The efficacy of using 3D printing models in the treatment of fractures: a randomised clinical trial

The Value of Using Patient-Specific 3D-Printed Anatomical Models in Surgical Planning for Patients With Complex Multifibroid Uteri

OBJECTIVES

To compare surgeon responses regarding their surgical plan before and after receiving a patient-specific three-dimensional (3D)-printed model of a patient's multifibroid uterus created from their magnetic resonance imaging.

METHODS

3D-printed models were derived from standard-of-care pelvic magnetic resonance images of patients scheduled for surgical intervention for multifibroid uterus. Relevant anatomical structures were printed using a combination of transparent and opaque resin types. 3D models were used for 7 surgical cases (5 myomectomies, 2 hysterectomies). A staff surgeon and 1 or 2 surgical fellow(s) were present for each case. Surgeons completed a questionnaire before and after receiving the model documenting surgical approach, perceived difficulty, and confidence in surgical plan. A postoperative questionnaire was used to assess surgeon experience using 3D models.

RESULTS

Two staff surgeons and 3 clinical fellows participated in this study. A total of 15 surgeon responses were collected across the 7 cases. After viewing the models, an increase in perceived surgical difficulty and confidence in surgical plan was reported in 12/15 and 7/15 responses, respectively. Anticipated surgical time had a mean ± SD absolute change of 44.0 ± 47.9 minutes and anticipated blood loss had an absolute change of 100 ± 103.5 cc. 2 of 15 responses report a change in pre-surgical approach. Intra-operative model reference was reported to change the dissection route in 8/15 surgeon responses. On average, surgeons rated their experience using 3D models 8.6/10 for pre-surgical planning and 8.1/10 for intra-operative reference.

CONCLUSIONS

Patient-specific 3D anatomical models may be a useful tool to increase a surgeon's understanding of complex gynaecologic anatomy and to improve their surgical plan. Future work is needed to evaluate the impact of 3D models on surgical outcomes in gynaecology.

3D printing assisted MIPO for treatment of complex middle-proximal humeral shaft fractures

BACKGROUND

This study was designed to explore the clinical efficacy of 3-dimensional (3D) printing assisted minimally invasive percutaneous plate osteosynthesis (MIPO) technique by comparing the clinical outcomes with traditional open reduction and internal plating fixation (ORIF) for treating complex middle-proximal humerus fractures (AO 12C fracture type).

MATERIALS AND METHODS

The data of 42 participants who received a complicated middle-proximal humerus fracture from the beginning of 2018 to the end of 2022 were retrospectively analyzed. All patients were assigned to two groups: MIPO with detailed preoperative planning assisted by 3D printing technique (MIPO group), and traditional ORIF (ORIF group).

RESULTS

This study included 21 patients in the ORIF group and 21 patients in the MIPO group. All patients were followed-up for at least one year (mean: 16.12 ± 4.13 months), and no difference was observed in the range of shoulder joint motion (ROM), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and Constant scores between the two groups. However, the occurrence of complications (surgical incision site infection, implant loosening, bone nonunion and radial nerve palsy) in ORIF group was remarkably higher compared to the MIPO group. All the cases achieved bone union within the MIPO group. Significant differences were found in surgical time, intraoperative blood loss and fracture healing time between the two groups.

CONCLUSION

Preoperative 3D printing assisted MIPO technique exhibits obvious advantages in high operational efficiency and low occurrence of complications, which is worthy of clinical application for treating complex middle-proximal humeral shaft fractures.

Three-dimensional printing versus traditional surgery for inveterate pelvic and acetabular fractures: A retrospective study of 37 patients

Treatment of deformed pelvic and acetabular fractures is a considerable challenge for orthopedic surgeons. The aim of this study was to assess the availability of a three-dimensional (3D) printing model used in patients with inveterate pelvic and acetabular fractures by comparing 3D printing technology with conventional surgery. We conducted a retrospective review of patients with inveterate pelvic and acetabular fractures treated in our department between January 2008 and June 2020. The patients were divided into 2 groups according to their willingness. Perioperative data and clinical outcomes were compared to evaluate clinical efficacy. The t-test, Fisher exact test, and multivariable logistic regression analysis were conducted. A P value of .05 or less was considered to be statistically significant (two-tailed). Thirty-seven patients were enrolled in our study. Seventeen patients were divided into the case group treated by 3D printing model-assisted preoperative planning, and 20 patients were divided into the control group treated by conventional surgery. Patients treated with the 3D printing model had significantly shorter operation times, less blood loss, and shorter fluoroscopy times. Patients in the case group also showed better pain relief according to visual analog scale scores. However, the elevations in pelvis and hip joint functional outcomes were similar between the 2 groups, and no significant difference was shown in the radiological result. The usage of 3D printing techniques in patients with inveterate pelvic and acetabular fractures is of great importance in preoperative preparation and optimization of surgery but cannot improve postoperative function compared with conventional treatment.

The Use of Patient-Specific Implants for the Treatment of Upper Extremity Fractures

In this article, we discuss the use of three-dimensional (3-D) printed patient-specific implants in the management of upper extremity fractures. Traditional fracture fixation methods involve the use of standard-sized implants, which may not adequately address the needs of every patient, particularly those who have complications related to fracture nonunion or malunion and those who have significant bone loss. The benefits and limitations of this technology are also discussed, along with considerations for implementation in clinical practice. Overall, the use of 3-D printed patient-specific implants holds promise for improving the accuracy and efficacy of upper extremity fracture management.

The Quantitative Impact of Using 3D Printed Anatomical Models for Surgical Planning Optimization: Literature Review

3D printing has entered the medical field as a visualization tool that allows the manufacture of three-dimensional (3D) models that physically represent the anatomy of a patient in need of analysis to improve surgical results. This article analyzes the literature around reported study cases that make use of anatomical models for their surgical processes' planning, focusing on obtaining the quantitative results of each one of them. A search of case studies was carried out in the main medical databases such as PubMed, ScienceDirect, SpringerLink, among others; to obtain the most relevant results of the 56 selected articles, the information of each study was analyzed and categorized. These articles presented figures and data about the benefits that are considered more representative to measure the positive impact of this technology. These benefits are summarized in variables such as the decrease in surgical time, greater accuracy in the diagnosis of pathology, blood loss reduction, and decreasing operating room costs; owed to an improvement in the surgery planning. It was found that in all the cases analyzed there was an improvement in the surgical results related to these variables, which were summarized in macro figures that combine this improvement quantitatively. In the analyzed studies, it was evident that there is great potential in the use of 3D printing for presurgical planning, being as the results of these analyzed interventions were better when using this technology. In addition, it was found that the results obtained initially, before applying the inclusion and exclusion criteria, were mostly of a qualitative nature; expressing the perception of researchers regarding the positive use of this tool in the field and evidencing an opportunity for this research to focus on concrete and technical information to show in numerical terms the effectiveness of this tool, to demonstrate the cost-benefit that it has for the field.

3-D Printed Fracture Models Improve Resident Performance and Clinical Outcomes in Operative Fracture Management

OBJECTIVE

To determine if preoperative examination of patient additive manufactured (AM) fracture models can be used to improve resident operative competency and patient outcomes.

DESIGN

Prospective cohort study. Seventeen matched pairs of fracture fixation surgeries (for a total of 34 surgeries) were performed. Residents first performed a set of baseline surgeries (n = 17) without AM fracture models. The residents then performed a second set of surgeries randomly assigned to include an AM model (n = 11) or to omit it (n = 6). Following each surgery, the attending surgeon evaluated the resident using an Ottawa Surgical Competency Operating Room Evaluation (O-Score). The authors also recorded clinical outcomes including operative time, blood loss, fluoroscopy duration, and patient reported outcome measurement information system (PROMIS) scores of pain and function at 6 months.

SETTING

Single-center academic level one trauma center.

PARTICIPANTS

Twelve orthopaedic residents, between postgraduate year (PGY) 2 and 5, participated in this study.

RESULTS

Residents significantly improved their O-Scores between the first and second surgery when they trained with AM models for the second surgery (p = 0.004, 2.43 ± 0.79 versus 3.73 ± 0.64). Similar improvements were not observed in the control group (p = 0.916, 2.69 ± 0.69 versus 2.77 ± 0.36). AM model training also significantly improved clinical outcomes, including surgery time (p = 0.006), fluoroscopy exposure time (p = 0.002), and patient reported functional outcomes (p = 0.0006).

CONCLUSIONS

Conclusions: Training with AM fracture models improves the performance of orthopaedic surgery residents during fracture surgery.

Short-term results and complications of the operative treatment of the distal radius fracture AO2R3 C type, planned by using 3D-printed models. Prospective randomized control study

PURPOSE

3D-printed models rapidly evolving in orthopaedic. Studies show that 3D-printed models used for preoperative planning improve a better understanding of fracture morphology and reduce operative time, blood loss and frequency of fluoroscopy, but there are no studies that investigated possible advantages in the outcomes and complications for the treatment of distal radius fracture (DRF). Our study aims to evaluate short-term functional results and complications between two groups treated DRF using 3D-printed models for preoperative planning and without. We hypothesize that the addition of 3D-printed models would improve functional outcomes and reduce complication rates.

METHODS

66 randomized cases of DRF AO/OTA C type were enrolled and divided into "Control group" (n = 33) and "3D-printed model group" (n = 33). Personalized 3D-printed models were created. The primary outcomes were: Patient-Rated Wrist Evaluation questionnaire, Quick Disabilities of the Arm, Shoulder and Hand Score questionnaire, and complications. The secondary outcomes were: measurement of the range of motions, grip strength, radiological evaluation, and the visual analogue scale. Assessments were measured at 6 weeks, 3 months, and 6 months intervals.

RESULTS

We found that the integration of the 3D-printed model in preoperative planning decreased complication incidence significantly - from 30.3% in the "Control group" to 6.1% in the "3D-printed model group", p = .022. But we did not find a difference in functional and radiological outcomes.

CONCLUSION

The 3D-printed models for preoperative planning surgically treating DRF AO/OTA C type can help minimize the complication rate, however, they can't improve functional outcomes in the short-term results.

LEVEL OF EVIDENCE

Level I randomized controlled study.

A systematic review of the application of 3D-printed models to colorectal surgical training

BACKGROUND

The aim of this review was to explore the role of three-dimensional (3D) printing in colorectal surgical education and procedural simulation, and to assess the effectiveness of 3D-printed models in anatomic and operative education in colorectal surgery.

METHODS

A systematic review of the literature was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify relevant publications relating to the use of 3D-printed models in colorectal surgery in an educational context. The search encompassed OVID Medline, Web of Science and EMBASE including papers in English published from 1 January 1995 to 1 January 2023. A total of 1018 publications were screened, and 5 met the criteria for inclusion in this review.

RESULTS

Four distinct 3D models were described across five studies. Two models demonstrated objective benefits in the use of 3D-printed models in anatomical education in academic outcomes at all levels of learner medical experience and were well accepted by learners. One model utilised for preoperative visualisation demonstrated improved operative outcomes in complete mesocolic excision compared with preoperative imaging review, with a 22.1% reduction in operative time (p < 0.001), 9.2% reduction in surgical duration (p = 0.035) and 37.3% reduction in intraoperative bleeding volume amongst novice surgeons (p < 0.01). Technical simulation has been demonstrated in a feasibility context in one model but remains limited in scope and application on account of the characteristics of available printing materials.

CONCLUSIONS

3D printing is well accepted and effective for anatomic education and preoperative procedural planning amongst colorectal surgeons, trainees and medical students but remains a technology in the early stages of its possible application. Technological advancements are required to improve the tissue realism of 3D-printed organ models to achieve greater fidelity and provide realistic colorectal surgical simulations.

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.

Insights and trends review: the role of three-dimensional technology in upper extremity surgery

The use of three-dimensional (3-D) technology in upper extremity surgery has the potential to revolutionize the way that hand and upper limb procedures are planned and performed. 3-D technology can assist in the diagnosis and treatment of conditions, allowing virtual preoperative planning and surgical templating. 3-D printing can allow the production of patient-specific jigs, instruments and implants, allowing surgeons to plan and perform complex procedures with greater precision and accuracy. Previously, cost has been a barrier to the use of 3-D technology, which is now falling rapidly. This review article will discuss the current status of 3-D technology and printing, including its applications, ethics and challenges in hand and upper limb surgery. We have provided case examples to outline how clinicians can incorporate 3-D technology in their clinical practice for congenital deformities, management of acute fracture and malunion and arthroplasty.

Clinical Applications of Three-Dimensional Printing in Upper Extremity Surgery: A Systematic Review

Three-dimensional printing for medical applications in surgery of the upper extremity has gained in popularity as reflected by the increasing number of publications. This systematic review aims to provide an overview of the clinical use of 3D printing in upper extremity surgery.

METHODS

We searched the databases PubMed and Web of Science for clinical studies that described clinical application of 3D printing for upper extremity surgery including trauma and malformations. We evaluated study characteristics, clinical entity, type of clinical application, concerned anatomical structures, reported outcomes, and evidence level.

RESULTS

We finally included 51 publications with a total of 355 patients, of which 12 were clinical studies (evidence level II/III) and 39 case series (evidence level IV/V). The types of clinical applications were for intraoperative templates (33% of a total of 51 studies), body implants (29%), preoperative planning (27%), prostheses (15%), and orthoses (1%). Over two third of studies were linked to trauma-related injuries (67%).

CONCLUSION

The clinical application of 3D printing in upper extremity surgery offers great potential for personalized approaches to aid in individualized perioperative management, improvement of function, and ultimately help to benefit certain aspects in the quality of life.

3D Printing as a Technological Strategy for the Personalized Treatment of Wound Healing

Wound healing is a dynamic process which involves stages of hemostasis, inflammation, proliferation and remodeling. Any error in this process results in abnormal wound healing, generating financial burdens for health systems and even affecting the physical and mental health of the patient. Traditional dressings do not meet the complexities of ideal treatment in all types of wounds. For this reason, in the last decades, different materials for drug delivery and for the treatment of wounds have been proposed reaching novel level of standards, such as 3D printing techniques. The use of natural or synthetic polymers, and the correct design of these printed products loaded with cells and/or combined with active compounds, can generate an effective system for the treatment of wounds, improving the healing process and generating customized dressings according to the patient needs. This manuscript provides a comprehensive review of different types of 3D printing techniques, as well as its use in wound healing and its different stages, including the advantages and limitations of additive manufacturing and future perspectives.

Three-dimensional technologies in presurgical planning of bone surgeries: current evidence and future perspectives

BACKGROUND

The recent development of three-dimensional (3D) technologies introduces a novel set of opportunities to the medical field in general, and specifically to surgery. The preoperative phase has proven to be a critical factor in surgical success. Utilization of 3D technologies has the potential to improve preoperative planning and overall surgical outcomes. In this narrative review article, the authors describe existing clinical data pertaining to the current use of 3D printing, virtual reality, and augmented reality in the preoperative phase of bone surgery.

METHODS

The methodology included keyword-based literature search in PubMed and Google Scholar for original articles published between 2014 and 2022. After excluding studies performed in nonbone surgery disciplines, data from 61 studies of five different surgical disciplines were processed to be included in this narrative review.

RESULTS

Among the mentioned technologies, 3D printing is currently the most advanced in terms of clinical use, predominantly creating anatomical models and patient-specific instruments that provide high-quality operative preparation. Virtual reality allows to set a surgical plan and to further simulate the procedure via a 2D screen or head mounted display. Augmented reality is found to be useful for surgical simulation upon 3D printed anatomical models or virtual phantoms.

CONCLUSIONS

Overall, 3D technologies are gradually becoming an integral part of a surgeon's preoperative toolbox, allowing for increased surgical accuracy and reduction of operation time, mainly in complex and unique surgical cases. This may eventually lead to improved surgical outcomes, thereby optimizing the personalized surgical approach.

3D printing in fracture treatment : Current practice and best practice consensus

The use of 3D printing in orthopedic trauma is supported by clinical evidence. Existing computed tomography (CT) data are exploited for better stereotactic identification of morphological features of the fracture and enhanced surgical planning. Due to complex logistic, technical and resource constraints, deployment of 3D printing is not straightforward from the hospital management perspective. As a result not all trauma surgeons are able to confidently integrate 3D printing into the daily practice. We carried out an expert panel survey on six trauma units which utilized 3D printing routinely. The most frequent indications are acetabular and articular fractures and malalignments. Infrastructure and manpower structure varied between units. The installation of industrial grade machines and dedicated software as well as the use of trained personnel can enhance the capacity and reliability of fracture treatment. Setting up interdisciplinary jointly used 3d printing departments with sound financial and management structures may improve sustainability. The sometimes substantial logistic and technical barriers which impede the rapid delivery of 3D printed models are discussed.

Use of a 3D-printed body surface percutaneous puncture guide plate in vertebroplasty for osteoporotic vertebral compression fractures

BACKGROUND

Percutaneous vertebroplasty (PVP) has been used widely to treat osteoporotic vertebral compression fractures (OVCFs). However, it has many disadvantages, such as excessive radiation exposure, long operation times, and high cement leakage rates. This study was conducted to explore the clinical effects and safety of the use of a three-dimensional (3D)-printed body-surface guide plate to aid PVP for the treatment of OVCFs.

METHODS

This prospective cohort study was conducted with patients with OVCFs presenting between October 2020 and June 2021. Fifty patients underwent traditional PVP (group T) and 47 patients underwent PVP aided by 3D-printed body-surface guide plates (3D group). The following clinical and adverse events were compared between groups: the puncture positioning, puncture, fluoroscopy exposure and total operation times; changes in vertebral height and the Cobb angle after surgery relative to baseline; preoperative and postoperative visual analog scale and Oswestry disability index scores; and perioperative complications (bone cement leakage, neurological impairment, vertebral infection, and cardiopulmonary complications.

RESULTS

The puncture, adjustment, fluoroscopy, and total operation times were shorter in the 3D group than in group T. Visual analog scale and Oswestry disability index scores improved significantly after surgery, with significant differences between groups (both p < 0.05). At the last follow-up examination, the vertebral midline height and Cobb angle did not differ between groups. The incidence of complications was significantly lower in the 3D group than in group T (p < 0.05).

CONCLUSION

The use of 3D-printed body-surface guide plates can simplify and optimize PVP, shortening the operative time, improving the success rate, reducing surgical complications, and overall improving the safety of PVP.

Comparing the effectiveness of 3D printing technology in the treatment of clavicular fracture between surgeons with different experiences

PURPOSE

This study aims to examine the use of 3D printing technology to treat clavicular fractures by skilled and inexperienced surgeons.

METHODS

A total of 80 patients with clavicle fractures (from February 2017 to May 2021) were enrolled in this study. Patients were divided randomly into four groups: group A: Patients underwent low-dose CT scans, and 3D models were printed before inexperienced surgeons performed surgeries; group B: Standard-dose CT were taken, and 3D models were printed before experienced surgeons performed surgeries; group C and D: Standard-dose CT scans were taken in both groups, and the operations were performed differently by inexperienced (group C) and experienced (group D) surgeons. This study documented the operation time, blood loss, incision length, and the number of intraoperative fluoroscopies.

RESULTS

No statistically significant differences were found in age, gender, fracture site, and fracture type (P value: 0.23-0.88). Group A showed shorter incision length and fewer intraoperative fluoroscopy times than groups C and D (P < 0.05). There were no significant differences in blood loss volume, incision length, and intraoperative fluoroscopy times between group A and group B (P value range: 0.11-0.28). The operation time of group A was no longer than those of groups C and D (P value range: 0.11 and 0.24).

CONCLUSION

The surgical effectiveness of inexperienced surgeons who applied 3D printing technology before clavicular fracture operation was better than those of inexperienced and experienced surgeons who did not use preoperative 3D printing technology.

The Efficacy of 3D Printing Model in the Intraarticular Osteotomy in the Treatment of Malunion of Tibial Plateau Fracture

OBJECTIVES

Three-dimensional (3D) printing technology has shown potential advantages in accurate and efficient tibial plateau fracture (TPF) treatment. This technology can provide structural morphology to repair fracture fragments. Here, we summarize our experience with the use of 3D printing technology during intraarticular osteotomy in the treatment of the malunion of TPF.

METHODS

The patients who were treated with malunion of TPF in our hospital between January 2015 and December 2018 were retrospectively analyzed. These patients were divided into two groups: the conventional group without 3D-printed model application and the 3D printing group with 3D-printed model application. All patients received the intraarticular osteotomy during operation, and we compared the operation time (min), fracture healing time (months), postoperative knee Rasmussen scores (0-30 points), knee mobility range (0-140°) (the independent t-test), fracture reduction evaluation (Biggi's method) (the chi-square test: Fisher's exact test), and postoperative complications of each group.

RESULTS

Twenty-six patients aged 18-65 years who underwent TPF revision operation were included in this study, including 18 patients in the conventional group, and eight patients in the 3D printing group. The follow-up time was 24-48 months, and the operation time was 185 min in the conventional group and 180 min in the 3D printing group. All patients received a bone union at the last follow-up. The healing time was 4.2 months in the conventional group and 3.75 months in the 3D printing group (p > 0.05). The respective postoperative Rasmussen scores were 24.6 and 26.2, and postoperative knee mobility was 103.5° and 118.5° in the conventional group and 3D printing group, respectively. Both the Rasmussen scores and degrees of mobility were significantly improved after surgery (p < 0.05), and the postoperative knee mobility was significantly better in the 3D printing group versus the conventional group (p < 0.05). Four patients still had a 2-mm collapse on the articular surface, and two patients still had slight valgus (<5°) in the conventional group. Only one case in the 3D printing group suffered from an articular surface collapse. Superficial wound infections occurred in two patients in the conventional group.

CONCLUSION

The results show that 3D printing technology is an effective preoperative preparation in the treatment of TPF malunion. This technology can facilitate accurate preoperative planning to select the optimal surgical approach, plan the implant placement, visualize the screw trajectory, and anticipate possible intraoperative difficulties.

An Experimental Study of a 3D Bone Position Estimation System Based on Fluoroscopic Images

To compare a 3D preoperative planning image and fluoroscopic image, a 3D bone position estimation system that displays 3D images in response to changes in the position of fluoroscopic images was developed. The objective of the present study was to evaluate the accuracy of the estimated position of 3D bone images with reference to fluoroscopic images. Bone positions were estimated from reference points on a fluoroscopic image compared with those on a 3D image. The four reference markers positional relationships on the fluoroscopic image were compared with those on the 3D image to evaluate whether a 3D image may be drawn by tracking positional changes in the radius model. Intra-class correlations coefficients for reference marker distances between the fluoroscopic image and 3D image were 0.98–0.99. Average differences between measured values on the fluoroscopic image and 3D bone image for each marker corresponding to the direction of the bone model were 1.1 ± 0.7 mm, 2.4 ± 1.8 mm, 1.4 ± 0.8 mm, and 2.0 ± 1.6 mm in the anterior-posterior view, ulnar side lateral view, posterior-anterior view, and radial side lateral view, respectively. Marker positions were more accurate in the anterior-posterior and posterior-anterior views than in the radial and ulnar side lateral views. This system helps in real-time comparison of dynamic changes in preoperative 3D and intraoperative fluoroscopy images.

Ex Vivo Evaluation of the Cranial Tibial Artery and Its Compression through Fragment Rotation during Tibia Plateau Levelling Osteotomy: An Angiographic Three-Dimensional Reconstruction

OBJECTIVE

 To illustrate the arterial vascularity of the proximal tibia three-dimensionally and to evaluate the impact of fragment rotation on the cranial tibial artery by tibia plateau levelling osteotomy (TPLO).

METHOD

 Radiographic angiography and computed tomography (CT) were performed on 12 pelvic limbs from six large-breed canine cadavers before and after TPLO. Three-dimensional (3D) models of the stifle, including osseous and vascular structures, were obtained, and the integrity of the cranial tibial artery was assessed. Post-TPLO CT images were used to analyze compression of the cranial tibial artery by the rotated fragment.

RESULTS

 The uncompressed cranial tibial artery caliber, measured proximally and distally to the osteotomy, was 9.52 mm² (6.07-18.90 mm²). In all adequately rotated fragments, the mean caliber of the artery on the level of the osteotomy was 1.57 mm² (0.89-2.93 mm²) after TPLO. This represented a significant decrease of approximately 81%. Only slight cross-sectional area decrease (8.8%) was seen in one limb, which was revealed to have insufficient fragment rotation (2.83 mm). Another limb only showed signs of stretching of the artery (31.51%), which was under-rotated and medially displaced. Pre-TPLO 3D reconstructions were mainly consistent with previous anatomic studies except for the distance between tibial cortex and cranial tibial artery, which appeared closer.

CONCLUSION

 Sufficient fragment rotation leads to compression of the cranial tibial artery. Intraoperative hemorrhage can be caused by laceration of the main cranial tibial artery or by multiple small branches reaching craniolaterally.

Full color 3D printing of anatomical models

INTRODUCTION

We propose an effective method for manufacturing human anatomical specimens in response to the shortage of cadaver specimens and the poor simulation results of anatomical specimen substitutes.

METHODS

Digital human data with high precision were used to create digital models and corresponding mapped textures. Different materials were chosen to print the digital models with full-color and multimaterial 3D-printing technology on the basis of the histological characteristics of the anatomical structures. Anatomy experts and surgeons were then invited to compare the 3D printed models with authentic anatomical specimens in terms of morphological appearance, anatomical detail, and textural properties.

RESULTS

The skull, brain, hand muscles, blood vessels and nerves of the hand, and the deep structure of the head and face were printed. The skull model used hard material, and the brain and hand muscles models used flexible and hard materials combined. The blood vessels, nerves of the hand, and the superficial and deep structure of the head and face used transparent materials, revealing the small vessels and nerves in the interior. In all the models there were no significant differences from anatomical specimens in morphological appearance and anatomical detail. They also affected vision and touch in the same way as authentic specimens in the textural properties of color, roughness, smoothness, and fineness.

CONCLUSION

Full-color and multi-material 3D printed anatomical models have the same visual and tactile properties as anatomical specimens and could serve to complement or supplement them in anatomy teaching to compensate for the shortage of cadavers. This article is protected by copyright. All rights reserved.

Use of a 3D Model for the Correction of a Complex Madelung Deformity in a Teenager: A Case Report

CASE

The aim of the article is to report on a case of a teenager affected by Madelung deformity treated with a double osteotomy, planned by means of a 3D model. Using a custom-made cutting guide, the radial osteotomy was performed, and after the reorientation, a shortening ulnar osteotomy completed the procedure. Postoperative clinical assessment showed a normal alignment of the ulna with increased range of motion wrist motion.

CONCLUSIONS

Using a 3D model when planning a multidirectional correction of a Madelung deformity may be advantageous to achieve a more accurate and precise realignment of the carpus and distal radioulnar joint.

The current and possible future role of 3D modelling within oesophagogastric surgery: a scoping review

BACKGROUND

3D reconstruction technology could revolutionise medicine. Within surgery, 3D reconstruction has a growing role in operative planning and procedures, surgical education and training as well as patient engagement. Whilst virtual and 3D printed models are already used in many surgical specialities, oesophagogastric surgery has been slow in their adoption. Therefore, the authors undertook a scoping review to clarify the current and future roles of 3D modelling in oesophagogastric surgery, highlighting gaps in the literature and implications for future research.

METHODS

A scoping review protocol was developed using a comprehensive search strategy based on internationally accepted guidelines and tailored for key databases (MEDLINE, Embase, Elsevier Scopus and ISI Web of Science). This is available through the Open Science Framework (osf.io/ta789) and was published in a peer-reviewed journal. Included studies underwent screening and full text review before inclusion. A thematic analysis was performed using pre-determined overarching themes: (i) surgical training and education, (ii) patient education and engagement, and (iii) operative planning and surgical practice. Where applicable, subthemes were generated.

RESULTS

A total of 56 papers were included. Most research was low-grade with 88% (n = 49) of publications at or below level III evidence. No randomised control trials or systematic reviews were found. Most literature (86%, n = 48) explored 3D reconstruction within operative planning. These were divided into subthemes of pre-operative (77%, n = 43) and intra-operative guidance (9%, n = 5). Few papers reported on surgical training and education (14%, n = 8), and were evenly subcategorised into virtual reality simulation (7%, n = 4) and anatomical teaching (7%, n = 4). No studies utilising 3D modelling for patient engagement and education were found.

CONCLUSION

The use of 3D reconstruction is in its infancy in oesophagogastric surgery. The quality of evidence is low and key themes, such as patient engagement and education, remain unexplored. Without high quality research evaluating the application and benefits of 3D modelling, oesophagogastric surgery may be left behind.

The Role of 3D Printing in Planning Complex Medical Procedures and Training of Medical Professionals-Cross-Sectional Multispecialty Review

Medicine is a rapidly-evolving discipline, with progress picking up pace with each passing decade. This constant evolution results in the introduction of new tools and methods, which in turn occasionally leads to paradigm shifts across the affected medical fields. The following review attempts to showcase how 3D printing has begun to reshape and improve processes across various medical specialties and where it has the potential to make a significant impact. The current state-of-the-art, as well as real-life clinical applications of 3D printing, are reflected in the perspectives of specialists practicing in the selected disciplines, with a focus on pre-procedural planning, simulation (rehearsal) of non-routine procedures, and on medical education and training. A review of the latest multidisciplinary literature on the subject offers a general summary of the advances enabled by 3D printing. Numerous advantages and applications were found, such as gaining better insight into patient-specific anatomy, better pre-operative planning, mock simulated surgeries, simulation-based training and education, development of surgical guides and other tools, patient-specific implants, bioprinted organs or structures, and counseling of patients. It was evident that pre-procedural planning and rehearsing of unusual or difficult procedures and training of medical professionals in these procedures are extremely useful and transformative.

Accuracy of the Application of 3-Dimensional Printing Models in Orbital Blowout Fractures-A Preliminary Study

BACKGROUND

Application of 3-dimensional (3D) printing technology has grown in the medical field over the past 2 decades. In managing orbital blowout fractures, 3D printed models can be used as intraoperative navigators and could shorten the operational time by facilitating prebending or shaping of the mesh preoperatively. However, a comparison of the accuracy of computed tomography (CT) images and printed 3D models is lacking.

MATERIAL AND METHODS

This is a single-center retrospective study. Patients with unilateral orbital blowout fracture and signed up for customized 3D printing model were included. Reference points for the 2D distance were defined (intersupraorbital notch distance, transverse horizontal, sagittal vertical, and anteroposterior axes for orbital cavity) and measured directly on 3D printing models and on corresponding CT images. The difference and correlation analysis were conducted.

RESULTS

In total, 9 patients were reviewed from June 2017 to December 2020. The mean difference in the intersupraorbital notch measurement between the 2 modules was -0.14 mm (P = 0.67). The mean difference in the distance measured from the modules in the horizontal, vertical, and anteroposterior axes of the traumatic orbits was 0.06 mm (P = 0.85), -0.23 mm (P = 0.47), and 0.51 mm (P = 0.32), whereas that of the unaffected orbits was 0.16 mm (P = 0.44), 0.34 mm (P = 0.24), and 0.1 mm (P = 0.88), respectively. Although 2D parameter differences (<1 mm) between 3D printing models and CT images were discovered, they were not statistically significant.

CONCLUSIONS

Three-dimensional printing models showed high identity and correlation to CT image. Therefore, personalized models might be a reliable tool of virtual surgery or as a guide in realistic surgical scenarios for orbital blowout fractures.

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.

Advantages of three-dimensional printing in the management of acetabular fracture fixed by the Kocher-Langenbeck approach: randomised controlled trial

PURPOSE

To compare the outcomes of the Kocher-Langenbeck reduction and fixation of the posterior structures of the acetabulum between 3D printing technique and conventional technique.

METHODS

Forty-three patients who sustained fractures of the posterior part of the acetabulum were randomly assigned to two groups: 3D printing (G1; n = 20) and conventional technique (G2; n = 23). The surgical time, intra-operative blood loss, differences between pre-and post-operative haemoglobin, universal functional and radiographic scores, and complications were compared between the groups. The minimum follow-up was 18 months.

RESULTS

The average operating time (120.75 min) and intra-operative blood loss (244 ml) were lower in G1 than in G2 (125.87 min and 268.7 ml, respectively; p = 0.42, p = 0.1, respectively). The difference between the pre- and post-operative haemoglobin was 1.71 g/dl in G1 and 1.93 g/dl in G2 (p = 0.113). Post-operative complications occurred more frequently in patients in G2 (34.7%) than in patients in G1 (15%), though these differences were also not significant (p = 0.6). The radiographic result was satisfactory in 16 patients (80%) in G1 and 18 patients (78.26%) in G2 (p = 0.5). The clinical result was satisfactory in 15 patients (75%) in G1 and in 17 patients (73.9%) in G2 (p = 0.6).

CONCLUSIONS

No significant differences were found in terms of surgical time, overall complications, and radiographic or functional outcomes between 3D printing and the conventional technique.

The use of 3D printed models for the pre-operative planning of surgical correction of pediatric hip deformities: a case series and concise review of the literature

BACKGROUND AND AIM

Three-dimensional (3D) printing is prevailing in surgical planning of complex cases. The aim of this study is to describe the use of 3D printed models during the surgical planning for the treatment of four pediatric hip deformity cases. Moreover, pediatric pelvic deformities analyzed by 3D printed models have been object of a concise review.

METHODS

All treated patients were females, with an average age of 5 years old. Patients' dysplastic pelvises were 3D-printed in real scale using processed files from Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). Data about 3D printing, surgery time, blood loss and fluoroscopy have been recorded.

RESULTS

The Zanoli-Pemberton or Ganz-Paley osteotomies were performed on the four 3D printed models, then the real surgery was performed in the operating room. Time and costs to produce 3D printed models were respectively on average 17:26 h and 34.66 €. The surgical duration took about 87.5 min while the blood loss average was 1.9 ml/dl. Fluoroscopy time was 21 sec. MRI model resulted inaccurate and more difficult to produce. 10 papers have been selected for the concise literature review.

CONCLUSIONS

3D printed models have proved themselves useful in the reduction of surgery time, blood loss and ionizing radiation, as well as they have improved surgical outcomes. 3D printed model is a valid tool to deepen the complex anatomy and orientate surgical choices by allowing surgeons to carefully plan the surgery.

3D printing-assisted surgery for proximal humerus fractures: a systematic review and meta-analysis

AIM

This study aimed to assess the efficacy of three-dimensional (3D) printing to conventional surgeries in proximal humerus fractures (PHFs).

METHODS

Eight databases were comprehensively searched for data on clinical characteristics and outcomes, including operation time, time to bone healing, blood loss volume, number of intraoperative fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, loss of humeral head height, and complications. These data were compared between 3D printing-assisted versus conventional surgeries to learn the efficacy of 3D printing-assisted surgery.

RESULTS

3D printing-assisted surgery outperformed conventional procedures in operation time, blood loss volume, time to the union of PHFs, number of fluoroscopies, the reduction rate of anatomic proximal humeri, Constant scores, Neer rating, and complications.

CONCLUSION

3D printing-assisted surgery improves operation time, anatomic healing, pain, and motion, with less harm to patients.

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 printing-assisted extended lateral approach for displaced intra-articular calcaneal fractures: a systematic review and meta-analysis

BACKGROUND

Three-dimensional (3D) printing technology has developed rapidly in orthopaedic surgery and effectively achieves precise and personalized surgery. The purpose of this meta-analysis was to assess the efficacy of 3D printing technology in the management of displaced intra-articular calcaneal fractures (DICFs) by extended lateral approach (ELA).

METHODS

We searched PubMed, Web of Science, Embase, Cochrane Library, CNKI, VIP, and VANFUN databases were searched up to October 2020. All clinical studies comparing traditional surgery and 3D printing-assisted surgery in the management of DICFs were obtained, evaluating the quality of the included studies and extracting data. For each study, we assessed odds ratios (ORs), standard mean difference (SMD), and 95% confidence interval (95% CI) to assess and synthesize the outcomes.

RESULTS

Three RCTs and nine retrospective studies involving 732 patients were included met our inclusion criteria with 366 patients in the 3D group and 366 patients in the conventional group. The meta-analysis showed that there were significant differences of the operative time in the 3D group [SMD =  - 1.86, 95% CI (- 2.23, - 1.40), P < 0.001], intraoperative blood loss [SMD =  - 1.26, 95% CI (- 1.82, - 0.69), P < 0.001], the number of intraoperative X-ray exposures [SMD =  - 0.66, 95% CI (- 1.20, - 0.12), P < 0.001], postoperative complications [OR = 0.49, 95% CI (0.31, 0.79), P < 0.001], excellent and good rate of calcaneal fracture outcome [OR = 4.09, 95% CI (2.03, 8.22), P < 0.001].

CONCLUSION

The current study indicates that 3D printing-assisted ELA surgery showed a better rate of excellent and good outcome, shorter operation time, less intraoperative blood loss, fewer intraoperative fluoroscopies, fewer complications. Besides, there is still a need for large-sample, high-quality, long-term randomized controlled trials to confirm the conclusion.

Creation of 3D anatomical models illustrating an intact and centrally torn triangular fibrocartilage complex for patient education prior treatment

BACKGROUND

The triangular fibrocartilage complex (TFCC) is a composite structure located in the human wrist and is made up from fibrocartilage and ligaments. It consists of eight distinct structures, with the ligamentous structures acting as the major stabilizer of the distal radioulnar joint and with the articular disc acting as a shock absorber at the ulnocarpal joint. The articular disc can be called the triangular fibrocartilage (TFC). Thus, traumatic injuries of the TFCC ligamentous structures cause instability of the joint and a centrally torn TFC disc causes ulnar sided wrist pain. TFCC pathologies can be difficult for patients to understand in clinic, due to their complex three-dimensional (3D) nature. The purpose of this study was to produce 3D anatomical models illustrating the normal anatomy of the wrist joint with the TFCC structure and a pathological model with a centrally torn TFC. These models would be used in a hand clinic to aid explanation of this complex three-dimensional anatomical structure and their injury to patients and trainee doctors.

MATERIALS

Three fresh frozen forearm and hand specimens were dissected, 3D scanned, 3D printed and painted. These models were introduced into a hand clinic to aid explanation of the complex anatomical structures, with the first 50 patients being asked, on a visual analog scale of 0-10, to state how much the models helped their understanding of the condition.

RESULTS

Three 3D printed anatomical models were produced to illustrate the (1) forearm muscles and wrist tendons, (2) an intact TFC and (3) a centrally torn TFC. 48 of 50 patients surveyed completed the scale, with an average rating of 8.7 increase in understanding with the models.

CONCLUSION

Patient education and understanding is crucial as it enhances decision making between surgeon and patient. These 3D anatomical models were shown to increase patient's understanding of the pathology. This should consequentially improve discussions on corresponding treatment options during consultation.

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.

A review and guide to creating patient specific 3D printed anatomical models from MRI for benign gynecologic surgery

Background

Patient specific three-dimensional (3D) models can be derived from two-dimensional medical images, such as magnetic resonance (MR) images. 3D models have been shown to improve anatomical comprehension by providing more accurate assessments of anatomical volumes and better perspectives of structural orientations relative to adjacent structures. The clinical benefit of using patient specific 3D printed models have been highlighted in the fields of orthopaedics, cardiothoracics, and neurosurgery for the purpose of pre-surgical planning. However, reports on the clinical use of 3D printed models in the field of gynecology are limited.

Main text

This article aims to provide a brief overview of the principles of 3D printing and the steps required to derive patient-specific, anatomically accurate 3D printed models of gynecologic anatomy from MR images. Examples of 3D printed models for uterine fibroids and endometriosis are presented as well as a discussion on the barriers to clinical uptake and the future directions for 3D printing in the field of gynecological surgery.

Conclusion

Successful gynecologic surgery requires a thorough understanding of the patient’s anatomy and burden of disease. Future use of patient specific 3D printed models is encouraged so the clinical benefit can be better understood and evidence to support their use in standard of care can be provided.

Are the common sterilization methods completely effective for our in-house 3D printed biomodels and surgical guides?

INTRODUCTION

In-hospital 3D printing is being implemented in orthopaedic departments worldwide, being used for additive manufacturing of fracture models (or even surgical guides) which are sterilized and used in the operating room. However, to save time and material, prints are nearly hollow, while 3D printers are placed in non-sterile rooms. The aim of our study is to evaluate whether common sterilization methods can sterilize the inside of the pieces, which would be of utmost importance in case a model breaks during a surgical intervention.

MATERIAL AND METHOD

A total of 24 cylinders were designed and printed with a 3D printer in Polylactic Acid (PLA) with an infill density of 12%. Manufacturing was paused when 60% of the print was reached and 20 of the cylinders were inoculated with 0.4 mL of a suspension of S epidermidis ATTCC 1228 in saline solution at turbidity 1 McFarland. Printing was resumed, being all the pieces completely sealed with the inoculum inside. Posteriorly, 4 groups were made according to the chosen sterilization method: Ethylene Oxide (EtO), Gas Plasma, Steam Heat or non-sterilized (positive control). Each group included 5 contaminated cylinders and 1 non-contaminated cylinder as a negative control. After sterilization, the inside of the cylinders was cultured during 7 days.

RESULTS

We observed bacterial growth of just a few Forming Colony Units (FCU) in 4 out of 5 positive controls and in 2 out of 5 contaminated cylinders sterilized with Gas Plasma. We could not assess any bacterial growth in any of the EtO or Steam Heat samples or in any of the negative controls. Pieces sterilized under Steam Heat resulted completely deformed.

CONCLUSIONS

High temperatures reached during the procedure of additive manufacturing can decrease the bacterial load of the biomodels. However, there is a potential risk of contamination during the procedure. We recommend sterilization with EtO for in-hospital 3D-printed PLA hollow biomodels or guides. Otherwise, in case of using Gas Plasma, an infill of 100% should be applied.

The use of 3D printing for osteopathic medical education of rib disorders

Context

With the advent of increasingly accessible three-dimensional (3D) printing, the possibility to efficiently design and generate prototype innovations is also increasing. This type of manufacturing can potentially enhance medical education by allowing design of models specific to osteopathic manipulative medicine (OMM).

Objectives

To determine the viability of a 3D-printed mechanically moveable rib cage in enhancing the teaching of rib osteopathic principles.

Methods

A single-blind, qualitative study was conducted to evaluate the use of educating students with this novel 3D-printed, movable rib model vs. a traditional static rib model. A total of 237 first-year medical students participated in the study and received the same standardized lecture on the rib dysfunction. Students were also assigned at random to either a comparison group, which would utilize the 3D printed rib model, or the control group, which would utilize the traditional static model. Students would also complete an entrance and exit surveys assessing subjective scores of overall student satisfaction and objective scores for knowledge of OMM rib dysfunction and treatment. An independent samples t-test was applied to assess potential differences between select student evaluation scores (those with continuous variables) of the rib model in the comparison and experiment groups. Chi-square goodness of fit test was conducted to determine if there were any significant differences in entry and exit survey responses between the two groups. Descriptive statistics of the mean and standard deviation were also reported.

Results

For both comparison and control groups, the mean score on an 11-point scale for the evaluation question, "Please rank on a scale of 0-10 how helpful you thought the rib models were to your education," was 9.08 (SD, 1.397). Independent t-test results showed that the comparison group had higher scores than the control group when queried about whether they felt the model accurately depicted the material presented (comparison group mean, 9.55 [SD, 978] vs. control group mean, 9.06 [SD, 1.33; t(235) = 3.253; p=0.01). Chi-square test of goodness-of-fit showed that the differences between the number of correct answers chosen by participants for Item 3 (a case-based question asking students which rib they would treat for a patient presenting to an OMT clinic) was statistically significantly higher for the comparison group (51.9% correct in comparison group vs. 48.1% in control group), even though both groups scored similarly on this item during the entry survey.

Conclusions

The results of this study suggest that utilizing 3D printing to demonstrate somatic dysfunctions of the rib cage may improve understanding and student satisfaction for diagnosis and treatment.

Three-dimensional evaluations of preoperative planning reproducibility for the osteosynthesis of distal radius fractures

BACKGROUND

Three-dimensional preoperative planning was applied for the osteosynthesis of distal radius fractures. The objective of this study was to evaluate the reproducibility of three-dimensional preoperative planning for the osteosynthesis of distal radius fractures with three-dimensional reference points.

METHODS

Sixty-three wrists of 63 distal radius fracture patients who underwent osteosynthesis with three-dimensional preoperative planning were evaluated. After taking preoperative CT scans of the injured wrists, 3D images of the distal radius were created. Fracture reduction, implants choices, and placements simulation were performed based on the 3D images. One month after the surgery, postoperative CT images were taken. The reproducibility was evaluated with preoperative plan and postoperative 3D images. The images were compared with the three-dimensional coordinates of radial styloid process, volar and dorsal edges of sigmoid notch, and the barycentric coordinates of the three reference points. The reproducibility of the preoperative plan was evaluated by the distance of the coordinates between the plan and postoperative images for the reference points. The reproducibility of radial inclination and volar tilt on three-dimensional images were evaluated by intra-class correlation coefficient (ICC).

RESULTS

The distances between the preoperative plan and the postoperative reduction for each reference point were (1) 2.1±1.3 mm, (2) 1.9±1.2 mm, and (3) 1.9±1.2 mm, respectively. The distance between the preoperative plan and postoperative reduction for the barycentric coordinate was 1.3±0.8 mm. ICCs were 0.54 and 0.54 for the volar tilt and radial inclination, respectively (P<0.01).

CONCLUSIONS

Three-dimensional preoperative planning for the osteosynthesis of distal radius fracture was reproducible with an error of about 2 mm for each reference point and the correlations of reduction shapes were moderate. The analysis method and reference points may be helpful to understand the accuracy of reductions for the three-dimensional preoperative planning in the osteosynthesis of distal radius fractures.

TRIAL REGISTRATION

Registered as NCT02909647 at ClinicalTrials.gov.

Application of ultra-low-dose CT in 3D printing of distal radial fractures

PURPOSE

To explore the effect of ultra-low-dose computed tomography (CT) on three-dimensional (3D) printing models and the diagnosis of wrist fractures.

METHOD

This study enrolled 76 patients with distal radial fractures (DRFs). All patients underwent 320-row detector CT and were divided randomly into two groups. In Group A, 38 patients were scanned with the standard-dose protocol using a tube voltage of 120 kV and current of 100 mA. In Group B, 38 patients were scanned with the ultra-low-dose protocol using a tube voltage of 80 kV and current of 10 mA. For objective image quality assessment, the noise, CT number, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were measured. Subjectively, two experienced orthopaedic surgeons blinded to the scan parameters evaluated the clarity of the 3D printing model and fracture line using a 3-point scale (the diagnosis was considered acceptable with scores ≥2). The mean radiation dose was calculated. The diagnostic performances for the fractures between the two groups were compared.

RESULTS

The effective radiation dose was significantly reduced by 97.1 % in Group B, compared to Group A (0.28 ± 0.05vs. 9.75 ± 2.23 μSv, respectively). Quantitative objective image quality parameters (e.g., CNR, SNR, and CT numbers) were higher in the standard-dose group (p < 0.001). However, there was no difference in subjective scoring of the 3D printing model. Although the fracture line score was higher in Group A (2.92±0.27 vs. 2.16 ± 0.37; p < 0.001), the diagnostic performance of the two groups was consistent (all scores ≥2). There were no statistically significant differences in the sensitivity, specificity or accuracy between standard-dose group and ultra-low-dose group.

CONCLUSIONS

The ultra-low-dose protocol effectively reduced the radiation dose by 97.1 %, while maintaining the image quality for diagnosis of DRFs. Therefore, this protocol can meet the needs of 3D printing models for preoperative assessments.

Do 3-D Printed Handheld Models Improve Surgeon Reliability for Recognition of Intraarticular Distal Radius Fracture Characteristics?

BACKGROUND

For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined.

QUESTIONS/PURPOSES

(1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model?

METHODS

We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test.

RESULTS

We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09).

CONCLUSIONS

Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius.

LEVEL OF EVIDENCE

Level II, diagnostic study.

3D printed bismuth oxide-polylactic acid composites for radio-mimetic computed tomography spine phantoms

Polylactic acid (PLA) composite filaments with varying concentrations of bismuth oxide microparticle additives were fabricated for use with commercially available fused filament fabrication (FFF) printing systems for the production of spine phantoms that mimic the radiopacity of bone. Thermal analysis showed that the additives had limited impact on the glass transition temperature and melting point of the filaments, allowing for their use in commercial FFF systems with standard printer settings. The ultimate strength of the printed test specimens was found to reduce slightly when bismuth oxide was added in high concentrations, with a moderate reduction of 12% compared to PLA at the highest concentration of 30 wt%. The modulus of the specimens increased by up to 24% with the addition of the additive. The radiopacity of specimens printed with the composite filaments were measured by X-ray microcomputed tomography (micro-CT) and clinical computed tomography (CT). The CT number was found to increase by approximately 196 HU per wt% of bismuth oxide added to the filaments. A phantom model of a cervical spine deformity was successfully printed by FFF with a composite filament which was calibrated to mimic the radiopacity of cervical and cortical bone. The results indicate that the composite filaments have direct applicability for the production of phantoms used for education and preoperative planning.

The efficacy of 3D printing-assisted surgery in treating distal radius fractures: systematic review and meta-analysis

Aim: To compare the efficacy of 3D printing-assisted surgery with routine surgery in the treatment of distal radius fractures to evaluate whether 3D printing technology has more advantages. Materials & methods: To retrieve all published studies that compared the efficacy of 3D printing-assisted surgery with routine surgery for distal radius fractures. Operation time, frequency of intraoperative fluoroscopy, blood loss and other outcomes were assessed. Results: The results suggested that 3D printing-assisted surgery was better than routine surgery in the fields of operation time, frequency of intraoperative fluoroscopy, and blood loss. Conclusion: In the treatment of distal radius fractures, 3D printing-assisted surgery may be superior to routine surgery.

Impact of 3D Printed Calcaneal Models on Fracture Understanding and Confidence in Orthopedic Surgery Residents

OBJECTIVE

To determine if three-dimensionally printed (3Dp) fracture models can improve orthopedic trainee education.

DESIGN

A prospective comparison study of orthopedic trainees and attending surgeons was performed, where a range of calcaneal fractures were used for creating anonymized 3Dp models. Study participants rotated through workstations viewing computed tomography images and either a digital 3D volume rendering or 3Dp model of the fractured calcaneus. Diagnosis, time for evaluation, confidence of fracture understanding, perceived model accuracy, and proposed treatment were compared using a standardized questionnaire.

PARTICIPANTS

Sixteen resident trainees and 5 attending surgeons participated in this study. Attending surgeons were required to have fellowship training in trauma or foot and ankle surgery and manage calcaneal fractures as part of their current practice.

RESULTS

Junior residents had the slowest time of assessment (mean = 121 ± 54 seconds) and lowest percentage of correct diagnoses (69%), although these findings did not reach significance compared to the other residency years. Residents displayed higher levels of confidence in fracture understanding with increasing residency year of training (p < 0.0001), and this confidence was greater for cases that included a 3Dp model (p < 0.03). Perceived accuracy of cases with 3Dp models was significantly higher than cases without 3Dp models (7.0 vs 5.5 p < 0.001).

CONCLUSIONS

This study found that 3Dp models increase the perceived accuracy of fracture assessment, though no statistically significant improvement in diagnostic accuracy was observed. The 3Dp models did improve trainee confidence, although this effect diminished with increasing residency year. In orthopedic residency training programs, 3Dp models of complex fractures can be a valuable educational tool, especially for junior trainees.

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 .

Anatomic three-dimensional model-assisted surgical planning for treatment of pediatric hip dislocation due to osteomyelitis

Management of pediatric septic coxarthritis and osteomyelitis of the femur is challenging, and the sequelae of multiplanar hip joint deformity with instability are difficult to reconstruct. The inadequacy of a suitable device for fixing small bones during pediatric osteotomy is a hindrance to the correction of subluxated hip joints and deformed femurs in children. Two-dimensional axial images and three-dimensional (3D) virtual models representing the patient’s individual anatomy are usually reserved for more complex cases of limb deformity. 3D printing technology can be used for preoperative planning of complex pediatric orthopedic surgery. However, there is a paucity of literature reports regarding the application of 3D-printed bone models for pediatric post-osteomyelitis deformity. We herein present a case of a 4-year-old boy who underwent treatment for post-osteomyelitis deformity. We performed corrective surgery with Pemberton osteotomy of the right hip, multilevel varus derotation osteotomy of the right femur, and immobilization with a hip spica cast. A 3D-printed bone model of this patient was used to simulate the surgery, determine the proper osteotomy sites, and choose the appropriate implant for the osteotomized bone. A satisfactory clinical outcome was achieved.