MR-Neurography of the facial nerve in parotid tumors: intra-parotid nerve visualization and surgical correlation.

PURPOSE: One of the most severe complications in surgery of parotid tumors is facial palsy. Imaging of the intra-parotid facial nerve is challenging due to small dimensions. Our aim was to assess, in patients with parotid tumors, the ability of high-resolution 3D double-echo steady-state sequence with water excitation (DE3D-WE) (1) to visualize the extracranial facial nerve and its tracts, (2) to evaluate their relationship to the parotid lesion and (3) to compare MRI and surgical findings. METHODS: A retrospective study was conducted including all patients with parotid tumors, who underwent MRI from April 2022 to December 2023. Two radiologists independently reviewed DE3D-WE images, assessing quality of visualization of the facial nerve bilaterally and localizing the nerve's divisions in relation to the tumor. MRI data were compared with surgical findings. RESULTS: Forty consecutive patients were included (M:F = 22:18; mean age 56.3 ± 17.4 years). DE3D-WE could excellently visualize the nerve main trunk and the temporofacial division in all cases. The cervicofacial branch was visible in 99% of cases and visibility was good. Distal divisions were displayed in 34% of cases with a higher visibility on the tumor side (p < 0.05). Interrater agreement was high (weighted kappa 0.94 ± 0.01 [95% CI 0.92-0.97]). Compared to surgery accuracy of MRI in localizing the nerve was 100% for the main trunk, 96% for the temporofacial and 89% for the cervicofacial branches. CONCLUSIONS: Facial nerve MR-neurography represents a reliable tool. DE3D-WE can play an important role in surgical planning of patients with parotid tumors, reducing the risk of nerve injury.

Long-Term Aesthetic Cicatrization Analysis of Lower Eyelid Incision for Orbital Floor Fracture Approach.

Orbital fractures are among the most frequent facial injuries. Of the 3 most widely described approaches in the literature, the lower eyelid approach is the authors' preference. This study retrospectively analyzed the patients treated at the Trauma Center of the Umberto I Hospital, Sapienza University of Rome from January 2010 to December 2020. Inclusion criteria were as follows: diagnosis of pure/impure orbital bone fracture, complete clinical and radiological documentation, and a minimum of 12 months follow-up. Sex, age, etiology, treatment, and associated complications were analyzed using IBM SPSS Statistics. Two internationally validated scales were used for the functional and esthetic long-term evaluation: the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver one. The scales were compiled by the patient himself and by 3 independent expert observers. Of the 543 patients who underwent surgery in the specified period, 208 fully met the inclusion criteria. One hundred forty-two (68.2%) were males and 66 (31.8%) were females, with a mean age of 40.68 years. The main cause was represented by assaults (33.1%). One hundred seventy-nine patients had a pure orbital fracture (83.8%) and 29 an impure one (16.2%). The most frequent symptoms at the time of diagnosis were diplopia (31.2%), followed by anesthesia of the second trigeminal branch (24.3%). Open reduction with internal fixation was the preferred treatment and proved to be effective in reducing the main signs and symptoms of the fracture in a statistically significant way ( P < 0.05). Long-term esthetic results of the lower eyelid, using the Vancouver and POSASs, were respectively as follows: Vancouver Scar Scale mean total score was 2.41 (range: 0-8), observer POSAS mean total score was 1.83 (range: 1.2-3.9), observer general opinion mean score was 1.66, patient POSAS mean total score was 2.23 (range: 1.33-3.7), and patient general opinion mean score was 2.87. The lower eyelid approach has proven to be reproducible, with a fast-learning curve and a low complication rate. The analysis conducted highlighted an excellent long-term esthetic-functional result. Further studies will be needed to statistically compare the results obtained with other orbital floor surgical approaches.

Genetically driven CD39 expression shapes human tumor-infiltrating CD8+ T-cell functions.

In our study, we investigated the role of CD39 on tumor-infiltrating CD8+ T lymphocytes (CD8+ TILs) in colorectal, head and neck and pancreatic cancers. Partially confirming recent observations correlating the CD39 expression with T-cell exhaustion, we demonstrated a divergent functional activity in CD39+ CD8+ TILs. On the one hand, CD39+ CD8+ TILs (as compared to their CD39- counterparts) produced significantly lower IFN-γ and IL-2 amounts, expressed higher PD-1, and inversely correlated with perforin and granzyme B expression. On the other, they displayed a significantly higher proliferative capacity ex vivo that was inversely correlated with the PD-1 expression. Therefore, CD39+ CD8+ TILs, including those co-expressing the CD103 (a marker of T resident memory [TRM] cells), were defined as partially dysfunctional T cells that correlate with tumor patients with initial progression stages. Interestingly, our results identified for the first time a single nucleotide polymorphism (SNP rs10748643 A>G), as a genetic factor associated with CD39 expression in CD8+ TILs. Finally, we demonstrated that compounds inhibiting CD39-related ATPases improved CD39+ CD8+ T-cell effector function ex vivo, and that CD39+ CD8+ TILs displayed effective suppression function in vitro. Overall these data suggest that the SNP analysis may represent a suitable predictor of CD39+ CD8+ T-cell expression in cancer patients, and propose the modulation of CD39 as a new strategy to restore partially exhausted CD8+ TILs.

Maxillo-Mandibular Reconstruction in Pediatric Patients: How To Do It?

Maxillo-mandibular reconstruction in pediatric patients involves particular functional and cosmetic implications. Attention is required for the craniofacial growth over time, involvement of the permanent dentition, facial symmetry, and donor site morbidity. Our aim is to identify the best reconstructive options for maxilla-mandibular defects in children (<18 years) based on our experience with 25 pediatric patients. We believe that reconstruction has to be performed at the same time as resection in pediatric patients. Local flaps should be reserved for cases of maxillary defects because of malignant neoplasms, which ultimately have poor prognosis. In cases of large mandibular defects, radiotherapy is eventually required. When the condition of the soft tissues is poor (because of previous surgery, etc), free flaps potentially represent the best options. Nevertheless, in patients younger than 5 years old (with no damaged tissues), reconstruction with rib grafts should be performed, and the use of titanium plates should be reserved for very select cases (such as temporary reconstruction in toddlers).

Mandibular subluxation as an adjunct in very distal carotid arterial reconstruction: incidence of peripheral and cerebral neurologic sequelae in a single-center experience.

BACKGROUND: The location of the carotid bifurcation and a very distal extension of internal carotid atherosclerotic disease may challenge vascular surgeons performing carotid endarterectomy (CEA) by increasing technical difficulty and possibly the incidence of cranial nerve damage or palsies. The objective of the present study is to report on the safety of CEA with mandibular subluxation (MS) and to compare results of CEA in 2 groups of patients treated by standard CEA or by MS-CEA according to rates of major neurologic complications, death, and the occurrence of postoperative peripheral nerve palsy. METHODS: Between July 2000 and June 2012, 1,357 CEAs were performed. MS was additionally used in 43 patients. Only patients with primary atherosclerotic internal carotid artery (ICA) lesions in the 2 groups (38 in the MS-CEA group and 1,289 in the standard CEA group) were considered for comparative analysis. RESULTS: MS-CEA patients were more frequently male (P = 0.03), presented more frequently with symptomatic lesions (P = 0.007), longer lesions (P = 0.01), and had common ICA bypass implantation (P = 0.02). Mean follow-up was 68.75 ± 37.87 months (range: 1-144 months). No perioperative neurologic mortality and no prolonged discomfort related to MS was recorded. The overall neurologic morbidity rate (major stroke/minor stroke/transient ischemic attach) was comparable in the 2 groups (P = 0.78). The overall immediate peripheral nerve injury rate was 7.89% in the MS-CEA group and 5.27% in the standard CEA group (P = 0.73). Three cases of permanent dysphonia in the standard CEA group (0.23%) and 1 case of dysphagia in the MS-CEA group (2.63%) were reported at follow-up (P = 0.24). CONCLUSIONS: MS-CEA can be a very useful technical adjunct for high-located carotid bifurcations or challenging carotid lesions, with an overall risk comparable to that of standard CEA.

Giant "Panfacial" Chordoma Involving Skull Base With Intracranial Invasion.

Chordomas are rare, low-grade, primary malignant bone tumor arising from primitive notochord remnants of the axial skeleton. They rarely occur in an extraosseus craniofacial location such as nasopharynx, nasal septum, paranasal sinuses, and orbits. We report here an extreme case of "panfacial" chordoma involving middle and anterior skull base with intracranial invasion, which reached considerable size because of a delay in diagnosis and treatment. In this case, a wide surgical excision was performed to improve quality of life.

Surgical management of enophthalmos in Duane syndrome.

Duane syndrome is a congenital disorder of eye movement characterized by partial or absent development of the sixth cranial nerve nucleus and/or the sixth nerve itself. Patients often undergo procedures, both surgical and nonsurgical, to correct ocular misalignment and improve the resulting visual problems. We present a case report of a 49-year-old woman with left-sided Duane syndrome who underwent aesthetic surgical correction of enophthalmos.

Dermal Regeneration Template: Reconstruction in Oral Cancer Defects.

Background: Post ablative oral mucosal defect resulting from the removal of tumors can be treated with various techniques. Purpose: In this paper, we are showing what, in our experience, are the advantages and disadvantages given using biosynthetic skin substitutes when dealing with this kind of lesions. Materials and methods: Patients included in the sample came to our attention with both neoplastic lesions (11 subjects) and important scar retraction after previous oncologic surgery (1 subject). All patients underwent trans-oral resection surgery following the same surgical protocol and post ablative oral mucosal defect were treated using the dermal regeneration template. The surgical defect location, size, and time of removal of the silicone layer varied from one subject to the other. Results: Most patients showed good healing with reduced scarring and adequate remucosalisation of the defect. The main complications were shown in a palatal lesion treated with concomitant osteal resection, which developed an oroantral fistula at follow up, and tongue lesions which showed some scarring. Conclusions: Given our experience, we would advise using dermal substitutes when reconstructing oral defects only after a cautious evaluation of the area of the lesion, the gap size, the possible adherence of the membrane to the gap, and the presence of tissue supporting the overlying membrane.

The 'Maxillary Pull-through' Technique: A Minimally Invasive Endoscopic-Assisted Approach to Nasal Septum Neoformations with Maxillary Bone Infiltration.

Study Design: Description and validation of a surgical technique. Objective: En-bloc maxillectomy with removal of the nasal septum is a rare procedure; preservation of the nasal bones and integrity of the alveolar ridge is even rarer. These procedures traditionally required a combined transfacial-transoral approach based on lateral rhinotomy. We describe a combined endoscopic transnasal-transoral approach for treatment of nasal septal malignancies that involve the hard palate. Methods: Excision of malignant tumours arising from the nasal septum was achieved in 4 patients using a transnasal-transoral endoscopic approach. Using 4-mm optics angled at 0° and 30°, the septum was freed from the ethmoid and removed en-bloc with the hard palate, by pulling the septum down through the hard palate. Results: Of the 4 patients, 2 underwent complete removal of septal chondrosarcomas, one removal of a sinonasal undifferentiated carcinoma and one removal of a mucoepidermoid carcinoma. In two cases, the palatal mucosa was spared and repositioned to restore separation between the nose and oral cavity. The remaining two cases underwent complete resection of the hard palate; one palate was reconstructed using a pedicled temporalis muscle flap and the other by employing an obturator. No infection was encountered. Partial ethmoidectomy was performed in all four cases. The mean hospital stay was 5 days. All patients are free of disease after a mean follow-up of 4 years (range: 2-7 years). Conclusions: Our new approach allows for minimally invasive resection of nasal septal malignancies that extend to the palate. Our maxillary pull-through technique is a valuable new surgical procedure for malignant pathologies of the nasal septum; the only drawback is that endoscopic surgery has a steep learning curve.

Odontogenic-Related Head and Neck Infections: From Abscess to Mediastinitis: Our Experience, Limits, and Perspectives-A 5-Year Survey.

BACKGROUND: Head and neck infections are commonly caused by affections with an odontogenic origin. Untreated or non-responsive to treatment odontogenic infections can cause severe consequences such as localized abscesses, deep neck infections (DNI), and mediastinitis, conditions where emergency procedures such as tracheostomy or cervicotomy could be needed. METHODS: An epidemiological retrospective observational study was performed, and the objective of the investigation was to present a single-center 5-years retrospective analysis of all patients admitted to the emergency department of the hospital Policlinico Umberto I "Sapienza" with a diagnosis of odontogenic related head and neck infection, observing the epidemiological patterns, the management and the type of surgical procedure adopted to treat the affections. RESULTS: Over a 5-year period, 376,940 patients entered the emergency room of Policlinico Umberto I, "Sapienza" University of Rome, for a total of 63,632 hospitalizations. A total of 6607 patients were registered with a diagnosis of odontogenic abscess (10.38%), 151 of the patients were hospitalized, 116 of them were surgically treated (76.8%), and 6 of them (3.9%) manifested critical conditions such as sepsis and mediastinitis. CONCLUSIONS: Even today, despite the improvement of dental health education, dental affections can certainly lead to acute conditions, necessitating immediate surgical intervention.

Risk of Oral Squamous Cell Carcinoma in One Hundred Patients with Oral Lichen Planus: A Follow-Up Study of Umberto I University Hospital of Rome.

This study aims to retrospectively assess the potential risk of malignant transformation in patients with diagnosed oral lichen planus (OLP) between 2015 and 2022, and to evaluate the influence of different risk factors. The department's database and medical records from 2015 to 2022 were searched for patients with a confirmed diagnosis of OLP based on both clinical and histological parameters. A total of 100 patients (59 females and 41 males) were found with a mean age of 64.03 years. In the considered period, the percentage of diagnosed OLP patients was 1.6%, while the percentage of diagnosed OLP patients with transformation to oral squamous cell carcinoma (OSCC) was 0.18%. A statistically significant difference was found with age (p = 0.038), tobacco status (p = 0.022), and radiotherapy (p = 0.041). The analysis revealed the presence of significant risk in ex-smokers (>20 pack-years), with an odds ratio (OR) of 10.0000 (95% confidence interval (95% CI) 1.5793-63.3186); in alcohol-drinker patients, with an OR of 4.0519 (95% CI 1.0182-16.1253); in ex-smoker and alcohol-drinker patients, with OR of 17.6250 (95% CI 2.2464-138.2808); and in patients who had undergone radiotherapy, with OR of 6.3000 (95% CI 1.2661-31.3484). The malignant transformation of oral lichen planus was slightly higher than thought, and the results revealed a possible association with age, tobacco and alcohol status, and history of radiotherapy. An elevated risk of malignant transformation was observed in heavy ex-smoker patients, alcohol-drinker patients, and alcohol-drinker patients with a history of smoking (ex-smokers). Persuading the patient to quit tobacco and alcohol consumption and periodic follow-ups are recommended in general, but particularly in the presence of these risk factors.

Lipostructure in Parry-Romberg disease.

Parry-Romberg syndrome is a disease characterized by progressive hemifacial atrophy. Multiple surgical procedures have been used to improve the facial volume and contours of patients with this disease, including alloplastic, silicone, or collagen implants; lipofilling; and pedicled or free-flap transplants. The present case describes the successful application of lipostructure to treat a woman with Parry-Romberg syndrome affecting the left side of her face.

Single-step nasal reconstruction with osteocutaneous forearm flap after total rhinectomy.

PURPOSE: Nasal defects resulting from tumor excision can be classified according to tissues involved, such as skin, cartilage, and bone. Although in the case of "simple" defects, reconstruction with loco-regional flap eventually associated with cartilage grafts can lead to satisfactory results; in the case of total or partial rhinectomy, a minimum of 3 and a maximum of 7 operations have to be performed in the current series to achieve an acceptable end result. We present the case of a total rhinectomy reconstruction in a single-step procedure with an osteocutaneous forearm free flap (RFOFF). CLINICAL REPORT: A 50-year-old man underwent total rhinectomy to excise a pathologically proven T4aN0 moderately differentiated squamous cell carcinoma of the nose; contemporary single-step reconstruction with an RFOFF was performed. Adjuvant radiotherapy was performed. RESULT: At 18 months of follow-up, the patient is free of disease and no postirradiation flap damage has been experienced; the flap notably did not appear to be bulky. CONCLUSIONS: We believe that the RFOFF is morphologically and functionally better than other flaps owing to its capability to adapt to the new environments of the nasal cavity, and to avoid, when possible, a three-dimensional reconstruction of the same.

Intramasseterin-infiltrating angiolipoma: a challenging diagnosis.

Angiolipomas are benign mesenchymal tumors infrequently affecting the head and neck region, manifesting themselves as small (<4 cm), slow-growing mass that are painful or tender to palpation. Ultrasonography, fine needle aspiration biopsy, computed tomography, and magnetic resonance imaging can be used to make a diagnosis. Surgical excision is the treatment of choice in both infiltrating and noninfiltrating forms, even if liposuction can be considered in multiple forms. We describe a case of infiltrating intramasseterin angiolipoma, in which diagnosis was suspected after magnetic resonance imaging with gadolinium; then a transoral surgical excision was performed. To the best of our knowledge, only 1 other case of intramasseterin-infiltrating angiolipoma has been previously described.

Three-Dimensional Comparison of the Maxillary Surfaces through ICP-Type Algorithm: Accuracy Evaluation of CAD/CAM Technologies in Orthognathic Surgery.

PURPOSE: This retrospective study aims to compare the accuracy of two different CAD/CAM systems in orthognathic surgery. The novelty of this work lies in the method of evaluating the accuracy, i.e., using an Iterative Closest Point (ICP) algorithm, which matches a pair of 2D or 3D point clouds with unknown dependencies of the transition from scan s(k) to scan s(k+1). METHODS: The study population was composed of ten patients who presented to the Maxillofacial Surgery Department of the University "Sapienza" of Rome for the evaluation and management of skeletal malocclusions. The patients were divided into two groups, depending on the technique used: group 1: splintless group (custom-made cutting guide and plates); group 2: splint group (using a 3D-printed splint). STL files were imported into Geomagic® Control X™ software, which allows for comparison and analysis using an ICP algorithm. The RMSE parameter (3D error) was used to calculate the accuracy. In addition, data were compared in two different patient subgroups. The first subgroup only underwent a monobloc Le Fort I osteotomy (p-value = 0.02), and the second subgroup underwent a Le Fort I osteotomy associated with a segmental osteotomy of the maxilla (p-value = 0.23). RESULTS: Group 1 showed a 3D error of 1.22 mm ± SD 0.456, while group 2 showed a 3D error of 1.63 mm ± SD 0.303. These results have allowed us to compare the accuracy of the two CAD/CAM systems (p-value = 0.09). CONCLUSIONS: The ICP algorithm provided a reproducible method of comparison. The splintless method would seem more accurate (p-value = 0.02) in transferring the surgical programming into the operating room when only a Le Fort I osteotomy is to be performed.

Management of benign parotid tumors. What can we learn from our experience?

AIM: Parotid gland is the most common location for salivary gland tumors, more commonly pleomorphic adenoma and Warthin's tumor. Types of parotid surgery include superficial parotidectomy (SP), partial superficial parotidectomy (PSP), total conservative parotidectomy (TCP), enucleation (E), extracapsular dissection (ECD), and are related to different incidence of complications. The choice depends on tumors localization, dimension and histology. The aim was to compare complications rate such as facial and great auricular nerve impairment and Frey syndrome according to type of surgery performed. MATERIALS AND METHODS: We retrospectively review the management of 116 benign tumors of the parotid gland treated between January 2004 and January 2020 at our Department. RESULTS: Most frequent complication observed was a GAN deficiency (22.41%), permanent in 13% of cases. Post-operative facial nerve impairment was observed in 19 patients (persistent only in 1 case). Only Frey syndrome (4,31% of cases) seemed to be related to type of surgery (p<0.05) resulting more frequent in the group of patients that underwent "classical" parotidectomy, while facial nerve impairment, even if more frequent in this cases, did not statistically correlated with operative technique (p=0.054). CONCLUSIONS: Once experience is gained, in order to reduce post-operative morbidity extracapsular dissection is a reliable technique in the management of these neoplasms, even if attention has to be paid particularly in the removal of superficial masses "emerging" from the parenchyma. PSP is an alternative to SP, while CTP has to be reserved to selected cases ot tumors arising in the deep lobe. KEY WORDS: Benign tumor, Extracapsular dissection, Enucleation, Facial nerve Parotid gland, Parotidectomy, Superficial parotidectomy.

Orbital lesions, an interdisciplinary pathology. The experience of the maxillo-facial surgeons.

AIM: The main focus of this paper was to describe our experience in the management of primary lesions involving the orbit, analyzing signs and symptoms and illustrating surgical management. MATERIAL OF STUDY: We describe our experience managing 62 consecutive patients diagnosed with orbital tumors confined to the orbital content (not involving skin or bone, with no intracranial invasion) and treated between January 2013 and December 2016. Demographic characteristics, symptoms, clinical findings, histological types and approaches have been recorded. RESULTS: We found that the most common clinical manifestations were exophthalmos/proptosis and ocular movement impairment; the most common histological types were vascular malformation and ocular adnexal lymphomas. DISCUSSION: Primary neoplasms involving orbital contents include a broad spectrum of pathologies difficult to manage without a firm diagnosis, usually histological. Different surgical accesses are described in order to perform incisional biopsy or resection of the mass. CONSCLUSION: In every case, accurate surgical planning is mandatory, in order to prevent functional and/or aesthetic complications. KEY WORDS: Blepharoplasty incision, Intraorbital neoplasia, Lateral orbital tumor, Orbitotomy, Surgical treatment, Transconjunctival approach.

Reconstruction of the mandibular symphysis: pilot study compares three different flaps.

BACKGROUND: Restoration of mandibular continuity, functionality and attempting to return to the patient's premorbid state is the ultimate goal of reconstruction. Some studies compare different flaps, but the reconstructed portions vary and there is little consensus on the best option for a particular defect. METHODS: This pilot study compares three different reconstructive options with free flaps. We will analyze the accuracy of the reconstruction, the postoperative complications related to the reconstruction, the morbidity of the donor site. This pilot study compares three different reconstructive options with free flap in the reconstruction of the mandibular symphysis: iliac crest, scapula and fibula. RESULTS: In our sample the morbidity of the donor site was overlapping, as for all three choices free from complications. In post resection edentulous patients, the fibula seems to guarantee better positioning, while in patients with residual occlusion the iliac crest seems to allow a more congruous repositioning. The fibula seems to have a superiority over the other flaps in terms of accuracy in all types of patients. CONCLUSIONS: Contrary to the most recent work on the accuracy of CAD/CAM, we have analyzed the error in the reconstruction of a specific segment and in the repositioning of the residual mandibular component without the use of guided computer programming.

Effectiveness of Resective Surgery in Complex Ameloblastoma of the Jaws: A Retrospective Multicenter Observational Study.

Ameloblastoma is a rare, benign, odontogenic tumor of epithelial origin, characterized by locally aggressive, expansive growth. Treatment is controversial due to the risk of relapse. The aim of this multicenter retrospective study was to evaluate the effectiveness of complete resection in cases of complex ameloblastoma, which is considered at a higher risk of recurrence. Patients who met at least one of these criteria were included: recurrence, soft-tissue involvement, complete erosion of internal/external cortical walls with involvement of the inferior margin of the mandible, and invasion of the maxillary sinus or nasal cavity. Demographic data, tumor site, type of surgery, histological features, and follow-up information were collected for each patient. The cohort included 55 patients with a mean follow-up of 108 ± 66 months. A multivariate logistic model was used to evaluate variables independently associated with relapse. There were six soft-tissue or maxillary sinus relapses, with a recurrence rate of 10.9%. Most of them arose in patients previously treated. The statistical analysis identified the maxillary location as a fundamental relapse risk factor. En bloc resection with large surgical safety margins seemed to be effective in preventing the relapses. However, complete resection was less effective in preventing recurrences in the soft tissues or maxillary sinus.

Cerebrospinal Fluid Leaks After Anterior Skull Base Trauma: A Systematic Review of the Literature.

BACKGROUND: Anterior skull base (ASB) fractures are reported in 4% of head injuries and represent 21% of all skull fractures. Cerebrospinal fluid (CSF) leaks may follow, severely exacerbating outcomes. We systematically reviewed the literature to analyze and compare the roles of endoscopic surgery, open surgery, and combined approaches in the management of CSF leak repair after posttraumatic ASB fractures. METHODS: PubMed, Web of Science, and Scopus databases were searched in accordance with the PRISMA guidelines. Studies reporting clinical data of patients with CSF leaks after ASB fracture were reviewed, focusing on management strategies and posttreatment outcomes. RESULTS: We included 29 articles comprising 888 patients. The average age at diagnosis was 34 years (range, 18-91 years), with a male predominance (54%) and a male/female ratio of 2.9:1 (647:241). Clinical data were available for 888 patients with CSF leaks after ASB fracture, reporting a median follow-up time of 33.5 months (standard deviation, ±29; range, 0.5-330.0 months). Open surgical repair was the most common approach (67.9%), followed by endoscopic surgical repair (32.1%). The endoscopy cohort showed lower rates of complications (0.7% vs. 11.1%) and fistula recurrence (2.8% vs. 5.3%) compared with open surgery. CONCLUSIONS: ASB fractures are frequently treated as late surgery, 24 hours from injury or later, especially for endoscopic surgery. Overall, the endoscopic approach is preferred, mostly because of its safety and effectiveness, offering lower failure rates than does open surgery.