Last year a surgical team led by retired Air Force Col. (Dr.) Warren Dorlac, a Uniformed Services University alumnus and Associate Professor of Surgery, arrived in Ukraine, to begin a volunteer mission supporting Ukraine’s civilian Emergency Medical Clinical Hospital. Dorlac, a recognized expert in trauma surgery and trauma care, was uniquely qualified to lead the team. After a few months of activity in Ukraine, when faced with the case of a Ukrainian soldier who had lost a large part of his skull, he immediately knew that no existing implant solution could address this type of injury. So, he contacted a well-known US-based institute for regenerative medicine and, through them, got in touch with bioprinting specialist T&R Biofab, with the goal to create a unique, resorbable PSI.
“As a military surgeon, I have seen the worst that humanity can do, but I have also been fortunate enough to see the best,” said Dorlac, writing from Lviv to its Alma Mater, USU. “It is a privilege to be part of this lifesaving mission serving the brave people of Ukraine.”
Bringing out the best
This unique collaboration with T&R falls under the “best” category. Not only did it help the Ukrainian soldier fully recover from an injury that would have been completely debilitating or worse, but it also showed how useful additive manufacturing can be when no other solution exists. The section of the skull that needed to be replaced was larger than any implant readily available, especially considering that metal is not usually a feasible solution for such a large part of the skull. In addition, it needed to be personalized to achieve an ideal fit.
That’s why T&R’s technology provided the only possible solution: its 3D bioprinters can print using various biomaterials, including deCelluid (a hydrogel tissue-derived bioink), ceramics as well as synthetic and biodegradable (bioresorbable) polymers that can ideally replicate special tissue microenvironments through the printing process. In this case the PCL : TCP material, a mixture of bioresorbable polycaprolactone (PCL) and beta-tricalcium phosphate (which is one of the materials human bones are made of) provided the ideal environment for a skull implant that would be strong enough and that would enable the bone to grow back onto and into it.
Within their first few days in Ukraine, Dorlac’s evaluated conditions, offered recommendations and delivered lectures and training on topics including end points of resuscitation and the use of ultrasound in trauma and critical care. According to Dorlac, emergency medicine is not a dedicated specialty in Ukraine. The emergency hospital staff that the team assisted included trauma and general surgeons, thoracic surgeons, vascular surgeons, pediatric surgeons, orthopedic surgeons, anesthesiologists/intensivists, and surgical and critical care nurses. The caseload included “typical combat wounds –- extensive burns, complex fractures, nerve injuries, soft tissue loss, and wounds and amputations,” said Dorlac.
Dorlac was accompanied on the Ukraine mission by a distinguished team of medical professionals including military trauma surgeon and USU Surgery department faculty member Air Force Col. (Dr.) Jay Johannigman, renowned burn surgeon Dr. William Hickerson, and surgical physician assistant Kelley Thompson. With their work in Ukraine, Dorlac, Johannigman and the other surgical team members continue the tradition of US military medical aid for conflict victims around the world, a tradition interwoven throughout USU’s entire 50-year history, beginning with Dr. Rich.
Emergency lifesaving solutions
To design and produce the proper PSI, multiple meetings had to be held between T&R Biofab, the Ukrainian surgeons and US doctors. Once the exact specifications required were ascertained, T&R manufactured the implant within days, based on the CT data that was sent to the company directly from Ukraine. At this point the T&R team used its bioprinting technology to produce 3 identical custom cranial implants. These were then shipped out to Poland so that they could be delivered by military personnel to the surgeons operating inside Ukraine.
The first of the three PSIs was immediately used for the intended patient. During the operation, US and Ukrainian doctors shared knowledge on how to use the implant through online meetings and the surgery was a complete success. The surgeons confirmed that the results were very satisfactory and pointed out that it was easier to operate since the PSI fit so well with the actual defect in the skull. The patient has since been recovering without complications.
“There are other synthetic options for these implants to include polyetheretherketone and polymethylmethacrylate and titanium,” Dr. Dorlac said. “They too are computer generated for the individual patient. They are expensive and have some problems with sterilization. This T&R Biofab product has the possibility of being better integrated into the skull as a biological implant which may offer some protection against infection as well.”
In an emergency, the ability to improvise can make all the difference in the world. As a further demonstration of the viability of T&R’s implants, the second implant was modified – as a unique wartime solution – by the surgical team and used on a second patient. Showing exceptional skill, the surgeons were able to manually adapt and implant the PSI to treat a different but also extensive skull injury.
As Paulo André Marinho, Head of Scientific Strategy at T&R Biofab explained to VoxelMatters, T&R’s work on custom PSI focuses on advancing PSI technology and improving the patient’s quality of life through advanced personalization, rather than scalability and profitability. This project in particular was operated pro bono, as a humanitarian effort to decrease people’s suffering in this war.
“The results of the PSI work are undeniably meaningful, not just for the medical and scientific community, but especially for the patients,” Marinho said. “At T&R, we believe it is our social responsibility to keep contributing to the community with technologies that can’t be found elsewhere.”