Patient-specific outcome simulation after surgical correction of Pectus Excavatum: a preliminary study

Although minimally invasive Nuss procedure is frequently performed to correct Pectus Excavatum, the successful aesthetical outcome is not always ensured. Using the computed tomography (CT) data of six patients, high-quality surfaces of the anterior chest wall were generated, alongside with a personalized corrective-bar. Through finite element method (FEM), replicating the surgical procedure, a simulation of the anterior chest wall correction was conducted. The assessment of this methodology was verified by comparing the metrics from the real meshes (3D scanned before and after surgery) and simulated meshes (obtained before and after FEM). Results show a mean difference of 2.85 +/- 5.77 mm on the point of maximum correction between simulated and real outcomes. No statistical differences were found (p = 0.281). High aesthetical similarity was observed concerning simulated and real outcomes. The proposed methodology presents a patient-specific simulation that may be used to plan, predict and improve the surgical outcome of the Nuss procedure. Further studies should continue to improve the presented methodology.This work has been funded by FEDER funds, through the Competitiveness Factors Operational Programme (COMPETE), and by National funds, through the Foundation for Science and Technology (FCT), under the scope of the projects POCI-01-0145-FEDER-007038; NORTE-01-0145-FEDER-000013; and NORTE-01-0145-FEDER-024300, supported by the Northern Portugal Regional Operational Programme (NORTE 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER). Joao Gomes-Fonseca was funded by FCT under the Ph.D. grant PD/BDE/113597/2015

Pectus Excavatum postsurgical outcome based on preoperative soft body dynamics simulation

Pectus excavatum is the most common congenital deformity of the anterior chest wall, in which an abnormal formation of the rib cage gives the chest a caved-in or sunken appearance. Today, the surgical correction of this deformity is carried out in children and adults through Nuss technic, which consists in the placement of a prosthetic bar under the sternum and over the ribs. Alth ough this technique has been shown to be safe and reliable, not all patients have achieved adequate cosmetic outcome. This often leads to psyc hological problems and social stress, before and after the surgical correction. This paper targets this particular problem by presenting a method to predict the patient surgical outcome based on pre-surgical imagiologic information and chest skin dynamic modulation. The proposed approach uses the patient pre-surgical thoracic CT scan and anatomical-surg ical references to perform a 3D segmentation of the left ribs, right ribs, sternum and skin. The technique encompasses three steps: a) approximation of the cartilages, between the ribs and the sternum, trough b-spline interpolation; b) a volu metric mass spring model that connects two layers - inner skin layer based on the outer pleura contour and the outer su rface skin; and c) displacement of the sternum according to the prosthetic bar position. A dynamic model of the skin around the chest wall region was generated, capable of simulating the effect of the movement of the prosthetic bar along the sternum. The results were compared and validated with patient postsurgical skin surface acquired with Polhemus FastSCAN system.Fundação para a Ciência e Tecnologi

Development and Validation of a Hybrid Virtual/Physical Nuss Procedure Surgical Trainer

With continuous advancements and adoption of minimally invasive surgery, proficiency with nontrivial surgical skills involved is becoming a greater concern. Consequently, the use of surgical simulation has been increasingly embraced by many for training and skill transfer purposes. Some systems utilize haptic feedback within a high-fidelity anatomically-correct virtual environment whereas others use manikins, synthetic components, or box trainers to mimic primary components of a corresponding procedure. Surgical simulation development for some minimally invasive procedures is still, however, suboptimal or otherwise embryonic. This is true for the Nuss procedure, which is a minimally invasive surgery for correcting pectus excavatum (PE) – a congenital chest wall deformity. This work aims to address this gap by exploring the challenges of developing both a purely virtual and a purely physical simulation platform of the Nuss procedure and their implications in a training context. This work then describes the development of a hybrid mixed-reality system that integrates virtual and physical constituents as well as an augmentation of the haptic interface, to carry out a reproduction of the primary steps of the Nuss procedure and satisfy clinically relevant prerequisites for its training platform. Furthermore, this work carries out a user study to investigate the system’s face, content, and construct validity to establish its faithfulness as a training platform

Evolution of the Nuss procedure for the repair of Pectus Excavatum: Our experience.

The aim of this study is to collect the variables of the Nuss procedure developed by experts in this technique around the world and present their advantages and disadvantages compared to the original description of the Nuss procedure. The Nuss procedure since it was first reported, has underwent from slight to major modifications aiming to make it safer and more succesfull

Development and Validation Methodology of the Nuss Procedure Surgical Planner

Pectus excavatum (PE) is a congenital chest wall deformity which is characterized, in most cases, by a deep depression of the sternum. A minimally invasive technique for the repair of PE (MIRPE), often referred to as the Nuss procedure, has been proven to be more advantageous than many other PE treatment techniques. The Nuss procedure consists of placement of a metal bar(s) underneath the sternum, thereby forcibly changing the geometry of the ribcage. Because of the prevalence of PE and the popularity of the Nuss procedure, the demand to perform this surgery is greater than ever. Therefore, a Nuss procedure surgical planner would be an invaluable planning tool ensuring an optimal physiological and aesthetic outcome. In this dissertation, the development and validation of the Nuss procedure planner is investigated. First, a generic model of the ribcage is developed to overcome the issue of missing cartilage when PE ribcages are segmented and facilitate the flexibility of the model to accommodate a range of deformity. Then, the CT data collected from actual patients with PE is used to create a set of patient specific finite element models. Based on finite element analyses performed over those models, a set force-displacement data set is created. This data is used to train an artificial neural network to generalize the data set. In order to evaluate the planning process, a methodology which uses an average shape of the chest for comparison with results of the Nuss procedure planner is developed. This method is based on a sample of normal chests obtained from the ODU male population using laser surface scanning and overcomes challenging issues such as hole-filling, scan registration and consistency. Additionally, this planning simulator is optimized so that it can be used for training purposes. Haptic feedback and inertial tracking is implemented, and the force-displacement model is approximated using a neural network approach and evaluated for real-time performance. The results show that it is possible to utilize this approximation of the force-displacement model for the Nuss procedure simulator. The detailed ribcage model achieves real-time performance

Development and Validation of a Three-Dimensional Optical Imaging System for Chest Wall Deformity Measurement

Congenital chest wall deformities (CWD) are malformations of the thoracic cage that become more pronounced during early adolescence. Pectus excavatum (PE) is the most common CWD, characterized by an inward depression of the sternum and adjacent costal cartilage. A cross-sectional computed tomography (CT) image is mainly used to calculate the chest thoracic indices. Physicians use the indices to quantify PE deformity, prescribe surgical or non-surgical therapies, and evaluate treatment outcomes. However, the use of CT is increasingly causing physicians to be concerned about the radiation doses administered to young patients. Furthermore, radiographic indices are an unsafe and expensive method of evaluating non-surgical treatments involving gradual chest wall changes. Flexible tape or a dowel-shaped ruler can be used to measure changes on the anterior side of the thorax; however, these methods are subjective, prone to human error, and cannot accurately measure small changes. This study aims to fill this gap by exploring three-dimensional optical imaging techniques to capture patients’ chest surfaces. The dissertation describes the development and validation of a cost-effective and safe method for objectively evaluating treatment progress in children with chest deformities. First, a study was conducted to evaluate the performance of low-cost 3D scanning technologies in measuring the severity of CWD. Second, a multitemporal surface mesh registration pipeline was developed for aligning 3D torso scans taken at different clinical appointments. Surface deviations were assessed between closely aligned scans. Optical indices were calculated without exposing patients to ionizing radiation, and changes in chest shape were visualized on a color-coded heat map. Additionally, a statistical model of chest shape built from healthy subjects was proposed to assess progress toward normal chest and aesthetic outcomes. The system was validated with 3D and CT datasets from a multi-institutional cohort. The findings indicate that optical scans can detect differences on a millimeter scale, and optical indices can be applied to approximate radiographic indices. In addition to improving patient awareness, visual representations of changes during nonsurgical treatment can enhance patient compliance

Product development in custom-made medical devices

The 21st century presents a revolution in additive manufacturing, and these technologies will continue to grow. Osteobionix S.L., the company where the internship took place, has been designing and producing titanium prosthetic parts for human implantation since 2008. The company’s goal is to design and build parts of the human body tailored for patients in which standard prostheses do not solve the problem. Based on this, the company’s methodology was to obtain 3D images of each case, discuss, design and build a final solution. As soon as the solution is accepted by the surgeon, it proceeds to the production phase, mainly using an electron beam fusion machine (ARCAM S12). The objective in the internship time was to understand the company’s workflow, help in the production line and develop some design cases in order to learn and analyze what is a complete design follow-up case. The main results obtained are the prototypes that are manufactured in EBM. Licensing for human use and implantation of products in humans is a slow process. Animal testing should be the next step to obtain useful data. Finally, several cases developed during the internship will be presented and explained

3D Printing Technologies

The family of technologies collectively known as additive manufacturing (AM) technologies, and often called 3D-printing technologies, is rapidly revolutionizing industrial production. AM’s potential to produce intricate and customized parts starting from a digital 3D model makes it one of the main pillars for the forthcoming Industry 4.0. Thanks to its advantages over traditional manufacturing methodologies, AM finds potential applicability in virtually all production fields. As a natural consequence of this, research in this field is primarily focused on the development of novel materials and techniques for 3D printing. This Special Issue of Technologies, titled “3D Printing Technologies”, aims at promoting the latest knowledge in materials, processes, and applications for AM. It is composed of six contributions, authored by influential scientists in the field of advanced 3D printing. The intended audience includes professors, graduate students, researchers, engineers and specialists working in the field of AM