Initial experience with 3D printing in the use of customized Nuss bars in pectus excavatum surgery. / Experiencia inicial en la impresión 3D para el uso de barras de Nuss personalizadas en la cirugía del pectus excavatum.

INTRODUCTION: Pectus excavatum (PE) surgical repair according to Nuss procedure is based on the intrathoracic insertion of one (or more) metallic bars for anatomical defect repair. Number of bars, bar length, bar shape, and thoracic insertion site are established during surgery, according to patient morphology, CT-scan, and especially the surgeon's experience. OBJECTIVE: To assess the usefulness of the design, simulation, and 3D printing of customized Nuss bars for each patient. MATERIAL AND METHODS: A prospective descriptive study of all patients undergoing PE surgery under 3D printing from June to December 2019 was carried out. Curvature, bar length, and optimal intercostal space were designed based on diagnostic CT-scan, and they were 3D printed full size. The resulting model was reproduced preoperatively on the usual prosthetic material, sterilized, and kept until surgery. RESULTS: The study cohort consisted of 6 patients. Median age was 15 years old (interquartile range: 14.25-15.25), median Haller index was 4.05 (interquartile range: 3.5-4.49), and repair index was 36.98% (interquartile range: 33.86-38.48%). A Nuss bar was introduced in all cases, without requiring removal or re-insertion. Median operating time was 79.5 minutes (interquartile range: 72.5-103). No postoperative complications were noted during follow-up (12 months). CONCLUSIONS: The preoperative design of Nuss bars with customized shape and size facilitates surgical planning. It also allows for the most optimal and accurate morphological repair possible, according to patient anatomy, thus reducing the risk of requiring removal and/or re-insertion, and therefore, of surgical complications.

INTRODUCCION: La corrección quirúrgica del pectus excavatum (PE) con técnica de Nuss, se basa en la inserción intratorácica de una (o más) barras metálicas para la corrección del defecto anatómico. El número de barras, su longitud, forma y punto de inserción torácico, se deciden durante la cirugía, según la morfología del paciente, el TC y, fundamentalmente, la experiencia del cirujano. OBJETIVO: Evaluar la utilidad del diseño, simulación e impresión 3D de barras de Nuss personalizadas para cada paciente. MATERIAL Y METODOS: Estudio descriptivo prospectivo, incluyendo a todos los pacientes intervenidos de PE bajo impresión 3D entre junio-diciembre 2019. Se diseñó la curvatura, longitud de la barra y espacio intercostal óptimo, en base al TC diagnóstico, y se imprimió en 3D en tamaño real. El modelo resultante se reprodujo prequirúrgicamente sobre material protésico habitual, se esterilizó y se reservó hasta la cirugía. RESULTADOS: Se recogieron 6 pacientes, mediana de edad 15 años (rango intercuartil 14,25-15,25 años). Mediana del Índice de Haller 4,05 (rango intercuartil 3,5-4,49) e índice de corrección 36,98% (rango intercuartil 33,86-38,48%). Se introdujo una barra de Nuss en todos los casos, sin precisar retirada ni reinserción. Mediana del tiempo quirúrgico 79,5 minutos (rango intercuartil 72,5-103 min). Ninguna complicación postquirúrgica durante el seguimiento (12 meses). CONCLUSIONES: El diseño prequirúrgico de la barra de Nuss, mediante forma y tamaño personalizados, facilita la planificación del procedimiento. A su vez, permite conseguir la corrección morfológica más óptima y precisa posible, según la anatomía del paciente, disminuyendo el riesgo de precisar retirada y/o reinserción de la barra, y por ende de complicaciones quirúrgicas.

Experiencia inicial en la impresión 3D para el uso de barras de Nuss personalizadas en la cirugía del pectus excavatum / Initial experience with 3D printing in the use of customized Nuss bars in pectus excavatum surgery

Introducción: La corrección quirúrgica del pectus excavatum (PE)con técnica de Nuss, se basa en la inserción intratorácica de una (o más)barras metálicas para la corrección del defecto anatómico. El númerode barras, su longitud, forma y punto de inserción torácico, se decidendurante la cirugía, según la morfología del paciente, el TC y, fundamentalmente, la experiencia del cirujano. Objetivos: Evaluar la utilidad del diseño, simulación e impresión3D de barras de Nuss personalizadas para cada paciente. Material y métodos: Estudio descriptivo prospectivo, incluyendoa todos los pacientes intervenidos de PE bajo impresión 3D entre junio-diciembre 2019. Se diseñó la curvatura, longitud de la barra y espaciointercostal óptimo, en base al TC diagnóstico, y se imprimió en 3D entamaño real. El modelo resultante se reprodujo prequirúrgicamente sobrematerial protésico habitual, se esterilizó y se reservó hasta la cirugía. Resultados. Se recogieron 6 pacientes, mediana de edad 15 años(rango intercuartil 14,25-15,25 años). Mediana del Índice de Haller4,05 (rango intercuartil 3,5-4,49) e índice de corrección 36,98% (rangointercuartil 33,86-38,48%). Se introdujo una barra de Nuss en todos loscasos, sin precisar retirada ni reinserción. Mediana del tiempo quirúrgico79,5 minutos (rango intercuartil 72,5-103 min). Ninguna complicaciónpostquirúrgica durante el seguimiento (12 meses). Conclusiones: El diseño prequirúrgico de la barra de Nuss, mediante forma y tamaño personalizados, facilita la planificación del procedimiento. A su vez, permite conseguir la corrección morfológica másóptima y precisa posible, según la anatomía del paciente, disminuyendoel riesgo de precisar retirada y/o reinserción de la barra, y por ende decomplicaciones quirúrgicas.(AU)

Introduction: Pectus excavatum (PE) surgical repair according toNuss procedure is based on the intrathoracic insertion of one (or more)metallic bars for anatomical defect repair. Number of bars, bar length,bar shape, and thoracic insertion site are established during surgery,according to patient morphology, CT-scan, and especially the surgeon’sexperience. Objective: To assess the usefulness of the design, simulation, and3D printing of customized Nuss bars for each patient. Materials and methods: A prospective descriptive study of all patients undergoing PE surgery under 3D printing from June to December2019 was carried out. Curvature, bar length, and optimal intercostalspace were designed based on diagnostic CT-scan, and they were 3Dprinted full size. The resulting model was reproduced preoperatively onthe usual prosthetic material, sterilized, and kept until surgery.Results. The study cohort consisted of 6 patients. Median age was15 years old (interquartile range: 14.25-15.25), median Haller indexwas 4.05 (interquartile range: 3.5-4.49), and repair index was 36.98%(interquartile range: 33.86-38.48%). A Nuss bar was introduced in allcases, without requiring removal or re-insertion. Median operating timewas 79.5 minutes (interquartile range: 72.5-103). No postoperative complications were noted during follow-up (12 months). Conclusions: The preoperative design of Nuss bars with custom-ized shape and size facilitates surgical planning. It also allows for themost optimal and accurate morphological repair possible, accordingto patient anatomy, thus reducing the risk of requiring removal and/orre-insertion, and therefore, of surgical complications.(AU)

Role of the orthopaedic surgeon in 3D printing: current applications and legal issues for a personalized medicine. / Papel del cirujano ortopédico y traumatólogo en la impresión 3D: aplicaciones actuales y aspectos legales para una medicina personalizada.

3D printing (I3D) is an additive manufacturing technology with a growing interest in medicine and especially in the specialty of orthopaedic surgery and traumatology. There are numerous applications that add value to the personalised treatment of patients: advanced preoperative planning, surgeries with specific tools for each patient, customised orthotic treatments, personalised implants or prostheses and innovative development in the field of bone and cartilage tissue engineering. This paper provides an update on the role that the orthopaedic surgeon and traumatologist plays as a user and prescriber of this technology and a review of the stages required for the correct integration of I3D into the hospital care flow, from the necessary resources to the current legal recommendations.

Teaching Patients How to Reduce a Shoulder Dislocation: A Randomized Clinical Trial Comparing the Boss-Holzach-Matter Self-Assisted Technique and the Spaso Method.

BACKGROUND: There are many different techniques for reducing acute anterior dislocations of the shoulder, and their use depends on surgeon preference. The objective of this study was to compare the pain experienced by a patient performing a self-reduction technique with the pain felt during a reduction performed by a trained physician. METHODS: The study was carried out at the emergency department of a tertiary referral center. Patients between 18 and 60 years of age with an acute anterior shoulder dislocation were randomly allocated into 2 groups. In 1 group the emergency doctor actively guided the reduction process with the Spaso technique (Sp group), and in the other group the patient used the Boss-Holzach-Matter (also known as Davos or Aronen) self-reduction technique (BHM group). The pain experienced by the patient during the reduction was recorded by means of a visual analogue scale (VAS) ranging from 0 to 10. Other recorded data included demographic characteristics, reduction time, and success rate. RESULTS: Of 378 patients assessed for eligibility from May 2015 until February 2017, 197 did not meet the inclusion criteria, 58 met exclusion criteria, 22 declined to participate, and 41 withdrew before randomization. Sixty acute anterior shoulder dislocations were randomized into the Sp group (n = 30) or the BHM group (n = 30). The BHM group experienced significantly less pain during reduction than the Sp group (p = 0.047), with mean pain scores of 3.57 (standard deviation [SD] = 2.1]) and 5.26 (SD = 2.9), respectively. No significant difference between groups was found with respect to reduction time (105 seconds [range, 10 to 660 seconds] in the Sp group and 90 seconds [range, 5 to 600 seconds] in the BHM group; p = 0.6) or success rate (67% and 77%, respectively; p = 0.39). CONCLUSIONS: The self-reduction technique results in less pain than, and is as efficient in achieving reduction of anterior shoulder dislocations as, the Spaso technique. These findings favor the use of the self-assisted method as an effective first-line treatment for shoulder dislocations seen in the emergency department as well as its use by patients with recurrent dislocation. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Enclavado retrógrado en fractura tibial / Retrograde nailing in a tibial fracture

Se describe un caso de fractura abierta de tibia grado iiia con gran conminución y pérdida distal de stock óseo ( cm) con total afectación de la superficie articular tibial y gran inestabilidad de la articulación peroneo-astragalina. El tratamiento realizado consintió en practicar una exhaustiva limpieza, colocándose un enclavado fresado retrógrado calcáneo-astrágalo-tibial con bloqueos proximales y distales, además de una aguja de Kirschner peroneo-astragalina. Se consiguió el cierre primario de la piel. A las 3 semanas se procedió al aporte de injerto óseo autólogo de cresta ilíaca rellenando el defecto óseo, a la reimpactación del clavo endomedular que estaba protuido distalmente y a la dinamización distal. Se consiguió la consolidación del defecto óseo en 16 semanas. Actualmente, el paciente deambula sin dolor con la artrodesis tibio-astragalina consolidada (AU)

We describe a case of a severely comminuted type iiia open tibial fracture, with distal loss of bone stock (7 cm), total involvement of the tibial joint surface, and severe instability of the fibular-talar joint. The treatment performed consisted of thorough cleansing, placing a retrograde reamed calcaneal-talar-tibial nail with proximal and distal blockage, as well as a fibular-talar Kirschner nail. Primary closure of the skin was achieved. After 3 weeks, an autologous iliac crest bone graft was performed to fill the bone defect, and the endomedullary nail, which had protruded distally was reimpacted and dynamized distally. The bone defect was eventually consolidated after 16 weeks. Currently, the patient can walk without pain the tibial-astragal arthrodesis is consolidated (AU)

[Retrograde nailing in a tibial fracture]. / Enclavado retrógrado en fractura tibial.

We describe a case of a severely comminuted type iiia open tibial fracture, with distal loss of bone stock (7 cm), total involvement of the tibial joint surface, and severe instability of the fibular-talar joint. The treatment performed consisted of thorough cleansing, placing a retrograde reamed calcaneal-talar-tibial nail with proximal and distal blockage, as well as a fibular-talar Kirschner nail. Primary closure of the skin was achieved. After 3 weeks, an autologous iliac crest bone graft was performed to fill the bone defect, and the endomedullary nail, which had protruded distally was reimpacted and dynamized distally. The bone defect was eventually consolidated after 16 weeks. Currently, the patient can walk without pain the tibial-astragal arthrodesis is consolidated.