Over 10% of Surgically Treated High-Energy Pelvic Fractures are Associated with Undiagnosed Ligamentous Knee Injuries: An Epidemiologic Study in Italy’s Largest Trauma Centre

Over 10% of Surgically Treated High-Energy Pelvic Fractures are Associated with Undiagnosed Ligamentous Knee Injuries: An Epidemiologic Study in Italy’s Largest Trauma Centre | 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 Article Over 10% of Surgically Treated High-Energy Pelvic Fractures are Associated with Undiagnosed Ligamentous Knee Injuries: An Epidemiologic Study in Italy’s Largest Trauma Centre Simone Giusti, Vittorio Alfonsi, Edoardo De Fenu, Claudia Franco, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6539745/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To evaluate the prevalence of undiagnosed ligamentous knee injuries in patients surgically treated for high-energy pelvic ring or acetabular fractures and propose a mechanism to diagnose these briefly post-hospital discharge. Methods A retrospective observational study was conducted at Italy’s largest trauma centre. Medical records from 2018–2023 were reviewed to identify patients who underwent surgical treatment for pelvic or acetabular fractures. Eligible patients were contacted for a structured telephone interview, which included a questionnaire on knee symptoms and the International Knee Documentation Committee (IKDC) score. Associations between demographic factors, trauma mechanism, and knee outcomes were statistically analyzed. Results Fifty-nine patients (mean age 55 years, 72.9% male) were enrolled. Undiagnosed knee ligament injuries were present in 11.9%, with an additional 8.5% reporting persistent knee symptoms. The average time to diagnosis was 6.4 months post-discharge. Patients involved in road traffic accidents showed a significantly higher incidence of knee injuries (34.8%) compared to those who fell from height (3.9%) (p = 0.049). Patients who had undergone ligament reconstruction had significantly lower IKDC scores (62.0 ± 8.2) than non-surgical cases (82.4 ± 12.1, p = 0.0002). No association was found with age or sex. Conclusion Ligamentous knee injuries are frequently overlooked in the acute management of high-energy pelvic fractures, particularly in road traffic accidents. A systematic knee assessment before discharge or early outpatient imaging should be considered to improve detection and outcomes. Health sciences/Anatomy/Musculoskeletal system Health sciences/Medical research/Epidemiology Figures Figure 1 Figure 2 Introduction High-energy trauma, including motor vehicle accidents and falls from height, are amongst the primary causes of multi-organ injury 1,2 . Pelvic fractures (PT) commonly arise as a consequence of these high-impact accidents and are frequently associated with isolated or multi-ligamentous injuries around the knee joint 3,4 . The incidence of PT accounts for 5% of all skeletal injuries, with a significant prevalence among young adults presenting high Injury Severity Scores (ISS) 5 . The acetabulum is the most commonly affected anatomical structure, with a frequency of 3 cases per 100,000 individuals, predominantly young adults aged 20 to 50 years 6 .The mortality rate for these injuries is significantly elevated (8%-15%) 7 , particularly in hemodynamically unstable patients, due to rapid blood loss and challenges in achieving hemostasis 7,8 . Given the high number of significant comorbidities, initial management typically prioritizes hemodynamic stabilization, which may occasionally lead to the neglect of secondary injuries, particularly capsuloligamentous injuries around the knee. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are the most frequently compromised structures 9–11 . As evidenced in the literature, early diagnosis and thorough management of knee ligamentous injuries is crucial to achieve high functional outcomes in the medium-to-long term and preventing the development of post-traumatic osteoarthritis and instability. To avoid these complications, it is essential to implement procedures that facilitate prompt diagnosis and timely management 12–14 . Identifying risk factors based on injury models or mechanisms could be pivotal for early diagnosis and treatment, ultimately aiding in the prevention of long-term complications 15 . This study aims to i dentify the percentage of undiagnosed knee ligament injuries in patients admitted with pelvic ring or acetabular fractures managed surgically in Italy’s largest trauma centre, in order to provide a measure of how significant the issue is and what procedures could be put into place to help reduce the chance of these injuries being missed in the acute setting. Materials and Methods Experimental protocol ethical approval was obtained by our institution’s ethics committee. The study was conducted according to the Helsinki Declaration and in adherence with human right laws. We conducted an epidemiologic observational study at Italy's largest trauma centre. A retrospective medical record review was performed to identify all patients admitted with a pelvic ring or acetabular fracture treated surgically from January 1st, 2018, to December 31st, 2023, to allow for at least 12 months follow-up. The records were consulted by 3 different members of staff. An attempt was made to contact all of these patients via telephone call. Informed consent was obtained both verbally and in written form from all the participants who we were able to enroll. A verbal questionnaire was administered to all of the patients in order to identify if they had developed any knee pathology during or after their hospital stay (Table 1 ). Table 1 – Telephone Questionnaire Questions Telephone Questionnaire Trauma Mechanism Fracture Side Days of Hospital Stay In-Hopsital Diagnosis of Knee Pathology? Knee Issues Post-Hospital Discharge? If Yes, how was it diagnosed and when Current Knee Issues All responding patients were also asked to complete an IKDC questionnaire which was also filed via telephone consultation. A selection flowchart is provided in Fig. 1 . Study Outcomes Demographic patient data such as age at time of injury, sex, body mass index (BMI) and any relevant co-morbidities was extrapolated from the medical charts. Patients who had received prior diagnosis or treatment for a knee ligamentous injury were identified from the records. Patient demographics are summarised in Table 2 and Fig. 2 . Age (years) 55 (17–81) Patient sex (male) 43 (72.9%) Patient sex (femlae) 16 (27.1%) Body Mass Index (Kg/m 2 ) 26.2 (3.3) Patients with previous ligamentous reconstruction 1 (1.7%) Values are presented as mean (standard deviation) or count (proportion). Table 2 – Patient Demographics Statistical analysis Statistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, N.Y., USA). Data of continuous variables were presented as mean values ± standard deviation (SD). Differences were considered significant at the p < 0.05 level. Results The datasets used and/or analysed during the current study available from the corresponding author on reasonable request. The study population age ranged from 17 to 81 years, with a mean age of 55 years, a median of 56 years, and a standard deviation of 15.36. Out of 59 patients, the majority were male with 43 patients (72.88%) and 16 females (27.12%). Among 59 patients, 20.34% currently have knee pathology and 18.64% experienced knee issues in the first 12 months post-discharge. The most commonly reported knee symptoms were joint instability, arthrofibrosis and pain. 7 patients (11.86%) had undergone ACL or PCL reconstruction for a ligamentous injury sustained during the original pelvic trauma at the time of the telephone consultation. The average time from hospital discharge to diagnosis of knee ligamentous injury was 6.38 months from the traumatic event. We found no statistically significant associations between sex (p = 0.202) and age (p = 0.549) and likelihood of sustaining a ligamentous knee injury. However, a statistically significant association was identified between trauma mechanism and development of knee pathology (p = 0.049), with road accident-related trauma showing higher rates of knee injuries (34.78%) compared to falls from heights (3.85%). This strongly suggests that trauma mechanism may be an important predictor of long-term knee complications in patients admitted with pelvic ring or acetabular fracture. The mean IKDC score amongst the 59 patients we interviewed was 79.93 (44–93, SD 13.43). Patients who had received either ACL or PCL reconstruction had significantly lower IKDS scores compared to those who did not. In our analysis, these patients (7) showed a mean IKDC score of 62.00 (± 8.23) compared to a mean score of 82.35 (± 12.13) in the non-reconstructed group (52), p = 0.0002. There was no statistically significant correlation between IKDC score and trauma mechanism of the original pelvic-ring or acetabular fracture. Discussion In our study we aimed to investigate the prevalence of undiagnosed knee ligament injuries in patients undergoing surgical treatment for high-energy pelvic ring and acetabular fractures. The coexistence of major skeletal injuries, such as pelvic and acetabular fractures resulting from high-energy trauma (e.g., motor vehicle accidents or falls from significant heights), is often associated with other significant injuries 16,17 . It has been reported that up to 90% of patients with pelvic and acetabular fractures present with associated injuries such as thoracic injuries (10–21%), abdominal injuries (8–28%), urogenital injuries (3–22%), and lower limb injuries (35–41%) 16,18 . Our study adds another dimension to this complexity, suggesting that knee ligament injuries could be an underappreciated associated injury in this patient population 19,20 . The complexity of these clinical scenarios is dictated by the traumatic mechanism, which influences the type of fracture and the associated soft tissue damage. Mixed trauma, both contusive and distortive, involves the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), collateral ligaments (MCL and LCL) and often, the articular capsule itself. These factors, along with the potential presence of meniscal injuries and bone quality related to age, significantly affects clinical and radiographic outcomes, favoring the development of post-traumatic osteoarthritis. Among the 59 patients examined, 20.34% are currently affected by knee pathology, and 18.64% have experienced knee-related issues after discharge. The most common issues reported were joint instability (3 patients), joint rigidity (2 patients), and pain (2 patients). Seven patients (11.86%) underwent anterior or posterior cruciate ligament reconstruction. A statistically significant association between trauma mechanism and presence of ligamentous knee injury was observed, with motor vehicle accidents exhibiting higher rates (34.78%) compared to falls from height (3.85%). The high-energy trauma mechanism capable of causing pelvic and acetabular fractures may extend to the knee joint, leading to ligamentous injuries which may not be immediately evident due to the context of the more severe injuries. The initial priority in the treatment of these patients often focuses on hemodynamic stabilization and the management of life-threatening trauma 6,16 . In this context, a comprehensive knee evaluation may be secondary or limited by the patient's inability to cooperate due to pain or altered consciousness. The existing literature consistently regards pelvic ring and acetabular fractures as severe orthopedic trauma and, consequently, underscores the importance of peripheral limb evaluation in the emergency setting 17 . Pelvic and acetabular fractures can have a profound impact on patients' medium- and long-term quality of life, especially in young patients, as many do not fully regain their pre-injury functional level in activities of daily living (ADL) and may experience mental health issues 21,22 . Mult-ligamentous knee injuries (MLKI) represent a complex and severe condition affecting the knee joint, characterized by heterogeneous injury patterns caused mainly by high-energy trauma. Their complexity arises not only from their rarity but also from the wide spectrum of injury patterns and severity, each presenting unique challenges 23,24 . MLKIs involve partial or complete rupture of two or more of the major knee ligaments, including the ACL, PCL, medial collateral ligament (MCL), and lateral collateral ligament (LCL). These injuries range from isolated, closed ligamentous tears without additional structural damage to complex polytraumatic (PT) injuries. This variability requires a highly individualized approach to treatment, ranging from non-surgical methods, such as limb immobilization, to more commonly used surgical interventions, including acute ligament repair and reconstruction, the latter showing better functional and clinical outcomes 23–25 . Although PCL injuries are less common than ACL injuries, they are often involved in high-energy injury mechanisms and in the context of major pelvic and acetabular fractures. 26–28 . Our findings are significant, suggesting that the injury mechanism is a crucial predictor of long-term knee complications, highlighting the importance of examining the knee joints prior to discharge especially in those patients involved in road traffic accidents (RTA). Demographic factors such as age and sex have a lesser influence on outcomes in this patient population. Several studies, including the one by Levy et al., have shown that early surgical treatment significantly impacts medium- to long-term clinical and functional outcomes 29–31 . Therefore, failure to diagnose knee ligament injuries early could lead to chronic instability, loss of range of motion (ROM), persistent pain, and an increased risk of long-term osteoarthritis 25,32–34 , which can have long lasting effects especially in younger patients. Therefore, we recommend that all patients with high-energy pelvic rings and acetabular fractures undergo a thorough knee examination as soon as their clinical condition allows for it, ideally before hospital discharge. Furthermore, we also suggest that all patients who suffered pelvic ring or acetabular fractures as a consequence of an RTA should routinely be sent for an outpatient MRI at 3 months from hospital discharge, due to the higher likelihood of knee ligamentous injury. Our study presents several limitations, including its retrospective nature, which may have restricted the completeness of knee assessment data at the time of initial trauma, and the relatively small sample size, which may limit the generalizability of the findings to a broader population. Prospective studies with standardized knee evaluation protocols would be necessary to confirm our findings and better quantify the true prevalence of these injuries. Moreover, the low incidence of these injuries has resulted in a shortage of large-scale, definitive clinical studies, leading to a lack of consensus on the key diagnostic and management strategies. Consequently, future research directions may include prospective studies systematically evaluating knee injuries in patients with high-energy pelvic and acetabular fractures using both clinical examination and early MRI imaging. Additionally, further research could focus on the impact of early diagnosis and treatment of knee ligament injuries on long-term functional outcomes in this patient population. In conclusion, our study suggests that undiagnosed knee ligament injuries may be more common than previously recognized in patients with surgically treated high-energy pelvic ring and acetabular fractures. Greater awareness of this potential association and the implementation of more comprehensive evaluation protocols could enhance the overall management of these patients and potentially improve their long-term outcomes. Given the complexity and severity of multiligamentous knee injuries, early diagnosis and appropriate treatment are essential to minimize long-term disability, especially in the younger population. A systematic approach to evaluating knee ligamentous injuries in patients with pelvic and acetabular fractures is recommended to ensure prompt recognition and management of associated injuries, especially in those patients who were victims of RTA’s. Future studies should focus on developing diagnostic protocols to facilitate early identification of knee injuries in polytrauma patients, with the aim of improving functional outcomes and quality of life in the long term. Declarations Funding NO funding was received by any of the authors. Author Contribution S.G wrote the main manuscript. V.A helped write some extracts of the main manuscript. S.G and C.F did the retrospective data collection. S.G did the statistical analysis of the data. F.L was the senior surgeon who carried out all the procedures. E.A provided senior review and conceptualization of the study together with F.L. All authors reviewed the manuscript. 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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-6539745","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":475713467,"identity":"55bd6c94-ae16-477b-88bf-5186b6dd8d17","order_by":0,"name":"Simone 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Sex Distribution of the Study Population\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6539745/v1/3da6913abd478a42bb718893.jpeg"},{"id":86508125,"identity":"a8ed8894-4b06-4763-8f9a-9169eee8f2b5","added_by":"auto","created_at":"2025-07-11 12:24:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":610524,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6539745/v1/a9125706-dd19-48fa-8463-9fe7542395d8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Over 10% of Surgically Treated High-Energy Pelvic Fractures are Associated with Undiagnosed Ligamentous Knee Injuries: An Epidemiologic Study in Italy’s Largest Trauma Centre","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHigh-energy trauma, including motor vehicle accidents and falls from height, are amongst the primary causes of multi-organ injury \u003csup\u003e1,2\u003c/sup\u003e. Pelvic fractures (PT) commonly arise as a consequence of these high-impact accidents and are frequently associated with isolated or multi-ligamentous injuries around the knee joint \u003csup\u003e3,4\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe incidence of PT accounts for 5% of all skeletal injuries, with a significant prevalence among young adults presenting high Injury Severity Scores (ISS) \u003csup\u003e5\u003c/sup\u003e. The acetabulum is the most commonly affected anatomical structure, with a frequency of 3 cases per 100,000 individuals, predominantly young adults aged 20 to 50 years \u003csup\u003e6\u003c/sup\u003e .The mortality rate for these injuries is significantly elevated (8%-15%) \u003csup\u003e7\u003c/sup\u003e, particularly in hemodynamically unstable patients, due to rapid blood loss and challenges in achieving hemostasis \u003csup\u003e7,8\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGiven the high number of significant comorbidities, initial management typically prioritizes hemodynamic stabilization, which may occasionally lead to the neglect of secondary injuries, particularly capsuloligamentous injuries around the knee. The anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are the most frequently compromised structures \u003csup\u003e9\u0026ndash;11\u003c/sup\u003e. As evidenced in the literature, early diagnosis and thorough management of knee ligamentous injuries is crucial to achieve high functional outcomes in the medium-to-long term and preventing the development of post-traumatic osteoarthritis and instability. To avoid these complications, it is essential to implement procedures that facilitate prompt diagnosis and timely management \u003csup\u003e12\u0026ndash;14\u003c/sup\u003e. Identifying risk factors based on injury models or mechanisms could be pivotal for early diagnosis and treatment, ultimately aiding in the prevention of long-term complications\u003csup\u003e15\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study aims to i\u003cem\u003edentify the percentage\u003c/em\u003e of undiagnosed knee ligament injuries in patients admitted with pelvic ring or acetabular fractures managed surgically in Italy\u0026rsquo;s largest trauma centre, in order to provide a measure of how significant the issue is and what procedures could be put into place to help \u003cem\u003ereduce the chance\u003c/em\u003e of these injuries being missed in the acute setting.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e Experimental protocol ethical approval was obtained by our institution\u0026rsquo;s ethics committee. The study was conducted according to the Helsinki Declaration and in adherence with human right laws. We conducted an epidemiologic observational study at Italy's largest trauma centre. A retrospective medical record review was performed to identify all patients admitted with a pelvic ring or acetabular fracture treated surgically from January 1st, 2018, to December 31st, 2023, to allow for at least 12 months follow-up. The records were consulted by 3 different members of staff. An attempt was made to contact all of these patients via telephone call. Informed consent was obtained both verbally and in written form from all the participants who we were able to enroll. A verbal questionnaire was administered to all of the patients in order to identify if they had developed any knee pathology during or after their hospital stay (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Telephone Questionnaire Questions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTelephone Questionnaire\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma Mechanism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture Side\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDays of Hospital Stay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-Hopsital Diagnosis of Knee Pathology?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnee Issues Post-Hospital Discharge?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIf Yes, how was it diagnosed and when\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrent Knee Issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll responding patients were also asked to complete an IKDC questionnaire which was also filed via telephone consultation. A selection flowchart is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Outcomes\u003c/h2\u003e \u003cp\u003eDemographic patient data such as age at time of injury, sex, body mass index (BMI) and any relevant co-morbidities was extrapolated from the medical charts. Patients who had received prior diagnosis or treatment for a knee ligamentous injury were identified from the records. Patient demographics are summarised in Table\u0026nbsp;2 and Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"2\"\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 \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (17\u0026ndash;81)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient sex (male)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e43 (72.9%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient sex (femlae)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (27.1%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Mass Index (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26.2 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatients with previous ligamentous reconstruction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1 (1.7%)\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\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eValues are presented as mean (standard deviation) or count (proportion).\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eTable\u0026nbsp;2 \u0026ndash; Patient Demographics\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using IBM SPSS Statistics for Windows, Version 28.0 (IBM Corp., Armonk, N.Y., USA). Data of continuous variables were presented as mean values\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Differences were considered significant at the p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 level.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request. The study population age ranged from 17 to 81 years, with a mean age of 55 years, a median of 56 years, and a standard deviation of 15.36. Out of 59 patients, the majority were male with 43 patients (72.88%) and 16 females (27.12%). Among 59 patients, 20.34% currently have knee pathology and 18.64% experienced knee issues in the first 12 months post-discharge. The most commonly reported knee symptoms were joint instability, arthrofibrosis and pain. 7 patients (11.86%) had undergone ACL or PCL reconstruction for a ligamentous injury sustained during the original pelvic trauma at the time of the telephone consultation. The average time from hospital discharge to diagnosis of knee ligamentous injury was 6.38 months from the traumatic event. We found no statistically significant associations between sex (p\u0026thinsp;=\u0026thinsp;0.202) and age (p\u0026thinsp;=\u0026thinsp;0.549) and likelihood of sustaining a ligamentous knee injury. However, a statistically significant association was identified between trauma mechanism and development of knee pathology (p\u0026thinsp;=\u0026thinsp;0.049), with road accident-related trauma showing higher rates of knee injuries (34.78%) compared to falls from heights (3.85%). This strongly suggests that trauma mechanism may be an important predictor of long-term knee complications in patients admitted with pelvic ring or acetabular fracture.\u003c/p\u003e \u003cp\u003eThe mean IKDC score amongst the 59 patients we interviewed was 79.93 (44\u0026ndash;93, SD 13.43). Patients who had received either ACL or PCL reconstruction had significantly lower IKDS scores compared to those who did not. In our analysis, these patients (7) showed a mean IKDC score of 62.00 (\u0026plusmn;\u0026thinsp;8.23) compared to a mean score of 82.35 (\u0026plusmn;\u0026thinsp;12.13) in the non-reconstructed group (52), p\u0026thinsp;=\u0026thinsp;0.0002. There was no statistically significant correlation between IKDC score and trauma mechanism of the original pelvic-ring or acetabular fracture.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study we aimed to investigate the prevalence of undiagnosed knee ligament injuries in patients undergoing surgical treatment for high-energy pelvic ring and acetabular fractures. The coexistence of major skeletal injuries, such as pelvic and acetabular fractures resulting from high-energy trauma (e.g., motor vehicle accidents or falls from significant heights), is often associated with other significant injuries \u003csup\u003e16,17\u003c/sup\u003e. It has been reported that up to 90% of patients with pelvic and acetabular fractures present with associated injuries such as thoracic injuries (10\u0026ndash;21%), abdominal injuries (8\u0026ndash;28%), urogenital injuries (3\u0026ndash;22%), and lower limb injuries (35\u0026ndash;41%) \u003csup\u003e16,18\u003c/sup\u003e. Our study adds another dimension to this complexity, suggesting that knee ligament injuries could be an underappreciated associated injury in this patient population \u003csup\u003e19,20\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe complexity of these clinical scenarios is dictated by the traumatic mechanism, which influences the type of fracture and the associated soft tissue damage. Mixed trauma, both contusive and distortive, involves the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), collateral ligaments (MCL and LCL) and often, the articular capsule itself. These factors, along with the potential presence of meniscal injuries and bone quality related to age, significantly affects clinical and radiographic outcomes, favoring the development of post-traumatic osteoarthritis.\u003c/p\u003e \u003cp\u003eAmong the 59 patients examined, 20.34% are currently affected by knee pathology, and 18.64% have experienced knee-related issues after discharge. The most common issues reported were joint instability (3 patients), joint rigidity (2 patients), and pain (2 patients).\u003c/p\u003e \u003cp\u003eSeven patients (11.86%) underwent anterior or posterior cruciate ligament reconstruction. A statistically significant association between trauma mechanism and presence of ligamentous knee injury was observed, with motor vehicle accidents exhibiting higher rates (34.78%) compared to falls from height (3.85%).\u003c/p\u003e \u003cp\u003eThe high-energy trauma mechanism capable of causing pelvic and acetabular fractures may extend to the knee joint, leading to ligamentous injuries which may not be immediately evident due to the context of the more severe injuries. The initial priority in the treatment of these patients often focuses on hemodynamic stabilization and the management of life-threatening trauma \u003csup\u003e6,16\u003c/sup\u003e. In this context, a comprehensive knee evaluation may be secondary or limited by the patient's inability to cooperate due to pain or altered consciousness.\u003c/p\u003e \u003cp\u003eThe existing literature consistently regards pelvic ring and acetabular fractures as severe orthopedic trauma and, consequently, underscores the importance of peripheral limb evaluation in the emergency setting \u003csup\u003e17\u003c/sup\u003e. Pelvic and acetabular fractures can have a profound impact on patients' medium- and long-term quality of life, especially in young patients, as many do not fully regain their pre-injury functional level in activities of daily living (ADL) and may experience mental health issues \u003csup\u003e21,22\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eMult-ligamentous knee injuries (MLKI) represent a complex and severe condition affecting the knee joint, characterized by heterogeneous injury patterns caused mainly by high-energy trauma. Their complexity arises not only from their rarity but also from the wide spectrum of injury patterns and severity, each presenting unique challenges \u003csup\u003e23,24\u003c/sup\u003e. MLKIs involve partial or complete rupture of two or more of the major knee ligaments, including the ACL, PCL, medial collateral ligament (MCL), and lateral collateral ligament (LCL). These injuries range from isolated, closed ligamentous tears without additional structural damage to complex polytraumatic (PT) injuries. This variability requires a highly individualized approach to treatment, ranging from non-surgical methods, such as limb immobilization, to more commonly used surgical interventions, including acute ligament repair and reconstruction, the latter showing better functional and clinical outcomes \u003csup\u003e23\u0026ndash;25\u003c/sup\u003e. Although PCL injuries are less common than ACL injuries, they are often involved in high-energy injury mechanisms and in the context of major pelvic and acetabular fractures. \u003csup\u003e26\u0026ndash;28\u003c/sup\u003e. Our findings are significant, suggesting that the injury mechanism is a crucial predictor of long-term knee complications, highlighting the importance of examining the knee joints prior to discharge especially in those patients involved in road traffic accidents (RTA). Demographic factors such as age and sex have a lesser influence on outcomes in this patient population.\u003c/p\u003e \u003cp\u003eSeveral studies, including the one by Levy et al., have shown that early surgical treatment significantly impacts medium- to long-term clinical and functional outcomes \u003csup\u003e29\u0026ndash;31\u003c/sup\u003e. Therefore, failure to diagnose knee ligament injuries early could lead to chronic instability, loss of range of motion (ROM), persistent pain, and an increased risk of long-term osteoarthritis \u003csup\u003e25,32\u0026ndash;34\u003c/sup\u003e, which can have long lasting effects especially in younger patients.\u003c/p\u003e \u003cp\u003eTherefore, we recommend that all patients with high-energy pelvic rings and acetabular fractures undergo a thorough knee examination as soon as their clinical condition allows for it, ideally before hospital discharge. Furthermore, we also suggest that all patients who suffered pelvic ring or acetabular fractures as a consequence of an RTA should routinely be sent for an outpatient MRI at 3 months from hospital discharge, due to the higher likelihood of knee ligamentous injury.\u003c/p\u003e \u003cp\u003eOur study presents several limitations, including its retrospective nature, which may have restricted the completeness of knee assessment data at the time of initial trauma, and the relatively small sample size, which may limit the generalizability of the findings to a broader population. Prospective studies with standardized knee evaluation protocols would be necessary to confirm our findings and better quantify the true prevalence of these injuries.\u003c/p\u003e \u003cp\u003eMoreover, the low incidence of these injuries has resulted in a shortage of large-scale, definitive clinical studies, leading to a lack of consensus on the key diagnostic and management strategies.\u003c/p\u003e \u003cp\u003eConsequently, future research directions may include prospective studies systematically evaluating knee injuries in patients with high-energy pelvic and acetabular fractures using both clinical examination and early MRI imaging. Additionally, further research could focus on the impact of early diagnosis and treatment of knee ligament injuries on long-term functional outcomes in this patient population.\u003c/p\u003e \u003cp\u003eIn conclusion, our study suggests that undiagnosed knee ligament injuries may be more common than previously recognized in patients with surgically treated high-energy pelvic ring and acetabular fractures. Greater awareness of this potential association and the implementation of more comprehensive evaluation protocols could enhance the overall management of these patients and potentially improve their long-term outcomes.\u003c/p\u003e \u003cp\u003eGiven the complexity and severity of multiligamentous knee injuries, early diagnosis and appropriate treatment are essential to minimize long-term disability, especially in the younger population. A systematic approach to evaluating knee ligamentous injuries in patients with pelvic and acetabular fractures is recommended to ensure prompt recognition and management of associated injuries, especially in those patients who were victims of RTA\u0026rsquo;s.\u003c/p\u003e \u003cp\u003eFuture studies should focus on developing diagnostic protocols to facilitate early identification of knee injuries in polytrauma patients, with the aim of improving functional outcomes and quality of life in the long term.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNO funding was received by any of the authors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eS.G wrote the main manuscript. V.A helped write some extracts of the main manuscript. S.G and C.F did the retrospective data collection. S.G did the statistical analysis of the data. F.L was the senior surgeon who carried out all the procedures. E.A provided senior review and conceptualization of the study together with F.L. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analysed during the current study available from the corresponding author on reasonable request\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBurgess AR, Eastridge BJ, Young JW, Ellison TS, Ellison PS Jr, Poka A, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990;30(7):848\u0026ndash;56. doi:10.1097/00005373-199007000-00008\u003c/li\u003e\n\u003cli\u003eTile M. Acute pelvic fractures: I. Causation and classification. J Am Acad Orthop Surg. 1996;4(3):143\u0026ndash;51. doi:10.5435/00124635-199605000-00002\u003c/li\u003e\n\u003cli\u003eMcCarthy ML, MacKenzie EJ, Bosse MJ, Copeland C, Hash CS, Burgess AR. Functional status following orthopedic trauma in young women. J Trauma. 1995;39(5):828\u0026ndash;36. doi:10.1097/00005373-199511000-00016\u003c/li\u003e\n\u003cli\u003eSeroyer ST, Musahl V, Harner CD. Management of the multiple ligament injured knee. Clin Sports Med. 2008;27(1):113\u0026ndash;26. doi:10.1016/j.csm.2007.10.002\u003c/li\u003e\n\u003cli\u003ePohlemann T, Gansslen A, Schellwald O, Tscherne H. Outcome after pelvic ring injuries. Injury. 1996;27(Suppl 2):B31\u0026ndash;8. doi:10.1016/S0020-1383(96)90106-4\u003c/li\u003e\n\u003cli\u003eLaird A, Keating JF. Acetabular fractures: a 16-year prospective epidemiological study. J Bone Joint Surg Br. 2005;87(7):969\u0026ndash;73. doi:10.1302/0301-620X.87B7.16130\u003c/li\u003e\n\u003cli\u003eSathy AK, Starr AJ, Smith WR, Elliott A, Agudelo J, Reinert CM. The effect of pelvic fracture on mortality after trauma: an analysis of 63,000 trauma patients. J Bone Joint Surg Am. 2009;91(12):2803\u0026ndash;10. doi:10.2106/JBJS.H.01694\u003c/li\u003e\n\u003cli\u003eRommens PM, Wagner D, Hofmann A. Minimal invasive surgical treatment of fragility fractures of the pelvis. Chin J Traumatol. 2017;20(4):191\u0026ndash;7. doi:10.1016/j.cjtee.2017.03.004\u003c/li\u003e\n\u003cli\u003eMargheritini F, Mariani PP. Ligament injuries resulting from sports trauma. Curr Rev Musculoskelet Med. 2008;1(1):37\u0026ndash;43. doi:10.1007/s12178-007-9004-z\u003c/li\u003e\n\u003cli\u003eFanelli GC, Edson CJ. Surgery for acute posterior cruciate ligament injuries. J Knee Surg. 2002;15(2):83\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eLogan M, Williams A, Lavelle J, Gedroyc W, Freeman M, Murray D. The effect of posterior cruciate ligament deficiency on knee kinematics. Am J Sports Med. 2004;32(8):1915\u0026ndash;22. doi:10.1177/0363546504266075\u003c/li\u003e\n\u003cli\u003eMook WR, Miller MD, Diduch DR, Hertel J, Boachie-Adjei Y, Hart JM. Multiple-ligament knee injuries: a systematic review of the timing of operative intervention and postoperative rehabilitation. J Bone Joint Surg Am. 2009;91(12):2946\u0026ndash;57. doi:10.2106/JBJS.H.01273\u003c/li\u003e\n\u003cli\u003eHarner CD, Waltrip RL, Bennett CH, Francis KA, Cole B, Irrgang JJ. Surgical management of knee dislocations. J Bone Joint Surg Am. 2004;86(2):262\u0026ndash;73. doi:10.2106/00004623-200402000-00006\u003c/li\u003e\n\u003cli\u003eWascher DC. High-velocity knee dislocation with vascular injury. Treatment principles. Clin Sports Med. 2000;19(3):457\u0026ndash;77. doi:10.1016/S0278-5919(05)70210-7\u003c/li\u003e\n\u003cli\u003eRihn JA, Groff YJ, Harner CD, Cha PS. The acutely dislocated knee: evaluation and management. J Am Acad Orthop Surg. 2004;12(5):334\u0026ndash;46. doi:10.5435/00124635-200409000-00005\u003c/li\u003e\n\u003cli\u003eGiannoudis PV, Grotz MRW, Tzioupis C, Dinopoulos H, Wells GE, Bouamra O, et al. Prevalence of pelvic fractures, associated injuries, and mortality: the United Kingdom perspective. J Trauma. 2007;63(4):875\u0026ndash;83. doi:10.1097/TA.0b013e3181271b1c\u003c/li\u003e\n\u003cli\u003eVallier HA, Cureton BA, Patterson BM. Function after acetabular fractures: a prospective series. J Bone Joint Surg Am. 2010;92(3):557\u0026ndash;64. doi:10.2106/JBJS.I.00356\u003c/li\u003e\n\u003cli\u003eBecker C, Bl\u0026auml;ttler W, Rommens PM. Associated injuries in patients with pelvic fractures. Eur J Trauma Emerg Surg. 2022;48(5):3699\u0026ndash;3707. doi:10.1007/s00068-021-01814-w\u003c/li\u003e\n\u003cli\u003eDente CJ, Feliciano DV. Pelvic fractures: should they be stabilized early? Curr Opin Crit Care. 2003;9(6):536\u0026ndash;40. doi:10.1097/00075198-200312000-00009\u003c/li\u003e\n\u003cli\u003eHauschild O, Aghayev E, von Heyden J, Strohm PC, Suedkamp NP, Pohlemann T. Pelvic injuries in severely injured patients: results of the German Pelvic Registry. Injury. 2012;43(8):1237\u0026ndash;45. doi:10.1016/j.injury.2011.09.022\u003c/li\u003e\n\u003cli\u003eMehta S, Auerbach JD, Born CT, Chin KR. Sacral fractures. J Am Acad Orthop Surg. 2006;14(12):725\u0026ndash;37. doi:10.5435/00124635-200612000-00005\u003c/li\u003e\n\u003cli\u003eDujardin FH, Hossenbaccus M, Duparc F, Biga N, Thomine JM. Long-term functional prognosis of posterior injuries in pelvic disruptions. Clin Orthop Relat Res. 1998;(346):73\u0026ndash;9. doi:10.1097/00003086-199801000-00009\u003c/li\u003e\n\u003cli\u003eFanelli GC. Multiple ligament injuries. J Knee Surg. 2011;24(1):1\u0026ndash;3.\u003c/li\u003e\n\u003cli\u003eLevy BA, Dajani KA, Morgan JA, Shah JP, Dahm DL, Stuart MJ, et al. Repair versus reconstruction of the multiligament-injured knee: a critical analysis. Clin Orthop Relat Res. 2011;469(10):2474\u0026ndash;8. doi:10.1007/s11999-011-1908-0\u003c/li\u003e\n\u003cli\u003eShelbourne KD, Gray T. 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Fate of the ACL-injured patient: a prospective outcome study. Am J Sports Med. 1994;22(5):632\u0026ndash;44. doi:10.1177/036354659402200511\u003c/li\u003e\n\u003cli\u003eTorg JS, Conrad W, Kalen V. Clinical diagnosis of posterior cruciate ligament instability. Am J Sports Med. 1981;9(2):85\u0026ndash;9. doi:10.1177/036354658100900204\u003c/li\u003e\n\u003cli\u003eHughston JC, Barrett GR. Acute anteromedial rotatory instability: long-term results of surgical repair. J Bone Joint Surg Am. 1983;65(2):145\u0026ndash;53.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6539745/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6539745/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eTo evaluate the prevalence of undiagnosed ligamentous knee injuries in patients surgically treated for high-energy pelvic ring or acetabular fractures and propose a mechanism to diagnose these briefly post-hospital discharge.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective observational study was conducted at Italy\u0026rsquo;s largest trauma centre. Medical records from 2018\u0026ndash;2023 were reviewed to identify patients who underwent surgical treatment for pelvic or acetabular fractures. Eligible patients were contacted for a structured telephone interview, which included a questionnaire on knee symptoms and the International Knee Documentation Committee (IKDC) score. Associations between demographic factors, trauma mechanism, and knee outcomes were statistically analyzed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFifty-nine patients (mean age 55 years, 72.9% male) were enrolled. Undiagnosed knee ligament injuries were present in 11.9%, with an additional 8.5% reporting persistent knee symptoms. The average time to diagnosis was 6.4 months post-discharge. Patients involved in road traffic accidents showed a significantly higher incidence of knee injuries (34.8%) compared to those who fell from height (3.9%) (p\u0026thinsp;=\u0026thinsp;0.049). Patients who had undergone ligament reconstruction had significantly lower IKDC scores (62.0\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2) than non-surgical cases (82.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1, p\u0026thinsp;=\u0026thinsp;0.0002). No association was found with age or sex.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eLigamentous knee injuries are frequently overlooked in the acute management of high-energy pelvic fractures, particularly in road traffic accidents. A systematic knee assessment before discharge or early outpatient imaging should be considered to improve detection and outcomes.\u003c/p\u003e","manuscriptTitle":"Over 10% of Surgically Treated High-Energy Pelvic Fractures are Associated with Undiagnosed Ligamentous Knee Injuries: An Epidemiologic Study in Italy’s Largest Trauma Centre","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-29 14:45:29","doi":"10.21203/rs.3.rs-6539745/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"410cb9db-4cc0-4627-86c7-085ba764b2fc","owner":[],"postedDate":"June 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":50513838,"name":"Health sciences/Anatomy/Musculoskeletal system"},{"id":50513839,"name":"Health sciences/Medical research/Epidemiology"}],"tags":[],"updatedAt":"2025-07-11T12:23:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-29 14:45:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6539745","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6539745","identity":"rs-6539745","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}