{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,6]],"date-time":"2026-11-06T05:35:57Z","timestamp":1793943357886,"version":"4.8.0"},"reference-count":38,"publisher":"MDPI AG","issue":"11","license":[{"start":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T00:00:00Z","timestamp":1762387200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Medicina"],"abstract":"<jats:p>Background and Objectives: The objective of this study was to construct and validate a novel, clinically practical risk-stratification score, PEARL (Pelvic and Acetabular Adverse-event Risk Level), integrating established preoperative and intraoperative predictors, to accurately estimate the likelihood of major postoperative complications in patients undergoing open reduction and internal fixation for pelvic and\/or acetabular fractures. Materials and Methods: We retrospectively analyzed 200 adult patients treated surgically between January 2019 and January 2024 at two tertiary trauma centers. Demographic, injury-related, and perioperative data were collected. Major complications were defined as postoperative adverse events occurring within 30 days after surgery or during hospitalization, whereas delayed union and nonunion were evaluated as secondary long-term outcomes. Multivariable logistic regression identified independent risk factors, which were weighted to create the PEARL score (range: 0\u20136). Predictive performance was assessed using ROC (Receiver Operating Characteristic) analysis. We randomly split the sample into a 70% derivation and a 30% validation cohort. A multivariable LASSO-penalized logistic model identified independent predictors, which were weighted to construct the PEARL score. Discrimination (AUC) and calibration (Brier score, calibration curve) were assessed. Results: Major complications occurred in 29% of patients. Four independent predictors were identified: age \u2265 60 years, BMI \u2265 30 kg\/m2, severe associated injury, and operative time \u2265 180 min. The score showed good discrimination (derivation AUC = 0.82) and acceptable external validation (validation AUC = 0.78), with Brier scores of 0.19 and 0.21, respectively. PEARL demonstrated good discriminative ability, AUC (Area Under the Curve) = 0.82. Complication rates increased across risk strata: low (7.5%), moderate (30%), and high risk (62%). Conclusions: The PEARL score is a simple, reliable tool to stratify the risk of major postoperative complications after pelvic and acetabular fracture surgery. Early identification of high-risk patients may facilitate targeted preventive strategies and improve outcomes. Further multicenter prospective validation is warranted.<\/jats:p>","DOI":"10.3390\/medicina61111995","type":"journal-article","created":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T17:51:43Z","timestamp":1762451503000},"page":"1995","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["The PEARL Score for Predicting Postoperative Complication Risk in Patients with Pelvic and Acetabular Fractures: Development of a Novel Comprehensive Risk Scoring System"],"prefix":"10.3390","volume":"61","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6033-0795","authenticated-orcid":false,"given":"Fatih Emre","family":"Topsakal","sequence":"first","affiliation":[{"name":"Department of Orthopedics and Traumatology, Erzurum City Hospital, Erzurum 25240, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3709-558X","authenticated-orcid":false,"given":"Ekrem","family":"\u00d6zdemir","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Traumatology, Erzurum City Hospital, Erzurum 25240, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nasuhi","family":"Altay","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Traumatology, Erzurum City Hospital, Erzurum 25240, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Esra","family":"Demirel","sequence":"additional","affiliation":[{"name":"Department of Orthopedics and Traumatology, Erzurum City Hospital, Erzurum 25240, T\u00fcrkiye"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,11,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"744","DOI":"10.5312\/wjo.v13.i8.744","article-title":"Epidemiology of pelvic and acetabular fractures across 12-mo at a level-1 trauma centre","volume":"13","author":"Cuthbert","year":"2022","journal-title":"World J. Orthop."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1007\/s00402-024-05726-3","article-title":"Increased risk of adverse events following the treatment of associated versus elementary acetabular fractures: A matched analysis of short-term complications","volume":"145","author":"Cole","year":"2024","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"e001820","DOI":"10.1136\/tsaco-2025-001820","article-title":"Managing severe (and open) pelvic disruption","volume":"10","author":"Eastman","year":"2025","journal-title":"Trauma Surg. Acute Care Open"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e93","DOI":"10.1097\/TA.0000000000003331","article-title":"Pelvic fracture-related hypotension: A review of contemporary adjuncts for hemorrhage control","volume":"91","author":"DuBose","year":"2021","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"877","DOI":"10.1007\/s00590-022-03215-0","article-title":"Complications after surgical treatment of pelvic fractures: A five-year follow-up of 194 patients","volume":"33","author":"Lundin","year":"2023","journal-title":"Eur. J. Orthop. Surg. Traumatol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"111843","DOI":"10.1016\/j.injury.2024.111843","article-title":"Orthopedic pelvic and extremity injuries increase overall hospital length of stay but not in-hospital complications or mortality in trauma ICU patients: Orthopedic Injuries in Trauma ICU Patients","volume":"55","author":"Anil","year":"2024","journal-title":"Injury"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Inagaki, N., Tanaka, T., Udaka, J., Akiyama, S., Matsuoka, T., and Saito, M. (2022). Distribution of hounsfield unit values in the pelvic bones: A comparison between young men and women with traumatic fractures and older men and women with fragility fractures: A retrospective cohort study. BMC Musculoskelet. Disord., 23.","DOI":"10.1186\/s12891-022-05263-3"},{"key":"ref_8","first-page":"S70","article-title":"A comprehensive basic understanding of pelvis and acetabular fractures after high-energy trauma with associated injuries: Narrative review of targeted literature","volume":"70","author":"Atif","year":"2020","journal-title":"J. Pak. Med. Assoc."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"2773","DOI":"10.1007\/s00590-024-03985-9","article-title":"Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges","volume":"34","author":"Hasegawa","year":"2024","journal-title":"Eur. J. Orthop. Surg. Traumatol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"109","DOI":"10.1007\/s00113-022-01256-y","article-title":"Management of complications of acetabular fractures","volume":"126","author":"Orth","year":"2023","journal-title":"Unfallchirurgie"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"111773","DOI":"10.1016\/j.injury.2024.111773","article-title":"Pelvic ring fracture in the older adults after minor pelvic trauma\u2014Is it an innocent injury?","volume":"55","author":"Jammal","year":"2024","journal-title":"Injury"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"709","DOI":"10.1007\/s00068-022-02118-3","article-title":"The relation between surgical approaches for pelvic ring and acetabular fractures and postoperative complications: A systematic review","volume":"49","author":"Timmer","year":"2023","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1307","DOI":"10.1097\/TA.0b013e31828c3f59","article-title":"The impact of major operative fractures in blunt abdominal injury","volume":"74","author":"Nahm","year":"2013","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2172","DOI":"10.1016\/j.ajem.2018.03.058","article-title":"Displaced anterior pelvic fracture on initial pelvic radiography predicts massive hemorrhage","volume":"36","author":"Tanizaki","year":"2018","journal-title":"Am. J. Emerg. Med."},{"key":"ref_15","first-page":"875","article-title":"Prevalence of pelvic fractures, associated injuries, and mortality: The United Kingdom perspective","volume":"63","author":"Giannoudis","year":"2007","journal-title":"J. Trauma"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Zikrin, E., Hilali, A.E.K., Shacham, D., Frenkel, R., Abel, O., Abed, M.A., Abu-Ajaj, A., Velikiy, N., Freud, T., and Press, Y. (2025). FI-Lab predicts all-cause mortality, but not successful rehabilitation, among patients aged 65 and older after hip or pelvic fracture. Front. Med., 12.","DOI":"10.3389\/fmed.2025.1627026"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e126","DOI":"10.1097\/BOT.0000000000002769","article-title":"Early Acetabular Fracture Repair Through an Anterior Approach Is Associated with Increased Blood Loss","volume":"38","author":"Ambrose","year":"2024","journal-title":"J. Orthop. Trauma"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e28","DOI":"10.1097\/BOT.0000000000002684","article-title":"Early Treatment of Acetabular Fractures Using an Anterior Approach Increases Blood Loss but not Packed Red Blood Cell Transfusion","volume":"38","author":"Mullis","year":"2024","journal-title":"J. Orthop. Trauma"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"269","DOI":"10.13107\/jocr.2025.v15.i06.5734","article-title":"Long-term Patient-reported Functional Outcome after Pelvic Ring Injuries: Analysis using Two Different Types of Outcome Scores","volume":"15","author":"Aggarwal","year":"2025","journal-title":"J. Orthop. Case Rep."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"60","DOI":"10.1186\/s13018-015-0202-z","article-title":"Incidence and clinical relevance of heterotopic ossification after internal fixation of acetabular fractures: Retrospective cohort and case control study","volume":"10","author":"Baschera","year":"2015","journal-title":"J. Orthop. Surg. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"839","DOI":"10.1302\/0301-620X.107B8.BJJ-2024-1704.R2","article-title":"Fracture-related infection after internal fixation of pelvic and acetabular fractures: A population-based analysis of risk factors and economic costs","volume":"107-B","author":"Axelrod","year":"2025","journal-title":"Bone Jt. J."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Cheng, P., Cheng, B., Wu, L., Zhang, H., and Yang, Y. (2024). Association of thromboelastogram hypercoagulability with postoperative deep venous thrombosis of the lower extremity in patients with femur and pelvic fractures: A cohort study. BMC Musculoskelet. Disord., 25.","DOI":"10.1186\/s12891-024-08135-0"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1186\/s13037-024-00401-3","article-title":"The clinical relevance of fixation failure after pubic symphysis plating for anterior pelvic ring injuries: An observational cohort study with long-term follow-up","volume":"18","author":"Notov","year":"2024","journal-title":"Patient Saf. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1710","DOI":"10.1097\/CORR.0000000000003030","article-title":"Are Current Survival Prediction Tools Useful When Treating Subsequent Skeletal-related Events From Bone Metastases?","volume":"482","author":"Pan","year":"2024","journal-title":"Clin. Orthop. Relat. Res."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1007\/s00068-025-02861-3","article-title":"Influencing factors for fragility fractures of the pelvis on length of stay and complication rate","volume":"51","author":"Termer","year":"2025","journal-title":"Eur. J. Trauma Emerg. Surg."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"7181","DOI":"10.1097\/JS9.0000000000002776","article-title":"Health-related quality-of-life, complications, and mortality rates after geriatric acetabular fracture, non-operative compared to operative management a systematic review and meta-analysis","volume":"111","author":"Khalifa","year":"2025","journal-title":"Int. J. Surg."},{"key":"ref_27","first-page":"e21.00058","article-title":"Is Obesity Associated With an Increased Risk of Complications After Surgical Management of Acetabulum and Pelvis Fractures? A Systematic Review","volume":"5","author":"Mittwede","year":"2021","journal-title":"J. Am. Acad. Orthop. Surg. Glob. Res. Rev."},{"key":"ref_28","first-page":"22104917211006890","article-title":"Risk factors for complications following pelvic ring and acetabular fractures: A retrospective analysis at an urban level 1 trauma center","volume":"28","author":"Henstenburg","year":"2021","journal-title":"J. Orthop. Trauma Rehabil."},{"key":"ref_29","first-page":"75","article-title":"Operative management of acetabulum fractures in the obese patient: Challenges and solutions","volume":"9","author":"Sardesai","year":"2017","journal-title":"Orthop. Res. Rev."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"W\u00f3jcicki, R., Pielak, T., Walus, P.M., Jaworski, \u0141., Ma\u0142kowski, B., Jasiewicz, P., Gagat, M., \u0141apaj, \u0141., and Zabrzy\u0144ski, J. (2024). The Association of Acetabulum Fracture and Mechanism of Injury with BMI, Days Spent in Hospital, Blood Loss, and Surgery Time: A Retrospective Analysis of 67 Patients. Medicina, 60.","DOI":"10.3390\/medicina60030455"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"921","DOI":"10.1097\/TA.0000000000004547","article-title":"Longer time to surgery for pelvic ring injuries is associated with increased systemic complications","volume":"98","author":"Patel","year":"2023","journal-title":"J. Trauma Acute Care Surg."},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Regenbogen, S., Leister, I., Trulson, A., Wenzel, L., Friederichs, J., Stuby, F.M., H\u00f6ch, A., Beck, M., and Working Group on Pelvic Fractures of the German Trauma Society (2023). Early Stabilization Does Not Increase Complication Rates in Acetabular Fractures of the Elderly: A Retrospective Analysis from the German Pelvis Registry. J. Clin. Med., 12.","DOI":"10.3390\/jcm12227043"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"112208","DOI":"10.1016\/j.injury.2025.112208","article-title":"Intraoperative complications in acetabular fracture management using the Stoppa approach: A retrospective cohort study","volume":"56","author":"Kumar","year":"2025","journal-title":"Injury"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"983","DOI":"10.1016\/j.jcot.2020.09.017","article-title":"A systematic review of combined pelvic and acetabular injuries","volume":"11","author":"Veerappa","year":"2020","journal-title":"J. Clin. Orthop. Trauma"},{"key":"ref_35","doi-asserted-by":"crossref","unstructured":"van Boekel, A.M., van der Meijden, S.L., Arbous, S.M., Nelissen, R., Veldkamp, K.E., Nieswaag, E.B., Jochems, K.F.T., Holtz, J., Veenstra, A.V.I., and Reijman, J. (2024). Systematic evaluation of machine learning models for postoperative surgical site infection prediction. PLoS ONE, 19.","DOI":"10.1371\/journal.pone.0312968"},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Kuwahara, Y., Takemoto, G., Mitsuya, S., and Yamauchi, K.I. (2024). The Long-Term Clinical and Radiographic Outcomes of Cerclage Cable Fixation for Displaced Acetabular Fractures Using a Posterior Approach: A Retrospective Cohort Study. Medicina, 60.","DOI":"10.3390\/medicina60101659"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1093\/ckj\/sfaa188","article-title":"External validation of prognostic models: What, why, how, when and where?","volume":"14","author":"Ramspek","year":"2021","journal-title":"Clin. Kidney J."},{"key":"ref_38","doi-asserted-by":"crossref","unstructured":"Chuang, C.H., Chuang, H.C., Wang, J.H., Yang, J.M., Wu, P.T., Hu, M.H., Su, H.L., and Lee, P.Y. (2024). Anatomical Posterior Acetabular Plate Versus Conventional Reconstruction Plates for Acetabular Posterior Wall Fractures: A Comparative Study. J. Clin. Med., 13.","DOI":"10.3390\/jcm13175341"}],"container-title":["Medicina"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/11\/1995\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,11,6]],"date-time":"2025-11-06T18:22:34Z","timestamp":1762453354000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1648-9144\/61\/11\/1995"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11,6]]},"references-count":38,"journal-issue":{"issue":"11","published-online":{"date-parts":[[2025,11]]}},"alternative-id":["medicina61111995"],"URL":"https:\/\/doi.org\/10.3390\/medicina61111995","relation":{},"ISSN":["1648-9144"],"issn-type":[{"value":"1648-9144","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,11,6]]}}}