Int Orthop. 2025 Oct 25. doi: 10.1007/s00264-025-06680-4. Online ahead of print.

ABSTRACT

PURPOSE: Sleep disturbance is common in patients with rotator cuff tear arthropathy (RCTA). While reverse shoulder arthroplasty (RSA) is effective for improving pain and function, its effect on sleep quality (SQ) has not been well defined. This study aimed to evaluate the impact of RSA on SQ, recovery trajectory, and clinical outcomes.

METHODS: This retrospective study included patients with RCTA who underwent RSA between 2014 and 2021 with a minimum follow-up of 24 months. SQ and clinical outcomes were assessed using the Visual Analog Scale (VAS), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES) score, Pittsburgh Sleep Quality Index (PSQI), and Jenkins Sleep Scale (JSS). Preoperative and postoperative values were compared to evaluate changes over time.

RESULTS: Forty-six patients (mean age, 68 years) with a mean follow-up of 5.7 years were included. Sleep disturbance was reported by 45.7% of patients preoperatively, decreasing to 26.1% at three months and 21.7% at the last follow-up (p < 0.001). Median PSQI scores improved from 6 preoperatively to 5 at three months and remained stable thereafter. The mean ASES score increased from 40.2 preoperatively to 62.2 postoperatively (p < 0.001), and the average VAS score decreased from 6.0 to 2.0 by six months (p < 0.001).

CONCLUSION: RSA leads to improvements in sleep and function in RCTA patients, though gains plateau with time. Future studies using objective sleep measures may further refine rehabilitation outcomes.

PMID:41137888 | DOI:10.1007/s00264-025-06680-4

Int Orthop. 2025 Oct 23. doi: 10.1007/s00264-025-06675-1. Online ahead of print.

ABSTRACT

PURPOSE: Displaced intra-articular calcaneal fracture treatment may involve surgical intervention to restore the anatomy of the calcaneus and promote proper healing. Numerous surgical techniques, such as open reduction internal fixation (ORIF) or percutaneous fixation, have been utilized with varying degrees of success in achieving anatomical reduction and functional outcomes. However, complication rates are still high, and there is ongoing debate regarding the optimal surgical approach. This study presents a delta-frame triplanar external fixation technique combining intra- and extra-calcaneal distraction, specifically designed for Sanders III/IV fractures with soft-tissue compromise.

METHODS: The technique combines intra-calcaneal and extra-calcaneal distraction principles to restore calcaneal morphology in three planes. 18 patients with Sanders type III and IV DIACFs were definitively surgically treated using a delta type triplanar fixator in a single stage between 2017 and 2020. Calcaneal restoration was achieved through the intra- and extra-articular distraction principle. Outcome measures included clinical, radiological and patient-reported outcomes including the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the Foot and Ankle Disability Index (FADI).

RESULTS: Eighteen patients (mean age 38 years) representing 26 fractures were evaluated. Two patients required subtalar arthrodesis by one year post injury. The post-operative Bohler and Gissane angles averaged 29.1° and 112.4°, respectively. Calcaneal inclination angle, height, and Böhler angle were restored within appropriate limits in all cases. At a mean follow-up of 52 ± 8.6 months (range 42 to 84 months), mean AOFAS and FADI scores were 82.5 and 85.5, respectively.

CONCLUSION: The delta-framed triplanar external fixation technique appears safe, yielding favorable radiological outcomes and a low complication rate in the management of displaced intra-articular calcaneus fractures. These findings suggest effective restoration of calcaneal anatomy using triplanar external fixation.

PMID:41128844 | DOI:10.1007/s00264-025-06675-1

Int Orthop. 2025 Oct 21. doi: 10.1007/s00264-025-06671-5. Online ahead of print.

ABSTRACT

PURPOSE: Femoral neck fractures in nongeriatric patients pose a significant clinical challenge due to the high clinical failure rate. To address this, Alpha fixation and the Femoral Neck System (FNS) were developed but seldom been compared head-to-head. The purpose of this study was to compare the clinical prognosis of these two methods with traditional parallel screws.

METHODS: This retrospective cohort study included 341 patients aged 18-65 years, treated between June 2020 and June 2023. Patients were grouped by fixation strategies: (1) parallel screws (n = 206), (2) Alpha fixation (n = 73), and (3) FNS (n = 62). Fixation failure (nonunion, severe femoral neck shortening, varus collapse) was compared as primary clinical outcome using univariate and multivariate analyses. Secondary outcomes included avascular necrosis and reoperation rates. Analyses were stratified by Pauwels classification.

RESULTS: Fixation failure rates were highest with parallel screws (21.4%), intermediate with FNS (12.9%), and lowest with Alpha fixation (9.6%). Multivariate analysis showed significantly lower fixation failure with Alpha fixation compared to parallel screws (adjusted OR = 0.29, 95% CI: 0.10-0.73, p = 0.014). Alpha fixation significantly reduced femoral neck shortening (p = 0.017), whereas FNS significantly reduced varus collapse (p = 0.013). In Pauwels type III fractures, Alpha fixation and FNS both significantly reduced fixation failure rates compared to parallel screws; no difference was found in Pauwels types I-II.

CONCLUSIONS: Alpha fixation and FNS significantly outperformed parallel screws in reducing fixation failure in vertical femoral neck fractures among nongeriatric patients. Alpha fixation showed advantages in limiting femoral neck shortening, whereas FNS more effectively prevented varus collapse. For stable fractures, conventional parallel screws remain a reasonable choice.

PMID:41117917 | DOI:10.1007/s00264-025-06671-5

Int Orthop. 2025 Oct 21. doi: 10.1007/s00264-025-06676-0. Online ahead of print.

ABSTRACT

PURPOSE: Eccentric rotational acetabular osteotomy (ERAO) is an effective treatment for acetabular dysplasia, but delayed union of the superior pubic ramus is a concern. This study identified risk factors for delayed pubic union post-ERAO and evaluated its clinical impact.

METHODS: This retrospective study included 101 patients who underwent ERAO during 2014-2022, grouped according to one year pubic union status: union (n = 78) and delayed union (n = 23). We compared demographics, pre-and postoperative radiographic parameters (including lateral, anterior, and posterior centre-edge angles; acetabular sector angles; acetabular anteversion; pubic osteotomy site; and femoral head centre lateralisation), and clinical outcomes.

RESULTS: Multivariate logistic regression identified older age (odds ratio [OR], 1.07; 95% CI, 1.00-1.13), a more medial pubic osteotomy site relative to the iliopectineal eminence (OR, 1.28; 95% CI, 1.10-1.49), and insufficient femoral head centre medialisation (OR, 1.40; 95% CI 1.12-1.74) as independent risk factors for delayed union. The pubic osteotomy site cutoff was 12.0 mm medial to the iliopectineal eminence (AUC 0.759). The delayed union group exhibited significantly higher rates of inferior pubic ramus stress fractures (17.4% vs. 1.3%, p = 0.009), although two year JOA scores were similar between groups.

CONCLUSION: Older age, pubic osteotomy more medial to the iliopectineal eminence, and insufficient femoral head medialisation are key risk factors for delayed pubic union after ERAO. While these factors did not directly affect hip function at two years postoperatively, they significantly increased the risk of inferior pubic ramus stress fractures. Therefore, accurate pubic osteotomy and careful avoidance of femoral head lateralisation are essential.

PMID:41117916 | DOI:10.1007/s00264-025-06676-0

Int Orthop. 2025 Oct 15. doi: 10.1007/s00264-025-06672-4. Online ahead of print.

ABSTRACT

PURPOSE: Registry data suggests that robotic-assisted unicompartmental knee arthroplasty (rUKA) significantly reduces all-cause revisions compared to conventional implantation (cUKA). This study aims to compare joint line-related parameters and their reconstruction accuracy between rUKA and cUKA.

METHODS: Five databases were searched using a pre-defined strategy and inclusion criteria: (1) comparative studies reporting radiological outcomes, (2) human studies, (3) English language, and (4) meta-analyses for cross-referencing. Cadaveric or saw-bone studies were excluded. Data extracted included demographics data, pre- and postoperative radiological parameters (HKA, MPTA, LDFA, posterior tibial slope, femoral sagittal angle, joint line height, implant congruency), and outliers. A random-effects meta-analysis was conducted using mean difference (MD) and odds ratio (OR) as main effect estimators. Risk of bias was assessed using the Newcastle-Ottawa Scale (NOS), and publication bias was evaluated with funnel plots.

RESULTS: A total of 18 studies assessing 2470 patients (1112 rUKA, 1358 cUKA) were included in the analysis. No significant baseline differences were found in age, sex, BMI, follow-up period, MPTA, LDFA, or tibial slope. Postoperative radiological parameters showed no significant differences between groups for HKA, LDFA, MPTA, or tibial slope (p > 0.05). Joint line height was significantly lower in cUKA compared to rUKA (MD = -1.37 mm, 95% CI: -2.06 to -0.69, p < 0.001). Outlier analysis revealed that rUKA had significantly fewer outliers across relevant radiological parameters, including HKA, joint line height, tibial slope, femoral flexion, femoral implant congruency, and medial, anterior, and posterior tibial congruency.

CONCLUSION: Reporting pre- and postoperative mean alignment parameters undermines patient-specific anatomy reconstruction with advanced technologies. Outlier reporting showed significant variability, with limited evidence supporting its clinical relevance. Future studies should focus on patient-specific reconstruction and define clinical thresholds for outliers.

PMID:41091159 | DOI:10.1007/s00264-025-06672-4

Int Orthop. 2025 Oct 15. doi: 10.1007/s00264-025-06670-6. Online ahead of print.

NO ABSTRACT

PMID:41087774 | DOI:10.1007/s00264-025-06670-6

Int Orthop. 2025 Oct 15. doi: 10.1007/s00264-025-06666-2. Online ahead of print.

NO ABSTRACT

PMID:41087773 | DOI:10.1007/s00264-025-06666-2

Int Orthop. 2025 Oct 9. doi: 10.1007/s00264-025-06665-3. Online ahead of print.

ABSTRACT

PURPOSE: Conserving the subscapularis tendon during reverse shoulder arthroplasty (RSA) has proven its impact on postoperative outcomes, particularly regarding stability and range of motion. A subscapularis preserving approach has been developed: the Anterior Muscle Sparing (AMS) approach that enables not to violate the subscapularis tendon. Our aim was to compare this approach with the conventional approach, which consists of reinserting the subscapularis at the end of the procedure, with a specific focus on intraoperative complications and postoperative position of the implants.

METHODS: A retrospective consecutive study was performed of patients undergoing a primary RSA between January 2021 and December 2024 performed by the same surgeon. We included 32 patients receiving the standard approach (SA) and 24 patients receiving the AMS approach. Implant positioning was assessed through three different variables: the glenoid implant inclination relative to the floor of the supraspinatus fossa; the glenoid implant height described as the distance between the inferior border of the glenoid bone surface and the inferior part of the glenoid baseplate; and the humeral stem alignment relative to the intramedullary humeral shaft axis.

RESULTS: There were no significant differences in terms of glenoid implant inclination (-4.71 ± 6.3° Vs -3.8 ± 7.17°; p = 0.68), glenoid implant height (0.608 ± 1.94 mm Vs 0.315 ± 0.896 mm ; p = 0.655), and PERFORM® humeral stem alignment ( 1.34 ± 4.11° Vs 1.89° ± 4.63°; p = 0.715) between the two groups. The intraoperative complication rate was not significant different between the groups, with only two cases within the AMS approach group (p = 0.181). The mean operative times were not significantly different between the groups (94.06 min ± 18,71 Vs 81,73 min. ±16,58; p = 0,06). Since September 2023, when the senior author started performing RSAs with the described technique only one patient was converted from an AMS to a traditional approach during surgery due to an intraoperative complication.

CONCLUSION: When compared to the standard approach, the AMS showed no significant difference in terms of implant positioning, surgical operative times and intraoperative complication rate. An attempt to preserve the subscapularis tendon seems to be always justified, as this method is a safe and reliable alternative to the traditional approach.

LEVEL OF EVIDENCE: Level III, Retrospective Cohort Comparison Treatment study.

PMID:41065821 | DOI:10.1007/s00264-025-06665-3

Int Orthop. 2025 Oct 8. doi: 10.1007/s00264-025-06668-0. Online ahead of print.

NO ABSTRACT

PMID:41060390 | DOI:10.1007/s00264-025-06668-0

Int Orthop. 2025 Oct 7. doi: 10.1007/s00264-025-06667-1. Online ahead of print.

NO ABSTRACT

PMID:41055733 | DOI:10.1007/s00264-025-06667-1

Int Orthop. 2025 Oct 1. doi: 10.1007/s00264-025-06661-7. Online ahead of print.

ABSTRACT

PURPOSE: In shoulder arthroplasty, three-dimensional computed tomography (3D CT) has become the gold standard for preoperative version assessment. Meanwhile, postoperative version is usually evaluated using radiographs (XR), in particular an axillary view, in which the view of the scapular body is often truncated, preventing the scapular plane from being used as a reference. This study introduces the posterolateral acromion-to-coracoid (PLAC) line, which can be assessed on a standard truncated axillary radiograph.

MATERIALS AND METHODS: Forty-six shoulders were studied. Four angles were measured including 3D CT (CT Version), 3D CT PLAC line to glenoid face angle (CT PLAC-GFA), 2) radiographic PLAC line to glenoid face angle (XR PLAC-GFA), and 3) the radiographic glenoid vault line to glenoid face angle (XR GV-GFA). Variation and linear relationship between these angles were calculated.

RESULTS: The mean difference between CT PLAC-GFA and XR PLAC-GFA was 1.0º (95% CI -0.7 to 2.8)(IQR = 8.5º, -3.0º to 5.4º), with a strong correlation on linear regression (R2 = 0.76, p < 0.001). XR PLAC-GFA and XR GV-GFA demonstrated strong correlations with CT measured version (R2 = 0.72 and 0.70, respectively; p < 0.001). Inter-rater reliability was excellent for all metrics (ICC ≥ 0.93).

CONCLUSIONS: The PLAC and the glenoid vault lines are highly reproducible references on truncated axillary views. These alternative reference lines allow accurate comparison of preoperative and postoperative glenoid orientation using standard axillary radiographs.

PMID:41032114 | DOI:10.1007/s00264-025-06661-7

Int Orthop. 2025 Oct 1. doi: 10.1007/s00264-025-06664-4. Online ahead of print.

ABSTRACT

BACKGROUND: Posturography is a diagnostic technique that quantifies postural control through Centre of Pressure (CoP) displacement analysis on a force platform. Footwear characteristics, particularly heel-to-toe drop, may influence balance by modifying plantar pressure distribution and proprioceptive feedback. The aim of this study was to evaluate the impact of different footwear drops (0 mm, 5 mm, 10 mm) on postural control in healthy young adults, considering sex, BMI, and shoe size.

METHODS: A cross-sectional study was conducted in 117 participants (56 men, 61 women) using the Dinascan/IBV® platform and the Romberg test. CoP displacement and velocity were analyzed.

RESULTS: Significant differences were observed in CoP total displacement (p < 0.001), mean velocity (p < 0.001), and medio-lateral dispersion (p = 0.024) when comparing 0 mm to 5 mm and 10 mm drops. Sex differences were significant at 0 mm drop for maximum medio-lateral force (p < 0.001) and mean velocity (p = 0.042), with men exhibiting greater values. At 5 mm drop, men showed significantly higher swept area (p = 0.029) and anteroposterior displacement (p = 0.007) than women.

CONCLUSIONS: Small variations in footwear drop can affect postural control, particularly in the medio-lateral plane. Sex and BMI significantly influence CoP behavior, suggesting the need to consider these factors in footwear design and clinical balance assessments.

PMID:41032113 | DOI:10.1007/s00264-025-06664-4

Int Orthop. 2025 Sep 30. doi: 10.1007/s00264-025-06634-w. Online ahead of print.

NO ABSTRACT

PMID:41026200 | DOI:10.1007/s00264-025-06634-w

Int Orthop. 2025 Sep 29. doi: 10.1007/s00264-025-06639-5. Online ahead of print.

ABSTRACT

This study evaluated the outcomes of double mobility trapeziometacarpal prostheses for treating osteoarthritis (OA) of the trapeziometacarpal (TMC) joint. A prospective observational analysis was conducted on 150 implants with a maximum follow-up of four years, including a clinical and radiographic assessment and an evaluation of complications. The results indicate a prosthesis survival rate of 97.9% after the first two years post-surgery, calculated using the Kaplan-Meier method. Significant improvements were observed in pain reduction (mean VAS at 3 months post-surgery 2,9 and 1.5 after 6 months), hand grip strength (25.93 kg at 6 months post-surgery), and range of motion (Kapandji score from 8.8 to 9.2, comparing the preoperative mean with the mean after the first postoperative month). The complication rate was low, with only two cases of cup migration and one case of trapezium resorption. Patient satisfaction was high due to the rapid functional recovery and reduced invasiveness compared to traditional techniques. Double-mobility prostheses offer a highly effective treatment for stage II and III TMC OA according to the Eaton-Littler classification, with minimal need for revision surgeries.

PMID:41020960 | DOI:10.1007/s00264-025-06639-5

Int Orthop. 2025 Sep 29. doi: 10.1007/s00264-025-06663-5. Online ahead of print.

ABSTRACT

PURPOSE: Calcium pyrophosphate dihydrate (CPPD) deposition, often visible radiographically as chondrocalcinosis, frequently accompanies knee osteoarthritis and is usually encountered at the time of arthroplasty. Whether its presence influences the outcome of patellofemoral arthroplasty (PFA) remains uncertain.

METHODS: We reviewed 100 PFAs performed in 82 patients between 1997 and 2005, and followed them for an average of 22 years (range, 20-25 years). At surgery, 35 knees showed radiographic chondrocalcinosis, and an additional 33 developed calcification during follow-up.

RESULTS: Fifteen knees (15%) required revision to total knee arthroplasty (TKA) at a mean of 12 years after PFA. The main reasons for revision were tibiofemoral osteoarthritis progression (6 knees), patellar malalignment (7 knees), one implant loosening, and one patella fracture. The 20-year survival rates were 87% for knees without chondrocalcinosis and 90% for those with chondrocalcinosis, with no significant difference in revision timing between groups (log-rank p = 0.64).

CONCLUSION: Although chondrocalcinosis became more prevalent with age and follow-up, it did not increase the risk of conversion to TKA. These findings suggest that PFA remains a suitable option in carefully selected patients, regardless of the presence of chondrocalcinosis.

PMID:41020959 | DOI:10.1007/s00264-025-06663-5

Int Orthop. 2025 Sep 29. doi: 10.1007/s00264-025-06662-6. Online ahead of print.

ABSTRACT

PURPOSE: Recurrent hip dislocation after total hip arthroplasty is among the most distressing complications for patients, often reshaping their everyday lives. Beyond the immediate physical consequences, repeated instability generates fear of movement, social withdrawal, and emotional strain. Yet, the extent of this burden has rarely been quantified using patient-centered methods.

METHODS: We evaluated 170 patients who had experienced at least three dislocations and were scheduled for revision surgery. To capture the impact on health-related quality of life (HRQoL), patients completed a Time Trade-Off (TTO) assessment, estimating how many years of life they would exchange for a dislocation-free state. A parallel measure, the Survival Implant TTO, explored whether patients would sacrifice implant longevity in favor of greater stability. Their preferences were compared with surgeons' attitudes toward balancing implant durability and stability.

RESULTS: Patients consistently described instability as a devastating experience, with many reporting restrictions in daily activities and a loss of independence. On average, patients were prepared to exchange nearly one quarter of their remaining life expectancy for stability and were also willing to shorten projected implant survival if this reduced the likelihood of further dislocations. In contrast, surgeons-particularly when treating younger patients-often emphasized implant durability over stability.

CONCLUSIONS: Recurrent hip dislocation has a far-reaching impact on quality of life, comparable to or exceeding that of chronic systemic diseases. Importantly, patient priorities differ from those of surgeons: stability is consistently valued over implant longevity. Incorporating these perspectives into revision planning is essential for truly patient-centered care.

PMID:41020958 | DOI:10.1007/s00264-025-06662-6

Int Orthop. 2025 Sep 26. doi: 10.1007/s00264-025-06655-5. Online ahead of print.

NO ABSTRACT

PMID:41003786 | DOI:10.1007/s00264-025-06655-5

Int Orthop. 2025 Sep 26. doi: 10.1007/s00264-025-06653-7. Online ahead of print.

ABSTRACT

PURPOSE: We examined The Seven Works of Mercy, painted by the Master of Alkmaar in 1504, through the lens of orthopaedic pathology. This study approaches the panels from a medical perspective, aiming to uncover visual indicators of disease and disability. The findings offer insight into how physical abnormalities were observed and depicted in the early sixteenth century. To our knowledge, this is the first study to explore orthopaedic pathology in the Seven Works of Mercy.

METHODS: An interdisciplinary analysis of The Seven Works of Mercy was undertaken, with a focus on the visual representation of illness and physical disabilities. The seven panels were examined to identify physical abnormalities. The findings were compared with clinical features of the suggested illnesses and disabilities and with known medical conditions prevalent in the fifteenth and sixteenth century in Europe.

RESULTS: Several depicted orthopaedic disabilities were suggested in the panels of The Seven Works of Mercy. Possible underlying conditions included clubfeet, spinal tuberculosis (Pott's disease), syphilis, poliomyelitis, ergotism, and genu recurvatum. The physical deformities, depicted with remarkable anatomical detail, were cross-referenced with known clinical presentations. In several cases, assistive devices and posture supported the proposed diagnoses.

CONCLUSION: The Seven Works of Mercy by the Master of Alkmaar is a mirror of society in the early sixteenth century, in which a number of depicted orthopaedic conditions were identified. While artistic interpretation must be considered, several physical deformities and disabilities are reproduced with remarkable detail. The artist captured in this masterpiece, a gallery of orthopaedic pathologies common in his time.

PMID:41003785 | DOI:10.1007/s00264-025-06653-7

Int Orthop. 2025 Sep 25. doi: 10.1007/s00264-025-06658-2. Online ahead of print.

ABSTRACT

PURPOSE: This study compared the demographics and outcomes of patients with Parkinson's disease (PD) undergoing total knee arthroplasty (TKA) to those without PD. Additionally, it aimed to assess the impact of implant design on TKA survival in PD patients.

METHODS: Using data from the Emilia Romagna Registry of Orthopedic Prosthetic Implants, 551 TKA procedures in patients with PD were identified and compared to 52,022 TKAs in patients without PD. Kaplan-Meier survivorship analysis was used to compare implant survival, with revision surgery as the endpoint. Cox multivariate analysis was performed to assess the influence of age, gender, PD diagnosis, and implant design on implant failure.

RESULTS: The average age of PD patients was 72.2 years, with 66.2% being female. Implant survival was significantly lower in the PD group compared to the control group (p < 0.001). At 13 years, the survival rate was 88.8% in the PD group and 94.3% in the control group. PD patients had a 2.7 times higher risk of implant failure after adjusting for age and gender. Constrained implant designs were associated with a 1.7 times higher risk of failure compared to non-constrained designs in PD patients.

CONCLUSION: PD negatively affects implant survival in patients undergoing TKA. Careful consideration should be given to patient selection and implant design in this patient population.

PMID:40996522 | DOI:10.1007/s00264-025-06658-2

Int Orthop. 2025 Sep 25. doi: 10.1007/s00264-025-06656-4. Online ahead of print.

ABSTRACT

BACKGROUND: Osteoporotic vertebral compression fractures (OVCFs) are highly prevalent among the elderly. However, spinal metastases can also lead to pathological fractures that are often misdiagnosed as OVCFs. This study aimed to determine the prevalence of unsuspected malignant vertebral compression fractures (VCFs) among patients initially suspected to have OVCFs.

METHODS: From October 2020 to December 2023, 141 patients with suspected OVCFs underwent routine vertebral biopsy during percutaneous kyphoplasty (PKP) at our institution. All patients received standardized treatment and prospective clinical data collection. Follow-up questionnaires were completed in person or via telephone.

RESULTS: A total of 168 biopsy specimens were obtained from 141 patients, and all samples (100%) were successfully evaluated histopathologically. Unexpected spinal metastases were identified in six patients (4.3%). Of the 19 patients with a known history of malignancy but without characteristic radiographic features of pathological fracture, only two cases (10.5%) were confirmed as metastatic involvement from the primary cancer. Among the remaining 112 patients without a cancer history, four unexpected malignancies were identified (one lymphoma and three lung cancers). The overall prevalence of unsuspected malignant VCFs in this cohort was 4.3%.

CONCLUSIONS: Given the observed prevalence of unsuspected malignant VCFs, we recommend that routine vertebral biopsy be performed during every PKP procedure for patients with OVCFs to ensure early detection of occult malignancy.

PMID:40996521 | DOI:10.1007/s00264-025-06656-4