaced with a sterile ostomy bag, The cystostomy tube was cut short, sealed with the skin and replaced later (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC). The lower limb on the traction side was disinfected to below the knee.\u003c/p\u003e\n\u003cp\u003e3.2 Surgical methods\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e3.2.1 The pelvic unlocking reduction device connected to the pelvis\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eInsertion of half-threaded transverse screws above the acetabulum: The frontal image shows the inlet point of the screw and the lateral cortex of the ilium point to the hip of the acetabulum. The fluoroscopy direction was adjusted to the inlet point/mild obturator oblique position to clearly show the outlet point of the screw in the quadrangle.\u003c/p\u003e\n\u003cp\u003eInsertion of LC-II half-threaded screw: The screw channel was displayed in three directions of fluoroscopy images. The Teepee image shows the inlet point of the LC-II screw: the iliac oblique view shows the screw channels at the inlet point of the anterior inferior iliac spine and above the greater sciatic notch. The down-the-wing image illustrates the route of the screw within the ilium is in between the internal and external iliac plates.\u003c/p\u003e\n\u003cp\u003e3.2.2 Intraoperative reduction and fixation\u003c/p\u003e\n\u003cp\u003eThe basic principle of controlling the pelvis with a reduction device is to first fix the stable pelvic side on the scaffold, then control the displaced side and the normal reduction side, and evaluate pelvic reduction using fluoroscopic monitoring. For bilateral pelvic injuries, the same reduction principle is used (during preoperative preparation, the upper body shall be fixed with straps to counter traction): the sacrum is the reference point of reduction, and the pelvis and sacrum on each side are reduced separately. The difference between bilateral and unilateral injuries is that once one side is reduced, the technique is then applied alternately to the other side.\u003c/p\u003e\n\u003cp\u003eFor lateral pelvic compressive fractures, the locked iliosacral joint and fracture end can be unlocked through traction using the acetabular half-threaded screws, and the vertical displacement and forward rotation displacement can be corrected in combination with skeletal traction through supracondyle of femur. The LC-II half-threaded screw was glided, through the connecting rod, onto the pelvic reduction frame to adjust the inversion, eversion, forward and backward displacement, and forward and backward rotation of the injured half pelvis. In addition to the acetabular screws and LC-II screws, more screws or some rods can be placed on the iliac crest to assist reduction when needed. The specific order of reduction and internal fixation will be elaborated in the discussion. The posterior ring was fixed with percutaneous iliosacral screws; the anterior ring was fixed with internal fixator (INFIX), symphysis pubis screws, symphysis pubis plate, and LC-II channel screws. A typical case is shown in Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003cp\u003e3.3. Postoperative processing\u003c/p\u003e\n\u003cp\u003eLow-molecular-weight heparin anticoagulation is routinely used 12 hours after surgery to prevent deep vein thrombosis in lower limbs. The patients were observed for any intraoperative vascular nerve injury, and pelvic fluoroscopy and three-dimensional reconstruction CT were reexamined to evaluate fracture reduction and internal fixation. Active and passive lower limb flexion and extension exercises can be performed on bed on the first day after surgery. Based on the follow-up radiographs at 1, 2, and 3 months after surgery, the patient can gradually start walking with partial weight bearing until full weight bearing. Postoperative follow-up radiographs and neurological function examinations were performed regularly (1, 2, 3, 6, and 12 months) to evaluate fracture healing and neurological function recovery.\u003c/p\u003e\n\u003cp\u003e4. Therapeutic effect evaluation criteria\u003c/p\u003e\n\u003cp\u003e4.1 Fracture healing: Fracture healing was assessed based on imaging examinations during follow-up. X-ray fluoroscopy showed continuous callus passed through the blur fracture lines, which was assessed as fracture healing.\u003c/p\u003e\n\u003cp\u003e\u003cspan\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e4.2 Pelvic fracture reduction was assessed using the Matta scoring system [\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e], where posterior pelvic ring displacement of \u0026le;\u0026thinsp;4 mm, 4\u0026ndash;10 mm, 11\u0026ndash;20 mm, and \u0026gt;\u0026thinsp;20 mm was considered as excellent, good, acceptable, and poor respectively.\u003c/p\u003e\u003cspan\u003e\n \u003cp\u003e4.3 Evaluation of clinical efficacy: The Majeed scoring system [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e] was used to evaluate the clinical efficacy and the degree of improvement in neurological function from the aspects of pain (30 points), work (20 points), sitting (10 points), sexual function (4 points), and standing (36 points, including assisted walking, gait, and walking distance, each with 12 points). The full score is 100 points, of which 85\u0026ndash;100, 70\u0026ndash;84, 55\u0026ndash;69, and \u0026lt;\u0026thinsp;55 points indicate excellent, good, acceptable, and poor respectively.\u003c/p\u003e\n\u003c/span\u003e\u003cspan\u003e\n \u003cp\u003e5. Statistical analysis\u003c/p\u003e\n\u003c/span\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analysis was conducted on SPSS 26.0. The measured data were examined via Shapiro-Wilk normality test. The age, time from injury to operation, operation time, intraoperative blood loss, times of fluoroscopy, fracture healing time, and follow-up time all conformed to the normal distribution and were expressed as (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s). The excellent and good rates of Matta score and Majeed score were expressed as number of cases (%).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e1. Basic results\u003c/p\u003e \u003cp\u003eAll 13 patients successfully completed closed reduction and internal fixation with the pelvic unlocking and reduction device. The posterior ring was fixed with percutaneous iliosacral screws, and the anterior ring was fixed with INFIX, symphysis pubis plates, symphysis pubis screws, or LC-II screws depending on the situation. The time from injury to surgery was 8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3 days, the surgery time was 172.3\u0026thinsp;\u0026plusmn;\u0026thinsp;73.4 min, the intraoperative fluoroscopy was 101.5\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2 times, and the intraoperative blood loss was 52.7\u0026thinsp;\u0026plusmn;\u0026thinsp;50.4 ml. The 13 patients were followed up for 12.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1 months (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIntraoperative situation with the pelvic unlocking and reduction device\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase NO.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDuration from injury to surgery (days)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurgery time (min)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBlood loss (ml)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTimes of fluoroscopy\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSurgical procedure for anterior pelvic ring\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSurgical procedure for posterior pelvic ring\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1,S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLC-II channel screw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (Double-sided S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1,S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e120\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1,S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e195\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u0026thinsp;+\u0026thinsp;Symphysis pubis screw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e126\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSymphysis pubis plate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e200\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1,S2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eINFIX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw(S1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e245\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e130\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSymphysis pubis screw\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePercutaneous iliosacral screw (S1,S2 through-fixation )\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e2. Fracture healing and evaluation\u003c/p\u003e \u003cp\u003eThere was no postoperative wound infection, loosening or breakage of internal fixation, or loss of reduction in the 13 patients, and the clinical healing time was 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 months. Among them, three cases (23.1%) developed unilateral anterolateral thigh paresthesia, which was considered to be injury to the lateral femoral cutaneous nerve. One case was relieved two weeks after surgery, and the other two cases were relieved when INFIX was removed after clinical healing. Two patients had lumbar sacral nerve symptoms before surgery. One patient's bladder function was recovered, but the sexual and rectal functions were not recovered at the last follow-up. The other patient's sacral nerve irritation symptoms were relieved after surgery. According to the postoperative imaging Matta score, 12 cases were excellent and 1 case was good, with an excellent and good rate of 100%. At the last follow-up, Majeed functional scores were excellent in all 13 cases. Details were shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative evaluation and fracture healing of patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCase NO.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealing time (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMatta scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMajeed scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eDuration of follow-up (months)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eComplications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnilateral anterolateral thigh paresthesia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnilateral anterolateral thigh paresthesia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eUnilateral anterolateral thigh paresthesia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNil\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTreatment of pelvic fractures in patients with severe trauma usually involves internal fixation of the fracture after the condition stabilizes and the skin conditions for surgery are met. The waiting time for surgery is often more than 2 weeks. Especially, for old patients combined with rectal rupture, bladder rupture or severe soft tissue injury, the waiting time is further extended, and the opportunity for surgery may even be lost. Traditional open reduction and internal fixation (ORIF) treatment requires extensive dissection due to hematoma organization and scar formation at the fracture ends, which increases intraoperative bleeding and the risk of postoperative infection. Furthermore, the surgical assistant is required to manually control the stability of the healthy pelvis and the reduction of the injured pelvis. Even if the reduction is successful, it cannot be maintained until the internal fixation is completed. In this case, multiple repeated operations may be required, which increases the operation time and risk. Even when patients with severe trauma have reached the surgical window, they may still suffer from late functional disorders due to their inability to tolerate ORIF or the difficulty in reduction.\u003c/p\u003e \u003cp\u003eTherefore, closed reduction and internal fixation is the key to early and minimally invasive treatment of pelvic fractures in patients with severe trauma. With the continuous development of the minimally invasive technology and surgical-assisted instruments, percutaneous screw fixation for treating acetabular and pelvic fractures has been increasingly popular worldwide and achieved good results [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The Well frame invented by Matta et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] fixes the healthy pelvis to the operating table and completes closed reduction through traction. However, this method requires continuous traction and is not effective in correcting rotational displacement. Later, the Starr reduction frame designed by Lefaivre et al. [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] not only fixes the pelvis, but also uses relevant fixation pins to decrease and maintain the reduction position in multiple directions. Finally, various anterior and posterior ring percutaneous fixation techniques are used to fix fractures, marking a new era in the minimally invasive treatment of pelvic fractures. Recently, Chen H et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] proposed a pelvic unlocking and reduction device using the improved Starr frame design based on the \u0026ldquo;unlocking and reduction concept\u0026rdquo;, which has been promoted to a certain extent in China [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Relying on the integrated rescue team and the support of the trauma intensive care unit, the trauma center of our hospital has applied this concept to patients with severe trauma who require early treatment of pelvic fractures. All the patients achieved clinical healing within the expected time, and the excellent rate of postoperative imaging evaluation and the last follow-up functional evaluation reached 100%, showing good clinical results.\u003c/p\u003e \u003cp\u003eThe AIS Committee defined patients with AIS\u0026thinsp;\u0026ge;\u0026thinsp;3 or ISS\u0026thinsp;\u0026ge;\u0026thinsp;16 as severe trauma patients. Among the 13 patients who successfully received surgeries, most of them had multiple injuries or multiple system injuries. The time from injury to surgery was 8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3 days, the shortest time period was 4 days, and the intraoperative blood loss was 52.7\u0026thinsp;\u0026plusmn;\u0026thinsp;50.4 ml. Compared with traditional open surgery, it greatly reduces the tolerance requirements for patients and advances the surgical window to about one week, leaving time for treating other combined injuries. Because closed reduction and internal fixation does not directly expose the fracture site, even if the patient undergoes colostomy or cystostomy in the surgical area, sterility can be maintained through local wound closure, reducing the risk of infection and making surgical contraindications possible. The operative time of this group was 172.3\u0026thinsp;\u0026plusmn;\u0026thinsp;73.4 min, which is similar to the reported operative time of 169.4 min [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] and 167 min [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This treatment showed no significant time advantage over traditional pelvic surgery, but did not increase surgical risks. The number of intraoperative fluoroscopy in this group was 101.5\u0026thinsp;\u0026plusmn;\u0026thinsp;22.2 times, indicating this surgery requires much time for fluoroscopy and has high fluoroscopy requirements. Therefore, preoperative intestinal preparation of patients is particularly important, and fluoroscopy examination is strongly recommended before sterilizing the drape to ensure that sufficiently clear images can be obtained. Our team treated a patient in the early stage where the enema was insufficient and the intraoperative fluoroscopy imaging was poor. Although the patient was reduced with a reduction device, percutaneous iliosacral screws cannot be inserted. Therefore, the patient was not included in this study. Three cases (23.1%) in this series developed lateral femoral cutaneous nerve injury, which was the only postoperative complication and had a high incidence. Similarly, Vaidya et al. [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] and Cole et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported incidence of 32% and 4%, respectively. According to the data analysis of this group, the prolonged operation time at the LC-II nail placement site in one case resulted in edema and compression of surrounding tissues, which resolved spontaneously about 2 weeks after surgery. In the other two cases, the anterior ring INFIX was fixed too low because the patients were thin, causing compression on the nerves. The symptoms were relieved when the INFIX was removed after clinical healing. This study recommends that to install the anterior ring INFIX, the incision shall be appropriately enlarged to expose and release the pin tail.\u003c/p\u003e \u003cp\u003eThe key to closed pelvic reduction is to understand the fracture pattern and the direction of reduction force. The basic types of pelvic fracture displacement include upward displacement, inversion, eversion, and forward and backward rotation. High-energy injuries are often manifested as two or even three combinations, which complicate reduction. Hence, preoperative three-dimensional CT reconstruction is needed to analyze the displacement of the fracture ends, and is combined with intraoperative fluoroscopy to determine the closed reduction technique to be adopted during the operation. (Entrance site: the backward and forward displacement of the posterior ring combined with the iliosacral joint indicates the inversion or eversion of the pelvis; outlet site: the up displacement of the fracture end in the posterior ring, and the up and down displacement of the pubic symphysis indicate the backward or forward rotation of the injured pelvis)The pelvic unlocking and reduction system was used to stabilize the hemipelvis, control contralateral pelvic displacement, and reduce with the stable hemipelvis as the reference. Theoretically, for C3 type pelvic fractures, the axial skeleton cannot be stabilized indirectly by fixing unilateral hemipelvis. It is preferred to first reduce the easily reducible hemipelvic fracture, so that the C3 type pelvic fracture becomes a C1 type, and finally the C1 type pelvic fracture is treated using a reduction method [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe order of reduction and internal fixation between anterior and posterior pelvic rings has not been clarified in the literature, but the concept of unlocking and reducing the fracture ends of the posterior ring emphasized in the pelvic unlocking and reduction device has been gradually accepted. If the posterior ring is locked, the iliac fracture ends and iliosacral joint must first be unlocked laterally using the acetabular half-threaded screws. However, when there is no interlocking in the posterior ring, this study believes reduction of the anterior ring will help reduce the posterior ring, and reduction must be performed from the anterior ring to the posterior ring. In case of anterior ring pubic ramus fracture, the hinge effect of soft tissues at the fracture end can still be utilized to reduce inversion, eversion and up and down rotation in the anterior ring using the LC-II half-threaded screws. However, when the pubic symphysis in the anterior ring is completely separated, the soft tissue hinge is destroyed and reduction cannot be completed by manipulating the acetabular half-threaded screws and the LC-II half-threaded screws. Generally, Kirschner wires, point reduction forceps, etc. are first used to temporarily reduce and stabilize the anterior ring before reducing the posterior ring. During reduction of the posterior ring, femoral supracondylar traction depends on the inserted LC-II half-threaded screws as a pivot to correct the vertical displacement of the posterior ring, and the LC-II half-threaded screws are pulled in the anterior-posterior direction to correct the backward displacement of the posterior ring. Finally, the acetabular half-threaded screws are used to reduce the fracture end under compression. Because anatomical reduction of the posterior ring is crucial in these displaced injury patterns, first the posterior ring and then the anterior ring are fixed and placed after successful reduction. This study summarizes the reduction and internal fixation as a 'turn-back order' reduction and internal fixation of 'posterior ring unlocking - anterior ring to posterior ring reduction stabilization - posterior ring to anterior ring internal fixation placement'. A typical case is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eFor patients with severe trauma and pelvic fracture, pelvic unlocking and reduction devices can be used for minimally invasive internal fixation treatment at an early stage as long as their vital signs are stable. This study summarizes and proposes for the first time the 'turn-back order' reduction and internal fixation philosophy of 'posterior-ring unlocking - anterior ring to posterior ring reduction stabilization - posterior ring to anterior ring internal fixation placement' in the closed pelvic reduction and internal fixation surgery. This study has some limitations. First, it is a retrospective study and lacks a control group with traditional surgery. Second, it is a single-center study with a small sample size, and presents the experience and conclusions that lack multi-center and large-sample verification.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAbbreviated Injury Scale (AIS)\u003c/p\u003e\n\u003cp\u003eInjury Severity Score (ISS)\u003c/p\u003e\n\u003cp\u003eInternal fixator (INFIX)\u003c/p\u003e\n\u003cp\u003eOpen reduction and internal fixation (ORIF)\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of our hospital, and all subjects signed informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe authors affirm that human research participants provided informed consent for publication of the images in Figure 1B,1C and 2I.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. These surgeries were performed by Yu Zhang, Rongbin Sun, Yiping Weng, Jie Chen. Data collection and analysis were performed by Jie Chen and Zhuangzhuang Zhang. The first draft of the manuscript was written by Jie Chen and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eYoshihara H, Yoneoka D. Demographic epidemiology of unstable pelvic fracture in the United States from 2000 to 2009: trends and in-hospital mortality. J Trauma Acute Care Surg. 2014;76(2):380\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhao JX, Zhang LC, Su XY, Zhao Z, Zhao YP, Sun GF, et al. Early Experience with Reduction of Unstable Pelvic Fracture Using a Computer-Aided Reduction Frame. Biomed Res Int. 2018;2018:7297635.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoudissa M, Francony F, Kerschbaumer G, Ruatti S, Milaire M, Merloz P, et al. Epidemiology and treatment of acetabular fractures in a level-1 trauma centre: Retrospective study of 414 patients over 10 years. Orthop Traumatol Surg Res. 2017;103(3):335\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElzohairy MM, Salama AM. Open reduction internal fixation versus percutaneous iliosacral screw fixation for unstable posterior pelvic ring disruptions. Orthop Traumatol Surg Res. 2017;103(2):223\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLefaivre KA, Starr AJ, Reinert CM. Reduction of displaced pelvic ring disruptions using a pelvic reduction frame. J Orthop Trauma. 2009;23(4):299\u0026ndash;308.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLefaivre KA, Starr AJ, Barker BP, Overturf S, Reinert CM. Early experience with reduction of displaced disruption of the pelvic ring using a pelvic reduction frame. J Bone Joint Surg Br. 2009;91(9):1201\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen H, Qi HZ, Zhu ZG, Guo YZ, Liang XD, Tang PF. External pelvic reduction frame system combined with tunnel screw fixation for Tile C1 pelvic fracture. Chin J Trauma. 2018;34(10):919\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQoreishi M, Seyyed Hosseinzadeh HR, Safdari F. Clinical Results of Percutaneous Fixation of Pelvic and Acetabular Fractures: A Minimally Invasive Internal Fixation Technique. Arch Bone Jt Surg. 2019;7(3):284\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e50th Annual Proceedings of the Association for the Advancement of Automotive Medicine. October 16\u0026ndash;18. 2006. Chicago, Illinois, USA. Annu Proc Assoc Adv Automot Med. 2006;50:1-410.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlam A, Gupta A, Gupta N, Yelamanchi R, Bansal L, Durga C. Evaluation of ISS, RTS, CASS and TRISS scoring systems for predicting outcomes of blunt trauma abdomen. Pol Przegl Chir. 2021;93(2):9\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatta JM. Indications for anterior fixation of pelvic fractures. Clin Orthop Relat Res 1996(329):88\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMajeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989;71(2):304\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaviglia H, Mejail A, Landro ME, Vatani N. Percutaneous fixation of acetabular fractures. EFORT Open Rev. 2018;3(5):326\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMatta JM, Yerasimides JG. Table-skeletal fixation as an adjunct to pelvic ring reduction. J Orthop Trauma. 2007;21(9):647\u0026ndash;56.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen H, Zhang Q, Hao M, Li J, Qi H, Yi C, et al. [A multicenter retrospective study assessing pelvic unlocking closed reduction device for reducing unstable pelvic posterior ring disruption]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2022;36(11):1327\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Li H, Li TY, He L, Luo YX, Hu YH, et al. Preliminary clinical application of external pelvic reduction frame in closed reduction and minimally invasive fixation of pelvic fractures. J Trauma Surg. 2021;23(1):5\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang CL, Yang XD, Liu J, Tang YJ, Liu ZX, Mai QG, et al. Closed reduction and minimally invasive fixation for the treatment of pelvic fractures of type C2 and C3. Chin J Orthop. 2021;41(19):1380\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaidya R, Tonnos F, Nasr K, Kanneganti P, Curtis G. The Anterior Subcutaneous Pelvic Fixator (INFIX) in an Anterior Posterior Compression Type 3 Pelvic Fracture. J Orthop Trauma. 2016;30(Suppl 2):S21\u0026ndash;2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCole PA, Dyskin EA, Gilbertson JA. Minimally-invasive fixation for anterior pelvic ring disruptions. Injury. 2015;46(Suppl 3):S27\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuo Y, Chen H, He L, Yi C. Displaced posterior pelvic ring fractures treated with an unlocking closed reduction technique: Prognostic factors associated with closed reduction failure, reduction quality, and fixation failure. Injury. 2023;54(Suppl 2):S21\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pelvic fracture, Closed reduction, Trauma, Internal fixation","lastPublishedDoi":"10.21203/rs.3.rs-4760232/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4760232/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eClosed reduction and internal fixation is the key to early and minimally invasive treatment of pelvic fractures in patients with severe trauma. Although the pelvic unlocking closed reduction device has been promoted to a certain extent, the therapeutic effect and surgical strategy skills of which in treating severe traumas were not clarified in particularly. Our study was to explore the therapeutic effect and surgical strategy skills of the pelvic unlocking closed reduction device in treating severe traumas combined with pelvic fractures.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003eData were retrospectively collected from 13 patients with severe traumas undergoing pelvic unlocking closed reduction for pelvic fractures in our hospital between July 2021 and December 2022. Seven males and six females aged 46.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.7 years were involved. The operation time, times of fluoroscopy, and blood loss were recorded intraoperatively. Postoperative complications, and fracture healing time were recorded. The Matta and Majeed scales were used to evaluate fracture reduction and clinical efficacy respectively.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe time from injury to surgery was 8.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3 (4\u0026ndash;14) days. No wound infection, loosening or breakage of internal fixation, or loss of reduction occurred. The clinical healing time was 3.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 (3\u0026ndash;5) months. Three cases suffered paresthesia on unilateral anterolateral thigh. According to the postoperative imaging Matta scores, 12 cases were excellent and 1 case was good, with an excellent and good rate of 100%. At the last follow-up, the Majeed functional scores were excellent in all 13 cases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFor patients with severe trauma combined with pelvic fracture, the pelvic unlocking and reduction device can be used for minimally invasive internal fixation at an early stage as long as their vital signs are stable. This study summarized and proposed for the first time the 'turn-back order' reduction and internal fixation philosophy of 'posterior-ring unlocking - anterior ring to posterior ring reduction stabilization - posterior ring to anterior ring internal fixation placement' in pelvic closed reduction and internal fixation surgery.\u003c/p\u003e","manuscriptTitle":"Pelvic Unlocking Closed Reduction Device for Treatment of Severe Traumas Combined with Pelvic Fractures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-09-04 23:18:07","doi":"10.21203/rs.3.rs-4760232/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-02T15:33:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-01T14:15:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-01T14:12:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-07-18T05:57:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"13be3414-a9e9-45b6-947a-68a5b64c134e","owner":[],"postedDate":"September 4th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-13T16:06:19+00:00","versionOfRecord":{"articleIdentity":"rs-4760232","link":"https://doi.org/10.1186/s12893-025-03199-8","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2025-10-07 15:57:43","publishedOnDateReadable":"October 7th, 2025"},"versionCreatedAt":"2024-09-04 23:18:07","video":"","vorDoi":"10.1186/s12893-025-03199-8","vorDoiUrl":"https://doi.org/10.1186/s12893-025-03199-8","workflowStages":[]},"version":"v1","identity":"rs-4760232","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4760232","identity":"rs-4760232","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}