Role of 3D printing in the management of complex acetabular fractures: a comparative study

Impact of introducing 3D printing-assisted surgery into clinical practice for traumatic pelvic and acetabular fractures

Background

Given the novelty of three-dimensional (3D) printing-assisted fracture surgery in orthopaedics, surgeon familiarity is limited and learning curve is high. As such, it is unclear how the introduction of 3D printing into clinical practice for pelvic and acetabular fracture surgery would impact perioperative outcomes. The aim of this study was to determine the impact of introducing 3D printing-assisted surgery on perioperative outcomes for traumatic pelvic and acetabular fractures.

Methods

We retrospectively identified consecutive patients who underwent surgical fixation of traumatic pelvic and acetabular fractures from 2018 to 2022 at a single tertiary hospital. The patients included in the study were divided into two groups: (1) 3D printing-assisted surgery and (2) conventional surgery. Baseline demographics and perioperative outcomes of total surgical duration, estimated blood loss, blood transfusion, number fluoroscopy images, fluoroscopy duration and postoperative disposition were recorded and compared between the two groups.

Results

In total, 26 patients were included in the present study, with 3D printing-assisted surgery being used in 34.6 % (n = 9) of cases. There were no significant differences in baseline demographics or fracture type between the 3D printing group and conventional group. As compared to patients who underwent conventional surgery, those that underwent 3D printing-assisted surgery had, on average, shorter surgical duration (299.8 ± 88.2 vs 309.1 ± 143.1 min), lesser estimated blood loss (706.3 ± 330.0 vs 800.0 ± 584.2 ml), lower transfusion rates (50.0 % vs 52.9 %), lower number of intraoperative fluoroscopy images (62.8 ± 74.5 vs 71.6 ± 47.9 images) and shorter fluoroscopy duration (235.0 ± 79.2 vs 242.3 ± 83.5 min), although statistical significance was not achieved. None of the patients in the present study developed surgical complications postoperatively.

Conclusion

The introduction of 3D printing-assisted surgery in clinical practice for pelvic and acetabular fractures is a safe and viable adjunct in pelvic and acetabular surgery, achieving comparable perioperative outcomes in the initial phase.

Age-period-cohort analysis of epidemiological trends in pelvic fracture in China from 1992 to 2021 and forecasts for 2046

Background

This study explored the epidemiological trends in pelvic fracture (PF) in China from 1992 to 2021, analyze their relationships with age-period-cohort (APC) factors, and predict the trends of PF from 2022 to 2046.

Methods

Incidence and years lived with disabilities (YLDs) of PF among sexes in China from 1992 to 2021 were obtained through the 2021 Global Burden of Disease (GBD) database. Trends in the incidence and YLDs were described, and a joinpoint regression model was used. The APC model was used to explore the effects of age, period, and cohort on the incidence and YLDs. Nordpred forecasted the incidence and YLDs in China from 2022 to 2046.

Results

In 2021, there were an estimated 0.63 million incidence cases and 0.33 million of YLDs, respectively. The number and age-standardized rate (ASR) of incidence and YLDs were both gradually increased. The average annual percent change (AAPC) in incidence and YLDs for men were 0.26% and -0.17%, respectively. For women, the AAPC values for incidence and YLDs were -0.03% and -0.57% (p < 0. 001), respectively. The relative risk (RR) of PF increases with age, with the lowest risk in those aged 10-14 years for incidence and aged 1-4 for YLDs and the highest risk in those aged >95 years for incidence and aged 90-94 years for YLDs. The period effect showed a totally increase in the risk across the general, male, and female populations. Cohort effects indicated a totally significant decline for both incidence and YLDs. The predicted incidence and YLDs of PF in China from 2022 to 2046 showed an initial rise, followed by a decline, with 2029 and 2034 being the turning point for incidence and YLDs, respectively.

Conclusion

The characteristics of pelvic fracture incidence and YLDs in China are complex. Thus, primary prevention measures must be strengthened. Raising awareness about osteoporosis prevention, enhancing public health education, and promoting good dietary and hygiene habits are appropriate preventive measures for PF in China.

Surgical treatment outcomes of acetabular posterior wall and posterior column fractures using 3D printing technology and individualized custom-made metal plates: a retrospective study

BACKGROUND

Fractures involving the posterior acetabulum with its rich vascular and neural supply present challenges in trauma orthopedics. This study evaluates the effectiveness of 3D printing technology with the use of custom-made metal plates in the treatment of posterior wall and column acetabular fractures.

METHODS

A retrospective analysis included 31 patients undergoing surgical fixation for posterior wall and column fractures of the acetabulum (16 in the 3D printing group, utilizing 3D printing for a 1:1 pelvic model and custom-made plates based on preoperative simulation; 15 in the traditional group, using conventional methods). Surgical and instrument operation times, intraoperative fluoroscopy frequency, intraoperative blood loss, fracture reduction quality, fracture healing time, preoperative and 12-month postoperative pain scores (Numeric Rating Scale, NRS), hip joint function at 6 and 12 months (Harris scores), and complications were compared.

RESULTS

The surgical and instrument operation times were significantly shorter in the 3D printing group (p < 0.001). The 3D printing group exhibited significantly lower intraoperative fluoroscopy frequency and blood loss (p = 0.001 and p < 0.001, respectively). No significant differences were observed between the two groups in terms of fracture reduction quality, fracture healing time, preoperative pain scores (NRS scores), and 6-month hip joint function (Harris scores) (p > 0.05). However, at 12 months, hip joint function and pain scores were significantly better in the 3D printing group (p < 0.05). Although the incidence of complications was lower in the 3D printing group (18.8% vs. 33.3%), the difference did not reach statistical significance (p = 0.433).

CONCLUSION

Combining 3D printing with individualized custom-made metal plates for acetabular posterior wall and column fractures reduces surgery and instrument time, minimizes intraoperative procedures and blood loss, enhancing long-term hip joint function recovery.

CLINICAL TRIAL REGISTRATION

12/04/2023;Trial Registration No. ChiCTR2300070438; http://www.chictr.org.cn .

Management of Complex Acetabular Fractures by Using 3D Printed Models

Background and Objectives: Using 3D printed models in orthopaedics and traumatology contributes to a better understanding of injury patterns regarding surgical approaches, reduction techniques, and fracture fixation methods. The aim of this study is to evaluate the effectiveness of a novel technique implementing 3D printed models to facilitate the optimal preoperative planning of the surgical treatment of complex acetabular fractures. Materials and Methods: Patients with complex acetabular fractures were assigned to two groups: (1) conventional group (n = 12) and (2) 3D printed group (n = 10). Both groups included participants with either a posterior column plus posterior wall fracture, a transverse plus posterior wall fracture, or a both-column acetabular fracture. Datasets from CT scanning were segmented and converted to STL format, with separated bones and fragments for 3D printing in different colors. Comparison between the two groups was performed in terms of quality of fracture reduction (good: equal to, or less than 2 mm displacement, and fair: larger than 2 mm displacement), functional assessment, operative time, blood loss, and number of intraoperative x-rays. Results: A significant decrease in operative time, blood loss, and number of intraoperative x-rays was registered in the 3D printed group versus the conventional one (p < 0.01), with 80% of the patients in the former having good fracture reduction and 20% having fair reduction. In contrast, 50% of the patients in the conventional group had good reduction and 50% had fair reduction. The functional score at 18-month follow-up was better for patients in the 3D printed group. Conclusions: The 3D printing technique can be considered a highly efficient and patient-specific approach for management of complex acetabular fractures, helping to restore patient′s individual anatomy after surgery.

Three-Dimensional Printing and Fracture Mapping in Pelvic and Acetabular Fractures: A Systematic Review and Meta-Analysis

Three-dimensional printing and fracture mapping technology is gaining popularity for preoperative planning of fractures. The aim of this meta-analysis is to further understand for the effects of 3D printing and fracture mapping on intraoperative parameters, postoperative complications, and functional recovery on pelvic and acetabular fractures. The PubMed, Embase, Cochrane and Web of Science databases were systematically searched for articles according to established criteria. A total of 17 studies were included in this study, of which 3 were RCTs, with a total of 889 patients, including 458 patients treated by traditional open reduction and internal fixation methods and 431 patients treated using 3D printing strategies. It was revealed that three-dimensional printing and fracture mapping reduced intraoperative surgical duration (RoM 0.74; 95% CI; 0.66–0.83; I² = 93%), and blood loss (RoM 0.71; 95% CI; 0.63–0.81; I² = 71%). as compared to traditional surgical approaches. In addition, there was significantly lower exposure to intraoperative imaging (RoM 0.36; 95% CI; 0.17–0.76; I² = 99%), significantly lower postoperative complications (OR 0.42; 95% CI; 0.22–0.78; I² = 9%) and significantly higher excellent/good reduction (OR 1.53; 95% CI; 1.08–2.17; I² = 0%) in the three-dimensional printing and fracture mapping group. Further stratification results with only prospective studies showed similar trends. Three-dimensional printing and fracture mapping technology has potential in enhancing treatment of complex fractures by improving surgical related factors and functional outcomes and therefore could be considered as a viable tool for future clinical applications.

Visualization of complicated fractures by 3D-printed models for teaching and surgery: hands-on transitional fractures of the ankle

Aims

Understanding the orientation of fracture lines and mechanisms is the essential key to sufficient surgical therapy, but there is still a lack of visualization and teaching methods in traumatology and fracture theory. 3D-printed models offer easy approach to those fractures. This paper explains the use of the teaching possibility with 3-dimensional models of transitional fractures of the ankle.

Methods and results

For generating 3D printable models, already obtained CT data were used and segmented into its different tissues, especially parts concerning the fracture. After the segmentation process, the models were produced with FFF (fused filament fabrication) printing technology. The fracture models then were used for hands-on teaching courses in AO course (Arbeitsgemeinschaft für Osteosynthesefragen) of pediatric traumatology in 2020 in Frankfurt. In the course fracture anatomy with typical fracture lines, approaches, and screw placement could be shown, discussed and practiced.

Conclusion

The study shows the use of 3D-printed teaching models and helps to understand complicated fractures, in this case, transitional fractures of the ankle. The teaching method can be adapted to numerous other use cases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01879-1.

Does 3D-Assisted Acetabular Fracture Surgery Improve Surgical Outcome and Physical Functioning?-A Systematic Review

Three-dimensional technology is increasingly being used in acetabular fracture treatment. No systematic reviews are available about the added clinical value of 3D-assisted acetabular fracture surgery compared to conventional surgery. Therefore, this study aimed to investigate whether 3D-assisted acetabular fracture surgery compared to conventional surgery improves surgical outcomes in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy usage, complications, and postoperative fracture reduction, and whether it improves physical functioning. Pubmed and Embase databases were searched for articles on 3D technologies in acetabular fracture surgery, published between 2010 and February 2021. The McMaster critical review form was used to assess the methodological quality. Differences between 3D-assisted and conventional surgery were evaluated using the weighted mean and odds ratios. Nineteen studies were included. Three-dimensional-assisted surgery resulted in significantly shorter operation times (162.5 ± 79.0 versus 296.4 ± 56.0 min), less blood loss (697.9 ± 235.7 mL versus 1097.2 ± 415.5 mL), and less fluoroscopy usage (9.3 ± 5.9 versus 22.5 ± 20.4 times). The odds ratios of complications and fracture reduction were 0.5 and 0.4 for functional outcome in favour of 3D-assisted surgery, respectively. Three-dimensional-assisted surgery reduces operation time, intraoperative blood loss, fluoroscopy usage, and complications. Evidence for the improvement of fracture reduction and functional outcomes is limited.

Meta-Analysis of 3D Printing Applications in Traumatic Fractures

Background: Traumatic fracture is a common orthopaedic disease, and application of 3D printing technology in fracture treatment, which entails utilisation of pre-operative printed anatomic fracture model, is increasingly gaining popularity. However, effectiveness of 3D printing-assisted surgery lacks evidence-based findings to support its application.

Materials and Methods: Embase, PubMed and Cochrane Library databases were systematically searched until October, 2020 to identify relevant studies. All randomised controlled trials (RCTs) comparing efficacy of 3D printing-assisted surgery vs. conventional surgery for traumatic fractures were reviewed. RevMan V.5.3 software was used to conduct meta-analysis.

Results: A total of 12 RCTs involving 641 patients were included. Pooled findings showed that 3D printing-assisted surgery had shorter operation duration [standardised mean difference (SMD) = −1.52, 95% confidence interval (CI) – 1.70 ~ −1.34, P < 0.00001], less intraoperative blood loss (SMD = 1.34, 95% CI 1.74 ~ 0.94, P < 0.00001), fewer intraoperative fluoroscopies (SMD = 1.25, 95% CI 1.64 ~ 0.87, P < 0.00001), shorter fracture union time (SMD = −0.15, 95% CI −0.25 ~ −0.05, P = 0.003), and higher rate of excellent outcomes (OR = 2.40, 95% CI 1.07 ~ 5.37, P = 0.03) compared with conventional surgery. No significant differences in complication rates were observed between the two types of surgery (OR = 0.69, 95% CI 0.69 ~ 1.42, P = 0.32).

Conclusions: Indicators including operation duration, intraoperative blood loss, number of intraoperative fluoroscopies, fracture union time, and rates of excellent outcomes showed that 3D printing-assisted surgery is a superior alternative in treatment of traumatic fractures compared with conventional surgery. Moreover, the current study did not report significant differences in incidence of complications between the two approaches.

Systematic Review Registration: CRD42021239507.

Application of three-dimensional printing technology in peripheral hip diseases

The incidence of peripheral hip diseases is increasing every year, and its treatment is always tricky due to the complexity of hip joint anatomy and a variety of surgical methods. This paper summarizes the application research and progress of three-dimensional (3D) printing technology in different peripheral hip diseases in recent years published by PubMed from January 2017 to July 2021 with the search terms including “3D or three-dimensional, print*, and hip*. In general, the application of 3D printing technology is mainly to print bone models of patients, make surgical plans, and simulate pre-operation, customized surgical navigation templates for precise positioning or targeted resection of tissue or bone, and customized patient-specific instruments (PSI) fully conforms to the patient’s anatomical morphology. It mainly reduces operative time, intraoperative blood loss, and improves joint function. Consequently, 3D printing technology can be customized according to the patient’s disease condition, which provides a new option for treating complex hip diseases and has excellent application and development potential.

A Systematic Review and Meta-Analysis of 3D Printing Technology for the Treatment of Acetabular Fractures

Purpose

Three-dimensional (3D) printing technology has been widely used in orthopedics surgery. However, its efficacy in acetabular fractures remains unclear. The aim of this systematic review and meta-analysis was to examine the effect of using 3D printing technology in the surgery for acetabular fractures.

Methods

The systematic review was performed following the PRISMA guidelines. Four major electronic databases were searched (inception to February 2021). Studies were screened using a priori criteria. Data from each study were extracted by two independent reviewers and organized using a standardized table. Data were pooled and presented in forest plots.

Results

Thirteen studies were included in the final analysis. Four were prospective randomized trials, and nine used a retrospective comparative design. The patients aged between 32.1 (SD 14.6) years and 51.9 (SD 18.9) years. Based on the pooled analyses, overall, 3D printing-assisted surgery decreased operation time by 38.8 minutes (95% CI: -54.9, -22.8), intraoperative blood loss by 259.7 ml (95% CI: -394.6, -124.9), instrumentation time by 34.1 minutes (95% CI: -49.0, -19.1). Traditional surgery was less likely to achieve good/excellent function of hip (RR, 0.53; 95% CI: 0.34, 0.82) and more likely to have complications than 3D printing-assisted surgery (RR, 1.19; 95% CI: 1.07, 1.33).

Conclusions

3D printing technology demonstrated efficacy in the treatment of acetabular fractures. It may improve surgery-related and clinical outcomes. More prospective studies using a rigorous design (e.g., randomized trial with blinding) are warranted to confirm the long-term effects of 3D printing technology in orthopedics surgeries.