Surgeries Latest open access articles published in Surgeries at https://www.mdpi.com/journal/surgeries https://www.mdpi.com/journal/surgeries MDPI en Creative Commons Attribution (CC-BY) MDPI support@mdpi.com Surgeries, Vol. 7, Pages 69: Attitudes Toward Perioperative Antibiotic Prophylaxis in Primary Hip and Knee Arthroplasty and Hip Hemiarthroplasty: A Survey of Egyptian Joint Replacement Surgeons—Is It Time for Developing National Guidelines? https://www.mdpi.com/2673-4095/7/2/69 Background: Periprosthetic joint infection is a severe complication after hip and knee arthroplasty, and using perioperative antibiotic prophylaxis (PABP) per guidelines and recommendations is one step in its prevention. The current study aimed to evaluate the attitude of Egyptian joint replacement surgeons toward PABP, their adherence to guidelines, and their insight into developing national guidelines. Methods: We conducted an online cross-sectional questionnaire study comprising three sections to collect information on various aspects of PABP and to gather insights into the development of national guidelines among members of the Egyptian Pelvis, Hip, and Knee Society (EPHAKS). The questionnaire targeted active practicing hip or knee replacement surgeons and was first sent by email to all members two weeks before the eighth EPHAKS annual conference. A reminder was announced during the conference, and subsequent email reminders were sent one week apart after the conference. The study was registered in clinicaltrials.gov (NCT06451224). Results: Out of 469 EPHAKS members, and among the 434 successfully delivered email invitations, 105 responded, giving a response rate of 24.2%. All were males, with a mean age of 42.98 ± 10.12 years; a total of 70.5% were consultants, and 13.3% performed more than 100 procedures annually. Most participants reported not following national or international guidelines, with response percentages of 80.9% and 62.9%, respectively. Consultants and surgeons performing more than 50 procedures annually showed significantly higher adherence to guidelines than others, with p-values of 0.046 and 0.004, respectively. Adherence to national or international guidelines for prescribing first- or second-generation cephalosporins was reported by 65.7% (preoperatively) and 59% (postoperatively). Only 9.5% reported prescribing antibiotics for the first 24 h postoperatively. Overall, 80% agreed that Egyptian patients are different and that PABP international guidelines do not suit them, and 98.1% agreed that developing national Egyptian PJI prevention guidelines is necessary owing to deficiencies and the broad applicability of the current national guidelines. Conclusions: Egyptian joint replacement surgeons rarely adhere to national or international guidelines for PABP, with higher adherence noticed among more experienced surgeons. The majority agreed that our patients are different and that international guidelines might not suit them, and nearly all participants expressed a strong desire to develop national guidelines. 2026-06-10 Surgeries, Vol. 7, Pages 69: Attitudes Toward Perioperative Antibiotic Prophylaxis in Primary Hip and Knee Arthroplasty and Hip Hemiarthroplasty: A Survey of Egyptian Joint Replacement Surgeons—Is It Time for Developing National Guidelines?

Surgeries doi: 10.3390/surgeries7020069

Authors: Ahmed A. Khalifa Heba M. Mohammed Ahmed M. Abdelaal

Background: Periprosthetic joint infection is a severe complication after hip and knee arthroplasty, and using perioperative antibiotic prophylaxis (PABP) per guidelines and recommendations is one step in its prevention. The current study aimed to evaluate the attitude of Egyptian joint replacement surgeons toward PABP, their adherence to guidelines, and their insight into developing national guidelines. Methods: We conducted an online cross-sectional questionnaire study comprising three sections to collect information on various aspects of PABP and to gather insights into the development of national guidelines among members of the Egyptian Pelvis, Hip, and Knee Society (EPHAKS). The questionnaire targeted active practicing hip or knee replacement surgeons and was first sent by email to all members two weeks before the eighth EPHAKS annual conference. A reminder was announced during the conference, and subsequent email reminders were sent one week apart after the conference. The study was registered in clinicaltrials.gov (NCT06451224). Results: Out of 469 EPHAKS members, and among the 434 successfully delivered email invitations, 105 responded, giving a response rate of 24.2%. All were males, with a mean age of 42.98 ± 10.12 years; a total of 70.5% were consultants, and 13.3% performed more than 100 procedures annually. Most participants reported not following national or international guidelines, with response percentages of 80.9% and 62.9%, respectively. Consultants and surgeons performing more than 50 procedures annually showed significantly higher adherence to guidelines than others, with p-values of 0.046 and 0.004, respectively. Adherence to national or international guidelines for prescribing first- or second-generation cephalosporins was reported by 65.7% (preoperatively) and 59% (postoperatively). Only 9.5% reported prescribing antibiotics for the first 24 h postoperatively. Overall, 80% agreed that Egyptian patients are different and that PABP international guidelines do not suit them, and 98.1% agreed that developing national Egyptian PJI prevention guidelines is necessary owing to deficiencies and the broad applicability of the current national guidelines. Conclusions: Egyptian joint replacement surgeons rarely adhere to national or international guidelines for PABP, with higher adherence noticed among more experienced surgeons. The majority agreed that our patients are different and that international guidelines might not suit them, and nearly all participants expressed a strong desire to develop national guidelines.

]]> Attitudes Toward Perioperative Antibiotic Prophylaxis in Primary Hip and Knee Arthroplasty and Hip Hemiarthroplasty: A Survey of Egyptian Joint Replacement Surgeons—Is It Time for Developing National Guidelines? Ahmed A. Khalifa Heba M. Mohammed Ahmed M. Abdelaal doi: 10.3390/surgeries7020069 Surgeries 2026-06-10 Surgeries 2026-06-10 7 2 Article 69 10.3390/surgeries7020069 https://www.mdpi.com/2673-4095/7/2/69 Surgeries, Vol. 7, Pages 68: Effect of Sagittal TTTG on Graft Failure After Anterior Cruciate Ligament Reconstruction https://www.mdpi.com/2673-4095/7/2/68 Background: Anterior cruciate ligament reconstruction (ACLR) is a common orthopedic procedure with generally favorable outcomes, yet graft failure remains a significant challenge, particularly in young and active patients. While various anatomical and biomechanical risk factors for graft failure have been proposed, the influence of the sagittal tibial tubercle–trochlear groove (sTTTG) distance, representing anterior–posterior alignment of the tibial tubercle, has not been sufficiently explored. This study aimed to evaluate the association between sTTTG and ACL graft failure and assess contributing biomechanical variables, including tibiofemoral rotation (TFR), posterior tibial slope (PTS), and knee flexion angle. Methods: For this secondary analysis, a retrospective matched case–control study was conducted, involving 151 patients with ACL graft failure who underwent revision ACLR and 151 controls with intact grafts after a minimum 2-year follow-up period. sTTTG was measured on axial MRI as the anteroposterior distance from the trochlear groove to the tibial tubercle, perpendicular to the posterior femoral condylar axis. Secondary measurements included TT-TG, TFR, medial and lateral PTS, and knee flexion angle. Group differences as well as factors predictive of sTTTG were analyzed. Results: The ACLR failure group demonstrated a significantly lower sTTTG distance compared to controls (0.5 ± 4.6 mm vs. 2.4 ± 4.8 mm, p = 0.001). Logistic regression analysis revealed that a 1 mm increase in sTTTG was associated with an 8% reduction in revision risk (OR = 0.93 per 1 mm increase; 95% CI, 0.88–0.97; p = 0.003), although the predictive accuracy was low (AUC = 0.6). Multivariable analysis identified lateral PTS and knee flexion as significant independent predictors of sTTTG. Conclusions: A decreased sTTTG distance was significantly associated with ACL graft failure, underscoring the relevance of sagittal tibial tubercle positioning in ACL biomechanics. While not an independent clinical decision-making tool, sTTTG appears relevant to graft failure and may be considered in future risk assessment strategies. 2026-06-09 Surgeries, Vol. 7, Pages 68: Effect of Sagittal TTTG on Graft Failure After Anterior Cruciate Ligament Reconstruction

Surgeries doi: 10.3390/surgeries7020068

Authors: Sebastian Schmidt Chilan B. G. Leite Domenico Franco Ali Darwich Cale A. Jacobs Christian Lattermann

Background: Anterior cruciate ligament reconstruction (ACLR) is a common orthopedic procedure with generally favorable outcomes, yet graft failure remains a significant challenge, particularly in young and active patients. While various anatomical and biomechanical risk factors for graft failure have been proposed, the influence of the sagittal tibial tubercle–trochlear groove (sTTTG) distance, representing anterior–posterior alignment of the tibial tubercle, has not been sufficiently explored. This study aimed to evaluate the association between sTTTG and ACL graft failure and assess contributing biomechanical variables, including tibiofemoral rotation (TFR), posterior tibial slope (PTS), and knee flexion angle. Methods: For this secondary analysis, a retrospective matched case–control study was conducted, involving 151 patients with ACL graft failure who underwent revision ACLR and 151 controls with intact grafts after a minimum 2-year follow-up period. sTTTG was measured on axial MRI as the anteroposterior distance from the trochlear groove to the tibial tubercle, perpendicular to the posterior femoral condylar axis. Secondary measurements included TT-TG, TFR, medial and lateral PTS, and knee flexion angle. Group differences as well as factors predictive of sTTTG were analyzed. Results: The ACLR failure group demonstrated a significantly lower sTTTG distance compared to controls (0.5 ± 4.6 mm vs. 2.4 ± 4.8 mm, p = 0.001). Logistic regression analysis revealed that a 1 mm increase in sTTTG was associated with an 8% reduction in revision risk (OR = 0.93 per 1 mm increase; 95% CI, 0.88–0.97; p = 0.003), although the predictive accuracy was low (AUC = 0.6). Multivariable analysis identified lateral PTS and knee flexion as significant independent predictors of sTTTG. Conclusions: A decreased sTTTG distance was significantly associated with ACL graft failure, underscoring the relevance of sagittal tibial tubercle positioning in ACL biomechanics. While not an independent clinical decision-making tool, sTTTG appears relevant to graft failure and may be considered in future risk assessment strategies.

]]> Effect of Sagittal TTTG on Graft Failure After Anterior Cruciate Ligament Reconstruction Sebastian Schmidt Chilan B. G. Leite Domenico Franco Ali Darwich Cale A. Jacobs Christian Lattermann doi: 10.3390/surgeries7020068 Surgeries 2026-06-09 Surgeries 2026-06-09 7 2 Article 68 10.3390/surgeries7020068 https://www.mdpi.com/2673-4095/7/2/68 Surgeries, Vol. 7, Pages 67: Artificial Intelligence-Based Prediction of Surgeon Stress in Robot-Assisted Minimally Invasive Surgery Using ECG Sensor Data https://www.mdpi.com/2673-4095/7/2/67 Background/Objectives: Robot-assisted surgery (RAS) has grown rapidly over the past few decades. To determine the effect of high stress levels on the performance of RAS, monitoring some parameters of surgeons is critical. This can be aided by the development of Artificial Intelligence (AI), which has exponentially grown in recent years. This study aims to predict the surgeon’s stress level based on ergonomic, kinematic and physiological parameters of the surgeon obtained in the immediately previous situation during RAS activities. Methods: Physiological data were recorded from surgeons during twenty-six surgical sessions involving twelve participants with different levels of experience and surgical specialties. After dataset generation, two preprocessing procedures (scaling and normalization) were applied to the recorded signals. The processed data were then partitioned into two subsets: 80% of the samples were used for model training and cross-validation, while the remaining 20% were reserved for testing. Six AI approaches were evaluated to build predictive models: multiple linear regression (MLR), a support vector machine (SVM), a multilayer perceptron (MLP), a convolutional neural network (CNN), random forest (RF), and a U-Net algorithm (UNET). These algorithms were trained using the training dataset and subsequently assessed on the independent test set. In addition, after each surgical session, surgeons completed a questionnaire reporting their perceived stress level, which was later compared with the stress estimates generated by the predictive models. Results: The results obtained showed that MLR and scaling pre-processing reached the highest R2 coefficients and the lowest error for each studied parameter. The results of the surgeons’ surveys were highly correlated for microsurgery activities (R2 = 0.7989) and for laparoscopy RAS (R2 = 0.8381). Conclusions: The linear models proposed were correctly validated on cross-validation and the test dataset. This fact demonstrates the possibility of predicting factors that help us to improve the surgeon’s health during RAS. 2026-06-04 Surgeries, Vol. 7, Pages 67: Artificial Intelligence-Based Prediction of Surgeon Stress in Robot-Assisted Minimally Invasive Surgery Using ECG Sensor Data

Surgeries doi: 10.3390/surgeries7020067

Authors: Daniel Caballero Manuel J. Pérez-Salazar Juan A. Sánchez-Margallo Francisco M. Sánchez-Margallo

Background/Objectives: Robot-assisted surgery (RAS) has grown rapidly over the past few decades. To determine the effect of high stress levels on the performance of RAS, monitoring some parameters of surgeons is critical. This can be aided by the development of Artificial Intelligence (AI), which has exponentially grown in recent years. This study aims to predict the surgeon’s stress level based on ergonomic, kinematic and physiological parameters of the surgeon obtained in the immediately previous situation during RAS activities. Methods: Physiological data were recorded from surgeons during twenty-six surgical sessions involving twelve participants with different levels of experience and surgical specialties. After dataset generation, two preprocessing procedures (scaling and normalization) were applied to the recorded signals. The processed data were then partitioned into two subsets: 80% of the samples were used for model training and cross-validation, while the remaining 20% were reserved for testing. Six AI approaches were evaluated to build predictive models: multiple linear regression (MLR), a support vector machine (SVM), a multilayer perceptron (MLP), a convolutional neural network (CNN), random forest (RF), and a U-Net algorithm (UNET). These algorithms were trained using the training dataset and subsequently assessed on the independent test set. In addition, after each surgical session, surgeons completed a questionnaire reporting their perceived stress level, which was later compared with the stress estimates generated by the predictive models. Results: The results obtained showed that MLR and scaling pre-processing reached the highest R2 coefficients and the lowest error for each studied parameter. The results of the surgeons’ surveys were highly correlated for microsurgery activities (R2 = 0.7989) and for laparoscopy RAS (R2 = 0.8381). Conclusions: The linear models proposed were correctly validated on cross-validation and the test dataset. This fact demonstrates the possibility of predicting factors that help us to improve the surgeon’s health during RAS.

]]> Artificial Intelligence-Based Prediction of Surgeon Stress in Robot-Assisted Minimally Invasive Surgery Using ECG Sensor Data Daniel Caballero Manuel J. Pérez-Salazar Juan A. Sánchez-Margallo Francisco M. Sánchez-Margallo doi: 10.3390/surgeries7020067 Surgeries 2026-06-04 Surgeries 2026-06-04 7 2 Article 67 10.3390/surgeries7020067 https://www.mdpi.com/2673-4095/7/2/67 Surgeries, Vol. 7, Pages 66: From Recurrent Interstitial Pregnancy to Term Delivery: A Case Report of Eccentric Implantation near a Previous Interstitial Surgical Site https://www.mdpi.com/2673-4095/7/2/66 Background: Interstitial ectopic pregnancy (IEP) is a rare but potentially life-threatening form of ectopic pregnancy because rupture can result in catastrophic hemorrhage. Accurate diagnosis is particularly challenging when implantation occurs near a previously operated interstitial/cornual region, where postoperative scarring and anatomical distortion may mimic recurrent IEP. We report a case of two surgically managed interstitial/cornual pregnancies at the same anatomical site, followed by a third pregnancy that initially appeared to be recurrent IEP but ultimately progressed to term delivery. Case Presentation: A 35-year-old woman underwent IVF-ET after unsuccessful intrauterine insemination and a prior failed IVF-ET attempt. After a missed abortion from the second IVF-ET cycle requiring dilatation and curettage, she conceived again through a third IVF-ET cycle. Transvaginal ultrasound demonstrated a gestational sac in the right interstitial/cornual region with outward bulging, thinning of the overlying myometrium, and delayed embryonic growth. Because of the high risk of rupture, laparoscopic wedge-shaped excision of the bulging gestational sac with uterine repair was performed. Three months later, she conceived spontaneously, and the gestational sac again developed at the previous interstitial/cornual surgical site. The surrounding myometrium was extremely thin, and serum β-hCG increased despite methotrexate treatment. Laparoscopic cornuostomy with right salpingectomy was therefore performed. After another 3-month recovery period, she conceived spontaneously again. The third pregnancy was initially suspected to represent recurrent IEP because the gestational sac was located near the same right posterior interstitial/cornual region. However, unlike the previous pregnancies, the gestational sac maintained broad contact with the endometrial cavity, showed no narrowed connection, preserved myometrial thickness of at least 5 mm, and expanded inward toward the uterine cavity rather than outward. With intensive ultrasound surveillance and fully informed consent, expectant management was continued. A healthy male infant weighing 2930 g was delivered by planned cesarean section at 37 + 0 weeks of gestation. Conclusions: This case highlights the importance of serial sonographic assessment in pregnancies suspected to be recurrent IEP. In a surgically altered cornual region, eccentric intrauterine implantation may mimic recurrent interstitial ectopic pregnancy at initial presentation. Broad communication with the endometrial cavity, absence of a narrowed connection, maintained myometrial thickness, and inward progression may help distinguish such cases from true recurrent IEP. Expectant management should be considered only in exceptional cases with hemodynamic stability, intensive imaging surveillance, immediate surgical availability, and fully informed patient consent. 2026-05-31 Surgeries, Vol. 7, Pages 66: From Recurrent Interstitial Pregnancy to Term Delivery: A Case Report of Eccentric Implantation near a Previous Interstitial Surgical Site

Surgeries doi: 10.3390/surgeries7020066

Authors: Jeong-A Hong Hyo Sang Han Dongsoo Jeon

Background: Interstitial ectopic pregnancy (IEP) is a rare but potentially life-threatening form of ectopic pregnancy because rupture can result in catastrophic hemorrhage. Accurate diagnosis is particularly challenging when implantation occurs near a previously operated interstitial/cornual region, where postoperative scarring and anatomical distortion may mimic recurrent IEP. We report a case of two surgically managed interstitial/cornual pregnancies at the same anatomical site, followed by a third pregnancy that initially appeared to be recurrent IEP but ultimately progressed to term delivery. Case Presentation: A 35-year-old woman underwent IVF-ET after unsuccessful intrauterine insemination and a prior failed IVF-ET attempt. After a missed abortion from the second IVF-ET cycle requiring dilatation and curettage, she conceived again through a third IVF-ET cycle. Transvaginal ultrasound demonstrated a gestational sac in the right interstitial/cornual region with outward bulging, thinning of the overlying myometrium, and delayed embryonic growth. Because of the high risk of rupture, laparoscopic wedge-shaped excision of the bulging gestational sac with uterine repair was performed. Three months later, she conceived spontaneously, and the gestational sac again developed at the previous interstitial/cornual surgical site. The surrounding myometrium was extremely thin, and serum β-hCG increased despite methotrexate treatment. Laparoscopic cornuostomy with right salpingectomy was therefore performed. After another 3-month recovery period, she conceived spontaneously again. The third pregnancy was initially suspected to represent recurrent IEP because the gestational sac was located near the same right posterior interstitial/cornual region. However, unlike the previous pregnancies, the gestational sac maintained broad contact with the endometrial cavity, showed no narrowed connection, preserved myometrial thickness of at least 5 mm, and expanded inward toward the uterine cavity rather than outward. With intensive ultrasound surveillance and fully informed consent, expectant management was continued. A healthy male infant weighing 2930 g was delivered by planned cesarean section at 37 + 0 weeks of gestation. Conclusions: This case highlights the importance of serial sonographic assessment in pregnancies suspected to be recurrent IEP. In a surgically altered cornual region, eccentric intrauterine implantation may mimic recurrent interstitial ectopic pregnancy at initial presentation. Broad communication with the endometrial cavity, absence of a narrowed connection, maintained myometrial thickness, and inward progression may help distinguish such cases from true recurrent IEP. Expectant management should be considered only in exceptional cases with hemodynamic stability, intensive imaging surveillance, immediate surgical availability, and fully informed patient consent.

]]> From Recurrent Interstitial Pregnancy to Term Delivery: A Case Report of Eccentric Implantation near a Previous Interstitial Surgical Site Jeong-A Hong Hyo Sang Han Dongsoo Jeon doi: 10.3390/surgeries7020066 Surgeries 2026-05-31 Surgeries 2026-05-31 7 2 Case Report 66 10.3390/surgeries7020066 https://www.mdpi.com/2673-4095/7/2/66 Surgeries, Vol. 7, Pages 65: Outcomes and Predictors of Recurrence Following Open Fasciectomy for Dupuytren’s Disease: A Cohort Study from an Australian Tertiary Centre https://www.mdpi.com/2673-4095/7/2/65 Background/Objectives: Open fasciectomy is the standard treatment for Dupuytren’s disease, but recent Australian outcome data are scarce. This study assessed outcomes and predictors of recurrence after open fasciectomy at a tertiary centre. Methods: We retrospectively reviewed all open fasciectomy procedures for Dupuytren’s disease at Peninsula Health, Victoria (January 2023–October 2024). Data included contracture correction, functional scores (URAM, Southampton), recurrence at 6 and 12 months, complications, and demographic predictors. Appropriate statistical tests were used (significance: p < 0.05). Results: Among 152 procedures (mean age 63.8; 70.2% male), contracture correction was significant for all joints. URAM and Southampton scores improved by 15.3 and 7.6 points (p < 0.001). Complications (22.4%) were mainly transient neuropraxia. Recurrence was 10.5% at six months and 13.8% at twelve months. Smoking and female sex increased recurrence risk. Conclusions: Open fasciectomy provides effective correction, functional gain, and low early recurrence rates. Smoking and female sex predict recurrence, supporting tailored counselling and reaffirming open fasciectomy as the standard for advanced Dupuytren’s disease. 2026-05-30 Surgeries, Vol. 7, Pages 65: Outcomes and Predictors of Recurrence Following Open Fasciectomy for Dupuytren’s Disease: A Cohort Study from an Australian Tertiary Centre

Surgeries doi: 10.3390/surgeries7020065

Authors: Ishith Seth Akshay Soni Omar Shadid James Venturini Angus Skeen Sai-Vignesh Ashok Richard J. Ross Warren M. Rozen

Background/Objectives: Open fasciectomy is the standard treatment for Dupuytren’s disease, but recent Australian outcome data are scarce. This study assessed outcomes and predictors of recurrence after open fasciectomy at a tertiary centre. Methods: We retrospectively reviewed all open fasciectomy procedures for Dupuytren’s disease at Peninsula Health, Victoria (January 2023–October 2024). Data included contracture correction, functional scores (URAM, Southampton), recurrence at 6 and 12 months, complications, and demographic predictors. Appropriate statistical tests were used (significance: p < 0.05). Results: Among 152 procedures (mean age 63.8; 70.2% male), contracture correction was significant for all joints. URAM and Southampton scores improved by 15.3 and 7.6 points (p < 0.001). Complications (22.4%) were mainly transient neuropraxia. Recurrence was 10.5% at six months and 13.8% at twelve months. Smoking and female sex increased recurrence risk. Conclusions: Open fasciectomy provides effective correction, functional gain, and low early recurrence rates. Smoking and female sex predict recurrence, supporting tailored counselling and reaffirming open fasciectomy as the standard for advanced Dupuytren’s disease.

]]> Outcomes and Predictors of Recurrence Following Open Fasciectomy for Dupuytren’s Disease: A Cohort Study from an Australian Tertiary Centre Ishith Seth Akshay Soni Omar Shadid James Venturini Angus Skeen Sai-Vignesh Ashok Richard J. Ross Warren M. Rozen doi: 10.3390/surgeries7020065 Surgeries 2026-05-30 Surgeries 2026-05-30 7 2 Article 65 10.3390/surgeries7020065 https://www.mdpi.com/2673-4095/7/2/65 Surgeries, Vol. 7, Pages 64: The Safety and Efficacy of Epinephrine-Added Irrigation Fluid in Arthroscopic ACL Reconstruction: A Systematic Review and Meta-Analysis https://www.mdpi.com/2673-4095/7/2/64 Background/Objectives: Anterior cruciate ligament (ACL) injuries are common in sports; they can be seen with an arthroscope in more than half of instances of acute traumatic hemarthrosis and are frequently associated with meniscal tears. By reducing soft tissue injury and enabling faster recovery while attaining comparable long-term outcomes, the switch from open surgery to arthroscopic ACL repair (ACLR) has transformed treatment. However, maintaining efficient intra-articular visualization is essential for both patient safety and surgical precision. Methods: Using the PRISMA guidelines, a comprehensive systematic search was conducted across major medical databases, including PubMed, Web of Science, and ScienceDirect. The search strategy incorporated key terms such as epinephrine, irrigation fluid, and ACL reconstruction to identify relevant studies. The study focused on English-language clinical studies within the last 10 years that clearly assessed the safety and efficacy of epinephrine-added irrigation in ACL repair. The study design, patient demographics, specific outcomes (visualization, operation time, hemodynamics), and statistical findings were all carefully retrieved. The results were combined to determine the intervention’s safety profile and clinical value. Results: The pooled analysis demonstrated that the intervention group significantly decreased operating time (SMD = −0.51, 95% CI: −0.90 to −0.12, p = 0.01; I2 = 24%). However, postoperative knee function showed no statistically significant difference between groups (OR = 1.80, 95% CI: 0.61 to 5.30, p = 0.29; I2 = 0%). Postoperative pain levels also did not differ significantly between groups (SMD = −0.27, 95% CI: −0.63 to 0.09, p = 0.14; I2 = 0%). Heterogeneity was low across all analyses (I2 = 0–24%). Conclusions: Low-dose epinephrine in irrigation fluid significantly reduces operative time during arthroscopic ACL reconstruction, suggesting improved surgical efficiency. However, it does not significantly improve postoperative knee function or reduce pain compared to control irrigation. The intervention appears to be a reasonable alternative to tourniquets without major systemic cardiovascular effects. Nevertheless, preclinical data indicate potential chondrotoxicity. Therefore, while epinephrine can be considered to improve operating efficiency and reduce tourniquet-related problems, surgeons should weigh its use cautiously, especially in younger patients or those with susceptible cartilage. 2026-05-29 Surgeries, Vol. 7, Pages 64: The Safety and Efficacy of Epinephrine-Added Irrigation Fluid in Arthroscopic ACL Reconstruction: A Systematic Review and Meta-Analysis

Surgeries doi: 10.3390/surgeries7020064

Authors: Hadeel Rshash Almutairi Abdullah Fahad Alkhalifah Rahaf Masaad Almutairi Wajd Fahad Alkhalifah Osama Omar Albladi Abdullah Saleh Almutairi Khaled Ghazzai Almutairi Moneerah Madallah Al-Harbi Ali Saud Alsaud Abdullah H. Alshahrani Ismail Hamad Almogbil

Background/Objectives: Anterior cruciate ligament (ACL) injuries are common in sports; they can be seen with an arthroscope in more than half of instances of acute traumatic hemarthrosis and are frequently associated with meniscal tears. By reducing soft tissue injury and enabling faster recovery while attaining comparable long-term outcomes, the switch from open surgery to arthroscopic ACL repair (ACLR) has transformed treatment. However, maintaining efficient intra-articular visualization is essential for both patient safety and surgical precision. Methods: Using the PRISMA guidelines, a comprehensive systematic search was conducted across major medical databases, including PubMed, Web of Science, and ScienceDirect. The search strategy incorporated key terms such as epinephrine, irrigation fluid, and ACL reconstruction to identify relevant studies. The study focused on English-language clinical studies within the last 10 years that clearly assessed the safety and efficacy of epinephrine-added irrigation in ACL repair. The study design, patient demographics, specific outcomes (visualization, operation time, hemodynamics), and statistical findings were all carefully retrieved. The results were combined to determine the intervention’s safety profile and clinical value. Results: The pooled analysis demonstrated that the intervention group significantly decreased operating time (SMD = −0.51, 95% CI: −0.90 to −0.12, p = 0.01; I2 = 24%). However, postoperative knee function showed no statistically significant difference between groups (OR = 1.80, 95% CI: 0.61 to 5.30, p = 0.29; I2 = 0%). Postoperative pain levels also did not differ significantly between groups (SMD = −0.27, 95% CI: −0.63 to 0.09, p = 0.14; I2 = 0%). Heterogeneity was low across all analyses (I2 = 0–24%). Conclusions: Low-dose epinephrine in irrigation fluid significantly reduces operative time during arthroscopic ACL reconstruction, suggesting improved surgical efficiency. However, it does not significantly improve postoperative knee function or reduce pain compared to control irrigation. The intervention appears to be a reasonable alternative to tourniquets without major systemic cardiovascular effects. Nevertheless, preclinical data indicate potential chondrotoxicity. Therefore, while epinephrine can be considered to improve operating efficiency and reduce tourniquet-related problems, surgeons should weigh its use cautiously, especially in younger patients or those with susceptible cartilage.

]]> The Safety and Efficacy of Epinephrine-Added Irrigation Fluid in Arthroscopic ACL Reconstruction: A Systematic Review and Meta-Analysis Hadeel Rshash Almutairi Abdullah Fahad Alkhalifah Rahaf Masaad Almutairi Wajd Fahad Alkhalifah Osama Omar Albladi Abdullah Saleh Almutairi Khaled Ghazzai Almutairi Moneerah Madallah Al-Harbi Ali Saud Alsaud Abdullah H. Alshahrani Ismail Hamad Almogbil doi: 10.3390/surgeries7020064 Surgeries 2026-05-29 Surgeries 2026-05-29 7 2 Systematic Review 64 10.3390/surgeries7020064 https://www.mdpi.com/2673-4095/7/2/64 Surgeries, Vol. 7, Pages 63: Wedge-Shaped Rib Detachment: A Simple Modification for Better Access to the Aortic Valve in Right Anterior Minimally Invasive Aortic Valve Replacement https://www.mdpi.com/2673-4095/7/2/63 Background/Objectives: Minimally invasive aortic valve replacement via right anterior thoracotomy (Mini-AVR) has been proven safe and effective. However, the restricted surgical field through this approach makes this surgery challenging and therefore limits its application. A simple modification of an exposure technique involving third-rib detachment from the sternum in a wedge shape allows for expansion of the surgical field to the left, facilitating surgical exposure and performance, which may shorten the learning curve for surgeons, and make this surgery applicable to patients with less favorable anatomy. Methods: This is a retrospective study. From 2019 to 2024, 176 patients aged 62.9 ± 17.5 years old underwent Mini-AVR via right anterior thoracotomy with third-rib detachment at our hospital in Vietnam. Results: A mechanical prosthesis was used in 98 patients (55.7%) and bioprosthesis in 78 patients (44.3%). Leftward and deep aorta position were seen in 57 (32.4%) and 18 (10.2%) patients, respectively. The aortic cross-clamp and bypass time were 78.69 ± 24.1 and 128.1 ± 26.3 min, respectively. Root enlargement was performed in 2 patients (1.1%). Conclusions: Wedge-shape detachment of the third rib from the sternum in Mini-AVR allows for expansion of the surgical field to the left, facilitating surgical exposure and performance, especially in patients with less favorable anatomy. 2026-05-28 Surgeries, Vol. 7, Pages 63: Wedge-Shaped Rib Detachment: A Simple Modification for Better Access to the Aortic Valve in Right Anterior Minimally Invasive Aortic Valve Replacement

Surgeries doi: 10.3390/surgeries7020063

Authors: Hien Sinh Nguyen Ngoc Minh Nguyen Kien The Nguyen Thang Duc Vu

Background/Objectives: Minimally invasive aortic valve replacement via right anterior thoracotomy (Mini-AVR) has been proven safe and effective. However, the restricted surgical field through this approach makes this surgery challenging and therefore limits its application. A simple modification of an exposure technique involving third-rib detachment from the sternum in a wedge shape allows for expansion of the surgical field to the left, facilitating surgical exposure and performance, which may shorten the learning curve for surgeons, and make this surgery applicable to patients with less favorable anatomy. Methods: This is a retrospective study. From 2019 to 2024, 176 patients aged 62.9 ± 17.5 years old underwent Mini-AVR via right anterior thoracotomy with third-rib detachment at our hospital in Vietnam. Results: A mechanical prosthesis was used in 98 patients (55.7%) and bioprosthesis in 78 patients (44.3%). Leftward and deep aorta position were seen in 57 (32.4%) and 18 (10.2%) patients, respectively. The aortic cross-clamp and bypass time were 78.69 ± 24.1 and 128.1 ± 26.3 min, respectively. Root enlargement was performed in 2 patients (1.1%). Conclusions: Wedge-shape detachment of the third rib from the sternum in Mini-AVR allows for expansion of the surgical field to the left, facilitating surgical exposure and performance, especially in patients with less favorable anatomy.

]]> Wedge-Shaped Rib Detachment: A Simple Modification for Better Access to the Aortic Valve in Right Anterior Minimally Invasive Aortic Valve Replacement Hien Sinh Nguyen Ngoc Minh Nguyen Kien The Nguyen Thang Duc Vu doi: 10.3390/surgeries7020063 Surgeries 2026-05-28 Surgeries 2026-05-28 7 2 Article 63 10.3390/surgeries7020063 https://www.mdpi.com/2673-4095/7/2/63 Surgeries, Vol. 7, Pages 62: Maxillary Resection Prosthesis Retained by Telescopic Crowns and a Rotational Latching Mechanism: A Case Report https://www.mdpi.com/2673-4095/7/2/62 Context: Prosthetic rehabilitation of acquired maxillary defects with Maxillary Resection Prostheses (MRPs) remains biomechanically challenging, particularly in partially edentulous patients, where conventional clasp-retained designs often yield suboptimal retention, stability, and functional outcomes. Research Gap: The integration of telescopic crown systems with semi-precision attachments incorporating a rotational latching mechanism has not been previously described as a unified approach to optimise load distribution and prosthesis stability in maxillary defect rehabilitation. Objective: To describe and clinically evaluate a novel prosthetic design combining telescopic crowns and a semi-precision rotational latching attachment to enhance retention, stability, and functional performance of MRPs. Methodology: A 31-year-old patient with a unilateral maxillary defect following partial maxillectomy presented with an unstable interim prosthesis and impaired speech and mastication. A definitive MRP was designed using telescopic crowns on the remaining dentition to establish a controlled path of insertion and improved axial load transfer. A semi-precision attachment with a key–keyway rotational latching mechanism was incorporated into the secondary framework to engage specific undercuts while minimising lateral forces on abutment teeth. A provisional prosthesis was used for 3 months to evaluate base extension, phonetics, and functional parameters before fabrication of the definitive prosthesis. Results: Serial follow-up at 1, 3, and 6 months demonstrate consistent prosthesis stability, precise seating, and favourable retention. Marked improvements were observed in speech intelligibility, masticatory efficiency, and patient-reported comfort. Conclusions: This combined prosthetic strategy represents a novel and biomechanically optimised approach for the rehabilitation of partially edentulous maxillary defects, with promising clinical and functional outcomes. 2026-05-24 Surgeries, Vol. 7, Pages 62: Maxillary Resection Prosthesis Retained by Telescopic Crowns and a Rotational Latching Mechanism: A Case Report

Surgeries doi: 10.3390/surgeries7020062

Authors: Panagiota Chatzidou Savvas Kamalakidis John Fanourgiakis Mathildi Tsekou Olga Naka

Context: Prosthetic rehabilitation of acquired maxillary defects with Maxillary Resection Prostheses (MRPs) remains biomechanically challenging, particularly in partially edentulous patients, where conventional clasp-retained designs often yield suboptimal retention, stability, and functional outcomes. Research Gap: The integration of telescopic crown systems with semi-precision attachments incorporating a rotational latching mechanism has not been previously described as a unified approach to optimise load distribution and prosthesis stability in maxillary defect rehabilitation. Objective: To describe and clinically evaluate a novel prosthetic design combining telescopic crowns and a semi-precision rotational latching attachment to enhance retention, stability, and functional performance of MRPs. Methodology: A 31-year-old patient with a unilateral maxillary defect following partial maxillectomy presented with an unstable interim prosthesis and impaired speech and mastication. A definitive MRP was designed using telescopic crowns on the remaining dentition to establish a controlled path of insertion and improved axial load transfer. A semi-precision attachment with a key–keyway rotational latching mechanism was incorporated into the secondary framework to engage specific undercuts while minimising lateral forces on abutment teeth. A provisional prosthesis was used for 3 months to evaluate base extension, phonetics, and functional parameters before fabrication of the definitive prosthesis. Results: Serial follow-up at 1, 3, and 6 months demonstrate consistent prosthesis stability, precise seating, and favourable retention. Marked improvements were observed in speech intelligibility, masticatory efficiency, and patient-reported comfort. Conclusions: This combined prosthetic strategy represents a novel and biomechanically optimised approach for the rehabilitation of partially edentulous maxillary defects, with promising clinical and functional outcomes.

]]> Maxillary Resection Prosthesis Retained by Telescopic Crowns and a Rotational Latching Mechanism: A Case Report Panagiota Chatzidou Savvas Kamalakidis John Fanourgiakis Mathildi Tsekou Olga Naka doi: 10.3390/surgeries7020062 Surgeries 2026-05-24 Surgeries 2026-05-24 7 2 Case Report 62 10.3390/surgeries7020062 https://www.mdpi.com/2673-4095/7/2/62 Surgeries, Vol. 7, Pages 61: From Imaging to Implementation: Computed-Tomography-Based Surgical Artificial Intelligence Using DIEP Flap Reconstruction as a Model System https://www.mdpi.com/2673-4095/7/2/61 Background/Objectives: Artificial intelligence (AI) is increasingly proposed to improve surgical planning, guidance, and postoperative surveillance. Yet many promising applications remain disconnected from the full surgical pathway and the feasible limitations of clinical deployment. In contrast to prior reviews that primarily catalog AI use cases, this review combines the literature to define the translational pathway—from label design through staged validation to workflow integration—required for clinically deployable computed tomography (CT)-based surgical AI. CT and particularly computed tomography angiography (CTA) are especially usable sources for surgical AI because they provide a standardized three-dimensional anatomic model that is already embedded in many clinical workflows. In autologous breast reconstruction, deep inferior epigastric perforator (DIEP) flap CTA offers an unusually strong model system: the anatomy is discrete, surgeon decisions are actionable, and downstream operative and postoperative outcomes are measurable. These characteristics make DIEP reconstruction suitable not only for technical model development, but also for exacting testing of how CT-based AI should be annotated, validated, displayed, and governed. Methods: This focused narrative review combines evidence across the surgical workflow, spanning preoperative planning and risk stratification, intraoperative support, and postoperative monitoring. Reporting standards, implementation frameworks, governance, and regulatory sources were also considered when directly relevant to clinical deployment. Results: Across the available literature on breast reconstruction with the DIEP flap, preoperative CTA has been associated with reductions in operative time of approximately 54–76 min in individual studies. Semi-automated perforator mapping can reduce review time from 2 to 3 h to approximately 30 min. Intraoperative extended-reality tools and surgeon-facing navigation systems illustrate the importance of the ‘last mile’ of translation, while postoperative monitoring models show how imaging-linked data can support a closed-loop learning system. Across these stages, recurring limits include target mismatch, weak external validation, protocol variability, inconsistent reporting, limited subgroup analysis, and inadequate integration of economic and governance considerations. Conclusions: We argue that the next important step is not a generic autonomous model, but a clinically deployable DIEP-CTA-AI program. The practical blueprint proposed here is staged: structured anatomical labels, separate imaging, surgeons’ decisions, and outcome reference standards, dense intermediate endpoints, retrospective and external validation, reader studies, prospective silent deployment, and workflow-impact assessment. If implemented in this way, DIEP flap CTA can serve as a practical blueprint for CT-based AI translation in surgery more broadly. 2026-05-20 Surgeries, Vol. 7, Pages 61: From Imaging to Implementation: Computed-Tomography-Based Surgical Artificial Intelligence Using DIEP Flap Reconstruction as a Model System

Surgeries doi: 10.3390/surgeries7020061

Authors: Carlotta E. R. Keunecke Nikolaus Watzinger Gabriel Hundeshagen Jochen-Frederick Hernekamp Valentin F. M. Haug

Background/Objectives: Artificial intelligence (AI) is increasingly proposed to improve surgical planning, guidance, and postoperative surveillance. Yet many promising applications remain disconnected from the full surgical pathway and the feasible limitations of clinical deployment. In contrast to prior reviews that primarily catalog AI use cases, this review combines the literature to define the translational pathway—from label design through staged validation to workflow integration—required for clinically deployable computed tomography (CT)-based surgical AI. CT and particularly computed tomography angiography (CTA) are especially usable sources for surgical AI because they provide a standardized three-dimensional anatomic model that is already embedded in many clinical workflows. In autologous breast reconstruction, deep inferior epigastric perforator (DIEP) flap CTA offers an unusually strong model system: the anatomy is discrete, surgeon decisions are actionable, and downstream operative and postoperative outcomes are measurable. These characteristics make DIEP reconstruction suitable not only for technical model development, but also for exacting testing of how CT-based AI should be annotated, validated, displayed, and governed. Methods: This focused narrative review combines evidence across the surgical workflow, spanning preoperative planning and risk stratification, intraoperative support, and postoperative monitoring. Reporting standards, implementation frameworks, governance, and regulatory sources were also considered when directly relevant to clinical deployment. Results: Across the available literature on breast reconstruction with the DIEP flap, preoperative CTA has been associated with reductions in operative time of approximately 54–76 min in individual studies. Semi-automated perforator mapping can reduce review time from 2 to 3 h to approximately 30 min. Intraoperative extended-reality tools and surgeon-facing navigation systems illustrate the importance of the ‘last mile’ of translation, while postoperative monitoring models show how imaging-linked data can support a closed-loop learning system. Across these stages, recurring limits include target mismatch, weak external validation, protocol variability, inconsistent reporting, limited subgroup analysis, and inadequate integration of economic and governance considerations. Conclusions: We argue that the next important step is not a generic autonomous model, but a clinically deployable DIEP-CTA-AI program. The practical blueprint proposed here is staged: structured anatomical labels, separate imaging, surgeons’ decisions, and outcome reference standards, dense intermediate endpoints, retrospective and external validation, reader studies, prospective silent deployment, and workflow-impact assessment. If implemented in this way, DIEP flap CTA can serve as a practical blueprint for CT-based AI translation in surgery more broadly.

]]> From Imaging to Implementation: Computed-Tomography-Based Surgical Artificial Intelligence Using DIEP Flap Reconstruction as a Model System Carlotta E. R. Keunecke Nikolaus Watzinger Gabriel Hundeshagen Jochen-Frederick Hernekamp Valentin F. M. Haug doi: 10.3390/surgeries7020061 Surgeries 2026-05-20 Surgeries 2026-05-20 7 2 Review 61 10.3390/surgeries7020061 https://www.mdpi.com/2673-4095/7/2/61 Surgeries, Vol. 7, Pages 60: Reconstruction of Elbow Soft-Tissue Defects Using the Reverse Lateral Arm Flap: A Case Series https://www.mdpi.com/2673-4095/7/2/60 Background: Complex elbow soft-tissue defects often combine exposed critical structures, unstable scars, and high mechanical stress, making durable coverage and early mobilization challenging. Among regional options, the reverse lateral arm flap provides thin fasciocutaneous tissue based on a reliable collateral circulation and preserves major forearm vessels. The aim of this study was to report our single-center experience with the pedicled reverse lateral arm flap for elbow soft-tissue reconstruction, focusing on stable coverage, donor-site morbidity, and functional recovery. Methods: A retrospective single-center case series was conducted at the Division of Plastic Surgery, University Hospital of Padua, Italy. All consecutive patients treated between 2013 and 2023 with a pedicled reverse lateral arm flap for elbow soft-tissue defects were included. Recorded variables included defect etiology, donor-site management, complications, range of motion, and follow-up. Elbow flexion–extension was recorded clinically preoperatively and at last follow-up. Minimum follow-up was 12 months in all patients. Results: Seven patients underwent reconstruction. Defect etiology was burn-related in four cases, shotgun trauma in one, crush injury in one, and melanoma resection in one. All defects were covered with a pedicled reverse lateral arm flap. All flaps survived completely without partial necrosis or flap-related reoperation. Donor-site closure was primary in four patients and required split-thickness skin grafting in three. One patient developed donor-site keloid, and one had donor-site skin-graft partial loss with delayed healing. Elbow flexion–extension improved in all seven cases, with a median gain in arc of motion of 25° (range 15–41°). Conclusions: In this series, the reverse lateral arm flap provided complete coverage of selected elbow defects with preserved motion and limited donor-site morbidity at a minimum follow-up of 12 months. Our findings suggest that it may represent a useful regional option in selected posterior and lateral elbow defects, particularly in post-burn and traumatic settings where thin vascularized tissue is needed, and free-flap reconstruction may be avoidable. 2026-05-11 Surgeries, Vol. 7, Pages 60: Reconstruction of Elbow Soft-Tissue Defects Using the Reverse Lateral Arm Flap: A Case Series

Surgeries doi: 10.3390/surgeries7020060

Authors: Pasquale Zona Luca Folini Alfio Luca Costa Daniele Brunelli Francesca Mazzarella Franco Bassetto Cesare Tiengo

Background: Complex elbow soft-tissue defects often combine exposed critical structures, unstable scars, and high mechanical stress, making durable coverage and early mobilization challenging. Among regional options, the reverse lateral arm flap provides thin fasciocutaneous tissue based on a reliable collateral circulation and preserves major forearm vessels. The aim of this study was to report our single-center experience with the pedicled reverse lateral arm flap for elbow soft-tissue reconstruction, focusing on stable coverage, donor-site morbidity, and functional recovery. Methods: A retrospective single-center case series was conducted at the Division of Plastic Surgery, University Hospital of Padua, Italy. All consecutive patients treated between 2013 and 2023 with a pedicled reverse lateral arm flap for elbow soft-tissue defects were included. Recorded variables included defect etiology, donor-site management, complications, range of motion, and follow-up. Elbow flexion–extension was recorded clinically preoperatively and at last follow-up. Minimum follow-up was 12 months in all patients. Results: Seven patients underwent reconstruction. Defect etiology was burn-related in four cases, shotgun trauma in one, crush injury in one, and melanoma resection in one. All defects were covered with a pedicled reverse lateral arm flap. All flaps survived completely without partial necrosis or flap-related reoperation. Donor-site closure was primary in four patients and required split-thickness skin grafting in three. One patient developed donor-site keloid, and one had donor-site skin-graft partial loss with delayed healing. Elbow flexion–extension improved in all seven cases, with a median gain in arc of motion of 25° (range 15–41°). Conclusions: In this series, the reverse lateral arm flap provided complete coverage of selected elbow defects with preserved motion and limited donor-site morbidity at a minimum follow-up of 12 months. Our findings suggest that it may represent a useful regional option in selected posterior and lateral elbow defects, particularly in post-burn and traumatic settings where thin vascularized tissue is needed, and free-flap reconstruction may be avoidable.

]]> Reconstruction of Elbow Soft-Tissue Defects Using the Reverse Lateral Arm Flap: A Case Series Pasquale Zona Luca Folini Alfio Luca Costa Daniele Brunelli Francesca Mazzarella Franco Bassetto Cesare Tiengo doi: 10.3390/surgeries7020060 Surgeries 2026-05-11 Surgeries 2026-05-11 7 2 Article 60 10.3390/surgeries7020060 https://www.mdpi.com/2673-4095/7/2/60 Surgeries, Vol. 7, Pages 59: Total Reconstruction of the Donor Site After Toe-to-Thumb Transfer: Introducing a Novel Technique https://www.mdpi.com/2673-4095/7/2/59 Traumatic thumb loss causes severe functional impairment, as the thumb provides approximately 40% of total hand function. Toe-to-thumb transfer remains the gold standard for thumb reconstruction, yet donor site morbidity represents a significant functional and aesthetic limitation. A total thumb reconstruction using a “trimmed” right great toe transfer, combined with immediate donor site reconstruction using a free SCIP (superficial circumflex iliac perforator) flap and iliac crest bone graft. The flap was designed as a tubular skin island to create a neo-hallux with optimal contour and volume, minimizing visible scarring and avoiding microcirculatory compression. The patient, a 33-year-old man with post-traumatic thumb avulsion, underwent delayed reconstruction three months after injury. The postoperative course was uneventful, with no vascular or wound complications. At 12 months, he resumed full ambulation and manual activities, including motorcycle driving and work tasks. Baropodometric analysis demonstrated symmetric load distribution and gait dynamics. Thumb opposition was satisfactory (Kapandji score: seven); the patient rated the aesthetic results as excellent. This case demonstrates that SCIP flap reconstruction with iliac crest bone graft enables complete functional and aesthetic restoration of the great toe donor site after total toe transfer. Compared to previous techniques using cross-flaps, skin grafts, or peroneal flaps, this approach minimizes morbidity, optimizes cosmetic outcomes, and preserves gait. Although representing a single case, this constitutes the first documented instance of total hallux reconstruction following toe-to-thumb transfer, emphasizing the importance of the foot as a functional and aesthetic unit and the need for donor-site preservation in microsurgical reconstructive planning. 2026-05-08 Surgeries, Vol. 7, Pages 59: Total Reconstruction of the Donor Site After Toe-to-Thumb Transfer: Introducing a Novel Technique

Surgeries doi: 10.3390/surgeries7020059

Authors: Pierfrancesco Pugliese Serafina Pepe Mara Franza Adriana Cordova

Traumatic thumb loss causes severe functional impairment, as the thumb provides approximately 40% of total hand function. Toe-to-thumb transfer remains the gold standard for thumb reconstruction, yet donor site morbidity represents a significant functional and aesthetic limitation. A total thumb reconstruction using a “trimmed” right great toe transfer, combined with immediate donor site reconstruction using a free SCIP (superficial circumflex iliac perforator) flap and iliac crest bone graft. The flap was designed as a tubular skin island to create a neo-hallux with optimal contour and volume, minimizing visible scarring and avoiding microcirculatory compression. The patient, a 33-year-old man with post-traumatic thumb avulsion, underwent delayed reconstruction three months after injury. The postoperative course was uneventful, with no vascular or wound complications. At 12 months, he resumed full ambulation and manual activities, including motorcycle driving and work tasks. Baropodometric analysis demonstrated symmetric load distribution and gait dynamics. Thumb opposition was satisfactory (Kapandji score: seven); the patient rated the aesthetic results as excellent. This case demonstrates that SCIP flap reconstruction with iliac crest bone graft enables complete functional and aesthetic restoration of the great toe donor site after total toe transfer. Compared to previous techniques using cross-flaps, skin grafts, or peroneal flaps, this approach minimizes morbidity, optimizes cosmetic outcomes, and preserves gait. Although representing a single case, this constitutes the first documented instance of total hallux reconstruction following toe-to-thumb transfer, emphasizing the importance of the foot as a functional and aesthetic unit and the need for donor-site preservation in microsurgical reconstructive planning.

]]> Total Reconstruction of the Donor Site After Toe-to-Thumb Transfer: Introducing a Novel Technique Pierfrancesco Pugliese Serafina Pepe Mara Franza Adriana Cordova doi: 10.3390/surgeries7020059 Surgeries 2026-05-08 Surgeries 2026-05-08 7 2 Case Report 59 10.3390/surgeries7020059 https://www.mdpi.com/2673-4095/7/2/59 Surgeries, Vol. 7, Pages 58: Trapeziectomy with Ligament Reconstruction and Tendon Interposition Versus Transosseous Suture Suspensionplasty for Thumb Trapeziometacarpal Osteoarthritis: A Retrospective Comparative Study https://www.mdpi.com/2673-4095/7/2/58 Background: Several surgical techniques are available for the treatment of thumb trapeziometacarpal (TMC) osteoarthritis. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is a widely accepted procedure, while suspensionplasty techniques have been introduced to improve first metacarpal stability after trapeziectomy. A simplified transosseous suture suspensionplasty (SUSP) has recently been introduced as an alternative to implant-based constructs, but comparative clinical data remain limited. This study aimed to compare the clinical and functional outcomes between LRTI and SUSP techniques in patients with TMC osteoarthritis. Methods: A retrospective comparative study was conducted on 54 consecutive patients treated surgically for TMC osteoarthritis between 2018 and 2022. Thirty-three patients underwent trapeziectomy with ligament reconstruction and tendon interposition (LRTI group), and 21 underwent trapeziectomy with transosseous suture suspensionplasty (SUSP group). At a minimum follow-up of 2 years, 44 patients were available for evaluation. Assessments were performed using DASH, 10 cm VAS, key pinch strength, Kapandji score, and radial/palmar abduction. Results: At 2 years, there were no significant between-group differences in DASH (median 4 vs. 16.5; p = 0.190), VAS (2.0 ± 2.1 vs. 2.9 ± 2.3; p = 0.235), key pinch (median 4 vs. 3 kg; p = 0.136), Kapandji score, or abduction. Both groups improved significantly over time in DASH and VAS (p < 0.001). Key pinch increased progressively in LRTI group (p < 0.001) but showed less consistent change in SUSP group. Conclusions: Both techniques provided comparable mid-term clinical and functional outcomes in patients with TMC osteoarthritis. No clear clinical advantage of suspensionplasty over tendon interposition was demonstrated. Transosseous suture suspensionplasty represents a valid alternative, while tendon interposition arthroplasty remains a reliable reference technique. 2026-05-07 Surgeries, Vol. 7, Pages 58: Trapeziectomy with Ligament Reconstruction and Tendon Interposition Versus Transosseous Suture Suspensionplasty for Thumb Trapeziometacarpal Osteoarthritis: A Retrospective Comparative Study

Surgeries doi: 10.3390/surgeries7020058

Authors: Morena Anna Basso Simona Scarpa Alessio Bernasconi Andrea Poggetti Lucian Lior Marcovici Francesco Smeraglia

Background: Several surgical techniques are available for the treatment of thumb trapeziometacarpal (TMC) osteoarthritis. Trapeziectomy with ligament reconstruction and tendon interposition (LRTI) is a widely accepted procedure, while suspensionplasty techniques have been introduced to improve first metacarpal stability after trapeziectomy. A simplified transosseous suture suspensionplasty (SUSP) has recently been introduced as an alternative to implant-based constructs, but comparative clinical data remain limited. This study aimed to compare the clinical and functional outcomes between LRTI and SUSP techniques in patients with TMC osteoarthritis. Methods: A retrospective comparative study was conducted on 54 consecutive patients treated surgically for TMC osteoarthritis between 2018 and 2022. Thirty-three patients underwent trapeziectomy with ligament reconstruction and tendon interposition (LRTI group), and 21 underwent trapeziectomy with transosseous suture suspensionplasty (SUSP group). At a minimum follow-up of 2 years, 44 patients were available for evaluation. Assessments were performed using DASH, 10 cm VAS, key pinch strength, Kapandji score, and radial/palmar abduction. Results: At 2 years, there were no significant between-group differences in DASH (median 4 vs. 16.5; p = 0.190), VAS (2.0 ± 2.1 vs. 2.9 ± 2.3; p = 0.235), key pinch (median 4 vs. 3 kg; p = 0.136), Kapandji score, or abduction. Both groups improved significantly over time in DASH and VAS (p < 0.001). Key pinch increased progressively in LRTI group (p < 0.001) but showed less consistent change in SUSP group. Conclusions: Both techniques provided comparable mid-term clinical and functional outcomes in patients with TMC osteoarthritis. No clear clinical advantage of suspensionplasty over tendon interposition was demonstrated. Transosseous suture suspensionplasty represents a valid alternative, while tendon interposition arthroplasty remains a reliable reference technique.

]]> Trapeziectomy with Ligament Reconstruction and Tendon Interposition Versus Transosseous Suture Suspensionplasty for Thumb Trapeziometacarpal Osteoarthritis: A Retrospective Comparative Study Morena Anna Basso Simona Scarpa Alessio Bernasconi Andrea Poggetti Lucian Lior Marcovici Francesco Smeraglia doi: 10.3390/surgeries7020058 Surgeries 2026-05-07 Surgeries 2026-05-07 7 2 Article 58 10.3390/surgeries7020058 https://www.mdpi.com/2673-4095/7/2/58 Surgeries, Vol. 7, Pages 57: Examining the Relationships and Differences of Satisfaction, Kinesiophobia, and Pain Between Rehabilitation Phases in Patients After Total Knee Replacement https://www.mdpi.com/2673-4095/7/2/57 Background/objectives: Total knee arthroplasty is one of the most commonly performed orthopedic procedures of the lower extremities, primarily for patients with osteoarthritis or rheumatoid arthritis. Despite its widespread use, evidence remains limited regarding the association between patient satisfaction, kinesiophobia, and pain during the early postoperative period. The purpose of the present study was to examine the relationships and differences among satisfaction, kinesiophobia, and pain in hospitalized patients following total knee arthroplasty, as well as to compare these variables across four postoperative time points. Methods: A total of 41 patients, aged 65–85 years, participated in this study. Patient satisfaction was assessed using a structured satisfaction questionnaire, kinesiophobia was assessed using the Greek version of Tampa Scale of Kinesiophobia, and pain was assessed using the Visual Analogue Scale. Measurements were obtained on the first postoperative day, on the day of hospital discharge, fifteen days after discharge, and four weeks after discharge. Normality was assessed using the Shapiro–Wilk test, indicating non-normally distributed data. The relationship between the variables were examined using Spearman’s correlation coefficient. Comparisons between the four postoperative time points were conducted using the Friedman test with Kendall’s W for effect size estimation, followed by Wilcoxon post hoc analyses with Bonferroni corrections. Results: The results showed that a significant negative correlation between satisfaction and kinesiophobia was observed at the fourth phase (r = −0.41, p = 0.04). Satisfaction was also negatively correlated with pain from the third to the fourth phase (r = −0.41, p = 0.008), whereas kinesiophobia demonstrated a significant positive correlation with pain from the second to the fourth phase (r = 0.47–0.56, p = 0.002). Friedman test comparisons revealed a significant increase in satisfaction over time (χ2 (3) = 13.88, p = 0.003), a significant progressive decrease in kinesiophobia with a moderate effect size (χ2 (3) = 76.40, p < 0.001; Kendall’s W = 0.62), and a significant progressive reduction in pain with a large effect size (χ2 (3) = 89.60, p < 0.001; Kendall’s W = 0.73). Conclusions: These findings indicate that satisfaction, kinesiophobia, and pain are significantly interrelated during the early postoperative period following total knee arthroplasty. Further studies with larger samples and longer follow-up periods are required to confirm these associations and support the development of targeted rehabilitation strategies. 2026-05-05 Surgeries, Vol. 7, Pages 57: Examining the Relationships and Differences of Satisfaction, Kinesiophobia, and Pain Between Rehabilitation Phases in Patients After Total Knee Replacement

Surgeries doi: 10.3390/surgeries7020057

Authors: Anna Christakou Danai Georgitsi Manolis Papadopoulos Nikolaos Zacharakis Panayiotis Papagelopoulos

Background/objectives: Total knee arthroplasty is one of the most commonly performed orthopedic procedures of the lower extremities, primarily for patients with osteoarthritis or rheumatoid arthritis. Despite its widespread use, evidence remains limited regarding the association between patient satisfaction, kinesiophobia, and pain during the early postoperative period. The purpose of the present study was to examine the relationships and differences among satisfaction, kinesiophobia, and pain in hospitalized patients following total knee arthroplasty, as well as to compare these variables across four postoperative time points. Methods: A total of 41 patients, aged 65–85 years, participated in this study. Patient satisfaction was assessed using a structured satisfaction questionnaire, kinesiophobia was assessed using the Greek version of Tampa Scale of Kinesiophobia, and pain was assessed using the Visual Analogue Scale. Measurements were obtained on the first postoperative day, on the day of hospital discharge, fifteen days after discharge, and four weeks after discharge. Normality was assessed using the Shapiro–Wilk test, indicating non-normally distributed data. The relationship between the variables were examined using Spearman’s correlation coefficient. Comparisons between the four postoperative time points were conducted using the Friedman test with Kendall’s W for effect size estimation, followed by Wilcoxon post hoc analyses with Bonferroni corrections. Results: The results showed that a significant negative correlation between satisfaction and kinesiophobia was observed at the fourth phase (r = −0.41, p = 0.04). Satisfaction was also negatively correlated with pain from the third to the fourth phase (r = −0.41, p = 0.008), whereas kinesiophobia demonstrated a significant positive correlation with pain from the second to the fourth phase (r = 0.47–0.56, p = 0.002). Friedman test comparisons revealed a significant increase in satisfaction over time (χ2 (3) = 13.88, p = 0.003), a significant progressive decrease in kinesiophobia with a moderate effect size (χ2 (3) = 76.40, p < 0.001; Kendall’s W = 0.62), and a significant progressive reduction in pain with a large effect size (χ2 (3) = 89.60, p < 0.001; Kendall’s W = 0.73). Conclusions: These findings indicate that satisfaction, kinesiophobia, and pain are significantly interrelated during the early postoperative period following total knee arthroplasty. Further studies with larger samples and longer follow-up periods are required to confirm these associations and support the development of targeted rehabilitation strategies.

]]> Examining the Relationships and Differences of Satisfaction, Kinesiophobia, and Pain Between Rehabilitation Phases in Patients After Total Knee Replacement Anna Christakou Danai Georgitsi Manolis Papadopoulos Nikolaos Zacharakis Panayiotis Papagelopoulos doi: 10.3390/surgeries7020057 Surgeries 2026-05-05 Surgeries 2026-05-05 7 2 Article 57 10.3390/surgeries7020057 https://www.mdpi.com/2673-4095/7/2/57 Surgeries, Vol. 7, Pages 56: Delayed Presentation of Nasal Glioma—Case Report and Literature Review https://www.mdpi.com/2673-4095/7/2/56 Background: Nasal glioma (NG), also known as nasal glial heterotopia, is an extremely rare congenital anomaly characterized by the presence of mature glial tissue outside the cranial cavity. Most patients present with midline craniofacial malformations at birth. However, a small subset of them is entirely intranasal and have no accompanying visible features. We present an unusual case of delayed diagnosis of NG, in tandem with a systematic literature review. Methods: A previously well 2-year-old male presented with obstructive apnea secondary to an intranasal mass. Neuroimaging of his paranasal sinuses demonstrated a bony defect in the anterior cribriform plate with herniation of a soft tissue structure into the right nasal cavity. He underwent craniotomy, total excision of the lesion and repair of skull base defect. His postoperative period was uneventful with resolution of his symptoms. Histology reported infiltrates of mature glial tissue with rare neurons forming the excised nasal mass. We conducted a structured literature review using PRISMA guidelines to evaluate clinical features of NG. Results: A comprehensive search of PubMed and Scopus databases featured 133 published cases of NG relevant to our case. Overall, NG is more common in males, with most cases diagnosed within the first year of life. Clinical presentation usually involved an external nasal mass (82.8%) and/or respiratory symptoms (28.7%), with prenatal detection reported in a subset of cases. Magnetic resonance imaging was the preferred imaging modality. Surgical excision was the mainstay of treatment. Postoperative outcomes were favorable in most patients, with 84.7% showing no complications or recurrence. Incomplete excision was associated with recurrence (10%). Conclusions: We present an intranasal case of NG with late diagnosis that was successfully managed with surgery. Our review underscores the importance of early imaging, accurate diagnosis, and complete surgical resection for best outcomes in affected children. 2026-05-04 Surgeries, Vol. 7, Pages 56: Delayed Presentation of Nasal Glioma—Case Report and Literature Review

Surgeries doi: 10.3390/surgeries7020056

Authors: Prabhpreet Kaur Yilong Wu Henry K. K. Tan Sze Jet Aw Wan Tew Seow Sharon Y. Y. Low

Background: Nasal glioma (NG), also known as nasal glial heterotopia, is an extremely rare congenital anomaly characterized by the presence of mature glial tissue outside the cranial cavity. Most patients present with midline craniofacial malformations at birth. However, a small subset of them is entirely intranasal and have no accompanying visible features. We present an unusual case of delayed diagnosis of NG, in tandem with a systematic literature review. Methods: A previously well 2-year-old male presented with obstructive apnea secondary to an intranasal mass. Neuroimaging of his paranasal sinuses demonstrated a bony defect in the anterior cribriform plate with herniation of a soft tissue structure into the right nasal cavity. He underwent craniotomy, total excision of the lesion and repair of skull base defect. His postoperative period was uneventful with resolution of his symptoms. Histology reported infiltrates of mature glial tissue with rare neurons forming the excised nasal mass. We conducted a structured literature review using PRISMA guidelines to evaluate clinical features of NG. Results: A comprehensive search of PubMed and Scopus databases featured 133 published cases of NG relevant to our case. Overall, NG is more common in males, with most cases diagnosed within the first year of life. Clinical presentation usually involved an external nasal mass (82.8%) and/or respiratory symptoms (28.7%), with prenatal detection reported in a subset of cases. Magnetic resonance imaging was the preferred imaging modality. Surgical excision was the mainstay of treatment. Postoperative outcomes were favorable in most patients, with 84.7% showing no complications or recurrence. Incomplete excision was associated with recurrence (10%). Conclusions: We present an intranasal case of NG with late diagnosis that was successfully managed with surgery. Our review underscores the importance of early imaging, accurate diagnosis, and complete surgical resection for best outcomes in affected children.

]]> Delayed Presentation of Nasal Glioma—Case Report and Literature Review Prabhpreet Kaur Yilong Wu Henry K. K. Tan Sze Jet Aw Wan Tew Seow Sharon Y. Y. Low doi: 10.3390/surgeries7020056 Surgeries 2026-05-04 Surgeries 2026-05-04 7 2 Case Report 56 10.3390/surgeries7020056 https://www.mdpi.com/2673-4095/7/2/56 Surgeries, Vol. 7, Pages 55: Extracorporeal Membrane Oxygenation in Pregnancy and the Postpartum Period: Two Case Reports and Narrative Review https://www.mdpi.com/2673-4095/7/2/55 In recent times, extracorporeal membrane oxygenation is increasingly employed in pregnant and postpartum patients with severe cardiopulmonary failure. This article presents two illustrative cases from our tertiary care center, highlighting the complexities of obstetric extracorporeal membrane oxygenation management. These cases are described within a synthesis of recent systematic reviews, registry data, and large case series focusing on maternal and fetal outcomes, extracorporeal membrane oxygenation modality impacts, timing of intervention, complication profiles, and anesthetic considerations. The concordance and contrasts between these cases and the existing literature underscore the evolving indications, improving survival rates, and critical perioperative management issues. Emphasis on multidisciplinary care and planning remains essential to optimize outcomes in this unique patient population. 2026-04-30 Surgeries, Vol. 7, Pages 55: Extracorporeal Membrane Oxygenation in Pregnancy and the Postpartum Period: Two Case Reports and Narrative Review

Surgeries doi: 10.3390/surgeries7020055

Authors: Mitch Daniel Alex Cao Suvikram Puri Joby Chandy Maksim Federau Carlos Miranda Christopher Ketchey David Koontz Cameron Dang Nicholas Martini John Hodgson Jeffrey Weiss Tanjina Jalil Enrico Camporesi

In recent times, extracorporeal membrane oxygenation is increasingly employed in pregnant and postpartum patients with severe cardiopulmonary failure. This article presents two illustrative cases from our tertiary care center, highlighting the complexities of obstetric extracorporeal membrane oxygenation management. These cases are described within a synthesis of recent systematic reviews, registry data, and large case series focusing on maternal and fetal outcomes, extracorporeal membrane oxygenation modality impacts, timing of intervention, complication profiles, and anesthetic considerations. The concordance and contrasts between these cases and the existing literature underscore the evolving indications, improving survival rates, and critical perioperative management issues. Emphasis on multidisciplinary care and planning remains essential to optimize outcomes in this unique patient population.

]]> Extracorporeal Membrane Oxygenation in Pregnancy and the Postpartum Period: Two Case Reports and Narrative Review Mitch Daniel Alex Cao Suvikram Puri Joby Chandy Maksim Federau Carlos Miranda Christopher Ketchey David Koontz Cameron Dang Nicholas Martini John Hodgson Jeffrey Weiss Tanjina Jalil Enrico Camporesi doi: 10.3390/surgeries7020055 Surgeries 2026-04-30 Surgeries 2026-04-30 7 2 Case Report 55 10.3390/surgeries7020055 https://www.mdpi.com/2673-4095/7/2/55 Surgeries, Vol. 7, Pages 54: Laparoscopic Resection of Oesophagal Bronchogenic Cyst During Nissen Fundoplication Procedure https://www.mdpi.com/2673-4095/7/2/54 Background/Objectives: Bronchogenic cysts are rare congenital cystic lesions caused by congenital bronchopulmonary dysplasia; incidental discovery during preoperative investigations or unrelated procedures raises operative management questions. We report successful concurrent resection during laparoscopic Nissen fundoplication. Methods/Case presentation: During elective laparoscopic Nissen fundoplication, a cystic lesion adjacent to the distal oesophagus, previously identified on preoperative imaging, was encountered. Laparoscopic enucleation was performed without compromising the integrity of the gastrointestinal tract or the cyst wall, and the 360° fundoplication was then completed. The specimen was sent for histopathology. Results: Resection was completed without conversion. Histology showed a glandular epithelial lining without features of malignancy, consistent with a bronchogenic cyst. The patient recovered uneventfully with resolution of reflux symptoms. Conclusions: Distal oesophageal bronchogenic cysts accessible via the hiatus can be safely enucleated during laparoscopic Nissen fundoplication in experienced hands, allowing definitive treatment in a single operation. Careful dissection, assessment of gastrointestinal patency and integrity, and histopathological confirmation are essential. 2026-04-29 Surgeries, Vol. 7, Pages 54: Laparoscopic Resection of Oesophagal Bronchogenic Cyst During Nissen Fundoplication Procedure

Surgeries doi: 10.3390/surgeries7020054

Authors: Jarosław Lichota Piotr Rękawek Jan Pawlus Piotr Janik Tadeusz Sulikowski

Background/Objectives: Bronchogenic cysts are rare congenital cystic lesions caused by congenital bronchopulmonary dysplasia; incidental discovery during preoperative investigations or unrelated procedures raises operative management questions. We report successful concurrent resection during laparoscopic Nissen fundoplication. Methods/Case presentation: During elective laparoscopic Nissen fundoplication, a cystic lesion adjacent to the distal oesophagus, previously identified on preoperative imaging, was encountered. Laparoscopic enucleation was performed without compromising the integrity of the gastrointestinal tract or the cyst wall, and the 360° fundoplication was then completed. The specimen was sent for histopathology. Results: Resection was completed without conversion. Histology showed a glandular epithelial lining without features of malignancy, consistent with a bronchogenic cyst. The patient recovered uneventfully with resolution of reflux symptoms. Conclusions: Distal oesophageal bronchogenic cysts accessible via the hiatus can be safely enucleated during laparoscopic Nissen fundoplication in experienced hands, allowing definitive treatment in a single operation. Careful dissection, assessment of gastrointestinal patency and integrity, and histopathological confirmation are essential.

]]> Laparoscopic Resection of Oesophagal Bronchogenic Cyst During Nissen Fundoplication Procedure Jarosław Lichota Piotr Rękawek Jan Pawlus Piotr Janik Tadeusz Sulikowski doi: 10.3390/surgeries7020054 Surgeries 2026-04-29 Surgeries 2026-04-29 7 2 Case Report 54 10.3390/surgeries7020054 https://www.mdpi.com/2673-4095/7/2/54 Surgeries, Vol. 7, Pages 53: Dual Mobility Prostheses Versus Suspension Arthroplasty for the Treatment of the First Carpometacarpal Joint Osteoarthritis: A 2-Year Follow-Up Prospective Study https://www.mdpi.com/2673-4095/7/2/53 Background/Objectives: Trapeziometacarpal osteoarthritis (TMC OA) is a common disabling condition. This study compared clinical and radiographic outcomes of trapeziectomy with suspension arthroplasty and dual mobility TMC joint replacement in a prospective comparative cohort study design. Methods: A prospective comparative study was conducted on 122 patients contributing 129 hands with Eaton–Littler stage II–III TMC osteoarthritis. Patients were treated with trapeziectomy with suspension arthroplasty (58 patients, 60 hands) or TMC joint replacement with a dual mobility prosthesis (64 patients, 69 hands), based on surgical indication and shared decision-making. Clinical and radiographic evaluations were performed up to 24 months postoperatively. Results: Both techniques significantly improved pain, function, range of motion, and strength (p < 0.05). Joint replacement provided faster pain relief and functional recovery, with superior strength at all follow-up points. At 12 months, pain and functional outcomes were comparable between groups. No implant loosening or failures were observed. Conclusions: Both surgical techniques are effective for TMC osteoarthritis. Dual mobility TMC joint replacement allows faster recovery and greater strength, while achieving comparable mid-term clinical outcomes to suspension arthroplasty. 2026-04-25 Surgeries, Vol. 7, Pages 53: Dual Mobility Prostheses Versus Suspension Arthroplasty for the Treatment of the First Carpometacarpal Joint Osteoarthritis: A 2-Year Follow-Up Prospective Study

Surgeries doi: 10.3390/surgeries7020053

Authors: Matteo Guzzini Giulia Frittella Giorgio Carrozzi Rocco De Vitis Leopoldo Arioli

Background/Objectives: Trapeziometacarpal osteoarthritis (TMC OA) is a common disabling condition. This study compared clinical and radiographic outcomes of trapeziectomy with suspension arthroplasty and dual mobility TMC joint replacement in a prospective comparative cohort study design. Methods: A prospective comparative study was conducted on 122 patients contributing 129 hands with Eaton–Littler stage II–III TMC osteoarthritis. Patients were treated with trapeziectomy with suspension arthroplasty (58 patients, 60 hands) or TMC joint replacement with a dual mobility prosthesis (64 patients, 69 hands), based on surgical indication and shared decision-making. Clinical and radiographic evaluations were performed up to 24 months postoperatively. Results: Both techniques significantly improved pain, function, range of motion, and strength (p < 0.05). Joint replacement provided faster pain relief and functional recovery, with superior strength at all follow-up points. At 12 months, pain and functional outcomes were comparable between groups. No implant loosening or failures were observed. Conclusions: Both surgical techniques are effective for TMC osteoarthritis. Dual mobility TMC joint replacement allows faster recovery and greater strength, while achieving comparable mid-term clinical outcomes to suspension arthroplasty.

]]> Dual Mobility Prostheses Versus Suspension Arthroplasty for the Treatment of the First Carpometacarpal Joint Osteoarthritis: A 2-Year Follow-Up Prospective Study Matteo Guzzini Giulia Frittella Giorgio Carrozzi Rocco De Vitis Leopoldo Arioli doi: 10.3390/surgeries7020053 Surgeries 2026-04-25 Surgeries 2026-04-25 7 2 Article 53 10.3390/surgeries7020053 https://www.mdpi.com/2673-4095/7/2/53 Surgeries, Vol. 7, Pages 52: Robotic Surgery Conservative Approaches for Uterine Adenomyosis: A Systematic Review https://www.mdpi.com/2673-4095/7/2/52 Background/Objectives: Adenomyosis is a common disorder of the uterus in those of reproductive age. Robotic-assisted surgery has been adopted to address the technical challenges of adenomyomectomy. This systematic review evaluated the current evidence regarding the feasibility, safety, and clinical outcomes of robotic-assisted conservative surgery for uterine adenomyosis. Methods: A systematic review of literature was performed on five databases, from the beginning to 21 December 2025, to identify studies reporting robotic-assisted uterus-sparing surgical approaches to adenomyosis. Data were collected on patient characteristics, surgical techniques used, pre- and post-operative pain, fertility outcomes, and complications. Risk of bias was evaluated using the ROBINS-I framework. Results: A total of 514 articles were found; six studies met the inclusion criteria. Most included studies were small and retrospective. The operative time ranged from 279 to 147 min. Mean blood loss ranged between 25 and 296 mL with a low rate of conversion and perioperative complications. Dysmenorrhea improved after surgery as reflected by the post operative visual analog scale pain score and serum CA-125 level. Few reproductive data were collected about successive spontaneous pregnancies. Risk of bias was serious or moderate in all studies included. Conclusions: Robotic-assisted conservative surgery for adenomyosis may represent a feasible and safe option for women with symptomatic adenomyosis who wish preserve the uterus, with a positive impact on patients’ symptoms. Large prospective, multicenter studies with standardized protocols and long-term follow-up are needed to clarify the real impact of robotic surgery in adenomyosis management. 2026-04-23 Surgeries, Vol. 7, Pages 52: Robotic Surgery Conservative Approaches for Uterine Adenomyosis: A Systematic Review

Surgeries doi: 10.3390/surgeries7020052

Authors: Mario Ardovino Davide Pisani Pasquale De Franciscis Ester Picone Antonio Conte Fatima Cherifi Maria Izzo Emanuele Amabile Marco La Verde

Background/Objectives: Adenomyosis is a common disorder of the uterus in those of reproductive age. Robotic-assisted surgery has been adopted to address the technical challenges of adenomyomectomy. This systematic review evaluated the current evidence regarding the feasibility, safety, and clinical outcomes of robotic-assisted conservative surgery for uterine adenomyosis. Methods: A systematic review of literature was performed on five databases, from the beginning to 21 December 2025, to identify studies reporting robotic-assisted uterus-sparing surgical approaches to adenomyosis. Data were collected on patient characteristics, surgical techniques used, pre- and post-operative pain, fertility outcomes, and complications. Risk of bias was evaluated using the ROBINS-I framework. Results: A total of 514 articles were found; six studies met the inclusion criteria. Most included studies were small and retrospective. The operative time ranged from 279 to 147 min. Mean blood loss ranged between 25 and 296 mL with a low rate of conversion and perioperative complications. Dysmenorrhea improved after surgery as reflected by the post operative visual analog scale pain score and serum CA-125 level. Few reproductive data were collected about successive spontaneous pregnancies. Risk of bias was serious or moderate in all studies included. Conclusions: Robotic-assisted conservative surgery for adenomyosis may represent a feasible and safe option for women with symptomatic adenomyosis who wish preserve the uterus, with a positive impact on patients’ symptoms. Large prospective, multicenter studies with standardized protocols and long-term follow-up are needed to clarify the real impact of robotic surgery in adenomyosis management.

]]> Robotic Surgery Conservative Approaches for Uterine Adenomyosis: A Systematic Review Mario Ardovino Davide Pisani Pasquale De Franciscis Ester Picone Antonio Conte Fatima Cherifi Maria Izzo Emanuele Amabile Marco La Verde doi: 10.3390/surgeries7020052 Surgeries 2026-04-23 Surgeries 2026-04-23 7 2 Systematic Review 52 10.3390/surgeries7020052 https://www.mdpi.com/2673-4095/7/2/52 Surgeries, Vol. 7, Pages 51: Direct Antiviral Agents May Obviate the Need for Liver Transplantation for HCV Cirrhosis by the End of the Decade https://www.mdpi.com/2673-4095/7/2/51 Background: Hepatitis C viral infection (HCV) has historically been a leading indication for liver transplantation (LTx), primarily due to its progression to cirrhosis and hepatocellular carcinoma (HCC). However, the advent of direct-acting antiviral agents (DAAs) over a decade ago has revolutionized HCV treatment, achieving sustained virologic response (SVR) in over 90% of patients and potentially altering LTx indications. Aim: To investigate the impact of DAAs on HCV-related indications, with or without HCC, and model future trends in LTx indications. Methods: We retrospectively reviewed 1504 liver transplants performed between 2000 and 2024 at a single center. Patients were categorized into three cohorts: HCV-only, HCC-only, and HCC with HCV co-infection (HCC/HCV). Relative transplant volumes by-year, post-operative outcomes, and HCC recurrence rates were analyzed across pre- and post-DAA eras. ARIMA modeling was employed to project trends in transplant indications through the year 2030. Results: The proportion of transplants for HCV alone declined by 82.3% from 2015 to 2020, while HCC/HCV transplants decreased by 68.8%. Conversely, the total number of transplants for HCC alone increased during this period, with a modest proportional decrease of 8.3% from 2015 to 2020. ARIMA modeling suggests that by 2030, LTxs for HCV alone may be nearly eliminated. The projected proportion of transplants conducted for HCC alone remains the highest of all three study indications at 4.3%. Conclusions: DAAs have reduced LTx due to HCV. By 2030, LTx for HCV-related cirrhosis, particularly without HCC, may be obviated. This underscores the need to reevaluate allocation for emerging oncologic indications. 2026-04-23 Surgeries, Vol. 7, Pages 51: Direct Antiviral Agents May Obviate the Need for Liver Transplantation for HCV Cirrhosis by the End of the Decade

Surgeries doi: 10.3390/surgeries7020051

Authors: Nathanael Haynes Allyson Cochran Maria Baimas-George William Archie Namratha Mylarapu Vincent Casingal Jose Soto Philippe Zamor Andrew DeLemos Paul Schmeltzer Steven Zacks Natasha Adlakha Roger Denny Mark Russo Lon Eskind Dionisios Vrochides

Background: Hepatitis C viral infection (HCV) has historically been a leading indication for liver transplantation (LTx), primarily due to its progression to cirrhosis and hepatocellular carcinoma (HCC). However, the advent of direct-acting antiviral agents (DAAs) over a decade ago has revolutionized HCV treatment, achieving sustained virologic response (SVR) in over 90% of patients and potentially altering LTx indications. Aim: To investigate the impact of DAAs on HCV-related indications, with or without HCC, and model future trends in LTx indications. Methods: We retrospectively reviewed 1504 liver transplants performed between 2000 and 2024 at a single center. Patients were categorized into three cohorts: HCV-only, HCC-only, and HCC with HCV co-infection (HCC/HCV). Relative transplant volumes by-year, post-operative outcomes, and HCC recurrence rates were analyzed across pre- and post-DAA eras. ARIMA modeling was employed to project trends in transplant indications through the year 2030. Results: The proportion of transplants for HCV alone declined by 82.3% from 2015 to 2020, while HCC/HCV transplants decreased by 68.8%. Conversely, the total number of transplants for HCC alone increased during this period, with a modest proportional decrease of 8.3% from 2015 to 2020. ARIMA modeling suggests that by 2030, LTxs for HCV alone may be nearly eliminated. The projected proportion of transplants conducted for HCC alone remains the highest of all three study indications at 4.3%. Conclusions: DAAs have reduced LTx due to HCV. By 2030, LTx for HCV-related cirrhosis, particularly without HCC, may be obviated. This underscores the need to reevaluate allocation for emerging oncologic indications.

]]> Direct Antiviral Agents May Obviate the Need for Liver Transplantation for HCV Cirrhosis by the End of the Decade Nathanael Haynes Allyson Cochran Maria Baimas-George William Archie Namratha Mylarapu Vincent Casingal Jose Soto Philippe Zamor Andrew DeLemos Paul Schmeltzer Steven Zacks Natasha Adlakha Roger Denny Mark Russo Lon Eskind Dionisios Vrochides doi: 10.3390/surgeries7020051 Surgeries 2026-04-23 Surgeries 2026-04-23 7 2 Article 51 10.3390/surgeries7020051 https://www.mdpi.com/2673-4095/7/2/51 Surgeries, Vol. 7, Pages 50: Pediatric and Adolescent Pancreatic Tumors: Population-Based Outcomes and Machine Learning Analysis https://www.mdpi.com/2673-4095/7/2/50 Background: Pancreatic tumors in pediatric and adolescent patients are rare, and guidance on prognostication and management is limited. Methods: Using the Surveillance, Epidemiology, and End Results (SEER) database (2004–2021), we analyzed clinicopathological characteristics, treatment patterns, and survival outcomes in patients younger than 20 years with pancreatic tumors. Analyses integrated conventional survival models with machine learning approaches to identify key predictors. Results: The cohort included 203 patients, of whom 108 (53.2%) had solid pseudopapillary neoplasms (SPNs), 59 (29.1%) neuroendocrine neoplasms, 16 (7.9%) pancreatoblastomas, 5 (2.5%) adenocarcinoma variants, 4 (2.0%) acinar cell carcinomas, and 11 (5.4%) other rare histologies. Most patients had localized disease (61.1%) and underwent surgical resection (85.2%). Estimated 5-year and 10-year overall survival rates were 87.8% and 84.0%, respectively. Survival differed significantly by histology, stage, and surgery status (all log-rank p < 0.001). In multivariable analysis, SPN histology was associated with lower mortality (hazard ratio (HR) 0.03, 95% confidence interval (CI) 0.01–0.13; p < 0.001), whereas distant disease was associated with markedly higher mortality (HR 21.49, 95% CI 7.52–133.41; p < 0.001). Surgical resection was independently associated with lower mortality (HR 0.13, 95% CI 0.02–0.29; p = 0.003). Among patients with known 5-year status, the Random Forest and Gradient Boosting models achieved cross-validated area under the curve values of 0.935 ± 0.060 and 0.886 ± 0.093, respectively; stage and surgery were the dominant predictors in both models. Conclusions: Surgery remains the cornerstone of management for pediatric pancreatic tumors, and advanced analytic approaches may enhance risk stratification in this rare population. 2026-04-23 Surgeries, Vol. 7, Pages 50: Pediatric and Adolescent Pancreatic Tumors: Population-Based Outcomes and Machine Learning Analysis

Surgeries doi: 10.3390/surgeries7020050

Authors: Dimitrios Moris Pejman Radkani Piyush Gupta

Background: Pancreatic tumors in pediatric and adolescent patients are rare, and guidance on prognostication and management is limited. Methods: Using the Surveillance, Epidemiology, and End Results (SEER) database (2004–2021), we analyzed clinicopathological characteristics, treatment patterns, and survival outcomes in patients younger than 20 years with pancreatic tumors. Analyses integrated conventional survival models with machine learning approaches to identify key predictors. Results: The cohort included 203 patients, of whom 108 (53.2%) had solid pseudopapillary neoplasms (SPNs), 59 (29.1%) neuroendocrine neoplasms, 16 (7.9%) pancreatoblastomas, 5 (2.5%) adenocarcinoma variants, 4 (2.0%) acinar cell carcinomas, and 11 (5.4%) other rare histologies. Most patients had localized disease (61.1%) and underwent surgical resection (85.2%). Estimated 5-year and 10-year overall survival rates were 87.8% and 84.0%, respectively. Survival differed significantly by histology, stage, and surgery status (all log-rank p < 0.001). In multivariable analysis, SPN histology was associated with lower mortality (hazard ratio (HR) 0.03, 95% confidence interval (CI) 0.01–0.13; p < 0.001), whereas distant disease was associated with markedly higher mortality (HR 21.49, 95% CI 7.52–133.41; p < 0.001). Surgical resection was independently associated with lower mortality (HR 0.13, 95% CI 0.02–0.29; p = 0.003). Among patients with known 5-year status, the Random Forest and Gradient Boosting models achieved cross-validated area under the curve values of 0.935 ± 0.060 and 0.886 ± 0.093, respectively; stage and surgery were the dominant predictors in both models. Conclusions: Surgery remains the cornerstone of management for pediatric pancreatic tumors, and advanced analytic approaches may enhance risk stratification in this rare population.

]]> Pediatric and Adolescent Pancreatic Tumors: Population-Based Outcomes and Machine Learning Analysis Dimitrios Moris Pejman Radkani Piyush Gupta doi: 10.3390/surgeries7020050 Surgeries 2026-04-23 Surgeries 2026-04-23 7 2 Article 50 10.3390/surgeries7020050 https://www.mdpi.com/2673-4095/7/2/50 Surgeries, Vol. 7, Pages 49: Prehabilitation in Patients Undergoing Cardiac Surgery: An Umbrella Review of Systematic Reviews and Meta-Analysis https://www.mdpi.com/2673-4095/7/2/49 Background/Objective: Prehabilitation aims to improve physiological reserve before surgery to enhance postoperative outcomes. Multiple systematic reviews have evaluated preoperative interventions in adult cardiac surgery; however, variability in scope, methodological quality, and overlap of primary trials complicates interpretation. The aim of this study is to synthesise and critically appraise evidence from systematic reviews and meta-analyses evaluating prehabilitation interventions in adults undergoing cardiac surgery. No funding was received for this study. Methods: We conducted an umbrella systematic review following a prospectively registered protocol (PROSPERO: CRD420261292354) and PRISMA 2020 guidance. PubMed, Web of Science, and Scopus were searched from inception to 31 December 2025. Eligible reviews included adults (≥18 years) undergoing cardiac surgery, evaluated and compared preoperative inspiratory muscle training (IMT), respiratory muscle training, and exercise-based, educational, or multimodal prehabilitation with usual care or sham intervention. Reviews focused solely on postoperative interventions or non-cardiac surgery were excluded. Methodological quality was assessed using AMSTAR-2. Certainty of evidence was evaluated using GRADE. Overlap of primary studies was quantified using the Corrected Covered Area (CCA). A structured narrative synthesis with a direction-of-effect framework was applied. Results: Eighteen systematic reviews (published 2012–2025) were included, comprising 46 unique primary studies and more than 6674 participants (exact totals unavailable due to incomplete reporting in at least one review). Overall overlap was high (CCA 12.5%). Respiratory-focused prehabilitation, particularly IMT, demonstrated consistent reductions in postoperative pulmonary complications (PPCs) (risk ratios approximately 0.42–0.53), pneumonia (RR ~0.44–0.45), and atelectasis (RR ~0.49–0.59), favouring prehabilitation over usual care. Hospital length of stay was reduced by approximately 1.5–3 days across multiple reviews. Inspiratory muscle strength improved consistently (mean difference ~+12 to +17 cmH2O). Effects on ICU length of stay and mechanical ventilation duration were inconsistent or non-significant. Exercise-based programmes improved functional capacity (6 min walk distance increase ~50–75 m) and showed modest reductions in hospital stay, but heterogeneity was substantial. No intervention demonstrated a consistent reduction in postoperative mortality. Evidence was limited by clinical heterogeneity, performance bias in primary trials, inconsistent outcome definitions, and high overlap of key IMT trials across reviews. Mortality outcomes were underpowered. Conclusions: Preoperative IMT provides evidence for reducing pulmonary complications and shortening hospital stays in adult cardiac surgery. Exercise-based prehabilitation improves functional capacity but requires further high-quality, standardised trials. Integration of respiratory prehabilitation into cardiac surgical pathways appears supported by the current evidence. 2026-04-23 Surgeries, Vol. 7, Pages 49: Prehabilitation in Patients Undergoing Cardiac Surgery: An Umbrella Review of Systematic Reviews and Meta-Analysis

Surgeries doi: 10.3390/surgeries7020049

Authors: Abubakar I. Sidik Maxim L. Khavandeev Malik K. Al-Ariki Vladislav V. Dontsov Ivan G. Karpenko Anvar K. Djumanov Alina V. Ogurchikova Sergey A. Kurnosov Dadaev Shirin

Background/Objective: Prehabilitation aims to improve physiological reserve before surgery to enhance postoperative outcomes. Multiple systematic reviews have evaluated preoperative interventions in adult cardiac surgery; however, variability in scope, methodological quality, and overlap of primary trials complicates interpretation. The aim of this study is to synthesise and critically appraise evidence from systematic reviews and meta-analyses evaluating prehabilitation interventions in adults undergoing cardiac surgery. No funding was received for this study. Methods: We conducted an umbrella systematic review following a prospectively registered protocol (PROSPERO: CRD420261292354) and PRISMA 2020 guidance. PubMed, Web of Science, and Scopus were searched from inception to 31 December 2025. Eligible reviews included adults (≥18 years) undergoing cardiac surgery, evaluated and compared preoperative inspiratory muscle training (IMT), respiratory muscle training, and exercise-based, educational, or multimodal prehabilitation with usual care or sham intervention. Reviews focused solely on postoperative interventions or non-cardiac surgery were excluded. Methodological quality was assessed using AMSTAR-2. Certainty of evidence was evaluated using GRADE. Overlap of primary studies was quantified using the Corrected Covered Area (CCA). A structured narrative synthesis with a direction-of-effect framework was applied. Results: Eighteen systematic reviews (published 2012–2025) were included, comprising 46 unique primary studies and more than 6674 participants (exact totals unavailable due to incomplete reporting in at least one review). Overall overlap was high (CCA 12.5%). Respiratory-focused prehabilitation, particularly IMT, demonstrated consistent reductions in postoperative pulmonary complications (PPCs) (risk ratios approximately 0.42–0.53), pneumonia (RR ~0.44–0.45), and atelectasis (RR ~0.49–0.59), favouring prehabilitation over usual care. Hospital length of stay was reduced by approximately 1.5–3 days across multiple reviews. Inspiratory muscle strength improved consistently (mean difference ~+12 to +17 cmH2O). Effects on ICU length of stay and mechanical ventilation duration were inconsistent or non-significant. Exercise-based programmes improved functional capacity (6 min walk distance increase ~50–75 m) and showed modest reductions in hospital stay, but heterogeneity was substantial. No intervention demonstrated a consistent reduction in postoperative mortality. Evidence was limited by clinical heterogeneity, performance bias in primary trials, inconsistent outcome definitions, and high overlap of key IMT trials across reviews. Mortality outcomes were underpowered. Conclusions: Preoperative IMT provides evidence for reducing pulmonary complications and shortening hospital stays in adult cardiac surgery. Exercise-based prehabilitation improves functional capacity but requires further high-quality, standardised trials. Integration of respiratory prehabilitation into cardiac surgical pathways appears supported by the current evidence.

]]> Prehabilitation in Patients Undergoing Cardiac Surgery: An Umbrella Review of Systematic Reviews and Meta-Analysis Abubakar I. Sidik Maxim L. Khavandeev Malik K. Al-Ariki Vladislav V. Dontsov Ivan G. Karpenko Anvar K. Djumanov Alina V. Ogurchikova Sergey A. Kurnosov Dadaev Shirin doi: 10.3390/surgeries7020049 Surgeries 2026-04-23 Surgeries 2026-04-23 7 2 Systematic Review 49 10.3390/surgeries7020049 https://www.mdpi.com/2673-4095/7/2/49 Surgeries, Vol. 7, Pages 48: A Mini-Invasive Dorsal Capsulodesis for the Treatment of Chronic Scapholunate Instability: Surgical Technique and Preliminary Outcomes in a Retrospective Case Series https://www.mdpi.com/2673-4095/7/2/48 Background: Chronic reducible scapholunate instability (SLI) remains a challenging condition, with multiple surgical options described, often associated with soft tissue disruption and postoperative stiffness. We describe a mini-invasive dorsal capsulodesis technique aimed at restoring carpal alignment while minimizing surgical morbidity, and we report preliminary clinical and radiographic outcomes. Methods: This study includes a retrospective analysis of the first 10 consecutive patients treated with this technique who had a minimum follow-up of 3 years. All patients presented with chronic, reducible scapholunate instability. Clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Radiographic evaluation was performed to assess maintenance of scapholunate alignment and progression to degenerative changes. Results: At a mean follow-up of approximately 4 years, patients showed a substantial reduction in pain (mean VAS from 8 preoperatively to 2 postoperatively) and improvement in function (mean QuickDASH from 74.6 to 16.5). Radiographic evaluation demonstrated maintenance of carpal alignment in all cases, with no progression to scapholunate advanced collapse (SLAC) observed. Wrist range of motion improved postoperatively, with extension reaching approximately 80° and flexion 70°, without significant functional limitations. No major complications or reoperations were recorded. Patient satisfaction was high, with 9 patients reporting being extremely satisfied and 1 satisfied. Conclusions: This mini-invasive dorsal capsulodesis appears to be a feasible and tissue-sparing option for selected cases of chronic reducible scapholunate instability. In this preliminary series, the technique was associated with favorable clinical and radiographic outcomes at mid-term follow-up. Further studies with larger cohorts and comparative designs are needed to confirm these findings. 2026-04-23 Surgeries, Vol. 7, Pages 48: A Mini-Invasive Dorsal Capsulodesis for the Treatment of Chronic Scapholunate Instability: Surgical Technique and Preliminary Outcomes in a Retrospective Case Series

Surgeries doi: 10.3390/surgeries7020048

Authors: Matteo Guzzini Federica Presutti Rosa Ballis Alice Patrignani

Background: Chronic reducible scapholunate instability (SLI) remains a challenging condition, with multiple surgical options described, often associated with soft tissue disruption and postoperative stiffness. We describe a mini-invasive dorsal capsulodesis technique aimed at restoring carpal alignment while minimizing surgical morbidity, and we report preliminary clinical and radiographic outcomes. Methods: This study includes a retrospective analysis of the first 10 consecutive patients treated with this technique who had a minimum follow-up of 3 years. All patients presented with chronic, reducible scapholunate instability. Clinical outcomes were assessed using the Visual Analog Scale (VAS) for pain and the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score. Radiographic evaluation was performed to assess maintenance of scapholunate alignment and progression to degenerative changes. Results: At a mean follow-up of approximately 4 years, patients showed a substantial reduction in pain (mean VAS from 8 preoperatively to 2 postoperatively) and improvement in function (mean QuickDASH from 74.6 to 16.5). Radiographic evaluation demonstrated maintenance of carpal alignment in all cases, with no progression to scapholunate advanced collapse (SLAC) observed. Wrist range of motion improved postoperatively, with extension reaching approximately 80° and flexion 70°, without significant functional limitations. No major complications or reoperations were recorded. Patient satisfaction was high, with 9 patients reporting being extremely satisfied and 1 satisfied. Conclusions: This mini-invasive dorsal capsulodesis appears to be a feasible and tissue-sparing option for selected cases of chronic reducible scapholunate instability. In this preliminary series, the technique was associated with favorable clinical and radiographic outcomes at mid-term follow-up. Further studies with larger cohorts and comparative designs are needed to confirm these findings.

]]> A Mini-Invasive Dorsal Capsulodesis for the Treatment of Chronic Scapholunate Instability: Surgical Technique and Preliminary Outcomes in a Retrospective Case Series Matteo Guzzini Federica Presutti Rosa Ballis Alice Patrignani doi: 10.3390/surgeries7020048 Surgeries 2026-04-23 Surgeries 2026-04-23 7 2 Technical Note 48 10.3390/surgeries7020048 https://www.mdpi.com/2673-4095/7/2/48 Surgeries, Vol. 7, Pages 47: Transcutaneous Fibrosis Perforation (Needle Fasciotomy) in Dupuytren’s Disease—A Retrospective Analysis of 1803 Cases https://www.mdpi.com/2673-4095/7/2/47 Background: Percutaneous needle fasciotomy has been practiced for many years as a therapeutic alternative to open fasciectomy in Dupuytren’s disease. In addition to collagenase injection, it has established itself as a minimally invasive procedure in everyday clinical practice. This study analyzes the treatment results of 1146 patients. Methods: Patients at a center for needle fasciotomy were surveyed retrospectively by means of a questionnaire. In addition to previous illnesses and the localization and number of affected fingers, the frequency of recurrences, the need for renewed treatment, and satisfaction with the surgical result were also surveyed. Results: Between 1994 and 2012, 1146 patients with 1803 finger rays were treated and their data analyzed on the basis of records. In addition, a questionnaire survey on patient satisfaction was conducted and 174 questionnaires were analyzed. Overall, 83% of the patients were male and 16% female. In 50% of cases the right side was treated, in 45% of cases the left side (5% unknown), while 46% of the finger rays treated were on the little finger and ring finger. In all but one case, an improvement in the contracture was achieved. Complications included skin tears (264 cases), increased swelling (five cases), hypesthesia (one case), flexor tendon rupture (four cases) and a mid-limb base fracture (one case). The mean operation time was 26.9 min, the duration of pain was 2.7 days, and patient satisfaction on a scale of 1–10 was 7.2. Overall, 77% of patients stated that there had been a further deterioration or recurrence within one year of treatment, and 35% of these patients stated that further treatment was necessary. Conclusions: Needle fasciotomy is a safe and effective method with a low complication rate, but targeted and stringent follow-up treatment is necessary, as is information about possible recurrences or further deterioration of the result. 2026-04-16 Surgeries, Vol. 7, Pages 47: Transcutaneous Fibrosis Perforation (Needle Fasciotomy) in Dupuytren’s Disease—A Retrospective Analysis of 1803 Cases

Surgeries doi: 10.3390/surgeries7020047

Authors: Philipp Groeben Ole Ackermann

Background: Percutaneous needle fasciotomy has been practiced for many years as a therapeutic alternative to open fasciectomy in Dupuytren’s disease. In addition to collagenase injection, it has established itself as a minimally invasive procedure in everyday clinical practice. This study analyzes the treatment results of 1146 patients. Methods: Patients at a center for needle fasciotomy were surveyed retrospectively by means of a questionnaire. In addition to previous illnesses and the localization and number of affected fingers, the frequency of recurrences, the need for renewed treatment, and satisfaction with the surgical result were also surveyed. Results: Between 1994 and 2012, 1146 patients with 1803 finger rays were treated and their data analyzed on the basis of records. In addition, a questionnaire survey on patient satisfaction was conducted and 174 questionnaires were analyzed. Overall, 83% of the patients were male and 16% female. In 50% of cases the right side was treated, in 45% of cases the left side (5% unknown), while 46% of the finger rays treated were on the little finger and ring finger. In all but one case, an improvement in the contracture was achieved. Complications included skin tears (264 cases), increased swelling (five cases), hypesthesia (one case), flexor tendon rupture (four cases) and a mid-limb base fracture (one case). The mean operation time was 26.9 min, the duration of pain was 2.7 days, and patient satisfaction on a scale of 1–10 was 7.2. Overall, 77% of patients stated that there had been a further deterioration or recurrence within one year of treatment, and 35% of these patients stated that further treatment was necessary. Conclusions: Needle fasciotomy is a safe and effective method with a low complication rate, but targeted and stringent follow-up treatment is necessary, as is information about possible recurrences or further deterioration of the result.

]]> Transcutaneous Fibrosis Perforation (Needle Fasciotomy) in Dupuytren’s Disease—A Retrospective Analysis of 1803 Cases Philipp Groeben Ole Ackermann doi: 10.3390/surgeries7020047 Surgeries 2026-04-16 Surgeries 2026-04-16 7 2 Article 47 10.3390/surgeries7020047 https://www.mdpi.com/2673-4095/7/2/47 Surgeries, Vol. 7, Pages 46: The Effect of Marginal Ischemia on Colonic Anastomotic Leakage: A Rat Model https://www.mdpi.com/2673-4095/7/2/46 Background: Anastomotic leakage remains a serious complication of colorectal surgery, often linked to impaired blood supply at the incision site. Objective: To develop and validate a reproducible rat model of colonic anastomotic leakage induced by graded mesocolon ischemia. Methods: Of 144 operated rats, 138 survived surgery and underwent end-to-end colonic anastomosis with five levels of mesocolon ligation (0–2 cm of unilateral mesocolic ischemia). Postoperative outcomes, including anastomotic integrity, abscess formation, and mortality, were assessed on postoperative day 10. Anastomotic bursting pressures were also measured in a subset of animals. Results: Leak rates increased with ischemia severity: 0% in controls, 16.7% at 0.2 cm, 42.6% at 0.4 cm, 95.8% at 1 cm, and 100% at 2 cm (p < 0.0001, trend test). Bursting pressures decreased progressively with increasing anastomotic severity. The 0.4 cm ischemia condition produced a reproducible intermediate leak rate suitable for experimental interventions. Conclusions: This rat model reliably induces graded anastomotic leaks and can serve as a platform for testing strategies to prevent leakage in high-risk colorectal surgery. 2026-04-10 Surgeries, Vol. 7, Pages 46: The Effect of Marginal Ischemia on Colonic Anastomotic Leakage: A Rat Model

Surgeries doi: 10.3390/surgeries7020046

Authors: Guy Barsky Grace Haj Anton Osyntsov Ivan Kukeev Yulia Vaynshtein Elchanan Quint Ilia Vasiliev Nur Alkrinawi Sergey Yerep Dmitry Likalter Sofyan Abu Freih Nir Nessim Cohen David Czeiger

Background: Anastomotic leakage remains a serious complication of colorectal surgery, often linked to impaired blood supply at the incision site. Objective: To develop and validate a reproducible rat model of colonic anastomotic leakage induced by graded mesocolon ischemia. Methods: Of 144 operated rats, 138 survived surgery and underwent end-to-end colonic anastomosis with five levels of mesocolon ligation (0–2 cm of unilateral mesocolic ischemia). Postoperative outcomes, including anastomotic integrity, abscess formation, and mortality, were assessed on postoperative day 10. Anastomotic bursting pressures were also measured in a subset of animals. Results: Leak rates increased with ischemia severity: 0% in controls, 16.7% at 0.2 cm, 42.6% at 0.4 cm, 95.8% at 1 cm, and 100% at 2 cm (p < 0.0001, trend test). Bursting pressures decreased progressively with increasing anastomotic severity. The 0.4 cm ischemia condition produced a reproducible intermediate leak rate suitable for experimental interventions. Conclusions: This rat model reliably induces graded anastomotic leaks and can serve as a platform for testing strategies to prevent leakage in high-risk colorectal surgery.

]]> The Effect of Marginal Ischemia on Colonic Anastomotic Leakage: A Rat Model Guy Barsky Grace Haj Anton Osyntsov Ivan Kukeev Yulia Vaynshtein Elchanan Quint Ilia Vasiliev Nur Alkrinawi Sergey Yerep Dmitry Likalter Sofyan Abu Freih Nir Nessim Cohen David Czeiger doi: 10.3390/surgeries7020046 Surgeries 2026-04-10 Surgeries 2026-04-10 7 2 Article 46 10.3390/surgeries7020046 https://www.mdpi.com/2673-4095/7/2/46 Surgeries, Vol. 7, Pages 45: Cost–Benefit Analysis in the Surgical Management of Thumb Carpometacarpal Osteoarthritis: Dual-Mobility Total Joint Replacement Versus Trapeziectomy with Ligament Reconstruction and Suspension Arthroplasty https://www.mdpi.com/2673-4095/7/2/45 Background: Trapeziometacarpal (TM) osteoarthritis (OA) is a common condition, especially among postmenopausal women, often requiring surgical intervention when conservative treatment fails. In recent years, dual-mobility prostheses have been increasingly used as an alternative to traditional trapeziectomy with suspension arthroplasty. However, limited data exist regarding their comparative cost-effectiveness in public healthcare systems. Purpose: The aim of this study was to compare the cost–benefit ratio and clinical outcomes of two surgical techniques for TM OA: trapeziectomy with suspension arthroplasty and total joint arthroplasty with a dual-mobility prosthesis. Methods: We conducted a retrospective cohort study of 116 hands treated between 2020 and 2024. Patients were divided into two groups based on the surgery they received: trapeziectomy with suspension arthroplasty or implantation of a dual-mobility TM prosthesis. Clinical outcomes were assessed using VAS, DASH, Kapandji score, grip strength, and pinch strength at 12, 36, and 48 months postoperatively. A cost analysis was performed based on hospital reimbursement (Diagnosis-Related Group) and estimated productivity loss. Results: Both techniques yielded significant improvements in pain and function. Patients who were operated on with a prosthesis showed faster recovery and better early outcomes, while the trapeziectomy group had lower direct surgical costs and fewer complications. At 48 months, clinical scores were comparable. The overall cost–benefit ratio favoured trapeziectomy with suspension arthroplasty, while TM prosthesis’s higher costs were justified due to improved short-term functional recovery. Conclusions: Both surgical techniques achieved satisfactory long-term clinical outcomes. The prosthetic option allows for quicker recovery and reduces indirect social costs, while suspension arthroplasty remains more cost-effective for direct costs. These findings highlight the importance of balancing clinical benefit and economic sustainability in surgical decision-making for TM osteoarthritis. Level of Evidence: Level III, retrospective comparative study. 2026-04-01 Surgeries, Vol. 7, Pages 45: Cost–Benefit Analysis in the Surgical Management of Thumb Carpometacarpal Osteoarthritis: Dual-Mobility Total Joint Replacement Versus Trapeziectomy with Ligament Reconstruction and Suspension Arthroplasty

Surgeries doi: 10.3390/surgeries7020045

Authors: Leopoldo Arioli Giulia Frittella Fatma Abidi Edoardo Venturini Matteo Guzzini

Background: Trapeziometacarpal (TM) osteoarthritis (OA) is a common condition, especially among postmenopausal women, often requiring surgical intervention when conservative treatment fails. In recent years, dual-mobility prostheses have been increasingly used as an alternative to traditional trapeziectomy with suspension arthroplasty. However, limited data exist regarding their comparative cost-effectiveness in public healthcare systems. Purpose: The aim of this study was to compare the cost–benefit ratio and clinical outcomes of two surgical techniques for TM OA: trapeziectomy with suspension arthroplasty and total joint arthroplasty with a dual-mobility prosthesis. Methods: We conducted a retrospective cohort study of 116 hands treated between 2020 and 2024. Patients were divided into two groups based on the surgery they received: trapeziectomy with suspension arthroplasty or implantation of a dual-mobility TM prosthesis. Clinical outcomes were assessed using VAS, DASH, Kapandji score, grip strength, and pinch strength at 12, 36, and 48 months postoperatively. A cost analysis was performed based on hospital reimbursement (Diagnosis-Related Group) and estimated productivity loss. Results: Both techniques yielded significant improvements in pain and function. Patients who were operated on with a prosthesis showed faster recovery and better early outcomes, while the trapeziectomy group had lower direct surgical costs and fewer complications. At 48 months, clinical scores were comparable. The overall cost–benefit ratio favoured trapeziectomy with suspension arthroplasty, while TM prosthesis’s higher costs were justified due to improved short-term functional recovery. Conclusions: Both surgical techniques achieved satisfactory long-term clinical outcomes. The prosthetic option allows for quicker recovery and reduces indirect social costs, while suspension arthroplasty remains more cost-effective for direct costs. These findings highlight the importance of balancing clinical benefit and economic sustainability in surgical decision-making for TM osteoarthritis. Level of Evidence: Level III, retrospective comparative study.

]]> Cost–Benefit Analysis in the Surgical Management of Thumb Carpometacarpal Osteoarthritis: Dual-Mobility Total Joint Replacement Versus Trapeziectomy with Ligament Reconstruction and Suspension Arthroplasty Leopoldo Arioli Giulia Frittella Fatma Abidi Edoardo Venturini Matteo Guzzini doi: 10.3390/surgeries7020045 Surgeries 2026-04-01 Surgeries 2026-04-01 7 2 Article 45 10.3390/surgeries7020045 https://www.mdpi.com/2673-4095/7/2/45 Surgeries, Vol. 7, Pages 44: Massive Pulmonary Hemorrhage After Pulmonary Endarterectomy: Updated Outcomes of a Standardized Management Protocol over 14 Years https://www.mdpi.com/2673-4095/7/2/44 Background: Massive pulmonary hemorrhage is a life-threatening complication of pulmonary endarterectomy (PEA) with limited evidence to guide standardized management. Methods: We retrospectively evaluated consecutive PEA procedures performed at a high-volume center and analyzed the incidence, perioperative characteristics, management strategies, and early outcomes of patients who developed massive pulmonary hemorrhage. Results: Among 1123 patients who underwent PEA, massive pulmonary hemorrhage occurred in 51 (4.54%) and developed intraoperatively after completion of PEA and separation from total circulatory arrest. Primary suturing achieved hemostasis in 12 patients (23.5%), and bronchial isolation was applied in 18 (35.3%). Local adjuncts included intraoperative bronchial clamping in 1 patient (2.0%) and biological glue occlusion in 2 (3.9%). Extracorporeal membrane oxygenation (ECMO) was required in 25 patients (49.0%), initiated intraoperatively in 22 and postoperatively in 3. Overall in-hospital mortality was 41.2%, while 30 patients (58.8%) survived to hospital discharge; among survivors, mean hospital length of stay was 16.1 ± 6.8 days. Conclusions: Massive pulmonary hemorrhage after PEA remains associated with substantial early mortality and resource utilization; a stepwise institutional algorithm combining bronchoscopy-guided localization, targeted airway/surgical control, and timely ECMO support may help standardize management in this critical setting. 2026-03-30 Surgeries, Vol. 7, Pages 44: Massive Pulmonary Hemorrhage After Pulmonary Endarterectomy: Updated Outcomes of a Standardized Management Protocol over 14 Years

Surgeries doi: 10.3390/surgeries7020044

Authors: Cagatay Cetinkaya Sehnaz Olgun Yildizeli Altug Sagir Mustafa Emre Kavlak Bedrettin Yildizeli

Background: Massive pulmonary hemorrhage is a life-threatening complication of pulmonary endarterectomy (PEA) with limited evidence to guide standardized management. Methods: We retrospectively evaluated consecutive PEA procedures performed at a high-volume center and analyzed the incidence, perioperative characteristics, management strategies, and early outcomes of patients who developed massive pulmonary hemorrhage. Results: Among 1123 patients who underwent PEA, massive pulmonary hemorrhage occurred in 51 (4.54%) and developed intraoperatively after completion of PEA and separation from total circulatory arrest. Primary suturing achieved hemostasis in 12 patients (23.5%), and bronchial isolation was applied in 18 (35.3%). Local adjuncts included intraoperative bronchial clamping in 1 patient (2.0%) and biological glue occlusion in 2 (3.9%). Extracorporeal membrane oxygenation (ECMO) was required in 25 patients (49.0%), initiated intraoperatively in 22 and postoperatively in 3. Overall in-hospital mortality was 41.2%, while 30 patients (58.8%) survived to hospital discharge; among survivors, mean hospital length of stay was 16.1 ± 6.8 days. Conclusions: Massive pulmonary hemorrhage after PEA remains associated with substantial early mortality and resource utilization; a stepwise institutional algorithm combining bronchoscopy-guided localization, targeted airway/surgical control, and timely ECMO support may help standardize management in this critical setting.

]]> Massive Pulmonary Hemorrhage After Pulmonary Endarterectomy: Updated Outcomes of a Standardized Management Protocol over 14 Years Cagatay Cetinkaya Sehnaz Olgun Yildizeli Altug Sagir Mustafa Emre Kavlak Bedrettin Yildizeli doi: 10.3390/surgeries7020044 Surgeries 2026-03-30 Surgeries 2026-03-30 7 2 Article 44 10.3390/surgeries7020044 https://www.mdpi.com/2673-4095/7/2/44 Surgeries, Vol. 7, Pages 43: Reassessing Routine Postoperative Imaging in Acromegaly: Insights from a Cohort with Biochemical Remission https://www.mdpi.com/2673-4095/7/2/43 Background: Postoperative evaluation for growth hormone-producing pituitary tumors entails assessing remission via biochemical markers alongside MRI to detect residual tumors. While postoperative imaging provides important anatomical information regarding potential residual tumor, it is reasonable to ask if imaging offers largely redundant data when biochemical remission is already established. This study aimed to determine the clinical utility of post-surgical surveillance imaging in patients who achieved biochemical remission with normal age- and sex-matched IGF-1 at ~3 months postoperatively. Furthermore, we sought to evaluate the long-term durability of biochemical control in this patient subset. Methods: We conducted a retrospective analysis on patients who underwent endoscopic endonasal approach surgery for acromegaly and had a minimum of 3 years of follow-up clinical, biochemical and imaging data. Results: In total, 15 of 28 patients (54%) achieved initial biochemical remission and had a 100% sustained remission rate during the follow-up period of 3–14 years, underscoring the importance of surgical radicality for achieving durable remission. Conclusions: Our findings suggest that for patients who achieved biochemical remission following transsphenoidal surgery for acromegaly, routine postoperative imaging provides negligible additional diagnostic information from an endocrinological perspective. As such, we propose that no further postoperative imaging is needed for patients in clinical and biochemical remission. This approach offers a significant reduction in the clinical burden and healthcare costs for patients associated with long-term management of their disease. 2026-03-26 Surgeries, Vol. 7, Pages 43: Reassessing Routine Postoperative Imaging in Acromegaly: Insights from a Cohort with Biochemical Remission

Surgeries doi: 10.3390/surgeries7020043

Authors: Jelena Maletkovic Marvin Bergsneider Won Kim Marilene B. Wang Jeffrey D. Suh Michael Linetsky Noriko Salamon Sandra Pekic Djurdjevic Anthony P. Heaney

Background: Postoperative evaluation for growth hormone-producing pituitary tumors entails assessing remission via biochemical markers alongside MRI to detect residual tumors. While postoperative imaging provides important anatomical information regarding potential residual tumor, it is reasonable to ask if imaging offers largely redundant data when biochemical remission is already established. This study aimed to determine the clinical utility of post-surgical surveillance imaging in patients who achieved biochemical remission with normal age- and sex-matched IGF-1 at ~3 months postoperatively. Furthermore, we sought to evaluate the long-term durability of biochemical control in this patient subset. Methods: We conducted a retrospective analysis on patients who underwent endoscopic endonasal approach surgery for acromegaly and had a minimum of 3 years of follow-up clinical, biochemical and imaging data. Results: In total, 15 of 28 patients (54%) achieved initial biochemical remission and had a 100% sustained remission rate during the follow-up period of 3–14 years, underscoring the importance of surgical radicality for achieving durable remission. Conclusions: Our findings suggest that for patients who achieved biochemical remission following transsphenoidal surgery for acromegaly, routine postoperative imaging provides negligible additional diagnostic information from an endocrinological perspective. As such, we propose that no further postoperative imaging is needed for patients in clinical and biochemical remission. This approach offers a significant reduction in the clinical burden and healthcare costs for patients associated with long-term management of their disease.

]]> Reassessing Routine Postoperative Imaging in Acromegaly: Insights from a Cohort with Biochemical Remission Jelena Maletkovic Marvin Bergsneider Won Kim Marilene B. Wang Jeffrey D. Suh Michael Linetsky Noriko Salamon Sandra Pekic Djurdjevic Anthony P. Heaney doi: 10.3390/surgeries7020043 Surgeries 2026-03-26 Surgeries 2026-03-26 7 2 Article 43 10.3390/surgeries7020043 https://www.mdpi.com/2673-4095/7/2/43 Surgeries, Vol. 7, Pages 42: Stratified Procedural Risk Assessment in Colorectal Surgery: A Comparative Analysis of Statistical and Machine Learning Approaches Using Combined Surgical Approach and Operative Duration Categories https://www.mdpi.com/2673-4095/7/2/42 Background: Postoperative complications following colorectal surgery remain a persistent clinical challenge. Traditional risk stratification has focused on patient characteristics, while conventional modeling approaches treat procedural factors such as operative duration and surgical approach as independent predictors, potentially obscuring interaction effects. Methods: This study developed a machine learning model stratifying 7908 colorectal surgery patients into four distinct procedural risk categories based on combined surgical approach and operative duration (laparoscopic-short, laparoscopic-long, open-short, open-long), rather than treating these factors as separate variables. A gradient boosting ensemble classifier with RUSBoost resampling was trained on predictor variables including patient demographics, comorbidities, and intraoperative factors. Results: Feature importance analysis revealed that the open-long category emerged as the single most important predictor, substantially exceeding all other variables. Weight loss, body mass index, patient age, and electrolyte abnormalities ranked as the next most important predictors. Stratified complication rates demonstrated a critical interaction: prolonged duration more than doubled complication risk in open procedures (short-duration: 9.99%, long-duration: 20.46%), whereas laparoscopic procedures showed only a modest increase from short-duration (10.45%) to long-duration (14.08%) cases. Logistic regression benchmark analysis confirmed the duration-approach interaction (OR = 1.53, 95% CI: 0.97–2.39), achieving comparable discrimination (c-statistic 0.678 vs. 0.665 for the ensemble model). Decision curve analysis demonstrated logistic regression provided superior clinical utility across most threshold probabilities. Conclusions: The dual analytical framework (i.e., statistical inference for quantifying associations and machine learning for predictive feature ranking) offers complementary insights for clinical application. These findings demonstrate that stratified feature engineering can elucidate complex risk phenotypes that may be obscured when procedural factors are analyzed independently. 2026-03-25 Surgeries, Vol. 7, Pages 42: Stratified Procedural Risk Assessment in Colorectal Surgery: A Comparative Analysis of Statistical and Machine Learning Approaches Using Combined Surgical Approach and Operative Duration Categories

Surgeries doi: 10.3390/surgeries7020042

Authors: Dennis Elengickal Michael Nizich Milan Toma

Background: Postoperative complications following colorectal surgery remain a persistent clinical challenge. Traditional risk stratification has focused on patient characteristics, while conventional modeling approaches treat procedural factors such as operative duration and surgical approach as independent predictors, potentially obscuring interaction effects. Methods: This study developed a machine learning model stratifying 7908 colorectal surgery patients into four distinct procedural risk categories based on combined surgical approach and operative duration (laparoscopic-short, laparoscopic-long, open-short, open-long), rather than treating these factors as separate variables. A gradient boosting ensemble classifier with RUSBoost resampling was trained on predictor variables including patient demographics, comorbidities, and intraoperative factors. Results: Feature importance analysis revealed that the open-long category emerged as the single most important predictor, substantially exceeding all other variables. Weight loss, body mass index, patient age, and electrolyte abnormalities ranked as the next most important predictors. Stratified complication rates demonstrated a critical interaction: prolonged duration more than doubled complication risk in open procedures (short-duration: 9.99%, long-duration: 20.46%), whereas laparoscopic procedures showed only a modest increase from short-duration (10.45%) to long-duration (14.08%) cases. Logistic regression benchmark analysis confirmed the duration-approach interaction (OR = 1.53, 95% CI: 0.97–2.39), achieving comparable discrimination (c-statistic 0.678 vs. 0.665 for the ensemble model). Decision curve analysis demonstrated logistic regression provided superior clinical utility across most threshold probabilities. Conclusions: The dual analytical framework (i.e., statistical inference for quantifying associations and machine learning for predictive feature ranking) offers complementary insights for clinical application. These findings demonstrate that stratified feature engineering can elucidate complex risk phenotypes that may be obscured when procedural factors are analyzed independently.

]]> Stratified Procedural Risk Assessment in Colorectal Surgery: A Comparative Analysis of Statistical and Machine Learning Approaches Using Combined Surgical Approach and Operative Duration Categories Dennis Elengickal Michael Nizich Milan Toma doi: 10.3390/surgeries7020042 Surgeries 2026-03-25 Surgeries 2026-03-25 7 2 Article 42 10.3390/surgeries7020042 https://www.mdpi.com/2673-4095/7/2/42 Surgeries, Vol. 7, Pages 41: Immediate Breast Reconstruction in Skin-Reducing Mastectomy Using Prepectoral Approach with Porcine-Derived Dermal Matrix and Autologous Dermal Sling: A Retrospective Observational Study https://www.mdpi.com/2673-4095/7/1/41 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. 2026-03-23 Surgeries, Vol. 7, Pages 41: Immediate Breast Reconstruction in Skin-Reducing Mastectomy Using Prepectoral Approach with Porcine-Derived Dermal Matrix and Autologous Dermal Sling: A Retrospective Observational Study

Surgeries doi: 10.3390/surgeries7010041

Authors: Luca Galassi Simone Scotti Federica Facchinetti Roberta Gilardi

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.

]]> Immediate Breast Reconstruction in Skin-Reducing Mastectomy Using Prepectoral Approach with Porcine-Derived Dermal Matrix and Autologous Dermal Sling: A Retrospective Observational Study Luca Galassi Simone Scotti Federica Facchinetti Roberta Gilardi doi: 10.3390/surgeries7010041 Surgeries 2026-03-23 Surgeries 2026-03-23 7 1 Article 41 10.3390/surgeries7010041 https://www.mdpi.com/2673-4095/7/1/41 Surgeries, Vol. 7, Pages 40: Preoperative Intra-Articular Corticosteroid Injection Is Not Associated with Inferior Reoperation or Patient-Reported Outcomes Following Chondrocyte Implantation https://www.mdpi.com/2673-4095/7/1/40 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. 2026-03-23 Surgeries, Vol. 7, Pages 40: Preoperative Intra-Articular Corticosteroid Injection Is Not Associated with Inferior Reoperation or Patient-Reported Outcomes Following Chondrocyte Implantation

Surgeries doi: 10.3390/surgeries7010040

Authors: Isabella Jazrawi Rushani K. Cameron Raven Hollis Stevie Tchako-Tchokouassi Cody Perskin Eric J. Strauss Laith M. Jazrawi Kirk A. Campbell

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.

]]> Preoperative Intra-Articular Corticosteroid Injection Is Not Associated with Inferior Reoperation or Patient-Reported Outcomes Following Chondrocyte Implantation Isabella Jazrawi Rushani K. Cameron Raven Hollis Stevie Tchako-Tchokouassi Cody Perskin Eric J. Strauss Laith M. Jazrawi Kirk A. Campbell doi: 10.3390/surgeries7010040 Surgeries 2026-03-23 Surgeries 2026-03-23 7 1 Article 40 10.3390/surgeries7010040 https://www.mdpi.com/2673-4095/7/1/40 Surgeries, Vol. 7, Pages 39: Comparative Study of Radiologic Changes in Ulnar Variance and Ulnolunate Distance After Distal Radius Fracture Surgery: Patients with vs. Without Lunate Ulnar Corner Cysts https://www.mdpi.com/2673-4095/7/1/39 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. 2026-03-17 Surgeries, Vol. 7, Pages 39: Comparative Study of Radiologic Changes in Ulnar Variance and Ulnolunate Distance After Distal Radius Fracture Surgery: Patients with vs. Without Lunate Ulnar Corner Cysts

Surgeries doi: 10.3390/surgeries7010039

Authors: Bong-Ju Lee Wongyu Jin Chul-Hyung Lee

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.

]]> Comparative Study of Radiologic Changes in Ulnar Variance and Ulnolunate Distance After Distal Radius Fracture Surgery: Patients with vs. Without Lunate Ulnar Corner Cysts Bong-Ju Lee Wongyu Jin Chul-Hyung Lee doi: 10.3390/surgeries7010039 Surgeries 2026-03-17 Surgeries 2026-03-17 7 1 Article 39 10.3390/surgeries7010039 https://www.mdpi.com/2673-4095/7/1/39 Surgeries, Vol. 7, Pages 38: The Emerging Role of Peri-Operative Methadone for the Management of Post-Operative Pain for Patients Undergoing Oesophagectomy: A Narrative Review https://www.mdpi.com/2673-4095/7/1/38 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. 2026-03-13 Surgeries, Vol. 7, Pages 38: The Emerging Role of Peri-Operative Methadone for the Management of Post-Operative Pain for Patients Undergoing Oesophagectomy: A Narrative Review

Surgeries doi: 10.3390/surgeries7010038

Authors: Alexandra Jolley Kelvin Le Charlotte Deng Khang Duy Ricky Le

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.

]]> The Emerging Role of Peri-Operative Methadone for the Management of Post-Operative Pain for Patients Undergoing Oesophagectomy: A Narrative Review Alexandra Jolley Kelvin Le Charlotte Deng Khang Duy Ricky Le doi: 10.3390/surgeries7010038 Surgeries 2026-03-13 Surgeries 2026-03-13 7 1 Review 38 10.3390/surgeries7010038 https://www.mdpi.com/2673-4095/7/1/38 Surgeries, Vol. 7, Pages 37: Prehabilitation in Plastic Surgery: Optimizing Patients for Superior Surgical Outcomes https://www.mdpi.com/2673-4095/7/1/37 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. 2026-03-12 Surgeries, Vol. 7, Pages 37: Prehabilitation in Plastic Surgery: Optimizing Patients for Superior Surgical Outcomes

Surgeries doi: 10.3390/surgeries7010037

Authors: Jelena Nikolić Marija Marinković Ivana Mijatov

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.

]]> Prehabilitation in Plastic Surgery: Optimizing Patients for Superior Surgical Outcomes Jelena Nikolić Marija Marinković Ivana Mijatov doi: 10.3390/surgeries7010037 Surgeries 2026-03-12 Surgeries 2026-03-12 7 1 Review 37 10.3390/surgeries7010037 https://www.mdpi.com/2673-4095/7/1/37 Surgeries, Vol. 7, Pages 36: Trend-Based Intermittent Neuromonitoring in Thyroid and Parathyroid Surgery: A Prospective Preliminary Observational Study https://www.mdpi.com/2673-4095/7/1/36 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. 2026-03-12 Surgeries, Vol. 7, Pages 36: Trend-Based Intermittent Neuromonitoring in Thyroid and Parathyroid Surgery: A Prospective Preliminary Observational Study

Surgeries doi: 10.3390/surgeries7010036

Authors: Paolo Del Rio Tommaso Loderer Gianluca Pasquini Alessandro Facchinetti Cristiana Madoni Elena Bonati

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.

]]> Trend-Based Intermittent Neuromonitoring in Thyroid and Parathyroid Surgery: A Prospective Preliminary Observational Study Paolo Del Rio Tommaso Loderer Gianluca Pasquini Alessandro Facchinetti Cristiana Madoni Elena Bonati doi: 10.3390/surgeries7010036 Surgeries 2026-03-12 Surgeries 2026-03-12 7 1 Article 36 10.3390/surgeries7010036 https://www.mdpi.com/2673-4095/7/1/36 Surgeries, Vol. 7, Pages 35: A Three-Morphotype Classification of Lip Aging Derived from Digital Image Analysis https://www.mdpi.com/2673-4095/7/1/35 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. 2026-03-05 Surgeries, Vol. 7, Pages 35: A Three-Morphotype Classification of Lip Aging Derived from Digital Image Analysis

Surgeries doi: 10.3390/surgeries7010035

Authors: Giordano Vespasiani Simone Michelini Federica Trovato Antonio Di Guardo Lorenzo Califano Stefania Guida Giovanni Pellacani

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.

]]> A Three-Morphotype Classification of Lip Aging Derived from Digital Image Analysis Giordano Vespasiani Simone Michelini Federica Trovato Antonio Di Guardo Lorenzo Califano Stefania Guida Giovanni Pellacani doi: 10.3390/surgeries7010035 Surgeries 2026-03-05 Surgeries 2026-03-05 7 1 Opinion 35 10.3390/surgeries7010035 https://www.mdpi.com/2673-4095/7/1/35 Surgeries, Vol. 7, Pages 34: Ten-Year Follow-Up: Collagenase Injection Versus Open Surgery for Dupuytren’s Disease https://www.mdpi.com/2673-4095/7/1/34 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. 2026-03-05 Surgeries, Vol. 7, Pages 34: Ten-Year Follow-Up: Collagenase Injection Versus Open Surgery for Dupuytren’s Disease

Surgeries doi: 10.3390/surgeries7010034

Authors: Camillo Fulchignoni Silvia Pietramala Marco Barbaliscia Marco Passiatore Ludovico Caruso Adriano Cannella Gianfranco Merendi Lorenzo Rocchi Giuseppe Taccardo Rocco de Vitis

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.

]]> Ten-Year Follow-Up: Collagenase Injection Versus Open Surgery for Dupuytren’s Disease Camillo Fulchignoni Silvia Pietramala Marco Barbaliscia Marco Passiatore Ludovico Caruso Adriano Cannella Gianfranco Merendi Lorenzo Rocchi Giuseppe Taccardo Rocco de Vitis doi: 10.3390/surgeries7010034 Surgeries 2026-03-05 Surgeries 2026-03-05 7 1 Article 34 10.3390/surgeries7010034 https://www.mdpi.com/2673-4095/7/1/34 Surgeries, Vol. 7, Pages 33: Closure of a Pleural Defect Using a Collagen Pad During Robotic Thymectomy: A Preliminary Experience https://www.mdpi.com/2673-4095/7/1/33 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. 2026-03-05 Surgeries, Vol. 7, Pages 33: Closure of a Pleural Defect Using a Collagen Pad During Robotic Thymectomy: A Preliminary Experience

Surgeries doi: 10.3390/surgeries7010033

Authors: Alfonso Fiorelli Beatrice Leonardi Vincenzo Di Filippo Francesca Capasso Massimo Ciaravola Giovanni Liguori Francesco Coppolino

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.

]]> Closure of a Pleural Defect Using a Collagen Pad During Robotic Thymectomy: A Preliminary Experience Alfonso Fiorelli Beatrice Leonardi Vincenzo Di Filippo Francesca Capasso Massimo Ciaravola Giovanni Liguori Francesco Coppolino doi: 10.3390/surgeries7010033 Surgeries 2026-03-05 Surgeries 2026-03-05 7 1 Technical Note 33 10.3390/surgeries7010033 https://www.mdpi.com/2673-4095/7/1/33 Surgeries, Vol. 7, Pages 32: Exploring Trends in Endoscopic Dacryocystorhinostomy Research in Asia: A Bibliometric Analysis https://www.mdpi.com/2673-4095/7/1/32 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. 2026-03-04 Surgeries, Vol. 7, Pages 32: Exploring Trends in Endoscopic Dacryocystorhinostomy Research in Asia: A Bibliometric Analysis

Surgeries doi: 10.3390/surgeries7010032

Authors: Josiah Irma Saraswati Anindita Rizki Arief S. Kartasasmita Angga Kartiwa Irawati Irfani

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.

]]> Exploring Trends in Endoscopic Dacryocystorhinostomy Research in Asia: A Bibliometric Analysis Josiah Irma Saraswati Anindita Rizki Arief S. Kartasasmita Angga Kartiwa Irawati Irfani doi: 10.3390/surgeries7010032 Surgeries 2026-03-04 Surgeries 2026-03-04 7 1 Article 32 10.3390/surgeries7010032 https://www.mdpi.com/2673-4095/7/1/32 Surgeries, Vol. 7, Pages 31: WALANT vs. Axillary Block for Dual Mobility Trapeziometacarpal Prosthesis: A Prospective Comparative Study https://www.mdpi.com/2673-4095/7/1/31 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. 2026-02-26 Surgeries, Vol. 7, Pages 31: WALANT vs. Axillary Block for Dual Mobility Trapeziometacarpal Prosthesis: A Prospective Comparative Study

Surgeries doi: 10.3390/surgeries7010031

Authors: Edoardo Biondi Guido Koverech Attilio Romano Giulia Frittella Matteo Guzzini

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.

]]> WALANT vs. Axillary Block for Dual Mobility Trapeziometacarpal Prosthesis: A Prospective Comparative Study Edoardo Biondi Guido Koverech Attilio Romano Giulia Frittella Matteo Guzzini doi: 10.3390/surgeries7010031 Surgeries 2026-02-26 Surgeries 2026-02-26 7 1 Perspective 31 10.3390/surgeries7010031 https://www.mdpi.com/2673-4095/7/1/31 Surgeries, Vol. 7, Pages 30: Functional Restoration of Binocular Vision After Trapdoor Fracture of the Orbit with Inferior Rectus Entrapment: Early Intervention Matters https://www.mdpi.com/2673-4095/7/1/30 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. 2026-02-25 Surgeries, Vol. 7, Pages 30: Functional Restoration of Binocular Vision After Trapdoor Fracture of the Orbit with Inferior Rectus Entrapment: Early Intervention Matters

Surgeries doi: 10.3390/surgeries7010030

Authors: Krzysztof Gąsiorowski Jakub Bargiel Michał Gontarz Tomasz Marecik Grażyna Wyszyńska-Pawelec

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.

]]> Functional Restoration of Binocular Vision After Trapdoor Fracture of the Orbit with Inferior Rectus Entrapment: Early Intervention Matters Krzysztof Gąsiorowski Jakub Bargiel Michał Gontarz Tomasz Marecik Grażyna Wyszyńska-Pawelec doi: 10.3390/surgeries7010030 Surgeries 2026-02-25 Surgeries 2026-02-25 7 1 Case Report 30 10.3390/surgeries7010030 https://www.mdpi.com/2673-4095/7/1/30 Surgeries, Vol. 7, Pages 29: Gene-Activated Octacalcium Phosphate (OCP/VEGF) Versus Autologous Bone Graft for Single-Level TLIF in Degenerative Lumbar Stenosis https://www.mdpi.com/2673-4095/7/1/29 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. 2026-02-22 Surgeries, Vol. 7, Pages 29: Gene-Activated Octacalcium Phosphate (OCP/VEGF) Versus Autologous Bone Graft for Single-Level TLIF in Degenerative Lumbar Stenosis

Surgeries doi: 10.3390/surgeries7010029

Authors: Renat Madekhatovich Nurmukhametov Medetbek Dzhumabekovich Abakirov Stepan Anatolyevich Kudryakov Medet Kaskirbayevich Dosanov Dilerbek Nuriddinov Batzayaa Beis Zhanchivdorj Kerly Sulay Borja Cevallos Ilya Yadigerovich Bozo Alberto Luis Martinez Mateo Nicola Montemurro

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.

]]> Gene-Activated Octacalcium Phosphate (OCP/VEGF) Versus Autologous Bone Graft for Single-Level TLIF in Degenerative Lumbar Stenosis Renat Madekhatovich Nurmukhametov Medetbek Dzhumabekovich Abakirov Stepan Anatolyevich Kudryakov Medet Kaskirbayevich Dosanov Dilerbek Nuriddinov Batzayaa Beis Zhanchivdorj Kerly Sulay Borja Cevallos Ilya Yadigerovich Bozo Alberto Luis Martinez Mateo Nicola Montemurro doi: 10.3390/surgeries7010029 Surgeries 2026-02-22 Surgeries 2026-02-22 7 1 Article 29 10.3390/surgeries7010029 https://www.mdpi.com/2673-4095/7/1/29 Surgeries, Vol. 7, Pages 28: Restoring Facial Balance Using a Creative, Cost-Effective Approach—How a Customized Unilateral Wing Osteotomy Corrected Mandibular Asymmetry https://www.mdpi.com/2673-4095/7/1/28 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. 2026-02-18 Surgeries, Vol. 7, Pages 28: Restoring Facial Balance Using a Creative, Cost-Effective Approach—How a Customized Unilateral Wing Osteotomy Corrected Mandibular Asymmetry

Surgeries doi: 10.3390/surgeries7010028

Authors: Guilherme Pivatto Louzada Bianca Pulino Henrique Furukawa Marcella Bonfim Guilherme Zanovelli Silva Hugo Jose Correia Lopes Gustavo Câmara Letícia Bezinelli Jamil Shibli Raphael Capelli Guerra

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.

]]> Restoring Facial Balance Using a Creative, Cost-Effective Approach—How a Customized Unilateral Wing Osteotomy Corrected Mandibular Asymmetry Guilherme Pivatto Louzada Bianca Pulino Henrique Furukawa Marcella Bonfim Guilherme Zanovelli Silva Hugo Jose Correia Lopes Gustavo Câmara Letícia Bezinelli Jamil Shibli Raphael Capelli Guerra doi: 10.3390/surgeries7010028 Surgeries 2026-02-18 Surgeries 2026-02-18 7 1 Case Report 28 10.3390/surgeries7010028 https://www.mdpi.com/2673-4095/7/1/28 Surgeries, Vol. 7, Pages 27: The Evolution of Inguinal Hernia Repair from the Langenbeck–Gerdy Subcutaneous Technique to Durham and Subsequent Dissection Procedures: A Historical Review https://www.mdpi.com/2673-4095/7/1/27 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. 2026-02-18 Surgeries, Vol. 7, Pages 27: The Evolution of Inguinal Hernia Repair from the Langenbeck–Gerdy Subcutaneous Technique to Durham and Subsequent Dissection Procedures: A Historical Review

Surgeries doi: 10.3390/surgeries7010027

Authors: Alfredo Moreno-Egea Carlos Moreno-Latorre Alfredo Moreno-Latorre

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.

]]> The Evolution of Inguinal Hernia Repair from the Langenbeck–Gerdy Subcutaneous Technique to Durham and Subsequent Dissection Procedures: A Historical Review Alfredo Moreno-Egea Carlos Moreno-Latorre Alfredo Moreno-Latorre doi: 10.3390/surgeries7010027 Surgeries 2026-02-18 Surgeries 2026-02-18 7 1 Review 27 10.3390/surgeries7010027 https://www.mdpi.com/2673-4095/7/1/27 Surgeries, Vol. 7, Pages 26: Image-Guided Autonomous Robotic Surgery in the Context of Therapies Managed by Intelligent Digital Technologies: A Narrative Review https://www.mdpi.com/2673-4095/7/1/26 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. 2026-02-16 Surgeries, Vol. 7, Pages 26: Image-Guided Autonomous Robotic Surgery in the Context of Therapies Managed by Intelligent Digital Technologies: A Narrative Review

Surgeries doi: 10.3390/surgeries7010026

Authors: Adel Razek

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.

]]> Image-Guided Autonomous Robotic Surgery in the Context of Therapies Managed by Intelligent Digital Technologies: A Narrative Review Adel Razek doi: 10.3390/surgeries7010026 Surgeries 2026-02-16 Surgeries 2026-02-16 7 1 Review 26 10.3390/surgeries7010026 https://www.mdpi.com/2673-4095/7/1/26 Surgeries, Vol. 7, Pages 25: Hospital Profitability of Robot-Assisted Gastrointestinal Cancer Surgery in Japan Under the National Fee Schedule: A Surgical Program Model with Required-Cut and Isoprofit Maps https://www.mdpi.com/2673-4095/7/1/25 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. 2026-02-14 Surgeries, Vol. 7, Pages 25: Hospital Profitability of Robot-Assisted Gastrointestinal Cancer Surgery in Japan Under the National Fee Schedule: A Surgical Program Model with Required-Cut and Isoprofit Maps

Surgeries doi: 10.3390/surgeries7010025

Authors: Kazuma Iwasaki Nobuo Kutsuna

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.

]]> Hospital Profitability of Robot-Assisted Gastrointestinal Cancer Surgery in Japan Under the National Fee Schedule: A Surgical Program Model with Required-Cut and Isoprofit Maps Kazuma Iwasaki Nobuo Kutsuna doi: 10.3390/surgeries7010025 Surgeries 2026-02-14 Surgeries 2026-02-14 7 1 Article 25 10.3390/surgeries7010025 https://www.mdpi.com/2673-4095/7/1/25 Surgeries, Vol. 7, Pages 24: Outcomes of Mechanical Mitral Valve Replacement with Preservation of Posterior Leaflet in Patients with Reduced Left Ventricular Function https://www.mdpi.com/2673-4095/7/1/24 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. 2026-02-14 Surgeries, Vol. 7, Pages 24: Outcomes of Mechanical Mitral Valve Replacement with Preservation of Posterior Leaflet in Patients with Reduced Left Ventricular Function

Surgeries doi: 10.3390/surgeries7010024

Authors: Binh Thanh Tran Viet Anh Le Dung Tien Nguyen Dung Van Nguyen Duong Minh Vu Vinh Duc An Bui Phu Duc Bui Nam Van Nguyen

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.

]]> Outcomes of Mechanical Mitral Valve Replacement with Preservation of Posterior Leaflet in Patients with Reduced Left Ventricular Function Binh Thanh Tran Viet Anh Le Dung Tien Nguyen Dung Van Nguyen Duong Minh Vu Vinh Duc An Bui Phu Duc Bui Nam Van Nguyen doi: 10.3390/surgeries7010024 Surgeries 2026-02-14 Surgeries 2026-02-14 7 1 Article 24 10.3390/surgeries7010024 https://www.mdpi.com/2673-4095/7/1/24 Surgeries, Vol. 7, Pages 23: The 50 Highest Cited Papers on Patellofemoral Instability https://www.mdpi.com/2673-4095/7/1/23 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. 2026-02-10 Surgeries, Vol. 7, Pages 23: The 50 Highest Cited Papers on Patellofemoral Instability

Surgeries doi: 10.3390/surgeries7010023

Authors: Federica Denami David H. Dejour Erminia Cofano Umile Giuseppe Longo Simone Cerciello Katia Corona Filippo Familiari Giorgio Gasparini Michele Mercurio

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.

]]> The 50 Highest Cited Papers on Patellofemoral Instability Federica Denami David H. Dejour Erminia Cofano Umile Giuseppe Longo Simone Cerciello Katia Corona Filippo Familiari Giorgio Gasparini Michele Mercurio doi: 10.3390/surgeries7010023 Surgeries 2026-02-10 Surgeries 2026-02-10 7 1 Review 23 10.3390/surgeries7010023 https://www.mdpi.com/2673-4095/7/1/23 Surgeries, Vol. 7, Pages 22: Revision Hip Arthroscopy Patients Face Higher Risk of THA at Long-Term Follow-Up vs. Primary: A Matched Cohort Analysis https://www.mdpi.com/2673-4095/7/1/22 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. 2026-02-10 Surgeries, Vol. 7, Pages 22: Revision Hip Arthroscopy Patients Face Higher Risk of THA at Long-Term Follow-Up vs. Primary: A Matched Cohort Analysis

Surgeries doi: 10.3390/surgeries7010022

Authors: Emily Berzolla Bradley Lezak Claire Thompson Vishal Sundaram Ariana Lott Thomas Youm

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.

]]> Revision Hip Arthroscopy Patients Face Higher Risk of THA at Long-Term Follow-Up vs. Primary: A Matched Cohort Analysis Emily Berzolla Bradley Lezak Claire Thompson Vishal Sundaram Ariana Lott Thomas Youm doi: 10.3390/surgeries7010022 Surgeries 2026-02-10 Surgeries 2026-02-10 7 1 Article 22 10.3390/surgeries7010022 https://www.mdpi.com/2673-4095/7/1/22 Surgeries, Vol. 7, Pages 21: Anaesthesia in Microsurgical Flap Reconstruction: A Review https://www.mdpi.com/2673-4095/7/1/21 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. 2026-02-09 Surgeries, Vol. 7, Pages 21: Anaesthesia in Microsurgical Flap Reconstruction: A Review

Surgeries doi: 10.3390/surgeries7010021

Authors: Arturi Federica Serra Letizia Melegari Gabriele Mosca Francesco Gazzotti Fabio Bertellini Elisabetta Colletti Giacomo Barbieri Alberto

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.

]]> Anaesthesia in Microsurgical Flap Reconstruction: A Review Arturi Federica Serra Letizia Melegari Gabriele Mosca Francesco Gazzotti Fabio Bertellini Elisabetta Colletti Giacomo Barbieri Alberto doi: 10.3390/surgeries7010021 Surgeries 2026-02-09 Surgeries 2026-02-09 7 1 Review 21 10.3390/surgeries7010021 https://www.mdpi.com/2673-4095/7/1/21 Surgeries, Vol. 7, Pages 20: Comparison of Biodegradable Versus Titanium Fixation Systems in Mandibular Fractures: Systematic Review and Meta-Analysis https://www.mdpi.com/2673-4095/7/1/20 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. 2026-01-28 Surgeries, Vol. 7, Pages 20: Comparison of Biodegradable Versus Titanium Fixation Systems in Mandibular Fractures: Systematic Review and Meta-Analysis

Surgeries doi: 10.3390/surgeries7010020

Authors: Abdulaziz Zailai Tahani Alenizi Rakan Sbitan Rana AlBraik Taha Abujohar Abdulmohsen Albraheem Sajad Al Suliman Raand Altayyar Abdullah Mohammed Abdullah Alshahrani Ahmed Alghandour Faisal Aldouiri Ayman Bukhari

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.

]]> Comparison of Biodegradable Versus Titanium Fixation Systems in Mandibular Fractures: Systematic Review and Meta-Analysis Abdulaziz Zailai Tahani Alenizi Rakan Sbitan Rana AlBraik Taha Abujohar Abdulmohsen Albraheem Sajad Al Suliman Raand Altayyar Abdullah Mohammed Abdullah Alshahrani Ahmed Alghandour Faisal Aldouiri Ayman Bukhari doi: 10.3390/surgeries7010020 Surgeries 2026-01-28 Surgeries 2026-01-28 7 1 Systematic Review 20 10.3390/surgeries7010020 https://www.mdpi.com/2673-4095/7/1/20 Surgeries, Vol. 7, Pages 19: Integrating Point-of-Care Ultrasound into Orthopedic Residency: A Longitudinal Evaluation https://www.mdpi.com/2673-4095/7/1/19 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. 2026-01-27 Surgeries, Vol. 7, Pages 19: Integrating Point-of-Care Ultrasound into Orthopedic Residency: A Longitudinal Evaluation

Surgeries doi: 10.3390/surgeries7010019

Authors: Sami Chergui Mostafa Alhabboubi Paul Brisebois Anthony Albers

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.

]]> Integrating Point-of-Care Ultrasound into Orthopedic Residency: A Longitudinal Evaluation Sami Chergui Mostafa Alhabboubi Paul Brisebois Anthony Albers doi: 10.3390/surgeries7010019 Surgeries 2026-01-27 Surgeries 2026-01-27 7 1 Article 19 10.3390/surgeries7010019 https://www.mdpi.com/2673-4095/7/1/19 Surgeries, Vol. 7, Pages 18: Is Lipofilling Predictable? Factors Associated with Delayed Lipofilling for Rippling After Prepectoral Direct-to-Implant Breast Reconstruction https://www.mdpi.com/2673-4095/7/1/18 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. 2026-01-26 Surgeries, Vol. 7, Pages 18: Is Lipofilling Predictable? Factors Associated with Delayed Lipofilling for Rippling After Prepectoral Direct-to-Implant Breast Reconstruction

Surgeries doi: 10.3390/surgeries7010018

Authors: Marco Franchello Gianluca Marcaccini Claudia Chiarini Roberto Cuomo Diletta Maria Pierazzi

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.

]]> Is Lipofilling Predictable? Factors Associated with Delayed Lipofilling for Rippling After Prepectoral Direct-to-Implant Breast Reconstruction Marco Franchello Gianluca Marcaccini Claudia Chiarini Roberto Cuomo Diletta Maria Pierazzi doi: 10.3390/surgeries7010018 Surgeries 2026-01-26 Surgeries 2026-01-26 7 1 Article 18 10.3390/surgeries7010018 https://www.mdpi.com/2673-4095/7/1/18 Surgeries, Vol. 7, Pages 17: Genicular Nerve Block in ACL Reconstruction: A Mini Review https://www.mdpi.com/2673-4095/7/1/17 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. 2026-01-26 Surgeries, Vol. 7, Pages 17: Genicular Nerve Block in ACL Reconstruction: A Mini Review

Surgeries doi: 10.3390/surgeries7010017

Authors: Stefan Stanciugelu Jenel Marian Patrascu Diana Nitusca Sorin Florescu Jenel Marian Patrascu

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.

]]> Genicular Nerve Block in ACL Reconstruction: A Mini Review Stefan Stanciugelu Jenel Marian Patrascu Diana Nitusca Sorin Florescu Jenel Marian Patrascu doi: 10.3390/surgeries7010017 Surgeries 2026-01-26 Surgeries 2026-01-26 7 1 Review 17 10.3390/surgeries7010017 https://www.mdpi.com/2673-4095/7/1/17 Surgeries, Vol. 7, Pages 16: Lymphadenectomy and Postoperative Complications in Stage III Melanoma: A Single-Center Analysis https://www.mdpi.com/2673-4095/7/1/16 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. 2026-01-23 Surgeries, Vol. 7, Pages 16: Lymphadenectomy and Postoperative Complications in Stage III Melanoma: A Single-Center Analysis

Surgeries doi: 10.3390/surgeries7010016

Authors: Francesca Tauceri Fabrizio D’Acapito Valentina Zucchini Daniela Di Pietrantonio Massimo Framarini Giorgio Ercolani

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.

]]> Lymphadenectomy and Postoperative Complications in Stage III Melanoma: A Single-Center Analysis Francesca Tauceri Fabrizio D’Acapito Valentina Zucchini Daniela Di Pietrantonio Massimo Framarini Giorgio Ercolani doi: 10.3390/surgeries7010016 Surgeries 2026-01-23 Surgeries 2026-01-23 7 1 Article 16 10.3390/surgeries7010016 https://www.mdpi.com/2673-4095/7/1/16 Surgeries, Vol. 7, Pages 15: Long Term Results of Clinical Outcome and Patients’ Satisfaction After Modular Stem-Neck Hip Arthroplasty https://www.mdpi.com/2673-4095/7/1/15 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. 2026-01-22 Surgeries, Vol. 7, Pages 15: Long Term Results of Clinical Outcome and Patients’ Satisfaction After Modular Stem-Neck Hip Arthroplasty

Surgeries doi: 10.3390/surgeries7010015

Authors: Panagiotis Karampinas Periklis Pelantis Evangelos Sakellariou Ioannis Spyrou Angelos Kontos Elias S. Vasiliadis John Vlamis Spiros G. Pneumaticos

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.

]]> Long Term Results of Clinical Outcome and Patients’ Satisfaction After Modular Stem-Neck Hip Arthroplasty Panagiotis Karampinas Periklis Pelantis Evangelos Sakellariou Ioannis Spyrou Angelos Kontos Elias S. Vasiliadis John Vlamis Spiros G. Pneumaticos doi: 10.3390/surgeries7010015 Surgeries 2026-01-22 Surgeries 2026-01-22 7 1 Article 15 10.3390/surgeries7010015 https://www.mdpi.com/2673-4095/7/1/15 Surgeries, Vol. 7, Pages 14: Reaches of Unilateral Biportal Endoscopy in Lower Thoracic and Lumbar Spinal Extramedullary Tumor Resection: Case Series, Surgical Note, and Outcomes https://www.mdpi.com/2673-4095/7/1/14 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. 2026-01-21 Surgeries, Vol. 7, Pages 14: Reaches of Unilateral Biportal Endoscopy in Lower Thoracic and Lumbar Spinal Extramedullary Tumor Resection: Case Series, Surgical Note, and Outcomes

Surgeries doi: 10.3390/surgeries7010014

Authors: Adrian Sanchez-Gomez Carlos Castillo-Rangel Gustavo Alberto Vera-Perez Malcom D. Prestonji Rodolfo Guerrero-Perez Gerardo Marín

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.

]]> Reaches of Unilateral Biportal Endoscopy in Lower Thoracic and Lumbar Spinal Extramedullary Tumor Resection: Case Series, Surgical Note, and Outcomes Adrian Sanchez-Gomez Carlos Castillo-Rangel Gustavo Alberto Vera-Perez Malcom D. Prestonji Rodolfo Guerrero-Perez Gerardo Marín doi: 10.3390/surgeries7010014 Surgeries 2026-01-21 Surgeries 2026-01-21 7 1 Article 14 10.3390/surgeries7010014 https://www.mdpi.com/2673-4095/7/1/14 Surgeries, Vol. 7, Pages 13: Successful Digital Replantation in a Resource-Limited Kenyan Hospital: A Case Report and Discussion https://www.mdpi.com/2673-4095/7/1/13 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. 2026-01-20 Surgeries, Vol. 7, Pages 13: Successful Digital Replantation in a Resource-Limited Kenyan Hospital: A Case Report and Discussion

Surgeries doi: 10.3390/surgeries7010013

Authors: Alfio Luca Costa Luca Folini Alvise Montanari Franco Bassetto

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.

]]> Successful Digital Replantation in a Resource-Limited Kenyan Hospital: A Case Report and Discussion Alfio Luca Costa Luca Folini Alvise Montanari Franco Bassetto doi: 10.3390/surgeries7010013 Surgeries 2026-01-20 Surgeries 2026-01-20 7 1 Case Report 13 10.3390/surgeries7010013 https://www.mdpi.com/2673-4095/7/1/13 Surgeries, Vol. 7, Pages 12: Treatments of Polyethylene Tibial Post Fracture in Posterior Stabilized Knee Prosthesis with Unstable Total Knee Arthroplasty: A Case Series https://www.mdpi.com/2673-4095/7/1/12 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. 2026-01-18 Surgeries, Vol. 7, Pages 12: Treatments of Polyethylene Tibial Post Fracture in Posterior Stabilized Knee Prosthesis with Unstable Total Knee Arthroplasty: A Case Series

Surgeries doi: 10.3390/surgeries7010012

Authors: Jaehoon Kim In-Soo Song Jae-Beom Bae

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.

]]> Treatments of Polyethylene Tibial Post Fracture in Posterior Stabilized Knee Prosthesis with Unstable Total Knee Arthroplasty: A Case Series Jaehoon Kim In-Soo Song Jae-Beom Bae doi: 10.3390/surgeries7010012 Surgeries 2026-01-18 Surgeries 2026-01-18 7 1 Case Report 12 10.3390/surgeries7010012 https://www.mdpi.com/2673-4095/7/1/12 Surgeries, Vol. 7, Pages 11: A Chronological Analysis of Fracture Surgery for Femoral Metastasis https://www.mdpi.com/2673-4095/7/1/11 Background: The prognostic trends for adults who undergo fracture surgery for metastatic long bones remain unclear, even as survival among individuals with bone metastasis has improved. Because prognoses after fracture surgery may shift over time, this chronological study aimed to evaluate outcomes in individuals who received surgical treatment for femoral metastasis. Methods: This multicenter retrospective study included 186 adults who underwent fracture surgery for metastatic femoral disease between 2008 and 2023. Individuals were categorized into period 1 (2008–2016) and period 2 (2017–2023). The primary outcome was 1-year overall survival. Prognostic variables included fracture type (impending pathological fracture (IF) or completed pathological fracture (CF)), recovery of ambulation, and receipt of chemotherapy. Results: Individuals in period 2 were older and had a higher rate of solitary bone metastasis; however, period 2 did not demonstrate a higher proportion of IF relative to CF. Multivariate analysis showed that the hazard ratio for period 2 compared with period 1 was 0.57 (95% confidence interval: 0.35 to 0.94, p = 0.02). Conclusions: This chronological assessment demonstrated that the later period was associated with improved 1-year overall survival after fracture surgery for metastatic long bone disease. Because prophylactic fixation for IF is linked to more favorable outcomes, increasing the proportion of IF cases relative to CF should be prioritized. 2026-01-18 Surgeries, Vol. 7, Pages 11: A Chronological Analysis of Fracture Surgery for Femoral Metastasis

Surgeries doi: 10.3390/surgeries7010011

Authors: Jurina Izaki Hirokazu Shimizu Masatake Matsuoka Tamotsu Soma Daisuke Takahashi Tomohiro Shimizu Kanako Ito Hiroaki Hiraga Norimasa Iwasaki Akira Iwata

Background: The prognostic trends for adults who undergo fracture surgery for metastatic long bones remain unclear, even as survival among individuals with bone metastasis has improved. Because prognoses after fracture surgery may shift over time, this chronological study aimed to evaluate outcomes in individuals who received surgical treatment for femoral metastasis. Methods: This multicenter retrospective study included 186 adults who underwent fracture surgery for metastatic femoral disease between 2008 and 2023. Individuals were categorized into period 1 (2008–2016) and period 2 (2017–2023). The primary outcome was 1-year overall survival. Prognostic variables included fracture type (impending pathological fracture (IF) or completed pathological fracture (CF)), recovery of ambulation, and receipt of chemotherapy. Results: Individuals in period 2 were older and had a higher rate of solitary bone metastasis; however, period 2 did not demonstrate a higher proportion of IF relative to CF. Multivariate analysis showed that the hazard ratio for period 2 compared with period 1 was 0.57 (95% confidence interval: 0.35 to 0.94, p = 0.02). Conclusions: This chronological assessment demonstrated that the later period was associated with improved 1-year overall survival after fracture surgery for metastatic long bone disease. Because prophylactic fixation for IF is linked to more favorable outcomes, increasing the proportion of IF cases relative to CF should be prioritized.

]]> A Chronological Analysis of Fracture Surgery for Femoral Metastasis Jurina Izaki Hirokazu Shimizu Masatake Matsuoka Tamotsu Soma Daisuke Takahashi Tomohiro Shimizu Kanako Ito Hiroaki Hiraga Norimasa Iwasaki Akira Iwata doi: 10.3390/surgeries7010011 Surgeries 2026-01-18 Surgeries 2026-01-18 7 1 Article 11 10.3390/surgeries7010011 https://www.mdpi.com/2673-4095/7/1/11 Surgeries, Vol. 7, Pages 10: Incidental Carcinomas and Lesions with Uncertain Malignant Potential (B3) Discovered During Symmetrization Mammoplasty in Breast Cancer Patients—Retrospective Single-Center Experience https://www.mdpi.com/2673-4095/7/1/10 Although occult breast carcinomas and lesions with uncertain malignant potential are rare, their incidental discovery during symmetrizing mammoplasty can significantly alter the treatment approaches and cancer staging. In the context of oncoplastic surgery, the systematic evaluation of the contralateral breast is a clinical priority that has been underexplored in Eastern Europe. Background/Objectives: This study aimed to assess the incidence and histological characteristics of incidental carcinomas and B 3 lesions detected during contralateral symmetry mammoplasty in patients with breast cancer. Methods: This retrospective study was conducted at the Plastic and Reconstructive Surgery Clinic of the “Pius Brînzeu” County Emergency Clinical Hospital in Timisoara, Romania, over six years (2018–2024), and included 180 of 256 patients who underwent contralateral breast symmetrization. Results: Among the 180 patients, 21 (11.66%) had incidental findings: eight (4.44%) had contralateral carcinomas, and 13 (7.22%) had B3 lesions. The histopathological types identified were invasive ductal carcinoma NST (one case), ductal carcinoma in situ (one case), invasive lobular carcinoma (five cases), and mucinous/papillary carcinoma (one case). Compared to the reported international range of 2–10%, our observed incidence of 11.66% reflects the unique aspects of our patient cohort and the thoroughness of our histological analyses. Conclusions: Detection of contralateral carcinomas and B3 lesions during symmetry mammoplasties underscores the importance of a multidisciplinary approach, comprehensive bilateral screening, and detailed histopathological examination of specimens. 2026-01-04 Surgeries, Vol. 7, Pages 10: Incidental Carcinomas and Lesions with Uncertain Malignant Potential (B3) Discovered During Symmetrization Mammoplasty in Breast Cancer Patients—Retrospective Single-Center Experience

Surgeries doi: 10.3390/surgeries7010010

Authors: Daciana Grujic Horia Cristian Alis Dema Mihai Iliescu Glaja Teodora Hoinoiu Fabiana Simion Daniel Pit Isabela Caizer-Găitan Cristina Oprean

Although occult breast carcinomas and lesions with uncertain malignant potential are rare, their incidental discovery during symmetrizing mammoplasty can significantly alter the treatment approaches and cancer staging. In the context of oncoplastic surgery, the systematic evaluation of the contralateral breast is a clinical priority that has been underexplored in Eastern Europe. Background/Objectives: This study aimed to assess the incidence and histological characteristics of incidental carcinomas and B 3 lesions detected during contralateral symmetry mammoplasty in patients with breast cancer. Methods: This retrospective study was conducted at the Plastic and Reconstructive Surgery Clinic of the “Pius Brînzeu” County Emergency Clinical Hospital in Timisoara, Romania, over six years (2018–2024), and included 180 of 256 patients who underwent contralateral breast symmetrization. Results: Among the 180 patients, 21 (11.66%) had incidental findings: eight (4.44%) had contralateral carcinomas, and 13 (7.22%) had B3 lesions. The histopathological types identified were invasive ductal carcinoma NST (one case), ductal carcinoma in situ (one case), invasive lobular carcinoma (five cases), and mucinous/papillary carcinoma (one case). Compared to the reported international range of 2–10%, our observed incidence of 11.66% reflects the unique aspects of our patient cohort and the thoroughness of our histological analyses. Conclusions: Detection of contralateral carcinomas and B3 lesions during symmetry mammoplasties underscores the importance of a multidisciplinary approach, comprehensive bilateral screening, and detailed histopathological examination of specimens.

]]> Incidental Carcinomas and Lesions with Uncertain Malignant Potential (B3) Discovered During Symmetrization Mammoplasty in Breast Cancer Patients—Retrospective Single-Center Experience Daciana Grujic Horia Cristian Alis Dema Mihai Iliescu Glaja Teodora Hoinoiu Fabiana Simion Daniel Pit Isabela Caizer-Găitan Cristina Oprean doi: 10.3390/surgeries7010010 Surgeries 2026-01-04 Surgeries 2026-01-04 7 1 Article 10 10.3390/surgeries7010010 https://www.mdpi.com/2673-4095/7/1/10 Surgeries, Vol. 7, Pages 9: Is Chronic Pelvic Sepsis Complicating Low Anterior Resection of Rectal Cancer Preventable? https://www.mdpi.com/2673-4095/7/1/9 The combination of anatomical inaccessibility, less-than-optimal blood supply, tightly closed anal sphincters below a low anastomosis, and an infected haematoma is likely to be contributory to anastomotic leakage following low anterior resection of the rectum for rectal cancer. Although under-reported, chronic pelvic sepsis complicating low anterior resection of the rectum is still a major problem associated with impaired quality of life. It should be avoided as much as possible, in addition to the fact that it is more difficult to manage surgically than acute sepsis. Primary preventive measures are well established. Secondary prevention of chronic pelvic sepsis is achieved by early diagnosis and active management of the anastomotic leak. However, optimal postoperative management cannot fully eliminate chronic sinuses or delayed reactivation leaks. With chronic leakage, major restorative redo-anastomosis or ablative abdominal perineal resection is required and 20% of patients will require a permanent stoma. 2026-01-01 Surgeries, Vol. 7, Pages 9: Is Chronic Pelvic Sepsis Complicating Low Anterior Resection of Rectal Cancer Preventable?

Surgeries doi: 10.3390/surgeries7010009

Authors: Elroy Weledji

The combination of anatomical inaccessibility, less-than-optimal blood supply, tightly closed anal sphincters below a low anastomosis, and an infected haematoma is likely to be contributory to anastomotic leakage following low anterior resection of the rectum for rectal cancer. Although under-reported, chronic pelvic sepsis complicating low anterior resection of the rectum is still a major problem associated with impaired quality of life. It should be avoided as much as possible, in addition to the fact that it is more difficult to manage surgically than acute sepsis. Primary preventive measures are well established. Secondary prevention of chronic pelvic sepsis is achieved by early diagnosis and active management of the anastomotic leak. However, optimal postoperative management cannot fully eliminate chronic sinuses or delayed reactivation leaks. With chronic leakage, major restorative redo-anastomosis or ablative abdominal perineal resection is required and 20% of patients will require a permanent stoma.

]]> Is Chronic Pelvic Sepsis Complicating Low Anterior Resection of Rectal Cancer Preventable? Elroy Weledji doi: 10.3390/surgeries7010009 Surgeries 2026-01-01 Surgeries 2026-01-01 7 1 Opinion 9 10.3390/surgeries7010009 https://www.mdpi.com/2673-4095/7/1/9 Surgeries, Vol. 7, Pages 8: Use of the Vascularized Fascial Flap Based on the 1,2 ICSRA Artery for Scapholunate Ligament Repair: An Anatomic Study https://www.mdpi.com/2673-4095/7/1/8 Scapholunate (SL) ligament injuries, if not properly treated, can compromise wrist biomechanics, leading to instability, scapholunate advanced collapse (SLAC) and progressive osteoarthritis. Depending on the severity of the injury, current repair techniques include either arthroscopic or open surgical approaches; however, the limited vascularization of the region often represents an obstacle to optimal ligament healing. This study aims to assess the feasibility of using a vascularized fascial flap based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for biological augmentation of the scapholunate ligament. Five previously injected cadaveric upper limbs were dissected and flap dimensions, including length, width, and pedicle length, were measured using a millimeter-calibrated ruler by two independent operators. All flaps provided sufficient coverage, and the vascular pedicle length allowed tension-free positioning without vascular kinking. These findings demonstrate that a 1,2 ICSRA-based fascial flap is anatomically feasible for scapholunate ligament augmentation. It should be noted that this is a purely cadaveric study, and the technique has not yet been tested in vivo. The results suggest potential surgical applications, providing a vascularized biological option that may enhance ligament healing in future clinical studies. 2026-01-01 Surgeries, Vol. 7, Pages 8: Use of the Vascularized Fascial Flap Based on the 1,2 ICSRA Artery for Scapholunate Ligament Repair: An Anatomic Study

Surgeries doi: 10.3390/surgeries7010008

Authors: Enrico Palombo Simone Otera Yuri Piccolo Stefano Gumina Diego Ribuffo Alessia Pagnotta

Scapholunate (SL) ligament injuries, if not properly treated, can compromise wrist biomechanics, leading to instability, scapholunate advanced collapse (SLAC) and progressive osteoarthritis. Depending on the severity of the injury, current repair techniques include either arthroscopic or open surgical approaches; however, the limited vascularization of the region often represents an obstacle to optimal ligament healing. This study aims to assess the feasibility of using a vascularized fascial flap based on the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) for biological augmentation of the scapholunate ligament. Five previously injected cadaveric upper limbs were dissected and flap dimensions, including length, width, and pedicle length, were measured using a millimeter-calibrated ruler by two independent operators. All flaps provided sufficient coverage, and the vascular pedicle length allowed tension-free positioning without vascular kinking. These findings demonstrate that a 1,2 ICSRA-based fascial flap is anatomically feasible for scapholunate ligament augmentation. It should be noted that this is a purely cadaveric study, and the technique has not yet been tested in vivo. The results suggest potential surgical applications, providing a vascularized biological option that may enhance ligament healing in future clinical studies.

]]> Use of the Vascularized Fascial Flap Based on the 1,2 ICSRA Artery for Scapholunate Ligament Repair: An Anatomic Study Enrico Palombo Simone Otera Yuri Piccolo Stefano Gumina Diego Ribuffo Alessia Pagnotta doi: 10.3390/surgeries7010008 Surgeries 2026-01-01 Surgeries 2026-01-01 7 1 Technical Note 8 10.3390/surgeries7010008 https://www.mdpi.com/2673-4095/7/1/8 Surgeries, Vol. 7, Pages 7: Biomechanics, Material Performance, and Wear Analysis in Total Hip Arthroplasty: A Review https://www.mdpi.com/2673-4095/7/1/7 Total hip arthroplasty (THA) is a transformative procedure for managing severe hip disorders, yet implant longevity remains a critical challenge, particularly for younger, active patients. Wear-related complications are a leading cause of revision surgery, emphasizing the need for optimized design and material performance. This systematic review aims to synthesize evidence on the wear behavior, material properties, and design parameters of hip implants with a focus on finite element analysis (FEA)-based predictive approaches. A comprehensive literature search was conducted across Scopus, PubMed, ScienceDirect, MDPI, and Cochrane databases following PRISMA guidelines. Studies published between 2010 and 2025 were included if they addressed THA biomechanics, wear analysis, or material optimization using FEA, hip simulators, or radiostereometric techniques. Key findings reveal that larger femoral heads, while reducing contact pressure, increase wear due to greater sliding distance. Gravimetric wear rates ranged from 3.15 ± 0.27 mg/Mc to 2.18 ± 0.31 mg/Mc, while linear and volumetric wear reached 0.0375 mm/Mc and 33.6 mm3/Mc, respectively. Stress analysis showed custom stems exhibited markedly lower von Mises stress (194.9 MPa) compared to standard designs (664.3 MPa), and fatigue assessments confirmed a factor of safety > 1 across profiles. Patient-specific factors, such as body weight, significantly influenced wear with a 26% increase in metal wear observed between 100 kg and 140 kg. This systematic review synthesizes current research on total hip arthroplasty, emphasizing biomechanical and material factors critical for implant longevity and patient care. It uniquely integrates FEA-based wear prediction with clinical implications, bridging computational modeling, geometry optimization, and material performance to provide actionable insights for next-generation, patient-specific hip implant design. 2025-12-30 Surgeries, Vol. 7, Pages 7: Biomechanics, Material Performance, and Wear Analysis in Total Hip Arthroplasty: A Review

Surgeries doi: 10.3390/surgeries7010007

Authors: Nishant Nikam Satish Shenoy B. Sawan Shetty Shyamasunder Bhat N. Laxmikant G. Keni Chethan K. N. Şenay Mihçin

Total hip arthroplasty (THA) is a transformative procedure for managing severe hip disorders, yet implant longevity remains a critical challenge, particularly for younger, active patients. Wear-related complications are a leading cause of revision surgery, emphasizing the need for optimized design and material performance. This systematic review aims to synthesize evidence on the wear behavior, material properties, and design parameters of hip implants with a focus on finite element analysis (FEA)-based predictive approaches. A comprehensive literature search was conducted across Scopus, PubMed, ScienceDirect, MDPI, and Cochrane databases following PRISMA guidelines. Studies published between 2010 and 2025 were included if they addressed THA biomechanics, wear analysis, or material optimization using FEA, hip simulators, or radiostereometric techniques. Key findings reveal that larger femoral heads, while reducing contact pressure, increase wear due to greater sliding distance. Gravimetric wear rates ranged from 3.15 ± 0.27 mg/Mc to 2.18 ± 0.31 mg/Mc, while linear and volumetric wear reached 0.0375 mm/Mc and 33.6 mm3/Mc, respectively. Stress analysis showed custom stems exhibited markedly lower von Mises stress (194.9 MPa) compared to standard designs (664.3 MPa), and fatigue assessments confirmed a factor of safety > 1 across profiles. Patient-specific factors, such as body weight, significantly influenced wear with a 26% increase in metal wear observed between 100 kg and 140 kg. This systematic review synthesizes current research on total hip arthroplasty, emphasizing biomechanical and material factors critical for implant longevity and patient care. It uniquely integrates FEA-based wear prediction with clinical implications, bridging computational modeling, geometry optimization, and material performance to provide actionable insights for next-generation, patient-specific hip implant design.

]]> Biomechanics, Material Performance, and Wear Analysis in Total Hip Arthroplasty: A Review Nishant Nikam Satish Shenoy B. Sawan Shetty Shyamasunder Bhat N. Laxmikant G. Keni Chethan K. N. Şenay Mihçin doi: 10.3390/surgeries7010007 Surgeries 2025-12-30 Surgeries 2025-12-30 7 1 Review 7 10.3390/surgeries7010007 https://www.mdpi.com/2673-4095/7/1/7 Surgeries, Vol. 7, Pages 6: Primary Trapeziometacarpal (TMC) Arthroplasty for Bennett Fracture in Setting of Severe Thumb Osteoarthritis: A Case Report https://www.mdpi.com/2673-4095/7/1/6 Bennett fractures are common intra-articular fractures of the base of the first metacarpal. Not optimal restoration of the articular surface often leads to osteoarthritis, with pain and limited movement. In patients with established and symptomatic TMC osteoarthritis, arthroplasty with MAIA® prosthesis could be a valid option. In July 2024, a right-handed man of 68 years old fell on his hand. Radiographs showed a Bennett fracture in a setting of Eaton–Littler stage 3 osteoarthritis, already painful and disabling according to the patient. For correct pre-operative planning, a 3D model of the affected hand was produced. The patient underwent TMC arthroplasty with a MAIA® prosthesis. Two months after surgery, the results reported no pain (VAS scale) and considerable functionality and mobility of the first ray (AROM, Kapandji score, and PRWHE were investigated). The mean pinch strength of the right hand was 7 kg and of the left hand 7.5 kg using a pinch meter. At one-year follow-up, no complications were reported: the implant did not show signs of loosening or subsidence. TMC arthroplasty in Bennett fractures could represent a safe procedure in patients with established TMC osteoarthritis; however, further studies are requested in order to clarify effectiveness and indications. 2025-12-26 Surgeries, Vol. 7, Pages 6: Primary Trapeziometacarpal (TMC) Arthroplasty for Bennett Fracture in Setting of Severe Thumb Osteoarthritis: A Case Report

Surgeries doi: 10.3390/surgeries7010006

Authors: Chiara Stambazzi Marvin Menini Luca Pandolfo

Bennett fractures are common intra-articular fractures of the base of the first metacarpal. Not optimal restoration of the articular surface often leads to osteoarthritis, with pain and limited movement. In patients with established and symptomatic TMC osteoarthritis, arthroplasty with MAIA® prosthesis could be a valid option. In July 2024, a right-handed man of 68 years old fell on his hand. Radiographs showed a Bennett fracture in a setting of Eaton–Littler stage 3 osteoarthritis, already painful and disabling according to the patient. For correct pre-operative planning, a 3D model of the affected hand was produced. The patient underwent TMC arthroplasty with a MAIA® prosthesis. Two months after surgery, the results reported no pain (VAS scale) and considerable functionality and mobility of the first ray (AROM, Kapandji score, and PRWHE were investigated). The mean pinch strength of the right hand was 7 kg and of the left hand 7.5 kg using a pinch meter. At one-year follow-up, no complications were reported: the implant did not show signs of loosening or subsidence. TMC arthroplasty in Bennett fractures could represent a safe procedure in patients with established TMC osteoarthritis; however, further studies are requested in order to clarify effectiveness and indications.

]]> Primary Trapeziometacarpal (TMC) Arthroplasty for Bennett Fracture in Setting of Severe Thumb Osteoarthritis: A Case Report Chiara Stambazzi Marvin Menini Luca Pandolfo doi: 10.3390/surgeries7010006 Surgeries 2025-12-26 Surgeries 2025-12-26 7 1 Case Report 6 10.3390/surgeries7010006 https://www.mdpi.com/2673-4095/7/1/6 Surgeries, Vol. 7, Pages 5: Laparoscopic Repair of Primary Ventral Hernias: Outcomes of a Retrospective Cohort Study on 200 Surgeries Using Single Mesh and IPOM Technique https://www.mdpi.com/2673-4095/7/1/5 Background: Primary ventral hernias (PVHs) are a frequent disease that can impair quality of life. Laparoscopic intraperitoneal onlay mesh (IPOM) technique has shown good outcomes in appropriately selected cases. Methods: We report the results of a retrospective analysis involving 200 consecutive patients who underwent laparoscopic ventral hernia repair with a standardized technique using a single mesh from January 2011 to September 2024 to define the safety of laparoscopy in ventral hernia treatment. Results: The study included 147 umbilical hernias (73%) and 53 epigastric hernias (27%). The average defect measured 3 cm, with sizes ranging from 2 to 7 cm. After a mean follow-up of 1708 days (range 117–4642), no complications associated with the mesh were observed; there was only one (0.5%) recurrence documented and no bulging was observed. Conclusions: Laparoscopic repair of PVH using a standardized technique and using the same mesh, which has been proven safe over the last 15 years, offers good results. 2025-12-25 Surgeries, Vol. 7, Pages 5: Laparoscopic Repair of Primary Ventral Hernias: Outcomes of a Retrospective Cohort Study on 200 Surgeries Using Single Mesh and IPOM Technique

Surgeries doi: 10.3390/surgeries7010005

Authors: Gaetano Vetrone Luca Negosanti Rossella Sgarzani Michele Masetti

Background: Primary ventral hernias (PVHs) are a frequent disease that can impair quality of life. Laparoscopic intraperitoneal onlay mesh (IPOM) technique has shown good outcomes in appropriately selected cases. Methods: We report the results of a retrospective analysis involving 200 consecutive patients who underwent laparoscopic ventral hernia repair with a standardized technique using a single mesh from January 2011 to September 2024 to define the safety of laparoscopy in ventral hernia treatment. Results: The study included 147 umbilical hernias (73%) and 53 epigastric hernias (27%). The average defect measured 3 cm, with sizes ranging from 2 to 7 cm. After a mean follow-up of 1708 days (range 117–4642), no complications associated with the mesh were observed; there was only one (0.5%) recurrence documented and no bulging was observed. Conclusions: Laparoscopic repair of PVH using a standardized technique and using the same mesh, which has been proven safe over the last 15 years, offers good results.

]]> Laparoscopic Repair of Primary Ventral Hernias: Outcomes of a Retrospective Cohort Study on 200 Surgeries Using Single Mesh and IPOM Technique Gaetano Vetrone Luca Negosanti Rossella Sgarzani Michele Masetti doi: 10.3390/surgeries7010005 Surgeries 2025-12-25 Surgeries 2025-12-25 7 1 Article 5 10.3390/surgeries7010005 https://www.mdpi.com/2673-4095/7/1/5 Surgeries, Vol. 7, Pages 4: Shock Wave-Induced Regeneration in Soft Tissue Reconstruction: Clinical Application in Hand Surgery https://www.mdpi.com/2673-4095/7/1/4 Background/Objectives: Chronic ulcers are often characterized by impaired microcirculation, delayed epithelialization, and persistent pain. Extracorporeal shock wave therapy (ESWT) has emerged as a regenerative approach capable of modulating angiogenesis and tissue repair. This study aimed to evaluate the effects of ESWT on wound healing, microvascular remodeling, sensory recovery, and joint mobility in patients with chronic ulcerative lesions. Methods: In this prospective observational study, patients with chronic ulcers underwent a standardized ESWT protocol in addition to conventional wound care. Clinical outcomes were assessed at baseline and at the end of follow-up using the Bates–Jensen Wound Assessment Tool (BWAT), pain visual analogue scale (VAS), capillaroscopy, Semmes–Weinstein monofilament test (SWMT), two-point discrimination (2PD), and range of motion (ROM). Results: ESWT was associated with a significant improvement in wound status, pain, sensory function, and ROM. Capillaroscopy showed robust correlations with clinical recovery, inversely with BWAT (ρ = −0.64, p < 0.01), SWMT (ρ = −0.55, p < 0.05), and 2PD (ρ = −0.49, p < 0.05), and positively with ROM recovery (ρ = 0.58, p < 0.01). Diabetic and smoking patients required a longer healing period (5.8 ± 1.3 weeks) than non-diabetic, non-smoking patients (4.2 ± 0.9 weeks, p = 0.03), although BWAT, capillaroscopy, and ROM values converged by week 8. Conclusions: ESWT was associated with meaningful structural, microvascular, and functional improvements in chronic ulcers. Microvascular remodeling, assessed by capillaroscopy, emerged as a key correlate of clinical recovery. Despite slower early healing in diabetic and smoking patients, final regenerative outcomes were ultimately comparable across risk profiles. 2025-12-25 Surgeries, Vol. 7, Pages 4: Shock Wave-Induced Regeneration in Soft Tissue Reconstruction: Clinical Application in Hand Surgery

Surgeries doi: 10.3390/surgeries7010004

Authors: Luciana Marzella Michele Riccio Maria Cristina D’Agostino Alberto Lazzerini Francesco De Francesco

Background/Objectives: Chronic ulcers are often characterized by impaired microcirculation, delayed epithelialization, and persistent pain. Extracorporeal shock wave therapy (ESWT) has emerged as a regenerative approach capable of modulating angiogenesis and tissue repair. This study aimed to evaluate the effects of ESWT on wound healing, microvascular remodeling, sensory recovery, and joint mobility in patients with chronic ulcerative lesions. Methods: In this prospective observational study, patients with chronic ulcers underwent a standardized ESWT protocol in addition to conventional wound care. Clinical outcomes were assessed at baseline and at the end of follow-up using the Bates–Jensen Wound Assessment Tool (BWAT), pain visual analogue scale (VAS), capillaroscopy, Semmes–Weinstein monofilament test (SWMT), two-point discrimination (2PD), and range of motion (ROM). Results: ESWT was associated with a significant improvement in wound status, pain, sensory function, and ROM. Capillaroscopy showed robust correlations with clinical recovery, inversely with BWAT (ρ = −0.64, p < 0.01), SWMT (ρ = −0.55, p < 0.05), and 2PD (ρ = −0.49, p < 0.05), and positively with ROM recovery (ρ = 0.58, p < 0.01). Diabetic and smoking patients required a longer healing period (5.8 ± 1.3 weeks) than non-diabetic, non-smoking patients (4.2 ± 0.9 weeks, p = 0.03), although BWAT, capillaroscopy, and ROM values converged by week 8. Conclusions: ESWT was associated with meaningful structural, microvascular, and functional improvements in chronic ulcers. Microvascular remodeling, assessed by capillaroscopy, emerged as a key correlate of clinical recovery. Despite slower early healing in diabetic and smoking patients, final regenerative outcomes were ultimately comparable across risk profiles.

]]> Shock Wave-Induced Regeneration in Soft Tissue Reconstruction: Clinical Application in Hand Surgery Luciana Marzella Michele Riccio Maria Cristina D’Agostino Alberto Lazzerini Francesco De Francesco doi: 10.3390/surgeries7010004 Surgeries 2025-12-25 Surgeries 2025-12-25 7 1 Article 4 10.3390/surgeries7010004 https://www.mdpi.com/2673-4095/7/1/4 Surgeries, Vol. 7, Pages 3: Augmentation and Increased Projection of Buttocks with a Sofiderm® Cross-Linked Hyaluronic Acid Filler: A Deep and Superficial Implantation Technique https://www.mdpi.com/2673-4095/7/1/3 Background: In recent years, hyaluronic acid filler for the restoration and increase in buttock volume has been a procedure that has seen increasing success, both thanks to the considerable increase in patient demand and thanks to the improvement of implant techniques and device manufacturing technologies. Aims: The primary objective of this pilot study is to demonstrate the validity of an innovative filler inoculation technique in the upper quadrants of the buttocks and in the supra- and subfascial area in order to optically restore the appearance of a pleasant lumbar lordosis and to lift the upper quadrants with reduction in the infragluteal fold. The secondary objective is to evaluate the safety and efficacy of Sofiderm SubSkin® (Techderm Biological Products Co., Ltd., Hangzhou, China), a highly versatile hyaluronic acid filler, formulated with a rheology suitable for use on the face and body. Patients/Methods: Five female subjects (50–63 years) were subjected to gluteal fillers in the supra- and subfascial areas; the correct positioning of the filler was investigated by means of a 20 Mhz ultrasound probe. Results: All patients obtained a significant improvement in the projection of the upper part of the buttocks. The implantation technique and the optimal rheological properties of the device brought about a natural and well-defined increase in volume, with a projection of the upper part of the buttocks and a consequent lifting of the lower parts and reduction in the length of the infragluteal fold. Conclusions: This study confirmed the efficacy and safety of the cross-linked hyaluronic acid Sofiderm Derm SubSkin® in increasing the projection of the upper part of the buttocks, using an innovative mixed implantation technique, in a sample of selected patients. 2025-12-25 Surgeries, Vol. 7, Pages 3: Augmentation and Increased Projection of Buttocks with a Sofiderm® Cross-Linked Hyaluronic Acid Filler: A Deep and Superficial Implantation Technique

Surgeries doi: 10.3390/surgeries7010003

Authors: Giordano Vespasiani Giuseppina Ricci Simone Michelini Federica Trovato Antonio Di Guardo Lorenzo Califano Laura Nesticò Stefania Guida Giovanni Pellacani

Background: In recent years, hyaluronic acid filler for the restoration and increase in buttock volume has been a procedure that has seen increasing success, both thanks to the considerable increase in patient demand and thanks to the improvement of implant techniques and device manufacturing technologies. Aims: The primary objective of this pilot study is to demonstrate the validity of an innovative filler inoculation technique in the upper quadrants of the buttocks and in the supra- and subfascial area in order to optically restore the appearance of a pleasant lumbar lordosis and to lift the upper quadrants with reduction in the infragluteal fold. The secondary objective is to evaluate the safety and efficacy of Sofiderm SubSkin® (Techderm Biological Products Co., Ltd., Hangzhou, China), a highly versatile hyaluronic acid filler, formulated with a rheology suitable for use on the face and body. Patients/Methods: Five female subjects (50–63 years) were subjected to gluteal fillers in the supra- and subfascial areas; the correct positioning of the filler was investigated by means of a 20 Mhz ultrasound probe. Results: All patients obtained a significant improvement in the projection of the upper part of the buttocks. The implantation technique and the optimal rheological properties of the device brought about a natural and well-defined increase in volume, with a projection of the upper part of the buttocks and a consequent lifting of the lower parts and reduction in the length of the infragluteal fold. Conclusions: This study confirmed the efficacy and safety of the cross-linked hyaluronic acid Sofiderm Derm SubSkin® in increasing the projection of the upper part of the buttocks, using an innovative mixed implantation technique, in a sample of selected patients.

]]> Augmentation and Increased Projection of Buttocks with a Sofiderm® Cross-Linked Hyaluronic Acid Filler: A Deep and Superficial Implantation Technique Giordano Vespasiani Giuseppina Ricci Simone Michelini Federica Trovato Antonio Di Guardo Lorenzo Califano Laura Nesticò Stefania Guida Giovanni Pellacani doi: 10.3390/surgeries7010003 Surgeries 2025-12-25 Surgeries 2025-12-25 7 1 Article 3 10.3390/surgeries7010003 https://www.mdpi.com/2673-4095/7/1/3 Surgeries, Vol. 7, Pages 2: Immediate Postoperative Biofeedback with an Insole Device in Unilateral TKA https://www.mdpi.com/2673-4095/7/1/2 Background: After unilateral total knee arthroplasty (TKA), patients place more weight on the nonsurgical limb than the surgical limb. The objective of this study was to determine the possibility of providing live biofeedback during early recovery of patients undergoing unilateral TKA and to determine the necessary sample size for future trials. Methods: Twenty patients with unilateral TKA were randomized into two groups: a feedback group and a control group. Inclusion criteria included no contralateral knee pain and aid-free walking before surgery. There were 8 patients in the feedback group and 10 in the control group. Compliance with the recommended training was 91%. The feedback group trained with an insole device for 15 min a day for 4 weeks, along with normal physiotherapy. The control group received normal physiotherapy only. Gait parameters were recorded on level ground at two and six weeks. The primary outcome was the percent loading rate. The secondary outcomes included gait speed, cadence, percent peak force, and pain. Results: Patients within the feedback group showed a small, non-significant trend toward a higher precent load rate at 6 weeks compared to the control group in level walking (p = 0.92). Conclusions: Our findings indicate that live biofeedback on a gait parameter, like percent load rate, can be provided by the mentioned system and may support immediate changes in gait parameters. The compliance of 91% with training and no reported adverse events indicates that the system was easy to use. Following TKA, there may be a potential exploratory use of mobile, real-time biofeedback to help address gait abnormalities and accelerate rehabilitation. This clinical trial was registered at clinicaltrials.gov (Identifier: NCT03673293) on 14 September 2018. This study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of the University of Utah (IRB_00110935) on 10 September 2018. 2025-12-23 Surgeries, Vol. 7, Pages 2: Immediate Postoperative Biofeedback with an Insole Device in Unilateral TKA

Surgeries doi: 10.3390/surgeries7010002

Authors: Daniel Pfeufer Mike B. Anderson Jeremy Gililland Robert Hube Christoph Linhart Julius Brendler Christopher E. Pelt

Background: After unilateral total knee arthroplasty (TKA), patients place more weight on the nonsurgical limb than the surgical limb. The objective of this study was to determine the possibility of providing live biofeedback during early recovery of patients undergoing unilateral TKA and to determine the necessary sample size for future trials. Methods: Twenty patients with unilateral TKA were randomized into two groups: a feedback group and a control group. Inclusion criteria included no contralateral knee pain and aid-free walking before surgery. There were 8 patients in the feedback group and 10 in the control group. Compliance with the recommended training was 91%. The feedback group trained with an insole device for 15 min a day for 4 weeks, along with normal physiotherapy. The control group received normal physiotherapy only. Gait parameters were recorded on level ground at two and six weeks. The primary outcome was the percent loading rate. The secondary outcomes included gait speed, cadence, percent peak force, and pain. Results: Patients within the feedback group showed a small, non-significant trend toward a higher precent load rate at 6 weeks compared to the control group in level walking (p = 0.92). Conclusions: Our findings indicate that live biofeedback on a gait parameter, like percent load rate, can be provided by the mentioned system and may support immediate changes in gait parameters. The compliance of 91% with training and no reported adverse events indicates that the system was easy to use. Following TKA, there may be a potential exploratory use of mobile, real-time biofeedback to help address gait abnormalities and accelerate rehabilitation. This clinical trial was registered at clinicaltrials.gov (Identifier: NCT03673293) on 14 September 2018. This study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of the University of Utah (IRB_00110935) on 10 September 2018.

]]> Immediate Postoperative Biofeedback with an Insole Device in Unilateral TKA Daniel Pfeufer Mike B. Anderson Jeremy Gililland Robert Hube Christoph Linhart Julius Brendler Christopher E. Pelt doi: 10.3390/surgeries7010002 Surgeries 2025-12-23 Surgeries 2025-12-23 7 1 Article 2 10.3390/surgeries7010002 https://www.mdpi.com/2673-4095/7/1/2 Surgeries, Vol. 7, Pages 1: The “Bank Finger” Principle in Hand Surgery—Retrospective Study vs. Systematic Review https://www.mdpi.com/2673-4095/7/1/1 Background/Objectives: The “bank-finger” or “spare-parts” principle offers an immediate reconstructive solution in mutilating hand injuries by repurposing viable tissues from non-salvageable digits to restore length, coverage, and function. Although described for decades, systematic evidence remains scarce. This study compared a single-center retrospective cohort with a systematic review of the specialized literature (2015–2025) to clarify the indications, reconstructive models, assessment of functional outcomes, and complication profiles associated with this technique. Methods: A retrospective analysis was performed on 35 adult patients treated for complex hand trauma between 2017 and 2024. It was compared with a systematic review of nine clinical studies identified across PubMed, Scopus, Embase, Web of Science, and Cochrane Library. Extracted variables included demographics, mechanisms of injury, type of tissues transferred, vascularization method, complications, and functional outcomes. Methodological quality was assessed using the Joanna Briggs Institute (JBI) criteria for case reports and case series. Results: Across 78 cases (43 from the literature and 35 institutional), vascularized fillet and osteo-cutaneous transfers constituted the predominant reconstructive approach, providing immediate skeletal stability and durable, sensate soft-tissue coverage. All flaps and grafts survived, and functional recovery was consistently favorable. In the retrospective cohort, standardized evaluation demonstrated excellent outcomes (mean DASH 14.6, MHQ 82.5, VAS 1.8). The overall complication rate remained below 10%, limited to transient venous congestion or mild postoperative stiffness. No infections, flap losses, or donor-site morbidity were reported. Conclusions: The bank-finger technique is a reliable, biologically efficient reconstructive strategy for acute mutilating hand trauma. When applied early and with appropriate tissue selection, it achieves outcomes comparable to conventional microsurgical options while avoiding additional donor-site morbidity. The present combined analysis highlights its reproducibility and underscores the need for prospective multicenter studies employing standardized functional metrics. 2025-12-23 Surgeries, Vol. 7, Pages 1: The “Bank Finger” Principle in Hand Surgery—Retrospective Study vs. Systematic Review

Surgeries doi: 10.3390/surgeries7010001

Authors: Mihaela Pertea Mihai-Codrin Constantinescu Andra-Irina Bulgaru-Iliescu Stefana Avadanei-Luca Dan Cristian Moraru Bogdan Veliceasa Alexandru Filip Claudiu Carp Alexandru-Hristo Amarandei

Background/Objectives: The “bank-finger” or “spare-parts” principle offers an immediate reconstructive solution in mutilating hand injuries by repurposing viable tissues from non-salvageable digits to restore length, coverage, and function. Although described for decades, systematic evidence remains scarce. This study compared a single-center retrospective cohort with a systematic review of the specialized literature (2015–2025) to clarify the indications, reconstructive models, assessment of functional outcomes, and complication profiles associated with this technique. Methods: A retrospective analysis was performed on 35 adult patients treated for complex hand trauma between 2017 and 2024. It was compared with a systematic review of nine clinical studies identified across PubMed, Scopus, Embase, Web of Science, and Cochrane Library. Extracted variables included demographics, mechanisms of injury, type of tissues transferred, vascularization method, complications, and functional outcomes. Methodological quality was assessed using the Joanna Briggs Institute (JBI) criteria for case reports and case series. Results: Across 78 cases (43 from the literature and 35 institutional), vascularized fillet and osteo-cutaneous transfers constituted the predominant reconstructive approach, providing immediate skeletal stability and durable, sensate soft-tissue coverage. All flaps and grafts survived, and functional recovery was consistently favorable. In the retrospective cohort, standardized evaluation demonstrated excellent outcomes (mean DASH 14.6, MHQ 82.5, VAS 1.8). The overall complication rate remained below 10%, limited to transient venous congestion or mild postoperative stiffness. No infections, flap losses, or donor-site morbidity were reported. Conclusions: The bank-finger technique is a reliable, biologically efficient reconstructive strategy for acute mutilating hand trauma. When applied early and with appropriate tissue selection, it achieves outcomes comparable to conventional microsurgical options while avoiding additional donor-site morbidity. The present combined analysis highlights its reproducibility and underscores the need for prospective multicenter studies employing standardized functional metrics.

]]> The “Bank Finger” Principle in Hand Surgery—Retrospective Study vs. Systematic Review Mihaela Pertea Mihai-Codrin Constantinescu Andra-Irina Bulgaru-Iliescu Stefana Avadanei-Luca Dan Cristian Moraru Bogdan Veliceasa Alexandru Filip Claudiu Carp Alexandru-Hristo Amarandei doi: 10.3390/surgeries7010001 Surgeries 2025-12-23 Surgeries 2025-12-23 7 1 Article 1 10.3390/surgeries7010001 https://www.mdpi.com/2673-4095/7/1/1 Surgeries, Vol. 6, Pages 112: Postoperative Blood Pressure Does Not Affect Lactate Clearance in Cardiac Surgery: A Retrospective Observational Cohort Study https://www.mdpi.com/2673-4095/6/4/112 Background: Tight blood pressure control is a cornerstone of postoperative cardiac surgery patients. In addition, plasma lactate levels are frequently monitored in this setting as it is a marker for malperfusion, with early elevated levels being associated with increased morbidity and mortality. Elevations from malperfusion may be due to decreased cardiac output, hypovolemia, or persistent post-bypass vasoplegic response. Here, we investigate whether lower blood pressures, significant changes from baseline, and cardiac perfusion pressures delay the clearance of lactate after cardiac surgery. Methods: This is a retrospective cohort observational study of patients who have undergone coronary artery bypass graft (CABG) and valve replacement or repair surgeries at NYU Langone Long Island Hospital over a 6-month period. Postoperative blood pressures and lactate levels were examined over the first 16 h of care. Primary outcome: The relationship between blood pressure parameters and lactate clearance. Secondary outcomes: ICU length of stay, hospital length of stay, and mortality. Results: A total of 81 patients met inclusion criteria. The average pre-operative mean arterial blood pressure (MAP) was 95.4 mmHg and the average MAP in the first 6 h post-operatively was 78.4 mmHg. The average change in MAP from baseline was a decrease of 16.7%. The average cleared lactate fraction by 16 h postoperatively was 85.9%. Lactate clearance was associated in a statistically significant way only with the need for inotropic support on postoperative day 1, p = 0.03. There was a slight trend toward a delay in lactate clearance in those with lower early systolic blood pressures, p = 0.14. Conclusions: Lactate clearance appears to occur largely independently of postoperative blood pressures in the first 16 h after surgery but may be delayed in those requiring inotropic support through the morning or postoperative day one. 2025-12-17 Surgeries, Vol. 6, Pages 112: Postoperative Blood Pressure Does Not Affect Lactate Clearance in Cardiac Surgery: A Retrospective Observational Cohort Study

Surgeries doi: 10.3390/surgeries6040112

Authors: James Hall George Elkomos-Botros Michael Khilkin

Background: Tight blood pressure control is a cornerstone of postoperative cardiac surgery patients. In addition, plasma lactate levels are frequently monitored in this setting as it is a marker for malperfusion, with early elevated levels being associated with increased morbidity and mortality. Elevations from malperfusion may be due to decreased cardiac output, hypovolemia, or persistent post-bypass vasoplegic response. Here, we investigate whether lower blood pressures, significant changes from baseline, and cardiac perfusion pressures delay the clearance of lactate after cardiac surgery. Methods: This is a retrospective cohort observational study of patients who have undergone coronary artery bypass graft (CABG) and valve replacement or repair surgeries at NYU Langone Long Island Hospital over a 6-month period. Postoperative blood pressures and lactate levels were examined over the first 16 h of care. Primary outcome: The relationship between blood pressure parameters and lactate clearance. Secondary outcomes: ICU length of stay, hospital length of stay, and mortality. Results: A total of 81 patients met inclusion criteria. The average pre-operative mean arterial blood pressure (MAP) was 95.4 mmHg and the average MAP in the first 6 h post-operatively was 78.4 mmHg. The average change in MAP from baseline was a decrease of 16.7%. The average cleared lactate fraction by 16 h postoperatively was 85.9%. Lactate clearance was associated in a statistically significant way only with the need for inotropic support on postoperative day 1, p = 0.03. There was a slight trend toward a delay in lactate clearance in those with lower early systolic blood pressures, p = 0.14. Conclusions: Lactate clearance appears to occur largely independently of postoperative blood pressures in the first 16 h after surgery but may be delayed in those requiring inotropic support through the morning or postoperative day one.

]]> Postoperative Blood Pressure Does Not Affect Lactate Clearance in Cardiac Surgery: A Retrospective Observational Cohort Study James Hall George Elkomos-Botros Michael Khilkin doi: 10.3390/surgeries6040112 Surgeries 2025-12-17 Surgeries 2025-12-17 6 4 Article 112 10.3390/surgeries6040112 https://www.mdpi.com/2673-4095/6/4/112 Surgeries, Vol. 6, Pages 110: New Methodology for the Shoulder Biomechanical CAD Model Position Parametrization https://www.mdpi.com/2673-4095/6/4/110 Background: The development of CAD, FEA, and biomechanical models of the shoulder is challenging due to the joint’s complexity. The spatial relationships between bones, muscles and ligaments are difficult to parameterize, both statically and dynamically, because these structures move three-dimensionally and synergistically. Methods: An assembly of the shoulder joint was developed, including parameterisation of the positional relationships among the rotator cuff structures, with particular focus on the bone components: Humerus, Scapula, Clavicle, and Sternum. Discussion: The abundance of existing CAD models of the shoulder makes it difficult to compare numerical results. Variability in reference frames, positioning assumptions and geometric relationships often hinders reproducibility and cross-study interpretation. Conclusions: The presented methodology supports standardised assembly of a shoulder joint model, ensuring consistent assumptions about the relative positioning of the bony structures. This standardization enables more accurate numerical comparisons across studies and improves the reliability of biomechanical research on the shoulder. 2025-12-16 Surgeries, Vol. 6, Pages 110: New Methodology for the Shoulder Biomechanical CAD Model Position Parametrization

Surgeries doi: 10.3390/surgeries6040110

Authors: Vítor Maranha Luis Roseiro Pedro Carvalhais Maria A. Neto

Background: The development of CAD, FEA, and biomechanical models of the shoulder is challenging due to the joint’s complexity. The spatial relationships between bones, muscles and ligaments are difficult to parameterize, both statically and dynamically, because these structures move three-dimensionally and synergistically. Methods: An assembly of the shoulder joint was developed, including parameterisation of the positional relationships among the rotator cuff structures, with particular focus on the bone components: Humerus, Scapula, Clavicle, and Sternum. Discussion: The abundance of existing CAD models of the shoulder makes it difficult to compare numerical results. Variability in reference frames, positioning assumptions and geometric relationships often hinders reproducibility and cross-study interpretation. Conclusions: The presented methodology supports standardised assembly of a shoulder joint model, ensuring consistent assumptions about the relative positioning of the bony structures. This standardization enables more accurate numerical comparisons across studies and improves the reliability of biomechanical research on the shoulder.

]]> New Methodology for the Shoulder Biomechanical CAD Model Position Parametrization Vítor Maranha Luis Roseiro Pedro Carvalhais Maria A. Neto doi: 10.3390/surgeries6040110 Surgeries 2025-12-16 Surgeries 2025-12-16 6 4 Article 110 10.3390/surgeries6040110 https://www.mdpi.com/2673-4095/6/4/110 Surgeries, Vol. 6, Pages 111: PerClot for Use in Surgical Hemostasis: A Systemic Review and Meta-Analysis of Clinical Data https://www.mdpi.com/2673-4095/6/4/111 Objective: To demonstrate that PerClot’s efficacy is non-inferior to other hemostatic treatments and its safety is non-inferior to the standard of care (SoC) during surgery. Methods: Applying keywords and inclusion criteria, we queried electronic databases to conduct a systematic (e.g., Embase and Cochrane Library, etc.) and manual search (e.g., Google Scholar, etc.) for studies from 1 January 2008 (first CE marked date) to 30 March 2024. Results: Five published studies were included in this systematic review. From the included studies, 691 patients received either PerClot (n = 315) or other hemostatic agents/SoC/control (n = 376) in different surgical specialties. All five studies had comparable outcome measures, interventions, and control groups, allowing for the pooling of the study data. The primary outcomes were the achievement of hemostasis and time to hemostasis. At 7 min post-application, PerClot demonstrated non-inferior hemostasis performance as compared to Arista (absolute difference: −1.4%; 95% CI: −7.54, 4.74; p = 0.65). The time to achieve hemostasis was comparable between PerClot and other hemostatic agents (mean difference: 0.00 min; 95% CI: 0.00, 0.00; p = 1.00). No statistically significant difference in adverse event occurrence was observed between PerClot and other hemostatic agents/SoC groups (absolute difference: 0.02; 95% CI: −0.30, 0.35; p = 0.2691) and the absence of new unknown adverse events indicates the safety profile of PerClot. The results of all outcome measures are statistically insignificant. Conclusions: Our systematic review demonstrated that PerClot achieved comparable hemostasis with no new safety concerns and a statistically significant reduction in postoperative drainage volume, indicating its safety, efficacy, and performance as an alternative for hemostasis across multiple surgical specialties. 2025-12-16 Surgeries, Vol. 6, Pages 111: PerClot for Use in Surgical Hemostasis: A Systemic Review and Meta-Analysis of Clinical Data

Surgeries doi: 10.3390/surgeries6040111

Authors: Terri Siebert Stephen Dierks Piotr Maniak Torben Colberg

Objective: To demonstrate that PerClot’s efficacy is non-inferior to other hemostatic treatments and its safety is non-inferior to the standard of care (SoC) during surgery. Methods: Applying keywords and inclusion criteria, we queried electronic databases to conduct a systematic (e.g., Embase and Cochrane Library, etc.) and manual search (e.g., Google Scholar, etc.) for studies from 1 January 2008 (first CE marked date) to 30 March 2024. Results: Five published studies were included in this systematic review. From the included studies, 691 patients received either PerClot (n = 315) or other hemostatic agents/SoC/control (n = 376) in different surgical specialties. All five studies had comparable outcome measures, interventions, and control groups, allowing for the pooling of the study data. The primary outcomes were the achievement of hemostasis and time to hemostasis. At 7 min post-application, PerClot demonstrated non-inferior hemostasis performance as compared to Arista (absolute difference: −1.4%; 95% CI: −7.54, 4.74; p = 0.65). The time to achieve hemostasis was comparable between PerClot and other hemostatic agents (mean difference: 0.00 min; 95% CI: 0.00, 0.00; p = 1.00). No statistically significant difference in adverse event occurrence was observed between PerClot and other hemostatic agents/SoC groups (absolute difference: 0.02; 95% CI: −0.30, 0.35; p = 0.2691) and the absence of new unknown adverse events indicates the safety profile of PerClot. The results of all outcome measures are statistically insignificant. Conclusions: Our systematic review demonstrated that PerClot achieved comparable hemostasis with no new safety concerns and a statistically significant reduction in postoperative drainage volume, indicating its safety, efficacy, and performance as an alternative for hemostasis across multiple surgical specialties.

]]> PerClot for Use in Surgical Hemostasis: A Systemic Review and Meta-Analysis of Clinical Data Terri Siebert Stephen Dierks Piotr Maniak Torben Colberg doi: 10.3390/surgeries6040111 Surgeries 2025-12-16 Surgeries 2025-12-16 6 4 Systematic Review 111 10.3390/surgeries6040111 https://www.mdpi.com/2673-4095/6/4/111 Surgeries, Vol. 6, Pages 109: Surgical Management of Bilateral Trapeziometacarpal Arthritis: Suspension Arthroplasty and Dual Mobility Prosthesis in the Same Patient, Treated at the Same Time https://www.mdpi.com/2673-4095/6/4/109 Background: Trapeziometacarpal osteoarthritis (TMC OA) is a prevalent degenerative disorder that causes considerable pain and functional limitations, especially in older individuals, whose ideal treatment is still debated in the literature. Various treatments are described to restore a good functional outcome of the thumb; over the past 50 years, biological arthroplasties have been considered the gold standard for treating advanced stages of TMC OA. However, in the last decade, the use of dual mobility cup prostheses has significantly increased, with numerous studies reporting excellent clinical outcomes. In this case report, we show the results of a patient treated on the left hand with suspension arthroplasty and on his right hand with dual mobility arthroplasty in one-stage surgery. The aim of this case report is to directly compare outcomes between trapeziometacarpal prosthesis and suspension arthroplasty performed simultaneously in the same patient. Case Presentation: The present case reports a 71-year-old male patient with bilateral TMC osteoarthritis, referred to our clinic in May 2024. His medical history included hypertension, hypertriglyceridemia, paroxysmal atrial fibrillation, and benign prostatic hyperplasia. On examination, the right hand showed grade 3 osteoarthritis according to the Eaton–Littler classification, with the trapezium maintaining adequate bone stock, making the patient eligible for trapeziometacarpal prosthesis implantation. Conversely, the left hand demonstrated scaphotrapezoid arthritis with a slight reduction in trapezial bone stock, indicating the need for trapeziectomy followed by suspension arthroplasty. Both procedures were performed during the same surgical session by the same experienced hand surgeon using a lateral approach. On the right side, the trapeziometacarpal joint surfaces were resected and replaced with a dual mobility prosthesis, while on the left side, the trapezium was excised, and suspension arthroplasty was performed using a slip of the flexor carpi radialis (FCR) tendon. Methods: The patient underwent simultaneous treatment with a dual mobility trapeziometacarpal prosthesis on the right hand and trapeziectomy with suspension arthroplasty on the left hand. Clinical outcomes (grip and pinch strength, pain, QuickDASH, satisfaction, and range of motion) were evaluated at 1, 3, 6, and 12 months. Paired comparative statistics were applied with significance set at p < 0.05. Results: At all follow-up intervals (1, 3, 6, and 12 months), the hand treated with a trapeziometacarpal prosthesis demonstrated superior grip and pinch strength compared to the hand treated with trapeziectomy and suspension arthroplasty, with the greatest difference observed at 3 months. At 12 months, grip strength increased from 28 kg to 40 kg in the prosthesis-treated hand and from 25 kg to 33 kg in the suspension arthroplasty hand. Paired comparisons were performed at each follow-up interval up to 12 months, confirming a significant difference for grip strength. Pain levels (VAS, Visual Analogue Scale) decreased progressively in both hands, with a more rapid reduction in the hand treated with a trapeziometacarpal prosthesis, reaching statistical significance. QuickDASH scores indicated an earlier return to daily activities in the hand treated with the prosthesis, although this difference was not statistically significant. Patient satisfaction was consistently higher for the hand treated with a trapeziometacarpal prosthesis, with the patient reporting a ‘very satisfied’ rating at all timepoints. Range of motion recovery, assessed through the Kapandji score and measurements of thumb abduction and extension, also favored the hand treated with the prosthesis, with statistically significant differences for abduction and extension, whereas the hand treated with trapeziectomy and suspension arthroplasty demonstrated more gradual improvement over time. Conclusions: This case highlights the functional efficacy of both surgical approaches—biological arthroplasty and trapeziometacarpal prosthesis—in the treatment of TMC osteoarthritis. Both procedures resulted in a good clinical outcome and high patient satisfaction. However, recovery was noticeably faster in the hand treated with a trapeziometacarpal prosthesis, which is consistent with findings previously reported in the literature. These observations suggest that, while both techniques are valid and effective, trapeziometacarpal prosthetic replacement may offer a quicker return to function in appropriately selected patients. 2025-12-06 Surgeries, Vol. 6, Pages 109: Surgical Management of Bilateral Trapeziometacarpal Arthritis: Suspension Arthroplasty and Dual Mobility Prosthesis in the Same Patient, Treated at the Same Time

Surgeries doi: 10.3390/surgeries6040109

Authors: Matteo Guzzini Alice Patrignani Claudio Bagni Rocco De Vitis Simone Cerciello Stefano Palermi

Background: Trapeziometacarpal osteoarthritis (TMC OA) is a prevalent degenerative disorder that causes considerable pain and functional limitations, especially in older individuals, whose ideal treatment is still debated in the literature. Various treatments are described to restore a good functional outcome of the thumb; over the past 50 years, biological arthroplasties have been considered the gold standard for treating advanced stages of TMC OA. However, in the last decade, the use of dual mobility cup prostheses has significantly increased, with numerous studies reporting excellent clinical outcomes. In this case report, we show the results of a patient treated on the left hand with suspension arthroplasty and on his right hand with dual mobility arthroplasty in one-stage surgery. The aim of this case report is to directly compare outcomes between trapeziometacarpal prosthesis and suspension arthroplasty performed simultaneously in the same patient. Case Presentation: The present case reports a 71-year-old male patient with bilateral TMC osteoarthritis, referred to our clinic in May 2024. His medical history included hypertension, hypertriglyceridemia, paroxysmal atrial fibrillation, and benign prostatic hyperplasia. On examination, the right hand showed grade 3 osteoarthritis according to the Eaton–Littler classification, with the trapezium maintaining adequate bone stock, making the patient eligible for trapeziometacarpal prosthesis implantation. Conversely, the left hand demonstrated scaphotrapezoid arthritis with a slight reduction in trapezial bone stock, indicating the need for trapeziectomy followed by suspension arthroplasty. Both procedures were performed during the same surgical session by the same experienced hand surgeon using a lateral approach. On the right side, the trapeziometacarpal joint surfaces were resected and replaced with a dual mobility prosthesis, while on the left side, the trapezium was excised, and suspension arthroplasty was performed using a slip of the flexor carpi radialis (FCR) tendon. Methods: The patient underwent simultaneous treatment with a dual mobility trapeziometacarpal prosthesis on the right hand and trapeziectomy with suspension arthroplasty on the left hand. Clinical outcomes (grip and pinch strength, pain, QuickDASH, satisfaction, and range of motion) were evaluated at 1, 3, 6, and 12 months. Paired comparative statistics were applied with significance set at p < 0.05. Results: At all follow-up intervals (1, 3, 6, and 12 months), the hand treated with a trapeziometacarpal prosthesis demonstrated superior grip and pinch strength compared to the hand treated with trapeziectomy and suspension arthroplasty, with the greatest difference observed at 3 months. At 12 months, grip strength increased from 28 kg to 40 kg in the prosthesis-treated hand and from 25 kg to 33 kg in the suspension arthroplasty hand. Paired comparisons were performed at each follow-up interval up to 12 months, confirming a significant difference for grip strength. Pain levels (VAS, Visual Analogue Scale) decreased progressively in both hands, with a more rapid reduction in the hand treated with a trapeziometacarpal prosthesis, reaching statistical significance. QuickDASH scores indicated an earlier return to daily activities in the hand treated with the prosthesis, although this difference was not statistically significant. Patient satisfaction was consistently higher for the hand treated with a trapeziometacarpal prosthesis, with the patient reporting a ‘very satisfied’ rating at all timepoints. Range of motion recovery, assessed through the Kapandji score and measurements of thumb abduction and extension, also favored the hand treated with the prosthesis, with statistically significant differences for abduction and extension, whereas the hand treated with trapeziectomy and suspension arthroplasty demonstrated more gradual improvement over time. Conclusions: This case highlights the functional efficacy of both surgical approaches—biological arthroplasty and trapeziometacarpal prosthesis—in the treatment of TMC osteoarthritis. Both procedures resulted in a good clinical outcome and high patient satisfaction. However, recovery was noticeably faster in the hand treated with a trapeziometacarpal prosthesis, which is consistent with findings previously reported in the literature. These observations suggest that, while both techniques are valid and effective, trapeziometacarpal prosthetic replacement may offer a quicker return to function in appropriately selected patients.

]]> Surgical Management of Bilateral Trapeziometacarpal Arthritis: Suspension Arthroplasty and Dual Mobility Prosthesis in the Same Patient, Treated at the Same Time Matteo Guzzini Alice Patrignani Claudio Bagni Rocco De Vitis Simone Cerciello Stefano Palermi doi: 10.3390/surgeries6040109 Surgeries 2025-12-06 Surgeries 2025-12-06 6 4 Case Report 109 10.3390/surgeries6040109 https://www.mdpi.com/2673-4095/6/4/109 Surgeries, Vol. 6, Pages 108: Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians https://www.mdpi.com/2673-4095/6/4/108 Introduction: Chest drainage is central to thoracic surgery, pleural medicine, and emergency care, yet practice remains heterogeneous in tube caliber, access, suction, device selection, and removal thresholds. This narrative review aims to synthesize evidence and translate it into guidance. Materials and Methods: We performed a narrative review with PRISMA-modeled transparency. Using backward citation from recent comprehensive overviews, we included randomized trials, meta-analyses, guidelines/consensus statements, and high-quality observational studies. We extracted data on indications, technique, tube size, analog versus digital drainage, suction versus water-seal drainage, removal criteria, and key pleural conditions. Due to heterogeneity in device generations, suction targets, and outcomes, we synthesized the findings qualitatively according to converged evidence. Results: After lung resection, single-drain strategies, early use of water-seal, and standardized removal at ≤300–500 mL/day reduce pain and length of stay without increasing the need for reintervention; digital systems support objective removal using sustained low-flow thresholds (approximately 20–40 mL/min). Small-bore (≤14 Fr) Seldinger catheters perform comparably to larger tubes for secondary and primary pneumothorax and enable ambulatory pathways. In trauma, small-bore approaches can match large-bore drainage in stable patients when paired with surveillance and early escalation of care. For pleural infection, image-guided drainage, combined with fibrinolytics or surgery, is key. Indwelling pleural catheters provide relief comparable to talc in dyspnea associated with malignant effusions in patients with non-expandable lungs. Complications are mitigated by ultrasound guidance and avoiding abrupt high suction after chronic collapse; however, these strategies must be balanced against risks of malposition, occlusion or retained collections, prolonged air leaks, and device complexity, which demand protocolized escalation and team training. Conclusions: Practice coalesces around three pillars—right tube, right system, proper criteria. Adopt standardized pathways, device-agnostic thresholds, and volume or airflow criteria. Trials should harmonize “seal” definitions and validate telemetry-informed removal strategies. 2025-12-02 Surgeries, Vol. 6, Pages 108: Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians

Surgeries doi: 10.3390/surgeries6040108

Authors: Paolo Albino Ferrari Cosimo Bruno Salis Elisabetta Pusceddu Massimiliano Santoru Gianluca Canu Antonio Ferrari Alessandro Giuseppe Fois Antonio Maccio

Introduction: Chest drainage is central to thoracic surgery, pleural medicine, and emergency care, yet practice remains heterogeneous in tube caliber, access, suction, device selection, and removal thresholds. This narrative review aims to synthesize evidence and translate it into guidance. Materials and Methods: We performed a narrative review with PRISMA-modeled transparency. Using backward citation from recent comprehensive overviews, we included randomized trials, meta-analyses, guidelines/consensus statements, and high-quality observational studies. We extracted data on indications, technique, tube size, analog versus digital drainage, suction versus water-seal drainage, removal criteria, and key pleural conditions. Due to heterogeneity in device generations, suction targets, and outcomes, we synthesized the findings qualitatively according to converged evidence. Results: After lung resection, single-drain strategies, early use of water-seal, and standardized removal at ≤300–500 mL/day reduce pain and length of stay without increasing the need for reintervention; digital systems support objective removal using sustained low-flow thresholds (approximately 20–40 mL/min). Small-bore (≤14 Fr) Seldinger catheters perform comparably to larger tubes for secondary and primary pneumothorax and enable ambulatory pathways. In trauma, small-bore approaches can match large-bore drainage in stable patients when paired with surveillance and early escalation of care. For pleural infection, image-guided drainage, combined with fibrinolytics or surgery, is key. Indwelling pleural catheters provide relief comparable to talc in dyspnea associated with malignant effusions in patients with non-expandable lungs. Complications are mitigated by ultrasound guidance and avoiding abrupt high suction after chronic collapse; however, these strategies must be balanced against risks of malposition, occlusion or retained collections, prolonged air leaks, and device complexity, which demand protocolized escalation and team training. Conclusions: Practice coalesces around three pillars—right tube, right system, proper criteria. Adopt standardized pathways, device-agnostic thresholds, and volume or airflow criteria. Trials should harmonize “seal” definitions and validate telemetry-informed removal strategies.

]]> Comprehensive Overview of Current Pleural Drainage Practice: A Tactical Guide for Surgeons and Clinicians Paolo Albino Ferrari Cosimo Bruno Salis Elisabetta Pusceddu Massimiliano Santoru Gianluca Canu Antonio Ferrari Alessandro Giuseppe Fois Antonio Maccio doi: 10.3390/surgeries6040108 Surgeries 2025-12-02 Surgeries 2025-12-02 6 4 Review 108 10.3390/surgeries6040108 https://www.mdpi.com/2673-4095/6/4/108 Surgeries, Vol. 6, Pages 107: Endoscopic Management of an Inflammatory Lesion Suspected of Being a Brown Tumor of the Frontal Process of the Maxilla—Case Report https://www.mdpi.com/2673-4095/6/4/107 The study reports a diagnostic challenge involving an inflammatory lesion mimicking a brown tumor. A 23-year-old male patient was referred for treatment of a cystic lesion in the left frontal process of the maxilla and ethmoid region. The leading symptoms were hemoptysis and chronic sinus inflammation. Endoscopic surgery was performed under general anesthesia, including curettage and drainage of the lesion into the middle nasal meatus. Histopathological examination revealed chronic inflammatory and fibrotic changes with hemosiderin deposits and CD68(+) histiocytes, findings that could suggest a brown tumor. However, subsequent laboratory investigations excluded this diagnosis. Postoperative healing was uneventful, with complete resolution of symptoms. This report highlights the importance of distinguishing inflammatory from metabolic bone lesions in the paranasal sinuses and underscores the critical role of histopathological evaluation in differentiating true neoplasms from inflammatory pseudotumors. 2025-12-02 Surgeries, Vol. 6, Pages 107: Endoscopic Management of an Inflammatory Lesion Suspected of Being a Brown Tumor of the Frontal Process of the Maxilla—Case Report

Surgeries doi: 10.3390/surgeries6040107

Authors: Tomasz Marecik Michał Gontarz Krzysztof Gąsiorowski Jakub Bargiel Grażyna Wyszyńska-Pawelec

The study reports a diagnostic challenge involving an inflammatory lesion mimicking a brown tumor. A 23-year-old male patient was referred for treatment of a cystic lesion in the left frontal process of the maxilla and ethmoid region. The leading symptoms were hemoptysis and chronic sinus inflammation. Endoscopic surgery was performed under general anesthesia, including curettage and drainage of the lesion into the middle nasal meatus. Histopathological examination revealed chronic inflammatory and fibrotic changes with hemosiderin deposits and CD68(+) histiocytes, findings that could suggest a brown tumor. However, subsequent laboratory investigations excluded this diagnosis. Postoperative healing was uneventful, with complete resolution of symptoms. This report highlights the importance of distinguishing inflammatory from metabolic bone lesions in the paranasal sinuses and underscores the critical role of histopathological evaluation in differentiating true neoplasms from inflammatory pseudotumors.

]]> Endoscopic Management of an Inflammatory Lesion Suspected of Being a Brown Tumor of the Frontal Process of the Maxilla—Case Report Tomasz Marecik Michał Gontarz Krzysztof Gąsiorowski Jakub Bargiel Grażyna Wyszyńska-Pawelec doi: 10.3390/surgeries6040107 Surgeries 2025-12-02 Surgeries 2025-12-02 6 4 Case Report 107 10.3390/surgeries6040107 https://www.mdpi.com/2673-4095/6/4/107 Surgeries, Vol. 6, Pages 106: Minimally Invasive Subcutaneous Adipose Tissue Biopsy in a Nonhuman Primate Model: Approach and Outcomes https://www.mdpi.com/2673-4095/6/4/106 Background/Objectives: Adipose tissue (AT) plays significant roles in energy storage, metabolite signaling, and immunomodulation. The understanding of its underlying mechanisms of dysregulation can provide insight into complex disease processes through analysis with histology, flow cytometry, metabolomics, and proteomics. Tissue sampling in the clinical setting has largely shifted towards minimally invasive approaches to improve factors such as patient satisfaction, post-operative recovery, and procedure length. In contrast, preclinical animal models continue to rely on more invasive methods until refined, minimally invasive techniques are developed and systematically assessed. To improve animal welfare and enhance clinical translatability, there is a critical need to reverse translate these approaches into animal models. Methods: Our study evaluated the feasibility and performance of a commercially available vacuum-assisted biopsy (VAB) device for AT sampling in a preclinical nonhuman primate (NHP) model. Six rhesus NHPs successfully underwent three serial AT biopsies with a VAB device (n = 18). Results: All animals recovered without any serious or unexpected adverse events. The amount of adipose tissue collected per biopsy (0.5–2.7 g) was proportional to the number of individual tracks. Isolation of the stromal vascular fraction (SVF) from a subset of samples (n = 6) yielded 0.41 ± 0.12 × 106 cells/g of tissue. Conclusions: The minimally invasive VAB technique is a safe and reliable method of AT collection in NHPs. This feasibility study demonstrated adequate volumes of tissue cores that are suitable for typical, downstream research applications including immunologic studies and pathology, while improving animal welfare. 2025-11-26 Surgeries, Vol. 6, Pages 106: Minimally Invasive Subcutaneous Adipose Tissue Biopsy in a Nonhuman Primate Model: Approach and Outcomes

Surgeries doi: 10.3390/surgeries6040106

Authors: Cheyenna M. Espinoza Cole Myers Scott H. Oppler Laura Hocum Stone Davis Seelig Parthasarathy Rangarajan Sabarinathan Ramachandran Melanie L. Graham

Background/Objectives: Adipose tissue (AT) plays significant roles in energy storage, metabolite signaling, and immunomodulation. The understanding of its underlying mechanisms of dysregulation can provide insight into complex disease processes through analysis with histology, flow cytometry, metabolomics, and proteomics. Tissue sampling in the clinical setting has largely shifted towards minimally invasive approaches to improve factors such as patient satisfaction, post-operative recovery, and procedure length. In contrast, preclinical animal models continue to rely on more invasive methods until refined, minimally invasive techniques are developed and systematically assessed. To improve animal welfare and enhance clinical translatability, there is a critical need to reverse translate these approaches into animal models. Methods: Our study evaluated the feasibility and performance of a commercially available vacuum-assisted biopsy (VAB) device for AT sampling in a preclinical nonhuman primate (NHP) model. Six rhesus NHPs successfully underwent three serial AT biopsies with a VAB device (n = 18). Results: All animals recovered without any serious or unexpected adverse events. The amount of adipose tissue collected per biopsy (0.5–2.7 g) was proportional to the number of individual tracks. Isolation of the stromal vascular fraction (SVF) from a subset of samples (n = 6) yielded 0.41 ± 0.12 × 106 cells/g of tissue. Conclusions: The minimally invasive VAB technique is a safe and reliable method of AT collection in NHPs. This feasibility study demonstrated adequate volumes of tissue cores that are suitable for typical, downstream research applications including immunologic studies and pathology, while improving animal welfare.

]]> Minimally Invasive Subcutaneous Adipose Tissue Biopsy in a Nonhuman Primate Model: Approach and Outcomes Cheyenna M. Espinoza Cole Myers Scott H. Oppler Laura Hocum Stone Davis Seelig Parthasarathy Rangarajan Sabarinathan Ramachandran Melanie L. Graham doi: 10.3390/surgeries6040106 Surgeries 2025-11-26 Surgeries 2025-11-26 6 4 Article 106 10.3390/surgeries6040106 https://www.mdpi.com/2673-4095/6/4/106 Surgeries, Vol. 6, Pages 105: A Novel Modification of Anconeus Muscle Flap for Extensor Digitorum Communis-Selective Lateral Epicondylitis: Preliminary Clinical Study https://www.mdpi.com/2673-4095/6/4/105 Introduction: Lateral epicondylitis (LE) typically affects the extensor carpi radialis brevis (ECRB) tendon, while isolated degeneration of the extensor digitorum communis (EDC) origin is rare and poorly characterized. Surgical debridement of these lesions may result in capsular exposure requiring soft-tissue coverage, which can be achieved through a vascularized muscle flap to enhance tendon healing potential and reduce recurrence. This study aimed to describe a modification of the anconeus rotation flap as originally described by Almquist in 1998, and to evaluate its clinical and functional outcomes in patients with isolated EDC tendinopathy. The modified technique consists of a simpler muscle advancement (AMA) that preserves the distal vascular pedicle and reduces soft-tissue dissection. Methods: A retrospective study was conducted on 12 consecutive patients with lateral epicondylitis with isolated EDC tendon involvement (10.71% of all operative cases at our Institution between 2019 and 2022), who were surgically treated with the anconeus muscle advancement modification. Clinical outcomes, including the visual analog pain scale (VAS), grip strength and patient-reported outcome measures (PROMs), which include the QuickDASH score, the Mayo Elbow Performance Score (MEPS) and the Patient-Rated Tennis Elbow Evaluation (PRTEE) score were assessed. Paired statistical tests with 95% confidence intervals and minimal clinically important difference (MCID) thresholds were applied. Results: At a mean follow-up of 38 months, all outcomes demonstrated statistically significant and clinically meaningful improvements (p < 0.05). Reductions in pain/disability (VAS, QuickDASH, PRTEE scores) and functional gains (Grip strength, MEPS) far exceeded their respective MCID thresholds, with 100% attainment for each outcome. Conclusions: This modified anconeus muscle advancement appears to be a technically feasible option for managing isolated EDC-related lateral epicondylitis, preserving vascular integrity while limiting dissection. Although favorable results were obtained, the small retrospective cohort precludes definitive conclusions regarding efficacy. The findings support the technical feasibility of the proposed modification and warrant further prospective comparative investigations. 2025-11-25 Surgeries, Vol. 6, Pages 105: A Novel Modification of Anconeus Muscle Flap for Extensor Digitorum Communis-Selective Lateral Epicondylitis: Preliminary Clinical Study

Surgeries doi: 10.3390/surgeries6040105

Authors: Ignazio Marcoccio Jacopo Maffeis Pasquale Gravina Carolina Civitenga Andrea Gervasio

Introduction: Lateral epicondylitis (LE) typically affects the extensor carpi radialis brevis (ECRB) tendon, while isolated degeneration of the extensor digitorum communis (EDC) origin is rare and poorly characterized. Surgical debridement of these lesions may result in capsular exposure requiring soft-tissue coverage, which can be achieved through a vascularized muscle flap to enhance tendon healing potential and reduce recurrence. This study aimed to describe a modification of the anconeus rotation flap as originally described by Almquist in 1998, and to evaluate its clinical and functional outcomes in patients with isolated EDC tendinopathy. The modified technique consists of a simpler muscle advancement (AMA) that preserves the distal vascular pedicle and reduces soft-tissue dissection. Methods: A retrospective study was conducted on 12 consecutive patients with lateral epicondylitis with isolated EDC tendon involvement (10.71% of all operative cases at our Institution between 2019 and 2022), who were surgically treated with the anconeus muscle advancement modification. Clinical outcomes, including the visual analog pain scale (VAS), grip strength and patient-reported outcome measures (PROMs), which include the QuickDASH score, the Mayo Elbow Performance Score (MEPS) and the Patient-Rated Tennis Elbow Evaluation (PRTEE) score were assessed. Paired statistical tests with 95% confidence intervals and minimal clinically important difference (MCID) thresholds were applied. Results: At a mean follow-up of 38 months, all outcomes demonstrated statistically significant and clinically meaningful improvements (p < 0.05). Reductions in pain/disability (VAS, QuickDASH, PRTEE scores) and functional gains (Grip strength, MEPS) far exceeded their respective MCID thresholds, with 100% attainment for each outcome. Conclusions: This modified anconeus muscle advancement appears to be a technically feasible option for managing isolated EDC-related lateral epicondylitis, preserving vascular integrity while limiting dissection. Although favorable results were obtained, the small retrospective cohort precludes definitive conclusions regarding efficacy. The findings support the technical feasibility of the proposed modification and warrant further prospective comparative investigations.

]]> A Novel Modification of Anconeus Muscle Flap for Extensor Digitorum Communis-Selective Lateral Epicondylitis: Preliminary Clinical Study Ignazio Marcoccio Jacopo Maffeis Pasquale Gravina Carolina Civitenga Andrea Gervasio doi: 10.3390/surgeries6040105 Surgeries 2025-11-25 Surgeries 2025-11-25 6 4 Article 105 10.3390/surgeries6040105 https://www.mdpi.com/2673-4095/6/4/105 Surgeries, Vol. 6, Pages 104: The Modified Orbay Approach: A New Perspective to Obtain Better Exposure of the Radial Styloid https://www.mdpi.com/2673-4095/6/4/104 Background: The Orbay approach to volar distal radius described a volar zig-zag incision across the wrist crease, allowing a more distal exposure than traditional approaches. This adaptation enhances mobilization of the proximal radial fragment and improves visualization of both the articular surface and dorsally displaced distal radius fractures. Methods: In the present paper, we propose a further modification of the volar zig-zag approach, positioning the apex of the incision at the level of the radial styloid. Results: This modification aims to improve visualization of the radial styloid, the articular comminution, and the dorsal aspect of the distal radius, thereby optimizing fracture exposure and reduction. Conclusions: The principal advantage lies in the reduced need for traction along the radial margin of the incision to achieve adequate visualization and the avoidance of crossing the wrist crease, thereby preventing the formation of unsightly or adherent scars. 2025-11-25 Surgeries, Vol. 6, Pages 104: The Modified Orbay Approach: A New Perspective to Obtain Better Exposure of the Radial Styloid

Surgeries doi: 10.3390/surgeries6040104

Authors: Giulio Lauri Andrea Poggetti Chiara Suardi

Background: The Orbay approach to volar distal radius described a volar zig-zag incision across the wrist crease, allowing a more distal exposure than traditional approaches. This adaptation enhances mobilization of the proximal radial fragment and improves visualization of both the articular surface and dorsally displaced distal radius fractures. Methods: In the present paper, we propose a further modification of the volar zig-zag approach, positioning the apex of the incision at the level of the radial styloid. Results: This modification aims to improve visualization of the radial styloid, the articular comminution, and the dorsal aspect of the distal radius, thereby optimizing fracture exposure and reduction. Conclusions: The principal advantage lies in the reduced need for traction along the radial margin of the incision to achieve adequate visualization and the avoidance of crossing the wrist crease, thereby preventing the formation of unsightly or adherent scars.

]]> The Modified Orbay Approach: A New Perspective to Obtain Better Exposure of the Radial Styloid Giulio Lauri Andrea Poggetti Chiara Suardi doi: 10.3390/surgeries6040104 Surgeries 2025-11-25 Surgeries 2025-11-25 6 4 Brief Report 104 10.3390/surgeries6040104 https://www.mdpi.com/2673-4095/6/4/104 Surgeries, Vol. 6, Pages 103: A Comparison of Functional Outcomes in Open Fractures of Phalanges, Early Versus Delayed Treatment, and Considerations on Tulipan’s Classification https://www.mdpi.com/2673-4095/6/4/103 Background: Open phalangeal fractures raise timing questions that may not mirror long-bone protocols. We aimed to test whether time-to-surgery is associated with infection, time to union, and return to work. Methods: A single-centre retrospective cohort study was conducted between October 2023 and January 2025. Adults with open phalangeal fractures were grouped by time-to-surgery: ≤24 h (A), 24–72 h (B), and ≥72 h (C). Primary outcome was infection while secondary outcomes were time to radiographic union and time to return to work. Results: Ninetypatients were finally included. Baseline demographics and injury characteristics did not differ significantly among groups (all p >0.05). Infection occurred in 10/90 patients (11%); rates were similar across the three windows—10%, 10%, and 12%—with no association between timing and infection (χ2 = 0.09; p =0.96). Mean time to union was 48.4 ± 16.2, 56.0 ± 2.9, and 47.8 ± 14.4 days for the ≤24 h, 24–72 h, and ≥72 h groups, respectively, without significant between-group differences (p = 0.61). Return to work occurred at 92.0 ± 25.5, 70.0 ± 17.3, and 74.0 ± 46.0 days, again with no significant difference by timing (p = 0.53). Overall, no clinically meaningful trend favoured earlier surgery within the studied windows. Conclusions: In this heterogeneous yet clinically representative cohort of open phalangeal fractures, surgical timing up to and beyond 72 h was not associated with infection, time to union, or time to return to work. These findings support individualized decision-making, while larger prospective studies are needed to refine timing thresholds. 2025-11-21 Surgeries, Vol. 6, Pages 103: A Comparison of Functional Outcomes in Open Fractures of Phalanges, Early Versus Delayed Treatment, and Considerations on Tulipan’s Classification

Surgeries doi: 10.3390/surgeries6040103

Authors: Camillo Fulchignoni Silvia Pietramala Andrea Cruciani Alessio Greco Stella La Rocca Leopoldo Arioli Emanuele Gerace Lorenzo Rocchi

Background: Open phalangeal fractures raise timing questions that may not mirror long-bone protocols. We aimed to test whether time-to-surgery is associated with infection, time to union, and return to work. Methods: A single-centre retrospective cohort study was conducted between October 2023 and January 2025. Adults with open phalangeal fractures were grouped by time-to-surgery: ≤24 h (A), 24–72 h (B), and ≥72 h (C). Primary outcome was infection while secondary outcomes were time to radiographic union and time to return to work. Results: Ninetypatients were finally included. Baseline demographics and injury characteristics did not differ significantly among groups (all p >0.05). Infection occurred in 10/90 patients (11%); rates were similar across the three windows—10%, 10%, and 12%—with no association between timing and infection (χ2 = 0.09; p =0.96). Mean time to union was 48.4 ± 16.2, 56.0 ± 2.9, and 47.8 ± 14.4 days for the ≤24 h, 24–72 h, and ≥72 h groups, respectively, without significant between-group differences (p = 0.61). Return to work occurred at 92.0 ± 25.5, 70.0 ± 17.3, and 74.0 ± 46.0 days, again with no significant difference by timing (p = 0.53). Overall, no clinically meaningful trend favoured earlier surgery within the studied windows. Conclusions: In this heterogeneous yet clinically representative cohort of open phalangeal fractures, surgical timing up to and beyond 72 h was not associated with infection, time to union, or time to return to work. These findings support individualized decision-making, while larger prospective studies are needed to refine timing thresholds.

]]> A Comparison of Functional Outcomes in Open Fractures of Phalanges, Early Versus Delayed Treatment, and Considerations on Tulipan’s Classification Camillo Fulchignoni Silvia Pietramala Andrea Cruciani Alessio Greco Stella La Rocca Leopoldo Arioli Emanuele Gerace Lorenzo Rocchi doi: 10.3390/surgeries6040103 Surgeries 2025-11-21 Surgeries 2025-11-21 6 4 Article 103 10.3390/surgeries6040103 https://www.mdpi.com/2673-4095/6/4/103 Surgeries, Vol. 6, Pages 102: Facelift Approach for Hemimandibulectomy and Costochondral Autologous Graft Reconstruction in a Pediatric Odontogenic Myxoma https://www.mdpi.com/2673-4095/6/4/102 Background: Odontogenic myxoma (OM) is a rare, benign, but locally aggressive tumor of odontogenic mesenchymal origin. This study aims to expand current knowledge by integrating a concise literature review with a detailed case report of a surgically complex pediatric OM, treated using a biologically advantageous reconstructive technique. Methods: In this study, we report the case of an eight-year-old girl presenting with a large OM that caused complete disruption of the architecture of the left hemimandible. Due to the tumor’s size and bone involvement, radical resection was necessary. A modified extraoral facelift approach was employed to ensure adequate surgical access while avoiding intraoral incisions and minimizing visible scarring. Immediate mandibular reconstruction was performed using an autologous costochondral graft. Discussion: Although infrequently used in modern surgical practice, the costochondral graft offers unique advantages in pediatric patients due to its inherent growth potential and capacity for long-term biological integration. In this case, the graft allowed restoration of mandibular continuity and form with minimal donor site morbidity, demonstrating its viability even today. Conclusions: This case underlines the importance of tailored reconstructive strategies in pediatric OM. The costochondral graft provided excellent functional and esthetic results, with four-year follow-up confirming stable anatomical remodeling and bone regeneration. 2025-11-20 Surgeries, Vol. 6, Pages 102: Facelift Approach for Hemimandibulectomy and Costochondral Autologous Graft Reconstruction in a Pediatric Odontogenic Myxoma

Surgeries doi: 10.3390/surgeries6040102

Authors: Alice Marzi Manfroni Valerio Cancilla Edlira Baruti Papa Marjon Sako Francesco Laganà

Background: Odontogenic myxoma (OM) is a rare, benign, but locally aggressive tumor of odontogenic mesenchymal origin. This study aims to expand current knowledge by integrating a concise literature review with a detailed case report of a surgically complex pediatric OM, treated using a biologically advantageous reconstructive technique. Methods: In this study, we report the case of an eight-year-old girl presenting with a large OM that caused complete disruption of the architecture of the left hemimandible. Due to the tumor’s size and bone involvement, radical resection was necessary. A modified extraoral facelift approach was employed to ensure adequate surgical access while avoiding intraoral incisions and minimizing visible scarring. Immediate mandibular reconstruction was performed using an autologous costochondral graft. Discussion: Although infrequently used in modern surgical practice, the costochondral graft offers unique advantages in pediatric patients due to its inherent growth potential and capacity for long-term biological integration. In this case, the graft allowed restoration of mandibular continuity and form with minimal donor site morbidity, demonstrating its viability even today. Conclusions: This case underlines the importance of tailored reconstructive strategies in pediatric OM. The costochondral graft provided excellent functional and esthetic results, with four-year follow-up confirming stable anatomical remodeling and bone regeneration.

]]> Facelift Approach for Hemimandibulectomy and Costochondral Autologous Graft Reconstruction in a Pediatric Odontogenic Myxoma Alice Marzi Manfroni Valerio Cancilla Edlira Baruti Papa Marjon Sako Francesco Laganà doi: 10.3390/surgeries6040102 Surgeries 2025-11-20 Surgeries 2025-11-20 6 4 Case Report 102 10.3390/surgeries6040102 https://www.mdpi.com/2673-4095/6/4/102 Surgeries, Vol. 6, Pages 101: Surgical Outcomes, Complications, and Cost-Effectiveness of Total Knee Arthroplasty in Hemophilic Versus Non-Hemophilic Patients: A Comparative Study https://www.mdpi.com/2673-4095/6/4/101 Background: Total knee arthroplasty (TKA) is the gold standard for advanced hemophilic arthropathy. However, surgical management in hemophilic patients is complex due to joint deformities, bleeding risk, and systemic comorbidities. This study aimed to compare the surgical outcomes and cost-effectiveness of TKA in hemophilic versus non-hemophilic patients. Methods: This prospective study included 50 patients treated between 2010 and 2024 at Elias University Hospital, Romania. Group 1 included 20 male patients with severe hemophilia (2 with inhibitors); Group 2 included 30 non-hemophilic male patients. Data collection was standardized and conducted preoperatively, at 6 and 12 months postoperatively, and annually thereafter for up to 14 years following surgery. The mean follow-up duration across the cohort was 7.3 ± 3.9 years (range: 0.5–14 years), allowing for consistent long-term evaluation of clinical and functional outcomes. Study included operative time, transfusion requirements, hospitalization length, perioperative complications, functional outcomes (Knee Society Score—KSS), quality of life (EQ-5D), and cost per quality-adjusted life year (QALY). Results: Hemophilic patients had significantly longer operative times (154.5 vs. 88.7 min; p < 0.001), higher transfusion rates (45% vs. 20%, p < 0.047), and longer hospital stays (mean 12.3 vs. 6.6 days). Perioperative complications occurred in 90% of hemophilic patients (anemia requiring transfusion: 45%; compressive hematomas: 10%; wound dehiscence: 15%) compared to 10% in controls. Non-hemophilic patients achieved superior postoperative functional scores. Mean preoperative KSS was 32.25 ± 11.24 and postoperatively, the mean score increased to 98 ± 1.34. The mean preoperative KSS in the hemophilic group was 31 ± 13.93 and postoperative KSS was 74.5 ± 19.92. The cost per QALY was €2506 in the hemophilic group versus €1258 in controls. The economic assessment was conducted from the hospital perspective, focusing on direct medical costs incurred during hospitalization and the perioperative period. Cost components included factor replacement therapy, surgical and anesthesia costs, hospital stay, laboratory investigations, blood transfusions, and management of postoperative complications. Conclusion: Although TKA improves quality of life and function in hemophilic patients, it is associated with higher complication rates and costs. These findings highlight the need for careful patient selection and informed consent when considering TKA in hemophilic patients. 2025-11-20 Surgeries, Vol. 6, Pages 101: Surgical Outcomes, Complications, and Cost-Effectiveness of Total Knee Arthroplasty in Hemophilic Versus Non-Hemophilic Patients: A Comparative Study

Surgeries doi: 10.3390/surgeries6040101

Authors: Gabriel Stan Horia Orban Rares Deculescu Mihai Roman Nicolae Gheorghiu

Background: Total knee arthroplasty (TKA) is the gold standard for advanced hemophilic arthropathy. However, surgical management in hemophilic patients is complex due to joint deformities, bleeding risk, and systemic comorbidities. This study aimed to compare the surgical outcomes and cost-effectiveness of TKA in hemophilic versus non-hemophilic patients. Methods: This prospective study included 50 patients treated between 2010 and 2024 at Elias University Hospital, Romania. Group 1 included 20 male patients with severe hemophilia (2 with inhibitors); Group 2 included 30 non-hemophilic male patients. Data collection was standardized and conducted preoperatively, at 6 and 12 months postoperatively, and annually thereafter for up to 14 years following surgery. The mean follow-up duration across the cohort was 7.3 ± 3.9 years (range: 0.5–14 years), allowing for consistent long-term evaluation of clinical and functional outcomes. Study included operative time, transfusion requirements, hospitalization length, perioperative complications, functional outcomes (Knee Society Score—KSS), quality of life (EQ-5D), and cost per quality-adjusted life year (QALY). Results: Hemophilic patients had significantly longer operative times (154.5 vs. 88.7 min; p < 0.001), higher transfusion rates (45% vs. 20%, p < 0.047), and longer hospital stays (mean 12.3 vs. 6.6 days). Perioperative complications occurred in 90% of hemophilic patients (anemia requiring transfusion: 45%; compressive hematomas: 10%; wound dehiscence: 15%) compared to 10% in controls. Non-hemophilic patients achieved superior postoperative functional scores. Mean preoperative KSS was 32.25 ± 11.24 and postoperatively, the mean score increased to 98 ± 1.34. The mean preoperative KSS in the hemophilic group was 31 ± 13.93 and postoperative KSS was 74.5 ± 19.92. The cost per QALY was €2506 in the hemophilic group versus €1258 in controls. The economic assessment was conducted from the hospital perspective, focusing on direct medical costs incurred during hospitalization and the perioperative period. Cost components included factor replacement therapy, surgical and anesthesia costs, hospital stay, laboratory investigations, blood transfusions, and management of postoperative complications. Conclusion: Although TKA improves quality of life and function in hemophilic patients, it is associated with higher complication rates and costs. These findings highlight the need for careful patient selection and informed consent when considering TKA in hemophilic patients.

]]> Surgical Outcomes, Complications, and Cost-Effectiveness of Total Knee Arthroplasty in Hemophilic Versus Non-Hemophilic Patients: A Comparative Study Gabriel Stan Horia Orban Rares Deculescu Mihai Roman Nicolae Gheorghiu doi: 10.3390/surgeries6040101 Surgeries 2025-11-20 Surgeries 2025-11-20 6 4 Article 101 10.3390/surgeries6040101 https://www.mdpi.com/2673-4095/6/4/101 Surgeries, Vol. 6, Pages 100: Postprocedural Pyrolysis: A Feasibility Study on Chemical Recycling of Plastics Used During Surgery https://www.mdpi.com/2673-4095/6/4/100 Background: Hospitals generate large volumes of single-use plastic waste, which are predominantly incinerated. To improve sustainability, standardized procedure-specific surgical trays have been implemented, reducing waste and setup time. This early feasibility study investigated whether all residual plastics from surgical procedures could be recycled via pyrolysis into high-quality oil for circular reuse in medical supply production. Methods: All residual plastics from five transurethral resection (TUR) trays were subjected to pyrolysis at 430–460 °C in a batch reactor. Condensable fractions were separated into heavy (HF) and light (LF) oils, while non-condensable gases and coke were quantified. Chemical analyses included the density, water content, heating value, and elemental composition. Results: From 1.102 kg of input material, the process yielded 78 weight percent (wt%) oil (HF 59.1%, LF 40.9%), 20.5 wt% gas, and 1.5 wt% coke. HF solidified at room temperature, whereas LF remained liquid, reflecting distinct hydrocarbon chain distributions. The oils exhibited densities of 767.0 kg/m3 (HF) and 748.9 kg/m3 (LF), heating values of 46.39–46.80 MJ/kg, low water contents (<0.05 wt%), and minimal contamination (silicone ≤ 193 mg/kg; chlorine ≤ 110 mg/kg). Conclusions: Pyrolysis of surgical tray plastics produces decontaminated high-energy oils comparable in quality to fossil fuels, with a material recovery rate exceeding 75% and potential CO2 savings of ~ 2.9 ton per t plastic compared with incineration. This process provides a technically and ecologically viable pathway toward a scalable circular economy in healthcare. 2025-11-20 Surgeries, Vol. 6, Pages 100: Postprocedural Pyrolysis: A Feasibility Study on Chemical Recycling of Plastics Used During Surgery

Surgeries doi: 10.3390/surgeries6040100

Authors: Nils Prinz Anne Püllen Dimitri Barski Barbara Hermann Christian Haessler Thomas Otto

Background: Hospitals generate large volumes of single-use plastic waste, which are predominantly incinerated. To improve sustainability, standardized procedure-specific surgical trays have been implemented, reducing waste and setup time. This early feasibility study investigated whether all residual plastics from surgical procedures could be recycled via pyrolysis into high-quality oil for circular reuse in medical supply production. Methods: All residual plastics from five transurethral resection (TUR) trays were subjected to pyrolysis at 430–460 °C in a batch reactor. Condensable fractions were separated into heavy (HF) and light (LF) oils, while non-condensable gases and coke were quantified. Chemical analyses included the density, water content, heating value, and elemental composition. Results: From 1.102 kg of input material, the process yielded 78 weight percent (wt%) oil (HF 59.1%, LF 40.9%), 20.5 wt% gas, and 1.5 wt% coke. HF solidified at room temperature, whereas LF remained liquid, reflecting distinct hydrocarbon chain distributions. The oils exhibited densities of 767.0 kg/m3 (HF) and 748.9 kg/m3 (LF), heating values of 46.39–46.80 MJ/kg, low water contents (<0.05 wt%), and minimal contamination (silicone ≤ 193 mg/kg; chlorine ≤ 110 mg/kg). Conclusions: Pyrolysis of surgical tray plastics produces decontaminated high-energy oils comparable in quality to fossil fuels, with a material recovery rate exceeding 75% and potential CO2 savings of ~ 2.9 ton per t plastic compared with incineration. This process provides a technically and ecologically viable pathway toward a scalable circular economy in healthcare.

]]> Postprocedural Pyrolysis: A Feasibility Study on Chemical Recycling of Plastics Used During Surgery Nils Prinz Anne Püllen Dimitri Barski Barbara Hermann Christian Haessler Thomas Otto doi: 10.3390/surgeries6040100 Surgeries 2025-11-20 Surgeries 2025-11-20 6 4 Article 100 10.3390/surgeries6040100 https://www.mdpi.com/2673-4095/6/4/100 Surgeries, Vol. 6, Pages 99: Quadrant-Specific Distribution of Peritoneal Metastases as a Prognostic Factor in Colorectal Cancer Treated with CRS and HIPEC https://www.mdpi.com/2673-4095/6/4/99 Background: Peritoneal metastasis (PM) from colorectal cancer (CRC) carries a poor prognosis. The Peritoneal Cancer Index (PCI) is among the principal prognostic stratification tools, yet the prognostic value of the anatomical distribution of disease beyond total PCI is underexplored. This pilot study evaluated whether quadrant-specific involvement adds prognostic information in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), with a focused analysis of oligometastatic disease (PCI ≤ 6). Methods: A single-institution cohort of 48 CRC-PM patients treated with CRS + HIPEC was analyzed. Primary endpoints were OS, DFS, and PRFS, with a focused evaluation of the oligometastatic subset (PCI ≤ 6). Comparative statistics used Student’s two-sample t test for continuous variables and chi-square or two-sided Fisher’s exact tests for categorical variables. Survival was estimated by Kaplan–Meier with log-rank tests, and prognostic factors were evaluated using Cox regression. Results: Median follow-up was 177 months (IQR 87–224). Outcomes favored PCI ≤ 6: 5-year OS and DFS were 54% and 37.5% versus 6.6% and 0% for PCI > 6, and median OS 64 vs. 29 months (log-rank p = 0.007), median DFS 30 vs. 7 months (p = 0.0002), and median PRFS 26 vs. 8 months (p = 0.0002). In the PCI ≤ 6 subset (n = 27), quadrant 3 (left upper quadrant) was associated with higher recurrence risk and shorter DFS, remaining independently prognostic for DFS (p = 0.005) and PRFS (p = 0.005). For PRFS, quadrants 7 and 8 also showed associations on univariable analysis; Q7 remained independent (p = 0.047), whereas Q8 was borderline (p = 0.077). A histology-related signal at Q8 (p = 0.011) was exploratory due to very small mucinous and signet-ring strata. Sidedness and synchronicity yielded no significant differences in quadrant involvement within PCI ≤ 6. No quadrant effects were observed in PCI > 6. Conclusions: PCI remains the dominant prognostic determinant after CRS + HIPEC, yet in oligometastatic disease, the anatomical distribution adds complementary prognostic information, particularly involvement of Q3 and Q7. These findings are hypothesis-generating and warrant validation in larger, preferably multicenter cohorts with standardized quadrant mapping. If confirmed, quadrant-directed operative planning, including consideration of prophylactic resection in selected high-risk regions, could be prospectively evaluated. 2025-11-15 Surgeries, Vol. 6, Pages 99: Quadrant-Specific Distribution of Peritoneal Metastases as a Prognostic Factor in Colorectal Cancer Treated with CRS and HIPEC

Surgeries doi: 10.3390/surgeries6040099

Authors: Valentina Zucchini Fabrizio D’Acapito Massimo Framarini Giulia Elena Cantelli Giulia Marchetti Eleonora Pozzi Riccardo Turrini Marco Barbini Giorgio Ercolani

Background: Peritoneal metastasis (PM) from colorectal cancer (CRC) carries a poor prognosis. The Peritoneal Cancer Index (PCI) is among the principal prognostic stratification tools, yet the prognostic value of the anatomical distribution of disease beyond total PCI is underexplored. This pilot study evaluated whether quadrant-specific involvement adds prognostic information in patients undergoing cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC), with a focused analysis of oligometastatic disease (PCI ≤ 6). Methods: A single-institution cohort of 48 CRC-PM patients treated with CRS + HIPEC was analyzed. Primary endpoints were OS, DFS, and PRFS, with a focused evaluation of the oligometastatic subset (PCI ≤ 6). Comparative statistics used Student’s two-sample t test for continuous variables and chi-square or two-sided Fisher’s exact tests for categorical variables. Survival was estimated by Kaplan–Meier with log-rank tests, and prognostic factors were evaluated using Cox regression. Results: Median follow-up was 177 months (IQR 87–224). Outcomes favored PCI ≤ 6: 5-year OS and DFS were 54% and 37.5% versus 6.6% and 0% for PCI > 6, and median OS 64 vs. 29 months (log-rank p = 0.007), median DFS 30 vs. 7 months (p = 0.0002), and median PRFS 26 vs. 8 months (p = 0.0002). In the PCI ≤ 6 subset (n = 27), quadrant 3 (left upper quadrant) was associated with higher recurrence risk and shorter DFS, remaining independently prognostic for DFS (p = 0.005) and PRFS (p = 0.005). For PRFS, quadrants 7 and 8 also showed associations on univariable analysis; Q7 remained independent (p = 0.047), whereas Q8 was borderline (p = 0.077). A histology-related signal at Q8 (p = 0.011) was exploratory due to very small mucinous and signet-ring strata. Sidedness and synchronicity yielded no significant differences in quadrant involvement within PCI ≤ 6. No quadrant effects were observed in PCI > 6. Conclusions: PCI remains the dominant prognostic determinant after CRS + HIPEC, yet in oligometastatic disease, the anatomical distribution adds complementary prognostic information, particularly involvement of Q3 and Q7. These findings are hypothesis-generating and warrant validation in larger, preferably multicenter cohorts with standardized quadrant mapping. If confirmed, quadrant-directed operative planning, including consideration of prophylactic resection in selected high-risk regions, could be prospectively evaluated.

]]> Quadrant-Specific Distribution of Peritoneal Metastases as a Prognostic Factor in Colorectal Cancer Treated with CRS and HIPEC Valentina Zucchini Fabrizio D’Acapito Massimo Framarini Giulia Elena Cantelli Giulia Marchetti Eleonora Pozzi Riccardo Turrini Marco Barbini Giorgio Ercolani doi: 10.3390/surgeries6040099 Surgeries 2025-11-15 Surgeries 2025-11-15 6 4 Article 99 10.3390/surgeries6040099 https://www.mdpi.com/2673-4095/6/4/99 Surgeries, Vol. 6, Pages 98: Free Peritoneal Cancer Cells in Patients with Adenocarcinoma of the Stomach or Esophagogastric Junction: Risk Factors and Outcomes https://www.mdpi.com/2673-4095/6/4/98 Background/Objectives: To identify independent predictors of free peritoneal cancer cells (FPCC), and to investigate survival outcomes relative to peritoneal cytology status among patients who underwent intended curative gastrectomy for adenocarcinoma of the stomach or esophagogastric junction. Methods: Medical records of patients who underwent radical surgery between January 2005 and December 2020 were retrospectively reviewed. Clinical data and cytology results were evaluated. Multivariate Cox regression analysis was used to identify independent predictors of FPCC. Kaplan–Meier survival analysis was used to estimate disease recurrence and survival outcomes. Results: Out of the 349 enrolled patients, 188 (53.8%) had negative cytology, 32 (9.2%) were positive, and 129 (36.9%) showed atypical cells in peritoneal cytology. Poor differentiation (adjusted odds ratio [aOR]: 2.63, 95% confidence interval [95%CI]: 1.04–6.82; p = 0.015), pT4 (aOR: 4.62, 95%CI: 1.28–14.34; p = 0.018), pN3 (aOR: 4.13, 95%CI: 1.14–15.03; p = 0.031), and metastatic lymph node ratio >0.40 (aOR: 6.49, 95%CI: 1.44–29.14; p = 0.015) were independent predictors of FPCC. Median overall survival was 34.1 months in the negative group, 13.1 months in the positive group, and 28.7 months in the atypical cell group (p < 0.001). Median time to disease recurrence was 20.5, 4.9, and 11.3 months, respectively (p < 0.001). Survival and recurrence outcomes in the atypical cell group were comparable to those with negative cytology. Conclusions: Poorly differentiated histology, pT4, pN3, and metastatic lymph node ratio >0.40 are independent predictors of FPCC, which is significantly associated with poor survival and disease recurrence outcomes. These findings suggest that high-risk patients may benefit from routine peritoneal cytologic screening during surgery to improve risk stratification and guide postoperative treatment planning. 2025-11-10 Surgeries, Vol. 6, Pages 98: Free Peritoneal Cancer Cells in Patients with Adenocarcinoma of the Stomach or Esophagogastric Junction: Risk Factors and Outcomes

Surgeries doi: 10.3390/surgeries6040098

Authors: Asada Methasate Akarawin Sirimongkol Chawisa Nampoolsuksan Jirawat Swangsri Thammawat Parakonthun

Background/Objectives: To identify independent predictors of free peritoneal cancer cells (FPCC), and to investigate survival outcomes relative to peritoneal cytology status among patients who underwent intended curative gastrectomy for adenocarcinoma of the stomach or esophagogastric junction. Methods: Medical records of patients who underwent radical surgery between January 2005 and December 2020 were retrospectively reviewed. Clinical data and cytology results were evaluated. Multivariate Cox regression analysis was used to identify independent predictors of FPCC. Kaplan–Meier survival analysis was used to estimate disease recurrence and survival outcomes. Results: Out of the 349 enrolled patients, 188 (53.8%) had negative cytology, 32 (9.2%) were positive, and 129 (36.9%) showed atypical cells in peritoneal cytology. Poor differentiation (adjusted odds ratio [aOR]: 2.63, 95% confidence interval [95%CI]: 1.04–6.82; p = 0.015), pT4 (aOR: 4.62, 95%CI: 1.28–14.34; p = 0.018), pN3 (aOR: 4.13, 95%CI: 1.14–15.03; p = 0.031), and metastatic lymph node ratio >0.40 (aOR: 6.49, 95%CI: 1.44–29.14; p = 0.015) were independent predictors of FPCC. Median overall survival was 34.1 months in the negative group, 13.1 months in the positive group, and 28.7 months in the atypical cell group (p < 0.001). Median time to disease recurrence was 20.5, 4.9, and 11.3 months, respectively (p < 0.001). Survival and recurrence outcomes in the atypical cell group were comparable to those with negative cytology. Conclusions: Poorly differentiated histology, pT4, pN3, and metastatic lymph node ratio >0.40 are independent predictors of FPCC, which is significantly associated with poor survival and disease recurrence outcomes. These findings suggest that high-risk patients may benefit from routine peritoneal cytologic screening during surgery to improve risk stratification and guide postoperative treatment planning.

]]> Free Peritoneal Cancer Cells in Patients with Adenocarcinoma of the Stomach or Esophagogastric Junction: Risk Factors and Outcomes Asada Methasate Akarawin Sirimongkol Chawisa Nampoolsuksan Jirawat Swangsri Thammawat Parakonthun doi: 10.3390/surgeries6040098 Surgeries 2025-11-10 Surgeries 2025-11-10 6 4 Article 98 10.3390/surgeries6040098 https://www.mdpi.com/2673-4095/6/4/98 Surgeries, Vol. 6, Pages 97: Inguinal Herniation of the Transplanted Ureter: A Systematic Review https://www.mdpi.com/2673-4095/6/4/97 Herniation of the transplanted ureter into the inguinal canal is an exceptionally rare complication following renal transplantation. Most cases present as delayed-onset obstructions, typically occurring more than one year post-transplant and often involving the ipsilateral inguinal canal. We presented the case of a 49-year-old male kidney transplant recipient who developed obstructive uropathy due to herniation of the graft ureter into the ipsilateral inguinal canal. Diagnosis was confirmed by computed tomography (CT), which proved superior to ultrasonography in delineating the ureteral course. A JJ ureteral stent was successfully placed, followed by inguinal hernia repair using the Lichtenstein technique. The postoperative course was uneventful, with complete resolution of symptoms and preservation of graft function. Transplanted ureteral herniation is a rare but important cause of late post-transplant obstruction. Cross-sectional imaging, particularly CT, offers greater diagnostic accuracy than ultrasound alone in identifying ureteral displacement. When feasible, primary ureteral stenting may obviate the need for nephrostomy, thereby reducing patient morbidity. 2025-11-10 Surgeries, Vol. 6, Pages 97: Inguinal Herniation of the Transplanted Ureter: A Systematic Review

Surgeries doi: 10.3390/surgeries6040097

Authors: Pajtim Emini Riccardo Scarponi Salvatore Spiezia Pasquale Avella Luigi Ricciardelli Germano Guerra Graziano Ceccarelli Michele De Rosa

Herniation of the transplanted ureter into the inguinal canal is an exceptionally rare complication following renal transplantation. Most cases present as delayed-onset obstructions, typically occurring more than one year post-transplant and often involving the ipsilateral inguinal canal. We presented the case of a 49-year-old male kidney transplant recipient who developed obstructive uropathy due to herniation of the graft ureter into the ipsilateral inguinal canal. Diagnosis was confirmed by computed tomography (CT), which proved superior to ultrasonography in delineating the ureteral course. A JJ ureteral stent was successfully placed, followed by inguinal hernia repair using the Lichtenstein technique. The postoperative course was uneventful, with complete resolution of symptoms and preservation of graft function. Transplanted ureteral herniation is a rare but important cause of late post-transplant obstruction. Cross-sectional imaging, particularly CT, offers greater diagnostic accuracy than ultrasound alone in identifying ureteral displacement. When feasible, primary ureteral stenting may obviate the need for nephrostomy, thereby reducing patient morbidity.

]]> Inguinal Herniation of the Transplanted Ureter: A Systematic Review Pajtim Emini Riccardo Scarponi Salvatore Spiezia Pasquale Avella Luigi Ricciardelli Germano Guerra Graziano Ceccarelli Michele De Rosa doi: 10.3390/surgeries6040097 Surgeries 2025-11-10 Surgeries 2025-11-10 6 4 Review 97 10.3390/surgeries6040097 https://www.mdpi.com/2673-4095/6/4/97 Surgeries, Vol. 6, Pages 96: Severe Versus Mild–Moderate Pulmonary Hypertension: Outcomes Following Mechanical Mitral Valve Replacement with Posterior Leaflet Preservation https://www.mdpi.com/2673-4095/6/4/96 Background: Pulmonary hypertension is common in left-sided heart valve disease, with historical studies reporting mortality rates up to 31% in severe cases undergoing mitral valve surgery. This study evaluates the impact of severe pulmonary hypertension on outcomes of mechanical mitral valve replacement with posterior leaflet preservation by comparing results with patients having mild-to-moderate pulmonary hypertension. Methods: Prospective analysis of 86 patients with mitral valve disease undergoing mechanical valve replacement with posterior leaflet preservation from March 2015 to September 2016 was conducted. Patients were stratified by pulmonary artery pressure: severe (≥60 mmHg, n = 19) versus mild–moderate (35–59 mmHg, n = 67). Primary outcomes included mortality, complications, and functional recovery at 1, 6, and 12 months. Results: The cohort included 67 patients (77.9%) with mild–moderate pulmonary hypertension and 19 patients (22.1%) with severe pulmonary hypertension. Severe pulmonary hypertension patients demonstrated higher NYHA functional class (73.7% class III vs. 46.2%, p = 0.03), larger left atrial diameter (56.3 ± 9.8 vs. 49.5 ± 6.7 mm, p = 0.01), and higher mean pressure gradients (14.4 ± 5.3 vs. 11.3 ± 5.0 mmHg, p = 0.025). Mortality was 5.3% in the severe group versus 0% in the mild–moderate group (p = 0.331). Patients with severe pulmonary hypertension required longer ICU stays (6.3 ± 3.7 vs. 4.7 ± 2.2 days, p = 0.024) but showed no significant differences in ventilation time, reoperation rates, or major complications. At the 12-month follow-up, both groups achieved equivalent outcomes in pulmonary artery pressures, left ventricular function, and cardiac dimensions. Conclusion: In this study with a relatively small sample size, severe pulmonary hypertension was associated with significantly longer intensive care unit stay but not with higher mortality compared to mild–moderate pulmonary hypertension, with both groups attaining comparable functional and hemodynamic parameters at 12 months after mechanical mitral valve replacement with posterior leaflet preservation. 2025-11-05 Surgeries, Vol. 6, Pages 96: Severe Versus Mild–Moderate Pulmonary Hypertension: Outcomes Following Mechanical Mitral Valve Replacement with Posterior Leaflet Preservation

Surgeries doi: 10.3390/surgeries6040096

Authors: Binh Thanh Tran Viet Anh Le Dung Tien Nguyen Duong Minh Vu Vinh Duc An Bui Phu Duc Bui Nam Van Nguyen Thang Ba Ta

Background: Pulmonary hypertension is common in left-sided heart valve disease, with historical studies reporting mortality rates up to 31% in severe cases undergoing mitral valve surgery. This study evaluates the impact of severe pulmonary hypertension on outcomes of mechanical mitral valve replacement with posterior leaflet preservation by comparing results with patients having mild-to-moderate pulmonary hypertension. Methods: Prospective analysis of 86 patients with mitral valve disease undergoing mechanical valve replacement with posterior leaflet preservation from March 2015 to September 2016 was conducted. Patients were stratified by pulmonary artery pressure: severe (≥60 mmHg, n = 19) versus mild–moderate (35–59 mmHg, n = 67). Primary outcomes included mortality, complications, and functional recovery at 1, 6, and 12 months. Results: The cohort included 67 patients (77.9%) with mild–moderate pulmonary hypertension and 19 patients (22.1%) with severe pulmonary hypertension. Severe pulmonary hypertension patients demonstrated higher NYHA functional class (73.7% class III vs. 46.2%, p = 0.03), larger left atrial diameter (56.3 ± 9.8 vs. 49.5 ± 6.7 mm, p = 0.01), and higher mean pressure gradients (14.4 ± 5.3 vs. 11.3 ± 5.0 mmHg, p = 0.025). Mortality was 5.3% in the severe group versus 0% in the mild–moderate group (p = 0.331). Patients with severe pulmonary hypertension required longer ICU stays (6.3 ± 3.7 vs. 4.7 ± 2.2 days, p = 0.024) but showed no significant differences in ventilation time, reoperation rates, or major complications. At the 12-month follow-up, both groups achieved equivalent outcomes in pulmonary artery pressures, left ventricular function, and cardiac dimensions. Conclusion: In this study with a relatively small sample size, severe pulmonary hypertension was associated with significantly longer intensive care unit stay but not with higher mortality compared to mild–moderate pulmonary hypertension, with both groups attaining comparable functional and hemodynamic parameters at 12 months after mechanical mitral valve replacement with posterior leaflet preservation.

]]> Severe Versus Mild–Moderate Pulmonary Hypertension: Outcomes Following Mechanical Mitral Valve Replacement with Posterior Leaflet Preservation Binh Thanh Tran Viet Anh Le Dung Tien Nguyen Duong Minh Vu Vinh Duc An Bui Phu Duc Bui Nam Van Nguyen Thang Ba Ta doi: 10.3390/surgeries6040096 Surgeries 2025-11-05 Surgeries 2025-11-05 6 4 Article 96 10.3390/surgeries6040096 https://www.mdpi.com/2673-4095/6/4/96 Surgeries, Vol. 6, Pages 95: The Burden of Weight on Joint Replacement: A 1.6 Million-Patient Analysis of BMI and Hip Arthroplasty Outcomes https://www.mdpi.com/2673-4095/6/4/95 Background: THA is a gold-standard intervention for end-stage hip osteoarthritis, historically performed in older adults. However, the growing global obesity epidemic is reshaping this landscape. Emerging evidence suggests that elevated body mass index (BMI) may not only worsen perioperative outcomes but also accelerate the need for surgery at a younger age. Understanding how BMI influences both the timing and safety of THA is crucial to optimizing care in this evolving patient population. Methods: We conducted a retrospective analysis of 1,626,965 elective THA hospitalizations from the Nationwide Inpatient Sample. Patients were stratified by BMI into three categories: <29.9, 30–34.9, and ≥35. Fracture- and oncology-related cases were excluded. ICD-10 codes identified comorbidities and complications. Primary outcomes included age at surgery, in-hospital mortality, length of stay (LOS), complications, and hospitalization costs. Statistical analysis used Pearson correlation, linear regression, chi-square tests, and t-tests via SPSS version 26.0.0.0. Results: Higher BMI was significantly associated with younger age at THA (r = −0.187, p < 0.001). Each 5-unit BMI increase corresponded to a ~2-year decrease in age at surgery. Obese patients had higher rates of hypertension, diabetes, dyslipidemia, and sleep apnea. Complications including blood loss anemia, acute kidney injury, venous thromboembolism, and postoperative infections were more common in higher BMI groups. LOS increased with BMI, though total hospital charges showed minimal clinical variation. Conclusions: Obesity is a key driver of earlier THA and elevated perioperative risk. These findings underscore the need for BMI-tailored surgical planning and risk stratification. As younger, high-BMI patients increasingly undergo THA, future strategies must focus on preoperative optimization, complication prevention, and long-term implant durability. 2025-10-29 Surgeries, Vol. 6, Pages 95: The Burden of Weight on Joint Replacement: A 1.6 Million-Patient Analysis of BMI and Hip Arthroplasty Outcomes

Surgeries doi: 10.3390/surgeries6040095

Authors: Yaron Berkovich Shelly Feygelman Ela Cohen Nissan Linor Fournier Yaniv Steinfeld David Maman

Background: THA is a gold-standard intervention for end-stage hip osteoarthritis, historically performed in older adults. However, the growing global obesity epidemic is reshaping this landscape. Emerging evidence suggests that elevated body mass index (BMI) may not only worsen perioperative outcomes but also accelerate the need for surgery at a younger age. Understanding how BMI influences both the timing and safety of THA is crucial to optimizing care in this evolving patient population. Methods: We conducted a retrospective analysis of 1,626,965 elective THA hospitalizations from the Nationwide Inpatient Sample. Patients were stratified by BMI into three categories: <29.9, 30–34.9, and ≥35. Fracture- and oncology-related cases were excluded. ICD-10 codes identified comorbidities and complications. Primary outcomes included age at surgery, in-hospital mortality, length of stay (LOS), complications, and hospitalization costs. Statistical analysis used Pearson correlation, linear regression, chi-square tests, and t-tests via SPSS version 26.0.0.0. Results: Higher BMI was significantly associated with younger age at THA (r = −0.187, p < 0.001). Each 5-unit BMI increase corresponded to a ~2-year decrease in age at surgery. Obese patients had higher rates of hypertension, diabetes, dyslipidemia, and sleep apnea. Complications including blood loss anemia, acute kidney injury, venous thromboembolism, and postoperative infections were more common in higher BMI groups. LOS increased with BMI, though total hospital charges showed minimal clinical variation. Conclusions: Obesity is a key driver of earlier THA and elevated perioperative risk. These findings underscore the need for BMI-tailored surgical planning and risk stratification. As younger, high-BMI patients increasingly undergo THA, future strategies must focus on preoperative optimization, complication prevention, and long-term implant durability.

]]> The Burden of Weight on Joint Replacement: A 1.6 Million-Patient Analysis of BMI and Hip Arthroplasty Outcomes Yaron Berkovich Shelly Feygelman Ela Cohen Nissan Linor Fournier Yaniv Steinfeld David Maman doi: 10.3390/surgeries6040095 Surgeries 2025-10-29 Surgeries 2025-10-29 6 4 Article 95 10.3390/surgeries6040095 https://www.mdpi.com/2673-4095/6/4/95 Surgeries, Vol. 6, Pages 94: Pelvic Neuroanatomy in Colorectal Surgery: Advances in Nerve Preservation for Optimized Functional Outcomes https://www.mdpi.com/2673-4095/6/4/94 Background: Pelvic autonomic nerve injury during colorectal surgery causes debilitating urinary, bowel, and sexual dysfunction. This review synthesizes contemporary evidence on neuroanatomy, nerve-sparing techniques, and functional outcomes to minimize iatrogenic injury while maintaining oncologic efficacy. Methods: Systematic analysis of cadaveric studies, clinical trials, and imaging advancements focused on the superior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves (S2–S4), and inferior hypogastric plexus. Surgical innovations evaluated included robotic-assisted dissection, fluorescence-guided visualization, and intraoperative neuromonitoring. We distinguished evidence for nerve identification from evidence for functional protection and graded study designs accordingly. Results: Anatomical variability (e.g., superior hypogastric plexus leftward deviation 58.8%; hypogastric nerve median width 3.5 mm) necessitates precision techniques. Nerve-sparing approaches reduce urinary dysfunction from 30–70% to 10–30% and sexual dysfunction from 40–80% to 15–30%. However, the functional benefit of specific technical steps is often derived from anatomical rationale and cohort studies, with limited randomized trials for individual maneuvers. While technique refinements such as Denonvilliers’ fascia preservation may offer early sexual function benefits, randomized evidence shows no 12-month urinary advantage and uncertainty regarding longer-term durability; routine adoption should be individualized. Advanced imaging (3 T MRI, diffusion tensor imaging) and fluorescence guidance improve pre-/intraoperative visualization, but randomized evidence for improved postoperative urinary or sexual function is limited. Randomized data support pelvic intraoperative neuromonitoring in reducing urinary deterioration; most adjuncts have observational or feasibility-level support. Conclusions: Integrating neuroanatomical knowledge with advanced technologies enhances identification and may support nerve-sparing execution; however, robust randomized evidence for durable functional protection of novel technologies and specific technical steps remains limited. Priorities include standardizing preservation protocols, conducting randomized trials that validate the efficacy of individual surgical maneuvers, linking identification to functional outcomes, and validating long-term patient-reported outcomes. 2025-10-28 Surgeries, Vol. 6, Pages 94: Pelvic Neuroanatomy in Colorectal Surgery: Advances in Nerve Preservation for Optimized Functional Outcomes

Surgeries doi: 10.3390/surgeries6040094

Authors: Asim M. Almughamsi Yasir Hassan Elhassan

Background: Pelvic autonomic nerve injury during colorectal surgery causes debilitating urinary, bowel, and sexual dysfunction. This review synthesizes contemporary evidence on neuroanatomy, nerve-sparing techniques, and functional outcomes to minimize iatrogenic injury while maintaining oncologic efficacy. Methods: Systematic analysis of cadaveric studies, clinical trials, and imaging advancements focused on the superior hypogastric plexus, hypogastric nerves, pelvic splanchnic nerves (S2–S4), and inferior hypogastric plexus. Surgical innovations evaluated included robotic-assisted dissection, fluorescence-guided visualization, and intraoperative neuromonitoring. We distinguished evidence for nerve identification from evidence for functional protection and graded study designs accordingly. Results: Anatomical variability (e.g., superior hypogastric plexus leftward deviation 58.8%; hypogastric nerve median width 3.5 mm) necessitates precision techniques. Nerve-sparing approaches reduce urinary dysfunction from 30–70% to 10–30% and sexual dysfunction from 40–80% to 15–30%. However, the functional benefit of specific technical steps is often derived from anatomical rationale and cohort studies, with limited randomized trials for individual maneuvers. While technique refinements such as Denonvilliers’ fascia preservation may offer early sexual function benefits, randomized evidence shows no 12-month urinary advantage and uncertainty regarding longer-term durability; routine adoption should be individualized. Advanced imaging (3 T MRI, diffusion tensor imaging) and fluorescence guidance improve pre-/intraoperative visualization, but randomized evidence for improved postoperative urinary or sexual function is limited. Randomized data support pelvic intraoperative neuromonitoring in reducing urinary deterioration; most adjuncts have observational or feasibility-level support. Conclusions: Integrating neuroanatomical knowledge with advanced technologies enhances identification and may support nerve-sparing execution; however, robust randomized evidence for durable functional protection of novel technologies and specific technical steps remains limited. Priorities include standardizing preservation protocols, conducting randomized trials that validate the efficacy of individual surgical maneuvers, linking identification to functional outcomes, and validating long-term patient-reported outcomes.

]]> Pelvic Neuroanatomy in Colorectal Surgery: Advances in Nerve Preservation for Optimized Functional Outcomes Asim M. Almughamsi Yasir Hassan Elhassan doi: 10.3390/surgeries6040094 Surgeries 2025-10-28 Surgeries 2025-10-28 6 4 Review 94 10.3390/surgeries6040094 https://www.mdpi.com/2673-4095/6/4/94 Surgeries, Vol. 6, Pages 93: Minimizing Postoperative Scars in Upper Eyelid Blepharoplasty: A Concise Review https://www.mdpi.com/2673-4095/6/4/93 Background: Upper eyelid blepharoplasty is one of the most common aesthetic surgeries performed worldwide. The procedure consists of removing excess skin with or without muscle and/or fat from the upper eyelid by a transcutaneous approach and placement of a supratarsal crease. The surgery is performed in a cosmetically sensitive area and every attempt to avoid poor scar formation should be made. Methods: This review presents a conspectus of the existing medical literature regarding scar-avoiding strategies in upper blepharoplasty with the aim of contributing to the reduction in postoperative scar formation. The Medline, Embase, and Cochrane databases were searched on 2 September 2025. Results: The search yielded a total of 562 records, and, following screening, eleven publications were included. Conclusions: A systematic approach to pre-, intra-, and postoperative measures to minimize scarring are presented. There is a need to standardize scar assessment and reporting to facilitate inter-study comparison of effects, as well as prospective, randomized studies comparing suture materials and techniques. 2025-10-23 Surgeries, Vol. 6, Pages 93: Minimizing Postoperative Scars in Upper Eyelid Blepharoplasty: A Concise Review

Surgeries doi: 10.3390/surgeries6040093

Authors: Fredrik Andreas Fineide Ayyad Zartasht Khan Lars Christian Boberg-Ans Richard C. Allen Elin Bohman Kim Alexander Tønseth Tor Paaske Utheim

Background: Upper eyelid blepharoplasty is one of the most common aesthetic surgeries performed worldwide. The procedure consists of removing excess skin with or without muscle and/or fat from the upper eyelid by a transcutaneous approach and placement of a supratarsal crease. The surgery is performed in a cosmetically sensitive area and every attempt to avoid poor scar formation should be made. Methods: This review presents a conspectus of the existing medical literature regarding scar-avoiding strategies in upper blepharoplasty with the aim of contributing to the reduction in postoperative scar formation. The Medline, Embase, and Cochrane databases were searched on 2 September 2025. Results: The search yielded a total of 562 records, and, following screening, eleven publications were included. Conclusions: A systematic approach to pre-, intra-, and postoperative measures to minimize scarring are presented. There is a need to standardize scar assessment and reporting to facilitate inter-study comparison of effects, as well as prospective, randomized studies comparing suture materials and techniques.

]]> Minimizing Postoperative Scars in Upper Eyelid Blepharoplasty: A Concise Review Fredrik Andreas Fineide Ayyad Zartasht Khan Lars Christian Boberg-Ans Richard C. Allen Elin Bohman Kim Alexander Tønseth Tor Paaske Utheim doi: 10.3390/surgeries6040093 Surgeries 2025-10-23 Surgeries 2025-10-23 6 4 Review 93 10.3390/surgeries6040093 https://www.mdpi.com/2673-4095/6/4/93 Surgeries, Vol. 6, Pages 92: Ultrasound-Guided Carpal Tunnel Release: Results from a Multicenter Italian Cohort of 735 Patients https://www.mdpi.com/2673-4095/6/4/92 Background/Objectives: Ultrasound-guided carpal tunnel release (UGCTR) has emerged as a minimally invasive alternative to open surgery for the treatment of carpal tunnel syndrome (CTS). This study aimed to evaluate the clinical outcomes, complication rates, and recovery profiles associated with UGCTR in a large multicenter cohort. Methods: A retrospective observational study was conducted across Italian hand surgery centers, including 735 patients who underwent UGCTR between January 2012 and April 2025. Data were collected on demographics, comorbidities, ultrasound measurements, and surgical outcomes. Primary endpoints included pain (measured using the Visual Analog Scale [VAS]), symptom severity and function (assessed via the Boston Carpal Tunnel Questionnaire [BCTQ]), complication rates, time to return to daily activities (RDA), and return to work (RTW). Follow-up assessments were performed at 1, 4, and 12 weeks postoperatively. Results: A significant improvement in pain was observed, with mean VAS scores decreasing from 6.37 preoperatively to 0.58 at 12 weeks. The mean cross-sectional area (CSA) of the median nerve decreased from 12.81 mm2 to 8.83 mm2 at 4 weeks. Both the BCTQ Symptom Severity Scale (BCTQ-SS) and Functional Status Scale (BCTQ-FS) scores showed significant improvement by week 1. The mean RDA was 5.7 days, and RTW was 14.5 days. Complication rates were low and decreasing over time, from 8.7% at 1 week to 3.4% at 12 weeks. Conclusions: UGCTR is a safe and effective technique for the treatment of CTS, offering rapid functional recovery and a favorable complication profile. Its feasibility in outpatient settings and potential for cost-effectiveness support its role as a viable alternative to open surgery and as a model of image-guided, minimally invasive intervention. 2025-10-21 Surgeries, Vol. 6, Pages 92: Ultrasound-Guided Carpal Tunnel Release: Results from a Multicenter Italian Cohort of 735 Patients

Surgeries doi: 10.3390/surgeries6040092

Authors: Andrea Poggetti Alberto Rinaldi Marco Biondi Prospero Bigazzi Priscilla Di Sette Pierfrancesco Pugliese Angela Sulpasso Federico Pilla Francesco Smeraglia Antonio Brando

Background/Objectives: Ultrasound-guided carpal tunnel release (UGCTR) has emerged as a minimally invasive alternative to open surgery for the treatment of carpal tunnel syndrome (CTS). This study aimed to evaluate the clinical outcomes, complication rates, and recovery profiles associated with UGCTR in a large multicenter cohort. Methods: A retrospective observational study was conducted across Italian hand surgery centers, including 735 patients who underwent UGCTR between January 2012 and April 2025. Data were collected on demographics, comorbidities, ultrasound measurements, and surgical outcomes. Primary endpoints included pain (measured using the Visual Analog Scale [VAS]), symptom severity and function (assessed via the Boston Carpal Tunnel Questionnaire [BCTQ]), complication rates, time to return to daily activities (RDA), and return to work (RTW). Follow-up assessments were performed at 1, 4, and 12 weeks postoperatively. Results: A significant improvement in pain was observed, with mean VAS scores decreasing from 6.37 preoperatively to 0.58 at 12 weeks. The mean cross-sectional area (CSA) of the median nerve decreased from 12.81 mm2 to 8.83 mm2 at 4 weeks. Both the BCTQ Symptom Severity Scale (BCTQ-SS) and Functional Status Scale (BCTQ-FS) scores showed significant improvement by week 1. The mean RDA was 5.7 days, and RTW was 14.5 days. Complication rates were low and decreasing over time, from 8.7% at 1 week to 3.4% at 12 weeks. Conclusions: UGCTR is a safe and effective technique for the treatment of CTS, offering rapid functional recovery and a favorable complication profile. Its feasibility in outpatient settings and potential for cost-effectiveness support its role as a viable alternative to open surgery and as a model of image-guided, minimally invasive intervention.

]]> Ultrasound-Guided Carpal Tunnel Release: Results from a Multicenter Italian Cohort of 735 Patients Andrea Poggetti Alberto Rinaldi Marco Biondi Prospero Bigazzi Priscilla Di Sette Pierfrancesco Pugliese Angela Sulpasso Federico Pilla Francesco Smeraglia Antonio Brando doi: 10.3390/surgeries6040092 Surgeries 2025-10-21 Surgeries 2025-10-21 6 4 Article 92 10.3390/surgeries6040092 https://www.mdpi.com/2673-4095/6/4/92 Surgeries, Vol. 6, Pages 91: Comparative Clinical and Volumetric Outcomes of Contemporary Surgical Techniques for Lumbar Foraminal Stenosis: A Retrospective Cohort Study https://www.mdpi.com/2673-4095/6/4/91 Background: Lumbar foraminal stenosis (LFS) is a prevalent degenerative condition associated with significant radicular pain and impaired quality of life. Advances in minimally invasive and fusion-based surgical techniques have introduced new strategies for decompressing the neural elements. However, comparative data correlating volumetric foraminal expansion with functional outcomes remain limited. Methods: This retrospective cohort study analyzed 256 patients treated surgically for symptomatic LFS between December 2017 and December 2023. Patients were categorized into four surgical subgroups: endoscopic decompression, anterior lumbar interbody fusion (ALIF), microsurgical decompression, and transforaminal lumbar interbody fusion (TLIF). Preoperative and postoperative assessments included magnetic resonance imaging (MRI) to calculate foraminal volume and standardized clinical scales: the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, and SF-36 health-related quality-of-life scores. Statistical significance was determined using p-values, and inter-observer agreement was evaluated via κ-statistics. Results: Postoperative imaging demonstrated a significant increase in foraminal canal volume across all surgical groups: endoscopy (29.9%), ALIF (71.8%), microsurgery (48.06%), and TLIF (67.0%). ODI scores improved from a preoperative mean of 55.25 to 18.27 at 24 months post-surgery (p < 0.001). VAS scores for back pain decreased from 6.37 to 2.1 (p < 0.001), while leg pain scores declined from 6.85 to 2.05 (p < 0.001). Functional improvement reached or exceeded the minimal clinically important difference (MCID) threshold in over 66% of patients. Conclusions: Modern surgical strategies for LFS, particularly fusion-based techniques, yield significant volumetric decompression and durable clinical improvement. Volumetric gain in the foraminal canal is closely associated with pain reduction and enhanced functional outcomes. These findings support a tailored surgical approach based on anatomical pathology and segmental stability. 2025-10-20 Surgeries, Vol. 6, Pages 91: Comparative Clinical and Volumetric Outcomes of Contemporary Surgical Techniques for Lumbar Foraminal Stenosis: A Retrospective Cohort Study

Surgeries doi: 10.3390/surgeries6040091

Authors: Renat M. Nurmukhametov Vladimir Klimov Abakirov Medetbek Stepan Anatolevich Kudryakov Medet Dosanov Anastasiia Alekseevna Guseva Petr Ruslanovich Baigushev Timur Arturovich Kerimov Nicola Montemurro

Background: Lumbar foraminal stenosis (LFS) is a prevalent degenerative condition associated with significant radicular pain and impaired quality of life. Advances in minimally invasive and fusion-based surgical techniques have introduced new strategies for decompressing the neural elements. However, comparative data correlating volumetric foraminal expansion with functional outcomes remain limited. Methods: This retrospective cohort study analyzed 256 patients treated surgically for symptomatic LFS between December 2017 and December 2023. Patients were categorized into four surgical subgroups: endoscopic decompression, anterior lumbar interbody fusion (ALIF), microsurgical decompression, and transforaminal lumbar interbody fusion (TLIF). Preoperative and postoperative assessments included magnetic resonance imaging (MRI) to calculate foraminal volume and standardized clinical scales: the Oswestry Disability Index (ODI), Visual Analogue Scale (VAS) for back and leg pain, and SF-36 health-related quality-of-life scores. Statistical significance was determined using p-values, and inter-observer agreement was evaluated via κ-statistics. Results: Postoperative imaging demonstrated a significant increase in foraminal canal volume across all surgical groups: endoscopy (29.9%), ALIF (71.8%), microsurgery (48.06%), and TLIF (67.0%). ODI scores improved from a preoperative mean of 55.25 to 18.27 at 24 months post-surgery (p < 0.001). VAS scores for back pain decreased from 6.37 to 2.1 (p < 0.001), while leg pain scores declined from 6.85 to 2.05 (p < 0.001). Functional improvement reached or exceeded the minimal clinically important difference (MCID) threshold in over 66% of patients. Conclusions: Modern surgical strategies for LFS, particularly fusion-based techniques, yield significant volumetric decompression and durable clinical improvement. Volumetric gain in the foraminal canal is closely associated with pain reduction and enhanced functional outcomes. These findings support a tailored surgical approach based on anatomical pathology and segmental stability.

]]> Comparative Clinical and Volumetric Outcomes of Contemporary Surgical Techniques for Lumbar Foraminal Stenosis: A Retrospective Cohort Study Renat M. Nurmukhametov Vladimir Klimov Abakirov Medetbek Stepan Anatolevich Kudryakov Medet Dosanov Anastasiia Alekseevna Guseva Petr Ruslanovich Baigushev Timur Arturovich Kerimov Nicola Montemurro doi: 10.3390/surgeries6040091 Surgeries 2025-10-20 Surgeries 2025-10-20 6 4 Article 91 10.3390/surgeries6040091 https://www.mdpi.com/2673-4095/6/4/91 Surgeries, Vol. 6, Pages 90: Surgeon-Delivered Bupivacaine Achieves Analgesic Efficacy Comparable to ESP and TAP Blocks in Laparoscopic Cholecystectomy: A Randomized Controlled Trial https://www.mdpi.com/2673-4095/6/4/90 Background and Objectives: Effective pain management is essential for optimizing recovery after laparoscopic cholecystectomy (LC). Ultrasound-guided erector spinae plane (ESP) and transversus abdominis plane (TAP) blocks are validated techniques, but may be limited by equipment requirements and technical complexity. This study aimed to evaluate whether surgeon-delivered local anesthetic infiltration provides comparable analgesic efficacy. Materials and Methods: This prospective, randomized, controlled, single-center trial enrolled 172 patients undergoing elective LC between November 2020 and June 2022. Patients were randomized into four groups: Group A—surgeon-delivered port-site and intraperitoneal bupivacaine infiltration; Group B—ESP block; Group C—TAP block; and Group D—control. Primary outcomes were postoperative pain assessed by Visual Analog Scale (VAS) scores at 1, 3, 6, 12, and 24 h, and Behavioral Pain Scale (BPS) scores at 1 and 3 h. Secondary outcomes included 24 h tramadol consumption, patient satisfaction, additional rescue analgesia requirement, and procedure duration. Results: All intervention groups (A–C) demonstrated significantly lower VAS and BPS scores compared to controls (VAS at 24 h: 1.8 ± 0.9 vs. 2.8 ± 1.3, p < 0.001). Tramadol use was also reduced (≈82 mg vs. 97 mg, p < 0.001), with fewer opioid-related adverse effects. No significant differences were observed among Groups A–C. Patient satisfaction was higher in the intervention groups, and no major complications were reported. Conclusions: Surgeon-delivered local infiltration achieved analgesic efficacy equivalent to ESP and TAP blocks. Considering its simplicity, safety, and minimal resource demands, this method may represent a practical alternative for enhanced recovery pathways following LC. 2025-10-17 Surgeries, Vol. 6, Pages 90: Surgeon-Delivered Bupivacaine Achieves Analgesic Efficacy Comparable to ESP and TAP Blocks in Laparoscopic Cholecystectomy: A Randomized Controlled Trial

Surgeries doi: 10.3390/surgeries6040090

Authors: Melih Can Gül Ramazan Koray Akbudak

Background and Objectives: Effective pain management is essential for optimizing recovery after laparoscopic cholecystectomy (LC). Ultrasound-guided erector spinae plane (ESP) and transversus abdominis plane (TAP) blocks are validated techniques, but may be limited by equipment requirements and technical complexity. This study aimed to evaluate whether surgeon-delivered local anesthetic infiltration provides comparable analgesic efficacy. Materials and Methods: This prospective, randomized, controlled, single-center trial enrolled 172 patients undergoing elective LC between November 2020 and June 2022. Patients were randomized into four groups: Group A—surgeon-delivered port-site and intraperitoneal bupivacaine infiltration; Group B—ESP block; Group C—TAP block; and Group D—control. Primary outcomes were postoperative pain assessed by Visual Analog Scale (VAS) scores at 1, 3, 6, 12, and 24 h, and Behavioral Pain Scale (BPS) scores at 1 and 3 h. Secondary outcomes included 24 h tramadol consumption, patient satisfaction, additional rescue analgesia requirement, and procedure duration. Results: All intervention groups (A–C) demonstrated significantly lower VAS and BPS scores compared to controls (VAS at 24 h: 1.8 ± 0.9 vs. 2.8 ± 1.3, p < 0.001). Tramadol use was also reduced (≈82 mg vs. 97 mg, p < 0.001), with fewer opioid-related adverse effects. No significant differences were observed among Groups A–C. Patient satisfaction was higher in the intervention groups, and no major complications were reported. Conclusions: Surgeon-delivered local infiltration achieved analgesic efficacy equivalent to ESP and TAP blocks. Considering its simplicity, safety, and minimal resource demands, this method may represent a practical alternative for enhanced recovery pathways following LC.

]]> Surgeon-Delivered Bupivacaine Achieves Analgesic Efficacy Comparable to ESP and TAP Blocks in Laparoscopic Cholecystectomy: A Randomized Controlled Trial Melih Can Gül Ramazan Koray Akbudak doi: 10.3390/surgeries6040090 Surgeries 2025-10-17 Surgeries 2025-10-17 6 4 Article 90 10.3390/surgeries6040090 https://www.mdpi.com/2673-4095/6/4/90 Surgeries, Vol. 6, Pages 89: Perioperative Complications in the Primary Vaginal Mesh Surgery for Pelvic Organ Prolapse https://www.mdpi.com/2673-4095/6/4/89 Background/Objectives: The use of vaginal mesh for pelvic organ prolapse (POP) repair remains controversial following global restrictions due to safety concerns. This study evaluated intra- and perioperative morbidity following a standardized single-incision, six-point fixation approach using an ultralight vaginal mesh in primary surgery for anterior/central POP. Methods: We conducted a retrospective multicenter study including 426 women who underwent primary POP repair with the InGYNious mesh system between May 2016 and February 2024. All surgeries followed a uniform technique across seven Italian centers. Data were collected on perioperative complications, urinary function, postoperative pain, and catheter duration. Results: The overall morbidity rate was 7.3% (31/426), primarily due to hematomas (4.5%), bladder injuries (1.4%), and ureteral injuries (0.7%). Median surgery duration was 40 min with minimal blood loss. Early postoperative pain was associated with higher POP-Q scores, longer surgical duration, and lower BMI. No cases of de novo urinary incontinence or urinary tract infection were reported in the perioperative period. Conclusions: This large multicenter case series suggests that, in experienced hands, this standardized vaginal mesh approach is associated with a low perioperative complication rate. However, the absence of a control group and the short follow-up are major limitations. Long-term outcome data, particularly regarding mesh-related complications, are essential before drawing firm conclusions on the broader safety or role of vaginal mesh in POP repair. 2025-10-16 Surgeries, Vol. 6, Pages 89: Perioperative Complications in the Primary Vaginal Mesh Surgery for Pelvic Organ Prolapse

Surgeries doi: 10.3390/surgeries6040089

Authors: Francesco Deltetto Irene Deltetto Antonella Giannantoni Margaret Jorgensen Stefano Landi Marco Manni Luisa Marcato Daniela Mirabella Alessandro Libretti Valentino Remorgida

Background/Objectives: The use of vaginal mesh for pelvic organ prolapse (POP) repair remains controversial following global restrictions due to safety concerns. This study evaluated intra- and perioperative morbidity following a standardized single-incision, six-point fixation approach using an ultralight vaginal mesh in primary surgery for anterior/central POP. Methods: We conducted a retrospective multicenter study including 426 women who underwent primary POP repair with the InGYNious mesh system between May 2016 and February 2024. All surgeries followed a uniform technique across seven Italian centers. Data were collected on perioperative complications, urinary function, postoperative pain, and catheter duration. Results: The overall morbidity rate was 7.3% (31/426), primarily due to hematomas (4.5%), bladder injuries (1.4%), and ureteral injuries (0.7%). Median surgery duration was 40 min with minimal blood loss. Early postoperative pain was associated with higher POP-Q scores, longer surgical duration, and lower BMI. No cases of de novo urinary incontinence or urinary tract infection were reported in the perioperative period. Conclusions: This large multicenter case series suggests that, in experienced hands, this standardized vaginal mesh approach is associated with a low perioperative complication rate. However, the absence of a control group and the short follow-up are major limitations. Long-term outcome data, particularly regarding mesh-related complications, are essential before drawing firm conclusions on the broader safety or role of vaginal mesh in POP repair.

]]> Perioperative Complications in the Primary Vaginal Mesh Surgery for Pelvic Organ Prolapse Francesco Deltetto Irene Deltetto Antonella Giannantoni Margaret Jorgensen Stefano Landi Marco Manni Luisa Marcato Daniela Mirabella Alessandro Libretti Valentino Remorgida doi: 10.3390/surgeries6040089 Surgeries 2025-10-16 Surgeries 2025-10-16 6 4 Article 89 10.3390/surgeries6040089 https://www.mdpi.com/2673-4095/6/4/89 Surgeries, Vol. 6, Pages 88: Negative Pressure Wound Therapy for Surgical Site Infection Prevention Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis https://www.mdpi.com/2673-4095/6/4/88 Background/Objectives: Surgical site infections (SSIs) following pancreaticoduodenectomy contribute to significant morbidity and healthcare costs. Negative pressure wound therapy (NPWT) has emerged as a potential preventive intervention; however, evidence regarding its efficacy in pancreatic surgery remains limited. This systematic review and meta-analysis aimed to evaluate the efficacy of NPWT compared to conventional dressings in preventing SSI following pancreaticoduodenectomy. Methods: PubMed, Scopus, BASE, Cochrane CENTRAL, and ClinicalTrials.gov were systematically searched from their inception to 2 April 2025. Randomized clinical trials and observational studies comparing NPWT with conventional dressings in patients undergoing pancreaticoduodenectomy were included. Two independent reviewers extracted the data and assessed the methodological quality. Random-effects meta-analysis was performed to calculate the pooled relative risks (RRs) with 95% CIs. The primary outcome was the incidence of SSI. The secondary outcomes included pancreatic fistula, seroma formation, incisional hernia, and readmission rates. Results: Nine studies (three randomized clinical trials and six observational studies) comprising 1247 patients were included. NPWT was associated with a significant reduction in SSI compared with conventional dressings (RR, 0.61; 95% CI, 0.41–0.90). Subgroup analysis revealed varying effects by study design: retrospective cohort studies showed a nonsignificant trend toward SSI reduction (RR, 0.53; 95% CI, 0.19–1.48), randomized clinical trials demonstrated a nonsignificant trend favoring NPWT (RR, 0.67; 95% CI, 0.37–1.23), and the single prospective cohort study showed significant SSI reduction (RR, 0.48; 95% CI, 0.28–0.84). No significant differences were observed in pancreatic fistula rates between the NPWT and conventional dressing groups. Prophylactic NPWT application, longer duration (≥5 days), and higher negative pressure settings (−125 mmHg) appeared more effective than therapeutic application, shorter duration, and lower-pressure settings, respectively. Conclusions: This systematic review and meta-analysis suggests that NPWT is associated with a reduced SSI risk following pancreaticoduodenectomy. The greatest benefit may be achieved with prophylactic application in high-risk patients, longer therapy duration, and higher negative pressure settings. These findings support the consideration of NPWT as part of SSI prevention strategies in pancreatic surgery, particularly for patients with identified risk factors. 2025-10-10 Surgeries, Vol. 6, Pages 88: Negative Pressure Wound Therapy for Surgical Site Infection Prevention Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis

Surgeries doi: 10.3390/surgeries6040088

Authors: Musaed Rayzah Nasser A. N. Alzerwi Bandar Idrees Ahmed A. Alhumaid Yaser Baksh Afnan Alsultan Fares Rayzah

Background/Objectives: Surgical site infections (SSIs) following pancreaticoduodenectomy contribute to significant morbidity and healthcare costs. Negative pressure wound therapy (NPWT) has emerged as a potential preventive intervention; however, evidence regarding its efficacy in pancreatic surgery remains limited. This systematic review and meta-analysis aimed to evaluate the efficacy of NPWT compared to conventional dressings in preventing SSI following pancreaticoduodenectomy. Methods: PubMed, Scopus, BASE, Cochrane CENTRAL, and ClinicalTrials.gov were systematically searched from their inception to 2 April 2025. Randomized clinical trials and observational studies comparing NPWT with conventional dressings in patients undergoing pancreaticoduodenectomy were included. Two independent reviewers extracted the data and assessed the methodological quality. Random-effects meta-analysis was performed to calculate the pooled relative risks (RRs) with 95% CIs. The primary outcome was the incidence of SSI. The secondary outcomes included pancreatic fistula, seroma formation, incisional hernia, and readmission rates. Results: Nine studies (three randomized clinical trials and six observational studies) comprising 1247 patients were included. NPWT was associated with a significant reduction in SSI compared with conventional dressings (RR, 0.61; 95% CI, 0.41–0.90). Subgroup analysis revealed varying effects by study design: retrospective cohort studies showed a nonsignificant trend toward SSI reduction (RR, 0.53; 95% CI, 0.19–1.48), randomized clinical trials demonstrated a nonsignificant trend favoring NPWT (RR, 0.67; 95% CI, 0.37–1.23), and the single prospective cohort study showed significant SSI reduction (RR, 0.48; 95% CI, 0.28–0.84). No significant differences were observed in pancreatic fistula rates between the NPWT and conventional dressing groups. Prophylactic NPWT application, longer duration (≥5 days), and higher negative pressure settings (−125 mmHg) appeared more effective than therapeutic application, shorter duration, and lower-pressure settings, respectively. Conclusions: This systematic review and meta-analysis suggests that NPWT is associated with a reduced SSI risk following pancreaticoduodenectomy. The greatest benefit may be achieved with prophylactic application in high-risk patients, longer therapy duration, and higher negative pressure settings. These findings support the consideration of NPWT as part of SSI prevention strategies in pancreatic surgery, particularly for patients with identified risk factors.

]]> Negative Pressure Wound Therapy for Surgical Site Infection Prevention Following Pancreaticoduodenectomy: A Systematic Review and Meta-Analysis Musaed Rayzah Nasser A. N. Alzerwi Bandar Idrees Ahmed A. Alhumaid Yaser Baksh Afnan Alsultan Fares Rayzah doi: 10.3390/surgeries6040088 Surgeries 2025-10-10 Surgeries 2025-10-10 6 4 Systematic Review 88 10.3390/surgeries6040088 https://www.mdpi.com/2673-4095/6/4/88 Surgeries, Vol. 6, Pages 87: Data-Leakage-Aware Preoperative Prediction of Postoperative Complications from Structured Data and Preoperative Clinical Notes https://www.mdpi.com/2673-4095/6/4/87 Background/Objectives: Machine learning has been suggested as a way to improve how we predict anesthesia-related complications after surgery. However, many studies report overly optimistic results due to issues like data leakage and not fully using information from clinical notes. This study provides a transparent comparison of different machine learning models using both structured data and preoperative notes, with a focus on avoiding data leakage and involving clinicians throughout. We show how high reported metrics in the literature can result from methodological pitfalls and may not be clinically meaningful. Methods: We used a dataset containing both structured patient and surgery information and preoperative clinical notes. To avoid data leakage, we excluded any variables that could directly reveal the outcome. The data was cleaned and processed, and information from clinical notes was summarized into features suitable for modeling. We tested a range of machine learning methods, including simple, tree-based, and modern language-based models. Models were evaluated using a standard split of the data and cross-validation, and we addressed class imbalance with sampling techniques. Results: All models showed only modest ability to distinguish between patients with and without complications. The best performance was achieved by a simple model using both structured and summarized text features, with an area under the curve of 0.644 and accuracy of 60%. Other models, including those using advanced language techniques, performed similarly or slightly worse. Adding information from clinical notes gave small improvements, but no single type of data dominated. Overall, the results did not reach the high levels reported in some previous studies. Conclusions: In this analysis, machine learning models using both structured and unstructured preoperative data achieved only modest predictive performance for postoperative complications. These findings highlight the importance of transparent methodology and clinical oversight to avoid data leakage and inflated results. Future progress will require better control of data leakage, richer data sources, and external validation to develop clinically useful prediction tools. 2025-10-09 Surgeries, Vol. 6, Pages 87: Data-Leakage-Aware Preoperative Prediction of Postoperative Complications from Structured Data and Preoperative Clinical Notes

Surgeries doi: 10.3390/surgeries6040087

Authors: Anastasia Amanatidis Kyle Egan Kusuma Nio Milan Toma

Background/Objectives: Machine learning has been suggested as a way to improve how we predict anesthesia-related complications after surgery. However, many studies report overly optimistic results due to issues like data leakage and not fully using information from clinical notes. This study provides a transparent comparison of different machine learning models using both structured data and preoperative notes, with a focus on avoiding data leakage and involving clinicians throughout. We show how high reported metrics in the literature can result from methodological pitfalls and may not be clinically meaningful. Methods: We used a dataset containing both structured patient and surgery information and preoperative clinical notes. To avoid data leakage, we excluded any variables that could directly reveal the outcome. The data was cleaned and processed, and information from clinical notes was summarized into features suitable for modeling. We tested a range of machine learning methods, including simple, tree-based, and modern language-based models. Models were evaluated using a standard split of the data and cross-validation, and we addressed class imbalance with sampling techniques. Results: All models showed only modest ability to distinguish between patients with and without complications. The best performance was achieved by a simple model using both structured and summarized text features, with an area under the curve of 0.644 and accuracy of 60%. Other models, including those using advanced language techniques, performed similarly or slightly worse. Adding information from clinical notes gave small improvements, but no single type of data dominated. Overall, the results did not reach the high levels reported in some previous studies. Conclusions: In this analysis, machine learning models using both structured and unstructured preoperative data achieved only modest predictive performance for postoperative complications. These findings highlight the importance of transparent methodology and clinical oversight to avoid data leakage and inflated results. Future progress will require better control of data leakage, richer data sources, and external validation to develop clinically useful prediction tools.

]]> Data-Leakage-Aware Preoperative Prediction of Postoperative Complications from Structured Data and Preoperative Clinical Notes Anastasia Amanatidis Kyle Egan Kusuma Nio Milan Toma doi: 10.3390/surgeries6040087 Surgeries 2025-10-09 Surgeries 2025-10-09 6 4 Article 87 10.3390/surgeries6040087 https://www.mdpi.com/2673-4095/6/4/87 Surgeries, Vol. 6, Pages 86: Tray Application Versus the Standard Surgical Procedure: A Prospective Evaluation https://www.mdpi.com/2673-4095/6/4/86 (1) Background: trays are surgery-specific sets of required materials and medical devices, assembled in consultation between manufacturer and user, and provided in a sterile package. (2) Methods: in a high-volume urological center performing 11,920 operations/procedures annually (2023), we prospectively evaluated the effect of trays compared with the standard approach in a comparative study of 64 operations conducted between 29 October and 30 November 2024. The primary endpoints were the amount of operating room (OR) waste (volume/cm3, weight/g) and setup time (minutes). The secondary endpoint was the workflow assessment by nursing staff, rated on a numerical score (0–10) across seven relevant domains. (3) Results: for endourological procedures, setup time was reduced by 35%, operating room (OR) waste by 34%, and waste volume by 19.0%. Workflow was positively rated with a mean score of 9.75/10. For major open procedures, setup time was reduced by 43%, waste weight by 24.8%, and waste volume by 32%. Workflow was positively rated with a mean score of 8.9/10. (4) Conclusions: Trays have a sustainable and significant impact on reducing OR waste, save nursing staff preparation time, and facilitate improved workflow in the operating room. 2025-10-08 Surgeries, Vol. 6, Pages 86: Tray Application Versus the Standard Surgical Procedure: A Prospective Evaluation

Surgeries doi: 10.3390/surgeries6040086

Authors: Dimitri Barski Wilfried von Eiff Jochen Cramer Stefan Welter Thomas Otto

(1) Background: trays are surgery-specific sets of required materials and medical devices, assembled in consultation between manufacturer and user, and provided in a sterile package. (2) Methods: in a high-volume urological center performing 11,920 operations/procedures annually (2023), we prospectively evaluated the effect of trays compared with the standard approach in a comparative study of 64 operations conducted between 29 October and 30 November 2024. The primary endpoints were the amount of operating room (OR) waste (volume/cm3, weight/g) and setup time (minutes). The secondary endpoint was the workflow assessment by nursing staff, rated on a numerical score (0–10) across seven relevant domains. (3) Results: for endourological procedures, setup time was reduced by 35%, operating room (OR) waste by 34%, and waste volume by 19.0%. Workflow was positively rated with a mean score of 9.75/10. For major open procedures, setup time was reduced by 43%, waste weight by 24.8%, and waste volume by 32%. Workflow was positively rated with a mean score of 8.9/10. (4) Conclusions: Trays have a sustainable and significant impact on reducing OR waste, save nursing staff preparation time, and facilitate improved workflow in the operating room.

]]> Tray Application Versus the Standard Surgical Procedure: A Prospective Evaluation Dimitri Barski Wilfried von Eiff Jochen Cramer Stefan Welter Thomas Otto doi: 10.3390/surgeries6040086 Surgeries 2025-10-08 Surgeries 2025-10-08 6 4 Article 86 10.3390/surgeries6040086 https://www.mdpi.com/2673-4095/6/4/86 Surgeries, Vol. 6, Pages 85: Utilization of a Combined Procedure for Hemorrhoids and Chronic Anal Fissure Is Safe and Feasible https://www.mdpi.com/2673-4095/6/4/85 Background: Hemorrhoids and anal fissure are among the most common benign anorectal conditions. The incidence of synchronous symptomatic hemorrhoids and chronic anal fissure is unknown. In this study we evaluated the outcomes of our experience with concomitant surgical treatment for both these conditions. Methods: In this retrospective study we included consecutive patients who underwent surgical treatment for symptomatic hemorrhoids combined with lateral internal sphincterotomy for chronic anal fissure, during a time period of over 5 years. Eligible patients were contacted by phone and were asked to answer a questionnaire to evaluate recurrent symptoms, fecal incontinence, satisfaction, and improvement in quality-of-life. Results: A total of 56 patients were included, and 29 (51.8%) were female; the mean age was 46.9 ± 13.7 years, and the median follow-up time was 45.4 months. The median self-assessed improvement in quality-of-life on a scale of 0–10 was 10 [IQR 8, 10]. No significant differences were observed in satisfaction or self-assessed improvement in quality-of-life between genders or across different surgical procedures for hemorrhoids. Conclusions: Patients who underwent concomitant surgical treatment for hemorrhoids and chronic anal fissure were satisfied. This study supports our approach for synchronous treatment for different anorectal pathologies given the right patient selection, being safe and feasible. 2025-10-03 Surgeries, Vol. 6, Pages 85: Utilization of a Combined Procedure for Hemorrhoids and Chronic Anal Fissure Is Safe and Feasible

Surgeries doi: 10.3390/surgeries6040085

Authors: Rachel Gefen Adham Handal Carmel Ben-Ezra Shani Y. Parnasa Ido Mizrahi Mahmoud Abu-Gazala Alon J. Pikarsky Noam Shussman

Background: Hemorrhoids and anal fissure are among the most common benign anorectal conditions. The incidence of synchronous symptomatic hemorrhoids and chronic anal fissure is unknown. In this study we evaluated the outcomes of our experience with concomitant surgical treatment for both these conditions. Methods: In this retrospective study we included consecutive patients who underwent surgical treatment for symptomatic hemorrhoids combined with lateral internal sphincterotomy for chronic anal fissure, during a time period of over 5 years. Eligible patients were contacted by phone and were asked to answer a questionnaire to evaluate recurrent symptoms, fecal incontinence, satisfaction, and improvement in quality-of-life. Results: A total of 56 patients were included, and 29 (51.8%) were female; the mean age was 46.9 ± 13.7 years, and the median follow-up time was 45.4 months. The median self-assessed improvement in quality-of-life on a scale of 0–10 was 10 [IQR 8, 10]. No significant differences were observed in satisfaction or self-assessed improvement in quality-of-life between genders or across different surgical procedures for hemorrhoids. Conclusions: Patients who underwent concomitant surgical treatment for hemorrhoids and chronic anal fissure were satisfied. This study supports our approach for synchronous treatment for different anorectal pathologies given the right patient selection, being safe and feasible.

]]> Utilization of a Combined Procedure for Hemorrhoids and Chronic Anal Fissure Is Safe and Feasible Rachel Gefen Adham Handal Carmel Ben-Ezra Shani Y. Parnasa Ido Mizrahi Mahmoud Abu-Gazala Alon J. Pikarsky Noam Shussman doi: 10.3390/surgeries6040085 Surgeries 2025-10-03 Surgeries 2025-10-03 6 4 Article 85 10.3390/surgeries6040085 https://www.mdpi.com/2673-4095/6/4/85 Surgeries, Vol. 6, Pages 83: Exploring the Role of Artificial Intelligence in Enhancing Surgical Education During Consultant Ward Rounds https://www.mdpi.com/2673-4095/6/4/83 Background/Objectives: Surgical ward rounds are central to trainee education but are often associated with stress, cognitive overload, and inconsistent learning. Advances in artificial intelligence (AI), particularly large language models (LLMs), offer new ways to support trainees by simulating ward-round questioning, enhancing preparedness, and reducing anxiety. This study explores the role of generative AI in surgical ward-round education. Methods: Hypothetical plastic and reconstructive surgery ward-round scenarios were developed, including flexor tenosynovitis, DIEP flap monitoring, acute burns, and abscess management. Using de-identified vignettes, AI platforms (ChatGPT-4.5 and Gemini 2.0) generated consultant-level questions and structured responses. Outputs were assessed qualitatively for relevance, educational value, and alignment with surgical competencies. Results: ChatGPT-4.5 showed a strong ability to anticipate consultant-style questions and deliver concise, accurate answers across multiple surgical domains. ChatGPT-4.5 consistently outperformed Gemini 2.0 across all domains, with higher expert Likert ratings for accuracy, clarity, and educational value. It was particularly effective in pre-ward round preparation, enabling simulated questioning that mirrored consultant expectations. AI also aided post-round consolidation by providing tailored summaries and revision materials. Limitations included occasional inaccuracies, risk of over-reliance, and privacy considerations. Conclusions: Generative AI, particularly ChatGPT-4.5, shows promise as a supplementary tool in surgical ward-round education. While both models demonstrated utility, ChatGPT-4.5 was superior in replicating consultant-level questioning and providing structured responses. Pilot programs with ethical oversight are needed to evaluate their impact on trainee confidence, performance, and outcomes. Although plastic surgery cases were used for proof of concept, the findings are relevant to surgical education across subspecialties. 2025-09-30 Surgeries, Vol. 6, Pages 83: Exploring the Role of Artificial Intelligence in Enhancing Surgical Education During Consultant Ward Rounds

Surgeries doi: 10.3390/surgeries6040083

Authors: Ishith Seth Omar Shadid Yi Xie Stephen Bacchi Roberto Cuomo Warren M. Rozen

Background/Objectives: Surgical ward rounds are central to trainee education but are often associated with stress, cognitive overload, and inconsistent learning. Advances in artificial intelligence (AI), particularly large language models (LLMs), offer new ways to support trainees by simulating ward-round questioning, enhancing preparedness, and reducing anxiety. This study explores the role of generative AI in surgical ward-round education. Methods: Hypothetical plastic and reconstructive surgery ward-round scenarios were developed, including flexor tenosynovitis, DIEP flap monitoring, acute burns, and abscess management. Using de-identified vignettes, AI platforms (ChatGPT-4.5 and Gemini 2.0) generated consultant-level questions and structured responses. Outputs were assessed qualitatively for relevance, educational value, and alignment with surgical competencies. Results: ChatGPT-4.5 showed a strong ability to anticipate consultant-style questions and deliver concise, accurate answers across multiple surgical domains. ChatGPT-4.5 consistently outperformed Gemini 2.0 across all domains, with higher expert Likert ratings for accuracy, clarity, and educational value. It was particularly effective in pre-ward round preparation, enabling simulated questioning that mirrored consultant expectations. AI also aided post-round consolidation by providing tailored summaries and revision materials. Limitations included occasional inaccuracies, risk of over-reliance, and privacy considerations. Conclusions: Generative AI, particularly ChatGPT-4.5, shows promise as a supplementary tool in surgical ward-round education. While both models demonstrated utility, ChatGPT-4.5 was superior in replicating consultant-level questioning and providing structured responses. Pilot programs with ethical oversight are needed to evaluate their impact on trainee confidence, performance, and outcomes. Although plastic surgery cases were used for proof of concept, the findings are relevant to surgical education across subspecialties.

]]> Exploring the Role of Artificial Intelligence in Enhancing Surgical Education During Consultant Ward Rounds Ishith Seth Omar Shadid Yi Xie Stephen Bacchi Roberto Cuomo Warren M. Rozen doi: 10.3390/surgeries6040083 Surgeries 2025-09-30 Surgeries 2025-09-30 6 4 Article 83 10.3390/surgeries6040083 https://www.mdpi.com/2673-4095/6/4/83 Surgeries, Vol. 6, Pages 84: Surgical and Radiologic Outcomes Following Pulmonary Lobectomy: A Single-Center Experience https://www.mdpi.com/2673-4095/6/4/84 Background: Pulmonary lobectomy remains the gold standard for early-stage non-small cell lung cancer, with the primary goal of complete tumor removal. Postoperative imaging is critical for evaluating recovery and identifying complications, yet systematic descriptions of radiologic patterns after lobectomy are limited. Methods: We conducted a retrospective analysis of 125 patients who underwent pulmonary lobectomy between 2019 and 2024 at a tertiary thoracic surgery center. Preoperative and postoperative imaging findings were coded and compared using a standardized classification system. Modalities included chest radiography, thoracic CT, ultrasound, PET-CT and MRI. Results: Postoperative imaging demonstrated a clear reduction in pathological findings. Emphysema decreased from 29.6% to 21.6%, pleural effusion from 12.8% to 3.2%, atelectasis/pleural thickening from 15.2% to 8.8%, and ground-glass infiltrates from 12.0% to 8.0%. The proportion of patients without abnormalities increased from 18.5% to 24.8%. Chest radiography (92%) and CT (89.6%) were the most frequently employed modalities. Patients treated with VATS lobectomy showed slightly fewer postoperative abnormalities compared with those undergoing open surgery. Conclusions: Pulmonary lobectomy is associated with measurable radiologic improvement, reflecting favorable structural recovery. Routine imaging follow-up, particularly chest radiography, remains essential for early detection of complications and guiding postoperative care. However, the retrospective single-center design and limited generalizability represent important limitations that should be considered when interpreting these findings. 2025-09-30 Surgeries, Vol. 6, Pages 84: Surgical and Radiologic Outcomes Following Pulmonary Lobectomy: A Single-Center Experience

Surgeries doi: 10.3390/surgeries6040084

Authors: Raluca Oltean Liviu Oltean Andreea Nelson Twakor Teodor Horvat

Background: Pulmonary lobectomy remains the gold standard for early-stage non-small cell lung cancer, with the primary goal of complete tumor removal. Postoperative imaging is critical for evaluating recovery and identifying complications, yet systematic descriptions of radiologic patterns after lobectomy are limited. Methods: We conducted a retrospective analysis of 125 patients who underwent pulmonary lobectomy between 2019 and 2024 at a tertiary thoracic surgery center. Preoperative and postoperative imaging findings were coded and compared using a standardized classification system. Modalities included chest radiography, thoracic CT, ultrasound, PET-CT and MRI. Results: Postoperative imaging demonstrated a clear reduction in pathological findings. Emphysema decreased from 29.6% to 21.6%, pleural effusion from 12.8% to 3.2%, atelectasis/pleural thickening from 15.2% to 8.8%, and ground-glass infiltrates from 12.0% to 8.0%. The proportion of patients without abnormalities increased from 18.5% to 24.8%. Chest radiography (92%) and CT (89.6%) were the most frequently employed modalities. Patients treated with VATS lobectomy showed slightly fewer postoperative abnormalities compared with those undergoing open surgery. Conclusions: Pulmonary lobectomy is associated with measurable radiologic improvement, reflecting favorable structural recovery. Routine imaging follow-up, particularly chest radiography, remains essential for early detection of complications and guiding postoperative care. However, the retrospective single-center design and limited generalizability represent important limitations that should be considered when interpreting these findings.

]]> Surgical and Radiologic Outcomes Following Pulmonary Lobectomy: A Single-Center Experience Raluca Oltean Liviu Oltean Andreea Nelson Twakor Teodor Horvat doi: 10.3390/surgeries6040084 Surgeries 2025-09-30 Surgeries 2025-09-30 6 4 Article 84 10.3390/surgeries6040084 https://www.mdpi.com/2673-4095/6/4/84 Surgeries, Vol. 6, Pages 82: Intervenable Findings Are Common When ERCP Is Performed for Pediatric Patients When Large Duct Obstruction Is Found on Liver Biopsy: Initial Characterization https://www.mdpi.com/2673-4095/6/4/82 Background: Liver biopsy performed after less invasive workup, including imaging, for evaluation of abnormal liver function studies occasionally reveals large bile duct obstruction on histology without evidence of biliary obstruction on prior imaging. The utility of ERCP in this setting has not been studied in pediatrics. In the present study, we address this important clinical issue. Methods: A retrospective review of pediatric pathology and clinical records from 2010 to 2019 identified 123 pediatric patients with large duct obstruction on liver biopsy performed after imaging revealed no evidence of biliary obstruction. The absolute standardized difference (ASD) was used to compare baseline covariates between patients who underwent ERCP vs. all others. Covariates included age, gender, race, ethnicity, BMI, and labs (total bilirubin, GGT, alkaline phosphatase, AST, ALT, platelets, and INR). Results: Of 85 unique patients who met inclusion/exclusion criteria, 15 (17.6%) underwent ERCP. The majority of these patients who underwent ERCP (80%) had a therapeutic endoscopic intervention with a favorable impact on clinical trajectory. The mean age of patients with large duct obstruction was 7 years old. Most patients were white (47%), followed by Asian (17%). Only 25% of patients identified as Hispanic. The mean laboratory values were as follows: total bilirubin 4.61 mg/dL, GGT 353 U/L, alkaline phosphatase 403 U/L, AST 343 U/L, ALT 251 U/L, platelets 289 K/uL, and INR 1.19. Absolute standardized differences comparing baseline covariates between the ERCP and non-ERCP groups are included in Table 1. The largest absolute standardized difference between the two groups was for race (1.17), ethnicity (0.553), and GGT (0.463). Age, alkaline phosphatase, and INR were not significantly different between the two groups (ASD <0.2 for both). Conclusions: Only 17.6% of pediatric patients with large ducts undergo ERCP. Pediatric patients who underwent ERCP were more likely to be white, non-Hispanic, and have elevated GGT. Of interest, age did not differ significantly between the two groups, which may reflect enhanced uniformity of utilization of ERCP across age groups in pediatrics. Additional multi-center studies, including more patients and focused on understanding the utility of ERCP and the range of outcomes following the diagnosis of large duct obstruction in pediatrics, would be informative to guide pediatric hepatology and endoscopic practices. 2025-09-30 Surgeries, Vol. 6, Pages 82: Intervenable Findings Are Common When ERCP Is Performed for Pediatric Patients When Large Duct Obstruction Is Found on Liver Biopsy: Initial Characterization

Surgeries doi: 10.3390/surgeries6040082

Authors: Melissa Martin Justin Lee Roberto Gugig Greg Charville Monique T. Barakat

Background: Liver biopsy performed after less invasive workup, including imaging, for evaluation of abnormal liver function studies occasionally reveals large bile duct obstruction on histology without evidence of biliary obstruction on prior imaging. The utility of ERCP in this setting has not been studied in pediatrics. In the present study, we address this important clinical issue. Methods: A retrospective review of pediatric pathology and clinical records from 2010 to 2019 identified 123 pediatric patients with large duct obstruction on liver biopsy performed after imaging revealed no evidence of biliary obstruction. The absolute standardized difference (ASD) was used to compare baseline covariates between patients who underwent ERCP vs. all others. Covariates included age, gender, race, ethnicity, BMI, and labs (total bilirubin, GGT, alkaline phosphatase, AST, ALT, platelets, and INR). Results: Of 85 unique patients who met inclusion/exclusion criteria, 15 (17.6%) underwent ERCP. The majority of these patients who underwent ERCP (80%) had a therapeutic endoscopic intervention with a favorable impact on clinical trajectory. The mean age of patients with large duct obstruction was 7 years old. Most patients were white (47%), followed by Asian (17%). Only 25% of patients identified as Hispanic. The mean laboratory values were as follows: total bilirubin 4.61 mg/dL, GGT 353 U/L, alkaline phosphatase 403 U/L, AST 343 U/L, ALT 251 U/L, platelets 289 K/uL, and INR 1.19. Absolute standardized differences comparing baseline covariates between the ERCP and non-ERCP groups are included in Table 1. The largest absolute standardized difference between the two groups was for race (1.17), ethnicity (0.553), and GGT (0.463). Age, alkaline phosphatase, and INR were not significantly different between the two groups (ASD <0.2 for both). Conclusions: Only 17.6% of pediatric patients with large ducts undergo ERCP. Pediatric patients who underwent ERCP were more likely to be white, non-Hispanic, and have elevated GGT. Of interest, age did not differ significantly between the two groups, which may reflect enhanced uniformity of utilization of ERCP across age groups in pediatrics. Additional multi-center studies, including more patients and focused on understanding the utility of ERCP and the range of outcomes following the diagnosis of large duct obstruction in pediatrics, would be informative to guide pediatric hepatology and endoscopic practices.

]]> Intervenable Findings Are Common When ERCP Is Performed for Pediatric Patients When Large Duct Obstruction Is Found on Liver Biopsy: Initial Characterization Melissa Martin Justin Lee Roberto Gugig Greg Charville Monique T. Barakat doi: 10.3390/surgeries6040082 Surgeries 2025-09-30 Surgeries 2025-09-30 6 4 Article 82 10.3390/surgeries6040082 https://www.mdpi.com/2673-4095/6/4/82