Accurate fixation of plates and screws for the treatment of acetabular fractures using 3D-printed guiding templates: An experimental study

Three-Dimensional Printing Model Enhances Correct Identification and Understanding of Pelvic Fracture in Medical Students

OBJECTIVE

Understanding the anatomy behind a pelvic fracture can be a significant challenge to medical students. Recent advances in three-dimensional printing technology offers a novel approach to facilitate the learning of complex fracture. We have described here how the 3-dimension printing (3Dp) models can help medical students improve their understanding in and identification of pelvic fractures.

DESIGN

One hundred students were randomized into 2 teaching module groups (with or without 3Dp models). Prior to randomization assignment, a 50-minute didactic lecture covering elementary knowledge of anatomy, Young-Burgess classification, and traumatic mechanism of pelvic fracture was delivered to all students. The 3Dp group received X-rays, CT images, and 3Dp models of the eight pelvic fractures during presentation, while the students in the control group only obtained X-rays and CT scans of the same 8 pelvic fractures. Young-Burgess classification system and injury mechanism of pelvic fracture, time for evaluation, and subjective questions were conducted to assess the learning outcomes.

SETTING

A medical student program based in a LevelⅠtrauma center PARTICIPANTS: One hundred students in their 4th year of a 5-year clinical medicine program (for a medical bachelor degree) RESULTS: Students receiving 3Dp model had a higher rate of identifying the correct pelvic fracture via Young-Burgess identification compared to these without 3Dp model. Moreover, the accuracy of identifying the injury mechanism was significantly higher in the 3Dp group than that in group without 3Dp model. Participant in 3Dp group had faster assessment time compared to the control group. Subjective survey results suggested that 3Dp model would increase the learning interest and enhance the understanding of pelvic fracture. In addition, majority of students (83%) reported that they would like to use 3Dp model in other surgical course education.

CONCLUSIONS

3Dp model increased the perceived accuracy of pelvic fracture identification and understanding of injury mechanism. Moreover, 3Dp model promoted the subjective interest and motivation of students in pelvic fracture learning. Therefore, 3Dp model can be considered as a valuable educational tool for learning pelvic fracture in medical students.

The application of additive manufacturing technology in pelvic surgery: A bibliometrics analysis

With the development of material science, additive manufacturing technology has been employed for pelvic surgery, addressing the challenges, such as the complex structure of the pelvis, difficulty in exposing the operative area, and poor visibility, of the traditional pelvic surgery. However, only limited studies have been done to review the research hotspots and trends of the additive manufacturing technology applied for pelvic surgery. In this study, we comprehensively analyzed the literatures related to additive manufacturing technology in pelvic surgery by a bibliometrics analysis and found that additive manufacturing technology is widely used in several aspects of preoperative diagnosis, preoperative planning, intraoperative navigation, and personalized implants for pelvic surgery. Firstly, we searched and screened 856 publications from the Web of Science Core Collection (WoSCC) with TS = (3D printing OR 3D printed OR three-dimensional printing OR additive manufacturing OR rapid prototyping) AND TS = (pelvis OR sacrum OR ilium OR pubis OR ischium OR ischia OR acetabulum OR hip) as the search strategy. Then, 565 of these were eliminated by evaluating the titles and abstracts, leaving 291 pieces of research literature whose relevant information was visually displayed using VOSviewer. Furthermore, 10 publications with high citations were selected by reading all publications extensively for carefully evaluating their Titles, Purposes, Results, Limitations, Journal of affiliation, and Citations. Our results of bibliometric analysis demonstrated that additive manufacturing technology is increasingly applied in pelvic surgery, providing readers with a valuable reference for fully comprehending the research hotspots and trends in the application of additive manufacturing technology in pelvic surgery.

Preoperative templating in orthopaedic fracture surgery: The past, present and future

Preoperative planning in orthopaedic fracture surgery corroborates with the goal of establishing the best possible surgical result and ensuring a functioning limb for the patient. From placing sketches on overhead projector paper and measuring lengths from anatomical landmarks, ways of preoperative planning have evolved rapidly over the last 100 years. Today, preoperative planning includes methods such as advanced 3-Dimensional (3D) printed models and software programs incorporating entire libraries of osteosynthesis materials that can be shaped and rotated to fit a patient's specific anatomy. Relevant literature was evaluated to review the development of preoperative templating from the past and present, in order to assess its impact on the future of osteosynthesis.We identified studies on 3D-imaging, computer-assisted systems, and 3D-printed fractured bones and drill guides. The use of some of these systems resulted in a reduction in operation time, blood loss, perioperative fluoroscopy and hospital stay, as well as better placement of osteosynthesis material. Only few studies have identified differences in patient morbidity and mortality. Future techniques of preoperative templating are on the rise and the potential is vast. The cost-effectiveness and usefulness of certain methods need to be evaluated further, but the benefit of preoperative templating has the potential of being revolutionary, with the possibility of radical advances within orthopaedic surgery.

Clinical applications and prospects of 3D printing guide templates in orthopaedics

Background

With increasing requirements for medical effects, and huge differences among individuals, traditional surgical instruments are difficult to meet the patients' growing medical demands. 3D printing is increasingly mature, which connects to medical services critically as well. The patient specific surgical guide plate provides the condition for precision medicine in orthopaedics.

Methods

In this paper, a systematic review of the orthopedic guide template is presented, where the history of 3D-printing-guided technology, the process of guides, and basic clinical applications of orthopedic guide templates are described. Finally, the limitations of the template and possible future directions are discussed.

Results

The technology of 3D printing surgical templates is increasingly mature, standard, and intelligent. With the help of guide templates, the surgeon can easily determine the direction and depth of the screw path, and choose the angle and range of osteotomy, increasing the precision, safety, and reliability of the procedure in various types of surgeries. It simplifies the difficult surgical steps and accelerates the growth of young and mid-career physicians. But some problems such as cost, materials, and equipment limit its development.

Conclusions

In different fields of orthopedics, the use of guide templates can significantly improve surgical accuracy, shorten the surgical time, and reduce intraoperative bleeding and radiation. With the development of 3D printing, the guide template will be standardized and simplified from design to production and use. 3D printing guides will be further sublimated in the application of orthopedics and better serve the patients.

The translational potential of this paper

Precision, intelligence, and individuation are the future development direction of orthopedics. It is more and more popular as the price of printers falls and materials are developed. In addition, the technology of meta-universe, digital twin, and artificial intelligence have made revolutionary effects on template guides. We aim to summarize recent developments and applications of 3D printing guide templates for engineers and surgeons to develop more accurate and efficient templates.

Additive Manufacturing in Orthopedics: A Review

Additive manufacturing is an advanced manufacturing manner that seems like the industrial revolution. It has the inborn benefit of producing complex formations, which are distinct from traditional machining technology. Its manufacturing strategy is flexible, including a wide range of materials, and its manufacturing cycle is short. Additive manufacturing techniques are progressively used in bone research and orthopedic operation as more innovative materials are developed. This Review lists the recent research results, analyzes the strengths and weaknesses of diverse three-dimensional printing strategies in orthopedics, and sums up the use of varying 3D printing strategies in surgical guides, surgical implants, surgical predictive models, and bone tissue engineering. Moreover, various postprocessing methods for additive manufacturing for orthopedics are described.

Fast-Track-Protocol for Optimization of Presurgical Planning in Acute Surgical Treatment of Acetabular Quadrilateral Plate Fractures Using 3D Printing Technology and Pre-Contoured Reconstruction Plates

Background. Preoperative planning and 3D printing can be used to treat pelvic bone fractures using pre-contoured surgical plates, in particular complex, comminuted fractures involving the acetabulum and quadrilateral plate. The aim of the study was to develop a Fast-Track-Protocol (fast track methodology) for creating 3D anatomical models, that could be used to shape surgical plates, using open-source software and budget 3D printers. Such a ‘low-budget’ approach would allow a hospital-based multidisciplinary team to carry out pre-surgical planning and treat complex pelvic fractures using 3D technology. Methods. The study included 5 patients with comminuted pelvic fractures. For each patient, CT (computed tomography) data were converted into two 3D models of the pelvis-injured side and mirrored model of the contralateral, uninjured hemipelvis. These models were 3D printed and used as templates to shape surgical plates. Results. A Fast-Track-Protocol was established and used to successfully treat 5 patients with complex, comminuted fractures of the pelvis. Conclusion. Using the Fast-Track-Protocol it was possible to prepare 3D printed models and patient-specific pre-contoured plates within 2 days of hospital admittance. Such an approach resulted in better surgical technique and shorter operative times, while incurring relatively low costs.

3D Printing Applications in Orthopaedic Surgery: Clinical Experience and Opportunities

Background: Three-dimensional (3D) printing is a technology capable of creating solid objects based on the reproduction of computerised images. This technology offers revolutionary impacts on surgical practice, especially in prosthetic and traumatological surgery. Methods: 20 patients with proximal humeral fractures were divided into two groups, one of which involved the processing of a 3D model. The model made it possible to plan the positioning and dimensions of the implants. The results were then compared with those obtained according to the usual procedures. We also reported the irreparable case of a custom revision implants acetabular bone loss treated with a 3D-printed, custom-made implant. Results: In the processed 3D proximal humeral fracture series, in the face of time and costs expenses, surgical and X-ray times were shorter than in the control group. On the other hand, there were no differences in terms of blood loss. The patient who underwent acetabular re-prosthetic surgery in a 3B Paprosky bone loss was managed and solved with a 3D-printed, custom-made implant and reported excellent outcomes at a 1 year follow-up. Conclusion: Three-dimensional printing made it possible to create better pre-operative planning in traumatology in order to optimise surgical procedures and outcomes. It also made it possible to deal with large losses of bone stock in prosthetic revision surgery, even when reconstruction may have appeared impossible with traditional implants.

Accuracy of Patient-Specific Drilling Guides in Acetabular Fracture Surgery: A Human Cadaver Study

Due to the complex anatomical shape of the pelvis, screw placement can be challenging in acetabular fracture surgery. This study aims to assess the accuracy of screw placement using patient-specific surgical drilling guides applied to pre-contoured conventional implants in acetabular fracture surgery. CT scans were made of four human cadavers to create 3D models of each (unfractured) pelvis. Implants were pre-contoured on 3D printed pelvic models and optically scanned. Following virtual preoperative planning, surgical drilling guides were designed to fit on top of the implant and were 3D printed. The differences between the pre-planned and actual screw directions (degrees) and screw entry points (mm) were assessed from the pre- and postoperative CT-scans. The median difference between the planned and actual screw direction was 5.9° (IQR: 4–8°) for the in-plate screws and 7.6° (IQR: 6–10°) for the infra-acetabular and column screws. The median entry point differences were 3.6 (IQR: 2–5) mm for the in-plate screws and 2.6 (IQR: 2–3) mm for the infra-acetabular and column screws. No screws penetrated into the hip joint or caused soft tissue injuries. Three-dimensional preoperative planning in combination with surgical guides that envelope pre-contoured conventional implants result in accurate screw placement during acetabular fracture surgery.

Impact of the COVID-19 pandemic on orthopedic fracture characteristics in three hospitals in Turkey: A multi-center epidemiological study

Objectives

In this study, we present the use of case specific three- dimensional (3D) printed plastic models and custom-made acetabular implants in orthopedic surgery.

Materials and methods

Between March 2018 and September 2020, surgeries were simulated using plastic models manufactured by 3D printers on the two patients with pilon fractures. Also, custom-made acetabular implants were used on two patients with an acetabular bone defect for the revision of total hip arthroplasty (THA).

Results

More comfortable surgeries were experienced in pilon fractures using preoperative plastic models. Similarly, during the follow-up period, the patients that applied custom-made acetabular implants showed a fixed and well-positioning in radiographic examination. These patients did not experience any surgical complications and achieved an excellent recovery.

Conclusion

Preoperative surgical simulation with 3D printed models can increase the comfort of fracture surgeries. Also, custom-made 3D printed acetabular implants can perform an important task in patients treated with revision THA surgery due to severe acetabular defects.

Evaluation of the clinical efficacy of 3D Printing technology assisted surgery combined with early postoperative comprehensive rehabilitation in the treatment of Senile Intertrochanteric Fractures

OBJECTIVES

To observe the clinical value of 3D printing technology assisted surgery combined with early postoperative comprehensive rehabilitation in elderly patients with intertrochanteric fractures.

METHODS

Sixty elderly patients with intertrochanteric fractures of the femur who were treated in our hospital from January 2018 to January 2020 were selected and randomly divided into two groups. In the experimental group, 3D printing technology assisted surgery combined with early postoperative comprehensive rehabilitation was used for treatment. While in the control group, traditional open reduction and dynamic hip screw internal fixation combined with postoperative conventional treatment was utilized. The duration of surgery, intraoperative blood loss, postoperative hospital stay, weight bearing time, fracture healing time and other surgical indicators were recorded respectively, and hip joint function recovery was evaluated prior to and 2 weeks after surgery. All patients were followed up for six months to observe the occurrence of complications within half a year, including deep vein thrombosis, incision infection, avascular necrosis of femoral head, hip joint stiffness, delayed fracture healing, etc. Subsequently, the differences in postoperative complications between the two groups were compared and analyzed.

RESULTS

The operation time, blood loss, postoperative hospital stay, weight bearing time and fracture healing time of the experimental group were better than those of the control group, and the difference was statistically significant (p<0.05). After treatment, the hip joint function of the experimental group was significantly improved compared with the control group, with a statistically significant difference(p=0.03). The incidence of operative complications in the experimental group was 10% (3/30) within six months postoperatively, significantly lower than the 33% (10/30) in the control group, with statistical significance (p=0.03).

CONCLUSION

3D printing with early rehab proved to be effective treatment in our study. Such a combined treatment has the advantages of precise operative reduction, fast postoperative recovery, and certain safety and effectiveness.

Three-dimensional Printing in Orthopaedic Surgery: Current Applications and Future Developments

Three-dimensional (3D) printing is an exciting form of manufacturing technology that has transformed the way we can treat various medical pathologies. Also known as additive manufacturing, 3D printing fuses materials together in a layer-by-layer fashion to construct a final 3D product. This technology allows flexibility in the design process and enables efficient production of both off-the-shelf and personalized medical products that accommodate patient needs better than traditional manufacturing processes. In the field of orthopaedic surgery, 3D printing implants and instrumentation can be used to address a variety of pathologies that would otherwise be challenging to manage with products made from traditional subtractive manufacturing. Furthermore, 3D bioprinting has significantly impacted bone and cartilage restoration procedures and has the potential to completely transform how we treat patients with debilitating musculoskeletal injuries. Although costs can be high, as technology advances, the economics of 3D printing will improve, especially as the benefits of this technology have clearly been demonstrated in both orthopaedic surgery and medicine as a whole. This review outlines the basics of 3D printing technology and its current applications in orthopaedic surgery and ends with a brief summary of 3D bioprinting and its potential future impact.

Traditional three-dimensional printing technology versus three-dimensional printing mirror model technology in the treatment of isolated acetabular fractures: a retrospective analysis

OBJECTIVE

This study was performed to compare the clinical outcomes of traditional three-dimensional (3D) printing technology and 3D printing mirror model technology in the treatment of isolated acetabular fractures.

METHODS

Prospectively maintained databases were reviewed to retrospectively compare patients with an isolated acetabular fracture who were treated with traditional 3D printing technology (Group T) or 3D printing mirror model technology (Group M) from 2011 to 2017. In total, 146 advanced-age patients (146 hips) with an isolated acetabular fracture (Group T, n = 72; Group M, n = 74) were assessed for a mean follow-up period of 29 months (range, 24-34 months). The primary endpoint was the postoperative Harris hip score (HHS). The secondary endpoints were the operation time, intraoperative blood loss, fluoroscopy screening time, fracture reduction quality, and incidence of postoperative complications at the final follow-up.

RESULTS

The HHS, operation time, intraoperative blood loss, fluoroscopy screening time, and incidence of postoperative complications were significantly different between the groups, with Group M showing superior clinical outcomes.

CONCLUSION

In patients with an isolated acetabular fracture, 3D printing mirror model technology might lead to more accurate and efficient treatment than traditional 3D printing technology.

Preoperative 3D Modeling and Printing for Guiding Periacetabular Osteotomy

INTRODUCTION

Achieving adequate acetabular correction in multiple planes is essential to the success of periacetabular osteotomy (PAO). Three-dimensional (3D) modeling and printing has the potential to improve preoperative planning by accurately guiding intraoperative correction. The authors therefore asked the following questions: (1) For a patient undergoing a PAO, does use of 3D modeling with intraoperative 3D-printed models create a reproducible surgical plan to obtain predetermined parameters of correction including lateral center edge angle (LCEA), anterior center edge angle (ACEA), Tonnis angle, and femoral head extrusion index (FHEI)? and (2) Can 3D computer modeling accurately predict when a normalized FHEI can be achieved without the need for a concomitant femoral-sided osteotomy?

METHODS

A retrospective review was conducted on 42 consecutive patients that underwent a PAO. 3D modeling software was utilized to simulate a PAO in order to achieve normal LCEA, ACEA, Tonnis angle, and FHEI. If adequate FHEI was not achieved, a femoral osteotomy was simulated. 3D models were printed as intraoperative guides. Preoperative, simulated and postoperative radiographic ACEA, LCEA, Tonnis angle, and FHEI were measured and compared statistically.

RESULTS

A total of 40 patients had a traditional PAO, and 2 had an anteverting-PAO. The simulated LCEA, ACEA, Tonnis angle, and FHEI were within a median difference of 3 degrees, 1 degrees, 1 degrees, and 0% of postoperative values, respectively, and showed no statistical difference. Of those that had a traditional PAO, all 34 patients were correctly predicted to need a traditional acetabular-sided correction alone and the other 6 were correctly predicted to need a concomitant femoral osteotomy for a correct prediction in 100% of patients.

CONCLUSION

This study demonstrates that for PAO surgery, 3D modeling and printing allow the surgeon to accurately create a reproducible surgical plan to obtain predetermined postoperative hip coverage parameters. This new technology has the potential to improve preoperative/intraoperative decision making for hip dysplasia and other complex disorders of the hip.

A novel 3D technique to assess symmetry of hemi pelvises

Anatomical reconstruction of pelvic fractures has been shown to affect functional outcome. Using the contra lateral side of the extremities to create a template for an ipsilateral reconstruction is common practice in orthopedic surgery. We aimed to assess whether hemi pelvises are symmetrical in terms of translation and rotation using 3D reconstruction, point to point mirroring and merging of the 3D created volumes, a method with previous proven high precision and accuracy. CT images of ten randomly selected patients were used. The DICOM images were converted to STL files. Three dimensional images of left hemi pelvis were reversed and merged with the right side. The posterior aspect of the pelvises was considered static and the anterior aspect as moving. Differences in translation and rotation were measured. There were no statistically significant differences between right and left hemi pelvis. The 95% confidence interval (CI) for all mean angular differences between right hemi pelvis and mirrored left hemi pelvis were − 2° to 1.5°. The 95% CI for all mean translational differences between these two objects were − 2.3 to 2.9 mm. Differences between the right hemi pelvis and the mirrored images of the left hemi pelvis for any patient greater than 3 mm or 2 degrees could be excluded with a 95% confidence. The left and right hemi pelvis of healthy adults are symmetrical enough. The pre-operative planning based on a healthy contra lateral side seems reasonable.

A retrospective comparison of the conventional versus three-dimensional printed model-assisted surgery in the treatment of acetabular fractures

OBJECTIVE

The aim of this study was to compare the clinical and radiological outcomes of the conventional versus individualized three-dimensional (3D) printing model-assisted pre-contoured plate fixation in the treatment of patients with acetabular fractures.

METHODS

The data from 18 consecutive patients who underwent surgery for the acetabular fractures were retrospectively analyzed. The patients were divided into two groups (9 in each): conventional and 3D printed model-assisted. The groups were then compared in terms of the duration of surgery, time of instrumentation, time of intraoperative fluoroscopy, and volume of blood loss. The quality of the fracture reduction was also evaluated postoperatively by radiography and computed tomography in both the groups. The quality of the fracture reduction was defined as good (<2 mm) or fair (>2 mm) based on the amount of displacement in the acetabulum.

RESULTS

The conventional group included 9 patients (9 males; mean age=41.7 years; age range=16-70) with a mean follow-up of 11.9 months (range=8-15); the 3D printed model-assisted group consisted of 9 patients (9 males; mean age=46.2 years; age range=30-66) with a mean follow-up of 10.33 months (range=7-17). The average duration of surgery, mean time of instrumentation, time of intraoperative fluoroscopy, and mean volume of blood loss were 180.5±9 minutes, 36.2±3.6 minutes, 6±1 times, and 403.3±52.7 mL in the 3D printed model-assisted group, and 220±15.6 minutes, 57.4±10.65 minutes, 10.4±2.2 times, and 606.6±52.7 mL in the conventional group, respectively. Procedurally, the average duration of surgery, mean time of instrumentation, and mean time of fluoroscopy were significantly shorter, and the mean volume of blood loss was significantly lower in the 3D printed model-assisted group (p<0.05). The quality of the fracture reduction was good in 7 patients (78%) in the conventional group and 8 patients (89%) in the 3D printed model-assisted group.

CONCLUSION

As compared with the conventional surgery, the 3D printing model-assisted pre-contoured plate fixation technique can improve the clinical and radiological outcomes of the acetabular fractures, with shorter surgery, instrumentation, intraoperative fluoroscopy times, and blood loss.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Digital anatomical study and clinical application of screw placement for quadrilateral plate fractures in the danger zone

BACKGROUND

Direct screw placement for quadrilateral plate fractures in the danger zone of the acetabulum is very difficult. This study was performed to simulate the surgical procedure and try to obtain effective and safe screw angles through the middle window of the ilioinguinal approach in Chinese patients.

METHODS

We randomly collected the pelvic computed tomography (CT) scans of 100 adults. DICOM-formatted CT-scan images were imported into Mimics software. The three-dimensional reconstruction (3D) digital model of the semi-pelvis was established. A 3.5 mm cylinder was used to simulate the pathway of the screw from the designated insertion point. The angles of insertion and intersex differences were explored by statistical analyses.

RESULTS

The screws could be inserted via three angles: medial inclination, anterior inclination and posterior inclination. The mean minimum medial inclination angle (MIMIA) of insertion point A was 4.96° ± 1.11° in males and 8.66° ± 3.40° in females, and the intersex difference was significant. The mean minimum medial inclination angle (MIMIA) of insertion point B was - 5.31° ± 3.69° in males and 1.75° ± 8.95° in females, and the intersex difference was significant. There were no differences between any of the angles for males and females at insertion point O.

CONCLUSIONS

Preoperative measurement and calculation by digital tools before screw placement for quadrilateral plate fractures of the acetabulum are feasible. Double cortical screws could be placed safely in the danger zone through the middle window of the ilioinguinal approach to increase the stability of the acetabulum.

Key points in surgical management of mandibular condylar fractures

Mandibular condylar fractures are among the most common facial fractures and some of the most difficult to manage. Opinions about the management of mandibular condylar fractures differ among surgeons. With the implementation of new technology, an increased understanding of fracture management, and better functional and morphological outcomes reported in the literature, open reduction and internal fixation is becoming many surgeons' preferred choice for the treatment of condylar fractures. Because surgical treatment of such fractures is complex, certain factors must be considered to achieve satisfactory outcomes. In this article, we summarise six key points in the management of mandibular condylar fractures: virtual evaluation of condylar fracture, a suitable surgical approach, good reduction, stable internal fixation, repair of the articular disc, and restoration of the mandibular arch width. We believe that these points will help to improve the prognosis of mandibular condyle fractures.

An experimental study on the digital precision of internal fixation via the sinus tarsi approach for calcaneal fractures

OBJECTIVE

To investigate the effectiveness and accuracy of internal fixation of calcaneal fractures with a three-dimensional (3-D) printing navigation module via the sinus approach.

METHODS

Eleven lateral lower extremity specimens were used in the experiment and divided into the digital design (DD) group ( n = 11) and the real surgery (RS) group ( n = 11). For the DD group, thin-section computed tomography (CT) scans, virtual fracture modeling, virtual bone plate fixation, sinus occlusal module design, and navigation module design were performed for the cadaver specimens. A 3-D navigation module was printed using a 3-D printer. For the RS group, the sinus approach incision was made, and the navigation module was used to assist the placement of screw fixation and anatomically locked bone plate fixation. Thin-layer CT scans, 3-D reconstructions, and reconstruction of the nail paths were performed in the RS group and 3-D registered with the DD group. 3-D coordinate values for the screw entry and exit points in the RS and DD groups were recorded, and the corresponding offset values of the screw points were calculated. The number of qualified nails at different accuracy levels was counted. The χ² test was used to compare the data for the DD and RS groups to obtain the accuracy level for both groups when p > 0.05, which is the critical value for experimental accuracy.

RESULTS

A total of 11 bone plates were placed and 120 screws were locked. None of them protruded from the inferior articular surface. The screw entry and exit point offsets were 1.71 ± 0.11 mm and 3.10 ± 0.19 mm, respectively. When the accuracy requirement for the entry point was 3.8 mm, there was no statistically significant difference between the two groups ( p > 0.05). Similarly, the accuracy of the exit point of the screw could only reach 6.6 mm.

CONCLUSION

Internal fixation of calcaneal fractures via the sinus tarsi approach with an anatomical locking plate based on the 3-D printing navigation module can achieve accurate screw placement and good overall internal fixation.

A personalized preoperative modeling system for internal fixation plates in long bone fracture surgery-A straightforward way from CT images to plate model

BACKGROUND

Long bone fractures are a type of physical damage with high incidence rates that have serious impacts on the normal lives of humans.

AIMS

How to obtain a preoperative internal fixation plate model before cutting muscle has become a critical issue.

MATERIALS AND METHODS

In this paper, we present a new personalized modeling system for internal fixation plates in long bone fracture surgery. This system can achieve straight semi-automatic processing from CT images to 3D models. First, broken bones are separated in CT images. Second, the axes of long broken bones are extracted using 3D models. Third, the vertices on the broken bone cross-sections are segmented. Fourth, rough alignment and fine registration are implemented.

RESULTS

An internal fixation plate is reconstructed for a long bone fracture.

DISCUSSION

Three validations indicate that this method framework is reasonable and feasible.

CONCLUSION

This system can provide technical support for the personalized, minimally invasive and accurate operation on long bone fractures.

3D printing method for next-day acetabular fracture surgery using a surface filtering pipeline: feasibility and 1-year clinical results

Introduction

In orthopedic surgery, 3D printing is a technology with promising medical applications. Publications show promising results in acetabular fracture surgery over the last years using 3D printing. However, only little information about the workflow and circumstances of how to properly derive the 3D printed fracture model out of a CT scan is published.

Materials and methods

We conducted a retrospective analysis of patients with acetabular fractures in a level 1 trauma center. DICOM data were preoperatively used in a series of patients with acetabular fractures. The 3D mesh models were created using 3D Slicer (https://www.slicer.org) with a newly introduced surface filtering method. The models were printed using PLA material with FDM printer. After reduction in the printed model, the acetabular reconstruction plate was bent preoperatively and sterilized. A clinical follow-up after 12 months in average was conducted with the patients.

Results

In total, 12 patients included. Mean printing time was 8:40 h. The calculated mean printing time without applying the surface filter was 25:26 h. This concludes an average printing time reduction of 65%. Mean operation time was 3:16 h, and mean blood loss was 853 ml. Model creation time was about 11 min, and mean printing time of the 3D model was 8:40 h, preoperative model reduction time was 5 min on average, and preoperative bending of the plate took about 10 min. After 12 months, patients underwent a structured follow-up. Harris Hip Score was 75.7 points, the Modified Harris Hip Score 71.6 points and the Merle d’Aubigne Score 11.1 points on average.

Conclusions

We presented the first clinical practical technique to use 3D printing in acetabular fracture surgery. By introducing a new surface filtering pipeline, we reduced printing time and cost compared to the current literature and the state of the art. Low costs and easy handling of the 3D printing workflow make it usable in nearly every hospital setting for acetabular fracture surgery.

Comparative study of sacroiliac screw placement guided by 3D-printed template technology and X-ray fluoroscopy

OBJECTIVE

To compare the clinical effect of 3D-printed template technology with X-ray fluoroscopy in assisting surgery for sacroiliac screws placement.

DESIGN

Institutional review board-approved retrospective analysis.

PATIENTS

The clinical data of 31 cases of sacroiliac complex injury between January 2015 and December 2016 were analyzed. There were 16 patients, males 11 and females 5, who underwent surgery assisted by 3D-printed template in template group, and that of contemporaneous 15 patients, males 11 and females 4, who underwent traditional surgery were gathered as fluoroscopy group. All those patients were followed up for more than 6 months.

MAIN OUTCOME MEASURES

The operation time and X-ray fluoroscopy times for each screw placement, and the Matta and Majeed score were analyzed and the difference between the two group was tested.

RESULTS

All cases were followed up for 6-20 months, average 11.4 ± 0.6 months. In template group, 19 screws were implanted. Each screw spent 25-38 min, average 27.2 ± 5.3 min, and need 2-5 times fluoroscopy, average 2.7 ± 0.5. The fracture reduction quality was evaluated by Matta score scale: excellent 10, well 4, fair 2, good rate 87.5%; and pelvic function were evaluated by Majeed score scale: excellent 11, well 3, fair 2, and good rate 87.5%. In fluoroscopy group, 17 screws were implanted. Each screw spent 45-70 min, average 60.3 ± 5.8 min, and needs 11-23 times fluoroscopy, average 15.4 ± 3.5. The fracture reduction quality was evaluated by Matta score scale: excellent 7, well 6, fair 2, and good rate 86.7%; and pelvic function was evaluated by Majeed score scale: excellent 6, well 6, fair 3, and good rate 80.0%. The difference in operation time, X-ray fluoroscopy times between template group and fluoroscopy group had statistical significance. But the Matta and Majeed score had no difference between two groups.

CONCLUSION

Compared with traditional surgery, 3D-printed template technology-assisted surgery for sacroiliac screws placement in sacroiliac complex injury patients possesses advantage such as shortened operation time and reduced X-ray exposure times. This technology improves the safety profile of this operation and should be further studied in future clinical applications.

Value of three-dimensional printing of fractures in orthopaedic trauma surgery

Objective

Information technology-based innovation is playing an increasingly key role in healthcare systems. The use of three-dimensional (3D)-printed bone fracture replicas in orthopaedic clinical practice could provide a new tool for fracture simulations and treatment, and change the interaction between patient and surgeon. We investigated the additional value of 3D-printing in the preparation and execution of surgical procedures and communication with patients, as well as its teaching and economic implications.

Methods

Fifty-two patients with complex articular displaced fractures of the calcaneus, tibial plateau, or distal radius were enrolled. 3D-printed real-size models of the fractured bone were obtained from computed tomography scans and exported to files suitable for 3D-printing. The models were handled by trauma surgeons, residents, and patients to investigate the potential advantages and procedural improvements. The patients’ and surgeons’ findings were recorded using specific questionnaires.

Results

3D-printed replicas of articular fractures facilitated surgical planning and preoperative simulations, as well as training and teaching activities. They also strengthening the informed consent process and reduced surgical times and costs by about 15%.

Conclusion

3D-printed models of bone fractures represent a significant step towards more-personalized medicine, with improved education and surgeon–patient relationships.

3D printing of implants for patient-specific acetabular fracture fixation: an experimental study

PURPOSE

To test the effect of 3D printed implants, designed according to surgeon's individual plan, on the accuracy of reduction of an acetabular fracture model.

METHODS

Seven identical standardized plastic bone models of an anterior column/posterior hemi-transverse acetabular fracture were used. A CT of one plastic fracture model was made. Using preoperative planning software, three surgeons independently planned the reduction and fixation procedure and designed implants and drill guides. The designed implants and guides were then 3D printed. Each surgeon first executed his plan using his 3D printed plates and guides on one fracture model and then performed another procedure on an identical model with standard implants and instrumentation. Displacement of the fragments at the weight-bearing fracture lines in the acetabulum was measured after fixation. Linear mixed effect models were used to evaluate the effect of different solutions to the same fracture pattern.

RESULTS

Mean (SD) displacement of the fracture line between the ischium and stable fragment was 1.1 (0.9) mm for the standard implant and 0.8 (0.6) mm for the 3D printed implant, while the displacements of the fracture line between the stable fragment and anterior column were 0.6 (0.6) and 0.3 (0.3) for the standard and 3D printed methods, respectively (p < 0.001). Mean (SD) fracture line step-off at any fracture line for the standard implant was 1.2 (0.9) mm and 0.4 (0.4) mm for the 3D printed implant (p = 0.022).

CONCLUSIONS

Patient-specific 3D printed plates and drill guides may facilitate retaining accurate reduction and fixation of select acetabular fracture patterns.

Surgical applications of three-dimensional printing in the pelvis and acetabulum: from models and tools to implants

There are numerous orthopaedic applications of three-dimensional (3D) printing for the pelvis and acetabulum. The authors reviewed recently published articles and summarized their experience. 3D printed anatomical models are particularly useful in pelvic and acetabular fracture surgery for planning, implant templating and for anatomical assessment of pathologies such as CAM-type femoroacetabular impingement and rare deformities. Custom-made metal 3D printed patient-specific implants and instruments are increasingly being studied for pelvic oncologic resection and reconstruction of resected defects as well as for revision hip arthroplasties with favourable results. This article also discusses cost-effectiveness considerations when preparing pelvic 3D printed models from a hospital 3D printing centre.

Efficacy of 3D Printed Models on Resident Learning and Understanding of Common Acetabular Fracturers

RATIONALE AND OBJECTIVES

The conceptualization of acetabular fractures can present a daunting challenge to radiology residents. 3D models have been shown to aid in the spatial perception of complicated anatomy and may help residents grasp the elaborate classification systems for these anatomically complex fractures. Prior studies have explored the utility of 3D printed models for surgical planning in various settings. To our knowledge, no study has evaluated their efficacy in radiology resident training.

MATERIALS AND METHODS

Following IRB approval, 22 radiology residents were randomized and stratified by Post Graduate Year into two groups of 11 residents. Both groups received separate identical presentations on the 5 most common acetabular fractures given by a musculoskeletal trained radiologist. Residents in the experimental group received 3D printed models of the five most common fracture types with which to interact during the presentation, while the control group did not. Both groups received a pretest and a follow up posttest three weeks later.

RESULTS

A Wilcoxon rank sum test was performed to determine if statistically significant differences between the pretest and posttest scores of the experimental and control groups existed. There was no statistically significant difference in scores on the pre-test, which confirmed successful randomization. There was a statistically significant difference (P = 0.02) on the posttest scores between the experimental and control groups.

CONCLUSION

3D printed models promise as an effective educational tool for resident learning with respect to acetabular fractures, improving short-term understanding of complex anatomy and classification systems.

Radiological Society of North America (RSNA) 3D printing Special Interest Group (SIG): guidelines for medical 3D printing and appropriateness for clinical scenarios

Medical three-dimensional (3D) printing has expanded dramatically over the past three decades with growth in both facility adoption and the variety of medical applications. Consideration for each step required to create accurate 3D printed models from medical imaging data impacts patient care and management. In this paper, a writing group representing the Radiological Society of North America Special Interest Group on 3D Printing (SIG) provides recommendations that have been vetted and voted on by the SIG active membership. This body of work includes appropriate clinical use of anatomic models 3D printed for diagnostic use in the care of patients with specific medical conditions. The recommendations provide guidance for approaches and tools in medical 3D printing, from image acquisition, segmentation of the desired anatomy intended for 3D printing, creation of a 3D-printable model, and post-processing of 3D printed anatomic models for patient care.

3D printing- creating a blueprint for the future of orthopedics: Current concept review and the road ahead!

The use of 3D printing in Orthopedics is set to transform the way surgeries are planned and executed. The development of X rays and later the CT scan and MRI enabled surgeons to understand the anatomy and condition better and helped plan surgeries on images obtained. 3DGraphy a term used for 3D printed orthopedic patient models and Jigs has gone a step further by providing surgeons with a physical copy of the patient's affected part that can not only be seen but also felt and moved around spatially. Similarly 3D printed Jigs are patient specific devices that are used to ensure optimal screw trajectory and implant placement with minimal exposure. While the use of 3D printed models and Jigs have now become routine, a similar revolution is happening in the field of designing and printing patient specific implants. Metal printing along with enhanced capability to print other biocompatible materials like PEEK and PLA is likely to improve the current implant manufacturing process. On the horizon is another interesting development related to this field - 3D Bio printing. Printing human tissues and organs is considered the final frontier and impressive strides have been made in printing bone graft substitutes and cartilage like material. This paper is an overview of all the current developments and the road ahead in this invigorating field.

Validation study of 3D-printed anatomical models using 2 PLA printers for preoperative planning in trauma surgery, a human cadaver study

INTRODUCTION

3D printing contributes to a better understanding of the surgical approach, reduction and fixation of complex fractures. It is unclear how a 3D-printed model relates to a human bone. The accuracy of 3D-printed models is important to pre-bend plates and fit of surgical guides. We conduct a validation study in which we compare human cadavers with 3D-printed models to test the accuracy of 3D printing.

METHODS

Nine specimens were scanned, volume rendered into 3D reconstructions and saved as STL data. All models were in a ratio of 1:1 printed on the Ultimaker 3 and Makerbot Replicator Z18. Two independent observers measured all distances between the K-wires on the human cadavers, 2DCT, 3D reconstruction, Meshlab and both printers. A paired Samples T test was used to compare the measurements between the different modalities.

RESULTS

The least decrease in average distance in millimetres was seen in "the 3D printed pelvis 1", - 0.3 and - 0.8% on respectively the Ultimaker and Makerbot when compared with cadaver Pelvis (1) The 3D model of "Hand 2" showed the most decrease, - 2.5 and - 3.2% on the Ultimaker and Makerbot when compared with cadaver hand (2) Most significant differences in measurements were found in the conversion from 3D file into a 3D print and between the cadaver and 3D-printed model from the Makerbot.

CONCLUSION

Our 3D printing process results in accurate models suitable for preoperative workup. The Ultimaker 3 is slightly more accurate than the Makerbot Replicator Z18. We advise that medical professionals should perform a study that tests the accuracy of their 3D printing process before using the 3D-printed models in medical practice.