Enhanced recovery after orthognathic surgery: a retrospective comparison study of 56 patients

Enhanced Recovery After Surgery (ERAS) protocols have been demonstrated to expedite recovery and decrease hospital stay from multiple surgical specialties. This study sought to determine how an ERAS protocol would improve patient outcomes with regards to inpatient postoperative nausea, vomiting, and pain scores following orthognathic surgeries. This was a retrospective study comparing patients who underwent orthognathic surgery with and without an ERAS protocol. The primary measurables included opioid consumption, antiemetic medical consumption, nausea and vomiting incidences, and pain scores between the two groups during their hospital stays. A total of 56 patients were retrospectively analysed comparing ERAS protocol to non-ERAS protocol. The maximum pain score of the ERAS group was 5.50 out of 10 compared to the control group of 7.50 out of 10 (p<0.001). Morphine equivalent consumption during their time in the ward was statistically significant (51.4 mg control versus 9.4 mg ERAS group). ERAS protocol is safe and effective for decreasing postoperative pain and nausea. The ERAS protocol is not only applicable for orthognathic surgery but should be highly considered for other maxillofacial surgeries.     

Effects of throat packs during orthognathic surgery: a double-blind randomized controlled clinical trial

Throat packs are commonly used in maxillofacial surgeries. However, the evidence to support the benefits of their use is controversial. The aim of this study was to evaluate the effectiveness of throat packs in preventing postoperative nausea and vomiting, and their influence on the incidence of sore throat and dysphagia in patients undergoing orthognathic surgery. This was a prospective double-blind randomized study with 54 patients, who were randomized to two groups: with throat pack (n = 27) and without throat pack (n = 27). Fifty patients (25 in each group) were included in the analysis; 66% female and 34% male, mean age 29.44 ± 8.53 years. Postoperative nausea and vomiting (Kortilla scale), sore throat (visual analogue scale), and dysphagia were evaluated. Statistically significant differences in favour of the without-pack group were found for the variables throat pain at 24 hours (P = 0.002) and dysphagia at 2 hours (P = 0.007) and 24 hours (P < 0.001). There was no difference between the groups regarding postoperative nausea and vomiting (P = 1.00). The results of this study indicate that throat packs as utilized here do not prevent postoperative nausea and vomiting and are associated with worse sore throats and postoperative dysphagia.     

The effects of melatonin prophylaxis on sensory recovery and postoperative pain following orthognathic surgery: a triple-blind randomized controlled trial and biochemical analysis

Post-surgical neuropathy is a known complication of many surgical procedures for which few remedies are effective. This study used neurosensory assessments and biochemical assays to evaluate the efficacy of melatonin on nerve healing following orthognathic surgery. Thirty randomly allocated orthognathic patients were prophylactically administered either oral melatonin or identical placebo for 21 consecutive days. Pre- and post-surgical clinical parameters included subjective pain, numbness, and objective neurosensory function. Pre- and post-surgical biochemical parameters were serum hydrogen peroxide and antioxidant enzyme levels. Melatonin was found to significantly reduce subjective pain perception by 50% in the early postoperative days. A 30% reduction in subjective numbness perception was observed at 1-week postoperative, increasing to an over 80% reduction by 3 months postoperative (P < 0.00001). Objective neurosensory testing showed a significant improvement in healing profile in the melatonin group. Postoperatively, the hydrogen peroxide concentration was lower in the melatonin group (P < 0.00001), and the levels of antioxidant enzymes were higher (P < 0.00001). The strong correlations between clinical outcomes and biochemical changes suggest a link between antioxidant effects and reduced postsurgical pain and sensory recovery. The study findings suggest that the prophylactic administration of melatonin confers significant clinical benefits in terms of reduced postoperative pain and opioid use and improved sensory recovery following surgery.     

Improvement in quality of life after skeletal advancement surgery in patients with moderate-to-severe obstructive sleep apnoea: a longitudinal study

Skeletal advancement surgery with sagittal split ramus osteotomy (SSRO) or mandibular distraction osteogenesis (MDO) is effective in treating patients with obstructive sleep apnoea (OSA) and may improve their quality of life (QoL). This study aimed to evaluate the longitudinal QoL changes in moderate-to-severe OSA patients after skeletal advancement surgery. Eighteen patients were randomized to receive SSRO (n = 9) or MDO (n = 9) alone or as part of the skeletal advancement surgery. Baseline QoL was compared with that of a control group (n = 36). QoL was compared between the SSRO group and MDO group over a period of 2 years postoperative. The Epworth Sleepiness Scale (ESS), Calgary Sleep Apnea Quality of Life Index (SAQLI), Functional Outcomes of Sleep Questionnaire (FOSQ), and Short Form Health Survey (SF-36) were used as instruments. The OSA group had worse ESS, SF-36, FOSQ, and SAQLI preoperatively than the control group. The MDO and SSRO groups showed significant improvements in ESS at all postoperative time points (P ≤ 0.021). The FOSQ, SAQLI, and SF-36 of both groups at 2 years postoperative were similar to those of the control group. No differences in QoL were found between the SSRO and MDO groups. This study showed QoL was improved in patients with moderate-to-severe OSA after skeletal advancement surgery by SSRO or MDO.     

Comparison of patient satisfaction measures between in-person and telemedicine postoperative appointments following third molar surgery

The goal of this study was to compare key aspects of patient satisfaction in patients who underwent in-person and telemedicine postoperative appointments following third molar surgery. A total of 69 patients undergoing the removal of third molars were randomized to receive their postoperative care either in person or via telemedicine appointments. Following the postoperative visit, patients were asked to complete a survey that assessed elements of patient satisfaction using a visual analog scale. Forty-seven patients (37 female, 10 male) completed the study (in-person n = 24, telemedicine n = 23). The mean total patient satisfaction score (maximum 50) was 46.46 for the in-person group and 48.78 for the telemedicine group; the difference was not statistically significant (P = 0.11). There were no statistically significant differences in patient satisfaction scores between the two groups with regards to the ease of scheduling the appointment, ease of attending the appointment, perceived usefulness of the appointment, or the quality of patient education received at the appointment. However, the perceived cost-effectiveness was higher for patients in the telemedicine group (P = 0.01). The results of this study suggest that for third molar extraction surgery, telemedicine and in-office postoperative visits produce similar patient satisfaction experiences, but patient perceived cost-effectiveness was greater for telemedicine visits.     

Changing from epidurals to femoral nerve catheters for postoperative analgesia following total knee arthroplasty: Analysis of efficacy versus nurse perception

A retrospective review and survey was performed to evaluate a new protocol for postoperative pain control in patients undergoing total knee arthroplasty (TKA). The goal of the new protocol was to improve postoperative pain control, decrease side effects and facilitate participation in physical therapy. Previously, patients received an epidural infusion overnight (n = 130). With the new protocol, patients received a femoral nerve catheter (FNC) infusion until the morning of postoperative day two (POD2) (n = 170). Both groups received a combination of oral and intravenous analgesics. The FNC group was able to ambulate further, and was more likely to participate in physical therapy on the day of surgery. Patients in the FNC group also reported less pain, nausea and pruritis. Length of stay was not impacted on. Patients with an epidural required less opioid on the day of surgery but, there was no difference in opioid consumption compared through POD2. A survey was administered to nurses in the post anesthesia care unit and the orthopedic ward to investigate perceptions about the new protocol. The results of the survey demonstrated that although the change was effective, sufficient staff education is an important component of staff perceptions and implementing a change in practice.     

Increased tracheostomy rates in head and neck cancer surgery during the COVID-19 pandemic

Surgical practice during the coronavirus disease 2019 (COVID-19) pandemic has changed significantly, without supporting data. With increasing experience, a dichotomy of practice is emerging, challenging existing consensus guidelines. One such practice is elective tracheostomy. Here, we share our initial experience of head and neck cancer surgery in a COVID-19 tertiary care centre, emphasizing the evolved protocol of perioperative care when compared to pre-COVID-19 times. This was a prospective study of 21 patients with head and neck cancers undergoing surgery during the COVID-19 pandemic, compared to 193 historical controls. Changes in anaesthesia, surgery, and operating room practices were evaluated. A strict protocol was followed. One patient tested positive for COVID-19 preoperatively. There was a significant increase in pre-induction tracheostomies (28.6% vs 6.7%, P = 0.005), median hospital stay (10 vs 7 days, P = 0.001), and postponements of surgery (57.1% vs 27.5%, P = 0.01), along with a significant decrease in flap reconstructions (33.3% vs 59.6%, P = 0.03). There was no mortality and no difference in postoperative morbidity. No healthcare personnel became symptomatic for COVID-19 during this period. Tracheostomy is safe during the COVID-19 pandemic and rates have increased. Despite increased rescheduling of surgeries and longer hospital stays, definitive cancer care surgery has not been deferred and maximum patient and healthcare worker safety has been ensured.     

Clinical efficacy of acellular dermal matrix for plastic periodontal and implant surgery: a systematic review

This review was performed to validate the clinical efficacy of acellular dermal matrix (ADM) for plastic periodontal and implant surgery. Four electronic databases and a manual search were utilized to select randomized clinical trials (RCTs) published until March 2019. Overall, 28 RCTs were included: 25 on teeth and three on implants. For plastic periodontal surgery, ADM exhibited a comparable gingival recession reduction (RecRed) and soft tissue thickness (STT) gain to connective tissue graft (CTG). Subgroup analyses revealed that ADM obtained a similar keratinized tissue width (KTW) gain to CTG within 3–6 months postoperative, but significantly less KTW gain at 1–5 years postoperative (P = 0.01, mean difference (MD) −0.86 mm). Analyses comparing ADM with free gingival graft (FGG) demonstrated similar RecRed but significantly more KTW/STT gain favouring FGG (KTW: P = 0.01, MD −1.78 mm; STT: P = 0.01, MD −0.77 mm). Significantly more RecRed and KTW/STT gain were verified in ADM + coronally advanced flap/laterally positioned flap compared with these flaps alone (RecRed: P < 0.00001, MD 0.65 mm; KTW: P = 0.001, MD 0.66 mm; STT: P < 0.00001, MD 0.59 mm). Limited data for implant surgery indicated a similar trend as for periodontal surgery. Concerning patient-reported outcomes, ADM achieved favourable aesthetic appearance, alleviation of dentinal hypersensitivity, and less surgical morbidity. In conclusion, ADM exerted comparable clinical efficacy to autogenous tissue for root coverage procedures, with good long-term stability. However, for soft tissue augmentation, ADM exhibited inferior 3–6-month postoperative outcomes compared with FGG and less long-term stability of KTW gain compared with CTG.     

Comparison between computer-guided and freehand dental implant placement surgery: A systematic review and meta-analysis

The purpose of this systematic review was to compare computer-guided (fully guided) and freehand implant placement surgery in terms of marginal bone loss, complications, and implant survival. This review followed the PRISMA guidelines and was registered in the PROSPERO database (CRD42019135893). Two independent investigators performed the search of the PubMed/MEDLINE, Scopus, and Cochrane Library databases for studies published up to April 2020 and identified 1508 references. After a detailed review, only four studies were considered eligible. These studies involved a total of 154 patients with 597 dental implants and a mean follow-up period of 2.25 years. There was no difference between computer-guided surgery and freehand surgery in terms of the marginal bone loss (mean difference ?0.11 mm, 95% confidence interval (CI) ?0.27 to 0.04 mm; P = 0.16), mechanical complications (risk ratio (RR) 0.85, 95% CI 0.36–2.04; P = 0.72), biological complications (RR 1.56, 95% CI 0.42–5.74; P = 0.51), and implant survival rate (RR 0.53, 95% CI 0.11–2.43; P = 0.41). This meta-analysis demonstrated that both computer-guided and freehand surgeries yielded similar results for marginal bone loss, mechanical and biological complications, and implant survival rate.     

Accuracy of virtual planned surgery versus conventional free-hand surgery for reconstruction of the mandible with osteocutaneous free flaps

Virtual surgical planning (VSP) promises higher accuracy, efficiency, and superior patient outcomes, helping normalize outcomes from surgeons of different experience levels. A systematic review was conducted in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The objective was to evaluate the accuracy and secondarily efficiency of VSP compared with free-hand surgery, for mandibular reconstruction with free flaps. Six studies met inclusion criteria and had quantitative data suitable for meta-analysis. Intercondylar distance and gonion angle were used to assess accuracy, evaluated by mean change from preoperative VSP and postoperative imaging. The mean weighted difference in VSP intercondylar distance was 2.0 mm, compared with 3.9 mm for free hand (P = 0.101) and mean change in gonion angle for VSP was 3.6°, compared with 7.7° for free hand (P < 0.05). Efficiency assessed by mean ischemia time, was 73.8 min and 109.9 min, for VSP and free hand, respectively (P = 0.203), and by total operative time, which was 391.8 min and 457.6 min in the VSP and free hand, respectively (P = 0.340). VSP is consistently proven to be more accurate and efficient than traditional free-hand surgery; however, a standardized method for accuracy and efficiency measurements is still missing, causing heterogeneity among the scientific reports.     

Preoperative underweight is associated with adverse postoperative events in patients undergoing microvascular reconstruction surgery for oral and maxillofacial cancer

We aimed to describe the prevalence of postoperative complications and evaluate its relationship with underweight, obesity, preoperative nutritional status, and systemic inflammation status in patients undergoing microvascular reconstruction for oral and maxillofacial cancer. Patients who were ≥20 years old and underwent microvascular reconstruction surgery between January 2009 to June 2019 were investigated. Patient demographics including body mass index, prognostic nutritional status, and neutrophil-lymphocyte ratio were collected. Logistic regression analysis was applied to evaluate these impacts on postoperative complications. A postoperative complication was defined as a Clavien–Dindo classification more than or equal to II. Of the 145 patients included in the analysis, 83 patients (57.2%) experienced postoperative complications, belonging to a Clavien–Dindo classification Ⅱ (n = 71), Ⅲb (n = 11), and Ⅳa (n = 1). Multiple logistic regression revealed that a body mass index less than 18.5 kg/m² (odds ratio 6.19, 95% confidential interval 1.34–28.6, P = 0.02) was related to postoperative complications. Another multiple logistic regression model including all explanatory factors found that underweight (P = 0.03) was related to postoperative complications. This retrospective study showed that preoperative underweight was associated with postoperative complications as evaluated by the Clavien–Dindo classification.     

Comparison of three different types of splints and templates for maxilla repositioning in bimaxillary orthognathic surgery: a randomized controlled trial

The selection and implementation of a plan for maxillary surgery is of the utmost importance in achieving the desired outcome for the patient undergoing two-jaw orthognathic surgery. Some splint-based and splintless methods, accompanied by computer-assisted techniques, are helpful in improving surgical plan implementation. However, randomized controlled trials focused on this procedure are lacking. This study included 61 patients who underwent bimaxillary surgeries. The patients were randomly assigned to a conventional resin occlusal splint (CROS) group, a digital occlusal splint (DOS) group, or a digital templates (DT) group, in a 1:1:1 ratio. The mean linear distance between the planned and actual postoperative positions of eight selected points on the surfaces of the maxillary teeth was selected as the outcome measure. The distance was significantly smaller in the DT group (1.17 ± 0.66 mm) when compared to both the CROS group (2.55 ± 0.95 mm, P < 0.05) and DOS group (2.15 ± 1.12 mm, P < 0.05). However, the difference between the CROS group and DOS group was not statistically significant. These findings indicate that using digital templates results in the best performance in transferring the surgical plan to the operation environment as compared to the other two types of splints. This suggests that the application of digital templates could provide a reliable treatment option.     

Orthognathic surgery with or without induced hypotension

This study involved a retrospective evaluation of patients subjected to surgery for dentofacial deformities treated without induced controlled hypotension (group I, n = 50) and a prospective evaluation of patients who were subjected to surgery under hypotensive general anaesthesia (group II, n = 50). No statistical differences were found between the study groups with regard to the duration of surgery. However, there were statistically significant differences in the need for blood transfusion and the occurrence of bradycardia during the maxillary down-fracture. Hypotensive anaesthesia decreased the need for a blood transfusion and the occurrence of bradycardia, and is therefore considered highly beneficial for patients undergoing orthognathic surgery.     

Accuracy of maxillary repositioning in two-jaw surgery with conventional articulator model surgery versus virtual model surgery

The purpose of this study was to compare the accuracy of maxillary repositioning using the recently introduced computerized virtual model surgery (VMS) with conventional articulator model surgery (AMS). Forty-two patients who had undergone bimaxillary surgery were investigated retrospectively in this study. The patients were divided into two groups: conventional AMS (n = 23) and VMS (n = 19) for intermediate splint fabrication in maxillary positioning. Planned surgical movements and actual postsurgical changes of the lateral and frontal cephalometric measurements were compared. Although variations from the planned surgical movements were relatively small, both methods had statistically significant errors in some of the linear measurements. Both groups had a similar range of errors. The overall absolute mean discrepancy between the planned and actual surgical movements for the linear measurements was 1.17 mm (0–3.6 mm) in AMS and 0.95 mm (0–3.2 mm) in VMS. Of the total measurements, measurements reflecting a surgical discrepancy of more than 2 mm or 2° comprised 12.0% of the cases in AMS and 7.9% in VMS. The surgical accuracy of maxillary positioning with VMS was comparable to conventional AMS. Because VMS has the definitive advantage of eliminating the complex laboratory step and shortening the laboratory time, this can be accepted as an alternative to AMS.     

Incidence of bleeding after minor oral surgery in patients on dual antiplatelet therapy: a systematic review and meta-analysis

Bleeding is a feared complication of minor oral surgery in patients on treatment with antiplatelet agents and there is no agreed strategy regarding the cessation or not of antiplatelet treatment. The aim of this systematic review was to evaluate bleeding with minor oral surgery in patients on dual antiplatelet therapy (DAPT), single antiplatelet therapy (SAPT), or no antiplatelet therapy (no APT). The PubMed, Embase, Web of Science, and Cochrane Library databases were screened. Sixteen studies were included. DAPT was continued in all studies. The perioperative bleeding risk was significantly higher for DAPT than for SAPT (risk ratio (RR) 10.16, P =  0.010; risk difference (RD) 0.35, P =  0.269), but not higher compared to no APT (RR 6.50, P =  0.057; RD 0.19, P =  0.060). The postoperative bleeding risk was significantly elevated for DAPT compared to SAPT (RR 2.61, P =  0.010) and no APT (RR 3.63, P =  0.035), but only by 1% (RD 0.01, P =  0.103) and 1% (RD 0.01, P =  0.421), respectively. Clinically, this may be considered quite similar. Additionally, local haemostatic measures could control all reported bleeding and no lethal events occurred. Therefore, DAPT interruption is not advised before minor oral surgery.     

Evaluation of the efficacy of celecoxib and ibuprofen on postoperative pain,swelling, and mouth opening after surgical removal of impacted third molars: a randomized,controlled clinical trial

The objective of this study was to compare the efficacy of celecoxib and ibuprofen in reducing postoperative sequelae following the surgical removal of impacted mandibular third molars. Ninety-eight subjects who needed surgical extraction of an impacted mandibular third molar were selected for the study. All subjects were randomly allocated to receive one of the following treatments twice a day for 5 days after surgery: placebo (n = 32), ibuprofen (n = 33), or celecoxib (n = 33). The primary outcome chosen was postoperative pain, which was evaluated using the visual analogue scale (VAS) score recorded by each patient. The secondary outcomes chosen were changes in postoperative swelling and maximum mouth opening values compared to preoperative ones. Compared to placebo, treatment with celecoxib and ibuprofen resulted in improvements in the primary outcome. Furthermore, when compared to the other groups, patients in the celecoxib group showed a significant reduction in postoperative pain scores at 6 h (P < 0.001), 12 h (P = 0.011), and 24 h (P = 0.041) after surgery. Regarding swelling and maximum mouth opening values, there were no significant differences between the groups at each follow-up session. This study demonstrated that treatment with celecoxib decreased the incidence and severity of postoperative pain following third molar surgery compared to ibuprofen and placebo.     

Jaw-stretch reflex is weaker in patients after orthognathic surgery

ObjectivesThe jaw-stretch reflex (JSR) was studied in both patients and healthy participants in order to investigate the possible long-term impact of orthognathic surgery on the motor function of the masticatory system.DesignJSR was measured in patients before surgery (PC), 1 year after surgery (PS) and in healthy controls (HC) (N = 31 in each group). JSR was evoked by a standardized stretch device and recorded bilaterally from masseter and anterior temporalis muscles using surface electromyography (EMG).ResultsThe peak-to-peak amplitude (which was normalized to pre-stimulus EMG activity) of JSRs in PC and PS were significantly smaller than in HC (P < 0.001; P < 0.001). The onset latency in PS was significantly longer compared with HC (P < 0.05). The duration of JSR in PS was significantly longer than in HC and PC (P < 0.001; P < 0.05).ConclusionPatients with dentofacial deformities are characterized by reduced JSR amplitude. The delayed onset and elongated duration of JSR might be potential indicators of a long-term surgical impact on the motor function of the masticatory system.     

Splintless surgery using patient-specific osteosynthesis in Le Fort I osteotomies: a randomized controlled multi-centre trial

The accuracy of orthognathic surgery has improved with three-dimensional virtual planning. The translation of the planning to the surgical result is reported to vary by >2 mm. The aim of this randomized controlled multi-centre trial was to determine whether the use of splintless patient-specific osteosynthesis can improve the accuracy of maxillary translation. Patients requiring a Le Fort I osteotomy were included in the trial. The intervention group was treated using patient-specific osteosynthesis and the control group with conventional osteosynthesis and splint-based positioning. Fifty-eight patients completed the study protocol, 27 in the patient-specific osteosynthesis group and 31 in the control group. The per protocol median anteroposterior deviation was found to be 1.05 mm (interquartile range (IQR) 0.45–2.72 mm) in the patient-specific osteosynthesis group and 1.74 mm (IQR 1.02–3.02 mm) in the control group. The cranial–caudal deviation was 0.87 mm (IQR 0.49–1.44 mm) and 0.98 mm (IQR 0.28–2.10 mm), respectively, whereas the left–right translation deviation was 0.46 mm (IQR 0.19–0.96 mm) in the patient-specific osteosynthesis group and 1.07 mm (IQR 0.62–1.55 mm) in the control group. The splintless patient-specific osteosynthesis method improves the accuracy of maxillary translations in orthognathic surgery and is clinically relevant for planned anteroposterior translations of more than 3.70 mm.     

Variation between natural head orientation and Frankfort horizontal planes in orthognathic surgery patients: 187 consecutive cases

The purpose of this study was to assess the relationship between the Frankfort horizontal (FH) and natural head orientation (NHO), their correlation between patients’ malocclusion, and the impact of counterclockwise rotation (CCW) on the FH-NHO angle variation after orthognathic surgery. An evaluation of 187 consecutive patients was performed at the Maxillofacial Institute (Teknon Medical Center, Barcelona). FH-NHO° was measured pre- and postoperatively at 1 and 12 months, after three-dimensional (3D) superimposition using a software (Dolphin®). Patients were classified as follows: 3.2%, 48.7% and 48.1%, class I, II and III, respectively. Baseline FH-NHO° was significantly positive for patients with dentofacial deformities (2.73° ± 4.19 (2.12–3.33°, P < 0.001). The impact of orthognathic surgery in FH-NHO° was greater in class II when compared with class III patients, with a variation of 2.04° ± 4.79 (P < 0.001) and −1.20° ± 3.03 (P < 0.001), respectively. FH-NHO° increased when CCW rotational movements were performed (P = 0.006). The results of this study suggest that pre- and postoperative NHO differs from FH in orthognathic patients. The angle between FH and NHO is significantly larger in class III than in class II patients at baseline, which converges after orthognathic surgery when CCW rotation is performed. Therefore, NHO should be used as the real horizontal plane when planning for orthognathic surgery.     

The value of reconstructive surgery in the management of refractory jaw osteoradionecrosis: a single-center 10-year experience

Mandibular osteoradionecrosis (mORN) is a severe complication of head and neck irradiation. International consensus on the management of mORN is currently lacking. The present study sought to evaluate the effectiveness and benefits of early reconstructive surgery (resection of the diseased bone and immediate reconstruction with a free flap) in treatment-refractory mORN. A single-center retrospective study was carried out of operations performed in a French university medical center between 2003 and 2013 inclusive. For each patient, the surgical modalities and postoperative outcomes were recorded. A total of 55 operations (19 marginal resections and 36 segmental resections) were performed, and the overall success rate was 92.3%. Relative to marginal resections, segmental resections were associated with longer operating times (440 ± 62 min vs. 531 ± 72 min, respectively; P < 0.05 in Student’s t-test), a longer length of hospital stay (16.5 ± 6.5 days vs. 25.6 ± 11.3 days, respectively; P < 0.05), and a higher complication rate (26.3% vs. 63.9%, respectively; P < 0.05 in Fisher’s test). Given the unpredictable progression of treatment-refractory mORN and the risk–benefit ratio observed here, the value of early reconstructive surgery with curative intent should be reassessed.