Search Results (856)

Background: Diabetic foot osteomyelitis (DFO) poses significant challenges due to its high morbidity and recurring nature. Current treatments involve prolonged antibiotics and often surgical intervention; however, the optimal route of antibiotic administration is unknown. This study evaluated the effect of route of antibiotic administration on treatment failure among patients with diabetic foot osteomyelitis. Methods: The authors conducted a retrospective cohort study among patients with unresected diabetic foot osteomyelitis. A propensity score was used to match the treatment exposure groups. The primary outcome was treatment failure, defined as either (1) treatment with additional antibiotic course or (2) additional surgical debridement/amputation at the original site of infection within 1 year of initial treatment. Secondary outcomes included the impacts of hemoglobin A1c, peripheral arterial disease, obesity, and infection severity on treatment failure. Results: Among 152 patients meeting criteria, 49 matched pairs were analyzed. Treatment failure rates did not significantly differ between oral and intravenous groups (OR 0.98, 95% CI 0.30–3.19, p > 0.9). A time-to-event analysis similarly found no significant outcome disparities between groups (p = 0.3). Conclusions: The study results support the previously published literature that demonstrates comparable treatment outcomes between routes of antibiotic administration when treating diabetic foot osteomyelitis. Full article

Background and Objectives: Postoperative hematomas are relatively uncommon complications following total hip replacement (THR) which could result in persistent pain, surgical site infections, neurological deficits, and may require reoperation. The aim of this study is to evaluate the impact of electro-neuro-feedback (ENF), a portable Transcutaneous Electric Nerve Stimulation, in the management of hematomas following THR, focusing on postoperative pain, clinical outcome, and recovery time in a cohort of relatively young and active patients. Materials and Methods: Five 10-minute cycles of ENF Physio of risk class IIa, certificated 0476 were applied. Outcomes included hematoma volume (measured with triaxial ultrasound), thigh circumference, Visual Analog Scale (VAS), Global Perceived Effect (GPE) scale, and HOOS-Physical Function Short (HOOS-PS) form. Results: Twenty participants were enrolled. The reduction in hematoma volume was statistically significant (p-value < 0.001) after five ENF sessions from a pre-treatment mean value of 337.2 mL (SD: 160.5) to 115.9 mL (SD: 78.1) at follow-up. Each patient had a reduction in the hematoma volume superior to 20%. No difference in thigh circumference before and after treatment was reported (p-value = 0.694). Pain according to VAS significantly decreased at follow-up (p < 0.05). Conclusions: The application of ENF was associated with reduced hematoma volume and post-operative pain. These findings can pave the way for future research to evaluate the risks of hematoma following THR. Full article

Background/Objectives: Ankylosing Spinal Disorders (ASDs) encompass a heterogeneous group of rheumatic diseases characterized by progressive ankylosis of the axial skeleton, including Ankylosing Spondylitis (AS), Diffuse Idiopathic Skeletal Hyperostosis (DISH), and Non-Radiographic Axial Spondyloarthritis (nr-AxSpA). Spinal ankylosis profoundly alters the biomechanical properties of the vertebral column, transforming it into a rigid long-bone equivalent and dramatically increasing fracture risk even after low-energy trauma. Once a fracture occurs, the long lever arm created by the ankylosed segments generates enormous mechanical stress at the fracture site, making surgical stabilization mandatory in the vast majority of cases. Long posterior instrumentation is the treatment of choice; however, no consensus exists regarding the optimal number of instrumented levels. The aim of this study is to clinically and radiologically evaluate long posterior instrumentation in the 3 + 3 (3 proximal and 3 caudal screws), 3 + 2 (3 proximal and 2 caudal screws), or 2 + 2 (2 proximal and 2 caudal screws) configuration for the treatment of traumatic ASD thoracolumbar vertebral fractures, in terms of implant failure, infection rate, and mortality. Methods: Between 2018 and 2023, 65 consecutive patients with ASD-related thoracolumbar vertebral fractures were treated at our institution. After applying pre-defined inclusion and exclusion criteria, 37 patients were enrolled. Patients were retrospectively divided into three groups according to the posterior arthrodesis configuration (notation indicates number of instrumented vertebral levels proximal + distal to the fracture: 3 + 3, 3 + 2, or 2 + 2). Radiological outcomes were assessed for loosening, screw cut-out, and implant breakage. Infection and mortality rates within 3 months from surgery were evaluated as secondary endpoints. Statistical analysis was performed using the Fisher exact test (significance set at p < 0.05). Results: Thirty-seven patients (28 males and 9 females; mean age 77 ± 7.3 years) were included, with a mean follow-up of 30 ± 5.3 months. Instrumentation configurations were as follows: 23 (3 + 3), 5 (3 + 2), and 9 (2 + 2). Three implant failures (8.1%) and four infections (10.8%) were recorded. Eleven patients died within 3 months of surgery. A statistically significant difference was found between instrumentation length and mechanical complications (p = 0.0468), while no significant difference was observed for infection (p = 1) or mortality rate (p = 0.137). Conclusions: In this exploratory retrospective cohort, the 3 + 3 configuration was associated with the lowest observed rate of implant failure in ASD thoracolumbar fractures, suggesting a potential mechanical advantage over shorter constructs that warrants confirmation in larger prospective studies. No significant correlation was found between instrumentation length and infection rate or early mortality. Prospective, multicentre studies with larger cohorts are warranted to establish definitive guidelines for instrumentation length in this challenging patient population. Full article

Objectives: Surgical site infections (SSIs) represent a significant postoperative challenge. Although timely perioperative prophylaxis with cephalosporins is essential to prevention, adherence to the recommended 30–60 min administration window may be challenging with traditional intravenous infusion (IVI) in settings with high surgical turnover, as is the case in China. Intravenous push (IVP) has been proposed as a more time-efficient alternative. This scoping review aims to map the available evidence comparing IVP with IVI for perioperative cephalosporin administration across four domains: safety, pharmacokinetics/pharmacodynamics (PK/PD), efficacy, and economic impact. Methods: A systematic search was conducted across PubMed, Embase, Web of Science, the Cochrane Library, and gray literature up to February 2026. Data were systematically charted and extracted using a standardized form. Results: Of the 14 included sources, only 3 were peer-reviewed comparative studies; the remaining 11 (78.6%) were gray literature documents. Among the gray literature, 72.7% (8/11) permitted or recommended IVP for cephalosporin prophylaxis; however, this proportion reflected practice patterns of heterogeneous methodological rigor. The 3 peer-reviewed studies focused on the safety, PK/PD, and economic outcomes. Two studies—in orthopedic and bariatric surgery, respectively—found no significant difference in adverse event rates between IVP and IVI, though both were limited by small samples. A single small study suggested similar PK/PD target attainment between IVI and IVP cefazolin. No study directly compared SSI rates between the two routes. One study suggested potential cost savings with IVP, but the evidence was dated and based on limited patient numbers. Conclusions: The available evidence for IVP is predominantly derived from gray literature, while peer-reviewed articles suggest that safety and PK/PD profiles do not differ markedly from IVI in the limited populations, surgical procedures, and agents studied; economic data are suggestive but dated. Direct comparative data on clinical efficacy outcomes, such as SSI rates, are absent. Well-powered, multi-center comparative studies comparing IVP and IVI with SSI as a primary endpoint are needed. Full article

Background/Objectives: To evaluate the clinical and demographic characteristics of patients with impaired union of long bone fractures admitted to a specialized orthopedic center and to identify factors associated with infection on admission. Methods: A retrospective, single-center cohort study was conducted at the National Scientific Center of Traumatology and Orthopedics named after Academician N.D. Batpenov. The study included patients hospitalized between 2023 and 2025 with diagnoses of fracture nonunion or delayed union. Demographic characteristics, lesion location, interval from injury to hospitalization, previous treatment, presence of revision osteosynthesis, infection on admission, and length of hospitalization were analyzed. Univariate analysis and multivariate logistic regression were used to identify factors associated with infection. Patients with osteomyelitis were excluded from the regression model to avoid definitional collinearity. Results: During the study period, 360 hospitalizations were recorded in 336 unique patients. The annual incidence increased from 79 in 2023 to 166 in 2025. The median patient age was 50 years, with women accounting for 52.5% of the sample. The most common bone sites were the femur (36.1%), humerus (23.6%), and tibia (15.0%). The median interval from injury to hospitalization at a specialized center was 2 years. Prior revision osteosynthesis was noted in 34.2% of patients. Infection on admission was detected in 20.3% of patients and was associated with a longer hospital stay. In an exploratory multivariable model (EPV ≈ 2.8), previous revision osteosynthesis was associated with infection on admission (OR 8.26; 95% CI 2.76–24.74; p < 0.001). Conclusions: Patients with nonunion and delayed union of long-bone fractures referred to a specialized center represent a clinically complex population characterized by prolonged time from injury, previous surgical interventions, and a substantial burden of infection. In an exploratory multivariable analysis, previous revision osteosynthesis was associated with infection on admission and may represent a marker of clinical complexity and prior treatment burden rather than a causal determinant of infection. Further prospective studies are required to clarify factors associated with infection and treatment outcomes in this patient population. Full article

Background: Hemorrhagic wounds pose significant clinical challenges, with approximately 20% associated with surgical site infections and an increased mortality risk. Despite growing interest in natural product-based medicines, the molecular targets and bioactive phytochemicals of Musa acuminata peel relevant to hemorrhagic wound healing are insufficiently established. Methods: This study employed an integrative in silico approach to identify bioactive phytochemicals from the ethyl acetate extract of Musa acuminata peel as potential wound healing agents. Liquid chromatography-high resolution mass spectrometry (LC-HRMS) profiling was performed for phytochemical characterization, followed by drug-likeness and toxicity screening via OSIRIS DataWarrior. Network pharmacology, molecular docking, molecular dynamics (MD), binding free energy calculation, pharmacokinetic properties prediction, and density functional theory (DFT) analysis were subsequently conducted. Results: LC–HRMS profiling identified 211 compounds across 21 chemical classes, of which 18 met drug-likeness criteria. Network pharmacology revealed five key protein targets. Molecular docking demonstrated that Compound 16 (−9.34 kcal/mol) and Compound 17 (−9.26 kcal/mol) exhibited stronger binding affinity toward VEGFR2 than Axitinib (−9.15 kcal/mol), with key interactions at glutamic acid-917 (GLU917) and cysteine-919 (CYS919). MD simulations over 100 ns confirmed complex stability, with BP16 showing superior binding stability and favorable MM/PBSA free energy. Pharmacokinetics and DFT analysis further supported BP16 as the most promising lead compound, exhibiting favorable pharmacokinetic properties, low predicted toxicity, and enhanced electronic stability. Conclusions: BP16 and BP17 are identified as potential VEGFR2-targeting candidates, providing a rational mechanistic foundation for future experimental validation as natural hemorrhagic wound healing therapeutics. Full article

Surgical intervention in Crohn’s disease remains a significant contributor to patient morbidity, with postoperative complication rates reported between 20% and 50%. These complications include a broad spectrum of adverse outcomes, such as surgical site infections, intra-abdominal abscesses, and anastomotic leakage, all of which can substantially impact recovery, healthcare costs, and long-term prognosis. Although several clinical and perioperative risk factors have been identified, accurate prediction of postoperative outcomes remains challenging, highlighting the need for improved risk stratification strategies. In recent years, the evolution of biological therapies has transformed the management of Crohn’s disease, raising important questions regarding their influence on surgical outcomes and postoperative healing. Consequently, a more nuanced understanding of the interplay between medical and surgical approaches is required to optimize patient care. This systematic review aims to evaluate established and emerging predictive biomarkers associated with postoperative complications in Crohn’s disease surgery. Particular emphasis is placed on inflammatory markers, nutritional parameters, and novel molecular signatures. Furthermore, the review explores the growing role of multiomics approaches—including genomics, proteomics, and metabolomics—as well as the integration of machine learning models to enhance predictive accuracy. By synthesizing current evidence, this study underscores the potential of combining biomarkers with advanced analytical tools to support personalized risk assessment and guide clinical decision-making in Crohn’s disease surgery. Full article

Background: Ventral hernias are a common complication following abdominal surgery, occurring in up to 20% of patients after midline laparotomy and as many as 43% of those who undergo orthotopic liver transplantation (OLT). These hernias pose unique challenges due to chronic immunosuppression, impaired wound healing, and the anatomic disruption caused by subcostal and “Mercedes-Benz” incisions. As survival after OLT continues to improve, the need for durable, infection-resistant abdominal wall reconstruction has become increasingly important. Methods: We performed a single-institution retrospective review of all OLT patients undergoing abdominal wall reconstruction by the senior author between June 2014 and April 2026. Our approach emphasizes component separation to reestablish myofascial continuity, biologic onlay reinforcement with human acellular dermal matrix (HADM), and multipoint fixation in a progressive tension pattern. Results: Forty patients (43 encounters) were included. Mean age was 55.7 ± 10.2 years, mean BMI was 31.2 ± 4.9 kg/m², and 60.0% were obese. The majority presented with recurrent hernias (67.4%), and 41.9% had prior mesh in situ. Component separation was performed in all cases, and intraoperative Botox in 18.6%. HADM was used in 83.7% of encounters. At a mean follow-up of 34.0 months, there was 1 hernia recurrence (2.3%). The surgical site occurrence rate was 14.0%, with seroma as the most common complication (9.3%). There were no 30-day mortalities. Conclusions: By integrating biologic and mechanical principles, this reconstructive strategy provides a durable solution for abdominal wall repair in liver transplant recipients. A 2.3% recurrence rate and 14.0% surgical site occurrence rate compare favorably to published benchmarks in the transplant population. Full article

This study conducts a comparative analysis of surgical outcomes in patients who underwent FSF repair by a plastic surgeon versus an ENT using a national database. A retrospective analysis was conducted on patients who underwent surgical treatment of FSFs by a plastic or ENT surgeon using the de-identified American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patients were identified based on surgical CPT codes. Data extracted included primary surgeon specialty and patient demographics, comorbidities, and surgical outcomes. Statistical analysis was performed using Fisher’s Exact test and the Wilcoxon Rank-Sum test, with a p-value < 0.05 representing statistical significance. A total of 111 patients were analyzed, of which 85.6% were male. The mean age was 30.0 years [22.0, 48.0]. There were 70 patients (63.1%) treated by an ENT and 41 (36.9%) by a plastic surgeon. The median operative time was 131.0 min for ENT and 115.0 min for plastic surgery (p = 0.19). The median length of postoperative stay was 1.0 day for both groups. Postoperative complications included surgical site infection (SSI), wound disruption, and sepsis in five patients (4.5%). There was no statistically significant difference in the rate of complications between patients who underwent surgery with an ENT surgeon versus a plastic surgeon (p = 0.16). There were no statistically significant differences in operative time, length of stay, or complications between patients who underwent FSF repair by an ENT or by a plastic surgeon. Surgeon specialty training does not appear to influence intraoperative or postoperative outcomes. Studies with larger sample sizes may demonstrate statistically significant differences in outcomes. Full article

Background/Objectives: There is no consensus on whether it is possible to preserve implant retention during deep surgical site infections (SSIs), and there is no widely accepted treatment protocol to date for these patients. The aim of this study is to evaluate the efficacy of the debridement, antibiotics, and implant retention (DAIR) protocol in patients who were treated for degenerative thoracolumbar spinal disorder using spinal instrumentation. Methods: This retrospective study describes the 24-month outcomes of deep SSI that developed in 25 of 720 patients (3.5%) who underwent surgery for thoracolumbar degenerative spinal disorders (disc disease, spinal stenosis, and scoliosis) and were treated according to the DAIR protocol. Results: Of these 25 patients, 18 developed early infection (<1 month), 3 developed delayed infection (1–3 months), and 4 developed late-onset deep infection (>3 months). Staphylococcus aureus was isolated in 56% of the patients. The DAIR protocol was successful in 22 (88%) of the patients, while it failed in 3 (12%). Surgical implants were removed in 25% of patients with late-onset SSI, and only 11.1% with early onset and 0% with delayed SSI. All patients who failed DAIR were smokers. A significant association was found between the Charlson Comorbidity Index and the number of surgical interventions (p = 0.022). Conclusions: In this small retrospective cohort, the DAIR protocol appeared to be a feasible treatment option for deep SSI, particularly in early infections. Implant removal may be considered when infection persists after repeat DAIR or when implant loosening is observed. Full article

Background and Objectives: Surgical site infections (SSIs) remain common after elective colorectal surgery. This systematic review and meta-analysis evaluated whether adding oral antibiotic bowel preparation (OAB) to mechanical bowel preparation (MBP) reduces SSIs compared with MBP alone. Materials and Methods: PubMed, the Cochrane Library, Scopus, and ClinicalTrials.gov were searched for English-language randomized controlled trials published from January 2005 to January 2025. Eligible trials enrolled adults undergoing elective colorectal surgery and compared MBP+OAB versus MBP alone, with standard intravenous prophylaxis in both groups. The primary outcome was overall SSI; secondary outcomes were incisional SSI and organ-space SSI. Risk of bias was assessed with RoB 2, certainty with GRADE, and odds ratios (ORs) were pooled using DerSimonian–Laird random-effects models. The protocol was prespecified but not prospectively registered. Results: Twelve trials including 4073 patients were included (MBP+OAB, n = 2069; MBP, n = 2004). MBP+OAB reduced overall SSI (OR 0.53, 95% CI 0.37–0.75; p < 0.001; I² = 62.5%; 95% prediction interval 0.17–1.66), incisional SSI (OR 0.52, 95% CI 0.34–0.80; p = 0.003; I² = 57.5%), and organ-space SSI (OR 0.63, 95% CI 0.45–0.88; p = 0.007; I² = 8.3%). The effect was preserved in metronidazole-containing regimens (OR 0.46, 95% CI 0.33–0.65), but this subgroup was exploratory. Excluding high-risk-of-bias studies supported the primary result. Publication-bias assessment was underpowered. Overall and organ-space SSI were moderate-certainty outcomes; incisional SSI was low-certainty, and anastomotic leak was very low-certainty. Conclusions: In contemporary elective colorectal surgery when MBP is used, adding preoperative OAB probably reduces SSIs. Findings do not establish whether OAB alone is sufficient or whether MBP is necessary; stewardship-relevant outcomes remain insufficiently reported. Funding was provided by ISCIII grant PI25/01285. Full article

Background/Objectives: Delayed bone healing remains a relevant complication after polytrauma, where fracture repair occurs in the setting of systemic inflammation and repeated physiologic stress. This study evaluated whether serial changes in interleukin-6 (IL-6), C-reactive protein (CRP), and fibrinogen are associated with delayed union in polytrauma patients with long-bone fractures. Methods: We performed an exploratory retrospective cohort study including 115 adult polytrauma patients with long-bone fractures treated at a single tertiary trauma center between 2 January 2022 and 14 December 2024. Serum IL-6, CRP, and fibrinogen were recorded at 24 h, 72 h, 1 week, 2 weeks, and 4 weeks after injury. IL-6 was measured in the institutional clinical laboratory using routine immunoassay methods, whereas CRP and fibrinogen were measured using standard hospital analytical methods, including an immunoturbidimetric assay for CRP and the Clauss clotting method for fibrinogen. Radiographic healing was assessed at 6, 12, and 24 weeks using an mRUST-based healing score. The primary endpoint was clinician-assigned delayed union at 24 weeks; nonunion at 9 months was assessed secondarily. Complete-case multivariable logistic regression was performed in 86 patients, and exploratory longitudinal biomarker analyses used generalized estimating equations. Results: Delayed union at 24 weeks occurred in 39/115 patients (33.9%), while nonunion at 9 months occurred in 7/115 patients (6.1%). Patients with delayed union had longer time to definitive fixation (35.3 ± 10.2 h vs. 29.0 ± 14.0 h; p = 0.003) and more frequent shock on admission (43.6% vs. 23.7%; p = 0.047). IL-6 was higher in the delayed-union group at 1 week (57.3 ± 30.3 vs. 46.5 ± 29.2 pg/mL; p = 0.043) and 4 weeks (21.2 ± 11.6 vs. 17.1 ± 10.3 pg/mL; p = 0.022), whereas CRP was markedly higher at 4 weeks (29.4 ± 14.2 vs. 16.3 ± 10.6 mg/L; p < 0.001). After false-discovery-rate correction, only CRP at 4 weeks remained significant among serial biomarker comparisons. In multivariable analysis of 86 complete cases, CRP at 4 weeks remained independently associated with delayed union (adjusted OR 2.16 per 10 mg/L, 95% CI 1.36–3.43; p = 0.001). The model showed apparent discrimination with an AUC of 0.80 and acceptable calibration (Hosmer–Lemeshow p = 0.41). In sensitivity analysis excluding deep surgical-site infection cases, the association between CRP and delayed union persisted (adjusted OR 2.02 per 10 mg/L, 95% CI 1.26–3.26; p = 0.004). Conclusions: In this exploratory retrospective cohort of polytrauma patients with long-bone fractures, persistent post-traumatic CRP elevation at 4 weeks was associated with clinician-assigned delayed union, whereas IL-6 findings were weaker and exploratory. Because CRP is a nonspecific inflammatory marker, the observed association may reflect delayed healing, infection, reoperation, and/or persistent postoperative inflammatory burden. These data support association rather than validated prediction and require prospective validation with standardized outcome adjudication. Full article

Enhanced Recovery After Surgery (ERAS^®) is a multimodal perioperative framework designed to mitigate the physiological stress response to major surgery. While ERAS protocols consistently reduce length of hospital stay, overall complication rates, and healthcare costs compared to conventional care, their specific impact on surgical site infections (SSIs) remains poorly defined. This review explores the potential synergistic benefits of integrating ERAS protocols with established infection prevention bundles. By evaluating the current clinical evidence, we analyze how the co-implementation of these two evidence-based strategies can collectively reduce the incidence of SSIs. Full article

Bronchopleural fistula is a rare but severe complication of lung resection, associated with significant morbidity and mortality, especially when an open-window thoracostomy is required. The clinical and surgical management is complex and becomes even more challenging in the presence of underlying conditions such as recurrent infections or malignancy. Postoperative management is equally demanding, as local compression may help prevent fistula recurrence but can compromise flap perfusion. A 65-year-old male with a history of right upper lobectomy and subsequent sublobar resection for lung adenocarcinoma presented with an 8 × 4 cm open-window thoracostomy complicated by chronic bronchopleural fistula and empyema. Extensive fibrosis of the surrounding tissues, including the ipsilateral latissimus dorsi muscle, limited the available reconstructive locoregional options. Reconstruction was performed using primary fistula closure reinforced with a contralateral free latissimus dorsi musculocutaneous flap and a fascia patch graft secured with cyanoacrylate-based bioadhesive. Postoperatively, continuous near-infrared spectroscopy monitoring enabled safe application of compressive bandage while minimizing the risk of flap perfusion compromise. Complete fistula closure was achieved. Apart from a surgical site abscess requiring debridement on postoperative day 7, no further complications occurred. At the 2-year follow-up, the patient remains free of fistula recurrence, wound dehiscence, or oncological relapse. We describe a novel approach for open-window thoracostomy closure combining a free musculocutaneous flap with a fascia patch graft reinforced by bioadhesive, together with postoperative perfusion monitoring using near-infrared spectroscopy. This strategy may help address both the reconstructive and postoperative challenges associated with complex bronchopleural fistulas. Full article

Background: Thromboangiitis obliterans (TAO) is a nonatherosclerotic inflammatory vascular disorder affecting small- and medium-sized vessels, often leading to critical limb ischemia and a high risk of amputation. Conventional medical and surgical treatments remain limited, particularly for advanced diseases. Tibial transverse bone transport (TTT), based on the principles of distraction osteogenesis, has emerged as a novel technique to promote angiogenesis and improve microcirculation. This systematic review evaluated the clinical efficacy and safety of TTT in the management of TAO. Methods: A systematic review was conducted according to the PRISMA guidelines. A comprehensive search of PubMed, Scopus, Web of Science, ScienceDirect, and Google Scholar was performed until December 2025. Eligible studies included clinical investigations that evaluated TTT in patients with TAO. Data on patient characteristics, surgical techniques, clinical outcomes, and complications were extracted and analyzed descriptively because of the heterogeneity in study design and reporting. Results: Ten studies involving 368 patients were included in this review. TTT was consistently associated with significant clinical improvement, including pain relief, increased claudication distance, and ulcer healing, which were typically observed within weeks after the procedure. Limb salvage rates were high, with major amputation rates generally ranging from 3.3% to 13.3%. Objective improvements in perfusion parameters have also been reported in several studies. The most common complication was pin-site infection (up to 30%), while fractures, delayed consolidation, and osteomyelitis were less frequent complications. Conclusions: Current evidence suggests that TTT is a promising limb-salvage strategy for TAO and is associated with favorable clinical and functional outcomes, with an acceptable complication profile. However, the available evidence remains limited, partly because of the rarity of TAO and the specialized nature of the TTT procedure. Most available studies are observational, and further high-quality prospective and randomized trials are required to validate the long-term efficacy of this technique. Full article