Vertebrobasilar artery dissecting aneurysms (VBDAs) are the most surgically challenging type of aneurysm. Cerebral revascularization is the ultimate treatment for complex VBDAs. We retrospectively analysed the characteristics, surgical outcomes and follow-up data of 21 patients who underwent cerebral revascularization to treat complex VBDAs from 2015 to 2022. According to the location of the aneurysm and the anatomic relationship between the VBDA and the PICA, VBDA patients were classified into four groups: aneurysms located at the VA with PICA involvement (10 patients), aneurysms located at the VA without PICA involvement (1 patient), aneurysms located at the basilar apex segment (1 patient) and aneurysms located at the basilar trunk segment (9 patients). A surgical algorithm for complex VBDAs was determined primarily by the location of the aneurysm, the status of the aneurysm and the ability of retrograde blood flow to reach the proximal vertebrobasilar artery. Surgical modalities for patients with aneurysms in the VA with PICA involvement included low-flow (OA-PICA) bypasses with aneurysm trapping, aneurysm excision or reconstructive clip in 8 patients and STA-PCA bypass combined with PICA preservation and aneurysm trapping in 2 patients. In patients with aneurysms in the VA without PICA involvement, aneurysm excision was performed without cerebral bypass. In patients with aneurysms in the basilar apex segment, high-flow bypass (ECA-RA-P2) with aneurysm trapping was performed. In patients with aneurysms in the basilar trunk segment, surgical modalities included high-flow bypasses (ECA-RA-P2 and LVA-RA-P2) with aneurysm trapping or proximal occlusion in 6 patients, ECA-RA-P2 bypass with partial proximal occlusion in 1 patient, ECA-RA-P2 bypass alone in 1 patient, and STA-PCA bypass with R-VA narrowing in 1 patient. Of the 21 patients, 20 experienced clinical improvement or no change, and 17 of 21 patients achieved favourable functional outcomes (mRS ≤ 2). However, one patient died of infarction and respiratory failure postoperatively. Aneurysms were completely obliterated in 13 patients, shrank in 5 patients and stabilized in 2 patients. The median follow-up period was 32.5 months. During the follow-up period, all bypasses were patent, and further clinical improvement was observed in 11 patients. Cerebral revascularization appears to be safe and effective for the treatment of complex VBDAs, and cerebral revascularization could act as a complementary treatment strategy.

BACKGROUND: Previous reports on the treatment of sacral and ischial pressure injuries have not provided clear algorithms for surgical therapies. The objective of this study was to establish a reconstruction algorithm to guide the selection of an ideal free-style perforator flap that can be tailored to the defect in question.
METHODS: We used 23 perforator flaps to reconstruct 14 sacral and 8 ischial defects in 22 patients over 5 years. A reconstruction algorithm system was developed based on the anatomical features of the perforator vessels (diameter, D; pulsatility [++∼+++], P) and their position in the skin island (DPD) (ie, D+P+DPD). A perforator-based propeller flap was applied as the first-line choice; if this plan was not feasible, we applied an altered V-Y advancement model or another second-choice technique.
RESULTS: All flaps survived, and only 1 patient experienced partial wound dehiscence, which healed by secondary intention. After an average follow-up period of 11.2 months, no patient experienced recurrence or infection.
CONCLUSIONS: Free-style perforator flap selection is determined by pressure injury and the desired advantage of a specific approach. The use of free-style perforator-based propeller flaps allows a surgeon to transfer healthy tissue into the defect, shifts the suture line away from the bony prominence, and preserves additional future donor sites. In cases where unexpected variations are encountered, the V-Y advancement model or another technique can be used. The simplified surgical algorithm (D+P+DPD) can provide versatility and reliability, achieve a durable, natural esthetic outcome, and minimize injuries to future donor sites.

UNASSIGNED: The removal of pineal region lesions are challenging, and therapeutic strategies for their removal remain controversial. The current study was conducted to identify the characteristics and the optimal therapeutic strategies for pineal region lesions.
UNASSIGNED: This retrospective study reviewed the treatments of 101 patients with pineal region lesions, and different characteristics and therapeutic strategies were observed.
UNASSIGNED: There were no statistical differences in the total resection ratio, complications, and prognosis outcomes between the hydrocephalus group and non-hydrocephalus group, except patients in the hydrocephalus group were younger and pediatric patients had an increased level of intracranial infections. Treatments of lesions and hydrocephalus secondary to pineal region lesions were two integral parts to therapeutic strategies. For the management of lesions, germinoma or non-germinoma were diagnosed preoperatively, and resection or diagnostic radiation were chosen to deal with pineal region lesions. Endoscopic-assisted surgery provided a higher total resection rate. For the management of hydrocephalus, endoscopic third ventriculostomy (ETV) had the better therapeutic effect. Additionally, cerebrospinal fluid (CSF) diversion before radiotherapy or resection did not improve prognosis outcome, but it was necessary for patients with severe hydrocephalus. Logistical regression analysis indicated that age, lesion size, reoperation ratio, and intracranial complications were predictors of prognosis outcome.
UNASSIGNED: More attention should be paid to intracranial infections in pediatric patients with hydrocephalus secondary to pineal region lesions, and CSF diversion before radiotherapy or resection did not promote prognosis outcome, but it was necessary for patients with severe hydrocephalus. Age, lesion size, reoperation ratio, and intracranial complications may be the predictors of prognosis outcome. Most importantly, the surgical algorithm for pineal region lesions which was based on preoperatively diagnosis (non-germinoma and germinoma) is useful, especially for developing countries.

To analyze the effectiveness of an algorithmic anterior approach to the surgical treatment of patients with two-level cervical degenerative disk disease based on the preoperative clinical and imaging parameters. The study included 244 patients with two-level cervical degenerative disk disease. Three groups of patients were evaluated at 3 neurosurgical centers between 2016-2019. The prospective group (Group I, n = 126) consisted of patients who were treated using an algorithm to decide whether they should be treated with a two-level Total Disk replacement (TDR), Anterior Cervical Discectomy and Fusion (ACDF) and hybrid technique. The control group (Group II, n = 118) consisted of patients who underwent two-level anterior decompression with TDR, ACDF and hybrid stabilization between 2005-2015. Visual Analogue Scale (VAS) neck pain, VAS upper limbs pain, Neck Disability Index (NDI), SF-36, Macnab and Nurick scales were collected. Perioperative complications were identified. At 2 years of follow up Group I had significantly better clinical outcomes based on VAS neck pain score (p = 0.02), VAS upper limbs pain (p = 0.04), NDI score (p = 0.02), SF-36 score (p = 0.01), satisfaction with surgery on the Macnab scale (p < 0.001) and outcome of surgery based on Nurick scale (p < 0.001). Complication rate was lower in Group I, 6.3% compared to 24.6% in Group II, p = 0.0001. The algorithmic anterior approach to the surgical treatment of patients with two-level cervical degenerative disk disease resulted in significant improvement of functional outcomes and a decrease in complications at a minimum 2 years of follow-up.

BACKGROUND: The choice of surgical method for the treatment of multilevel degenerative cervical spine disease is based on the assessment of neurological symptoms and anatomical source of compression. However, such decision-making process remains complex and poorly defined.
OBJECTIVE: To analyze the effectiveness of an algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine based on the preoperative clinical and imaging parameters.
METHODS: Prospective nonrandomized multicenter cohort study.
METHODS: The study included 338 patients with multilevel degenerative disease of the cervical spine. Two groups of patients were evaluated at 3 neurosurgical centers between 2015 and 2019. The prospective group (Group I, n = 214) consisted of patients who were treated using an algorithm to decide whether they should be treated with an instrumented arthrodesis or a nonfusion procedure. The control group (Group II, n = 124) consisted of patients who underwent posterior decompression with or without stabilization between 2007 and 2014. A total of 192 patients in Group I and 112 in Group II had more than 2 years of follow-up. Visual analog scale (VAS) neck pain, Neck Disability Index (NDI), MacNab and Nurick Scales were collected. Perioperative complications were identified.
RESULTS: At 2-year follow-up, Group I had significantly better clinical outcomes based on VAS neck pain score (P = 0.02), NDI score (P = 0.01), satisfaction with surgery on the MacNab Scale (P < 0.001), and outcome of surgery based on the Nurick Scale (P < 0.001). Complication rate was lower in Group I, 5.7% compared with 34.8% in Group II, P = 0.004.
CONCLUSIONS: The algorithmic posterior approach to the surgical treatment of patients with multilevel degenerative disease of the cervical spine resulted in significant improvement of functional outcomes and a decrease in complications at a minimum 2 years of follow-up.
METHODS:

BACKGROUND: Algorithms define a sequence to approaching a subject. This study represents a scoping review seeking to define the role of surgical algorithms in rhinoplasty.
METHODS: A scoping review was conducted. Pubmed/MEDLINE, Web of Science, and Google Scholar, as well as a citation searching was performed to find eligible studies for review. Eligibility criteria included studies published in English, human subjects ≥ 15 years old, and all included surgical algorithms were for primary cosmetic rhinoplasty.
RESULTS: In total, 514 studies included the key search terms. Thirty-nine studies were evaluated for data extraction. The majority of the algorithms were from USA-based publications (22/39). Flow-chart type algorithm was used in 23 and text-based algorithms in 15 of the 39 studies. Algorithms related to tip shape and/or position were most frequent (19/39), followed by those for crooked nose and dorsal height. Only 7 of the algorithms described outcomes for utilizing the algorithm.
CONCLUSIONS: Very few surgical algorithms have been published for cosmetic rhinoplasty. A minority of these studies have published outcomes. This study provides a description and summary of these algorithms and also shows that future studies could be done to further develop surgical algorithms for rhinoplasty and evaluate outcomes.
UNASSIGNED: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com.

Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on individual basis to all type of patients.
A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision.
No recurrence of the deformity was observed as well as major complications such as necrosis, and high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days.
Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed.
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The current coronavirus disease 2019 (COVID-19) pandemic has revolutionized global healthcare in an unprecedented way and with unimaginable repercussions. Resource reallocation, socioeconomic confinement and reorganization of production activities are current challenges being faced both at the national and international levels, in a frame of uncertainty and fear. Hospitals have been restructured to provide the best care to COVID-19 patients while adopting preventive strategies not to spread the infection among healthcare providers and patients affected by other diseases. As a consequence, the concept of urgency and indications for elective treatments have been profoundly reshaped. In addition, several providers have been recruited in COVID-19 departments despite their original occupation, resulting in a profound rearrangement of both inpatient and outpatient care. Orthopaedic daily practice has been significantly affected by the pandemic. Surgical indications have been reformulated, with elective cases being promptly postponed and urgent interventions requiring exceptional attention, especially in suspected or COVID-19+ patients. This has made a strong impact on inpatient management, with the need of a dedicated staff, patient isolation and restrictive visiting hour policies. On the other hand, outpatient visits have been limited to reduce contacts between patients and the hospital personnel, with considerable consequences on post-operative quality of care and the human side of medical practice.In this review, we aim to analyze the effect of the COVID-19 pandemic on the orthopaedic practice. Particular attention will be dedicated to opportune surgical indication, perioperative care and safe management of both inpatients and outpatients, also considering repercussions of the pandemic on resident education and ethical implications.

Replacement of failing and ailing natural teeth with dental implants has become a mainstream treatment option since the discovery of osseointegration by P.-I. Brånemark in the 1960s. The techniques and the variety of methods for alveolar bone reconstruction have evolved to address a restoratively driven approach in implant dentistry. Modern 3D cone-bean computed tomography has helped with the diagnosis and treatment of bone deficiencies to idealize implant positioning. This article focuses on bone augmentation techniques, classified into horizontal and vertical ridge augmentation, and discusses block grafting, guided bone regeneration particulate grafting, distraction osteogenesis, and ridge-split expansion procedures.

Robotic-assisted laparoscopic surgery is the most common approach for the treatment of early-stage endometrial and cervical cancers in the US. Surgical staging requires pelvic and often aortic lymphadenectomy, depending on the primary tumor characteristics. Pelvic and aortic lymphadenectomy procedures may also be indicated for debulking of larger metastases to improve disease control. The infra-renal basin is an important anatomic site of metastasis from pelvic tumors, and robotic dissection techniques for this site have been described. In recent years, sentinel lymph node (SLN) mapping has been adopted into the National Comprehensive Cancer Network guidelines\' surgical algorithm for uterine and cervical cancers. SLN mapping has higher sensitivity for the detection of nodal metastasis, despite removing fewer lymph nodes, and potentially reduces morbidities such as lower extremity lymphedema. This article reviews current robotic pelvic and para-aortic lymphadenectomy dissection techniques for endometrial and cervical cancers and discusses the recent integration of pelvic SLN mapping in the surgical algorithm.