Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 8 appraisals
JBJS reviews
Reconstruction of the Proximal Tibia and Extensor Mechanism After Tumor Resection: A Systematic Review and Meta-Analysis
BACKGROUND: Proximal tibia reconstruction after tumor resection is technically challenging due to the dual requirement of skeletal stability and extensor mechanism restoration. Multiple reconstruction methods exist, but comparative data on complications, survival, and functional outcomes remain limited. This study aimed to compare complication rates and implant survival across different proximal tibia reconstruction methods (megaprostheses, osteoarticular allografts [OAs], intercalary allografts [ICAs], and allograft-prosthetic composites [APCs]) and to evaluate how extensor mechanism reconstruction technique influences functional outcomes. METHODS: A systematic review and meta-analysis was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed and Embase databases were searched through September 2025. Studies reporting outcomes of proximal tibia and/or extensor mechanism reconstruction for oncologic indications were included. Complications were classified using the Henderson system. Random-effects meta-analysis was performed for complication rates, implant survival, and extension lag. Subgroup analyses were performed by reconstruction type. RESULTS: Seventy-eight studies including 2,825 patients were analyzed (mean age 25.9 years, mean follow-up 84.7 months). Prosthetic reconstruction demonstrated the lowest overall complication rate (39.2%, 95% confidence interval [CI] 32%-45%) compared with OAs (69.6%, 95% CI 55%-82%), APCs (52.7%, 95% CI 32%-73%), and ICAs (53.4%, 95% CI 34%-70%) (p = 0.004). Biological reconstructions had significantly higher structural failure rates (OA 31.0%, ICA 24.5% vs. prosthesis 5.5%, p < 0.001). Five-year implant survival showed no significant differences between prosthesis (75.3%), OA (67.4%), and APC (74.3%). At 10 years, survival rates converged across all methods (63%-71%). Extensor mechanism reconstruction technique significantly influenced extension lag: direct tendon-to-metal reattachment (11.0°) resulted in worse outcomes than synthetic augmentation (5.7°), allograft reattachment (4.6°), or autograft reconstruction (2.3°) (p < 0.001). CONCLUSION: While prosthetic reconstruction offers lower short-term complication rates, long-term implant survival is comparable across reconstruction methods. Extensor mechanism reconstruction technique is a critical determinant of functional outcome. Surgeons should consider techniques beyond simple direct reattachment, particularly synthetic augmentation or biological reconstruction, when feasible to optimize extension function. Individual patient factors should guide selection between prosthetic and biological reconstruction. LEVEL OF EVIDENCE: Level IV. See Instructions for Authors for a complete description of levels of evidence.
27 May 2026
Read appraisal →Journal of plastic surgery and hand surgery
Atlas of recipient vessels for the superficial venous system of DIEP-flaps - a systematic literature review and clinical practice review
BACKGROUND: Venous congestion contributes to up to 40% of failures in abdominally based free flaps, underscoring the importance of optimising superficial venous drainage in deep inferior epigastric perforator (DIEP) flap breast reconstruction. The superficial inferior epigastric vein (SIEV) is sometimes essential to flap outflow. This systematic review investigates the choice of recipient vessels for superficial venous supercharging. METHODS: A systematic review was performed according to a PROSPERO-registered protocol (CRD42022353591) and PRISMA guidelines. PubMed, CINAHL, Embase, and the Cochrane Library were searched for studies describing SIEV recipient vessels or vessel-selection algorithms. Extracted data included study design, recipient vessel, graft use, and decision strategies. A clinical practice review was also conducted at Sahlgrenska University Hospital, where prophylactic SIEV-cephalic vein (CV) anastomosis has been used for over two decades. RESULTS: Twenty-nine studies were included. Reported recipient vessels outside the flap comprised, for example, the following veins: internal mammary, cephalic, thoracoacromial, and thoracodorsal. Intra-flap options included anastomoses to branches or the caudal end of the deep inferior epigastric vein. Three studies described interposition grafts, and eight proposed selection algorithms, with no consensus. The internal mammary vein was most frequently used. At Sahlgrenska, a short axillary-fold incision provides consistent and cosmetically favourable access to the CV, adding minimal operative time. CONCLUSION: Recipient vessel selection for SIEV anastomosis remains highly variable in the literature. Long-term institutional experience supports the CV as a reliable and versatile option. Prospective studies are needed to evaluate outcomes.
14 May 2026
Read appraisal →PloS one
A remote monitoring system based on deep learning for real-time assessment of free flaps
PURPOSE: Venous congestion is a major cause of postoperative free flap compromise, and early detection is crucial for improving flap salvage rates and patient outcomes. This study aimed to develop and validate a deep learning (DL)-integrated remote monitoring system with a smartphone application for real-time, quantitative assessment of free flaps, with a specific focus on the early detection of venous congestion. METHODS: This diagnostic study was conducted at our institution. Patients aged 18-60 years who underwent free flap reconstruction between January 2019 and June 2025 were included. The study was divided into three phases: a 5-month model training phase for DL model development and internal validation, a 5-month external validation and clinical application phase, and a 4-month clinical comparison phase. The DL model was developed using TensorFlow Lite and a Flap Segmentation Network (FS-Net). Performance was evaluated through accuracy, sensitivity, specificity, area under the receiver operating characteristic curve (AUC), and clinical outcomes including time to detection and flap survival. RESULTS: A total of 1649 photographs from 615 patients were analyzed in the development and validation of the DL classification model between January 2019 and February 2025. During model development, the model achieved an accuracy of 86.8%, sensitivity of 92.4%, specificity of 79.7%, and AUC of 0.88. Internal validation improved these metrics to 87.6%, 95.0%, 81.1%, and 0.92, respectively. External validation demonstrated the model's generalizability, with an accuracy of 89.3%, sensitivity of 96.2%, specificity of 84.9%, and AUC of 0.93. The clinical application phase showed that the system had an overall accuracy of 92.16%, sensitivity of 95.18%, false-positive rate of 2.62%, and false-negative rate of 4.82%. A total of 113 patients were included in clinical comparison between March 2025 and June 2025. The remote monitoring group exhibited a trend towards a shorter mean time to congestion detection, higher flap survival rate, and shorter mean time to re-exploration, although these differences were not statistically significant. CONCLUSIONS: The DL-integrated remote monitoring system demonstrated high accuracy and reliability in detecting venous congestion. It provided an objective and real-time tool that may help reduce clinical burden and support timely intervention in free flap management. However, its impact on definitive clinical outcomes required further validation in larger studies.
13 May 2026
Read appraisal →Oral and maxillofacial surgery
Preservation rhinoplasty versus conventional structural reduction: a systematic review of aesthetic, functional, and patient-reported outcomes
BACKGROUND: Dorsal preservation rhinoplasty aims to maintain the native dorsal roof while achieving aesthetic and functional goals comparable to structural dorsal hump reduction. This systematic review evaluates comparative outcomes, patient-reported measures, and complication patterns across techniques. METHODS: A systematic search of PubMed, Embase, Scopus, Web of Science, and Cochrane CENTRAL was performed from inception to November 1, 2025. Eligible studies included randomized trials, comparative cohorts, and case series with ≥ 10 patients and ≥ 6 months of follow-up. Two reviewers independently screened studies, extracted data, and assessed risk of bias using RoB 2 and ROBINS-I. Outcomes included validated PROs, objective airway metrics, aesthetic assessments, and complications. RESULTS: From 487 records identified, 20 studies met inclusion criteria. Across randomized and nonrandomized comparative studies, dorsal preservation demonstrated aesthetic and functional results equivalent to structural dorsal hump reduction at 6-12 months. Patient-reported improvement (ROE, NOSE, SCHNOS) was consistently favorable in both groups. The only comparative objective airway study showed no significant differences in cross-sectional area or nasal volume. Complication and revision rates were low overall, with pooled recurrence and revision typically between 2-4%. CONCLUSION: Current evidence indicates that dorsal preservation rhinoplasty provides outcomes comparable to structural reduction in appropriately selected patients. Standardized reporting and more objective physiologic evaluations are needed.
10 May 2026
Read appraisal →The Cochrane database of systematic reviews
Surgery for women with anterior compartment prolapse
BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse. Clinicians have utilised various surgical techniques to minimise the rate of recurrent pelvic organ prolapse (POP). OBJECTIVES: To determine the benefits and harms of surgery for anterior compartment prolapse. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register on 29 April 2024. This includes records indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, ClinicalTrials.gov and WHO ICTRP. We also handsearched journals, conference proceedings and the reference lists of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that compared surgical operations in women with anterior compartment prolapse. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, assessed their risk of bias and extracted their data. MAIN RESULTS: We included 41 RCTs evaluating 4531 women. The certainty of evidence ranged from very low to moderate due to risk of bias and imprecision. Anterior native tissue repair versus biological graft at 1 to 2 years There is likely little to no difference between these two methods in terms of awareness of prolapse (RR 1.20, 95% CI 0.80 to 1.81; 5 RCTs, 515 women; moderate certainty). Native tissue repair likely increases the risk of recurrent anterior compartment prolapse (RR 1.53, 95% CI 1.19 to 1.97; 8 RCTs, 707 women; moderate certainty); the result suggests that if 21% of women had recurrent prolapse after biological graft, 24% to 40% would have recurrence after native tissue repair. There may be little to no difference between native tissue repair and biological graft repair groups for repeat surgery for prolapse (RR 0.99, 95% CI 0.45 to 2.17; 6 RCTs, 524 women; low certainty). Surgery for stress urinary incontinence was not reported. There is likely little to no difference between groups in dyspareunia (RR 0.87, 95% CI 0.39 to 1.93; 2 RCTs, 151 women; moderate certainty). De novo dyspareunia was not reported. Anterior native tissue repair versus transvaginal anterior permanent mesh at 1 to 2 years Native anterior tissue repair likely results in more awareness of prolapse than anterior mesh repair (RR 1.77, 95% CI 1.37 to 2.27; 10 RCTs, 1203 women; moderate certainty); the result suggests that if 13% of women were aware of prolapse after mesh repair, 17% to 29% would be aware after native tissue repair. Native tissue repair may result in slightly increased recurrent anterior compartment prolapse (RR 3.21, 95% CI 2.27 to 4.55; 20 RCTs, 2483 women; low certainty). There was moderate heterogeneity (I2 = 73%). The result suggests that if 13% of women had recurrent prolapse after mesh repair, 29% to 58% would have recurrence after native tissue repair. Repeat surgery for prolapse is probably more likely after native tissue repair (RR 2.17, 95% CI 1.31 to 3.58; 14 RCTs, 1799 women; moderate certainty); the result suggests that if 2% of women required repeat surgery after mesh repair, 3% to 8% would do so after native tissue repair. There is likely little or no difference between groups in surgery for stress urinary incontinence (RR 1.32, 95% CI 0.73 to 2.40; 6 RCTs, 967 women; moderate certainty). There is likely little or no difference between groups for dyspareunia (RR 1.06, 0.59 to 1.90; 8 RCTs, 1096 women; moderate certainty). There is likely little or no difference between groups for de novo dyspareunia (RR 0.64, 95% CI 0.36 to 1.12; 11 RCTs, 797 women; moderate certainty); the result suggests that if 7% of women reported dyspareunia after mesh repair, 2% to 8% would do so after native tissue repair. Permanent anterior vaginal mesh versus abdominal sacrocolpopexy at 1 year There may be little to no difference between permanent anterior vaginal mesh and abdominal sacrocolpopexy groups in awareness of prolapse (RR 0.93, 95% CI 0.45 to 1.94; 3 RCTs, 441 women; low certainty). There was some heterogeneity (I2 = 37%). There is likely little or no difference between groups in recurrent anterior compartment prolapse (RR 0.95, 95% CI 0.46 to 1.97; 4 RCTs, 306 women; moderate certainty). There was some heterogeneity (I2 = 69%). The result suggests that if recurrent prolapse occurred in 26% of women after sacrocolpopexy, 12% to 51% would have recurrence after transvaginal mesh repair. There may be little or no difference between groups in repeat surgery for prolapse (RR 1.68, 95% CI 0.56 to 5.04; 3 RCTs, 455 women; low certainty). There may be little or no difference between groups in repeat surgery for mesh complications (RR 2.61, 95% CI 0.62 to 10.99; 2 RCTs, 373 women; low certainty); the result suggests that if 1% of women needed repeat surgery for mesh exposure after sacrocolpopexy, 0.5% to 12% would do so after transvaginal mesh repair. There may be little or no difference between groups in surgery for stress urinary incontinence (RR 0.78, 95% CI 0.20 to 3.12; 2 RCTs, 299 women; low certainty). There was some heterogeneity (I2 = 60%). Dyspareunia was not reported. De novo dyspareunia is probably more likely to be reported with permanent anterior vaginal mesh than after abdominal sacrocolpopexy (RR 2.15, 95% CI 1.17 to 3.98; 2 RCTs, 248 women; moderate certainty); the result suggests that if 10% of women reported dyspareunia after abdominal sacrocolpopexy, 12% to 40% would do so with permanent anterior vaginal mesh. AUTHORS' CONCLUSIONS: Recurrence is probably more likely after native tissue repair than with biological graft or absorbable synthetic mesh at one to two years. We found no data for surgery for stress urinary incontinence. Anterior native tissue repair likely increases awareness of prolapse, recurrence and surgery for prolapse compared with transvaginal anterior permanent mesh repair. It is likely that fewer women report dyspareunia after abdominal sacrocolpopexy than with permanent mesh repair. For other outcomes, there was little or no difference between the groups being compared. Many of the transvaginal permanent meshes evaluated have been removed from the market because of reported complications. Five studies tested mesh kits that are currently available. We suggest that clinicians and women use caution when utilising these products as their long-term safety and efficacy have not yet been established.
28 Apr 2026
Read appraisal →Annals of plastic surgery
Evaluating GPT-4 Performance on Plastic Surgery Oral Examination Vignettes: A Quantitative and Qualitative Analysis
BACKGROUND: The use of artificial intelligence (AI) in medicine is rapidly evolving. However, its role in plastic and reconstructive surgery remains underexplored. Plastic surgery requires nuanced, dynamic decision making, and individualized care, making AI integration challenging. This study evaluates GPT-4's ability to respond to American Board of Plastic Surgery (ABPS) Oral Board-style clinical vignettes and assesses its potential as a decision making and educational adjunct. METHODS: Twelve clinical vignettes spanning aesthetic, reconstructive, hand, craniofacial, pediatric, and trauma surgery were input into GPT-4. Each response was scored by 2 board-certified plastic surgeons across 6 clinical domains: Case Introduction, Diagnosis, Treatment Planning, Patient Counseling, Operative Steps, and Complication Management. Domains were scored on a 0-4 scale; scores <2 were considered failing. Interrater reliability was assessed via weighted κ . A structured qualitative interview was conducted. RESULTS: GPT-4 achieved mean domain scores ranging from 2.3 to 3.7 across vignettes, with passing rates of 91.7% (rater 1) and 83.3% (rater 2). The highest-performing domains were Diagnosis (84.4%) and Complication Handling (82.3%), and the lowest-performing domains were seen in Case Introductions (62.5%). Interrater agreement was strong across domains ( κ = 0.70-0.89). Qualitative findings emphasized GPT-4's accuracy in guideline-based cases, limitations in trauma triage, and potential as an educational resource. CONCLUSION: GPT-4 demonstrates concordance with board-level clinical reasoning in structured plastic surgery scenarios. However, limitations in heuristic judgment and real-time adaptability underscore the need for optimization with specialty-specific training datasets and performance rubrics. With appropriate curation, GPT-4 could serve as a valuable supplement in surgical education and oral board preparation.
13 Apr 2026
Read appraisal →The International journal of oral & maxillofacial implants
Bone Marrow Aspirate Concentrate and Xenograft Versus Autograft and Xenograft in the 3D Reconstruction of Atrophic Maxillary Ridges: A Split-Mouth Randomized Controlled Trial
PURPOSE: To evaluate bone quality and quantity after 3D augmentation of vertically and horizontally atrophied maxillary ridges and compare the use of bone marrow aspirate concentrate (BMAC) and xenograft versus autograft and xenograft, both using prebent titanium (Ti) mesh over a virtually augmented model. MATERIALS AND METHODS: Ten fully edentulous patients with severe maxillary vertical and horizontal bone loss were recruited. Virtual horizontal and vertical bone augmentation was performed for the deficient ridge to produce virtually augmented models for prebent Ti meshes preoperatively. Each patient was rehabilitated with BMAC and xenograft on one side of their mouth (test side) and with autograft and xenograft on the other (control side). For the test side, the mesh was loaded with a mix of xenograft and BMAC from the anterior iliac crest. For the control side, the mesh was loaded with a 1:1 ratio of xenograft to autograft mix. The meshes on both sides were fixed in place using miniscrews. RESULTS: CBCT scans were performed 6 months postoperatively for all patients. The test side showed a mean vertical bone gain of 3.47 ± 0.87 mm, which was comparable to that of the control side (4.10 ± 0.67 mm). The test side also showed a mean horizontal bone gain of 3.476 ± 0.59 mm, which was higher than that of the control side (2.918 ± 0.80 mm). While the mean resorption rate in the test side (106.2 ± 108.6 mm) was lower than the mean value in the control side (193.3 ± 107.9 mm), the differences in bone gain were not statistically significant. However, a statistically significant higher bone area percentage (47.9%) as well as a higher percentage of mature bone (67.7%) were detected in the test side compared to the control side (28.5% and 26.5%, respectively). CONCLUSIONS: 3D alveolar reconstruction using prebent Ti meshes loaded with xenograft mixed with BMAC could be a reliable and less complicated technique for vertically and horizontally atrophied maxillary ridges.
5 Apr 2026
Read appraisal →Clin Otolaryngol
Artificial Intelligence in Facial Plastic Procedures
OBJECTIVES: We reviewed the prospects of Artificial Intelligence (AI) and its usage in facial plastic surgery. METHODS: Literature search was performed using PubMed, Medline, Google and Google Scholar search engines between 2000 and 2025 years. RESULTS: AI is poised to impact the threefold missions of patient care, education and research. It plays a role in aiding clinician decision-making, serving as virtual conversational agents for patient engagement, and forecasting surgical outcomes. Primary areas of AI exploration in the medical field include machine learning (ML), neural networks (NN) and natural language processing (NLP). ML models have demonstrated the ability to detect facial features such as larger nasofrontal and nasolabial angles, correlating with increased attractiveness post-cosmetic rhinoplasty. Efficient resource allocation can be achieved through ML models guiding the analysis of post-operative free flap viability in facial skin cancer reconstruction. During online patient consultations, AI virtual assistants (AIVA) utilising NLP comprehend human speech intent, responding through dialogue. Unsupervised ML in facial analysis software is currently employed for correctly diagnosing rare diseases by recognising dysmorphic craniofacial features in two-dimensional photographs. AI also finds application in assessing post-operative outcomes, as well as in surgical training and research. CONCLUSION: The use of AI in healthcare is on the rise, contributing to advancements in pre-operative assessments, predicting prognoses, managing patients and monitoring postoperative progress. Surgeons are encouraged to explore collaboration with data scientists to shape the evolution of AI, aiming to enhance surgical efficiency, improve patient outcomes and potentially alleviate the workload associated with repetitive administrative duties.
1 Jan 2026
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