Surgeries, Volume 7, Issue 1 (March 2026) – 41 articles

Background: Immediate prepectoral implant-based breast reconstruction (IBR) following skin-reducing mastectomy (SRM) preserves the pectoralis major muscle, improving recovery and aesthetics. A dual-layer technique combining porcine-derived acellular dermal matrix (ADM) with an inferior autologous dermal sling may enhance implant support, vascularization, and lower-pole stability, particularly in patients with macromastia or ptosis. Methods: This retrospective single-center study included 20 patients (24 breasts) who underwent SRM with immediate prepectoral IBR using the dual-layer technique between January 2023 and May 2025. Demographic, oncologic, and perioperative data were collected prospectively. Complications were classified by severity, and patient-reported outcomes were evaluated using the BREAST-Q scale preoperatively and at 1, 3, 6, and 12 months postoperatively. Statistical analysis included paired t-tests, Shapiro–Wilk tests, and effect size estimation (Cohen’s dz). Results: Mean age was 42 ± 6.3 years and BMI 26.1 ± 3.2 kg/m². Mean mastectomy specimen weight was 432.5 ± 120.8 g, and implant volume 375 ± 60 cc. No reconstruction failures or infections occurred. Early complications were reported in 20.8% of breasts, including superficial nipple–areola complex epidermolysis (8.3%), seroma (4.2%), and hematoma (4.2%), all managed conservatively. At 12 months, BREAST-Q scores improved significantly: satisfaction with breasts increased from 63 ± 8 to 89 ± 11 (p < 0.001); psychosocial well-being from 60 ± 10 to 81 ± 11 (p < 0.001); and physical well-being from 62 ± 7 to 82 ± 10 (p < 0.001). Conclusions: Dual-layer prepectoral reconstruction using porcine ADM and autologous dermal sling is safe, provides durable implant stability, and significantly improves patient satisfaction and quality of life following SRM. Full article

Background/Objectives: The aim of this study is to evaluate whether preoperative intra-articular corticosteroid injections (CSIs) are associated with an increased risk of reoperation following matrix-associated or autologous chondrocyte implantation (MACI/ACI). Secondary aims included comparing reoperation-free survival, patient-reported outcomes (PROMs), and patient acceptable symptom state (PASS) achievement. Methods: A retrospective cohort study was conducted on adults undergoing primary MACI/ACI between 2011 and 2023 at a single academic institution. Patients with documented CSI status and ≥2 years of follow-up were included. Exclusion criteria were prior MACI/ACI, osteochondral allograft transplantation, multi-ligament reconstruction, or inadequate follow-up. Propensity score matching (2:1, no steroid/steroid) based on age, sex, BMI, laterality, procedure type, and prior surgery yielded 138 matched patients (92 no steroid, 48 steroid). The primary outcome was ipsilateral reoperation, analyzed as a binary outcome, with Kaplan–Meier reoperation-free survival and restricted mean survival time (RMST). PROMs and PASS achievement were also assessed. Statistical significance was set at p < 0.05. Results: Baseline characteristics and follow-up (6.55 ± 3.74 vs. 6.73 ± 3.99 years; p = 0.80) were similar. Graft failure rates were identical (4.3% each; p = 1.00). Reoperation occurred in 21.7% of patients without CSI and 23.9% with CSI (p = 0.83). CSI was not associated with reoperation (adjusted OR 2.28; 95% CI 0.54–9.95; p = 0.26). No significant difference in reoperation-free survival or PROMs was observed. Conclusions: Preoperative intra-articular corticosteroid injections were not associated with increased reoperation risk, inferior reoperation-free survival, or worse functional outcomes following MACI/ACI. Full article

Background: Subchondral cysts at the ulnar corner of the lunate are frequently encountered in patients with distal radius fractures. We hypothesized that the presence of these lunate subchondral cysts may be associatedwith decreased cortical bone density due to limited load translation. Consequently, this could lead to lunate fossa collapse and increased ulnar variance following fracture fixation. Methods: A retrospective analysis was performed on 176 patients who underwent open reduction and internal fixation using the Double-tiered Subchondral Support (DSS) procedure between May 2014 and June 2017. Twenty-eight patients identified with lunate subchondral cysts on preoperative CT scans were selected as the study group. A control group of 28 patients without cysts was selected using matched-pair analysis, controlling for gender, age, fracture classification, and follow-up period. Results: The mean change (delta) in ulnar variance was 0.191 mm in the cyst group, which was less than the 0.233 mm observed in the control group; however, this difference was not statistically significant (p = 0.557). Regarding ulnolunate distance, the cyst group showed a mean change (delta) of 0.991 mm, while the control group showed a change of 1.123 mm. This difference was also not statistically significant (p = 0.681). Conclusions: Although it was hypothesized that lunate subchondral cysts might limit load translation to the radius and compromise cortical bone density—potentially affecting fracture healing and the maintenance of reduction—our statistical analysis did not support this hypothesis. The presence of lunate subchondral cysts did not significantly increase the risk of lunate fossa collapse or ulnar variance progression compared to the control group. Full article

Background: Oesophageal cancer is a diagnosis carrying significant morbidity and mortality. Gold standard treatment is resection; however, this requires a complex operation. Despite progression to minimally invasive approaches, post-operative pain is a significant issue. Methadone is emerging as an additive intraoperative analgesic across specialities, with a single intra-operative dose seen to improve post-operative pain and reduce post-operative opioid use. This is promising for oesophagectomy patients, where pain is a significant issue; however, it remains poorly characterised. Aim: This paper aimed to assess the literature surrounding intra-operative methadone (IOM) in oesophagectomy, then broadly consider related evidence to consider how it may be applicable to patients undergoing oesophagectomy for oesophageal cancer. Methods: The search assessed existing evidence for efficacy and safety of IOM for patients undergoing oesophagectomy for oesophageal cancer. Of 1856 studies, only one fit inclusion criteria. Following this, the search was broadened to assess IOM use in related surgical contexts, deriving applicability to oesophagectomy. Results: There is very limited evidence for IOM use in oesophagectomy. Several papers explore its use in other intraabdominal and intrathoracic procedures. This evidence may be leveraged for oesophagectomy patients. There remain several safety concerns, most notably respiratory and cardiac risks. Further, several knowledge gaps remain. Conclusions: Overall, IOM represents a promising analgesic option. Unfortunately, current evidence is limited, predominantly derived from non-generalisable studies. This paper provides an up-to-date review of evidence, highlighting clear gaps. It is clear oesophagectomy patients are a vulnerable group who would benefit from improved pain and post-operative quality of life. As such, further focused research should be done to evaluate the role of IOM in oesophagectomy for oesophageal cancer. Full article

Prehabilitation represents a proactive, multimodal strategy to enhance patient resilience prior to plastic and reconstructive surgery, building on the success of Enhanced Recovery After Surgery (ERAS) pathways. This narrative review synthesizes the conceptual framework of prehabilitation—encompassing exercise training, nutritional optimization, risk factor modification, and psychological preparation—and examines its current application within plastic surgery. While evidence from selected randomized trials and systematic reviews in orthopedic and colorectal surgery suggests potential reductions in complications (often in the range of 20–40% in higher-risk populations), the results remain heterogeneous and context-dependent. To date, there have been no randomized controlled trials on plastic surgery, despite unique patient populations facing modifiable risks, including smoking, obesity, and malnutrition. This review proposes a risk-stratified prehabilitation framework tailored to key plastic surgery domains: breast reconstruction, head-and-neck microsurgery, post-bariatric body contouring, and major esthetic procedures. Practical implementation strategies address timelines, multidisciplinary teams, and digital delivery tools. By positioning prehabilitation as a structured preoperative component within ERAS pathways, plastic surgeons may support better perioperative readiness, potentially influencing complications, recovery, and patient experience. This review proposes conceptual frameworks intended to guide structured evaluation and future clinical research in plastic surgery. Full article

Background/Objectives: Intraoperative neuromonitoring (IONM) has improved safety in thyroid and parathyroid surgery, yet intermittent IONM (I-IONM) may miss traction injuries developing between stimulations. We evaluated the feasibility and clinical utility of a trend-based intermittent monitoring mode (NIM Vital NerveTrend®) that records closely spaced stimulations and plots amplitude and latency over time. Methods: We conducted a prospective observational study at a high-volume endocrine surgery unit (January–September 2025). Forty-four consecutive patients undergoing thyroidectomy and/or parathyroidectomy with NerveTrend® were enrolled. Electromyography (EMG) responses were categorized as Green (amplitude > 50% of baseline and latency < 110%), Yellow (amplitude < 50% or latency > 110%), Red (amplitude < 50% and latency > 110%), and Loss of Signal (LOS: amplitude <100 µV). Primary outcomes included LOS prevalence and the association between stimulation frequency and the appearance of Yellow trends. Ethical approval: AVEN protocol 486/2024/OSS/AOUPR; informed consent obtained. Results: Of 71 nerves at risk (NAR), 55 had a valid baseline and were analyzed; LOS occurred in 3/55 NAR (5.5%). The mean number of stimulations per NAR was 4.5 (range 1–9). Cases with both Green and Yellow points had a significantly higher mean number of stimulations than cases with only Green points (5.1 vs. 3.8; Student’s t-test p = 0.0059). One Red measurement occurred in a case that progressed to LOS. Conclusions: NerveTrend® provided near real-time functional feedback while maintaining the simplicity of I-IONM. Increased stimulation frequency was associated with early Yellow trend alerts, potentially signaling traction stress and enabling timely surgical adjustments. Larger multicenter studies and protocol standardization are warranted. Full article

Background: Lip aging is a heterogeneous and visually complex process, yet a standardized morphological classification applicable to clinical practice is still lacking. Current approaches mainly focus on volumetric loss or perioral rhytids, while the geometric features of the lips, including borders, projection, and eversion, remain poorly codified. Methods: Fifty anonymized lip images acquired under standardized conditions using digital facial imaging were independently evaluated by five physicians experienced in esthetic medicine. Images were classified according to three predefined morphotypes representing distinct patterns of lip aging. Inter-rater reliability was assessed using Fleiss’s kappa statistic. Results: Three recurrent morphotypes were consistently identified: devolumized lips, central lips, and chapped lips. Overall, 87% of images were assigned to one of the three morphotypes by at least four of five evaluators, while 13% were classified as undefined due to mixed features. Inter-rater agreement was substantial (κ = 0.89; 95% CI 0.79–0.99), confirming high reproducibility of the proposed classification. Conclusions: This study proposes a simple and reproducible image-based morphotypic classification of lip aging that captures recurrent visual patterns within this cohort. The framework may facilitate standardized clinical communication, support personalized rejuvenation strategies, and provide a foundation for future quantitative imaging studies and AI-based phenotype recognition in esthetic and reconstructive practice. Full article

Background: Dupuytren’s disease (DD) is a fibroproliferative disorder of the palmar fascia that results in progressive digital flexion contractures. Various treatment strategies have been developed to restore extension, ranging from minimally invasive collagenase clostridium histolyticum (CCH) injection to more invasive surgical procedures such as open selective aponeurectomy. While CCH has gained widespread adoption due to its limited invasiveness and rapid recovery, questions remain about its long-term durability compared with open surgery (OS). This study aims to compare long-term outcomes of CCH injection and OS in patients with stage 2 or higher single-digit DD, focusing on recurrence, patient satisfaction, complications, and return to work at least 10 years after treatment. Methods: A retrospective cohort study was conducted on patients treated in 2012 with either CCH injection or OS. All patients had at least stage 2 DD and at least 10 years of follow-up. The primary outcome was to compare recurrence rates between the two patient cohorts. Secondary outcomes included visual analogue scale (VAS) satisfaction, Michigan Hand Questionnaire (MHQ) scores, complications, and time to return to work. Results: A total of 97 patients completed 10-year follow-up (60 OS, 37 CCH). Recurrence at 7 years was relatively similar between groups. However, a pronounced divergence emerged between 7 and 10 years. At 10 years, recurrence occurred in 10 patients in the OS group versus 15 in the CCH group, with statistically significant differences overall (p = 0.0175) and particularly in the PIP subgroup (p = 0.0041). VAS satisfaction at 10 years was higher after OS (7.9 ± 1.5) than after CCH (6.4 ± 1.6), and return to work was significantly faster after CCH. MHQ scores were comparable. Conclusion: Both treatments provided acceptable patient satisfaction at 10 years; however, OS yielded better long-term recurrence rates and fewer complications. Although CCH offers rapid recovery, its durability beyond 7 years appears markedly inferior. These findings reinforce the need for careful patient selection and long-term counseling when considering minimally invasive treatment. Full article

Background/Objectives: Robotic thymectomy has become the preferred approach for the management of thymoma. Although robotic surgery allows for precise dissection, the contralateral pleura may accidentally be opened during thymus gland dissection, resulting in a tension pneumothorax due to the escape of CO₂ through the defect into the contralateral pleura or to significant postoperative air leaks and delayed drain removal. To prevent this potential complication, closure of the pleural defect is indicated. This procedure may be challenging using stitches or clips, especially during robotic surgery, as the pleura is a thin structure. Methods: We reported our preliminary experience in closing a pleural defect through application of a collagen pad; after applying the pad over the defect, gentle and uniform pressure was applied using a dry sponge for 2 min to seal the tissue surface. The pad closed the defect and formed a barrier that blocked the escape of CO₂ into the contralateral pleura. Results: This procedure was successfully performed in three consecutive patients to repair a defect in the contralateral pleura that occurred during RATS thymectomy for the management of B1 thymoma (n = 2) and B2 thymoma (n = 1). No intraoperative and postoperative complication was found, and six-month follow-up showed no recurrence. Conclusions: Closing pleural defects with a collagen pad is a promising technique to enhance safety during robotic thymectomy. Full article

Background/Objectives: This study aims to depict trends in Endoscopic Dacryocystorhinostomy research in Asian countries. Methods: A bibliometric analysis was performed in April 2024 utilizing the SCOPUS database. The keywords “Endoscopic Dacryocystorhinostomy” OR “Endo-DCR” OR “Endonasal Endoscopic Dacryocystorhinostomy” were used. Data cleaning was then performed. Microsoft Excel and Vosviewer software were used to analyze data. Results: 730 articles and 37 keywords were yielded after exclusion. Our analysis revealed a notable increase in Endoscopic Dacrycocystorhinostomy publications from the early 2000s, with a significant surge post-2010. India and China were the leading contributors to Endoscopic Dacryocystorhinostomy research in Asia. Keywords such as “endoscopy”, “silicone tube”, and “epiphora” were commonly used. However, keywords like “mitomycin C”, “mucosal flap” and “success rate” were infrequently found. Conclusions: The emergence of Endoscopic Dacryocystorhinostomy publications witnessed a notable increase from 1972 to 2023 with most studies affiliated to India and China. Certain keywords such as “mitomycin C”, “mucosal flap”, “revision”, “laser”, “drill”, and “success rate” were infrequently used. Full article

Background/Objectives: Thumb basal joint arthritis is a common degenerative condition often requiring surgery when conservative treatment fails. Dual mobility trapeziometacarpal prostheses are increasingly used, but the optimal anesthetic strategy remains debatable. This study aimed to explore whether WALANT provides intraoperative analgesia and short-term safety comparable to axillary block in dual mobility trapeziometacarpal arthroplasty. Methods: A prospective observational comparative study was carried out on 21 patients (11 WALANT, 10 axillary block) undergoing dual mobility trapeziometacarpal prosthesis for stage II–III in thumb basal joint arthritis according to Eaton–Littler classification at two hospital facilities of ASL Roma 5, from February–December 2025. Patients treated with the WALANT technique were assigned to Group A, whereas those undergoing an axillary block were assigned to Group B. Pain intensity was recorded on a 0–10 visual analogue scale at three stages: during anesthetic administration, during surgery, and 3 h after the procedure. Group A received a field infiltration with 1% mepivacaine combined with epinephrine 1:100,000 and sodium bicarbonate, while Group B underwent an ultrasound-guided brachial plexus block using 0.5–0.7% ropivacaine and a pneumatic tourniquet inflated to 250 mmHg. Results: Pain during anesthesia induction was similar between groups (Group A 3.18 ± 2.89 vs. Group B 2.20 ± 2.37, p = 0.393). Intraoperative pain did not differ significantly (Group A 2.27 ± 1.79 vs. Group B 2.00 ± 2.71, p = 0.898). At 3 h postoperative, Group B showed a trend toward lower pain levels (Group A 4.36 ± 2.54 vs. Group B 3.00 ± 3.08, p = 0.244). No anesthetic failures, no conversion to general anesthesia, and no neurological or ischemic complications occurred in either group. Conclusions: In this prospective observational comparative cohort, WALANT and axillary block provide comparable intraoperative analgesia for dual mobility trapeziometacarpal prosthesis, with comparable safety profiles. WALANT offers advantages in ease of administration, absence of tourniquet-related risks, and potential for intraoperative functional testing. Axillary block provides more prolonged postoperative analgesia in the first 3 h. The choice between techniques should be individualized based on patient-specific factors, anxiety profile, and local expertise. These results should be interpreted as preliminary and hypothesis-generating, given the exploratory design, the small sample size, and the limited statistical power of the study. Full article

Background: Pediatric orbital floor fractures differ from adult injuries due to bone elasticity and a higher incidence of trapdoor-type defects with extraocular muscle entrapment, often presenting with limited external signs but carrying a high risk of functional impairment. Early recognition and prompt surgical release are essential to prevent irreversible neuromuscular damage and persistent binocular vision disturbances. Case Presentation: A 13-year-old patient sustained an orbital floor blow-out fracture with inferior rectus muscle incarceration following blunt trauma. The child presented with vertical diplopia, ocular motility restriction, and infraorbital hypoesthesia. Computed tomography demonstrated a posteriorly located linear orbital floor defect with soft-tissue entrapment, supporting the indication for urgent surgical intervention to avoid ischemic injury. Management and Outcome: Through a transconjunctival retroseptal approach, the entrapped muscle was promptly released, and orbital floor continuity was restored using an autologous bone graft harvested from the anterior maxillary wall with piezosurgery. This technique allowed controlled and precise bone harvesting while preserving adjacent anatomical and developing dental structures. Postoperative recovery was uneventful, with complete resolution of diplopia and full restoration of binocular ocular motility during follow-up. Conclusion: Early surgical intervention plays a pivotal role in achieving functional recovery in pediatric orbital floor fractures with muscle entrapment. Autologous reconstruction supported by piezosurgical bone harvesting represents a safe and effective approach in growing patients, providing reliable functional and anatomical outcomes. This case reinforces the clinical relevance of timely intervention and highlights practical considerations in pediatric orbital trauma management. Full article

Background: Autologous bone graft is widely used for lumbar interbody fusion but may increase operative time and donor-site morbidity. Gene-activated grafts combining an osteoconductive scaffold with pro-angiogenic signaling may provide comparable fusion without graft harvesting. The aim of this paper is to compare radiographic fusion and health-related quality of life after single-level transforaminal lumbar interbody fusion (TLIF) using a gene-activated octacalcium phosphate graft containing plasmid DNA encoding vascular endothelial growth factor (OCP/VEGF) versus an autologous bone graft. Methods: 200 adults undergoing first-time single-level TLIF for degenerative lumbar stenosis were allocated 1:1 to OCP/VEGF (n = 100) or autograft (n = 100), prospectively. CT-based fusion assessment and SF-36 outcomes were evaluated at 6 and 12 months follow-up. Results: At 12 months after surgery, mean fusion-zone density was 617.6 ± 180.9 HU in the OCP/VEGF group versus 599.8 ± 181.9 HU in the autograft group (mean difference 17.8 HU; p = 0.484). Complete fusion on qualitative CT grading occurred in 77% versus 73%, respectively (risk difference 4%; p = 0.583). SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) improved significantly from baseline in both groups (p < 0.001), without clinically meaningful between-group differences at follow-up. Revision surgery occurred in 3% versus 5%. Conclusions: In single-level TLIF for degenerative lumbar stenosis, OCP/VEGF produced radiographic fusion and patient-reported outcomes comparable to autograft at 12 months, supporting its use as an autograft-sparing alternative. Full article

Background: Facial asymmetry affecting the mandibular contour may significantly impact facial harmony even in patients with stable occlusion. Although orthognathic surgery remains the standard for skeletal correction, it carries substantial morbidity. In selected cases, contour-focused approaches can achieve meaningful esthetic improvement with reduced surgical burden. Objective: To describe the virtual surgical planning (VSP) workflow and clinical outcome of a unilateral Wing osteotomy for mandibular contour asymmetry. Case presentation: A 24-year-old woman presented with left-sided mandibular contour deficiency and facial asymmetry, despite stable Class I occlusion and preserved function. VSP with contralateral mirroring guided the design of the osteotomy and fabrication of a stereolithographic model and patient-specific cutting guide. Surgery was performed through a tunnelized mandibular approach using a 702 bur and reciprocating saw. Fixation was achieved with pre-bent 2.0 plates adapted to the 3D model, and Bio-Oss Collagen was interposed within the osteotomy gap. Occlusion and mental nerve function were preserved. Results: Postoperatively, the patient demonstrated improved facial symmetry, uneventful healing, preserved long-term neurosensory function, and high esthetic satisfaction. Conclusions: Unilateral Wing osteotomy guided by VSP and patient-specific instrumentation is a predictable, minimally invasive alternative to bimaxillary orthognathic surgery with genioplasty in selected patients presenting contour-focused asymmetry and stable occlusion. This case highlights a rare, underreported application of the technique. Full article

Background: The history of radical hernia repair involves a period of intense surgical activity, influenced by factors of the time such as social development, hygiene, anesthesia, and antisepsis. Subcutaneous surgery, the initial option designed to avoid infections and peritonitis, was modified after the introduction of antisepsis, eventually leading to dissection surgery. Objective: We aim to analyze the publications from the period of radical hernia cures using current methodology, verifying when and how the transition occurred from subcutaneous surgery to dissection surgery. Methods: A literature review of the databases PubMed, LILACS, Cochrane Library, “Google” and university libraries is conducted. The following keywords were used: “anatomy and surgery”. A critical analysis of the known literature about this historical topic is carried out. Results: Under-vision dissection surgery, through incision of the aponeurosis of the external oblique muscle, began in England by Durham in 1866, almost 20 years before it was performed in France by Lucas-Championnière in 1885. Recurrences decreased after the introduction of the principle of closing the walls of the inguinal canal (Wood, 1860). The surgeon–anatomist Wood should be considered the first specialist in abdominal wall surgery, due to his extensive contributions from the pre-antiseptic era. The evolution of the radical cure of hernias was made possible by combining the knowledge of several countries: England, Germany, and Italy. Conclusions: Dissection surgery was initiated in England, Germany, and Italy, not in France. The influence of the French literature on the history of hernias is evident, to the detriment of the contributions of surgeons from other countries. Full article

This narrative review aims to highlight and analyze the supervision of precision robotic surgical interventions. These are autonomous, closed-loop procedures, assisted by images and managed by intelligent digital tools. These administered procedures are designed to be safe and reliable, adhering to the principles of minimal invasiveness, precise positioning, and non-toxicity. Thus, a precision intervention uses non-ionizing imaging-assisted robotics, controlled by a precise positioning device, forming an autonomous procedure augmented by artificial intelligence tools and supervised by digital twins. This intelligent digital management procedure allows staff to plan, train, predict, and execute interventions under human supervision. Patient safety and staff efficiency are linked to non-ionizing imaging, minimal invasiveness through image guidance, and strict delimitation of the intervention zone through precise positioning. This study includes, successively, sections covering an introduction, therapeutic and surgical interventions, imaging strategies integrating diagnostic and assistance functions, intelligent digital tools including digital twins and artificial intelligence, image-guided procedures including autonomous and precision robotic surgical interventions increased by machine learning, as well as augmented healthcare monitoring, and a discussion and conclusions of the review. All topics addressed in this analysis are supported by examples from the literature. Full article

Background/Objectives: Robot-assisted gastrointestinal (GI) cancer surgery has expanded in Japan since national reimbursement in 2018, yet hospital profitability remains uncertain because of capital, maintenance, and consumable costs. We examined whether a program-level volume threshold for profitability exists under Japan’s fee schedule and quantified actionable improvement targets. Methods: We developed a hospital-perspective, model-based economic evaluation (index admission to 30 days; 2025 Japanese yen (JPY)) comparing robot-assisted surgery (RAS) with conventional laparoscopic surgery (CLS) under Japan’s fee schedule (one point = ¥10) for gastrectomy, colectomy, rectal resection, and pancreatoduodenectomy. Case-level contribution margin differentials (ΔCM) were defined as the revenue differential minus the consumables differential and additional operating room (OR) time costs, plus savings from reduced length of stay (LOS), and were aggregated to annual program profit (Π) after fixed costs and platform sharing. Primary outputs were allowable consumables, required cut (%), and isoprofit contours. Uncertainty was assessed using 50,000-iteration probabilistic sensitivity analysis (PSA), one-way sensitivity analysis (OWSA), and learning-curve scenarios in line with Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022. Results: In the base case, ΔCM was predominantly ≤0 for colon, rectum, and pancreatoduodenectomy; therefore, when the case-mix-weighted mean ΔCM was ≤0, increasing volume could not achieve breakeven and instead increased losses. Each 10 min reduction in OR time increased allowable consumables by ¥15,000, and each bed-day reduction increased it by ¥30,000. These required-cut and isoprofit maps provide actionable targets for cost negotiation, operational improvement, and platform sharing. Conclusions: Volume expansion alone rarely yields profitability; coordinated reductions in consumables, OR time, and LOS, together with platform sharing, are required. Full article

Background: Compromised left ventricular function presents unique challenges during mitral valve surgery. Recent evidence suggests that subvalvular apparatus preservation might enhance postoperative recovery in high-risk populations. Methods: This prospective observational investigation (Hue Central Hospital, March 2015–September 2016) evaluated 87 patients undergoing mechanical mitral valve replacement with posterior leaflet preservation. Participants were stratified into two groups: reduced ejection fraction (EF ≤ 50%, n = 38) and preserved EF (>50%, n = 49). Comprehensive clinical and echocardiographic assessments were conducted at 1, 3, 6, and 12 months postoperatively. Statistical analysis employed parametric and non-parametric methodologies, with survival analyzed via Kaplan–Meier techniques. Results: The reduced EF cohort demonstrated significant improvement in contractile performance from 48.8 ± 5.2% preoperatively to 61.6 ± 7.2% at 12 months (p < 0.05). Ventricular dimensions decreased notably from 59.2 ± 6.6 mm to 47.6 ± 4.0 mm (p < 0.05). Hospital mortality was 2.3% (2 patients). Twelve-month survival rates reached 94.66% and 97.96% for reduced and preserved EF groups, respectively, without significant inter-group differences (p = 0.42). All surviving participants achieved functional status in NYHA class I or II. Conclusions: Mechanical mitral valve replacement with posterior leaflet preservation represents an effective approach for patients with reduced ventricular performance, promoting substantial improvement in cardiac function and excellent clinical outcomes. Full article

The aim of this research was to identify the 50 articles most frequently referenced concerning patellofemoral instability (PFI) and to analyze their features. A search was performed in the Thomson ISI Web of Science using keywords such as “patellofemoral instability,” “patellar instability,” “patellar dislocation,” and “patella luxation.” This research included all publications related to PFI, covering aspects such as diagnostic and both nonoperative and operative treatment. The citation counts for the 50 articles ranged from 165 to 1024 citations. Notably, the top ten articles received a minimum of 348 citations each. In total, 84% (n = 42) of the studies were clinical, while the remainder consisted of basic science investigations (including three anatomical and five biomechanical studies). The predominant level of evidence was IV, accounting for 32%. The American Journal of Sport Medicine was responsible for publishing 34% of these articles. Most of the research took place in the United States and twelve additional countries. The years when the most-referenced papers were published spanned from 1985 to 2020, with the 2000s representing the highest share of articles (74%), and the years between 2006 and 2010 showing the peak quantity of articles (n = 15). This article provides a building block in the PFI management. The selection of these articles is useful for learning more about current trends on PFI and anticipating future developments. Full article

Background/Objectives: While hip arthroscopy outcomes for femoroacetabular impingement syndrome (FAIS) are well-documented, there is limited research comparing revision hip arthroscopy for FAIS to primary procedures. This study aimed to compare clinical outcome scores, revision hip arthroscopy, and conversion to total hip arthroplasty (THA) between patients undergoing revision hip arthroscopy for residual FAIS and those undergoing primary hip arthroscopy. Methods: This retrospective study matched 47 patients who underwent revision hip arthroscopy 1:2 by age, sex, body mass index, and smoking status to 94 patients who underwent primary surgery. Patient-reported outcomes (PROs) were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) preoperatively and at 1-year follow-up. Long-term follow-up was performed to determine repeat surgical interventions at a minimum 5-year follow-up. Differences in postoperative outcomes were assessed using Mann–Whitney U tests and rate of subsequent surgery were compared using chi-squared analyses. Results: Both cohorts showed significant improvement in PROs at 1 year (p < 0.001). However, the revision cohort had lower preoperative scores (mHHS, p < 0.001; NAHS, p = 0.003) and lower postoperative scores (mHHS, p = 0.037; NAHS, p = 0.032) compared to the primary cohort. Despite these differences, the magnitude of improvement was similar between groups for the mHHS and NAHS (p > 0.05). Long-term follow-up revealed a significantly higher conversion rate to THA in the revision cohort compared to the primary group (p < 0.001). Conclusions: Patients undergoing revision hip arthroscopy start with lower baseline function but achieve similar improvements to those undergoing primary surgery. However, revision patients had a significantly higher rate of conversion to THA. Full article

Background: In head and neck reconstructive surgery, flap loss remains a major complication and continues to represent a significant challenge in perioperative management. Although free tissue transfer is widely used, unsatisfactory outcomes are still reported across different flap procedures. Anaesthetic management plays an important role in influencing flap perfusion through its effects on systemic haemodynamics, regional blood flow, and microcirculation. However, there is currently no consensus on universally acceptable haemodynamic targets, and the impact of intraoperative strategies appears to be highly application-specific. Materials and Methods: This narrative review was conducted in accordance with the 2019 SANRA guidelines. PubMed^® was used as the primary database for literature selection. Relevant studies addressing anaesthetic management in head and neck free flap surgery were reviewed, with a particular focus on intraoperative haemodynamic control, ischemia–reperfusion injury, fluid and transfusion management, vasoactive agents, and advanced monitoring techniques. Results: Ischemia–reperfusion injury represents a major mechanism of vascular compromise in free flap surgery and has a significant impact on microcirculatory perfusion. The literature suggests that several anaesthetic strategies—including goal-directed fluid therapy, cautious use of vasopressors, and advanced haemodynamic monitoring—may support intraoperative haemodynamic stability and improve flap perfusion. Nevertheless, the magnitude of haemodynamic improvement achievable with these strategies and their effect on graft survival vary according to patient characteristics, surgical factors, and flap type. Conclusions: Current evidence indicates that anaesthetic management has the potential to contribute to improved intraoperative haemodynamic control in head and neck free flap reconstruction, thereby supporting graft viability. However, haemodynamic targets and management strategies cannot be generalised and should be interpreted within specific clinical contexts. Rather than aiming for optimisation, future research should focus on defining acceptable clinical outcomes for individual applications and on evaluating whether achievable haemodynamic improvements are sufficient to reduce flap-related complications to clinically acceptable levels. Full article

Background/Objectives: Titanium fixation remains the gold standard for stabilizing mandibular fractures; however, associated complications often necessitate a second surgery for hardware removal. Consequently, biodegradable systems were introduced, though questions persist regarding their mechanical reliability and potential for tissue reactions. This systematic review and meta-analysis was conducted to compare the efficacy and morbidity of biodegradable versus titanium osteosynthesis systems for the treatment of mandibular fractures. Methods: Following PRISMA guidelines, a systematic literature search was conducted in MEDLINE, Embase, and CENTRAL. Comparative studies, such as randomized controlled trials (RCTs) and non-randomized studies, were included. The primary outcome was the rate of hardware removal; therefore, a random-effects meta-analysis was performed to calculate a pooled Odds Ratio (OR), while the risk of bias was assessed using the Cochrane RoB 2 and ROBINS-I tools. Results: Eight studies, including four RCTs, comprising a total of 369 patients, were included, with most studies judged to be at a high or serious risk of bias due to inadequate randomization, lack of blinding, and confounding co-interventions. The meta-analysis of four RCTs on hardware removal revealed no statistically significant difference between the biodegradable and titanium groups (pooled OR 0.28, 95% CI 0.04 to 1.90), with substantial and statistically significant heterogeneity observed (I² = 66.1%). Qualitative synthesis indicated that biodegradable systems were associated with higher rates of intraoperative screw breakage and longer operative times, while rates of successful bone union were comparable between the two groups. Conclusions: Biodegradable osteosynthesis systems represent a viable alternative to titanium for mandibular fracture fixation, demonstrating similar efficacy in achieving bone union, which is counterbalanced by higher rates of screw breakage and longer operative times. The decision to use a biodegradable system involves a critical trade-off that should be designed for the specific clinical scenario. The high risk of bias and significant heterogeneity limit the certainty of these findings, underscoring the imperative for future high-quality, long-term RCTs. Full article

Background/Objectives: Point-of-care ultrasound (POCUS) is an accessible and low-cost diagnostic tool that is seldom used by orthopedic residents. This study aims to assess the efficacy of a POCUS training program within an orthopedic surgery residency curriculum in terms of knowledge retention and clinical usage among the group of residents. Methods: This study included didactic and hands-on teaching sessions. The impact of the teaching sessions was evaluated through surveys (pre-course, immediate post-course, and 6 months post-course). The surveys were divided into three sections: participant’s interest in and usage of POCUS, ultrasound-related knowledge, and perceived limitations related to the usage of ultrasound. All orthopedic residents who attended the teaching sessions and completed all the surveys were included. Results: There were 14 participants. There was a significant increase in interest in POCUS (scale 1 to 5) from 3.36 ± 0.50 in the pre-course survey to 3.93 ± 0.83 in the final post-course survey (p = 0.04). However, there was no significant change in the amount of POCUS usage in clinical settings. Levels of comfort with ultrasound-related procedures significantly increased immediately following the teaching session but did not stay significantly higher after 6 months. When tested on knowledge, the residents’ scores were still significantly greater than they were at the time of the pre-course test at 6 months (p = 0.01). Lack of ultrasound-related knowledge, lack of time, and site culture were the two most prevalent perceived barriers. Conclusions: This study demonstrates that POCUS teaching for orthopedic residents yields long-term benefits in terms of interest and knowledge. However, recurrent teaching sessions and further efforts are required to address perceived obstacles to PoCUS usage and increase clinical implementation. Full article

Background/Objectives: Prepectoral direct-to-implant reconstruction is widely used, but implant rippling often necessitates lipofilling. This study aimed to identify preoperative and perioperative factors associated with delayed lipofilling. Methods: A retrospective cohort of consecutive patients who underwent immediate prepectoral implant reconstruction (April 2023–September 2024) was analyzed. Demographic data, BMI, smoking, comorbidities, oncologic treatments, surgical factors, and tumor location were recorded. Patients were divided according to whether delayed lipofilling was required. Univariate analysis was performed using Mann–Whitney U and Fisher’s exact tests. Results: Fifty-eight patients were included; approximately one-third required lipofilling. Patients who underwent lipofilling were younger and had lower BMI than those who did not. Tumor location was strongly associated with the outcome: upper inner quadrant tumors were consistently linked to delayed lipofilling, whereas upper outer quadrant tumors were more frequently observed in the group not requiring revision. Smoking history and planned radiotherapy showed nonsignificant trends toward higher lipofilling rates. No differences were found for diabetes or corticosteroid therapy. Conclusions: Younger age, low BMI, and tumor location, particularly in the upper inner quadrant, were key factors associated with delayed lipofilling after prepectoral reconstruction. These variables may support preoperative counseling and follow-up planning to better anticipate secondary procedures and optimize aesthetic outcomes. Full article

Background and objectives: Anterior cruciate ligament reconstruction (ACLR) is often associated with significant postoperative pain. Effective pain control is vital for early mobilization and reducing opioid use. While femoral nerve block (FNB) and adductor canal block (ACB) are common, they can cause motor weakness and incomplete analgesia. The genicular nerve block (GNB), typically used for chronic knee pain and arthroplasty, may offer a motor-sparing alternative for ACLR pain management. This review evaluates the evidence on GNB’s effectiveness for pain control, opioid reduction, and recovery after ACLR. Materials and Methods: A literature search (January 2014–May 2025) identified five studies involving adult ACLR patients receiving GNB. Data on demographics, techniques, pain scores, opioid use, and complications were analyzed. Results: Among 115 patients, GNB provided effective analgesia and reduced opioid needs. Randomized trials showed GNB was comparable to ACB and more effective when combined. Ultrasound, especially with Doppler, enhances precision and safety. No major motor deficits or adverse events were noted. Landmark-based approaches also showed utility in low-resource settings. Conclusions: GNB is a promising, motor-sparing option for postoperative pain in ACLR. Further high-quality trials are needed to confirm the benefits and standardize its use. The findings should be interpreted with caution, as the current evidence is of limited quality and lacks generalizability. Full article

Background/Objectives: Over the last decade, the role and timing of lymph node dissection (LND) in stage III melanoma has shifted from completion LND after a positive sentinel node to a mainly therapeutic procedure for clinically evident nodal disease, driven by randomized evidence showing no survival benefit for routine completion dissection. In this evolving landscape, real-world data on postoperative morbidity—by nodal basin—and on whether complications may influence melanoma-specific survival (MSS) and disease-free survival (DFS) remain limited. We evaluated 90-day postoperative complications after cervical, axillary, and inguino–iliac–obturator LND and explored their association with survival outcomes and treatment era. Methods: We retrospectively analyzed 185 consecutive stage III melanoma patients undergoing LND at a single tertiary center (January 2004–August 2025). Postoperative morbidity was recorded up to 90 days and graded by Clavien–Dindo; given the very low rate of grade > II events, the primary endpoint was a composite of loco-regional surgical field–related complications (persistent seroma, wound dehiscence, surgical-site infection, limb lymphedema). Risk factors were assessed using logistic regression; Firth’s penalized models were applied when appropriate. MSS and DFS were estimated by Kaplan–Meier and explored with Cox models. Results: Median follow-up was 105 months. Surgical field–related complications occurred in 16.8% (31/185), and postoperative mortality was 1.0% (2/185). In multivariable analyses, inguino–iliac–obturator LND was associated with higher odds of overall complications (OR 4.03) and specifically wound dehiscence (OR 4.79) and infection (OR 7.18) versus axillary LND. MSS (n = 179) was 82% at 1 year, 55% at 5 years, and 49% at 10 years; DFS (n = 171) was 63%, 42%, and 41%, respectively. In era-based comparisons, nodal yield decreased in the post–MSLT-II period without clear separation of MSS/DFS curves; exploratory models did not show a consistent independent signal linking postoperative complications to MSS/DFS. Conclusions: In stage III melanoma, LND was associated with low major morbidity, but clinically meaningful locoregional complications persisted—most notably after inguino–iliac–obturator dissection. These data support careful patient selection and basin-tailored strategies to reduce groin morbidity within modern multidisciplinary management. Full article

Background: The primary concern of hip surgeons is restoring the physiological biomechanics of the hip joint through arthroplasty, thereby enabling patients with osteoarthritis to engage better in daily activities. The modularity of the femoral stem-neck head allows surgeons to better restore the hip’s native biomechanics. However, concerns have been raised regarding the potential postoperative complications. This study aims to evaluate patients’ satisfaction and functional outcomes following primary Total Hip Arthroplasty (THA) with modular stem-neck, with a mean follow-up duration of eight years. Methods: We retrospectively reviewed 208 patients who underwent primary THA with modular stem-neck between February 2012 and July 2019. The follow-up period extended from November 2024 to April 2025. Patients who died from unrelated causes were excluded. Patients’ satisfaction was assessed using the SF-36 questionnaire, while functional outcomes were evaluated using the Harris Hip Score (HHS). Intraoperative and postoperative complications were meticulously documented. Results: The average follow-up duration was 95.6 months, with a range from 67.7 to 159.7 months. The mean SF-36 score was 91.2 out of 100, indicating high patient satisfaction. The mean HHS was 90 out of 100, reflecting excellent functional outcomes. Notably, some patients achieved the maximum score of 100 in both SF-36 and HHS assessments, while the lowest recorded scores were 54 and 50, respectively. The mean age of patients at the time of surgery was 67.1 years. One case of periprosthetic fracture was reported; however, no complications related to modular necks, such as trunnionosis or implant failure, were observed. Conclusions: The present study demonstrates that modular neck primary THA could achieve excellent functional and radiological outcomes, high patient satisfaction, and outstanding long-term survivorship, provided that implant selection and surgical technique follow biomechanical principles. Full article

Background: Extramedullary spinal tumors represent a significant challenge for spine surgeons. Currently, various techniques exist to perform tumor resection safely while optimizing patient outcomes. Historically, the standard of care has been open surgery; however, in the last two decades, Minimally Invasive Spine Surgery (MISS) techniques have gained importance due to superior postoperative recovery. Literature on Unilateral Biportal Endoscopy (UBE) for tumor resection is currently limited. We propose that UBE has the potential to become a standard approach for these lesions due to its distinct advantages. Methods: We performed a retrospective review of 11 patients who underwent UBE resection of lower thoracic and lumbar spinal extramedullary tumors. We analyzed clinical files and intraoperative endoscopic videos to describe our surgical technique step by step. We also evaluated the advantages of this approach in terms of resection rate, operative time, operative blood loss, and hospital stay. A representative case is also presented. Results: Clinical resolution and significant symptomatic improvement were achieved in all cases, as evidenced by functional and pain scales. In terms of tumor resection, we obtained results comparable to other MISS techniques and open surgery, with a low complication rate. Conclusions: UBE represents a safe, effective evolution in MISS for spinal tumors. Future studies with larger cohorts are needed to validate these findings as a standard of care. Full article

Replantation of an amputated finger is a complex microsurgical procedure that is rarely attempted in low-resource settings due to limited infrastructure and expertise. We report a case of complete amputation of a finger in rural Kenya that was successfully replanted during a humanitarian surgical mission. A 28-year-old man sustained a severe crush avulsion agricultural machine injury resulting in the amputation of all ten digits; only one digit was deemed suitable for replantation. The replantation was performed under loupe and microscope magnification by a visiting specialist team in collaboration with local staff. Intraoperatively, bony fixation with Kirschner wires, extensor and flexor digitorum profundus tendon repair, arterial and venous anastomoses, and neurorrhaphy of the digital nerve were achieved. Postoperatively, the finger survived with adequate perfusion. At one-month follow-up, the replanted finger was viable with progressing wound healing and early joint motion; further rehabilitation was arranged to maximize functional recovery. This case, which is, to our knowledge, one of the first documented digital replantations in East Africa, illustrates that successful microsurgical limb salvage is feasible in a non-specialized hospital setting. Our experience underscores that, with proper planning, training, and teamwork, advanced reconstructive procedures like finger replantation can be safely carried out even in resource-constrained hospitals, offering patients in low-income regions outcomes previously achievable only in high-resource centers. Full article

Background and Clinical Significance: With increasing demand for total knee arthroplasty (TKA), the incidence of post-operative instability has also risen. Although fracture of the polyethylene tibial post in posterior-stabilized (PS) prostheses is relatively uncommon, it should not be overlooked because delayed recognition may lead to severe late sequelae. Case Presentation: Between April 2008 and January 2020, 132 revision TKAs were performed at our institution due to suspected instability with or without component loosening. Among these, three patients were identified as having instability associated with fracture of the polyethylene tibial post in PS implants. All three patients presented late, with a mean interval of 49.66 months (range 34–74) after the index TKA. At presentation, all demonstrated multiplanar global instability, and two showed recurvatum deformity. Pre-operatively, revision surgery was indicated due to progressive global instability. Although tibial post fracture was suspected as a possible underlying cause, the diagnosis could not be definitively established until intraoperative inspection, which confirmed polyethylene tibial post fracture in all cases. Each patient underwent revision TKA using a semi-constrained prosthesis with an increased polyethylene insert height. At final follow-up (12–18 months), all patients achieved complete resolution of clinical instability and demonstrated meaningful improvement in the Hospital for Special Surgery (HSS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Conclusions: Although rare, polyethylene tibial post fracture should be considered in the differential diagnosis of post-operative knee instability following PS TKA. Early recognition may allow management with isolated polyethylene exchange, whereas delayed diagnosis can result in progressive ligamentous insufficiency and global multiplanar instability, ultimately necessitating revision using a semi-constrained implant. Full article