Tehran University of Medical Sciences Journal of Orthopedic and Spine Trauma 2538-2330 12 4 2026 09 23 179 84 Reza Zarei Department of Orthopedic Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Alireza Manafi Rasi Professor, Department of Orthopedic Surgery and Traumatology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mojtaba Baroutkoub Assistant Professor, Department of Orthopedic Surgery and Traumatology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Mehdi Ghasemi Nik Resident, Department of Orthopedic Surgery and Traumatology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Seyed Shahab Aldin Vaziri Researcher, Department of Orthopedic Surgery and Traumatology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran Ali Pourmojarab Assistant Professor, Department of Orthopedic Surgery and Traumatology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran 2026 02 26 2026 08 10 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. https://jost.tums.ac.ir/index.php/jost/article/view/781 https://jost.tums.ac.ir/index.php/jost/article/download/781/486