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Use and Versatility of Titanium for the Reconstruction of the Thoracic Wall
Utilidad y versatilidad del titanio para la reconstrucción de la pared torácica
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array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cirugía Torácica, Hospital del Vinalopó, Elche, Alicante, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Cirugía Torácica, Hospital General Universitario de Alicante, Alicante, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad y versatilidad del titanio para la reconstrucción de la pared torácica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 743 "Ancho" => 930 "Tamanyo" => 165113 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Rib fracture fixation with STRACOS system.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chest wall resections or deformities sometimes require complicated reconstruction for which several prosthetic<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> materials are used with the necessary traits to ensure maintenance of the basic functions of the chest<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> (protection of thoracic organs, mechanical ventilation). Titanium prostheses<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> are highly advantageous compared with traditional rigid prostheses due to the characteristics of the material (malleability, ductility, toughness, tensile strength, shape memory capacity, hypoallergenic properties). This results in relatively simple insertion and excellent final results.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Its versatility promotes use in many different interventions including chest wall resection, repair of chest wall deformities and surgical rib fracture repair.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">From September 2008 to August 2012 a prospective record of consecutive patients was made for whom the Strasbourg Thoracic Osteosyntheses System ([STRATOS] MedXpert, Heitersheim, Germany) titanium connecting bar system and the Strasbourg Costal Osteosyntehsis System ([STRACOS] MedXpert, Hitersheim, Germany) titanium clip system were used for chest wall reconstruction or repair. The database included clinical data, daily follow-up, a record of complications and, in the case of oncology patients, long-term outpatient neoplasia follow-up.</p><p id="par0020" class="elsevierStylePara elsevierViewall">14 patients were operated on (8 men and 6 women, with an age range from 17 to 78 and mean age of 58) for diverse disorders which were divided into 3 groups: chest wall tumours, chest wall defects/deformities and rib fractures with unstable thorax (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Chest Wall Tumour Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">The criteria for STRATOS usage in patients with chest wall tumours (7) were: extended resection which included several anterolateral ribs or sternal resection. Reconstruction in the case of chest tumours was always accompanied by a flexible prosthesis to protect the intrathoracic content from the titanium connecting bar system (4 polyester prosthesis covered with resorbable collagen and 3 Gore-tex prostheses), depending on the size of the overall defect. Muscle flap closure was used for the defects (in 5 cases latissimus dorsi flaps and in 1 case chest flap), with the exception of one case of primary closure. In one of the sternal resection cases with previous radiotherapy (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), the greater omentum was used to protect the organs and provide better adaptation of the prosthetic material. Only in the case of one patient (with upper thoracic wall leiomyosarcoma) was en bloc resection combined with an atypical resection of the upper right pulmonary lobe due to tumour infiltration.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">One bar was used in one patient, 2 in 3 patients and 3 in 3 patients. Chest drainage insertion was used for the soft tissues between the bars and the muscle flap.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Choice of type and number of bars was always made in the operating theatre following surgical extraction, after taking the measurements of the defect and discovering the position of the rib tips and their spatial orientation, with an anatomical (parallel) or crossed over positioning (2 patients).</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Chest Wall Deformities and Defect Patients</span><p id="par0040" class="elsevierStylePara elsevierViewall">In this patient group of 4 patients, 3 had deformities from previous trauma and presented with pulmonary hernia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) and 1 patient presented with pectus excavatum for whom the Nuss procedure had failed and who was reoperated by sternochondroplasty (Ravitch technique) with support from a retrosternal titanium bar (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) which was placed after osteotomy and sternal anatomical replacement. Indications were to prevent recurrence in all cases, prevent collapse of the sternum in the pectus excavatum and restore normal anatomy. In the 3 pulmonary hernia cases a flexible prosthesis was inserted (Gore-tex in all cases).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Patients with Severe Rib Injury</span><p id="par0045" class="elsevierStylePara elsevierViewall">Surgery was performed on 3 patients with severe rib injury (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Indication in all cases was the impossibility of mechanical ventilation extubation (over 7 days of mechanical ventilation). None of the 3 patients had intrathoracic lesions which required emergency surgery. Titanium clips were attached to at least 3 rib arches. In cases where there was double fracture a clip was attached to each rib fragment (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). Open pleura chest drainage and subcutaneous drainage for prevention of postoperative seroma were performed in all 3 cases.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Patients With Chest Wall Tumours</span><p id="par0050" class="elsevierStylePara elsevierViewall">Anatomopathological results were heterogeneous in the 7 patients (5 women and 2 men): 5 cases of primary chest wall tumours (1 chondrosarcoma, 1 malignant Schwannoma in the context of neurofibromatosis (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>), 1 leiomyosarcoma, 1 angiosarcoma and 1 liposarcoma) plus 2 metastatic cases (1 sternal metastasis from breast cancer and 1 rib metastasis from renal cancer). In all cases complete en bloc resections with tumour free borders were achieved, from disorders confirmed by anatomopathological analysis. All patients were extubated at the end of surgery with no complications. Average postoperative hospital stay was 6.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2 days. Only 2 complications were recorded (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>): partial flap necrosis (patient with leiomyosarcoma) where single use negative pressure wound therapy system [PICO]) was performed and primary closure was performed 20 days after the initial surgery; and a paroxysmal atrial fibrillation which was treated pharmacologically.</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Thirty days after surgery none of the patients needed pharmacological analgesia because of pain related to surgery.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In all cases oncological follow-up continued for over a year. 18 months after surgery only 1 death (patient with malignant schwannoma) was recorded. One leiomyosarcoma patient presented a single contralateral lung metastasis treated with atypical resection by videothorascopy 10 months after the initial surgery. One patient with sternal metastasis after breast cancer presented cerebral metastasis 5 months after surgery which required oncological treatment. Twelve months after the above mentioned chest wall surgery, the patient with rib metastasis from cancer of the kidney was diagnosed with lumbar and sternal bone metastasis. None of the patients presented local recurrence of their disease. The other (3) patients presented a mean follow-up of 16<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3 disease-free months.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients With Chest Wall Deformities or Defects</span><p id="par0065" class="elsevierStylePara elsevierViewall">The 4 patients were 3 men and 1 woman aged between 17 and 26. Average hospital stay was 4 days (3–6 days). At 30 days no postoperative complications had been recorded. None of the patients took analgesics one month after surgery. Both functional and cosmetic results were satisfactory. Follow-up was at least 12 months (12–19 months) in the 3 patients with no evidence of recurrence.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Patients With Severe Rib Injury</span><p id="par0070" class="elsevierStylePara elsevierViewall">The 3 patients were men with an average age of 56 years (range: 45–63). All cases were due to traffic accidents. Mean rib fractures were 9 rib arches (7–12 rib arches). All patients were admitted to the Intensive Care Unit (ICU). None presented brain injury, verified by CT scan. There were no intrathoracic injuries which required emergency surgery. One patient presented an open tibia fracture which required surgery on admittance and another had needed a chest drain which had already been positioned for pneumothorax. Two patients were admitted to hospital with intubation (one was the patient with the tibia fracture) and the third patient was intubated 6<span class="elsevierStyleHsp" style=""></span>h after admittance suffering from respiratory failure. Extubation was attempted in all 3 patients without success. They received mechanical ventilation for at least 7 days. All patients were extubated 24<span class="elsevierStyleHsp" style=""></span>h after surgery and left the ICU in less than 48<span class="elsevierStyleHsp" style=""></span>h. No intraoperative complications were recorded. One patient presented an ipsilateral pneumonia in the hemithorax on which surgery had been performed. The patient responded to antibiotherapy. No other postoperative complications were recorded. Overall average stay was 18 days (15–23 days). The patients were monitored at 1 month and 3 months following discharge, with satisfactory radiological and clinical condition.</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Discussion</span><p id="par0075" class="elsevierStylePara elsevierViewall">Extended wall resections, chest deformities and multiple rib fractures leading to chest wall failure present a challenge to the surgeon.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Several materials have been used in chest wall reconstruction. All aim to preserve mechanical ventilation and its rigidity with a satisfactory cosmetic result, as indicated by Weyant et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Traditional materials such as methylmethacrylate<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> or steel elements<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> have disadvantages such as longer surgery times, lack of material flexibility and even toxicity in the case of methylmethacrylate. Our case sample and several publications<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5,7–11</span></a> have shown that, due to its intrinsic characteristics, titanium aids reconstruction and repair of the rib cage and the STRATOS and STRACOS systems, in particular, offer great versatility, regardless of resection size (very large resections can be performed and reconstructed with titanium<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>) and type of disease to be treated. Furthermore, in both CT and MRI scans, titanium produces more precise images with fewer artefacts than steel. This is of extreme importance in cancer patient follow-up care.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,9</span></a> The learning curve is short and insertion is simple and safe, as indicated by Berthet et al.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">One of the main concerns after chest wall reconstruction or internal rib fixation is mechanical ventilation and pulmonary function disorder after surgery.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,8</span></a> All our patients could be extubated after surgery in the operating theatre and the patients with internal rib fixation were extubated less than 24<span class="elsevierStyleHsp" style=""></span>h after surgery. As stated by Weyant et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> the importance of this is that both local and general postoperative complications are reduced. This is the main aim of reconstruction. In our series there were no cases of postoperative mortality, which was probably due to the lower number of complications.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Another major factor is postoperative pain, as indicated by both Moreno de la Santa et al.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and Fabre et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In our series, none of the patients needed analgesics 30 days after surgery. Although rupture of material has been described<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> no cases were observed in our series, not even in patients with longer follow-up periods. Furthermore, as previously stated, titanium rarely deteriorates, does not corrode, is biocompatible and chemically inert.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The pectus excavatum was an isolated case, but turned out to be a good option to reinforce the Ravitch technique and all the more so, bearing in mind that the patient had relapsed following removal of the Nuss bar. Furthermore, another case with similar characteristics and an identical result has been reported.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Our experience with internal rib fracture fixation was positive. Early extubation following surgery (in less than 24<span class="elsevierStyleHsp" style=""></span>h) was achieved and postoperative evolution was favourable, even in the patient treated for pneumonia. Analysis of greater sample sizes<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> and our experience favours early rib fixation rather than pneumatic stabilization, since there will be fewer complications, reduced hospital stay and lower cost by reducing ICU stay (the 3 patients were in ICU for less than 48<span class="elsevierStyleHsp" style=""></span>h). Cost analysis of titanium implants is lower than that of a higher hospital stay with prolonged pneumatic stabilization.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">We conclude, therefore, that at present titanium and specifically the STRATOS and STRACOS systems are the best options for chest wall reconstruction and repair: easy to insert, versatile and with all the necessary characteristics for the chest wall to continue functioning in the short and long term.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of Interests</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres324908" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Material and methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec306566" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres324907" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec306567" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Chest Wall Tumour Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Chest Wall Deformities and Defect Patients" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Patients with Severe Rib Injury" ] ] ] 6 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Patients With Chest Wall Tumours" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Patients With Chest Wall Deformities or Defects" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Patients With Severe Rib Injury" ] ] ] 7 => array:2 [ "identificador" => "sec0050" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of Interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-05-13" "fechaAceptado" => "2013-07-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec306566" "palabras" => array:3 [ 0 => "Chest wall reconstructions" 1 => "Titanium" 2 => "STRATOS" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec306567" "palabras" => array:3 [ 0 => "Reconstrucción pared torácica" 1 => "Titanio" 2 => "STRATOS" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest wall deformities/defects and chest wall resections, as well as complex rib fractures require reconstruction with various prosthetic materials to ensure the basic functions of the chest wall. Titanium provides many features that make it an ideal material for this surgery.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The aim is to present our initial results with this material in several diseases.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">From 2008 to 2012, 14 patients were operated on and titanium was used for reconstruction of the chest wall. A total of 7 patients had chest wall tumours, 2 with sternal resection, 4 patients with chest wall deformities/defects and 3 patients with severe rib injury due to traffic accident.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The reconstruction was successful in all cases, with early extubation without detecting problems in the functionality of the chest wall at a respiratory level. Patients with chest wall tumours including sternal resections and with chest wall deformities were extubated in the operating room. Chest trauma cases were extubated within 24<span class="elsevierStyleHsp" style=""></span>h from internal rib fixation. There were no complications related to the material used and the method of implementation.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Titanium is an ideal material for reconstruction of the chest wall in several clinical situations allowing for great versatility and adaptability in different chest wall reconstructions.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">La resección y las deformidades/defectos de la pared torácica así como las fracturas costales complejas requieren de reconstrucción con diversos materiales protésicos para garantizar las funciones básicas de dicha pared. El titanio aporta múltiples características que lo hacen un material idóneo para esta cirugía.</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El objetivo es presentar nuestros resultados iniciales con este material en diversas afecciones.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">De 2008 a 2012 se ha intervenido a 14 pacientes en los que se ha empleado el titanio para la reconstrucción de la pared torácica. Un total de 7 pacientes presentaban tumores de pared torácica, 2 de ellos con resección esternal, 4 con deformidades/defectos de la pared torácica y 3 pacientes con traumatismo costal severo por accidente de tráfico.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">La reconstrucción fue satisfactoria en todos los casos, con extubación temprana y sin detectar problemas en la funcionalidad de la pared torácica a nivel respiratorio. Los pacientes con tumores de pared torácica, incluyendo las resecciones esternales, se extubaron en quirófano, así como las deformidades de pared torácica. Los casos de traumatismo torácico se extubaron en menos de 24<span class="elsevierStyleHsp" style=""></span>h desde la fijación costal interna. No hubo complicaciones en relación con el material utilizado ni con el método de implantación.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">El titanio es un material ideal para la reconstrucción de la pared torácica en diversas situaciones clínicas, al permitir una gran versatilidad y adaptabilidad en las diferentes reconstrucciones de pared torácica en que se quiera emplear.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Córcoles Padilla JM, Bolufer Nadal S, Kurowski K, Gálvez Muñoz C, Rodriguez Paniagua JM. Utilidad y versatilidad del titanio para la reconstrucción de la pared torácica. Cir Esp. 2014;92:89–94.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 579 "Ancho" => 1964 "Tamanyo" => 201090 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(A) Chest CT where sternal metastasis may be observed. (B) STRATOS connecting bars and flexible prosthesis. (C) Greater omentum covering the defect below and above the bars.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 716 "Ancho" => 1808 "Tamanyo" => 253409 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">(A) Detail of the diaphragmatic resection supported by Gore-tex prosthesis. (B) STATOS connecting bar above themyoplasty.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 698 "Ancho" => 930 "Tamanyo" => 172597 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Reconstruction using Ravitch technique and retrosternal STRATOS bar insertion.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 743 "Ancho" => 930 "Tamanyo" => 165113 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Rib fracture fixation with STRACOS system.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Fig. 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 615 "Ancho" => 1964 "Tamanyo" => 157782 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">(A) Preoperative thoracic MRI where an extensive lesion is observed. (B) View of flexible prosthesis and 2 STRATOS bars in place. (C) Radiography of thorax for postoperative control. Observe how in this case we inserted 2 of the bars in a crossed-over position.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Disease/Diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. of cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Summary of technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Postoperative complications \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Chest wall tumours</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Malignant Schwannoma of lower right chest wall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">En bloc resection<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>flexible polyester prosthesis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 STRATOS bars<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>wide dorsal musculo-cutaneous flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leiomyosarcoma of upper right chest wall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">En bloc resection with partial LSD pulmonary resection<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>flexible polyester prosthesis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>3 STRATOS bars<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>wide dorsal musculo-cutaneous flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Partial necrosis of the wide dorsal flap \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sternal metastasis breast cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">En bloc wall resection, including part of the sternum. Polyester prosthesis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>abdominal omentum flap. Three STRATOS bars and primary chest-free closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Right rib metastasis of cancer of the left kidney \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extensive rib resection<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>polyester prosthesis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2 STRATOS bars with primary closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chondrosarcoma of the chest wall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">En bloc resection with 2 left rib arches<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>Gore-tex prosthesis<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>2 STRATOS bars and wide dorsal musculo-cutaneous flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paroxysmal atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Sternal angiosarcoma \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">En bloc resection of the tumour with partial sternotomy. Gore-tex prosthesis. Two STRATOS bars and wide dorsal musculo-cutaneous flap \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Liposarcoma-chest wall tumour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">En bloc resection of tumour with 2 rib arches and Gore-tex prosthesis and one STRATOS bar. Wide dorsal musculo-cutaneous flap. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Chest wall deformities</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Postraumatic thoracoabdominal pulmonary hernia and diaphragm de-insertion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diaphragm resection with Gore-tex prosthesis. Myoplasty<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>one STRATOS bar. Primary cutaneous closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Central post traumatic pulmonary hernia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reconstuction with flexible Gore-tex prosthesis and one STRATOS bar. Primary closure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pectus excavatum \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ravitch technique after Nuss procedure failure. One retrosternal STRATOS bar \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Chest traumas</span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Post traumatic flail chest \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reconstruction with STRACOS of at least 3 rib arches \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">One patient with postoperative pneumonia \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab473575.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Summary of Clinical Cases and Surgical Techniques.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:13 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chest wall resection and reconstruction: a 25-year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 23 | 11 | 34 |
| 2024 September | 21 | 2 | 23 |
| 2024 August | 27 | 5 | 32 |
| 2024 July | 25 | 4 | 29 |
| 2024 June | 17 | 6 | 23 |
| 2024 May | 17 | 6 | 23 |
| 2024 April | 30 | 6 | 36 |
| 2024 March | 33 | 10 | 43 |
| 2024 February | 40 | 6 | 46 |
| 2024 January | 54 | 16 | 70 |
| 2023 December | 45 | 7 | 52 |
| 2023 November | 47 | 10 | 57 |
| 2023 October | 54 | 6 | 60 |
| 2023 September | 15 | 9 | 24 |
| 2023 August | 21 | 5 | 26 |
| 2023 July | 26 | 15 | 41 |
| 2023 June | 36 | 12 | 48 |
| 2023 May | 98 | 9 | 107 |
| 2023 April | 78 | 10 | 88 |
| 2023 March | 91 | 11 | 102 |
| 2023 February | 44 | 7 | 51 |
| 2023 January | 41 | 5 | 46 |
| 2022 December | 66 | 11 | 77 |
| 2022 November | 58 | 7 | 65 |
| 2022 October | 36 | 8 | 44 |
| 2022 September | 37 | 27 | 64 |
| 2022 August | 46 | 18 | 64 |
| 2022 July | 56 | 11 | 67 |
| 2022 June | 32 | 9 | 41 |
| 2022 May | 37 | 14 | 51 |
| 2022 April | 37 | 17 | 54 |
| 2022 March | 59 | 13 | 72 |
| 2022 February | 39 | 7 | 46 |
| 2022 January | 52 | 12 | 64 |
| 2021 December | 32 | 12 | 44 |
| 2021 November | 43 | 10 | 53 |
| 2021 October | 45 | 10 | 55 |
| 2021 September | 36 | 11 | 47 |
| 2021 August | 43 | 7 | 50 |
| 2021 July | 37 | 12 | 49 |
| 2021 June | 32 | 10 | 42 |
| 2021 May | 36 | 10 | 46 |
| 2021 April | 93 | 17 | 110 |
| 2021 March | 41 | 3 | 44 |
| 2021 February | 37 | 14 | 51 |
| 2021 January | 35 | 15 | 50 |
| 2020 December | 37 | 4 | 41 |
| 2020 November | 44 | 9 | 53 |
| 2020 October | 52 | 9 | 61 |
| 2020 September | 32 | 10 | 42 |
| 2020 August | 32 | 13 | 45 |
| 2020 July | 21 | 11 | 32 |
| 2020 June | 24 | 14 | 38 |
| 2020 May | 32 | 17 | 49 |
| 2020 April | 40 | 5 | 45 |
| 2020 March | 32 | 10 | 42 |
| 2020 February | 26 | 5 | 31 |
| 2020 January | 32 | 16 | 48 |
| 2019 December | 44 | 5 | 49 |
| 2019 November | 17 | 11 | 28 |
| 2019 October | 34 | 4 | 38 |
| 2019 September | 39 | 2 | 41 |
| 2019 August | 35 | 4 | 39 |
| 2019 July | 81 | 24 | 105 |
| 2019 June | 78 | 27 | 105 |
| 2019 May | 151 | 53 | 204 |
| 2019 April | 107 | 26 | 133 |
| 2019 March | 25 | 11 | 36 |
| 2019 February | 31 | 7 | 38 |
| 2019 January | 11 | 5 | 16 |
| 2018 December | 25 | 5 | 30 |
| 2018 November | 26 | 7 | 33 |
| 2018 October | 34 | 5 | 39 |
| 2018 September | 27 | 11 | 38 |
| 2018 August | 15 | 4 | 19 |
| 2018 July | 34 | 4 | 38 |
| 2018 June | 25 | 5 | 30 |
| 2018 May | 26 | 1 | 27 |
| 2018 April | 32 | 2 | 34 |
| 2018 March | 24 | 4 | 28 |
| 2018 February | 24 | 3 | 27 |
| 2018 January | 38 | 2 | 40 |
| 2017 December | 33 | 3 | 36 |
| 2017 November | 43 | 1 | 44 |
| 2017 October | 30 | 3 | 33 |
| 2017 September | 37 | 7 | 44 |
| 2017 August | 36 | 17 | 53 |
| 2017 July | 34 | 5 | 39 |
| 2017 June | 59 | 15 | 74 |
| 2017 May | 86 | 16 | 102 |
| 2017 April | 62 | 20 | 82 |
| 2017 March | 71 | 18 | 89 |
| 2017 February | 158 | 19 | 177 |
| 2017 January | 73 | 10 | 83 |
| 2016 December | 82 | 12 | 94 |
| 2016 November | 108 | 14 | 122 |
| 2016 October | 166 | 21 | 187 |
| 2016 September | 357 | 4 | 361 |
| 2016 August | 146 | 8 | 154 |
| 2016 July | 113 | 5 | 118 |
| 2016 June | 87 | 22 | 109 |
| 2016 May | 84 | 39 | 123 |
| 2016 April | 99 | 30 | 129 |
| 2016 March | 85 | 49 | 134 |
| 2016 February | 60 | 23 | 83 |
| 2016 January | 58 | 40 | 98 |
| 2015 December | 60 | 17 | 77 |
| 2015 November | 65 | 28 | 93 |
| 2015 October | 90 | 28 | 118 |
| 2015 September | 83 | 20 | 103 |
| 2015 August | 95 | 20 | 115 |
| 2015 July | 134 | 12 | 146 |
| 2015 June | 56 | 14 | 70 |
| 2015 May | 62 | 22 | 84 |
| 2015 April | 74 | 16 | 90 |
| 2015 March | 122 | 22 | 144 |
| 2015 February | 38 | 22 | 60 |
| 2015 January | 32 | 4 | 36 |
| 2014 December | 51 | 11 | 62 |
| 2014 November | 34 | 9 | 43 |
| 2014 October | 22 | 6 | 28 |
| 2014 September | 35 | 6 | 41 |
| 2014 August | 29 | 14 | 43 |
| 2014 July | 27 | 9 | 36 |
| 2014 June | 20 | 9 | 29 |
| 2014 May | 25 | 9 | 34 |
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