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Original Paper
Validation of patient-specific 3D impression models for pelvic oncological orthopedic surgery
Validación de los modelos de impresión 3D paciente-específicos para cirugía ortopédica oncológica pélvica
L. Mediavilla-Santosa,b,
Corresponding author
lmediavillas@hotmail.com

Corresponding author at: Corresponding author.
, M. García-Sevillac, J.A. Calvo-Haroa,b,c, M.T. Ruiz Albac, R. Pérez-Mañanesa,b,c, J. Pascau Gonzálezc, M. Cuervo Dehesaa, F.J. Vaquero Martína,b
a Sección de Oncología Musculoesquelética, Servicio de Cirugía Ortopédica y Traumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
b Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
c Departamento de Bioingeniería e Ingeniería Aeroespacial, Universidad Carlos III, Leganés, Madrid, Spain
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Hence the importance of increasing accuracy when performing oncological resection&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Extensive resection may cause major functional impairment both due to possible involvement of nerve roots and due to the proximity of the hip joint&#44; which often needs to be reconstructed&#46; Margins must therefore be adjusted to achieve adequate oncological resection aimed at preserving maximum functionality for the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Advances in imaging techniques and the development of navigation systems have facilitated preoperative planning and improved intraoperative accuracy of tumour resection&#46;<a class="elsevierStyleCrossRefs" href="#bib0115"><span class="elsevierStyleSup">5&#44;6</span></a> Other technological tools&#44; such as 3D printing&#44; allow the manufacture of patient-specific templates<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a> to guide the osteotomies to be performed and personalise them according to the patient and the tumour involvement present&#44; as they are designed to adapt to a specific bone region&#46; Although there are studies that defend the reliability of these patient-specific positioning templates&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> there are very few studies that study the positioning of the templates and the cutting planes with respect to preoperative planning&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study is to demonstrate that the use of patient-specific templates obtained with a desktop 3-D printer is high reliable in terms of translating such planning into reality&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0025" class="elsevierStylePara elsevierViewall">An experimental study was designed in freeze-preserved cadavers&#44; including 10 hemipelvises of both men and women and with size variability&#44; in which the use of patient-specific templates using desktop 3D planning and printing systems was analysed&#46; Firstly&#44; a computed tomography of each specimen was performed to obtain the images&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The processing and segmentation of the image studies is carried out with an open access programme &#40;3D slicer&#41; that allows a three-dimensional model to be obtained in stl format&#46; For positioning template design another open access programme is used &#40;Meshmixer&#44; Autodesk&#41;&#44; and after obtaining the three-dimensional mesh in stl format of each of the guides they are printed in biocompatible resin<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">9</span></a> on a desktop 3D printer &#40;FormLabs&#59; Form 2&#41; with working technology based on laser stereolithography&#46; The planning of the osteotomy planes follows the classic osteotomy lines of the different types of internal hemipelvectomies I&#44; II and III according to the classification of Enneking and Dunham<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">10</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Using the same templates&#44; a navigation system is developed through the use of rigid-body marking devices that serve to position the pelvis in space&#46; Each guide is identified with a letter and a number to identify the specimen to which it corresponds and its location in the pelvis&#58; S for the supracetabular guide&#44; C for the iliac crest&#44; P for the iliopubic branch and I for the ischiopubic branch&#46; In addition&#44; 4 reading points for navigation are placed in each of the guides and 2 holes for subsequent fixation to the bone by means of screws &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">When printing the orientation of the templates is taken into account to obtain a solid and non deformable guide on intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">11</span></a> Double printing is made and a posterior process is made with a UV curing station to solidify them&#46; They are then sterilised with ethylene oxide at 50&#176; to reproduce the real conditions of intraoperative use&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The pelvises are previously thawed in the dissection room and the usual approach is made for an internal hemipelvectomy&#44; maintaining the structures to be preserved in vivo&#46; Once the osteotomy areas are exposed at bone level&#44; all the templates are placed and fixed with screws &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; After placement&#44; the individual incomplete osteotomies are performed so that a proper measurement can be taken later&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">To check the position of the templates&#44; a different navigation protocol is used depending on the rigid-body positioning&#46; In hemipelvises 1&#8211;5 the rigid body was placed in the supracetabular template&#44; while in hemipelvises 6&#8211;10 it was placed in the iliac crest template&#46; In both cases&#44; 4 points &#40;cones&#41; are picked up on the navigation guides to make the registration between virtual and real&#44; as well as several points along the osteotomy performed &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">During planning a reference system is used based on the 3 specific space axes &#40;<span class="elsevierStyleItalic">x</span>&#44; <span class="elsevierStyleItalic">y</span>&#44; <span class="elsevierStyleItalic">z</span>&#41; for each hemipelvis&#46; By superimposing the measurements obtained from the surgical navigation on this previous reference system&#44; it is possible to measure the translations &#40;distance&#41; present in the 3 planes of space&#44; in relation to the previous positioning of the templates for each hemipelvis &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; as well as the possible errors of deviation along the entire osteotomy line&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">To obtain the definitive results&#44; the maximum osteotomy deviations are measured for each configuration&#44; i&#46;e&#46;&#44; the maximum distance between the osteotomy that would be performed following the virtual planning and the osteotomy obtained in reality&#46; With this reference&#44; the mean and standard deviation values are obtained for each osteotomy plane for the different patient-specific guides&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">After comparative analysis of the position of the guides in the virtual model and in the real model a different mean distance error is obtained depending on where the guides are placed&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#8226;</span><p id="par0070" class="elsevierStylePara elsevierViewall">Iliac crest guides&#58; 7&#46;2<span class="elsevierStyleHsp" style=""></span>mm for the left and 4&#46;8<span class="elsevierStyleHsp" style=""></span>mm for the right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#8226;</span><p id="par0075" class="elsevierStylePara elsevierViewall">Supracetabular guides&#58; 3&#46;7<span class="elsevierStyleHsp" style=""></span>mm for the left and 3&#46;4<span class="elsevierStyleHsp" style=""></span>mm for the right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">&#8226;</span><p id="par0080" class="elsevierStylePara elsevierViewall">Iliopubic branch guides&#58; 3&#46;8<span class="elsevierStyleHsp" style=""></span>mm for the left and 3&#46;06<span class="elsevierStyleHsp" style=""></span>mm for the right&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">&#8226;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Ischiopubic branch guides&#58; 4&#46;7<span class="elsevierStyleHsp" style=""></span>mm for the left and 3&#46;04<span class="elsevierStyleHsp" style=""></span>mm for the right&#46;</p></li></ul></p><p id="par0090" class="elsevierStylePara elsevierViewall">With the exception of the guidewires placed in the iliac crest&#44; which present more variability when adapting to the bony anatomy&#44; in the rest of the locations the average placement error with respect to what was planned is less than 4<span class="elsevierStyleHsp" style=""></span>mm&#44; and 4&#46;7<span class="elsevierStyleHsp" style=""></span>mm in the case of the guidewires in the left ischiopubic branch&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">As for the navigation results &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#44; the distance between the previously planned cutting plane and the osteotomy performed following the 3D templates and validated with navigation is analysed&#46; The mean error is around 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; except in the pubis &#40;5&#46;6<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; with 75&#37; of the cases showing errors below 5<span class="elsevierStyleHsp" style=""></span>mm The standard deviation is around 3<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; When analysing the results according to rigid body placement&#44; when the rigid body was placed in the supracetabular position&#44; the mean was &#60;5<span class="elsevierStyleHsp" style=""></span>mm in all cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In pelvises where the rigid body was placed in the iliac crest guide&#44; navigation errors were &#60;5<span class="elsevierStyleHsp" style=""></span>mm in all regions except the pubic region&#44; which had a mean error of 8<span class="elsevierStyleHsp" style=""></span>mm &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0100" class="elsevierStylePara elsevierViewall">The particularities of the pelvic ring&#44; as well as its anatomical relationships&#44; allow the growth of large tumour masses before the patient is diagnosed&#44; making any surgical procedure particularly difficult&#46; Achieving tumour-free surgical margins should be a priority in pelvic oncological surgery&#44; but even when performed by expert oncological surgeons&#44; adequate margins are obtained in only 52&#37; &#40;CI&#58; 37&#37;&#8211;67&#37;&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> making the treatment of malignant tumours of the pelvis one of the most difficult problems in musculoskeletal oncological surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">12</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">In order to improve the precision of oncological resection&#44; intraoperative navigation systems have been developed for pelvic bone tumour surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> Patient-specific templates obtained by 3D printing have also been developed to perform the different osteotomies&#44; improving surgical margins&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> This work provides an in-house and portable navigation system thanks to the use of patient-specific 3D printing tools that provide a margin of error of less than 5<span class="elsevierStyleHsp" style=""></span>mm&#44; improving precision and minimising possible calculation errors in comparison with those made following the present anatomical references&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">When analysing the results&#44; the greatest variability is given by the guidewires located on the iliac crest&#44; since due to its anatomy the guidewire can be adapted to various areas of the crest&#59; hence the placement error is on average around 7<span class="elsevierStyleHsp" style=""></span>mm In these cases&#44; associating these guides with intraoperative navigation or establishing the distance to certain anatomical references such as the anterosuperior and posterosuperior iliac spines in prior planning could reduce placement errors and&#44; therefore&#44; precision when performing the osteotomy&#44; which will have a direct influence on the resection margins&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">With regard to the navigation system&#44; it will be influenced by the position of the rigid body&#44; since in the hemipelvises where the marker was placed on the iliac crest template&#44; the error measured was greater the further away from the rigid body&#46; When the marker was placed at the supracetabular level&#44; the translation results of the actual versus planned osteotomy were &#60;5<span class="elsevierStyleHsp" style=""></span>mm</p><p id="par0120" class="elsevierStylePara elsevierViewall">There are not many articles in the literature validating the accuracy of these patient-specific templates&#46; Among these&#44; Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> also compared the accuracy of patient-specific templating and navigation in the treatment of periacetabular tumours compared to conventional techniques&#44; using 12 surgical templates to obtain the results&#46; Similarly&#44; Sallent et al&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> obtained similar results in terms of accuracy below 5<span class="elsevierStyleHsp" style=""></span>mm when using patient-specific templates&#44; without using an associated navigation system&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The use of patient-specific guide in daily clinical practice can help us to improve the quality of oncological resection&#46; Several authors have reported their experience in using navigation technology to resect bone tumours&#44; and significant improvements in surgical margins can be observed&#46; Jeys et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a> demonstrated a significantly reduced local recurrence rate&#46; In another study&#44; Evrard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a> demonstrate a lower local recurrence rate in cases where 3D patient-specific guides were used to perform tumour resection&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">As a limitation&#44; this is a cadaver study&#44; which does not exactly reproduce the real intraoperative conditions&#44; although the same approach routes were used&#46; Often pelvic tumours are associated with soft tissue masses that we cannot reproduce in the cadaver and that will condition both the resection and the possible placement of the guides&#46; To improve precision in these cases&#44; we can design the guides in the areas that will be accessible during surgery and combine them with navigation systems to perform the osteotomy with adequate resection margins&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Another limitation is that the results of the positioning of the guides and osteotomies will be influenced by whether the rigid body is placed more centrally &#40;supracetabular&#41; or more peripherally &#40;iliac crest&#41;&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0140" class="elsevierStylePara elsevierViewall">The use of patient-specific templates obtained by 3D printing is a useful and reliable tool for obtaining osteotomies in the desired cutting planes in pelvic oncological surgery&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">By using optical navigation combined with cutting guides&#44; we obtain osteotomy errors that are on average below 5<span class="elsevierStyleHsp" style=""></span>mm In view of the results&#44; when choosing where to place the rigid body&#44; it is best to place it closest to the osteotomy level&#44; as this increases the accuracy of the osteotomy&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">By using desktop 3D printers and a portable navigation system&#44; a more cost-effective and affordable system for performing pelvic osteotomies on tumours in this location with high accuracy of execution is developed&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Level of evidence</span><p id="par0155" class="elsevierStylePara elsevierViewall">Level of evidence III&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">Funding by the <span class="elsevierStyleGrantSponsor" id="gs1">SECOT Foundation</span> through the 2018 research initiation grant and the PI18&#47;01625 project &#40;<span class="elsevierStyleGrantSponsor" id="gs2">Ministry of Science&#44; Innovation and Universities</span>&#44; <span class="elsevierStyleGrantSponsor" id="gs3">Instituto de Salud Carlos III</span>&#44; and <span class="elsevierStyleGrantSponsor" id="gs4">European Regional Development Fund</span>&#59; A way of doing Europe&#41;&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0165" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest in the undertaking of this study&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pelvic ring tumours pose a challenge due to the difficulty in obtaining adequate surgical margins&#46; Tools such as surgical navigation or 3D printing for the fabrication of patient-specific surgical positioning templates help in preoperative planning and intraoperative execution&#46; Their correct positioning is essential in complex locations such as the pelvis&#44; so it is necessary to identify positioning errors&#46; The aim of this study is to demonstrate the reliability of 3D template placement for pelvic ring osteotomies&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Experimental study in cadaver with 10 hemipelvis&#46; CT was performed to obtain the three-dimensional model&#44; planning of osteotomies&#44; design of positioning templates in ischiopubic &#40;I&#41;&#44; iliopubic &#40;P&#41;&#44; supracetabular &#40;S&#41; and iliac crest &#40;C&#41; branches&#59; and a positioning marker &#40;rigid-body&#41; on the C and S templates for navigation&#46; The templates and rigid-body are 3D printed and positioned according to pre-planning&#46; Navigation allows the final position of the inserts and osteotomies to be checked&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The positioning of the templates with respect to the preoperative planning varied depending on the location&#44; being greater the error in those of the iliac crest&#46; Using navigation the mean error of distance to the cutting plane is 3&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; except in pubis &#40;5&#8211;8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; being conditioned by the position of the rigid body&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of patient-specific templates printed in 3D is a reliable tool for performing osteotomies in pelvic cancer surgery&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introduccion</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Los tumores del anillo p&#233;lvico suponen un reto por la dificultad de obtener m&#225;rgenes quir&#250;rgicos adecuados&#46; Herramientas como la navegaci&#243;n quir&#250;rgica o la impresi&#243;n 3D para la fabricaci&#243;n de plantillas de posicionamiento quir&#250;rgico paciente-espec&#237;ficas ayudan en la planificaci&#243;n preoperatoria y la ejecuci&#243;n intraoperatoria&#46; Su correcta colocaci&#243;n es fundamental en localizaciones complejas como la pelvis&#44; por lo que es necesario identificar los errores de posicionamiento&#46; El objetivo de este estudio es demostrar la fiabilidad en la colocaci&#243;n de plantillas 3D para la realizaci&#243;n de osteotom&#237;as en el anillo p&#233;lvico&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio experimental en cad&#225;ver con 10 hemipelvis&#46; Se realiz&#243; TC para la obtenci&#243;n del modelo tridimensional&#44; planificaci&#243;n de osteotom&#237;as&#44; dise&#241;o de plantillas de posicionamiento en rama isquiopubiana &#40;I&#41;&#44; iliopubiana &#40;P&#41;&#44; supracetabular &#40;S&#41; y cresta il&#237;aca &#40;C&#41; y se utiliz&#243; un marcador de posicionamiento &#40;<span class="elsevierStyleItalic">rigid-body</span>&#41; sobre las plantillas C y S para la navegaci&#243;n&#46; Las plantillas y el <span class="elsevierStyleItalic">rigid-body</span> fueron impresos en 3D y se colocaron seg&#250;n la planificaci&#243;n previa&#46; La navegaci&#243;n permiti&#243; comprobar la posici&#243;n final de las plantillas y de las osteotom&#237;as&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El posicionamiento de las plantillas respecto a la planificaci&#243;n preoperatoria vari&#243; dependiendo de la localizaci&#243;n&#59; el error fue mayor en las de cresta il&#237;aca&#46; Utilizando la navegaci&#243;n&#44; la media de error de distancia al plano de corte estuvo en 3&#44;5<span class="elsevierStyleHsp" style=""></span>mm&#44; excepto en el pubis &#40;5-8<span class="elsevierStyleHsp" style=""></span>mm&#41;&#44; que est&#225; condicionado por la posici&#243;n del <span class="elsevierStyleItalic">rigid-body</span>&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El uso de plantillas paciente-espec&#237;ficas impresas en 3D es una herramienta fiable para las osteotom&#237;as en cirug&#237;a oncol&#243;gica p&#233;lvica&#46;</p></span>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Final design of the guide in virtual mode &#40;A&#41; and after its printing in resin &#40;B&#41;&#46; Comparison of translations of the templates between virtual planning &#40;green&#41; and real planning &#40;grey&#41; in the 3 axes of the space &#40;C&#41;&#46;</p>"
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        "mostrarFloat" => true
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Collection of navigation points on each guidewire with pointer &#40;&#42;&#41; and portable navigation camera system &#40;&#42;&#42;&#41;&#46;</p>"
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        "etiqueta" => "Figure 5"
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\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&#46;7&nbsp;\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&#46;7&nbsp;\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">0&#46;9&nbsp;\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&#46;3&nbsp;\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&#46;3&nbsp;\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">4&#46;1&nbsp;\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">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&nbsp;\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">4&#46;6&nbsp;\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">4&#46;4&nbsp;\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&#46;1&nbsp;\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&#46;2&nbsp;\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&#46;9&nbsp;\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">5&nbsp;\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">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&nbsp;\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">4&#46;3&nbsp;\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&#46;5&nbsp;\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&#46;2&nbsp;\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&#46;6&nbsp;\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&nbsp;\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">5&#46;9&nbsp;\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">8&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">P&nbsp;\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">8&nbsp;\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&#46;1&nbsp;\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&#46;7&nbsp;\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">6&#46;5&nbsp;\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">7&#46;9&nbsp;\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">11&nbsp;\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">11&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3511083.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Distance &#40;mm&#41; between cutting plane planned with navigation and real with placing of rigid body in the supracetabular region&#46;</p>"
        ]
      ]
      7 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "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"><th 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" scope="col" style="border-bottom: 2px solid black">Region&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Mean&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Standard deviation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">50&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">75&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th 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" scope="col" style="border-bottom: 2px solid black">Max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\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&#46;5&nbsp;\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&#46;5&nbsp;\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">0&#46;9&nbsp;\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&#46;9&nbsp;\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&#46;9&nbsp;\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">4&#46;5&nbsp;\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">10&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">S&nbsp;\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&#46;1&nbsp;\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&#46;5&nbsp;\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">0&#46;4&nbsp;\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">0&#46;9&nbsp;\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&#46;9&nbsp;\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&#46;5&nbsp;\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">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">I&nbsp;\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&#46;7&nbsp;\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&#46;2&nbsp;\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&#46;3&nbsp;\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&#46;7&nbsp;\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&#46;7&nbsp;\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">4&#46;9&nbsp;\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
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                  \t\t\t\t">8&#46;2&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 18884415
Original language: English
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