Clinical feasibility and application value of computer virtual reduction combined with 3D printing technique in complex acetabular 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.

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

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

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

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

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Clinical outcomes of the use of 3D printing models in fracture management: a meta-analysis of randomized studies

PURPOSE

The use of three-dimensional printing models in medical practice has been booming recently and its application to orthopedic surgery is gaining popularity. When treating fractures by open reduction and internal fixation, potential benefits have been associated with the use of 3D printing models. This review aims to quantitatively analyze the effectiveness of using 3D printing models in fracture management.

MATERIALS AND METHODS

A structured systematic review was conducted, and multiple databases were searched using a combination of terms related to 3D printing in fracture management. The literature search was limited from inception to Nov 2020. Only comparative randomized studies were accepted for inclusion. Any software or material using 3D printing versus no technological assistance was included. All types of fracture treated by open reduction and internal fixation were included. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the Joanna Briggs Institute's critical appraisal tool used to assess the quality of the included studies. Quantitative analysis was performed.

RESULTS

Based on 13 RCTs including 673 patients (325 and 348 in the 3D and control groups, respectively), the weighted effect size outcomes were as follows: (a) operative duration - 1.47 (95% CI = - 1.759 to - 1.182), (b) intraoperative blood loss - 1.41 (95% CI = - 1.792 to - 1.029), (c) fluoroscopy use - 1.25 (95% CI = - 1.637 to - 0.867), in favor of the 3D group. The weighted Odds ratio outcomes were: (a) overall good or excellent result 2.05 (95% CI = 1.119 to 3.845) and (b) anatomic fracture reduction 2.64 (95% CI = 1.150 to 6.051) in favor of the 3D group. The mean residual displacement and time to union showed no significant difference. The mean JBI appraisal tool score for the randomized studies was of 9, out of a maximum of 13.

CONCLUSIONS

When compared to the non-use of 3D technology for open reduction and internal fixation of fractures, the review demonstrated evidence that 3D printing yielded significantly better perioperative results. Further studies are needed to evaluate the effect of 3D printing on union and long-term function.

LEVEL OF EVIDENCE

I.

Three-dimensional printing combined with open reduction and internal fixation versus open reduction and internal fixation in the treatment of acetabular fractures: A systematic review and meta-analysis

PURPOSE

This meta-analysis compared the clinical outcome of three-dimensional (3D) printing combined with open reduction and internal fixation (ORIF) to traditional ORIF in the treatment of acetabular fractures.

METHODS

We searched the Cochrane Library, PubMed, Embase, VIP database, CNKI, and Wanfang database with keywords "acetabular fracture", "3D printing", "three-dimensional printing", "open reduction and internal fixation", "Acetabulum", "Acetabula" from January 2000 to March 2020. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration' s tools and/or Newcastle-Ottawa scale. When the two analysts had different opinions, they would ask the third analyst for opinion. Randomized controlled trials or retrospective comparative studies of 3D printing combined with ORIF (3D printing group) versus traditional ORIF (conventional group) in the treatment of acetabular fractures were selected. The data of operation time, intraoperative blood loss, intraoperative fluoroscopy times, incidence of complications, excellent and good rate of Matta score for reduction, and excellent and good rate of hip function score were extracted. Stata14.0 statistical software was used for data analysis.

RESULTS

Altogether 9 articles were selected, including 5 randomized controlled trials and 4 retrospective studies. A total of 467 patients were analyzed, 250 in the conventional group, and 217 in the 3D printing group. The operation time in the 3D printing group was less than that in the conventional group and the difference was statistically significant (standardized mean difference (SMD) = -1.19, 95% CI: -1.55 to -0.82, p < 0.05). The intraoperative bleeding volume of the 3D printing group was significantly lower than that of the conventional group (SMD = -1.08, 95% CI: -1.65 to -0.51, p < 0.05). The fluoroscopy times were less in the 3D printing group than in the conventional group and the difference was statistically significant (SMD = -1.64, 95% CI: -2.35 to -0.93, p < 0.05). The total incidence of complications in the 3D printing group was significantly lower than that in the conventional group (OR = 0.43, 95% CI: 0.24-0.79, p < 0.05). There was no significant difference in the excellent and good rate of Matta score for reduction between the two groups (OR = 0.60, 95% CI: 0.34-1.06, p > 0.05). There was no significant difference in the excellent and good rate of hip function score at the end of postoperative follow-up between the two groups (OR = 0.84, 95% CI: 0.46-1.56, p > 0.05), but the follow-up time varies from 6 months to 40 months.

CONCLUSION

Compared with traditional ORIF, 3D printing combined with ORIF has certain advantages in terms that 3D printing not only helps surgeons to understand acetabular fractures more intuitively, but also effectively reduces operation time, intraoperative blood loss, intraoperative fluoroscopy times, and postoperative complications. However, there were no significant differences in the excellent and good rate of Matta score for reduction and the excellent and good rate of hip function score at the end of follow-up.

Clinical Utility of 3-Dimensional Reconstruction Images to Predict Conservative Treatment Outcomes of Intra-Articular Distal Radius Fractures

Background

Three-dimensional (3D) images can provide additional information on bone fractures, especially in patients with intra-articular distal radius fractures (DRFs). We aimed to identify possible risk factors for adverse outcomes using a 3D reconstruction technique.

Material/Methods

We retrospectively reviewed adult patients who underwent plaster immobilization with or without closed reduction for DRFs in our hospital between February 2016 and May 2019. The 3D reconstruction image of DRFs was viewed from multiple angles to determine the existence of gaps or steps. Then, a semiquantitative standard was used to assess the severity of fracture. The patients’ basic data and radiographic data were collected, and multiple linear regression analyses were used to identify possible risk factors associated with adverse outcomes.

Results

A total of 89 cases were analyzed in our study. There were 28, 39, and 22 patients with level 1, 2, or 3 fractures, respectively, based on the semiquantitative standard. In a multiple linear regression, preoperative severity degree (β, 0.393; 95% confidence interval [CI], 0.260–0.526) and postoperative rehabilitation exercise (β, 0.352; 95% CI, 0.023–0.681) were associated with the Patient-Rated Wrist Evaluation during follow-up.

Conclusions

Our study presents a new method based on 3D reconstruction images to assess the severity of intra-articular DRFs. Patients who were identified as having severe fractures based on this method were found to have worse functional outcome.

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

PURPOSE

The aim of this study is to assess the role of 3D printing of actual size pelvis in the management and outcome of acetabular fractures.

METHODS

Retrospective study with inclusion of acetabular fractures which were divided into two groups (traditional and 3D printing) was done over a 1 year period. The indices for comparison of both groups in this study were (a) operative time (from skin incision to suture), (b) intraoperative blood loss (noted from the anaesthetist notes), (c) times of intraoperative fluoroscopy, (d) postoperative complications, (e) quality of fracture reduction (good =  < 2 mm displacement, fair =  > 2 mm displacement) and (f) Harris hip score at final follow-up.

RESULTS

27 cases (traditional group = 15, 3D printing group = 12) meeting the study criteria were included in the study with a mean follow-up of 26.3 ± 11.2 months. There was a significant difference in the operative time, intraoperative blood loss and number of intraoperative fluoroscopy images. The mean operative time was shorter in the 3D printing group by 62 min. No difference was noted in the quality of reduction in either of the groups (p > 0.05).

CONCLUSION

3D imaging and printing helps in better understanding of the anatomy of acetabular fractures. It leads to reduced operative time, blood loss as well as exposure to radiation intraoperatively. There is no difference in functional outcome at final follow-up between 3D printing and traditional groups.

A New Diagnostic Approach for Periprosthetic Acetabular Fractures Based on 3D Modeling: A Study Protocol

Periprosthetic acetabular fractures after total hip arthroplasty (THA) are mostly related to low energy trauma reduced bone quality. CT-scan is widely used to evaluate acetabular fractures, however, metal artifacts produced prosthetic implants limit the visualization of the articular surface and bone loss assessment. 3D modeling software allows us to creating tridimensional images of the bony surface, removing the metallic implants trough image segmentation. We highlight the use of 3D modeling and rapid prototyping (3D printing) for the diagnostic process of periprosthetic acetabular fracture around THA. 3D modeling software was used to improve the assessment of fracture morphology and bone quality. Moreover, the 3D images were printed in a real-life size model and used for preoperative implant templating, sizing and surgical simulation.