Application of 3D Printing in the Surgical Planning of Trimalleolar Fracture and Doctor-Patient Communication. Biomed Res Int. 2016;2016:2482086. [PMID: 27446944 PMCID: PMC4947492 DOI: 10.1155/2016/2482086]

Does using 3D printed models for pre-operative planning improve surgical outcomes of foot and ankle fracture fixation? A systematic review and meta-analysis

PURPOSE

The systematic review aims to establish the value of using 3D printing-assisted pre-operative planning, compared to conventional planning, for the operative management of foot and ankle fractures.

METHODS

The systematic review was performed according to PRISMA guidelines. Two authors performed searches on three electronic databases. Studies were included if they conformed to pre-established eligibility criteria. Primary outcome measures included intraoperative blood loss, operation duration, and fluoroscopy time. The American orthopaedic foot and ankle score (AOFAS) was used as a secondary outcome. Quality assessment was completed using the Cochrane RoB2 form and a meta-analysis was performed to assess heterogeneity.

RESULTS

Five studies met the inclusion and exclusion criteria and were eventually included in the review. A meta-analysis established that using 3D printed models for pre-operative planning resulted in a significant reduction in operation duration (mean difference [MD] = - 23.52 min, 95% CI [- 39.31, - 7.74], p = 0.003), intraoperative blood loss (MD = - 30.59 mL, 95% CI [- 46.31, - 14.87], p = 0.0001), and number of times fluoroscopy was used (MD = - 3.20 times, 95% CI [- 4.69, - 1.72], p < 0.0001). Using 3D printed models also significantly increased AOFAS score results (MD = 2.24, 95% CI [0.69, 3.78], p = 0.005), demonstrating improved ankle health.

CONCLUSION

The systematic review provides promising evidence that 3D printing-assisted surgery significantly improves treatment for foot and ankle fractures in terms of operation duration, intraoperative blood loss, number of times fluoroscopy was used intraoperatively, and improved overall ankle health as measured by the AOFAS score.

A case report demonstrating the utilization of computer-aided design technology and intramedullary nails for the management of femoral deformity and fracture

BACKGROUND

To effectively address severe deformities at the fracture site in patients, meticulous preoperative preparation is essential. This involves ensuring the restoration of the normal structural force line of the affected area and prevention of any residual deformities. By utilizing E3D technology prior to surgery, creating models based on individual patient image data and performing osteotomy, the required surgical parameters can be measured, thereby reducing surgical risks and enhancing precision.

CASE PRESENTATION

This article documents a case involving a fractured femoral shaft resulting in femoral deformation. In this case, computer-aided design technology was employed for preoperative planning and data measurement to guide the corrective osteotomy and fracture fixation procedures.

CONCLUSION

The E3D software utilizes advanced techniques such as customized osteotomy, virtual reduction and internal fixation insertion technology. This enables the software to accurately pre-select the correction of femoral deformities and determine the appropriate specifications and types of internal implants. As a result, the software can create precise, rational, and personalized repair plans tailored to each patient's needs.

Virtual Surgical Planning and Three-Dimensional Models for Precision Sinonasal and Skull Base Surgery

Sinonasal and skull base malignancies represent a rare, heterogenous group of pathologies with an incidence of 0.556 per 100,000 persons in the population. Given the numerous critical anatomic structures located adjacent to the sinonasal cavity and skull base, surgery for tumors in this region requires careful pre-operative planning with the assistance of radiological imaging and intraoperative image guidance technologies to reduce the risk of complications. Virtual surgical planning (VSP) and three-dimensional models (3DMs) are adjunctive technologies which assist clinicians to better visualize patient anatomy using enhanced digital radiological images and physical stereolithographic models based on patients' personal imaging. This review summarizes our institutional experience with VSP and 3DMs in sinonasal and skull base surgical oncology. A clinical case series is used to thematically illustrate the application of VSP and 3DMs in surgical ablation, reconstruction, patient communication, medical education, and interdisciplinary teamwork in sinonasal and skull base surgery.

3D Printing Technology in Pediatric Orthopedics: a Primer for the Clinician

PURPOSE OF REVIEW

This article reviews the basics of 3D printing and provides an overview of current and future applications of this emerging technology in pediatric orthopedic surgery.

RECENT FINDINGS

Both preoperative and intraoperative utilization of 3D printing technology have enhanced clinical care. Potential benefits include more accurate surgical planning, shortening of a surgical learning curve, decrease in intraoperative blood loss, less operative time, and fluoroscopic time. Furthermore, patient-specific instrumentation can be used to improve the safety and accuracy of surgical care. Patient-physician communication can also benefit from 3D printing technology. 3D printing is rapidly advancing in the field of pediatric orthopedic surgery. It has the potential to increase the value of several pediatric orthopedic procedures by enhancing safety and accuracy while saving time. Future efforts in cost reduction strategies, making patient-specific implants including biologic substitutes and scaffolds, will further increase the relevance of 3D technology in the field of pediatric orthopedic surgery.

Application of preoperative 3D printing in the internal fixation of posterior rib fractures with embracing device: a cohort study

BACKGROUND

To explore the impact of preoperative 3D printing on the fixation of posterior rib fractures utilizing a memory alloy embracing device of rib under thoracoscopy.

METHODS

The enrolled patients were divided into the 3D printing (11 patients) and the non-3D printing (18 patients) groups, based on whether a 3D model of ribs was prepared prior to surgery. Analysis was conducted comparing the average fixation time per fracture, postoperative fixation loss, and poor reduction of fractured end between the two groups.

RESULTS

The average fixation time of each fracture was 27.2 ± 7.7 min in the 3D printing group and 29.3 ± 8.2 min in the non-3D printing group, with no statistically significant difference observed between the two groups (P > 0.05). The incidence of poor fracture fixation in the 3D printing group was statistically lower than that in the non-3D printing group (12.9% vs. 44.7%, P < 0.05). Further stratified analysis revealed that the off-plate rate in the 3D printing group and the non-3D group was (3.2% vs. 12.8%, P > 0.05), and the dislocation rate of the fractured end was (9.7% vs. 31.9%, P < 0.05).

CONCLUSIONS

The application of 3D printing technology to prepare the rib model before surgery is proves beneficial in reducing the occurrence of poor fixation of fractures and achieving precise and individualized treatment.

Clinical effects of 3D printing-assisted posterolateral incision in the treatment of ankle fractures involving the posterior malleolus

Objective

To explore the clinical outcomes of a 3D printing-assisted posterolateral approach for the treatment of ankle fractures involving the posterior malleolus.

Methods

A total of 51 patients with ankle fractures involving the posterior malleolus admitted to our hospital from January 2018 to December 2019 were selected. The patients were divided into 3D printing group (28 cases) and control group (23 cases). 3D printing was performed for ankle fractures, followed by printing of a solid model and simulation of the operation on the 3D model. The operation was then performed according to the preoperative plan, including open reduction and internal fixation via the posterolateral approach with the patient in the prone position. Routine x-ray and CT examinations of the ankle joint were performed, and ankle function was evaluated using the American Foot and Ankle Surgery Association (AOFAS) ankle-hindfoot score.

Results

All patients underwent x-ray and CT examinations. All fractures healed clinically, without loss of reduction or failure of internal fixation. Good clinical effects were achieved in both groups of patients. The operation time, intraoperative blood loss and intraoperative fluoroscopy frequency in the 3D printing group were significantly less than those in the control group (p < 0.05). There was no significant difference between the two groups in the anatomical reduction rate of fractures or the incidence of surgical complications (p > 0.05).

Conclusion

The 3D printing-assisted posterolateral approach is effective in the treatment of ankle fractures involving the posterior malleolus. The approach can be well planned before the operation, is simple to perform, yields good fracture reduction and fixation, and has good prospects for clinical application.

Exploring the value of three-dimensional printing and virtualization in paediatric healthcare: A multi-case quality improvement study

Background

Three-dimensional printing is being utilized in clinical medicine to support activities including surgical planning, education, and medical device fabrication. To better understand the impacts of this technology, a survey was implemented with radiologists, specialist physicians, and surgeons at a tertiary care hospital in Canada, examining multidimensional value and considerations for uptake.

Objectives

To examine how three-dimensional printing can be integrated into the paediatric context and highlight areas of impact and value to the healthcare system using Kirkpatrick's Model. Secondarily, to explore the perspective of clinicians utilizing three-dimensional models and how they make decisions about whether or not to use the technology in patient care.

Methods

A post-case survey. Descriptive statistics are provided for Likert-style questions, and a thematic analysis was conducted to identify common patterns in open-ended responses.

Results

In total, 37 respondents were surveyed across 19 clinical cases, providing their perspectives on model reaction, learning, behaviour, and results. We found surgeons and specialists to consider the models more beneficial than radiologists. Results further showed that the models were more helpful when used to assess the likelihood of success or failure of clinical management strategies, and for intraoperative orientation. We demonstrate that three-dimensional printed models could improve perioperative metrics, including a reduction in operating room time, but with a reciprocal effect on pre-procedural planning time. Clinicians who shared the models with patients and families thought it increased understanding of the disease and surgical procedure, and had no effect on their consultation time.

Conclusions

Three-dimensional printing and virtualization were used in preoperative planning and for communication among the clinical care team, trainees, patients, and families. Three-dimensional models provide multidimensional value to clinical teams, patients, and the health system. Further investigation is warranted to assess value in other clinical areas, across disciplines, and from a health economics and outcomes perspective.

The clinical performance of ultra-low-dose shoulder CT scans: The assessment on image and physical 3D printing models

Objectives

Evaluation of the clinical performance of ultra-low-dose computed tomography (CT) images of the shoulder joint on image-based diagnosis and three-dimensional (3D) printing surgical planning.

Materials and methods

A total of 93 patients with displaced shoulder fractures were randomly divided into standard-dose, low-dose, and ultra-low-dose groups. Three-dimensional printing models of all patients’ shoulder joints were fabricated. The subjective image quality and 3D-printing model were evaluated by two senior orthopedic surgeons who were blinded to any scanning setting. A 3-point scale system was used to quantitatively assess the image quality and 3D printing model, where more than 2 points meant adequate level for clinical application.

Results

Compared with the standard dose protocol, ultra-low-dose technique reduced the radiation dose by 99.29% without loss of key image quality of fracture pattern. Regarding the subjective image quality, the assessment scores for groups of standard, low, and ultra-low doses were 3.00, 2.76, 2.00 points on scapula and humerus, and 3.00, 2.73, 2.44 points on clavicle. Scores of the three groups for the assessment of 3D printing models were 3.00, 2.80, 1.34 on scapula and humerus, and 3.00, 2.90, 2.06 on clavicle. In the ultra-low-dose group, 24 out of 33 (72.7%) 3D printing models of scapula and humerus received lower than 2 points of the evaluation score, while nearly 94% of the clavicle models reached the adequate level.

Conclusion

An ultra-low-dose protocol is adequate for the diagnosis of either displaced or non-displaced fractures of the shoulder joint even though minor flaws of images are present. Three-dimensional printing models of shoulder joints created from ultra-low-dose CT scans can be used for surgical planning at specific bone like the clavicle but perform insufficiently in the overall surgical planning for shoulder injuries due to the significant geometric flaws.

Comparison of 2 open-sourced 3-dimensional modeling techniques for orthopaedic application

Objectives: Although 3-dimensional (3D) printing is becoming more widely adopted for clinical applications, it is yet to be accepted as part of standard practice. One of the key applications of this technology is orthopaedic surgical planning for urgent trauma cases. Anatomically accurate replicas of patients' fracture models can be produced to guide intervention. These high-quality models facilitate the design and printing of patient-specific implants and surgical devices. Therefore, a fast and accurate workflow will help orthopaedic surgeons to generate high-quality 3D printable models of complex fractures. Currently, there is a lack of access to an uncomplicated and inexpensive workflow. Methods: Using patient DICOM data sets (n = 13), we devised a novel, simple, open-source, and rapid modeling process using Drishti software and compared its efficacy and data storage with the 3D Slicer image computing platform. We imported the computed tomography image directory acquired from patients into the software to isolate the model of bone surface from surrounding soft tissue using the minimum functions. One pelvic fracture case was further integrated into the customized implant design practice to demonstrate the compatibility of the 3D models generated from Drishti. Results: The data sizes of the generated 3D models and the processing files that represent the original DICOM of Drishti are on average 27% and 12% smaller than that of 3D Slicer, respectively (both P < 0.05). The time frame needed to reach the stage of viewing the 3D bone model and the exporting of the data of Drishti is 39% and 38% faster than that of 3D Slicer, respectively (both P < 0.05). We also constructed a virtual model using third-party software to trial the implant design. Conclusions: Drishti is more suitable for urgent trauma cases that require fast and efficient 3D bone reconstruction with less hardware requirement. 3D Slicer performs better at quantitative preoperative planning and multilayer segmentation. Both software platforms are compatible with third-party programs used to produce customized implants that could be useful for surgical training. Level of Evidence: Level V.

Does a Customized 3D Printing Plate Based on Virtual Reduction Facilitate the Restoration of Original Anatomy in Fractures?

The purpose of this study was to evaluate the restoration of original anatomy after fixation of sawbone fractures using case-specific 3D printing plates based on virtual reduction (VR). Three-dimensional models of 28 tibia sawbones with cortical marking holes were obtained. The sawbones were fractured at various locations of the shaft and 3D models were obtained. The fractured models were reduced virtually and customized non-locking metal plates that fit the reduced model were produced via 3D printing. The fractured sawbones were actually fixed to the customized plate with nonlocking screws and 3D models were generated. With the proximal fragments of the 3D models overlapped, the changes in length, 3D angulation, and rotation of the distal fragment were evaluated. Compared to the intact model (IN), the virtual reduction model (VR) and the actual fixation model (AF) showed no significant differences in length. Compared to the IN, the VR and the AF had mean 3D angulations of 0.39° and 0.64°, respectively. Compared to the IN model, the VR and the AF showed mean rotations of 0.89° and 1.51°, respectively. A customized plate based on VR facilitates the restoration of near-original anatomy in fractures of tibial sawbone shaft.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

[3D printing in the field of shoulder surgery]

The 3D printing technology is a relatively new procedure with a high potential, especially in the field of shoulder surgery. The 3D printing procedures are increasingly being developed and also gaining new users. Principally, 3D printing procedures can be applied preoperatively in planning the surgical procedure, patient clarification and in teaching; however, the technology is increasing being used intraoperatively. In addition to intraoperative visualization of the models, 3D printing permits the use of individual and specific instruments and implants. This allows the precise transfer of the preoperative planning to the surgical procedure. Inaccuracies are mainly caused by soft tissues. The 3D printing can be beneficial in the fields of arthroplasty, shoulder instability as well as orthopedic trauma. The literature shows promising results in relation to duration of surgery, blood loss and clinical results of the procedure. On the other hand, it is still unclear which indications warrant the use of 3D printing. Other aspects that raise questions are the time of planning, the production time and the additional cost that the use of 3D printing entails. Nonetheless, 3D printing represents a meaningful enhancement of the portfolio of surgeons, which becomes highly beneficial and useful in complex situations. Furthermore, this procedure enables a certain amount of flexibility when reacting to certain circumstances.

The use of 3D-printed models in patient communication: a scoping review

3D models have been used as an asset in many clinical applications and a variety of disciplines, and yet the available literature studying the use of 3D models in communication is limited. This scoping review has been conducted to draw conclusions on the current evidence and learn from previous studies, using this knowledge to inform future work. Our search strategy revealed 269 papers, 19 of which were selected for final inclusion and analysis. When assessing the use of 3D models in doctor-patient communication, there is a need for larger studies and studies including a long-term follow up. Furthermore, there are forms of communication that are yet to be researched and provide a niche that may be beneficial to explore.

3D printing in orthopaedic surgery: a scoping review of randomized controlled trials

Aims

The use of 3D printing has become increasingly popular and has been widely used in orthopaedic surgery. There has been a trend towards an increasing number of publications in this field, but existing literature incorporates limited high-quality studies, and there is a lack of reports on outcomes. The aim of this study was to perform a scoping review with Level I evidence on the application and effectiveness of 3D printing.

Methods

A literature search was performed in PubMed, Embase, and Web of Science databases. The keywords used for the search criteria were ((3d print*) OR (rapid prototyp*) OR (additive manufactur*)) AND (orthopaedic). The inclusion criteria were: 1) use of 3D printing in orthopaedics, 2) randomized controlled trials, and 3) studies with participants/patients. Risk of bias was assessed with Cochrane Collaboration Tool and PEDro Score. Pooled analysis was performed.

Results

Overall, 21 studies were included in our study with a pooled total of 932 participants. Pooled analysis showed that operating time (p < 0.001), blood loss (p < 0.001), fluoroscopy times (p < 0.001), bone union time (p < 0.001), pain (p = 0.040), accuracy (p < 0.001), and functional scores (p < 0.001) were significantly improved with 3D printing compared to the control group. There were no significant differences in complications.

Conclusion

3D printing is a rapidly developing field in orthopaedics. Our findings show that 3D printing is advantageous in terms of operating time, blood loss, fluoroscopy times, bone union time, pain, accuracy, and function. The use of 3D printing did not increase the risk of complications.

Cite this article: Bone Joint Res 2021;10(12):807–819.

3D-printed models improve surgical planning for correction of severe postburn ankle contracture with an external fixator

Gradual distraction with an external fixator is a widely used treatment for severe postburn ankle contracture (SPAC). However, application of external fixators is complex, and conventional two-dimensional (2D) imaging-based surgical planning is not particularly helpful due to a lack of spatial geometry. The purpose of this study was to evaluate the surgical planning process for this procedure with patient-specific three-dimension-printed models (3DPMs). In this study, patients coming from two centers were divided into two cohorts (3DPM group vs. control group) depending on whether a 3DPM was used for preoperative surgical planning. Operation duration, improvement in metatarsal-tibial angle (MTA), range of motion (ROM), the American Orthopedic Foot and Ankle Society (AOFAS) scores, complications, and patient-reported satisfaction were compared between two groups. The 3DPM group had significantly shorter operation duration than the control group ((2.0±0.3) h vs. (3.2±0.3) h, P<0.01). MTA, ROM, and AOFAS scores between the two groups showed no significant differences pre-operation, after the removal of the external fixator, or at follow-up. Plantigrade feet were achieved and gait was substantially improved in all patients at the final follow-up. Pin-tract infections occurred in two patients (one in each group) during distraction and were treated with wound care and oral antibiotics. Patients in the 3DPM group reported higher satisfaction than those in the control group, owing to better patient-surgeon communication. Surgical planning using patient-specific 3DPMs significantly reduced operation duration and increased patient satisfaction, while providing similar improvements in ankle movement and function compared to traditional surgical planning for the correction of SPAC with external fixators.

Application of 3D printing in the treatment of appendicular skeleton fractures: Systematic review and meta-analysis

The objective of this study is to evaluate, through a systematic review of the scientific literature and meta-analysis, the applications of three-dimensional (3D) printing in the surgical treatment of complex fractures of the appendicular skeleton, mainly in terms of effectiveness and safety. A systematic review of the scientific literature was conducted in MEDLINE (PubMed) and the Cochrane Library combining different keywords. A specific methodological assessment scale was developed and applied to included papers. Ten studies were included; all of them were controlled trials, except for one retrospective observational cohort study. We observed statistically significant differences between the group that used 3D printing and the control group in terms of reduction in surgical time, reduction in the volume of blood lost during surgery and reduction in the number of intraoperative fluoroscopies, in favor of the 3D printing group. No statistically significant differences were observed in terms of fracture healing time, postoperative joint function, or postoperative complications. Meta-analysis revealed more favorable results for 3D-printing compared with conventional surgery, with the greatest difference observed for the number of intraoperative fluoroscopies. 3D printing might be considered effective and safe in the surgical treatment of anatomically complex appendicular skeleton fractures, in terms of reducing surgical time, lost blood volume, and radiation exposure of surgeons and patients.

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.

Applicability of 3D-printed models in hepatobiliary surgey: results from "LIV3DPRINT" multicenter study

BACKGROUND

Hepatobiliary resections are challenging due to the complex liver anatomy. Three-dimensional printing (3DP) has gained popularity due to its ability to produce anatomical models based on the characteristics of each patient.

METHODS

A multicenter study was conducted on complex hepatobiliary tumours. The endpoint was to validate 3DP model accuracy from original image sources for application in the teaching, patient-communication, and planning of hepatobiliary surgery.

RESULTS

Thirty-five patients from eight centers were included. Process testing between 3DP and CT/MRI presented a considerable degree of similarity in vascular calibers (0.22 ± 1.8 mm), and distances between the tumour and vessel (0.31 ± 0.24 mm). The Dice Similarity Coefficient was 0.92, with a variation of 2%. Bland-Altman plots also demonstrated an agreement between 3DP and the surgical specimen with the distance of the resection margin (1.15 ± 1.52 mm). Professionals considered 3DP at a positive rate of 0.89 (95%CI; 0.73-0.95). According to student's distribution a higher success rate was reached with 3DP (median:0.9, IQR: 0.8-1) compared with CT/MRI or 3D digital imaging (P = 0.01).

CONCLUSION

3DP hepatic models present a good correlation compared with CT/MRI and surgical pathology and they are useful for education, understanding, and surgical planning, but does not necessarily affect the surgical outcome.

Point-of-care manufacturing: a single university hospital's initial experience

Background

The integration of 3D printing technology in hospitals is evolving toward production models such as point-of-care manufacturing. This study aims to present the results of the integration of 3D printing technology in a manufacturing university hospital.

Methods

Observational, descriptive, retrospective, and monocentric study of 907 instances of 3D printing from November 2015 to March 2020. Variables such as product type, utility, time, or manufacturing materials were analyzed.

Results

Orthopedic Surgery and Traumatology, Oral and Maxillofacial Surgery, and Gynecology and Obstetrics are the medical specialties that have manufactured the largest number of processes. Working and printing time, as well as the amount of printing material, is different for different types of products and input data. The most common printing material was polylactic acid, although biocompatible resin was introduced to produce surgical guides. In addition, the hospital has worked on the co-design of custom-made implants with manufacturing companies and has also participated in tissue bio-printing projects.

Conclusions

The integration of 3D printing in a university hospital allows identifying the conceptual evolution to “point-of-care manufacturing.”

Conceptual evolution of 3D printing in orthopedic surgery and traumatology: from "do it yourself" to "point of care manufacturing"

BACKGROUND

3D printing technology in hospitals facilitates production models such as point-of-care manufacturing. Orthopedic Surgery and Traumatology is the specialty that can most benefit from the advantages of these tools. The purpose of this study is to present the results of the integration of 3D printing technology in a Department of Orthopedic Surgery and Traumatology and to identify the productive model of the point-of-care manufacturing as a paradigm of personalized medicine.

METHODS

Observational, descriptive, retrospective and monocentric study of a total of 623 additive manufacturing processes carried out in a Department of Orthopedic Surgery and Traumatology from November 2015 to March 2020. Variables such as product type, utility, time or materials for manufacture were analyzed.

RESULTS

The areas of expertise that have performed more processes are Traumatology, Reconstructive and Orthopedic Oncology. Pre-operative planning is their primary use. Working and 3D printing hours, as well as the amount of 3D printing material used, vary according to the type of product or material delivered to perform the process. The most commonly used 3D printing material for manufacturing is polylactic acid, although biocompatible resin has been used to produce surgical guides. In addition, the hospital has worked on the co-design of customized implants with manufacturing companies.

CONCLUSIONS

The integration of 3D printing in a Department of Orthopedic Surgery and Traumatology allows identifying the conceptual evolution from "Do-It-Yourself" to "POC manufacturing".

Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures

Hypothesis

This study aimed to examine whether three-dimensionally printed models (3D models) could improve interobserver and intraobserver agreement when classifying proximal humeral fractures (PHFs) using the Neer system. We hypothesized that 3D models would improve interobserver and intraobserver agreement compared with x-ray, two-dimensional (2D) and three-dimensional (3D) computed tomography (CT) and that agreement using 3D models would be higher for registrars than for consultants.

Methods

Thirty consecutive PHF images were selected from a state-wide database and classified by fourteen observers. Each imaging modality (x-ray, 2D CT, 3D CT, 3D models) was grouped and presented in a randomly allocated sequence on two separate occasions. Interobserver and intraobserver agreements were quantified with kappa values (κ), percentage agreement, and 95% confidence intervals (CIs).

Results

Seven orthopedic registrars and seven orthopedic consultants classified 30 fractures on one occasion (interobserver). Four registrars and three consultants additionally completed classification on a second occasion (intraobserver). Interobserver agreement was greater with 3D models than with x-ray (κ = 0.47, CI: 0.44-0.50, 66.5%, CI: 64.6-68.4% and κ = 0.29, CI: 0.26-0.31, 57.2%, CI: 55.1-59.3%, respectively), 2D CT (κ = 0.30, CI: 0.27-0.33, 57.8%, CI: 55.5-60.2%), and 3D CT (κ = 0.35, CI: 0.33-0.38, 58.8%, CI: 56.7-60.9%). Intraobserver agreement appeared higher for 3D models than for other modalities; however, results were not significant. There were no differences in interobserver or intraobserver agreement between registrars and consultants.

Conclusion

Three-dimensionally printed models improved interobserver agreement in the classification of PHFs using the Neer system. This has potential implications for using 3D models for surgical planning and teaching.

Application of 3D Printing in Preoperative Planning

Preoperative planning is critical for success in the surgical suite. Current techniques for surgical planning are limited; clinicians often rely on prior experience and medical imaging to guide the decision-making process. Furthermore, two-dimensional (2D) presentations of anatomical structures may not accurately portray their three-dimensional (3D) complexity, often leaving physicians ill-equipped for the procedure. Although 3D postprocessed images are an improvement on traditional 2D image sets, they are often inadequate for surgical simulation. Medical 3D printing is a rapidly expanding field and could provide an innovative solution to current constraints of preoperative planning. As 3D printing becomes more prevalent in medical settings, it is important that clinicians develop an understanding of the technologies, as well as its uses. Here, we review the fundamentals of 3D printing and key aspects of its workflow. The many applications of 3D printing for preoperative planning are discussed, along with their challenges.

Acceptability of 3D-printed breast models and their impact on the decisional conflict of breast cancer patients: A feasibility study

PURPOSE

To evaluate the acceptability and impact of 3D-printed breast models (3D-BMs) on treatment-related decisional conflict (DC) of breast cancer patients.

METHODS

Patients with breast cancer were accrued in a prospective institutional review board-approved trial. All patients underwent contrast-enhanced breast magnetic resonance imaging (MRI). A personalized 3D-BM was derived from MRI. DC was evaluated pre- and post-3D-BM review. 3D-BM acceptability was assessed post-3D-BM review.

RESULTS

DC surveys before and after 3D-BM review and 3D-BM acceptability surveys were completed by 25 patients. 3D-BM were generated in two patients with bilateral breast cancer. The mean patient age was 48.8 years (28-72). The tumor stage was Tis (7), 1 (8), 2 (8), and 3 (4). The nodal staging was 0 (19), 1 (7), and 3 (1). Tumors were unifocal (15), multifocal (8), or multicentric (4). Patients underwent mastectomy (13) and segmental mastectomy (14) with (20) or without (7) oncoplastic intervention. Neoadjuvant therapy was given to seven patients. Patients rated the acceptability of the 3D-BM as good/excellent in understanding their condition (24/24), understanding disease size (25/25), 3D-BM detail (22/25), understanding their surgical options (24/25), encouraging to ask questions (23/25), 3D-BM size (24/25), and impartial to surgical options (17/24). There was a significant reduction in the overall DC post-3D-BM review, indicating patients became more assured of their treatment choice (p = 0.002). Reduction post-3D-BM review was also observed in the uncertainty (p = 0.012), feeling informed about options (p = 0.005), clarity about values (p = 0.032), and effective (p = 0.002) Decisional Conflict Scale subscales.

CONCLUSIONS

3D-BMs are an acceptable tool to decrease DC in breast cancer patients.

Three-dimensional printing in orthopaedic surgery: a scoping review

Three-dimensional printing (3DP) has become more frequently used in surgical specialties in recent years. These uses include pre-operative planning, patient-specific instrumentation (PSI), and patient-specific implant production.The purpose of this review was to understand the current uses of 3DP in orthopaedic surgery, the geographical and temporal trends of its use, and its impact on peri-operative outcomesOne-hundred and eight studies (N = 2328) were included, published between 2012 and 2018, with over half based in China.The most commonly used material was titanium.Three-dimensional printing was most commonly reported in trauma (N = 41) and oncology (N = 22). Pre-operative planning was the most common use of 3DP (N = 63), followed by final implants (N = 32) and PSI (N = 22).Take-home message: Overall, 3DP is becoming more common in orthopaedic surgery, with wide range of uses, particularly in complex cases. 3DP may also confer some important peri-operative benefits. Cite this article: EFORT Open Rev 2020;5:430-441. DOI: 10.1302/2058-5241.5.190024.

3D printing in shoulder surgery

Three-dimensional (3D) printing is a novel modality with the potential to make a huge impact in the surgical field. The aim of this paper is to provide an overview on the current use of 3D printing in shoulder surgery. We have reviewed the use of this new method in 3 fields of shoulder surgery: shoulder arthroplasty, recurrent shoulder instability and orthopedic shoulder traumatology. In shoulder arthroplasty, several authors have shown that the use of the 3D printer improves the positioning of the glenoid component, even if longer clinical follow-up is needed to determine whether the cost of this system rationalizes the potential improved functional outcomes and decreases glenoid revision rates. In the treatment of anterior shoulder instability, the literature agrees on the fact that the use of the 3D printing can: enhance the dept and size of bony lesions, allowing a patient tailored surgical planning and potentially reducing operative times; allow the production of personalized implants to restore substantial bone loss; restore glenohumeral morphology and instability. In orthopedic trauma, the use of 3D printing can be helpful to increase the understanding of fracture patterns, facilitating a more personalized planning, and can be used for resident training and education. We can conclude the current literature regarding the use of 3D printed models in orthopedic surgery agrees finding objective improvements to preoperative planning and to the surgical procedure itself, by shortening the intraoperative time and by the possibility to develop custom-made, patient-specific surgical instruments, and it suggests that there are tangible benefits for its implementation.

Pre-operative simulation using a three-dimensional printing model for surgical treatment of old and complex tibial plateau fractures

To investigate the clinical efficacy of pre-operative simulation using a three-dimensional (3D) printing model for surgical treatment of old and complex tibial plateau fractures. Forty-two patients with old and complex tibial plateau fractures were retrospectively reviewed from January 2014 to January 2018, which were divided into a conventional planning group (n = 22) and a planning with 3D printing group (n = 20). In the planning with 3D printing group, preoperative equal-ratio fracture models prepared using the 3D printing technique were used to perform pre-operative simulation and guide the real surgical operation. In the conventional planning group, the operation was performed based on pre-operative computed tomography (CT) images. Surgery duration, blood loss and the number of fluoroscopy during operations were recorded. During follow-up, the quality of fracture reduction and complications were also recorded. Knee functions were evaluated using the hospital for special surgery (HSS) scoring system. The operation time, blood loss and the number of fluoroscopy during operation in the planning with 3D printing group were less than that in the conventional planning group (P < 0.01). All patients were followed up for mean of 24.38 ± 7.62 months. The rate of excellent fracture reduction in the planning with 3D printing group and conventional planning group was 75% and 45.45%, respectively (P = 0.05). The complication rate was 15% in the planning with 3D printing group and 31.82% in the conventional planning group. At the final follow-up evaluation, the mean HSS score was 86.05 ± 7.67 in the planning with 3D printing group and 79.09 ± 6.75 in the conventional planning group (P = 0.003). The rate of excellent results in the planning with 3D printing group was 70% and in the conventional planning group was 45.45% (P = 0.083). In conclusion, pre-operative simulation using a 3D printing model may be helpful for the treatment of old and complex tibial plateau fractures, which may be conducive to the pre-operative planning and to making the surgical procedure accurate and personalized. However, its clinical effectiveness need to be further assessed by a prospective randomized-controlled study.

Longer Operative Time Is Independently Associated With Surgical Site Infection and Wound Dehiscence Following Open Reduction and Internal Fixation of the Ankle

Background: Little is known regarding the association of operative time with adverse events following foot and ankle surgery. This study tests whether greater operative time is associated with the occurrence of adverse events following open reduction and internal fixation (ORIF) of the ankle. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for cases of ankle ORIF (primary CPT codes 27766, 27769, 27792, 27814, 27822, 27823) performed during 2005-2016. Operative time was tested for association with the occurrence of adverse events with controls for baseline characteristics and primary CPT code. Results: A total of 20 591 procedures met inclusion/exclusion criteria. The average (±SD) operative time was 75.7 (±37.3) minutes and varied by baseline characteristics and primary CPT code. After controlling for these factors, a 15-minute increase in operative time was associated with an 11% increase in risk for developing surgical site infection (SSI; relative risk [RR]: 1.11; 95% CI: 1.06-1.16), 20% for wound dehiscence (RR: 1.20; 95% CI: 1.11-1.29), 10% for anemia requiring transfusion (RR: 1.10; 95% CI: 1.04-1.17), 60% for cerebrovascular accident (RR: 1.60; 95% CI: 1.17-2.18), 14% for unplanned intubation (RR: 1.14; 95% CI: 1.03-1.26), and 7% for extended length of hospital admission (RR: 1.07; 95% CI: 1.05-1.09). Conclusion: Operative time is linearly and independently associated with the risks for SSI, wound dehiscence, and other adverse events following ORIF of the ankle. Efforts should be implemented to safely minimize operative duration without compromising the technical components of the procedure. Levels of Evidence: Therapeutic, Level IV.

Use of three-dimensional printing in preoperative planning in orthopaedic trauma surgery: A systematic review and meta-analysis

BACKGROUND

With the increasing complexity of surgical interventions performed in orthopaedic trauma surgery and the improving technologies used in three-dimensional (3D) printing, there has been an increased interest in the concept. It has been shown that 3D models allow surgeons to better visualise anatomy, aid in planning and performing complex surgery. It is however not clear how best to utilise the technique and whether this results in better outcomes.

AIM

To evaluate the effect of 3D printing used in pre-operative planning in orthopaedic trauma surgery on clinical outcomes.

METHODS

We performed a comprehensive systematic review of the literature and a meta-analysis. Medline, Ovid and Embase were searched from inception to February 8, 2018. Randomised controlled trials, case-control studies, cohort studies and case series of five patients or more were included across any area of orthopaedic trauma. The primary outcomes were operation time, intra-operative blood loss and fluoroscopy used.

RESULTS

Seventeen studies (922 patients) met our inclusion criteria and were reviewed. The use of 3D printing across all specialties in orthopaedic trauma surgery demonstrated an overall reduction in operation time of 19.85% [95% confidence intervals (CI): (-22.99, -16.71)], intra-operative blood loss of 25.73% [95%CI: (-31.07, -20.40)], and number of times fluoroscopy was used by 23.80% [95%CI: (-38.49, -9.10)].

CONCLUSION

Our results suggest that the use of 3D printing in pre-operative planning in orthopaedic trauma reduces operative time, intraoperative blood loss and the number of times fluoroscopy is used.

3D printing-based Ganz approach for treatment of femoral head fractures: a prospective analysis

BACKGROUND

Femoral head fractures are uncommon injuries. Open reduction and internal fixation (ORIF) of femoral head fracture is the preferred treatment for most patients. There are several surgical approaches and treatments for this difficult fracture. However, the optimal surgical approach for the treatment of femoral head fracture remains controversial. Meanwhile, the operation is difficult and the complications are numerous. We prospectively reviewed patients with femoral head fractures managed surgically through the 3D printing-based Ganz approach to define a better approach with the least morbidity.

PATIENTS AND METHODS

Between 2012 and 2017, a total of 17 patients were included in this study. An exact 1:1 3D printing model of the injured hip side was fabricated for each patient and simulated surgery was finished preoperative. The surgical approach was performed as described by Ganz. Functional assessment was performed using the modified Merle d'Aubigne scores. The reduction of the fracture was evaluated according to Matta's criteria. The incidence of complications, such as heterotopic ossification (HO) and avascular necrosis (AVN), and the need for additional surgery were also documented.

RESULTS

Twelve of 17 patients (four females and eight males) were available for 2 years follow-up. The mean follow-up was 35 months (25-48 months). Average age for the 12 patients was 39.9 ± 12.2 years. According to the Pipkin classification, four patients were type I fracture, three patients were type II fracture, and five patients were type IV fracture. The mean operative time was 124.2 ± 22.1 min, and the estimated blood loss was 437.5 ± 113.1 ml. According to Merle d' Aubigne scores, excellent results were achieved in six of the 12 patients; four good and two poor results occurred in the rest of the patients. On the radiograph evaluation, fracture reduction was defined as anatomical in eight patients, and imperfect in four. Most patients had good outcomes and satisfactory hip function at last follow-up. Almost all great trochanteric osteectomy healed uneventfully. One patient developed symptomatic AVN of the femoral head and underwent THA at 3 years. After THA, she regained a good hip function with the ability to return to work and almost no reduction in sports activities. Heterotopic ossification was found in four cases (type I-1, type II-2, and type III-1).

CONCLUSIONS

The 3D printing-based Ganz approach provides a safe and reliable approach and satisfactory results of treatment in femoral head fractures. Using 3D printed model for the fracture of the femoral head, the fracture can be viewed in every direction to provide an accurate description of fracture characteristics, which contributes to make a reasonable surgical plan for patients. In addition, the 3D printing-based Ganz approach can obtain excellent surgical exposure and protection of the femoral head blood supply, reduce the operation time and intraoperative blood loss, make the precise osteotomy, anatomically fix the intra-articular fragments, and effectively reduce postoperative complications.

TRIAL REGISTRATION

We register our research at http://www.researchregistry.com . The Unique Identifying Number (UIN) from the Research Registry of the study is researchregistry4847 .

The efficacy of 3D printing-assisted surgery for traumatic fracture: a meta-analysis

Background

Recent years have witnessed a rapid development of three-dimensional (3D) printing technology applied in orthopaedic surgery. To be assisted by 3D printing is a potent method to realise accurate and individualised operation. The objective of this meta-analysis was to assess the efficacy of 3D printing technology in the management of trauma fractures.

Methods

PubMed, Embase and the Cochrane Library were systematically searched up until January 2019 to identify relevant studies. All clinical studies comparing conventional surgery and 3D printing-assisted surgery in the management of orthopaedic trauma were obtained. The meta-analysis was performed with RevMan V.5.3 software.

Results

Four randomised controlled trials, four retrospective comparative studies and two prospective comparative studies involving 521 patients were included. Compared with conventional surgery, 3D printing-assisted surgery leads to shorter operation duration (mean difference (MD) −16.59 (95% CI −18.60 to –14.58), p<0.001), less intraoperative blood loss (standardised mean difference (SMD) −1.02 (95% CI –1.25 to –0.79), p<0.001) and fewer intraoperative fluroscopies (SMD −2.20 (95% CI –2.50 to –1.90), p<0.001). However, 3D printing-assisted surgery leads to longer hospital stay (MD 2.51 (95% CI 0.31 to –4.72), p=0.03). No significant results were found regarding fracture healing time, the rate of excellent and good outcomes, anatomical reduction and complications.

Conclusions

These results suggest that 3D printing-assisted surgery outperforms conventional surgery in the management of orthopaedic trauma fractures with shorter operation duration, less intraoperative blood loss and fewer intraoperative fluoroscopies.

Can Preoperative 3D Printing Change Surgeon's Operative Plan for Distal Tibia Fracture?

This study aimed to determine if 3D printing can affect surgeon's selection of plate for distal tibia fracture surgery and to find out whether orthopedic surgeons consider this technology necessary and would use it in their practice. A total of 102 orthopedic surgeons were asked to choose anatomically contoured locking plates among 5 most commonly used types for one simple and one complex distal tibia fracture based on X-ray and CT images. Next, they were provided real-size 3D printed models of the same fractures, allowed to apply each of the 5 plates to these models, and asked if they would change their choice of plate. A 10-point numeric rating scale was provided to measure the extent of the help that 3D printing provided on preoperative planning. Finally, we asked the surgeons if they would use 3D printing in their practice. Seventy-four percent of inexperienced surgeons changed their selection of plate after using 3D printed models for the complex fracture. In contrast, only 9% of experienced surgeons changed their selection of plate for the simple fracture. Surgeons rated the extent of usefulness of the 3D models in preoperative planning as a mean of 4.84 ± 2.54 points for the simple fracture and 6.63 ± 2.54 points for the complex fracture. The difference was significant (p < 0.001). Eighty-six percent of inexperienced surgeons wanted to use 3D models for complex fractures. However, only 18% of experienced surgeons wanted to use 3D printed models for simple fractures. The use of a real-size 3D-printed model often changed surgeon's preoperative selection of locking plates, especially when inexperienced surgeons evaluated a complex fracture. However, experienced surgeons did not find 3D models very useful when assessing simple fractures. Future applications of 3D models should focus on training beginners in fracture surgery, especially when complex fractures are concerned.

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.

Efficacy and safety of 3D print-assisted surgery for the treatment of pilon fractures: a meta-analysis of randomized controlled trials

OBJECTIVE

To compare the effects of 3D print-assisted surgery and conventional surgery in the treatment of pilon fractures.

METHODS

PubMed, Embase, Web of Science, CNKI, CBM, and WanFang data were searched until July 2018. Two reviewers selected relevant studies, assessed the quality of studies, and extracted data. For continuous data, a weighted mean difference (WMD) and 95% confidence intervals (CI) were used. For dichotomous data, a relative risk (RR) and 95% CI were calculated as the summary statistics.

RESULTS

There were seven randomized controlled trials (RCT) enrolling a total of 486 patients, 242 patients underwent 3D print-assisted surgery and 244 patients underwent conventional surgery. The pooled outcomes demonstrate 3D print-assisted surgery was superior to conventional surgery in terms of operation time [WMD = - 26.16, 95% CI (- 33.19, - 19.14), P < 0.001], blood loss [WMD = - 63.91, 95% CI (- 79.55, - 48.27), P < 0.001], postoperative functional scores [WMD = 8.16, 95% CI (5.04, 11.29), P < 0.001], postoperative visual analogue score (VAS) [WMD = - 0.59, 95% CI (- 1.18, - 0.01), P = 0.05], rate of excellent and good outcome [RR = 1.20, 95% CI (1.07, 1.34), P = 0.002], and rate of anatomic reduction [RR = 1.35, 95% CI (1.19, 1.53), P < 0.001]. However, there was no significant difference between the groups regarding the rate of infection [RR = 0.51, 95% CI (0.20, 1.31), P = 0.16], fracture union time [WMD = - 0.85, 95% CI (- 1.79, 0.08), P = 0.07], traumatic arthritis [RR = 0.34, 95% CI (0.06, 2.09), P = 0.24], and malunion [RR = 0.34, 95% CI (0.06, 2.05), P = 0.24].

CONCLUSIONS

Our meta-analysis demonstrates 3D print-assisted surgery was significantly better than conventional surgery in terms of operation time, blood loss, postoperative functional score, postoperative VAS, rate of excellent and good outcome, and rate of anatomic reduction. Concerning postoperative complications, there were no significant differences between the groups.

The Feasibility of 3D Printing Technology on the Treatment of Pilon Fracture and Its Effect on Doctor-Patient Communication

Purpose

The aim of this study was to assess the feasibility and effectiveness of the three-dimensional (3D) printing technology in the treatment of Pilon fractures.

Methods

100 patients with Pilon fractures from March 2013 to December 2016 were enrolled in our study. They were divided randomly into 3D printing group (n = 50) and conventional group (n = 50). The 3D models were used to simulate the surgery and carry out the surgery according to plan in 3D printing group. Operation time, blood loss, fluoroscopy times, fracture union time, and fracture reduction as well as functional outcomes including VAS and AOFAS score and complications were recorded. To examine the feasibility of this approach, we invited surgeons and patients to complete questionnaires.

Results

3D printing group showed significantly shorter operation time, less blood loss volume and fluoroscopy times, higher rate of anatomic reduction and rate of excellent and good outcome than conventional group (P < 0.001, P < 0.001, P < 0.001, P = 0.040, and P = 0.029, resp.). However, no significant difference was observed in complications between the two groups (P = 0.510). Furthermore, the questionnaire suggested that both surgeons and patients got high scores of overall satisfaction with the use of 3D printing models.

Conclusion

Our study indicated that the use of 3D printing technology to treat Pilon fractures in clinical practice is feasible.

Three-dimensional Technologies in Orthopedics

New 3-dimensional digital technologies are revolutionizing orthopedic clinical practice, allowing structures of any complexity to be manufactured in just hours. Such technologies can make surgery for complex cases more precise, more cost-effective, and possibly easier to perform. Applications include pre-operative planning, surgical simulation, patient-specific instrumentation and implants, bioprinting, prosthetics, and orthotics. The basic principles of 3- dimensional technologies, including imaging, design, numerical simulation, and printing, and their current applications in orthopedics are reviewed. [Orthopedics. 2018; 41(1):12-20.].

Clinical efficacy and effectiveness of 3D printing: a systematic review

OBJECTIVE

To evaluate the clinical efficacy and effectiveness of using 3D printing to develop medical devices across all medical fields.

DESIGN

Systematic review compliant with Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

DATA SOURCES

PubMed, Web of Science, OVID, IEEE Xplore and Google Scholar.

METHODS

A double-blinded review method was used to select all abstracts up to January 2017 that reported on clinical trials of a three-dimensional (3D)-printed medical device. The studies were ranked according to their level of evidence, divided into medical fields based on the International Classification of Diseases chapter divisions and categorised into whether they were used for preoperative planning, aiding surgery or therapy. The Downs and Black Quality Index critical appraisal tool was used to assess the quality of reporting, external validity, risk of bias, risk of confounding and power of each study.

RESULTS

Of the 3084 abstracts screened, 350 studies met the inclusion criteria. Oral and maxillofacial surgery contained 58.3% of studies, and 23.7% covered the musculoskeletal system. Only 21 studies were randomised controlled trials (RCTs), and all fitted within these two fields. The majority of RCTs were 3D-printed anatomical models for preoperative planning and guides for aiding surgery. The main benefits of these devices were decreased surgical operation times and increased surgical accuracy.

CONCLUSIONS

All medical fields that assessed 3D-printed devices concluded that they were clinically effective. The fields that most rigorously assessed 3D-printed devices were oral and maxillofacial surgery and the musculoskeletal system, both of which concluded that the 3D-printed devices outperformed their conventional comparators. However, the efficacy and effectiveness of 3D-printed devices remain undetermined for the majority of medical fields. 3D-printed devices can play an important role in healthcare, but more rigorous and long-term assessments are needed to determine if 3D-printed devices are clinically relevant before they become part of standard clinical practice.

Three dimensional printing technology and materials for treatment of elbow fractures

PURPOSE

3D printing is a rapid prototyping technology that uses a 3D digital model to physically build an object. The aim of this study was to evaluate the peri-operative effect of 3D printing in treating complex elbow fractures and its role in physician-patient communication and determine which material is best for surgical model printing.

METHOD

Forty patients with elbow fractures were randomly divided into a 3D printing-assisted surgery group (n = 20) and a conventional surgery group (n = 20). Surgery duration, intra-operative blood loss, anatomic reduction rate, incidence of complications and elbow function score were compared between the two groups. The printing parameters, the advantages and the disadvantages of PLA and ABS were also compared. The independent-samples t-test was used to compare the data between groups. A questionnaire was designed for orthopaedic surgeons to evaluate the verisimilitude, the appearance of being true or real, and effectiveness of the 3D printing fracture model. Another questionnaire was designed to evaluate physician-patient communication effectiveness.

RESULTS

The 3D group showed shorter surgical duration, lower blood loss and higher elbow function score, compared with the conventional group. PLA is an environmentally friendly material, whereas ABS produce an odour in the printing process. Curling edges occurred easily in the printing process with ABS and were observed in four of ten ABS models but in only one PLA model. The overall scores given by the surgeons about the verisimilitude and effectiveness of the 3D model were relatively high. Patient satisfaction scores for the 3D model were higher than those for the 2D imaging data during physician-patient discussions.

CONCLUSION

3D-printed models can accurately depict the anatomic characteristics of fracture sites, help surgeons determine a surgical plan and represent an effective tool for physician-patient communication. PLA is more suitable for desktop fused deposition printing in surgical modeling applications.

The role of 3D printing in anatomy education and surgical training: A narrative review

This article was migrated. The article was marked as recommended. Recent expansions in the development and availability of three-dimensional printing (3Dp) have led to the uptake of this valuable and effective technology within the modern context of medical education. It is proposed that 3Dp is entirely appropriate for the creation of anatomical models for purposes of teaching and training due to the ability of this technology to produce accurate 3D physical representations based on a processed data set acquired from sources including magnetic resonance imaging (MRI) and computed tomography (CT). When investigating the currently available educational research with respect to 3Dp, it is important that the best evidence supporting the practical and theoretical benefits of this technology in teaching and training can be identified, while any obstacles to the effective implementation of 3Dp can also be determined. Here, literature describing recent primary research with respect to the capability and utility of 3Dp in anatomy and surgery have been explored in a narrative review. The impact on resources of implementing this technology within medical education have also been investigated. In order to emphasise wider applications in medicine, the role of 3Dp in medical practice and research have also been examined. To identify recent literature appropriate for this review published up to March 2017, suitable search terms were determined and applied using PubMed and results were judged against an established checklist. The research identified was then allocated with respect to the agreed topic areas of anatomy education, surgical training, medical usage and medical research. A student partnership approach was utilised for this review and the focus of the work was driven by undergraduate students in collaboration with anatomy and medical educators. Preliminary findings from this narrative review support the implementation of 3Dp in anatomy education and surgical training as a supplement to traditional learning approaches.

[Application of 3D printing and computer-assisted surgical simulation in preoperative planning for acetabular fracture]

OBJECTIVE

To evaluate the feasibility and effectiveness of using 3D printing and computer-assisted surgical simulation in preoperative planning for acetabular fractures.

METHODS

A retrospective analysis was performed in 53 patients with pelvic fracture, who underwent surgical treatment between September, 2013 and December, 2015 with complete follow-up data. Among them, 19 patients were treated with CT three-dimensional reconstruction, computer-assisted virtual reset internal fixation, 3D model printing, and personalized surgery simulation before surgery (3D group), and 34 patients underwent routine preoperative examination (conventional group). The intraoperative blood loss, transfusion volume, times of intraoperative X-ray, operation time, Matta score and Merle D' Aubigne & Postel score were recorded in the 2 groups. Preoperative planning and postoperative outcomes in the two groups were compared.

RESULTS

All the operations were completed successfully. In 3D group, significantly less intraoperative blood loss, transfusion volume, fewer times of X-ray, and shortened operation time were recorded compared with those in the conventional group (P<0.05). According to the Matta scores, excellent or good fracture reduction was achieved in 94.7% (18/19) of the patients in 3D group and in 82.4% (28/34) of the patients in conventional group; the rates of excellent and good hip function at the final follow-up were 89.5% (17/19) in the 3D group and 85.3% (29/34) in the conventional group (P>0.05). In the 3D group, the actual internal fixation well matched the preoperative design.

CONCLUSIONS

3D printing and computer-assisted surgical simulation for preoperative planning is feasible and accurate for management of acetabular fracture and can effectively improve the operation efficiency.

[Application of 3D printing and computer-assisted surgical simulation in preoperative planning for acetabular fracture]

OBJECTIVE

To evaluate the feasibility and effectiveness of using 3D printing and computer-assisted surgical simulation in preoperative planning for acetabular fractures.

METHODS

A retrospective analysis was performed in 53 patients with pelvic fracture, who underwent surgical treatment between September, 2013 and December, 2015 with complete follow-up data. Among them, 19 patients were treated with CT three-dimensional reconstruction, computer-assisted virtual reset internal fixation, 3D model printing, and personalized surgery simulation before surgery (3D group), and 34 patients underwent routine preoperative examination (conventional group). The intraoperative blood loss, transfusion volume, times of intraoperative X-ray, operation time, Matta score and Merle D' Aubigne & Postel score were recorded in the 2 groups. Preoperative planning and postoperative outcomes in the two groups were compared.

RESULTS

All the operations were completed successfully. In 3D group, significantly less intraoperative blood loss, transfusion volume, fewer times of X-ray, and shortened operation time were recorded compared with those in the conventional group (P<0.05). According to the Matta scores, excellent or good fracture reduction was achieved in 94.7% (18/19) of the patients in 3D group and in 82.4% (28/34) of the patients in conventional group; the rates of excellent and good hip function at the final follow-up were 89.5% (17/19) in the 3D group and 85.3% (29/34) in the conventional group (P>0.05). In the 3D group, the actual internal fixation well matched the preoperative design.

CONCLUSIONS

3D printing and computer-assisted surgical simulation for preoperative planning is feasible and accurate for management of acetabular fracture and can effectively improve the operation efficiency.