Timothy M. Rankin

Three-dimensional printing surgical instruments: are we there yet?

BACKGROUND The applications for rapid prototyping have expanded dramatically over the last 20 y. In recent years, additive manufacturing has been intensely investigated for surgical implants, tissue scaffolds, and organs. There is, however, scant literature to date that has investigated the viability of three-dimensional (3D) printing of surgical instruments. MATERIALS AND METHODS Using a fused deposition modeling printer, an Army/Navy surgical retractor was replicated from polylactic acid (PLA) filament. The retractor was sterilized using standard Food and Drug Administration approved glutaraldehyde protocols, tested for bacteria by polymerase chain reaction, and stressed until fracture to determine if the printed instrument could tolerate force beyond the demands of an operating room (OR). RESULTS Printing required roughly 90 min. The instrument tolerated 13.6 kg of tangential force before failure, both before and after exposure to the sterilant. Freshly extruded PLA from the printer was sterile and produced no polymerase chain reaction product. Each instrument weighed 16 g and required only

A heads-up display for diabetic limb salvage surgery: a view through the google looking glass.

0.46 of PLA. CONCLUSIONS Our estimates place the cost per unit of a 3D-printed retractor to be roughly 1/10th the cost of a stainless steel instrument. The PLA Army/Navy retractor is strong enough for the demands of the OR. Freshly extruded PLA in a clean environment, such as an OR, would produce a sterile ready-to-use instrument. Because of the unprecedented accessibility of 3D printing technology world wide and the cost efficiency of these instruments, there are far reaching implications for surgery in some underserved and less developed parts of the world.

Reduction of pain via platelet-rich plasma in split-thickness skin graft donor sites: a series of matched pairs

Although the use of augmented reality has been well described over the past several years, available devices suffer from high cost, an uncomfortable form factor, suboptimal battery life, and lack an app-based developer ecosystem. This article describes the potential use of a novel, consumer-based, wearable device to assist surgeons in real time during limb preservation surgery and clinical consultation. Using routine intraoperative, clinical, and educational case examples, we describe the use of a wearable augmented reality device (Google Glass; Google, Mountain View, CA). The device facilitated hands-free, rapid communication, documentation, and consultation. An eyeglass-mounted screen form factor has the potential to improve communication, safety, and efficiency of intraoperative and clinical care. We believe this represents a natural progression toward union of medical devices with consumer technology.

Augmented Reality in Surgery

In the past decade, autologous platelet-rich plasma (PRP) therapy has seen increasingly widespread integration into medical specialties. PRP application is known to accelerate wound epithelialization rates, and may also reduce postoperative wound site pain. Recently, we observed an increase in patient satisfaction following PRP gel (Angel, Cytomedix, Rockville, MD) application to split-thickness skin graft (STSG) donor sites. We assessed all patients known to our university-based hospital service who underwent multiple STSGs up to the year 2014, with at least one treated with topical PRP. Based on these criteria, five patients aged 48.4±17.6 (80% male) were identified who could serve as their own control, with mean time of 4.4±5.1 years between operations. In both therapies, initial dressing changes occurred on postoperative day (POD) 7, with donor site pain measured by Likert visual pain scale. Paired t-tests compared the size and thickness of harvested skin graft and patient pain level, and STSG thickness and surface area were comparable between control and PRP interventions (p>0.05 for all). Donor site pain was reduced from an average of 7.2 (±2.6) to 3 (±3.7), an average reduction in pain of 4.2 (standard error 1.1, p=0.0098) following PRP use. Based on these results, the authors suggest PRP as a beneficial adjunct for reducing donor site pain following STSG harvest.

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration

Augmented reality (AR) has taken great strides in the last 20 years as microchips and heads-up displays have become ever smaller. The benefits afforded medical practitioners continues to be explored across many specialties. Head mounted displays have become more accessible and more affordable. While physicians are becoming acquainted with this new technology, researchers are pushing the envelope of bionanotechnology so that patients may benefit in addition to their medical practitioners. Our group has sought to find the utility of this new technology in limb salvage, resident education, and virtual consultation. However, this is just a fraction of what other investigators have attempted across subspecialties. Surgeons are constantly faced with the task of mentally integrating two-dimensional radiographs and the three-dimensional surgical field, which is the very reason that augmented reality is so attractive. AR has the potential to increase surgical precision, increase patient safety, and facilitate physician education. Until recently, augmented reality had neither the correct form factor to make intraoperative and in-clinic use practical, nor the efficacy to justify its application. Additionally, we must consider that the quest for increased efficiency could paradoxically result in decreased quality of care. Early simulation conducted by NASA in the 1980s revealed a risk of inattentional blindness during the use of head-up displays; therefore, it is unlikely that there will be one perfect system or technology that will suit every specialty. Further works will be required in this area in order to identify the requisite balance, but facilitating education, increasing safety, and improving care are not virtual goals, but are virtuous and ultimately realistic.

Plantar Fat Grafting and Tendon Balancing for the Diabetic Foot Ulcer in Remission

The US diabetic foot ulcer (DFU) incidence is 3-4% of 22.3 million diagnosed diabetes cases plus 6.3 million undiagnosed, 858 000 cases total. Risk of recurrence after healing is 30% annually. Lower extremity multiple nerve decompression (ND) surgery reduces neuropathic DFU (nDFU) recurrence risk by >80%. Cost effectiveness of hypothetical ND implementation to minimize nDFU recurrence is compared to the current

Early two-stage repair of clefts in holoprosencephaly

6.171 billion annual nDFU expense. A literature review identified best estimates of annual incidence, recurrence risk, medical management expense, and noneconomic costs for DFU. Illustrative cost/benefit calculations were performed assuming widespread application of bilateral ND after wound healing to the nDFU problem, using Center for Medicare Services mean expense data of

Palliative reconstructive surgery may improve quality of life in high functioning noncurable head and neck oncologic patients.

1143/case for unilateral lower extremity ND. Calculations use conservative, evidence-based cost figures, which are contemporary (2012) or adjusted for inflation. Widespread adoption of ND after nDFU healing could reduce annual DFU occurrences by at least 21% in the third year and 24% by year 5, representing calculated cost savings of

A Passing Glance? Differences in Eye Tracking and Gaze Patterns Between Trainees and Experts Reading Plain Film Bunion Radiographs

1.296 billion (year 3) to

Use of 3D Printing for Auricular Template Molds in First Stage Microtia

1.481 billion (year 5). This scenario proffers significant expense reduction and societal benefit, and represents a minimum 1.9× return on the investment cost for surgical treatment. Further large cost savings would require reductions in initial DFU incidence, which ND might achieve by selective application to advanced diabetic sensorimotor polyneuropathy (DSPN). By minimizing the contribution of recurrences to yearly nDFU incidence, ND has potential to reduce by nearly