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This is an interesting and clinically relevant study in which the authors have evaluated the utility of obturator oblique radiographic views in assessing the relationship between screw trajectories and the posterior cortical surface of the acetabulum. After thorough consideration of the reviewers’ comments and an overall assessment of the manuscript’s quality, the editorial decision is: MAJOR REVISION

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Richa Gupta

Academic Editor

PLOS One

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Additional Editor Comments:

EDITORIAL DECISION

This is an interesting and clinically relevant study in which the authors have evaluated the utility of obturator oblique radiographic views in assessing the relationship between screw trajectories and the posterior cortical surface of the acetabulum. After thorough consideration of the reviewers’ comments and an overall assessment of the manuscript’s quality, the editorial decision is: MAJOR REVISION

Please find attached reviewer’s comments:

REVIEWER 1 – MAJOR REVISION

The manuscript investigates whether posterior column screws penetrate the posterior cortical surface of the acetabulum when assessed using obturator oblique radiographs. The topic is clinically significant, as it directly relates to the intraoperative safety of acetabular fracture fixation.

1.The method used to measure the α angle should be described in more detail and clearly illustrated in a figure. It is not specified which anatomical reference points were used to define the sagittal plane (e.g., was it based on the line connecting the symphysis pubis and the sacral promontory?).

2. In the cadaveric study, the pelvic positioning and reproducibility of fluoroscopic imaging should be clarified. Cadaveric specimens may differ from living patients in terms of anatomical posture, which could affect measurement accuracy.

3. If multiple observers performed the measurements, interobserver reliability should be reported.

4. Demographic data of the CT cohort appear incomplete; the sex distribution (number of male and female participants) of the 50 healthy subjects should be specified.

5. The study appears to have been conducted in a single ethnic population, which may limit the generalizability of the α angle. This limitation should be acknowledged and discussed.

6. In the cadaveric analysis, the authors report that the Kirschner wire appeared intraosseous at 45° but breached the posterior cortex at 60°. It should be clarified whether this finding was consistent across all five specimens or observed only in selected cases, as this affects the generalizability of the results.

7. Beyond the mean and standard deviation, no additional statistical data are provided. It is recommended to include the minimum and maximum values of the measured α angles to better reflect the variability of the dataset.

8. The authors suggest that preoperative measurement of the α angle may guide intraoperative imaging. However, in fracture cases, the posterior column or wall anatomy may be distorted, making calculation on the injured side unreliable.Do the authors recommend measuring the α angle from the contralateral (uninjured) side?

If so, was any right–left difference assessed (e.g., bilateral comparison within the same individuals or supported by literature data)?

REVIEWER 2 – MINOR REVISION

Clarify whether the study included both male and female specimens, as pelvic morphology varies.

Important methodological details are included, but the narrative becomes overly technical. Consider simplifying the description of the imaging setup and experimental steps.

The rationale for measuring CT angles (α) and how this measurement informs the cadaveric imaging is not clearly explained.

It is unclear whether α refers to an individualized or an average angle - cadaveric work uses 60°, but the sample average is 60.2°, suggesting generalization. Clarify whether each pelvis was imaged at its own α or at a standardized angle.

The term posterior iliac line is newly defined here; however, its anatomical and clinical significance needs clearer justification.

The results describe radiographic relationships but do not clearly quantify the method’s accuracy or reliability. Author/s may add the number of cases in which screw placement assessment differed between 45° and α/60° views and whether observer agreement was assessed.

Author/s may add how the 45° and 60° views complement each other and what the clinical implication is (i.e., improved intraoperative safety).

Author/s may add limitations such as small cadaver sample sizes, the absence of soft tissue, standardized wire trajectories, and variability in pelvic morphology, which may affect generalizability to clinical practice.

Author/s may add future studies with larger samples, bilateral evaluation, and clinical validation to confirm the reliability and generalizability of this radiographic assessment technique.

REVIEWER 3 – ACCEPT

Interesting study of integrating x rays in oblique views for visualizing posterior column screws. Hope this becomes useful in clinical practice. The analysis is well done and the article is well written.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer’s Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

Reviewer #1: The manuscript investigates whether posterior column screws penetrate the posterior cortical surface of the acetabulum when assessed using obturator oblique radiographs. The topic is clinically significant, as it directly relates to the intraoperative safety of acetabular fracture fixation.

1.The method used to measure the α angle should be described in more detail and clearly illustrated in a figure. It is not specified which anatomical reference points were used to define the sagittal plane (e.g., was it based on the line connecting the symphysis pubis and the sacral promontory?).

2. In the cadaveric study, the pelvic positioning and reproducibility of fluoroscopic imaging should be clarified. Cadaveric specimens may differ from living patients in terms of anatomical posture, which could affect measurement accuracy.

3. If multiple observers performed the measurements, interobserver reliability should be reported.

4. Demographic data of the CT cohort appear incomplete; the sex distribution (number of male and female participants) of the 50 healthy subjects should be specified.

5. The study appears to have been conducted in a single ethnic population, which may limit the generalizability of the α angle. This limitation should be acknowledged and discussed.

6. In the cadaveric analysis, the authors report that the Kirschner wire appeared intraosseous at 45° but breached the posterior cortex at 60°. It should be clarified whether this finding was consistent across all five specimens or observed only in selected cases, as this affects the generalizability of the results.

7. Beyond the mean and standard deviation, no additional statistical data are provided. It is recommended to include the minimum and maximum values of the measured α angles to better reflect the variability of the dataset.

8. The authors suggest that preoperative measurement of the α angle may guide intraoperative imaging. However, in fracture cases, the posterior column or wall anatomy may be distorted, making calculation on the injured side unreliable.Do the authors recommend measuring the α angle from the contralateral (uninjured) side?

If so, was any right–left difference assessed (e.g., bilateral comparison within the same individuals or supported by literature data)?

Reviewer #2: Clarify whether the study included both male and female specimens, as pelvic morphology varies.

Important methodological details are included, but the narrative becomes overly technical. Consider simplifying the description of the imaging setup and experimental steps.

The rationale for measuring CT angles (α) and how this measurement informs the cadaveric imaging is not clearly explained.

It is unclear whether α refers to an individualized or an average angle - cadaveric work uses 60°, but the sample average is 60.2°, suggesting generalization. Clarify whether each pelvis was imaged at its own α or at a standardized angle.

The term posterior iliac line is newly defined here; however, its anatomical and clinical significance needs clearer justification.

The results describe radiographic relationships but do not clearly quantify the method’s accuracy or reliability. Author/s may add the number of cases in which screw placement assessment differed between 45° and α/60° views and whether observer agreement was assessed.

Author/s may add how the 45° and 60° views complement each other and what the clinical implication is (i.e., improved intraoperative safety).

Author/s may add limitations such as small cadaver sample sizes, the absence of soft tissue, standardized wire trajectories, and variability in pelvic morphology, which may affect generalizability to clinical practice.

Author/s may add future studies with larger samples, bilateral evaluation, and clinical validation to confirm the reliability and generalizability of this radiographic assessment technique.

Reviewer #3: Interesting study of integrating x rays in oblique views for visualizing posterior column screws. Hope this becomes useful in clinical practice. The analysis is well done and the article is well written.

**********

what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy..-->

Reviewer #1: Yes: erdem ateşerdem ateşerdem ateşerdem ateş

Reviewer #2: Yes: Dr Swati GoyalDr Swati GoyalDr Swati GoyalDr Swati Goyal

Reviewer #3: No

**********

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Utilization of the posterior iliac line for visualizing posterior column screws in obturator oblique view

PONE-D-25-26318R1

Dear Dr. Feng,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Mohmed Isaqali Karobari, BDS, MScD.Endo, Ph.D. Endo, FDS, FPFA, FICD, MFDS

Academic Editor

PLOS One

Additional Editor Comments (optional):

Dear Authors,

The authors have addressed all the reviewers' comments and suggestions, and the manuscript has undergone significant improvement. The manuscript can be accepted for publication in its current form. I would like to congratulate the authors and wish them all the very best in their future endeavours.

Best regards and keep well

Reviewers' comments:

Reviewer’s Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.-->

Reviewer #1: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #3: Yes

**********

Reviewer #1: Dear Editor,

I have carefully reviewed the revised version of the manuscript. The authors have adequately addressed the previously raised comments and made the necessary improvements.

In its current form, the manuscript is suitable for publication.

Kind regards,

Reviewer #3: Thank you for the scientific article, The Authors have addressed the clarifications from the reviewers adequately.

**********

what does this mean?). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our For information about this choice, including consent withdrawal, please see our Privacy Policy..-->

Reviewer #1: Yes: Erdem AteşErdem AteşErdem AteşErdem Ateş

Reviewer #3: Yes: Santosh PV RaiSantosh PV RaiSantosh PV RaiSantosh PV Rai

**********