Anterior-First Approach to Unstable Pelvic Ring Fracture Fixation: Functional Outcomes and the Importance of Anatomic Reduction
-
Reza Zarei
,
Alireza Manafi Rasi
,
Mojtaba Baroutkoub
,
Mehdi Ghasemi Nik
,
Seyed Shahab Aldin Vaziri
,
Ali Pourmojarab
Abstract
Background: Unstable pelvic ring fractures are high-energy injuries with complex anatomy and significant morbidity. Surgical fixation is the standard treatment; however, there is still controversy over the optimal sequence of anterior and posterior stabilization. An anterior-first fixation may help stabilize the pelvis, facilitate posterior reduction, and improve functional outcomes.
Methods: We retrospectively reviewed patients with unstable pelvic ring injuries using a standardized “anterior-first” fixation protocol. Radiographic reduction was assessed using Matta and Tornetta criteria on anteroposterior (AP), inlet, and outlet views. Functional outcomes at a minimum of 12 months were measured using the Iowa Pelvic Score (IPS) and Majeed Pelvic Score (MPS). Clinical complications, including bleeding requiring transfusion, hematuria, and limb-length discrepancy (LLD), were recorded.
Results: The study included 20 patients with a mean age of 40.7 ± 16.3 years. Excellent or good reductions were achieved in most patients, with 45% and 60% of cases rated as “Excellent” on the AP and inlet views, respectively. Outlet views showed greater variability, with 40% fair reduction. Mean IPS and MPS scores were 84.2 ± 16.7 and 78.9 ± 16.0, respectively, and were strongly correlated with each other (r = 0.82, P < 0.001). Older patients (> 50 years) achieved functional outcomes comparable to younger cohorts. Clinically, bleeding requiring transfusion occurred in 45%, hematuria in 35%, and LLD > 1 cm in 35%. No catastrophic complications were observed.
Conclusion: In this small retrospective case series, anterior-first fixation was associated with acceptable radiographic reduction and favorable functional outcomes in selected patients with unstable pelvic ring injuries. Given the limited sample size and the absence of a comparator group, these findings should be interpreted with caution. Larger prospective comparative studies are needed to clarify the optimal fixation sequence.
1. Hu S, Guo J, Zhu B, Dong Y, Li F. Epidemiology and burden of pelvic fractures: Results from the Global Burden of Disease Study 2019. Injury. 2023;54(2):589-97. doi: 10.1016/j.injury.2022.12.007. [PubMed: 36528424].
2. Stahel PF, Hammerberg EM. History of pelvic fracture management: A review. World J Emerg Surg. 2016;11:18. doi: 10.1186/s13017-016-0075-4. [PubMed: 27148396]. [PubMed Central: PMC4855448].
3. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013;21(8):448-57. doi: 10.5435/jaaos-21-08-448. [PubMed: 23908251].
4. Suzuki T, Shindo M, Soma K, Minehara H, Nakamura K, Uchino M, et al. Long-term functional outcome after unstable pelvic
ring fracture. J Trauma. 2007;63(4):884-8. doi: 10.1097/01.ta.0000235888.90489.fc. [PubMed: 18090021].
5. Hermans E, Brouwers L, van Gent T, Biert J, de Jongh MAC, Lansink KWW, et al. Quality of life after pelvic ring fractures: Long-term outcomes. A multicentre study. Injury. 2019;50(6): 1216-22. doi: 10.1016/j.injury.2019.04.002. [PubMed: 31029370].
6. Sabzghabaei A, Dolikhani M, Marivani M, Salehi S, Shakibamaram G. Effectiveness of Acupressure and Reflexology Combined with NSAIDs in Acute Low Back Pain: A Prospective Cohort Study. J Emerg Pract Trauma. 2025;11(1):e92622.
7. Alton TB, Gee AO. Classifications in brief: young and burgess classification of pelvic ring injuries. Clin Orthop Relat Res. 2014;472(8):2338-42. doi: 10.1007/s11999-014-3693-8. [PubMed: 24867452]. [PubMed Central: PMC4079881].
8. Gray A, Chandler H, Sabri O. Pelvic ring injuries: classification and treatment. Orthop Trauma. 2018;32(2):80-90. doi: 10.1016/j.mporth.2018.01.005.
9. Orthopaedic Trauma Research Group. Anterior and posterior fixation versus posterior fixation only of minimally displaced lateral compression type 1 pelvic ring injuries: A multicenter propensity-matched analysis. Injury. 2026;57(2):112964. doi: 10.1016/j.injury.2025.112964. [PubMed: 41500149].
10. Zhang BF, Shang K, Wang PF, Ke C, Han S, Yang K, et al. Comparison of posterior ring fixation with combined anterior and posterior ring fixation for the treatment of lateral compression type 2 pelvic fractures. Int Orthop. 2020;44(6):1187-93. doi: 10.1007/s00264-020-04512-1. [PubMed: 32125463].
11. Halawi MJ. Pelvic ring injuries: Surgical management and long-term outcomes. J Clin Orthop Trauma. 2016;7(1):1-6. doi:10.1016/j.jcot.2015.08.001. [PubMed: 26908968]. [PubMed
Central: PMC4735567].
12. Puchwein P, Sandersjöö G, Lindahl J, Eibinger N. Combined
pelvic ring and acetabular fractures - strategies and sequence of surgery. State of the art. Arch Orthop Trauma Surg. 2024;144(10):4577-86. doi: 10.1007/s00402-024-05555-4. [PubMed: 39311940]. [PubMed Central: PMC11576877].
13. Papathanasopoulos A, Tzioupis C, Giannoudis VP, Roberts C, Giannoudis PV. Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today. Injury. 2010;41(12):1220-7. doi: 10.1016/j.injury.2010.10.001. [PubMed: 21288466].
14. Moussa IS, Sallam AM, Mahmoud AK, Elzaher EH, Nagy AM, Eid AS. Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial. Chin J Traumatol. 2023;26(1):48-59. doi: 10.1016/j.cjtee.2022.06.003. [PubMed: 35750597]. [PubMed Central: PMC9912183].
15. Lodde MF, Katthagen JC, Schopper CO, Zderic I, Richards G, Gueorguiev B, et al. Biomechanical Comparison of Five Fixation Techniques for Unstable Fragility Fractures of the Pelvic Ring. J Clin Med. 2021;10(11):2326. doi: 10.3390/jcm10112326. [PubMed: 34073570]. [PubMed Central: PMC8199358].
16. Galvagno SM, Jr., Nahmias JT, Young DA. Advanced Trauma Life Support(®) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019;37(1):13- 32. doi: 10.1016/j.anclin.2018.09.009. [PubMed: 30711226].
17. Dehkhoda F, Manafi Rasi A, Zandi R, Abedi M, Ebadi SS. Percutaneous Sacroiliac Screw Fixation: A Modified Screw Insertion Method Using Just 2 Fluoroscopy Views. Arch Bone Jt Surg. 2024;12(8):574-9. doi: 10.22038/abjs.2024.77855.3589. [PubMed: 39211565]. [PubMed Central: PMC11353148].
18. Yu YH, Liu CH, Hsu YH, Chou YC, Chen IJ, Wu CC. Matta's criteria may be useful for evaluating and predicting the reduction quality of simultaneous acetabular and ipsilateral pelvic ring fractures. BMC Musculoskelet Disord. 2021;22(1):544. doi: 10.1186/s12891-021-04441-z. [PubMed: 34126982]. [PubMed Central: PMC8204573].
19. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989;71(2):304-6. doi: 10.1302/0301- 620x.71b2.2925751. [PubMed: 2925751].
20. Busso C, Cambursano S, Aprato A, Destefanis C, Gianotti A, Massazza G, et al. Algo-Functional Indexes and Spatiotemporal Parameters of Gait after Sacroiliac Joint Arthrodesis. J Clin Med. 2020;9(9):2860. doi: 10.3390/jcm9092860. [PubMed: 32899638]. [PubMed Central: PMC7563510].
21. Kumaran P, Wier J, Hasegawa I, Patterson JT, Gary JL. Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring? Eur J Orthop Surg Traumatol. 2024;34(6):3103-8. doi: 10.1007/s00590-024-04037-y. [PubMed: 38965132].
22. Zhao Y, Ma Y, Zou D, Sun X, Cheng G, Lian W, et al. Biomechanical comparison of three minimally invasive fixations for unilateral pubic rami fractures. BMC Musculoskelet Disord. 2020;21(1):594. doi: 10.1186/s12891-020- 03604-8. [PubMed: 32887595]. [PubMed Central: PMC7487546].
23. Bucholz RW, Heckman JD, Court-Brown CM, Rockwood CA, Green DP, Editor. Rockwood and Green's fractures in adults. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
24. Yao F, He Y, Qian H, Zhou D, Li Q. Comparison of Biomechanical Characteristics and Pelvic Ring Stability Using Different Fixation Methods to Treat Pubic Symphysis Diastasis: A Finite Element Study. Medicine (Baltimore). 2015;94(49):e2207. doi: 10.1097/md.0000000000002207. [PubMed: 26656353]. [PubMed Central: PMC5008498].
25. MoftakhariHajimirzaeiS,BagherzadehChamM,DolikhaniM, Tabatabaee SM, Ebrahimpour A. The Impact of Vitamin C on Analgesic, Anti-inflammatory, and Hemostatic Outcomes After Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. Arch Bone Jt Surg. 2025;13(11):676-92. doi: 10.22038/abjs.2025.89801.4070. [PubMed: 41509597]. [PubMed Central: PMC12777713].
26. Tripathi S, Nishida N, Soehnlen S, Kelkar A, Kumaran Y, Seki T, et al. Pelvic Ring Fractures: A Biomechanical Comparison of Sacral and Lumbopelvic Fixation Techniques. Bioengineering (Basel). 2024;11(4):348. doi: 10.3390/bioengineering11040348. [PubMed: 38671770]. [PubMed Central: PMC11048038].
27. Petryla G, Uvarovas V, Bobina R, Kurtinaitis J, PuronaitėR, Kvederas G, et al. Comparison of One-Year Functional Outcomes and Quality of Life between Posterior Pelvic Ring Fixation and Combined Anterior-Posterior Pelvic Ring Fixation after Lateral Compression (B2 Type) Pelvic Fracture. Medicina (Kaunas). 2021;57(3):204. doi: 10.3390/medicina57030204. [PubMed: 33652683]. [PubMed Central: PMC7996925].
28. Noorigaravand S, Yahyazadeh H, Amiri S, Zareie B, Sajedi S, Gharanizadeh K. Cephalomedullary Nail Versus Dynamic Hip Screw-plate Fixation: A Comparative Analysis of Ipsilateral Femoral Neck and Shaft Fracture Outcomes. J Res Orthop Sci. 2025;12(1):65-70. doi: 10.32598/JROSJ.12.1.2716.1.
29. Ebrahimpour A, Dolikhani M, Shakibamaram G. Artificial Intelligence (AI) as a Catalyst for Orthopedic Residency Training. Arch Bone Jt Surg. 2025;13(12):773-5. doi: 10.22038/abjs.2025.91837.4159. [PubMed: 41509057]. [PubMed Central: PMC12777714].
2. Stahel PF, Hammerberg EM. History of pelvic fracture management: A review. World J Emerg Surg. 2016;11:18. doi: 10.1186/s13017-016-0075-4. [PubMed: 27148396]. [PubMed Central: PMC4855448].
3. Langford JR, Burgess AR, Liporace FA, Haidukewych GJ. Pelvic fractures: part 1. Evaluation, classification, and resuscitation. J Am Acad Orthop Surg. 2013;21(8):448-57. doi: 10.5435/jaaos-21-08-448. [PubMed: 23908251].
4. Suzuki T, Shindo M, Soma K, Minehara H, Nakamura K, Uchino M, et al. Long-term functional outcome after unstable pelvic
ring fracture. J Trauma. 2007;63(4):884-8. doi: 10.1097/01.ta.0000235888.90489.fc. [PubMed: 18090021].
5. Hermans E, Brouwers L, van Gent T, Biert J, de Jongh MAC, Lansink KWW, et al. Quality of life after pelvic ring fractures: Long-term outcomes. A multicentre study. Injury. 2019;50(6): 1216-22. doi: 10.1016/j.injury.2019.04.002. [PubMed: 31029370].
6. Sabzghabaei A, Dolikhani M, Marivani M, Salehi S, Shakibamaram G. Effectiveness of Acupressure and Reflexology Combined with NSAIDs in Acute Low Back Pain: A Prospective Cohort Study. J Emerg Pract Trauma. 2025;11(1):e92622.
7. Alton TB, Gee AO. Classifications in brief: young and burgess classification of pelvic ring injuries. Clin Orthop Relat Res. 2014;472(8):2338-42. doi: 10.1007/s11999-014-3693-8. [PubMed: 24867452]. [PubMed Central: PMC4079881].
8. Gray A, Chandler H, Sabri O. Pelvic ring injuries: classification and treatment. Orthop Trauma. 2018;32(2):80-90. doi: 10.1016/j.mporth.2018.01.005.
9. Orthopaedic Trauma Research Group. Anterior and posterior fixation versus posterior fixation only of minimally displaced lateral compression type 1 pelvic ring injuries: A multicenter propensity-matched analysis. Injury. 2026;57(2):112964. doi: 10.1016/j.injury.2025.112964. [PubMed: 41500149].
10. Zhang BF, Shang K, Wang PF, Ke C, Han S, Yang K, et al. Comparison of posterior ring fixation with combined anterior and posterior ring fixation for the treatment of lateral compression type 2 pelvic fractures. Int Orthop. 2020;44(6):1187-93. doi: 10.1007/s00264-020-04512-1. [PubMed: 32125463].
11. Halawi MJ. Pelvic ring injuries: Surgical management and long-term outcomes. J Clin Orthop Trauma. 2016;7(1):1-6. doi:10.1016/j.jcot.2015.08.001. [PubMed: 26908968]. [PubMed
Central: PMC4735567].
12. Puchwein P, Sandersjöö G, Lindahl J, Eibinger N. Combined
pelvic ring and acetabular fractures - strategies and sequence of surgery. State of the art. Arch Orthop Trauma Surg. 2024;144(10):4577-86. doi: 10.1007/s00402-024-05555-4. [PubMed: 39311940]. [PubMed Central: PMC11576877].
13. Papathanasopoulos A, Tzioupis C, Giannoudis VP, Roberts C, Giannoudis PV. Biomechanical aspects of pelvic ring reconstruction techniques: Evidence today. Injury. 2010;41(12):1220-7. doi: 10.1016/j.injury.2010.10.001. [PubMed: 21288466].
14. Moussa IS, Sallam AM, Mahmoud AK, Elzaher EH, Nagy AM, Eid AS. Combined anterior and posterior ring fixation versus posterior ring fixation alone in the management of unstable Tile B and C pelvic ring injuries: A randomized controlled trial. Chin J Traumatol. 2023;26(1):48-59. doi: 10.1016/j.cjtee.2022.06.003. [PubMed: 35750597]. [PubMed Central: PMC9912183].
15. Lodde MF, Katthagen JC, Schopper CO, Zderic I, Richards G, Gueorguiev B, et al. Biomechanical Comparison of Five Fixation Techniques for Unstable Fragility Fractures of the Pelvic Ring. J Clin Med. 2021;10(11):2326. doi: 10.3390/jcm10112326. [PubMed: 34073570]. [PubMed Central: PMC8199358].
16. Galvagno SM, Jr., Nahmias JT, Young DA. Advanced Trauma Life Support(®) Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019;37(1):13- 32. doi: 10.1016/j.anclin.2018.09.009. [PubMed: 30711226].
17. Dehkhoda F, Manafi Rasi A, Zandi R, Abedi M, Ebadi SS. Percutaneous Sacroiliac Screw Fixation: A Modified Screw Insertion Method Using Just 2 Fluoroscopy Views. Arch Bone Jt Surg. 2024;12(8):574-9. doi: 10.22038/abjs.2024.77855.3589. [PubMed: 39211565]. [PubMed Central: PMC11353148].
18. Yu YH, Liu CH, Hsu YH, Chou YC, Chen IJ, Wu CC. Matta's criteria may be useful for evaluating and predicting the reduction quality of simultaneous acetabular and ipsilateral pelvic ring fractures. BMC Musculoskelet Disord. 2021;22(1):544. doi: 10.1186/s12891-021-04441-z. [PubMed: 34126982]. [PubMed Central: PMC8204573].
19. Majeed SA. Grading the outcome of pelvic fractures. J Bone Joint Surg Br. 1989;71(2):304-6. doi: 10.1302/0301- 620x.71b2.2925751. [PubMed: 2925751].
20. Busso C, Cambursano S, Aprato A, Destefanis C, Gianotti A, Massazza G, et al. Algo-Functional Indexes and Spatiotemporal Parameters of Gait after Sacroiliac Joint Arthrodesis. J Clin Med. 2020;9(9):2860. doi: 10.3390/jcm9092860. [PubMed: 32899638]. [PubMed Central: PMC7563510].
21. Kumaran P, Wier J, Hasegawa I, Patterson JT, Gary JL. Stability before and after percutaneous anterior medullary fixation of lateral compression 1 and 2 pelvic ring disruptions: Should surgeons prioritize the anterior ring? Eur J Orthop Surg Traumatol. 2024;34(6):3103-8. doi: 10.1007/s00590-024-04037-y. [PubMed: 38965132].
22. Zhao Y, Ma Y, Zou D, Sun X, Cheng G, Lian W, et al. Biomechanical comparison of three minimally invasive fixations for unilateral pubic rami fractures. BMC Musculoskelet Disord. 2020;21(1):594. doi: 10.1186/s12891-020- 03604-8. [PubMed: 32887595]. [PubMed Central: PMC7487546].
23. Bucholz RW, Heckman JD, Court-Brown CM, Rockwood CA, Green DP, Editor. Rockwood and Green's fractures in adults. Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
24. Yao F, He Y, Qian H, Zhou D, Li Q. Comparison of Biomechanical Characteristics and Pelvic Ring Stability Using Different Fixation Methods to Treat Pubic Symphysis Diastasis: A Finite Element Study. Medicine (Baltimore). 2015;94(49):e2207. doi: 10.1097/md.0000000000002207. [PubMed: 26656353]. [PubMed Central: PMC5008498].
25. MoftakhariHajimirzaeiS,BagherzadehChamM,DolikhaniM, Tabatabaee SM, Ebrahimpour A. The Impact of Vitamin C on Analgesic, Anti-inflammatory, and Hemostatic Outcomes After Total Hip and Knee Arthroplasty: A Systematic Review and Meta-Analysis. Arch Bone Jt Surg. 2025;13(11):676-92. doi: 10.22038/abjs.2025.89801.4070. [PubMed: 41509597]. [PubMed Central: PMC12777713].
26. Tripathi S, Nishida N, Soehnlen S, Kelkar A, Kumaran Y, Seki T, et al. Pelvic Ring Fractures: A Biomechanical Comparison of Sacral and Lumbopelvic Fixation Techniques. Bioengineering (Basel). 2024;11(4):348. doi: 10.3390/bioengineering11040348. [PubMed: 38671770]. [PubMed Central: PMC11048038].
27. Petryla G, Uvarovas V, Bobina R, Kurtinaitis J, PuronaitėR, Kvederas G, et al. Comparison of One-Year Functional Outcomes and Quality of Life between Posterior Pelvic Ring Fixation and Combined Anterior-Posterior Pelvic Ring Fixation after Lateral Compression (B2 Type) Pelvic Fracture. Medicina (Kaunas). 2021;57(3):204. doi: 10.3390/medicina57030204. [PubMed: 33652683]. [PubMed Central: PMC7996925].
28. Noorigaravand S, Yahyazadeh H, Amiri S, Zareie B, Sajedi S, Gharanizadeh K. Cephalomedullary Nail Versus Dynamic Hip Screw-plate Fixation: A Comparative Analysis of Ipsilateral Femoral Neck and Shaft Fracture Outcomes. J Res Orthop Sci. 2025;12(1):65-70. doi: 10.32598/JROSJ.12.1.2716.1.
29. Ebrahimpour A, Dolikhani M, Shakibamaram G. Artificial Intelligence (AI) as a Catalyst for Orthopedic Residency Training. Arch Bone Jt Surg. 2025;13(12):773-5. doi: 10.22038/abjs.2025.91837.4159. [PubMed: 41509057]. [PubMed Central: PMC12777714].
| Files | ||
| Issue | Vol 12 No 4 (2026) | |
| Section | Research Articles | |
| Keywords | ||
| Fracture Fixation Treatment Outcome Retrospective Studies Pelvic Bones | ||
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How to Cite
1.
Zarei R, Manafi Rasi A, Baroutkoub M, Ghasemi Nik M, Vaziri SSA, Pourmojarab A. Anterior-First Approach to Unstable Pelvic Ring Fracture Fixation: Functional Outcomes and the Importance of Anatomic Reduction. J Orthop Spine Trauma. 2026;12(4):179-84.
