Reconstructive Procedures Research Articles

Five-item modified frailty index does not outperform diabetes and hypertension alone in prediction of complications after breast reconstruction

Existing literature has emphasized the utility of the five-item modified frailty index (mFI-5) in predicting postoperative outcomes after surgical procedures. However, in breast reconstruction, a primarily elective post-oncologic procedure for otherwise relatively healthy patients, several components of the index may be sparse and not strongly contribute to predictive value. Breast reconstruction cases were identified in the 2012-2022 National Surgical Quality Improvement Program. Three metrics were compared in this cohort: 1) the mFI-5, 2) a simplified two-item index comprising diabetes and/or hypertension, and 3) American Society of Anesthesiologists (ASA) class. Each metric was incorporated into three multivariate logistic regression models for occurrence of at least one postoperative complication. Predictive performance among metrics was compared over fifty iterations (p<0.05). Performance was compared between autologous and implant-based modalities in a supplementary analysis. 134,983 breast reconstruction cases were identified in the final cohort. In multivariate regression, both MFI and the two-item index of diabetes and hypertension were significant predictors of postoperative complications (p<0.001). The mFI-5 (average AUC: 0.6106) and two-item index (average AUC: 0.6105) performed without significant difference (p=0.93). Discriminatory performance of ASA class (average AUC: 0.6115), was not significantly different from the other metrics (p>0.05). In the context of a population of mainly elective breast reconstruction procedures, the five-item modified frailty index does not outperform an index of diabetes and hypertension alone. Such findings may motivate the selection of other variables that may be more useful for prediction of postoperative outcomes.

Evaluating the impact of surgery sequence on infection rates in hip or knee arthroplasty: does sequence matter?

The potential influence of surgical sequence of elective hip-and-knee reconstructive surgery in relation to an infection-related procedure on postoperative infection rates is not clearly understood. Therefore, we aimed to examine the impact of surgical sequence on the incidence of postoperative infections within one-year and the longest available follow-up period in patients undergoing hip-and-knee reconstructive surgery. A case-control study with propensity matching was utilized to examine elective surgeries conducted at Sunnybrook Holland Orthopaedic & Arthritic centre, Toronto, Canada between 2015 and 2018. We determined and categorized them based on their operating room (OR) sequence in relation to an infected case; the cases were those performed right after (post-infection cohort), and the controls were those performed before an infection-related procedure in the same OR (pre-infection cohort). We employed survival analysis to compare the infection incidence within one year and at the longest available follow-up among the propensity-matched cohort. A total of 13,651 cases were identified during the four year period. We successfully matched 153 cases (21 post-infection and 132 pre-infection) using propensity scores. Demographic and clinical characteristics were balanced through matching. Kaplan-Meier survival analysis showed no significant difference in infection-free survival within one year and at a median follow-up of 2.2 years [interquartile range 0.9-5.0] between surgeries conducted before and after infected cases (both log-rank p-values = 0.4). The hazard ratios for infection within one year and the longest follow-up period were both 0.37 [95%Confidence Interval 0.03-4.09, p = 0.418], as no more events occurred after one year. The sequence of surgical procedures, whether or not an elective arthroplasty or lower limb reconstructive procedure occurs before or after an infection-related case in the same OR, does not significantly affect postoperative infection rates. This finding supports the efficacy of the current infection control measures and suggests a reconsideration of surgical scheduling standards.

Advances in Reconstructive Robotic Microsurgery in the Extremity.

Robotic surgery has emerged as a promising technique for reconstructive procedures, offering potential advantages across various surgical fields. Following initial case reports on the use of the Symani Surgical System (Medical Microinstruments, S.p.A) for microsurgical anastomosis, the authors evaluated its full potential in extremity reconstruction. They conducted a retrospective analysis of patients with soft tissue defects of the upper and lower extremities treated between February 2022 and May 2024. Each patient underwent soft tissue reconstruction with free tissue transfer with microsurgical anastomosis performed using the Symani Surgical System. The study included 7 male patients and 1 female patient, aged between 19 and 71 years (mean age: 50.6y). The most used recipient vessels were the anterior tibial artery and vein (37.5%). The preferred anastomotic technique was end-to-side in arterial anastomoses (6/8). All arterial anastomoses were performed using the Symani Surgical System. The mean anastomosis time was 33.2±5.8 minutes. One out of 8 patients required surgical revision outside of the anastomosis. The authors' findings suggest that using the Symani Surgical System for microanastomosis in extremity reconstruction is a safe and effective approach, leading to satisfactory outcomes in different anatomic regions. The system allows for the successful execution of various anastomosis techniques, including end-to-end and end-to-side connections, using single interrupted or running sutures, which enhances its versatility in complex reconstructive procedures. The benefits of robotic assistance in terms of precision and ergonomics are promising for the future of reconstructive microsurgery.

Can limb length discrepancies be corrected with the Masquelet technique? A technical trick

Masquelet technique is a well-established procedure for reconstruction of bone defects secondary to such causes as infections, non-unions, tumors or open fractures with bone loss. The management of limb length discrepancies following bone defects has been well established using bone transport and remains the preferred choice amongst reconstruction surgeons. One of the criticisms of the Masquelet technique has been its limitation to address limb length discrepancies. We describe a technique for the correction of limb length discrepancies using the Masquelet technique.

The World's first 3D-printed PEEK cranial implant: a new horizon in precision and personalized neurosurgery.

Cranioplasty is a reconstructive neurosurgical procedure that fixes the cranial bone defects after the craniotomy for brain surgeries like tumours, aneurysms, arterio-venous malformations, subdural empyemas and hematomas. Personalized 3D-printed implants offer various advantages, including anatomical accuracy, functional restoration, time-sparing surgery, excellent cosmetic outcomes through their impeccable adjustment to cranial vault defects, and better clinical outcomes. PEEK has a meritorious profile in terms of high success rate, low complication rate, fracture resistance and low toxicity profile, high strength, high toughness, and excellent biocompatibility in cranioplasty. On the other hand, the need for more cost-effective yet ideal biomaterials must be met for nations and patients with financial constraints. Nevertheless, this additively manufactured 3D-printed cranial implant marks the dawn of a new era in precision and personalized neurosurgery.

Early experience using vacuum-assisted closure for managing soft tissue injuries in open type IIIB tibial fractures, a non-randomised controlled trial from a North African level one trauma centre

Purpose: The primary objective was to investigate our early results of using vacuum-assisted closure (VAC) for wound management in patients with open IIIB tibial fractures and compare the results with a group subjected to conventional daily dressing. Methods: A prospective non-randomised clinical trial (NRCT) with a parallel design and allocation ratio of 1:1 was conducted after obtaining ethical committee approval. Forty skeletally mature patients with unilateral type IIIB open tibia fractures were included over two years, starting from April 2019. In group A, patients were treated with VAC, which was changed every four days if needed, and in group B, patients had daily conventional dressings. Results: Both groups had no differences in the basic demographic, comorbidities, injury mechanism, and associated injuries. The need for secondary debridement surgeries was significantly lower in Group A than in Group B, 1 ± 0.50 versus 2.50 ± 0.85, respectively ( P &lt; 0.001). The time till definitive coverage was significantly lower in Group A than in Group B, 12.22 ± 2.90 versus 23.56 ± 8.68 (days); P &lt; 0.001. All coverage procedures succeeded in Group A, while four (20%) failed in Group B, P = 0.04. Infection was higher in Group B, with six (30%) patients compared to one (5%) in Group A, P = 0.01. Conclusion: Reports on VAC's role in managing severe open fracture wounds are rare in our area, and the initial results we obtained are encouraging, with lower infection rates and less cumbersome reconstruction procedures; however, further evaluation of the procedure's cost-effectiveness is mandatory.

Pelvic Organ Prolapse Surgery: Postoperative Quality of Life in Ethiopian Women.

Pelvic organ prolapse (POP) has a profound influence on a woman's quality of life (QoL). Assessment of QoL using patient-reported outcome (PRO) measures in pelvic organ prolapse surgery is common practice in developed countries, but despite the burden of POP in developing countries, such as Ethiopia, the use of PROs to record preoperative and postoperative QoL scores is limited. This study is aimed at assessing the QoL among Ethiopian women with POP before and after surgery using the validated Pelvic Organ Quality of Life (P-QoL) questionnaire.Additionally, we will compare postoperative QoL measurements of reconstructive procedures with those of obliterative procedures. This is a prospective observational study conducted at a single hospital in Ethiopia on women who were scheduled for surgery for symptomatic POP. Patients' QoL was assessed preoperatively using the P-QoL questionnaire and at each subsequent follow-up visit for 1 year (3, 6, 9, and 12months). Patients undergoing an obliterative procedure were evaluated and compared with those having reconstructive procedures. The mean score for general health perceptions, prolapse impact, role limitations, physical limitations, social limitations, and emotions was 0 at 12 months postoperatively. Despite significant improvements from baseline, personal relationships, sleep or energy disturbance, and symptom severity measures continued to negatively impact QoL at 12 months postoperatively. Quality of life among Ethiopian women with POP is poor across all domains. Native tissue repair employing either reconstructive or obliterative methods significantly improves QoL across all domains up to 12months postoperatively. The use of validated tools to assess PROs is essential to provide evidence-based care that improves QoL in ways that are meaningful to patients.

WP8.11 - Perception of Patients, Physicians, and Chaperones Regarding the Use of Chaperones During Patient Examinations for Plastic Surgery: A Systemic Review

Abstract Aim There is a scarcity of information related to the use of chaperones during patient examinations of body areas where plastic and reconstructive surgery is performed. Methods In this systematic review, we searched electronic databases for literature addressing physician use of chaperones during examinations of patients undergoing plastic surgery from the perspective of the patient, physician, and chaperone from inception of the database until April 2023. We conducted an inductive thematic analysis of four domains (physician perspective, patient perspective, chaperone perspective, and chaperone documentation. Result The results of the analysis showed that surgeons who are experienced, are men, or have received education related to using chaperones are more likely to provide chaperones during patient examinations for medico-legal protection and patient comfort. A small percentage of surgeons have faced accusations from patients of inappropriate behavior. Most of these incidents have occurred without a chaperone present. Patients who have long associations with a particular plastic surgery practice are less likely to want a chaperone. When physicians examine nonsensitive areas, most patients prefer having no chaperone. However, young patients and patients undergoing reconstructive procedures are more likely to request chaperones. Patients prefer having family members or friends serve as chaperones. Notably, despite the presence of a chaperone, we found that documentation of the presence of a chaperone was inadequate. Conclusion Further research, including qualitative studies and multinational approaches, is warranted to gain deeper insights and develop comprehensive guidelines for chaperone use that empowers both patients and healthcare providers.

STAGED URETHROPLASTY FOLLOWING SEVERE ELECTRIC BURNS TO PERINEUM AND GENITALIA: A CASE REPORT

Objective: This study aims to know the surgical treatment of electrical injuries, perineum, and scrotum. Case(s) Presentation: A 55-year-old male sustained electric burns to the back, perineum and scrotum. The patient failed to void following removal of the catheter 6 weeks later, hence the patient was referred to the urology department for further management. was counselled for a two-phase urethral surgery. Discussion: In our case, the patient had sustained perineal and scrotal burns when he sat over a live wire. This led to the loss of skin and soft tissues, needing massive musculoskeletal and skin grafts. Our patient underwent a number of revision surgeries leading to repeated scarring of the perineal tissues and skin. Conclusion: Electrical injuries to the perinium and genitalia are rare. Hence the surgical strategy of electrical injuries requires a step-wise approach. Initially, conservative debridement needs to performed so as to preserve any tissue of questionable viability and ensure subsequent adequate soft-tissue coverage. The reconstructive surgical procedures bring about satisfactory outcomes. Keywords: Electrical injury, perineum, scrotum, surgical strategy.

Free functional gracilis transfer for reconstruction of isolated anterior deltoid atrophy following surgical proximal humerus fixation

BackgroundPalsy of the clavicular head of the deltoid is a complication after surgical fixation of proximal humerus fractures. Flexion of the shoulder joint may be impaired as a result. Additionally, patients may complain of joint instability, visible atrophy and pain. Where nerve reconstruction is not possible, muscle transfers remain as secondary reconstructive procedures. MethodsThree patients suffering from anterior deltoid palsy after proximal humerus fixation received a free functional gracilis transfer to the shoulder. Postoperatively, patients underwent biofeedback-based rehabilitation. Before and after the intervention, subjective complaints, pain level and active range of motion (ROM) were recorded. At the final follow-up patients completed a Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. ResultsThe surgery was successful in all patients with first muscle signals registered through sEMG approximately four months postoperatively. At the latest follow-up (> 3 years), the patients showed improved shoulder stability and pain scores. In two patients with preoperative restrictions, active ROM improved. The DASH score showed minimal to no disability in two patients and moderate disability in the third. Two patients voiced satisfaction with the restoration of the ventral bulk of the shoulder. ConclusionsThe free functional gracilis muscle transfer is a novel approach for secondary reconstruction in patients with anterior deltoid atrophy who don’t qualify for nerve intervention. It addresses shoulder instability and pain and may improve active ROM. The addition of fresh muscle tissue to the ventral shoulder can improve its natural contour and prevent protrusion of the humeral head.

Feasibility of a cross-face reconstruction of the mental nerve—A cadaveric simulation study with histomorphometric analysis

IntroductionThe inevitable sacrifice of the inferior alveolar nerve (IAN) during oncologic resections results in substantial sensory impairment, impacting crucial functions such as speech, saliva retention, and mastication. This study investigates the feasibility of sensory restoration through cross-face reconstruction of the mental nerve via a contralateral mental nerve branch. MethodsThe cross-face reconstruction procedure was simulated in five formalin-fixed cadavers for both sides to evaluate the anatomic fundamentals and the nerve gap between the mental nerve main trunk and the transferred contralateral mental nerve branch. Furthermore, a histomorphometric analysis was performed to assess cross-sectional area and axon counts. ResultsThe mean gap distance between the main mental nerve trunk and the transferred contralateral branch was 15.3mm. End-to-end coaptation was achieved in 9 out of 10 simulations. The mean cross-sectional area was 0.996 mm2 at the main mental nerve trunk and 0.253mm2 at the coaptation site of the nerve branch. The mean donor-to-recipient axon ratio was found to be 0.3:1. ConclusionThe cadaveric simulation demonstrates the feasibility of a cross-face reconstruction of the mental nerve with only minimal gapping. Advantages of the proposed technique include the use of shorter nerve grafts, minimizing donor site morbidity and enabling fast reinnervation. This technique may offer a promising method for enhancing the quality of life for a patient group with increasing survival rates and life expectancy.

Lens-free on-chip 3D microscopy based on wavelength-scanning Fourier ptychographic diffraction tomography

Lens-free on-chip microscopy is a powerful and promising high-throughput computational microscopy technique due to its unique advantage of creating high-resolution images across the full field-of-view (FOV) of the imaging sensor. Nevertheless, most current lens-free microscopy methods have been designed for imaging only two-dimensional thin samples. Lens-free on-chip tomography (LFOCT) with a uniform resolution across the entire FOV and at a subpixel level remains a critical challenge. In this paper, we demonstrated a new LFOCT technique and associated imaging platform based on wavelength scanning Fourier ptychographic diffraction tomography (wsFPDT). Instead of using angularly-variable illuminations, in wsFPDT, the sample is illuminated by on-axis wavelength-variable illuminations, ranging from 430 to 1200 nm. The corresponding under-sampled diffraction patterns are recorded, and then an iterative ptychographic reconstruction procedure is applied to fill the spectrum of the three-dimensional (3D) scattering potential to recover the sample’s 3D refractive index (RI) distribution. The wavelength-scanning scheme not only eliminates the need for mechanical motion during image acquisition and precise registration of the raw images but secures a quasi-uniform, pixel-super-resolved imaging resolution across the entire imaging FOV. With wsFPDT, we demonstrate the high-throughput, billion-voxel 3D tomographic imaging results with a half-pitch lateral resolution of 775 nm and an axial resolution of 5.43 μm across a large FOV of 29.85 mm2 and an imaging depth of >200 μm. The effectiveness of the proposed method was demonstrated by imaging various types of samples, including micro-polystyrene beads, diatoms, and mouse mononuclear macrophage cells. The unique capability to reveal quantitative morphological properties, such as area, volume, and sphericity index of single cell over large cell populations makes wsFPDT a powerful quantitative and label-free tool for high-throughput biological applications.

Impact of Prehabilitation With Preoperative Swallowing Exercises on Postoperative Swallowing Morbidity in Oral Cavity Cancer: Randomized Controlled Trial.

Oral cancer surgery and the associated reconstructive procedures cause mechanical and neurological impairment of swallowing. Despite postoperative rehabilitation, functional impairment of swallowing remains a concern. This study is to investigate the potential benefits of prehabilitation with preoperative swallowing exercises to patients undergoing composite resections and compartmental tongue resections so that it results in better swallowing outcomes and improved quality of life after surgery. Sixty patients included in the study were randomized into an exercise and control group of 30 each. Patients with squamous cell carcinoma of the oral cavity undergoing composite resection or compartmental tongue resections were included, and patients with severe trismus at presentation were excluded. Patients in the exercise group were instructed on a set of six active exercises to be followed strictly for a period of at least 1week before surgery. Preoperative swallowing exercises comprised of evidence-based exercises targeting the muscle groups involved in swallowing. Postoperative swallowing rehabilitation was the same as that of the control group. Patients were assessed after 6months of surgery. Outcomes were assessed both subjectively and objectively. Objective assessment was done by inexpensive, novel clinical methods of repetitive saliva swallow test (RSST), water swallow test (WST) and food swallow test (FST) to and graded using dysphagia severity scale (1-7). Average oral intake scale (1-Oral solids, 2-Oral semisolids/easy to chew foods, 3-Oral liquids only and 4-Non-oral, orogastric tube dependent) assessed subjectively was significantly lower in exercise arm, and the control arm had a significantly higher OIS score. Exercise arm had higher number of patients in DSS scores of 5, 6 and 7. The control arm had a higher number of patients in DSS scores of 3 and 4. The differences between the two groups were found to be statistically significant taking into consideration the confounding factors of radiation, wound morbidity and tongue resections. Preoperative swallowing exercises have shown a positive impact on postoperative swallowing ability. This is the first randomized trial to assess the effect of PSE in postoperative oral cancer patients. Our exercise protocol needs standardization, and clinical objective method of dysphagia assessment requires further validation. However, prehabilitation with PSE has the potential to improve the quality of life in oral cancer patients.

Optimising 4D imaging of fast-oscillating structures using X-ray microtomography with retrospective gating

Imaging the internal architecture of fast-vibrating structures at micrometer scale and kilohertz frequencies poses great challenges for numerous applications, including the study of biological oscillators, mechanical testing of materials, and process engineering. Over the past decade, X-ray microtomography with retrospective gating has shown very promising advances in meeting these challenges. However, breakthroughs are still expected in acquisition and reconstruction procedures to keep improving the spatiotemporal resolution, and study the mechanics of fast-vibrating multiscale structures. Thereby, this works aims to improve this imaging technique by minimising streaking and motion blur artefacts through the optimisation of experimental parameters. For that purpose, we have coupled a numerical approach relying on tomography simulation with vibrating particles with known and ideal 3D geometry (micro-spheres or fibres) with experimental campaigns. These were carried out on soft composites, imaged in synchrotron X-ray beamlines while oscillating up to 400 Hz, thanks to a custom-developed vibromechanical device. This approach yields homogeneous angular sampling of projections and gives reliable predictions of image quality degradation due to motion blur. By overcoming several technical and scientific barriers limiting the feasibility and reproducibility of such investigations, we provide guidelines to enhance gated-CT 4D imaging for the analysis of heterogeneous, high-frequency oscillating materials.

Effect of umbilical cord mesenchymal stem cell-derived mitochondrial transplantation on ischemia-reperfusion injury in a rat model.

Despite advancements in reconstructive procedures, ischemia-reperfusion (I/R) injury remains a significant challenge in reconstructive surgery, with mitochondrial dysfunction playing a pivotal role. Mitochondrial transplantation has emerged as a promising therapeutic strategy to address this issue. This study aims to evaluate the impact of umbilical cord mesenchymal stem cell-derived mitochondrial transplantation on skin flap I/R models in rats. Twenty male rats underwent I/R injury on skin flaps, with or without mitochondrial transplantation administered via intravenous or subcutaneous routes. Analysis encompassed histopathology, inflammatory, apoptotic, oxidative stress, and hypoxia markers. Results revealed a reduction in inflammation, apoptosis, oxidative stress, and hypoxia in the transplantation group compared to controls. The findings suggest that umbilical cord mesenchymal stem cell-derived mitochondrial transplantation shows promise in enhancing flap viability and attenuating I/R injury, offering valuable insights for improved outcomes in reconstructive surgery. However, further exploration in larger animal models and refinement of delivery methods and dosage are warranted to fully elucidate its clinical translatability.

Foot Tumor: Comprehensive Collation and Evaluation

Background: Considerable evidence showed that foot tumors can cause severe harm to people across various age groups, though they have relatively low incidence rate. Currently, substantial research articles provide thorough discoveries among diagnosis, treatment, reconstruction, and other related areas. However, a comprehensive literature evaluation of current study findings is required. Methods: A search approach implementing the PICOS principle was utilized to acquire the literature from mainly three databases—PubMed, NCBI and SpringerLink. All the included studies underwent independent screening and evaluations of quality and risk of bias. The outcomes covered evaluation and comparison of various tumor kinds, diagnostic techniques, treatment modalities, and reconstructive procedures. Results: The location of the foot is characterized by the presence of three primary bone tumor types — osteosarcoma (OS), chondrosarcoma (CDS) and Ewing sarcoma (ES)— and four forms of soft tissue tumor—Synovial sarcoma (SS), epithelioid sarcoma (EPS), clear cell (CC) sarcoma and melanoma. Diagnosis involves the utilization of four approaches—CT, MRI, X-ray and biopsy, either singly or in combination. Out of all the options, biopsy is the most effective and accurate. Surgery and immunotherapy are widely used to treat foot tumor. The advancement of immunotherapy can significantly improve the efficiency and effectiveness of foot tumor treatment due to its specific targets and better established adjustment mechanism. Combining various types of immunotherapy with additional medicines such as chemotherapy and radiotherapy can help improve the progression of foot tumor treatment. For the reconstruction methods, Structural allograft Plastic surgery is widely used for bone tumor and soft tissue sarcoma respectively. Conclusion: The clinical significance of foot tumors is attributed to their infrequency, resulting high possibility of delayed detection and difficulties in proper treatment. The text that provides a comprehensive discussion and analysis of the diagnostic, therapeutic tactics, and repair approaches for the foot tumor can be highly beneficial to the development of foot tumor in the medical area. The methodical collation on characteristics, data of foot tumor categories is therefore equally significant. By obtaining and analyzing such information, researchers and physicians can better identify certain pattern in foot tumor. For the treatment, Immunotherapy stands out among the existing methods since it has the highest potential to selectively target certain types of foot tumors depending on their distinct needs. The evaluation of immunotherapy and reconstruction methods still contain some limitations due to the lack of the latest and adequate research.

Analysis of the Pathogen Distribution and Antimicrobial Resistance after Plastic Surgery of the Urogenital System.

We aimed to summarize the distribution of pathogenic bacteria for postoperative infection of different genitourinary plastic surgery and the antimicrobial resistance of the major pathogens. Between January 2011 and December 2021, following plastic surgery of the urogenital system, microbial strains from infected patients were collected, identified, and counted. The antibiotic sensitivity and distribution characteristics of common pathogens in relation with the surgical procedures were studied by WHONET 5.6, along with the main bacteria accounting for early infection. A total of 76 cases were included in the study. Among these, 53 Gram-negative bacteria were detected, with Escherichia coli (18 of 53) and Pseudomonas aeruginosa (nine of 53) accounting for the majority. There were also 23 Gram-positive bacteria, among which Staphylococcus aureus (six of 23) and Coagulase-negative Staphylococcus (five of 23) were the most common. In terms of antimicrobial resistance, E. coli was highly sensitive to amikacin, piperacillin/tazobactam, cefoxitin, and imipenem, whereas P. aeruginosa was highly sensitive to gentamicin, amikacin, cefepime, piperacillin/tazobactam, imipenem, ceftazidime, and ciprofloxacin. Procedures for urethral repair, urethral reconstruction, and lump resection were most commonly associated with infection. Among these, urethral repair was responsible for the majority of infections. The pathogenic bacteria involved in postoperative infections varied overall, but the most prevalent was E. coli. Gram-negative bacteria are the major cause of infection following genitourinary plastic surgery. The specific bacterial strains, degrees of antimicrobial resistance, and length of infection varied among the various procedures. The results of this study may provide references for clinical medication and the prevention and control of such infections.

The use of peritoneum in female genital gender-affirming surgery: A systematic review

Genital gender-affirming surgery (GAS) plays a crucial role in alleviating psychological discomfort and assisting transgender patients in achieving their transition goals. One of the most common procedures for primary genital reconstruction in transwomen is penile inversion vaginoplasty. But it presents a risk of vaginal stenosis and limited depth, particularly in cases with inadequate penile and scrotal tissue. This limitation becomes more relevant as transgender individuals increasingly seek early hormone therapy and puberty blockade. We conducted a literature review focusing on studies published between 2000 and 2022 to explore the application of peritoneal vaginoplasty, a technique primarily used in cisgender women with congenital vaginal agenesis, to address these challenges in transwomen.Data were extracted from 13 selected articles reporting 313 patients who underwent peritoneal vaginoplasty.Peritoneal vaginoplasty was found to offer advantages in terms of neovaginal depth and width, with an average depth of 13.8 cm and width of 3.5 cm. Patient reporting satisfaction rates for sexual intercourse and dilatation achievement were high, with 96.2% and 94.4% respectively. The technique did not result in an increased rate of complications compared to traditional penile inversion vaginoplasty.This review suggests that peritoneal vaginoplasty could be consider first for transwomen genital GAS, especially in cases with limited penile tissue. The well-vascularized peritoneum provides tissue with regenerative capacities and reduces the risk of stenosis. Moreover, peritoneum remains unaffected by hormonal treatments and allows deep enough neovaginal canals. This method is safe and does not lead to increased complications compared to traditional techniques.

Evaluation of Tibiofemoral Contact Mechanics After a Novel Hybrid Procedure for Femoral Osteochondral Defect Repairs With a Subchondral Implant and Dermal Matrix.

There is a lack of procedures that adequately address the subchondral bone structure and function for reconstructing osteochondral defects in the femoral condyles. To biomechanically evaluate the tibiofemoral joint contact characteristics before and after reconstruction of femoral condylar osteochondral defects using a novel hybrid reconstructive procedure, which was hypothesized to restore the contact characteristics to the intact condition. Controlled laboratory study. Tibiofemoral contact areas, contact forces, and mean contact pressures were measured in 8 cadaveric knees (mean age 52 ± 11 years; 6 women, 2 men) using a custom testing system and pressure mapping sensors. Five conditions were tested for each condyle: intact, 8-mm defect, 8-mm repair, 10-mm defect, and 10-mm repair. Medial femoral condylar defects were evaluated at 30° of knee flexion and lateral condylar defects were evaluated at 60° of knee flexion, with compressive loads of 50, 100, and 150 N. The defects were reconstructed with a titanium fenestrated threaded implant countersunk in the subchondral bone and an acellular dermal matrix allograft. Repeated-measures analysis of variance with Bonferroni correction for multiple comparisons was used to compare the results between the 5 testing conditions at each load. Medial condylar defects significantly increased mean contact pressure on the lateral side (P < .042), which was restored to the intact levels with repair. The lateral condylar defect decreased the mean contact pressure laterally while increasing the mean pressure medially. The lateral and medial mean contact pressures were restored to intact levels with the 8-mm lateral condylar defect repair. The medial mean contact pressure was restored to intact levels with the 10-mm lateral condylar defect repair. The lateral mean contact pressure decreased compared with the intact state with the lateral condylar 10-mm defect repair. Tibiofemoral joint contact pressure was restored to the intact condition after reconstruction of osteochondral defects with dermal allograft matrix and subchondral implants for the repair of both 8- and 10-mm lateral condylar defects as well as 8-mm medial condylar defects but not completely for 10-mm medial condylar defects. The novel hybrid procedure for osteochondral defect repair restored tibiofemoral joint contact characteristics to normal in a cadaveric model.

520. TEMPORARY ESOPHAGEAL EXCLUSION IN THE MANAGEMENT OF DELAYED RECOGNITION OF THORACIC ESOPHAGEAL PERFORATION

Abstract Background Perforation of the esophagus is a rare surgical emergency and timing is crucial for prognosis. Late interventions are likely to result in terminal bipolar esophageal exclusion, requiring a subsequent reconstructive procedure to restore the esophageal transit, associated with high rate of morbidity and mortality. Methods From January 2013 to June 2023, 32 patients with esophageal perforations referred to our center required surgical treatment. We retrospectively analyzed two cases of late middle thoracic perforation treated with temporary esophageal exclusion. Results A 31-year-old male presented in May 2020 after 6 days from perforation due to bolus impaction in eosinophilic esophagitis and a 79-year-old male referred us in November 2022 8 days after Boerhaave syndrome. Direct closure wasn’t feasible due to tissue fibrosis and degeneration. In both cases we performed thoracoscopic toilette with drainage placement and bipolar temporary exclusion of the esophagus. A lateral esophagostomy was performed, and cardias was temporarily excluded. In the first case a PTFE prothesis was used as a loop around the EGJ and fixed on the abdominal esophagus, in the second case TA45 linear stapler loaded with 3.5 staples was used. For nutritional purposes a gastrostomy and a jejunostomy were placed. Post-operatively, pleural empyema was managed conservatively with a thoracic drain and antibiotic therapy, instead mediastinal collection sustained by the perforation was drained through the tangential esophagostomy with a NG tube placed endoscopically across the perforation. The patients were discharged in 27 and 20 POD respectively. The second patient was readmitted in 45 POD due right lobar pneumonia, treated with antibiotics. In the first case the PTFE prothesis was laparoscopically removed after 70 days and the tangential esophagostomy sutured. In the second case esophageal transit was spontaneously restored and esophagostomy was subsequentially sutured. Oral feeding was resumed in both patients, without resulting stenosis or leakage. Conclusion In selected patients with late thoracic esophageal perforations, temporary esophageal exclusion represented an alternative treatment, without mortality and with low morbidity, to terminal esophageal exclusion and a subsequent reconstructive procedure.