Robotic microsurgery offers important advantages in vascular anastomoses and nerve sutures, particularly for structures < 1 mm as required in supermicrosurgery. The Symani® surgical robot provides micrometric movements and tremor elimination through motion scaling, improving precision and reducing operator fatigue. Although several studies have investigated Symani-related training and learning curves, most were conducted on synthetic or in vitro animal models. The few studies performed on in vivo rat models involve microvascular surgeons with many years of experience in traditional microsurgery, rather than residents with no experience in robotic microsurgery and only limited exposure to conventional microsurgery. During the Advanced Microsurgery Course 2025 in Naples (Italy), held between May and December 2025, 14 participants with no prior robotic microsurgery experience and minimal conventional microsurgical training performed first a practice session on a silicone synthetic model to become familiar with the robot, and subsequently on in vivo murine models using the Symani® robot. Data from the in vivo exercise were collected and compared, focusing on time required to complete individual knots and intraoperative complications. Participants demonstrated rapid acquisition of operative skills, showing a reduction in suturing time during in vivo procedures, which indicates a fast adaptation to the robotic platform even among inexperienced operators. The Symani® robotic microsurgery system is intuitive and associated with a steep learning curve, even for users with no prior exposure to robotic microsurgery and only basic training in traditional microsurgery. This supports its potential as an effective training platform and clinical tool in supermicrosurgery.

Delayed tendon injury has been historically treated with several techniques, including staged tendon graft and flexor digitorum profundus (FDP) transfers from neighboring rays. Nevertheless, the use of the flexor digitorum superficialis (FDS) hemi-tendon from neighboring fingers may provide the same results with less donor site morbidity. This article aims to present the safety and effectiveness of the fourth FDS hemi-tendon transfer technique to treat zone I-5th FDP injuries on cadaver specimens, and to describe its in vivo application. In 4 fresh-frozen forearms, the fifth FDP was cut at zone I. All the fourth and fifth finger pulleys, except for A2 and A4, were incised. The fourth FDS ulnar hemi-tendon was harvested, passed through the A2 and A4 pulleys of the fifth finger, and sutured to the distal fifth FDP stump. To test finger flexion after tenorrhaphy, FDS and FDP tendons were pulled at wrist level, along the forearm axis, with a dynamometer. In all specimens, a complete flexion of fingers was obtained after FDS and combined FDS-FDP traction. The technique was applied in vivo for a staged reconstruction in a 35-year-old patient, resulting in good active and passive finger range of motion, a tip-to-palm distance of 0 mm, and no complications, bowstringing, or quadriga effect at 1-year follow-up. These cadaveric study and case report confirm that the fourth FDS ulnar hemi-tendon transfer is safe and effective in treating zone I fifth FDP delayed injuries, both during single and staged reconstructions.

This study provides a comprehensive guide to robotic-assisted microsurgery. Following more than 900 clinical cases in 13 centers, this joint project was initiated to summarize and consent to the user experience. Two robotic systems specifically designed for the needs of open microsurgery received the first certification for clinical application (CE mark) in 2019 and 2020. Since their introduction into clinical application, several European microsurgical centers have implemented these systems, generating user experiences in multiple microsurgical subspecialties. All institutions using the MUSA-2 microsurgical robot (Microsure B.V., Eindhoven, Netherlands) or Symani Surgical System (Medical Microinstruments, Inc., Wilmington, Delaware, US) were invited to join the multicenter project. A modified nominal group technique was applied to answer five major questions regarding current and future indications and developments in open robotic-assisted microsurgery. Steep preclinical and clinical learning curves were characterized. General considerations concerning the two different systems are presented. Specifics for each microsurgical subspecialty are reported. Following two voting rounds, a consensus was reached in three of the five major questions with “lymphatics” being the top indication, “higher precision” being the top benefit, and “automation” being the top long-term goal of robotic-assisted microsurgery. This joint project of all Symani and MUSA-2 users presents clinical cases and the subsequent initial knowledge and experience. Lymphatics as a top indicator and a higher precision as the top benefit point toward the capabilities of robotic-assisted microsurgery in manipulation of smallest structures. Automation may further enhance and simplify robotic procedures in future. This project also provides a comprehensive guide to any institution aiming to introduce such a system for open robotic-assisted microsurgery in future.

Background and Clinical Significance: Neurological complications in extension-type-III supracondylar humeral fractures (SCHFs) in children represent 11% of cases. An extension-type-III SCHF with posterolateral displacement of the distal fragment is commonly associated with damage to the median nerve and the anterior interosseous nerve (AIN). Neurological complications are often unnoticed, and their immediate postoperative diagnosis is difficult, particularly in young children. Neurapraxia, the most common complication, usually undergoes spontaneous nerve recovery. Case Presentation: We report a case of a 7-year-old patient with postoperative median nerve palsy after an SCHF (Gartland type III) who was referred to our unit from another hospital due to a lack of spontaneous recovery. In addition, motor and sensory functions were absent. As ultrasound (US) indicated nerve kinking at the fracture site, an exploration was performed. The nerve was trapped within the fracture and the callus. It was surgically extracted, and intraoperative examination with US indicated that resecting the kinked nerve, freeing the two stumps, and attempting a primary end-to-end suture represented the best course of action. We present this case with a 5-year follow-up surgery, which showed a good clinical outcome. Conclusions: This case is noteworthy because of its diagnostic and therapeutic pathways, and it is complemented by surgical and ultrasound images that can assist other surgeons in similar circumstances.

Background/Objective: Traumatic injuries to the flexor tendons of the hand are frequently treated by hand surgeons. Late repair is not classically considered to be feasible due to the high risk of failure and functional complications. The present study aims to present the functional results of primary flexor tendon repairs performed more than three months after trauma, along with evidence regarding the time limit for primary flexor tendon repair. Methods: The clinical outcomes of direct flexor tendon repairs in zones 1 and 2 of the long fingers or thumb are reported herein. A scoping review was undertaken using Medline and CINHAL to identify studies reporting the functional outcomes of flexor repair following trauma. Results: In this series, four patients were treated with direct M-Tang and epitendinous suture or pull-out reinsertion. Accessory procedures were required to perform a direct repair. The mean delay was 5.5 months, and the follow-up period was 24 months. The mean total active movement was 195°. Extension lags of 10° and 20° were registered at the proximal interphalangeal and distal interphalangeal joints, respectively. While a literature review showed that most cases treated with primary repair after three months resulted in functional complications, these procedures were performed around 40 years ago and no recent reports were found. Conclusions: In the small cohort of patients here reported it has been possible to repair flexor tendons in zones 1 and 2, and to reinsert a jersey finger, even three months after trauma. Accessory procedures were required. Accurate patient selection and counseling is mandatory before surgery to inform patients about alternatives. The literature review confirmed that no positive results have previously been reported in the literature on this topic. It is thought that modern materials and surgical techniques for flexor tendon repair should extend the edge for primary repair in selected patients, as compared to previous practices.

Background/Objectives: Neuropathic pain associated with neuromas is a complex clinical problem to treat. Targeted Muscle Reinnervation (TMR) has been demonstrated to treat pain both as a prophylactic procedure in amputated patients and in patients affected by painful neuromas. It is not clear what its role could be in chronic situations: the literature reports amazing results but also unsuccessful pain relief. Methods: A retrospective analysis was conducted on patients treated with TMR for long-lasting painful neuromas in the upper and lower limbs. Following a clinical and instrumental diagnosis, all patients responded positively to a local anesthetic block. During follow-up visits, the NRS and DN4 questionnaires were used to assess improvement in pain. Results: Three patients were included in this study. TMR was performed 45 months after trauma. Two TMRs involved nerves of the upper extremity, in one case, the tibial nerve. The recipient muscles were the second lumbricalis, pronator quadratus, and flexor digitorum longus of the foot. After surgery, pain decreased for 3 months, but patients experienced a relapse that returned to levels close to the pre-operative period. The types of pain, as reported in DN4 questionnaire, changed slightly compared to those in the pre-surgical period. Follow-up ranged between 12 and 19 months. Conclusions: This small series collected the results of TMR in patients affected by long-lasting symptomatic neuromas in the upper and lower extremities. Despite what is published in other series, this procedure reduced pain for up to 6 months. At final follow-up, the type of pain changed slightly as reported in the DN4 questionnaire, and pain scores reduced by just one point as shown by the NRS. Our experience suggests that TMR might have a slight effect on long-lasting painful neuromas and in these cases, only short-term pain relief could be expected. This suggests using TMR as close as possible to the trauma in order to increase the chances of relieving pain.

Background:Large post-traumatic defects of the lateral malleolus are uncommon but present major reconstructive challenges, particularly in the presence of segmental bone loss, infection, or soft-tissue compromise. The lateral malleolus is essential for ankle stability, and its absence leads to mechanical imbalance and early degenerative changes. Traditional solutions-including non-vascularized grafts, allografts, arthrodesis, or fibular transfers-may be inadequate when biological conditions are poor or when three-dimensional reconstruction is required. Vascularized bone flaps offer improved union rates and enhanced resistance to infection. The vascularized iliac crest flap, although well-established in limb reconstruction, remains infrequently reported for distal fibula restoration. Methods:Three patients with severe post-traumatic lateral malleolar defects were treated between 2002 and 2015 at two microsurgical centers. Reconstruction was performed using free vascularized iliac crest flaps based on the deep circumflex iliac artery. Flap configuration (osteo-muscular or osteo-cutaneous) was adapted to defect size and soft-tissue requirements. Technical details-including flap harvest, shaping of the iliac crest segment, fixation, and vascular anastomoses-are described. Clinical and radiographic outcomes were evaluated over 8-14 years. Results:All flaps survived without major postoperative complications. Radiographs demonstrated consistent osseous union between the iliac crest graft and tibia. All patients achieved full weight-bearing and stable ankle function. Mild-to-moderate radiographic osteoarthritis occurred at long-term follow-up but remained asymptomatic. Soft-tissue coverage was reliable, and no secondary flap procedures were required. Conclusions:The free vascularized iliac crest flap is a dependable and versatile reconstructive option for extensive lateral malleolar defects. It provides stable ankle restoration, predictable union, and durable function, and should be considered when conventional grafting or fibular transfers are unsuitable, particularly in complex post-traumatic or infected environments.

Background: Lesions of the digital apices are common, and several treatment strategies can be considered for them. Among these, the free great toe pulp flap can be used. Methods: This is a retrospective report in which five patients undergoing hallux free flap surgery for loss of pulpal substance at the level of the hand were evaluated. They were re-evaluated by using both clinical testing to assess sensitivity and the use of questionnaires to estimate function. Results: None of the performed flaps failed. The mean follow-up was 36 months (range 16–66 months). With SW-MF, the mean value was 3.734 compared to 2.986 for the same contralateral finger. The S2-PD test attested a mean value of 6.8 mm (range 6–8 mm) in contrast to the contralateral finger, which showed a mean result of 3.2 mm (range 3–5 mm), while the D-2PD indicated lower values for both the operated finger, with a mean value of 6.4 mm (range 4–8 mm), and the healthy finger. Conclusions: When a dystrophic fingertip results from an inappropriate acute management, the GTP flap appears to be an excellent strategy to restore the specialized tissue of finger pulp and to bring supple tissue to the correct PIP flexion contracture or the small first web space contracture. It is mostly required for thumb and radial fingers’ reconstruction, especially in young patients or those who need high functional demands and/or present an extensive loss of substance that cannot be resolved with local flaps.

Radial nerve palsies present a challenging clinical scenario, often leading to substantial functional impairment. This study focuses on evaluating the outcomes of tendon transfer surgeries in patients with post-traumatic radial nerve injuries. The radial nerve, vital for upper limb movements, faces various etiologies such as trauma, compression, or idiopathy. Patients with radial nerve palsy encounter difficulties in daily activities, emphasizing the need for effective management strategies. The research introduces a novel evaluation protocol, aiming to comprehensively assess tendon transfer outcomes. This protocol incorporates functional movements of wrist and finger joints, encompassing both objective and subjective parameters. The retrospective study includes eleven patients treated between 2010 and 2022, with a minimum follow-up of one year post-surgery. Tendon transfers demonstrated positive results. The evaluation protocol covers a wide range of parameters, including wrist and finger mobility, thumb function, grip strength, and patient satisfaction. The results indicate successful restoration of motor function, with an average grip strength of 70% compared to the healthy arm. The proposed evaluation protocol facilitates standardized and reproducible assessment, minimizing subjective errors in clinical evaluations. Despite the study's limitations, such as a relatively small sample size, the findings underscore the effectiveness of tendon transfers in treating radial nerve palsies. The introduced evaluation scheme provides a comprehensive and reproducible approach to assess outcomes, contributing to the global standardization of tendon transfer assessments in radial nerve injuries.

From the first surgical repair of a nerve in the 6th century, progress in the field of peripheral nerve surgery has marched on; at first slowly but today at great pace. Whether performing primary neurorrhaphy or managing multiple large nerve defects, the modern nerve surgeon has an extensive range of tools, techniques and choices available to them. Continuous innovation in surgical equipment and technique has enabled the maturation of autografting as a gold standard for reconstruction and welcomed the era of nerve transfer techniques all while bioengineers have continued to add to our armamentarium with implantable devices, such as conduits and acellular allografts. We provide the reader a concise and up-to-date summary of the techniques available to them, and the evidence base for their use when managing nerve transection including current use and applicability of nerve transfer procedures.

IntroductionPeripheral nerves are frequently affected by lesions caused by traumatic or iatrogenic damages, resulting in loss of motor and sensory function, crucial in orthopedic outcomes and with a significant impact on patients’ quality of life. Many strategies have been proposed over years to repair nerve injuries with substance loss, to achieve musculoskeletal reinnervation and functional recovery. Allograft have been tested as an alternative to the gold standard, the autograft technique, but nerves from donors frequently cause immunogenic response. For this reason, several studies are focusing to find the best way to decellularize nerves preserving either the extracellular matrix, either the basal lamina, as the key elements used by Schwann cells and axons during the regenerative process.MethodsThis study focuses on a novel decellularization protocol for porcine nerves, aimed at reducing immunogenicity while preserving essential elements like the extracellular matrix and basal lamina, vital for nerve regeneration. To investigate the efficacy of the decellularization protocol to remove immunogenic cellular components of the nerve tissue and to preserve the basal lamina and extracellular matrix, morphological analysis was performed through Masson’s Trichrome staining, immunofluorescence, high resolution light microscopy and transmission electron microscopy. Decellularized porcine nerve graft were then employed in vivo to repair a rat median nerve lesion. Morphological analysis was also used to study the ability of the porcine decellularized graft to support the nerve regeneration.Results and DiscussionThe decellularization method was effective in preparing porcine superficial peroneal nerves for grafting as evidenced by the removal of immunogenic components and preservation of the ECM. Morphological analysis demonstrated that four weeks after injury, regenerating fibers colonized the graft suggesting a promising use to repair severe nerve lesions. The idea of using a porcine nerve graft arises from a translational perspective. This approach offers a promising direction in the orthopedic field for nerve repair, especially in severe cases where conventional methods are limited.

Very often, post-traumatic defects involve multiple tissues. Microsurgical techniques can reconstruct them with tissues taken from a toe: from the nail complex alone to compound osteo-onychocutaneous flaps. Several techniques have been reported since the 1980s. This paper describes techniques and indications for microsurgical nail reconstruction. Technique differs according to the deficit, and first and foremost whether only the nail complex is involved or whether other components of the fingertip important for the normal growth of the nail, such as the phalanx bone or the finger pad, are also missing (toenail flaps and the custom-made osteo-onychocutaneous flaps). For most patients the absence of a fingernail is an esthetic rather than functional concern, and the outcomes of microsurgical reconstruction are far from ideal in this regard. We prefer to reserve reconstruction for symptomatic patients with functional impairment. (c) 2024 Published by Elsevier Masson SAS on behalf of SFCM.

Background: Virtual surgical planning has become a well-established practice in head and neck surgery. In oncological surgery, it permits the achievement of safe margins resections and ensures functional reconstructions and optimal esthetic outcomes. This study aimed to evaluate the long-term outcomes after virtually planned mandibular microvascular reconstruction, focusing on functional and esthetic results, as well as health-related quality of life. Methods: A long-term retrospective evaluation of 17 patients with oral cavity malignancy who underwent computer-assisted mandibular resection and reconstruction was performed. Functional and esthetic outcomes were analyzed using the EORTC, QLQ-C30, H&N35, and FACE-Q questionnaires. Results: Time since reconstruction ranged from 7 to 14 years. Patients reported high functional levels on the QLQ-C30 functional scales but lower scores on H&N35. On FACE-Q, patients demonstrated higher appraisal and satisfaction with their smiles compared to their overall facial appearance. Conclusions: In this retrospective case series, patients undergoing computer-assisted mandibular reconstruction for oral malignancies achieved good long-term functional and esthetic outcomes. Although limited by the small sample size, these results support the enduring benefits of virtual planning for mandibular reconstruction. To minimize declines in function and appearance, considerations should include immediate dental implants, enhanced reconstruction of the temporomandibular joint, newer methods of radiotherapy to minimize xerostomia, and oral exercises to prevent trismus.

Mangled upper-extremity injuries can have devastating consequences for the patient. The goal of treatment was to recreate a functional hand with a minimum of three sensitive and opposable fingers to achieve an acceptable quality of life. Early management of injuries is critical to treatment success. Initial assessment begins in the emergency department where the injury is quantified and the amputated segments are evaluated, particularly the possibility of replanting them or using them as spare parts as tissue bank. In the operating room, careful debridement is essential for any reconstruction. Despite advances in reconstructive techniques, the management of these injuries is a challenge for the surgeon. The main treatment guidelines and a step-by-step approach to the mangled hand are presented to achieve acceptable results.

The fingertip is a complex anatomical structure that is frequently injured, especially in manual workers. Different classifications have been reported, considering injury orientation, level and geometry. To optimize treatment planning, the area of soft-tissue defect should be considered. Treatment aims to conserve as long a finger as possible, restore sensation (S3 + or more) and ensure a pleasant esthetic appearance.When amputation occurs, the best treatment is replantation when conditions allow. When this is not possible, the fingertip should be used as a composite graft or the nail complex can be grafted and soft tissue reconstructed, according to the preferred method.In defect without amputation or if the distal part of the finger is not present or not useful, many reconstructive techniques have been described. Depending on the injury, patient characteristics and requirements and the surgeon’s skills and experience, the treatments vary from secondary healing to free flaps.In this paper, the various treatment options are described and discussed. Nowadays, considering most variables, the best treatment in fingertip injury is secondary healing with occlusive or non-occlusive dressing, even in case of bone exposure. This simple solution is able to restore a nearly normal fingertip with good sensation without further injuring the hand.

When a nerve injury occurs, the main goal of reconstructive surgery is to achieve nerve continuity as accurately as possible, in the view of fostering nerve regeneration and reinnervation of the distal organs. The advent of microsurgery and the use of dedicated instruments such as optical magnifications means and inert materials improved the results of nerve repair; however some general principles must be observed in order to maximize the potential outcome. The aim of the article was to describe the proper steps to follow during a nerve reconstruction as well as the main alternative when a direct nerve repair is not feasible.

The etiopathogenesis and clinical classification of the femoral head osteonecrosis are frequently discussed among the orthopedic field. The treatment options are even more debated as numerous solutions are described without clear correlation with the clinical picture. Among non-surgical and surgical options, vascularized bone grafts seem to be the more appropriate treatment in the early stages. Different donor sites have been described in the literature, but actually surgeons most frequently use free fibula flap. The implant of the fibula allows decompression at the level of the necrotic area, reducing the intraosseous hypertension of the femoral head, and at the same time it provides revascularization and restoration of an adequate blood flow to the femoral head, stopping the degenerative process and mechanically supporting the subchondral ischemic area. Although vascularized fibula graft treatment has reported encouraging results, it is a complex surgical technique. In accordance with the results of the literature, the stage of the disease at the time of surgery is the main factor determining the success or failure of the technique in terms of preservation of the femoral head. Other factors, which can be of fundamental importance from a prognostic point of view, are the etiology, the size of the necrotic area and the position of the fibula.

This article provides a comprehensive overview of bone and joint infections classification and treatment options, with a focus on osteomyelitis and joint infections. Osteomyelitis is classified using the Cierny-Mader classification, which provides prognostic data and assists in planning the treatment strategy: the appropriate treatment for acute primary and chronic osteomyelitis should follow a multidisciplinary approach, including antibiotic therapy and surgical management. The treatment it is determined based on the type of infection, according to the pathogens identified from intraoperative cultures. We examine microsurgical reconstructive possibilities for the most common sites of joint and bone infections, such as microsurgical soft tissue coverage and free flaps, which have both functional and therapeutic roles. Successful outcomes are defined as functional bone restoration without infection recurrence for at least two years.(Cite this article as: Rossello C, Crosio A, Pignatti M, Carrega G, Tos PL, Formica M, et al. Microsurgery in bone and joint infection. Minerva Orthop 2023;74:214-26. DOI: 10.23736/S2784-8469.23.04306-7)

Due to the enormous progress in microsurgery, the indications for replantation are constantly evolving, and correct patient selection and management play a key role in the outcome. Because of these reasons, the replantation after amputation is no longer just a surgical technique issue. The goal is not only to obtain a vascularized limb, but restoring function. This section aims to review the indications for upper and lower limb replantation considering the patient, the related trauma, and the status of the affected tissues, to avoid unsatisfactory results. In the first part are analyzed the problematics about upper limb replantations and in the second part lower limb that are different and more restricted.(Cite this article as: Battiston B, Faccenda C, Fulchignoni C, Adani R, Zoccolan A, Braghiroli L, et al. Indications to upper and lower limb replantations. Minerva Orthop 2023;74:310-21. DOI: 10.23736/S2784-8469.23.04310-9)