Quantitative analysis with a digital registration method of three-dimensional implant placement accuracy by novice operators using freehand surgery: An in vitro study.

To evaluate the acceptability, deviation, and efficiency of two automated, artificial intelligence-driven implant planning methods compared with a human-based approach for single-tooth replacement. Data of 32 patients, involving a single edentulous span, were retrospectively obtained, including cone-beam computed tomography (CBCT) and intraoral scans. Three implant planning methods were applied per case: human-based method (HP), automated CBCT-image-based method (AA), and automated CBCT-segmentation-based method (RL). Implant position acceptability was assessed by three prosthodontists using a standardized three-point scale on 12 surgical and prosthetic parameters. Using HP as a reference, angular and linear positional deviations were quantified at the implant platform and apex. Total planning time was recorded. Statistical analyses included Friedman's chi-square test, Wilcoxon test, ANOVA with Tukey's post hoc tests, and intraclass correlation coefficient (α = 0.05). No significant differences were observed between RL and HP for most surgical and prosthetic parameters except for the crestal bone and platform-planned gingival margin distance. At the same time, AA showed significantly lower scores than both methods. No significant differences were found among the three methods for implant-mandibular canal distance. AA demonstrated significantly higher positional deviation than RL (p < 0.001). Total planning time differed significantly among methods. HP (14.1 ±2.44 min), RL (8.91 ±2.89 min), and AA (3.59 ±1.44 min) with all pairwise comparisons significant (p < 0.001). Compared to HP, RL demonstrated similar surgical and prosthetic acceptability with faster planning time. AA was the most efficient but showed lower acceptability than both HP and RL, and demonstrated greater positional deviation than RL.

Reviewing the literature, the optimal implant position for 2-implant retained mandibular overdentures, which would be associated with improved peri-implant tissues, higher retention values, and better patient satisfaction, remains uncertain. The study was designed to assess the effect of the implant position of two implant-retained mandibular overdentures on clinical outcomes (peri-implant soft tissue health, bone loss, retention, and patient satisfaction). Ninety edentulous patients with unsatisfactory retention of their mandibular conventional dentures were included in this study and received 2-implant mandibular overdentures with Locator attachments. The patients were randomly divided into three groups based on the positions of the implants. Group LA (implants in lateral incisor positions), Group CA (implants in the canine positions), and Group PM (implants in the premolar positions). Changes in the peri-implant soft tissue health (plaque, gingival scores, and probing depth) and the retention values of overdentures were evaluated at prosthesis insertion (T0), 6 months (T6), and 12 months (T12) after insertion. The peri-implant marginal bone loss changes were evaluated one year (T12), 2 years (T24), and three years after insertion (T36). A visual analog scale (VAS) assessed patient satisfaction for conventional dentures (CD), LA, CA, and PM at T6. At T6 and T12, the highest plaque and gingival scores were noted with the PM, followed by LA, and the lowest scores were observed with CA. For all observations, the highest pocket depth was noted with PM, followed by CA, and the lowest pocket depth was noted with LA. CA and PM showed significantly higher bone loss compared to LA. The highest retention forces were exhibited by PM, followed by CA, and the lowest retention values were noted with LA. Regarding retention, stability, occlusion of the mandibular prosthesis, and ease of chewing, the PM group had the greatest patient satisfaction, then CA and LA. The lowest satisfaction scores were noted with CD. In selecting the implant position for two-implant mandibular overdentures, it is crucial to balance several key clinical outcomes. The chosen location for the implants should effectively prioritize bone preservation, the health of peri-implant soft tissues, retention, and overall patient satisfaction. Positioning the implants near the lateral incisors is advantageous for minimizing bone loss, while placement near the canines supports optimal soft tissue health. Conversely, positioning them near the premolars maximizes retention and enhances patient satisfaction. (NCT06166316) (12/13/2023).

Anatomical complexities and socket configuration in anterior maxilla often results in challenging immediate implant placement, where implants tend to be facially positioned. Implants with facially placed shoulders exhibited three times more midfacial recession. Despite using surgical guides, osteotomy drills tend to follow the least resistance path dictated by socket anatomy. This prospective clinical trial aimed to measure the deviation from the planned implant position during immediate implant placement in the anterior maxilla and its impact on esthetic outcomes, utilizing a new computer-guided plateau drilling protocol. Twenty-six patients (7 males and 19 females, ages 20-42) with non-restorable maxillary anterior teeth participated in this study. Virtual planning was done using the Safe Angle Concept and the implants were placed with a partially guided approach. Standard tessellation language files obtained from scanned casts and initial computed tomography scans were used to plan the virtual position of the implants and surgical guides fabrication. Angular, global platform and global apex deviations from the planned implant position were measured after three-months. Bone formed labial to the implant and pink esthetic score were assessed after nine-months. The current investigation showed that the use of the new computer-guided plateau drilling protocol resulted in clinically acceptable ranges of angular, global platform, and global apex deviation 4.56 ± 3.14°, 0.91 ± 0.61mm, 1.47 ± 0.88mm respectively. Radiographic analysis revealed mean mm amount of bone formed labial to the implant of 2.13 ± 0.99mm and pink esthetic score displayed a mean of 11.89 ± 1.75, with a median of 12.5 after nine months. The virtual safe angle planning concept combined with plateau drilling protocol showed promising accuracy in immediate implant placement in the anterior maxilla. The resultant deviation had no influence on the esthetic outcomes. The current trial was registered at Clinical trials.gov (ID: NCT05750004, Date: 19-February-2023).

In this study, a fully digital workflow enabling the alignment of pre- and postoperative mandibular intraoral scans in complete-arch implant rehabilitation using intraosseous fiducial reference markers is presented. A prosthetically driven digital workflow was implemented for mandibular complete-arch rehabilitation in which two cylindrical intraosseous pins were placed in a median or paramedian mandibular region and used as fiducial reference markers to align pre- and postoperative intraoral scans. Pin osteotomies were prepared using a calibrated drilling protocol and preserved throughout surgery to allow for the exact repositioning of the pins. Implant positions were recorded using photogrammetry, while postoperative intraoral scans were acquired after suturing with the pins reinserted. Scan alignment was performed using a best-fit algorithm based exclusively on the fiducial pin geometry. Standardized convergent scanbodies without undercuts were used for intraoral scanning. The proposed workflow allowed for the alignment of pre- and postoperative mandibular scans without additional radiographic acquisitions and was compatible with both guided and free-hand implant placement, regardless of the degree of mandibular atrophy. Within the limitations of a proof-of-concept report, the use of intraosseous fiducial reference markers represents a minimally invasive and clinically applicable solution to a critical limitation of fully digital mandibular rehabilitation workflows, without the quantitative validation of accuracy, trueness, or reproducibility.

Comparative analysis of prepectoral and subpectoral standalone placement of MicrothaneⓇ breast implants in post-mastectomy breast reconstruction: A retrospective study.

This study aimed to explore the effectiveness of a novel orientation gauge for undergraduate learning in implant dentistry hands-on practice. The individualized simulation models were processed based on cone beam computed tomography (CBCT) and intraoral scanning of a patient with an absence of bilateral mandibular first molars. A novel orientation gauge was invented to instruct students to place implants and assess dental implant buccal-lingual, mesial-distal, or coronal-apical penetration position deviations. Ninety-eight students were randomly enrolled in the implant dentistry program and assigned to the gauge group (n = 47) and the control group (n = 49). Pre-class videos of an implant surgery operation by freehand were given to students 1week before class. For the gauge group, an extra PowerPoint on the application of the novel orientation gauge was presented before class. Then, students are required to perform implant placement and complete questionnaires before/after class. CBCT and the orientation gauge were used to evaluate the three-dimensional (3D) accuracy of the implant placement. Students' perception related to the clinical practice skills was judged by questionnaire results. The linear deviation of the CBCT examination showed a significant difference concerning angular deviation (p=0.0193). A significant mesial-distal deviation was observed in the gauge group compared with the control group (mean: 0.5233 vs. 0.9259mm, p=0.0077), according to the absolute restoration-level deviation value. A tendency to reduce the buccal-lingual implantation deviation was also noticed in the gauge group (p=0.0640). Significant differences were elicited in the students' responses before and after training in both groups (p<0.001). Students' questionnaires showed better results in surgical procedures understanding, prosthetically driven implantology knowledge, the precise 3D spatial position of dental implants, and the usage of surgical cassettes before/after simulation training in the gauge group. The novel orientation gauge can help students reduce implant placement deviations and enhance their understanding of the implant surgery process.

Accurate three-dimensional positioning of dental implants is necessary for attaining optimal prosthetic outcomes and long-term implant success. Conventional free-hand implant placement is highly operator dependent and associated with greater positional deviations, whereas semi-active robotic systems offer real-time guidance and mechanical constraint to enhance surgical precision. To comparatively evaluate the accuracy of dental implant placement using a semi-active robotic assistance system versus the conventional free-hand technique in a randomized controlled clinical trial. This prospective parallel-arm randomized controlled trial included 200 implant sites allocated equally to a semi-active robotic group and a free-hand group. Preoperative cone-beam computed tomography (CBCT)-based virtual planning was performed for all cases. Implant placement accuracy was assessed postoperatively by superimposing pre- and postoperative CBCT scans to measure coronal deviation, apical deviation, and angular deviation. Secondary outcomes, such as surgical time, intraoperative complications, and postoperative pain, were considered. Statistical analysis was performed using appropriate parametric and nonparametric tests with significance set at P < 0.05. The semi-active robotic group demonstrated significantly lower coronal, apical, and angular deviations compared with the free-hand group (P < 0.001). Although surgical time was significantly longer in the robotic group, intraoperative complications and postoperative pain scores were comparable between groups. Semi-active robotic guidance significantly improves implant placement accuracy without increasing short-term patient morbidity, supporting its clinical utility in precision-driven implant dentistry.

Dislocation remains a common reason for revision after total hip arthroplasty (THA), and adverse spinopelvic mobility is increasingly recognized as a major contributor to instability. Whether its prevalence differs between surgical approaches is unclear. This study compared adverse spinopelvic mobility and associated risk factors in patients who sustained a dislocation after a posterior approach (PA) or a direct anterior approach (DAA), and evaluated whether implant positioning differed between groups. A retrospective analysis was performed on 133 patients with post-operative dislocation and available functional lateral radiographs and low-dose CT scans, including 85 PA and 48 DAA dislocations. Spinopelvic parameters, dynamic pelvic motion between standing, sitting, and supine postures, and established spinopelvic risk factors were assessed. Cup orientation, femoral version, combined anteversion, limb length, and global offset were compared. Spinopelvic morphology was similar, with no significant differences in standing spinopelvic tilt, pelvic incidence, PI-LL mismatch, lumbar lordosis, or lumbar flexion. However, dynamic motion differed markedly. A change in spinopelvic tilt (SPT) of ≥ 20° from standing to seated occurred in 41.3% of DAA dislocations versus 21.1% after PA (p = 0.029). A change in SPT ≤ - 13° from supine to standing occurred in 17.8% after DAA compared with 4.7% after PA (p = 0.048). Other spinopelvic risk factors showed no significant differences. Implant positioning was largely comparable; femoral and combined anteversion, cup inclination, and limb length were similar. Although femoral head size and global offset differed between groups, the association between surgical approach and adverse spinopelvic mobility persisted after accounting for these implant-related factors. Patients dislocating after DAA demonstrated a substantially higher prevalence of adverse spinopelvic mobility despite similar implant orientation and hip restoration. These findings suggest that dynamic pelvic behavior may contribute to anterior instability patterns and highlight the potential relevance of hip-spine assessment in patients undergoing anterior-approach THA. Retrospectively registered, CNIL MR004 2,225,508.

Study Design: Retrospective cohort study. Objective: To determine whether coronal implant position and implant alignment on first postoperative radiographs predict flexion-extension range of motion (ROM) following cervical disc replacement (CDR). Summary of Background Data: CDR is a motion-preserving alternative to anterior cervical discectomy and fusion. While sagittal alignment factors have been studied, the impact of coronal implant positioning on ROM preservation remains poorly understood. Methods: This retrospective radiographic study evaluated 236 CDR levels at a single academic institution. On first postoperative anteroposterior radiographs, we measured superior and inferior anatomic axis deviation (AAD), superior and inferior mechanical axis deviation (MAD), disc level deviation (DLD), and plumbline deviation (PD). Flexion-extension ROM was assessed at final follow-up at the disc space (DS ROM), functional spinal unit (FSU ROM), and C2–7 levels. Pearson correlations, multivariable linear regression adjusted for age, sex, and body mass index, dose-response quartile analysis, and receiver operating characteristic curve analysis were performed. Results: The mean follow-up was 1.8±1.7 years. Superior MAD demonstrated a significant negative correlation with FSU ROM ( r =−0.149, P =0.023), which persisted after multivariable adjustment ( β =−0.36, P =0.032). Dose-response analysis revealed that patients in the best alignment quartile had significantly higher FSU ROM than those in the worst quartile (10.2 vs. 8.0 degrees, P =0.046). Every 3 degrees of MAD corresponded to ∼1 degree of FSU ROM loss. Superior MAD &gt;3.8 degrees was associated with a 2.27-fold increased odds of poor FSU ROM ( P =0.024). Conclusions: Coronal MAD significantly impacts FSU ROM following CDR. Surgeons should target MAD &lt;3 degrees to optimize motion preservation. Level of Evidence: Level III—therapeutic study.

Bone resorption progresses in the alveolar ridge after tooth loss. In extremely athropic maxillae, treatment options include quad-zygoma implants, iliac bone augmentation with intraosseous implants, (the All-on-4 concept), Group-SUB periosteal implant. In this study, extremely atrophic maxilla was defined as an edentulous ridge with 3 mm crest thickness, 6 mm nasal base-crest distance, and 5 mm sinus floor-crest distance. This study aimed to compare stress distribution of these protocols using finite element analysis. In this study, analyses were performed using the finite element method A total of three groups were included in the finite element analysis, each representing a different treatment configuration applied to an extremely atrophic maxilla. The AOF (All-on-4) configuration consisted of four conventional implants placed in the canine and first molar regions following iliac bone augmentation, supporting a metal-ceramic prosthetic restoration. The ZYG (Zygomatic) configuration consisted of four extra-maxillary zygomatic implants (quad zygoma), with two implants placed in the canine region and two in the posterior region on each half of the maxilla, supporting a metal-ceramic prosthetic restoration. The SUB (Subperiosteal) configuration consisted of a subperiosteal implant framework supporting a metal-ceramic prosthetic restoration. For all three configurations, three-dimensional finite element models were generated based on standardized geometric reconstruction of an extremely atrophic maxilla. Implant positioning, prosthetic design, material properties, boundary conditions, and loading scenarios were defined according to previously published finite element modeling protocols, and identical modeling assumptions were applied to all groups to allow direct comparison. In this study, vertical occlusal force of 150 N and an oblique force of 50 N at a 30° angle were applied. In the models created, minimum stresses in the cortical bone and minimum and maximum principal stresses (P max) in the spongiose bone were observed. The Von Mises Stress values of the implants and abutments were analyzed. Stress in the alveolar bone remained within the physiological limits of the bone. However, it was determined that Group-SUB created less stress on the alveolar bone than the other Groups. When the Von Mises Stress values on the implants and abutments were examined, it was determined that Group-AOF had the highest Von Mises Stress values, followed by Group-ZYG (and Group 3-SUB had the lowest Von Mises Stress values. When the stresses occurring in the prosthetic restoration were evaluated, similar results were observed. Our data suggest that zygoma implants may reduce stress concentration in extremely atrophic maxillae; however, clinical validation is required.

Robotic knee arthroplasty has been associated with improved knee-specific outcomes, but results are relatively immature. The VELYS Robotic-Assisted Solution is an imageless semi-active system used with the ATTUNE knee arthroplasty system. Recently, the UK National Institute for Health and Care Excellence called for a multidomain evaluation of six robotic-surgery platforms in orthopaedics, of which VELYS is one. This review aimed to (i) evaluate current evidence on VELYS in total knee arthroplasty, (ii) assess outcomes, complications, cost and versatility, (iii) appraise study quality and (iv) identify knowledge gaps. A scoping review using five-stage methodology following Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines was undertaken. Articles were screened against pre-determined criteria, with data synthesized descriptively and thematically. One hundred twenty-six studies were identified, with 22 included. Evidence level ranged from II to IV. Analysis highlighted improved implant positioning as seen with other robotic systems, as well as a non-inferior safety profile. However, despite studies appearing to highlight favourable early patient-reported outcomes and function as well as greater workflow efficiency, the overall quality of the published work was poor, giving little evidence to robustly support many of the conclusions drawn in these studies. Limitations of these studies included small sample sizes, a lack of information on patient characteristics and patient selection, retrospective design and a lack of long-term follow-up. The available literature regarding the VELYS Robotic-Assisted Solution is limited and of moderate-to-poor quality. Implant positioning was more accurate; however, other results, especially regarding improved patient outcomes, are not currently well-evidenced. Evidence was largely retrospective or early prospective, with no randomized controlled trials or long-term data. High-quality, randomized studies are required to evidence this technology. N/A.

Management of extended oncologic orbital exenteration reconstruction: a collaboration between surgeons and prosthetists for optimized results.

Accuracy of scanning using photogrammetry and reverse scan for complete arch implant-supported prostheses: An in vitro comparative study.

Leadless pacemakers are typically implanted in the mid-septum of the right ventricle (RV) to mitigate the risk of perforation. However, reports on the precise location of these implants are limited. This study aimed to elucidate tine-based leadless pacemaker position and presence of subclinical RV perforation through computed tomography (CT) imaging, along with the associated prognosis. Patients who underwent heart, chest or abdomen CT after leadless pacemaker implantation were consecutively included. Two cardiologists and one radiologist reviewed the CT images to assess the position of tines and to detect RV perforation. The implantation position was categorized as the septum, RV free wall, junction of septum and RV free wall, moderator band, and RV apex. Subclinical perforation was defined as the tines of a leadless pacemaker beyond the outer myocardial contour without symptoms, pericardial effusion, hemodynamic instability, or pacemaker malfunction. A total of 88 patients (age, 72.9±12.1 years; 42 males) were included. The interval between procedure and CT scanning was 8.6±9.2 months. In 68 patients (77.3%), the leadless pacemaker was implanted at the junction of the septum and the RV free wall. Subclinical RV perforation occurred in 15 patients (17.0%). Among patients with RV perforation, the most common implantation site was the junction of the septum and the RV free wall. None of the patients with RV perforation experienced any adverse events for 12.4±12.3 months. The most common leadless pacemaker implantation site is the junction of the septum and the RV free wall. Subclinical RV perforation is not uncommon and not associated with overt adverse outcomes.

A footprint mismatch between the cervical disk replacement implant and vertebral endplates is common; however, debate remains regarding the optimal implant position when a footprint-undersized device is unavoidable. Our purpose is to evaluate the biomechanical impact of a footprint-undersized ball-and-socket cervical disk replacement on spinal kinematics, facet joint stress, endplate contact stress, and adjacent disk stress in different sagittal position. A validated C4-C7 finite element model was developed from computed tomography data. A Prodisc® C Vivo prosthesis was implanted at C5-C6 in 2 configurations: (1) footprint-matched and (2) mismatched using undersized implants positioned anteriorly, centrally, and posteriorly. Physiological follower loads (98 N) and pure moments (2 Nm) were applied to simulate flexion, extension, lateral bending, and axial rotation. Ranges of motion, implant-endplate contact stress, core stress, facet joint stress, and adjacent disk stress were compared. The mismatched-anterior model reduced C5-C6 ranges of motion by 22% in flexion but increased facet joint stress by 166% during extension and adjacent disk stress by up to 148% in flexion. Implant-endplate contact stress increased by up to 277% in the mismatched-anterior model, suggesting a higher risk of subsidence. The mismatched-central model exhibited lower increases in core stress, while the mismatched-posterior model preserved comparable flexion and extension motions, indicating that both models demonstrated relatively more favorable biomechanical performance. Undersized cervical disk implants significantly alter segmental biomechanics, especially when placed anteriorly, increasing the risk of subsidence, facet overload, and adjacent segment degeneration.

Tension band wiring (TBW) is one of the most commonly used methods of fixation for displaced olecranon fractures. This study aimed to assess whether implant positioning (IMPO) of TBW for olecranon fractures was associated with complications. This was a multicentre cohort study. Eligible patients were retrieved from the hospitals' administrative databases using diagnosis codes for elbow and olecranon fractures. The patients' healthcare files were reviewed for demographics and complications. A major complication was defined as any reoperation within eight weeks or deep infection. Any loss of fixation was added to define surgical complications. Preoperative X-rays were classified according to the Mayo classification. Post-operative X-rays were evaluated, and the IMPO of TBW was rated on a 0-10 scale, yielding 10 points if all conditions were met. A high IMPO score was 9-10 points, a low score was eight points or less. A total of 307 patients were included: 76% with Mayo type 2A and 20% with type 2B. The TBWs were rated with a median score of eight points (range: 3-10), and 11.8% had major complications. There was a 5% complication rate with a high IMPO score, compared with 15% with a low score (p = 0.010). A total of 105 patients (34%) had surgical complications: 21% with a high IMPO score and 44% with a low IMPO score. The IMPO score after TBW for olecranon fractures has a clear correlation with post-operative complications. We propose that at least nine out of ten points should be achieved before surgery is acceptable. None. Not relevant.

Tibial plateau fractures present a complex orthopaedic challenge and usually require surgical intervention to restore joint alignment and stability as well as to prevent complications. In practice, determining the most appropriate surgical approach, implant selection and positioning remains a challenge and depends on the surgeon's experience and patient-specific factors. Therefore, this scoping review aims to map the current evidence on surgical fixation methods for proximal tibia fractures in adults. In particular, we seek to first assess study types and their distribution across levels of evidence and second to identify knowledge gaps to support evidence-based surgical planning. The proposed scoping review will be conducted in accordance with the JBI methodology for scoping reviews and will be reported as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Information for this study will be gathered from Medline, Cochrane and Embase. Data analysis will involve categorising the studies by their level of evidence and extracting predefined parameters, including fracture characteristics, surgical approach, implant type and key findings relevant to the review question. The study focuses on surgically stabilised intra-articular proximal tibia fractures in adults. Only English- and German-language studies that are available in full text and published after 1995 will be included. No ethical approval is required. The findings of the proposed review will be disseminated through publications in peer-reviewed journals. Open Science Framework, osf.io/g9zfu.

Cardiorenal syndrome (CRS) exhibits high in-hospital mortality. Although aortic entrainment pumps can improve CRS patients’ hemodynamics, they can carry risks of blood-related complications. The limitations are further exacerbated by existing numerical studies, which often neglect arterial compliance and transient cardiac effects. Therefore, this study employed computational fluid dynamics (CFD) combined with a three-element Windkessel model to investigate the impact of different implantation positions on the aortic hemodynamics. The results showed that the blood pump implanted in the middle location of the aorta yielded the maximum aortic pressure and significantly enhanced the perfusion of the renal arteries. The blood pump induced the peak levels of wall shear stress (WSS) and scalar shear stress (SSS) at the peak systole phase. Posterior displacement of the blood pump reduced the hemolysis index (HI) by 19.6%, yet it resulted in an average increase of 4.9% in the thrombosis index (TI) across the entire cardiac cycle. This study used dynamic boundary conditions and made the working environment of the blood pump in the aorta more realistic. Meanwhile, the optimal implantation position of the blood pump in clinical treatment has a positive effect on improving the treatment effect.

Tension band wiring (TBW) is one of the most commonly used methods of fixation for displaced olecranon fractures. This study aimed to assess whether implant positioning (IMPO) of TBW for olecranon fractures was associated with complications. This was a multicentre cohort study. Eligible patients were retrieved from the hospitals' administrative databases using diagnosis codes for elbow and olecranon fractures. The patients' healthcare files were reviewed for demographics and complications. A major complication was defined as any reoperation within eight weeks or deep infection. Any loss of fixation was added to define surgical complications. Preoperative X-rays were classified according to the Mayo classification. Post-operative X-rays were evaluated, and the IMPO of TBW was rated on a 0-10 scale, yielding 10 points if all conditions were met. A high IMPO score was 9-10 points, a low score was eight points or less. A total of 307 patients were included: 76% with Mayo type 2A and 20% with type 2B. The TBWs were rated with a median score of eight points (range: 3-10), and 11.8% had major complications. There was a 5% complication rate with a high IMPO score, compared with 15% with a low score (p = 0.010). A total of 105 patients (34%) had surgical complications: 21% with a high IMPO score and 44% with a low IMPO score. The IMPO score after TBW for olecranon fractures has a clear correlation with post-operative complications. We propose that at least nine out of ten points should be achieved before surgery is acceptable. None. Not relevant.