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3D Printing Innovation: New Insights into Upper Extremity Surgery Planning.
Abstract
Introduction
: Surgical planning relies on the use of images to develop an action plan previous to the actual surgical intervention. Imaging technology improvement together with the development of specific software to treat three dimensional images has increased the accuracy and capabilities of pre-surgical planning. In addition to this, 3D printing allows us to manufacture customized surgical tools to implement and aid in the success of surgeries.
Material and Methods
: 3D virtual planning together with 3D printing has been implemented through different approaches in 8 different upper extremity trauma cases. We describe these 8 cases (2 women and 6 men with ages ranging from 16 to 67 years), their specific challenges and management.
Results
: We show how 3D technology changes the conception, planning and execution of surgery in 8 different cases. In addition, we describe what challenges were faced as well as the various utilities of 3D technology beyond that of anatomical model printing.
Conclusions
: The use of 3D technology has improved and enhanced surgical planning. It allows us to view and virtually manipulate fracture fragments prior to surgery. It also enables us to develop customized surgical tools and guides that can increase the accuracy of certain procedures, and help in the management of orthopedic and trauma lesions.
We believe that the use of this technology is beneficial to both the patient and surgeon, since it reduces surgical time and complications giving a better understanding of the injury and its treatment.
... [2][3][4] Researchers are now looking at 3DP to solve complex problems in orthopaedics that have been considered difficult to treat with traditional methods, including the fields of upper extremity, trauma, limb deformity, foot and ankle, arthroplasty, and spine. 5,6 In particular, 3D-printed models are uniquely suited for complex reconstructions in the setting of nonunion or malunion. 7 This article presents a review of patient-specific anatomical models and implants pertinent to fracture care complimented by a case series of varying uses of 3DP technology. ...
... 11 Screw lengths can be measured accurately and the trajectory of screws can also be planned and practiced, especially in regions with a high risk of injury to important structures (eg, clavicle fracture) or complex bony anatomy (eg, talus). 6,12 This has been associated with a reduction in intraoperative surgical time, blood loss, use of fluoroscopy, and shortened anesthesia time. 4 Postoperatively, benefits include reduction in the need for blood transfusion, analgesia requirement, improved functional outcomes, and decrease in the risk of infection and use of antibiotics, although this needs to be investigated further. ...
... Patient-specific 3D models allow surgical residents and trainees to practice before performing procedures on patients, improving preparedness and skill, and reducing the risk of intraoperative complications. 6 They also provide a better understanding of pathoanatomy. 3D-rendered images and 3D-printed models were used in an investigation to understand which would provide the most effective preoperative plan. ...
Three-dimensional (3D) offers exciting opportunities in medicine, particularly in orthopaedics. The boundaries of 3D printing are continuously being re-established and have paved the way for further innovations, including 3D bioprinting, custom printing refined methods, 4D bioprinting, and 5D printing potential. The quality of these applications have been steadily improving, increasing their widespread use among clinicians. This article provides a review of the current literature with a brief introduction to the process of additive manufacturing, 3D printing, and its applications in fracture care. We illustrate this technology with a case series of 3D printing used for correction of complex fractures/nonunion. Factors limiting the use of this technology, including cost, and potential solutions are discussed. Finally, we discuss 4D bioprinting and 5D printing and their potential role in fracture surgery.
... Several case reports and series reported similar clinical outcomes by using intraoperative aids such as 3D-printed cutting jigs, guides for drills and wires, and templates for bone grafting. The use of 3D-printed drill and cutting guides for intraoperative aids has been successfully applied to both extraarticular [30][31][32] and intraarticular [30,33,34] distal radius fracture malunion correction, malunion of metaphyseal [35] and diaphyseal [36] radius, diaphyseal ulna [36], distal humerus [30], and metacarpal bone [31], and even in nonunion correction of distal humerus [30] and epiphysiodesis correction of distal radius [37]. In malunion correction of proximal ulna, a 3D-printed navigation tool was successfully applied to obtain an accurate reposition of the ulna [38]. ...
... Several case reports and series reported similar clinical outcomes by using intraoperative aids such as 3D-printed cutting jigs, guides for drills and wires, and templates for bone grafting. The use of 3D-printed drill and cutting guides for intraoperative aids has been successfully applied to both extraarticular [30][31][32] and intraarticular [30,33,34] distal radius fracture malunion correction, malunion of metaphyseal [35] and diaphyseal [36] radius, diaphyseal ulna [36], distal humerus [30], and metacarpal bone [31], and even in nonunion correction of distal humerus [30] and epiphysiodesis correction of distal radius [37]. In malunion correction of proximal ulna, a 3D-printed navigation tool was successfully applied to obtain an accurate reposition of the ulna [38]. ...
... In malunion correction of proximal ulna, a 3D-printed navigation tool was successfully applied to obtain an accurate reposition of the ulna [38]. Furthermore, 3D-printed intraoperative aids were used as a navigation template for an accurate chondrosarcoma resection in the scapula [15] as well as for bone grafting in posttraumatic glenoid reconstruction [31] or for scaphoid reconstruction [39]. None of these studies reported 3D-printing-related adverse events, indicating that the use of 3D-printed intraoperative aids seems to be safe, especially for the use for drilling and cutting. ...
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.
... Recently, the combination of computer-assisted planning and patient-specific instruments (PSIs) has been reported as a mature technology to achieve accurate correction of complex limb deformities [15][16][17][18][19][20]. We further extended this technique in the correction of ankle OA deformities, and the purpose of this study was to verify the reliability and accuracy of PSI in corrective osteotomy for intra-articular varus OA with medial distal tibial platform erosion. ...
... To date, studies on the application of computer-assisted 3D virtual planning and PSI in treating complex deformities of the foot and ankle have been investigated less, however, the results are promising [15][16][17]20]. Weigelt et al. [15] reported that postoperative CT scans showed accurate reduction with a residual translational and rotational error of < 3 mm and < 6° in 4 cases who underwent computer-assisted corrective osteotomy of ankle deformities. ...
... Furthermore, our technique was different from the others in that we took the implant into account during design procedures, therefore, the plate could act as a reduction guide, and the placement of the implant and the insertion of locking screws could be simultaneously guided by the PSI with no need for an additional reduction guide in the operation. In addition to the benefits mentioned, we printed real-scale models for preoperative simulation and intraoperative reference, which provided both tactile and visual feedback [16,24]. This technique also enhanced the surgeon's understanding of the deformity and subsequent surgery, and provided practice opportunities for the residents and training fellows [16]. ...
Background
Computer-assisted preoperative planning, combined with PSI has become an effective technique for treating complex limb deformities. The purpose of this study was to evaluate the efficacy and safety of the novel technique in corrective osteotomy for intra-articular varus ankle deformities associated with osteoarthritis and ankle instability.
Methods
Nineteen patients with intra-articular varus ankle arthritis were reviewed between April 2017 and June 2019, including ten men and nine women with a mean age of 58.3 ± 9.9 years (range, 38 to 76 years). All patients underwent intra-articular opening wedge osteotomy assisted by 3D virtual planning and PSI. Weight-bearing radiographs were used to assess the radiographic results, including TAS angle, TT angle, TMM angle, TC angle, TLS angle, opening-wedge angle, and wedge height. Functional outcomes were assessed by the AOFAS score, VAS score, and ROM of the ankle.
Results
The average follow-up time was 32.2 ± 9.0 months (range, 22 to 47 months). The average union time was 4.4 ± 0.9 months (range, 3.0 to 6.5 months). The TAS angle significantly changed from 84.1 ± 4.6° preoperatively to 87.7 ± 3.1° at the 1-year follow-up and 86.2 ± 2.6° at the latest follow-up. Similarly, the TT angle, TMM angle and TC angle changed significantly at the 1-year follow-up compared with the preoperative assessment and remained stable until the last follow-up. However, the TLS was not corrected significantly. The postoperative obtained opening-wedge angle, and wedge height showed no significant change with preoperative planning. The overall complication rate was 15.8%. The mean VAS score improved from 5.3 ± 0.6 to 2.7 ± 0.7. The mean AOFAS score improved from 56.2 ± 7.6 to 80.6 ± 4.6. However, the ROM showed no significant change.
Conclusions
Accurate correction and satisfactory functional recovery were attained with computer-assisted planning and PSI in the corrective osteotomy of intra-articular varus ankle deformities.
... Three-dimensional (3D)-printed, patient-matched guides have been reported to help surgeons restore native anatomy as closely as possible. 5,6,9,[11][12][13] Most frequently, a preoperative computed tomography (CT) scan is obtained of the contralateral clavicle, which is then virtually mirrored to match the injured side. 8,[11][12][13] The affected and mirrored clavicles are then 3D printed, and the models may be used to judge restoration of anatomy and to precontour fixation plates that are used in surgery. ...
... 6 Three-dimensional printing has been used to manufacture customized tools for a variety of cases ranging from acetabular fractures 12 and shoulder fusions 12 to mapping periarticular screw trajectories in distal humerus fractures. 9 Three-dimensionally printed guides have also been used to try to improve outcomes and reduce postoperative complications. One randomized control trial in malunited distal radius fractures reported that 3D-printed guides led to greater improvements in postoperative radial inclination and volar tilt compared to those undergoing conventional planning techniques. ...
Background:
The objective of this study was to retrospectively review clinical and radiographic outcomes of patients who underwent corrective osteotomies for clavicle malunion and internal fixation for nonunion using a combination of virtual surgical planning, patient-specific 3D printed clavicles, and 3D printed cutting guides manufactured at the point of care.
Methods:
Between 2015 and 2021, 18 patients underwent corrective osteotomy for a clavicle malunion (7 shoulders) or internal fixation for a clavicle nonunion (11 shoulders). There were 11 males and 7 females with an average patient age of 43.9 (range 19-76) years. All patients underwent computed tomography (CT) evaluation of both clavicles. The DICOM files were manually segmented, virtual surgical planning was performed selectively using commercially available software, and a mirrored version of the normal clavicle was 3D printed along with a 3D printed replica of the affected clavicle. 3D printed mirrored clavicles were used in all cases to ensure adequate restoration of the shape and length of the clavicle and to pre-contour fixation plates. Virtual surgical planning (VSP) and 3D printed cutting guides for osteotomy were used in 4/18 (22%) patients. Either cancellous or structural intercalary bone grafting was used in 15/18 (83%) cases. Patients were contacted postoperatively to determine clinical outcome scores. Preoperative, early postoperative, and late postoperative radiographs were reviewed to assess for union and complications. The average follow-up time was 24.9 months.
Results:
Radiographic evaluation at most recent follow-up demonstrated adequate restoration of length and successful union for all shoulders. There were no complications or reoperations. Postoperative patient reported outcomes could be obtained in in 16/18 (88.9%) patients. At most recent follow-up, the mean VAS for pain was 2.38 points (range, 1 to 7), the mean shoulder ASES score was 73.2 points (range, 25 to 100), and the mean PROMIS Upper Extremity score was 26 points (range, 7 to 35). 100% of the patients were satisfied with their outcome (9 very satisfied, 7 satisfied), and their mean subjective shoulder value was 73% (range, 10% to 100%). However, two patients complained of hardware related symptoms, and one patient had return of preoperative symptoms after an interim two years of pain relief.
Conclusion:
The use of mirrored 3D printed clavicles combined with VSP and patient-specific 3D guides provides a reliable technique for restoring native anatomy when performing corrective osteotomies for clavicle malunion or internal fixation for clavicle nonunion, with a high rate of satisfactory clinical and radiographic outcomes.
... van Doremalen et al. [43] adjusted the plate preoperatively with 3D printed models and suggested preoperative preparation with 3D printed models may reduce implant removal caused by plate-related discomfort. Fillat-Gomà et al. [44] showed improvement and enhanced surgical planning not only in clavicle fractures but also in other upper extremity fractures by 3D printing technology. They also applied the plate on a 3D-printed clavicle model and choose the best fitting plate with optimal stability. ...
... 2 and 3). Also, based on advancements in 3D printing technology, surgical treatment with the aid of 3D printing has been introduced[6,43,44]. ...
Midshaft clavicle fractures are the most common fracture of the clavicle accounting for 80% of all clavicle fractures. Traditionally, midshaft clavicle fractures are treated with conservative treatment even when prominent displacement is observed; however, recent studies revealed that nonunion or malunion rate may be higher with conservative treatment. Moreover, recent studies have shown better functional results and patient satisfaction with surgical treatment. This review article provides a review of clavicle anatomy, describes the current clavicle fracture classification system, and outlines various treatment options including current surgical options for clavicle fracture in adults.
... Research in the field of 3D-printing to create anatomic models for orthopaedic fixation has been expanding rapidly [34,35]. Though limited, analysis of the utility of 3D virtual surgical planning with 3D-printing has been explored with injuries to the upper extremity and to complicated injuries of the ankle joint [30,[36][37][38]. Future studies should continue to investigate the utility, feasibility and cost effectiveness of 3D-printing. ...
Objectives: To investigate the effectiveness and reliability of 3-Dimensional (3D) printed models of the contralateral, unaffected clavicle to serve as templates of the affected side for preoperative planning. Method: Computed tomography scans of 18 embalmed cadavers (8 male and 10 female) were used to 3D-print mirror images of “unaffected” clavicles which were then used for the selection of a superior midshaft contoured plate. Various morphometric and goodness-of-fit measurements were taken of the 3D-printed clavicle and then the in-situ specimen. Statistical analysis was performed using two-tailed, unpaired t-tests with a p value < 0.05. Results: For 3D-printed models, 7/9 morphometric measurements differed significantly between males and females for both clavicles and in 1 additional measurement for right-sided clavicles. For in-situ specimens, 6/9 morphometric measurements differed significantly between male and female clavicles. When comparing the 3D-printed versus the corresponding in-situ clavicle, only 1/9 morphometric measurements differed significantly for both males and females and 1 additional measurement for each sex. The goodness-of-fit of the plate using the 3D-printed template for the in-situ specimen differed significantly only for males with a right clavicle mirrored to template for the left clavicle. Conclusions: Clavicular anatomic complexity and variance supports the need for many contoured plate options for adequate fixation. Preoperatively 3D-printed contralateral, mirrored clavicles for plate selection of midshaft clavicular fractures may reduce intraoperative time.
... These guides facilitated anatomically precise drilling of K-wires within the scaphoid, reducing operative time significantly compared to standard fluoroscopy methods. Further studies have reinforced these findings, indicating shorter procedures and fluoroscopy times while maintaining similar functional outcomes [60][61][62] . One prospective study reported improved outcomes and faster healing in displaced scaphoid fractures and nonunions with 3DP guides [60] . ...
With the rapid development of 3D printing (3DP) technology in both educational and perioperative settings, a thorough evaluation of the latest literature is warranted. This semi-systematic review explores the current educational, clinical, and rehabilitative applications of 3DP technology in hand surgery. In educational settings, student and trainee education improved with the use of inexpensive, accessible models for anatomy and surgical simulation, demonstrating an enhanced understanding of spatial relationships and increased confidence in surgical skills. Patient education and consent can be improved with the use of patient-specific models. Studies showed that patient-specific models led to higher patient comprehension and satisfaction during the consenting process. Patient-specific models also offer more comprehensive preoperative planning, and cutting guides facilitate more precise surgical techniques. Clinical outcomes indicated reduced operative times and radiation exposure, along with improved surgical accuracy. Additionally, 3DP enables the creation of cost-effective implants that precisely conform to each patient's anatomy. For rehabilitative purposes, 3DP can make splints that have the potential to reduce costs and improve compliance. Preliminary data indicated higher patient comfort and improved functional outcomes with 3D-printed splints. Overall, the current literature is mixed on the benefits of 3DP in hand surgery; however, many studies show promising results. As 3DP becomes more streamlined and the equipment becomes less expensive, its applications will continue to expand, and future research will be needed. Future studies should focus on long-term clinical outcomes and cost-effectiveness to fully ascertain the efficacy and value of 3DP in hand surgery.
... The use of engineering software allows for the three-dimensional model construction of human organs, reaching high levels of precise measurements and surgical simulations. Studies have demonstrated the feasibility and efficiency of CAD in preoperative planning, intraoperative assistance, and postoperative evaluation (16)(17)(18). However, studies utilizing CAD in the preoperative planning of THA to assist in selecting a suitable prosthesis have yet to reach clinical popularity. ...
Background
Hip replacement surgeries are increasing in demand, requiring rigorous improvements to a mature surgical protocol. Postoperative patient dissatisfaction mainly stems from postoperative complications resulting from the inappropriate selection of prostheses to meet the needs of each patient. This results in prosthesis loosening, hospital-related fractures, and postoperative complex pain, which can all be attributed to inappropriate sizing. In this study, we aimed to further explore the intraoperative and postoperative benefits of incorporating computer-aided design (CAD) in preoperative planning for total hip arthroplasty (THA).
Methods
A total of 62 patients requiring total hip replacement surgery from January 2021 to December 2021 were collected and randomly divided into a preoperative computer-aided simulated group and a conventional x-ray interpretation group. The accuracy of implant size selection (femoral and acetabular implant) between the preoperative planning and surgical procedure of the two groups was compared. Patient parameters, perioperative Harris hip scores, operative time (skin-to-skin time), surgical blood loss, and postoperative hospital stay were recorded, and the differences between the two groups were statistically compared using a single sample t-test.
Results
All patients in the study were successfully operated on and achieved good postoperative functional recovery. With CAD, the selection of the most suitable-sized prosthesis was significantly more accurate compared to the control group (accuracy of the acetabular component between the CAD/control: 80.6%/61.3%, and accuracy of the femoral component: 83.9%/67.7%). Intraoperative blood loss (177.4/231.0 ml, P = 0.002), operation time (84.2 ± 19.8 min/100.3 ± 25.9 min, P = 0.008), duration of hospital stay (6.5 ± 3/9.1 ± 3.9 days, P = 0.003), and postoperative Harris hip score (81.9 ± 6.5/74.7 ± 11.1, P = 0.003) were compared to the control group and showed statistical significance.
Conclusion
Incorporating CAD into the preoperative planning of total hip arthroplasty can effectively guide the selection of the most suitable-sized prosthesis, reduce intraoperative blood loss, and promote short-term functional recovery after THA.
... Current applications of in-hospital 3D printing are overwhelmingly increasing every year and can be summarized in three groups: (1) preoperative planning (which includes fracture and bone defect comprehension, pre-surgical plate bending, as well as applications in oncologic surgery) [2][3][4]; (2) manufacturing of patient-specific surgical guides or surgical tools [5,6]; and (3) teaching and learning of students, residents or specialists [7][8][9][10][11]. Many publications have arisen involving applications of this technology in orthopedic surgery. ...
Introduction: Interest in 3D printing for orthopedic surgery has been increasing since its progressive adoption in most of the hospitals around the world. The aim of the study is to describe all the current applications of 3D printing in patients undergoing hip surgery of any type at the present time. Materials and Methods: We conducted a systematic narrative review of publications indexed in MedLine through the search engine PubMed, with the following parameters: 3D printing AND (orthopedics OR traumatology) NOT tissue engineering NOT scaffold NOT in vitro and deadline 31 July 2023. After reading the abstracts of the articles, papers were selected according to the following criteria: full text in English or Spanish and content related to hip surgery. Those publications involving experimental studies (in vitro or with anatomical specimens) or 3D printing outside of hospital facilities as well as 3D-printed commercial implants were excluded. Results are presented as a reference guide classified by disease, including the used software and the steps required for the development of the idea. Results: We found a total of 27 indications for in-house 3D printing for hip surgery, which are described in the article. Conclusions: There are many surgical applications of 3D printing in hip surgery, most of them based on CT images. Most of the publications lack evidence, and further randomized studies should be encouraged to assess the advantages of these indications.
... Fillat-Gomà et al. demonstrated the potential of 3D printing technology in revolutionizing the treatment of upper extremity trauma through their exploration of 8 diverse cases. Their findings illuminate the advantages provided by this innovation, including the ability to precisely select the optimal implant prior to surgery, effectively preempting potential complications, and significantly reducing surgical duration (27). Furthermore, 3D printing can enhance the complex clavicle fracture surgical proficiency of inexperienced surgeons (28). ...
... 44 What about the printing of 3D models, which is more readily available and may help surgeons recognize the elbow fracture pattern and plan the surgery? 19,31 Could 3D printing may be used to produce intraoperative tools as patient-specific plates combined with drilling guides, and would that be an advantage? 24 Disclaimers: ...
The coronoid process is key to concentric elbow alignment. Malalignment can contribute to posttraumatic osteoarthritis. The aim of treatment is to keep the joint aligned while the collateral ligaments and fractures heal. The injury pattern is apparent in the shape and size of the coronoid fracture fragments: 1) coronoid tip fractures associated with terrible triad injuries (TT); 2) anteromedial facet fractures with posteromedial varus rotational type injuries (PMVRI); 3) large coronoid base fractures with anterior (trans-) or posterior olecranon fracture-dislocations.
Each injury pattern is associated with specific ligamentous injuries and fracture characteristics useful in planning treatment. The tip fractures associated with TT injuries are repaired with suture fixation or screw fixation in addition to repair or replacement of the radial head fracture and reattachment of the lateral collateral ligament origin. Anteromedial facet (AMF) fractures are usually repaired with a medial buttress plate. If the elbow is concentrically located on computed tomography and the patient can avoid varus stress for a month, TT and AMF injuries can be treated nonoperatively. Base fractures are associated with olecranon fractures and can usually be fixed with screws through the posterior plate or with an additional medial plate. If the surgery makes elbow subluxation or dislocation unlikely, and the fracture fixation is secure, elbow motion and stretching can commence within a week when the patient is comfortable.
... No studies have been published using this technology to perform complex knee ligament reconstructions. In recent years, PSI has been successfully applied to different areas in orthopaedics and trauma to improve the accuracy of different procedures, such as total knee replacement (TKR) [30,31], upper extremity fractures [32,33], or some other procedures showing similar results [34][35][36]. Differences of approximately 5° in the tunnel angle deviation from planning do not have a relevant surgical repercussion when performing bone tunnels. ...
Purpose:
Multiple-ligament knee reconstruction techniques often involve the creation of several bone tunnels for various reconstruction grafts. A critical step in this procedure is to avoid short tunnels or convergences among them. Currently, no specific template guide to reproduce these angulations has been reported in the literature, and the success of the technique still depends on the experience of the surgeon. The aim of this study is to analyze the accuracy and reliability of 3D-printed patient-specific instrumentation (PSI) for lateral and medial anatomical knee reconstructions.
Methods:
Ten cadaveric knees were scanned by computed tomography (CT). Using specific computer software, anatomical femoral attachments were identified: (1) on the lateral side the lateral collateral ligament (LCL) and the popliteal tendon (PT) and (2) on the medial side the medial collateral ligament (MCL) and the posterior oblique ligament (POL). Four bone tunnels were planned for each knee, and PSI with different directions were designed as templates to reproduce the planned tunnels during surgery. Twenty 3D-printed PSI were used: ten were tailored to the medial side for reconstructing MCL and POL tunnels, and the other ten were tailored to the lateral side for reconstructing LCL and PT tunnels. Postoperative CT scans were made for each cadaveric knee. The accuracy of the use of 3D-printed PSI was assessed by superimposing post-operative CT images onto pre-operative images and analyzing the deviation of tunnels performed based on the planning, specifically the entry point and the angular deviations.
Results:
The median entry point deviations for the tunnels were as follows: LCL tunnel, 1.88 mm (interquartile range (IQR) 2.2 mm); PT tunnel, 2.93 mm (IQR 1.17 mm); MCL tunnel, 1.93 mm (IQR 4.26 mm); and POL tunnel, 2.16 mm (IQR 2.39). The median angular deviations for the tunnels were as follows: LCL tunnel, 2.42° (IQR 6.49°); PT tunnel, 4.15° (IQR 6.68); MCL tunnel, 4.50° (IQR 6.34°); and POL tunnel, 4.69° (IQR 3.1°). No statistically significant differences were found in either the entry point or the angular deviation among the different bone tunnels.
Conclusion:
The use of 3D-printed PSI for lateral and medial anatomical knee reconstructions provides accurate and reproducible results and may be a promising tool for use in clinical practice.
Purpose:
Derotational distal femoral osteotomy (DDFO) has good clinical outcomes for the treatment of the recurrent patellar dislocation combined with increased femoral anteversion angle (FAA). Currently, there is no uniform surgical technique. The purpose of this study was to evaluate the safety and efficacy of computer-aided design (CAD) combined 3D-printed osteotomy guide-assisted DDFO for treating these patients.
Methods:
In a retrospective study of 36 patients with recurrent patellar dislocation (RPD) from December 2017 to December 2020, all patients had increased FAA and underwent DDFO assisted by CAD combined with a 3D-printed osteotomy guide. Patients' radiological parameters were used to assess the correction of increased femoral torsion and preoperative and postoperative subjective scores were recorded to evaluate the knee function. Complications were recorded to determine the safety of the surgery.
Result:
A total of 36 knees were included in this study, with a mean follow-up time of 32.6 ± 8.1 months. The mean age of the patients was 24.9±4.4 years and all patients experienced patellar dislocation preoperatively with a mean of 5.7±3.2 times. The patients' femoral anteversion angle decreased from 35.03±3.05° preoperatively to 14.80±0.87°, and the TT-TG distance decreased from 20.03±1.27 mm preoperatively to 19.22±1.22 mm. The hip-knee-ankle (HKA) angle and Insall-Salvatti index were not significantly different postoperatively compared to preoperatively. The knee function scores and visual analogue scale at the last follow-up were significantly improved compared to the preoperative scores. No major complications such as redislocation, nonunion, fixation or graft failure, or infection were observed in any patients.
Conclusion:
Computer-aided design combined with 3D-printed osteotomy guide-assisted derotational distal femoral osteotomy could correct the increased anterior femoral torsion and demonstrate good results. There were no patients experienced re-dislocation during follow-up period and the overall complication rate is low.
Background: Three-dimensional (3D) printing is a technique based on overlapping layers of a material (eg, plastic, clay, and metal). The widespread implementation of 3D printers has resulted in a notable increase in use. Fields such as construction, engineering, and medicine benefit from this technique.
Aim: The use of 3D printed scale models permits better surgical planning and results.
Methods: The models were created based on CT images of seven patients (age range, 5 to 61 years) with different pathologies who were candidates for surgery.
Results: Surgical time decreased as a result of detailed surgical planning with printed models. This technique also was associated with a decrease in bleeding, a reduction in the amount of anesthesia required, and greater precision. In some patients, a change in surgical strategy was noted, thus allowing for a reduction in the number of surgeries and the aggressiveness of surgery. Finally, the preoperative practice (virtual and physical osteotomies using cutting tools) that was performed in two cases allowed the surgeon to evaluate the different approach alternatives and establish the best strategy.
Conclusions: The use of 3D–printed anatomic models has improved surgical planning, especially for patients in whom the conventional techniques are insufficient for establishing a proper strategy. The extra information provided by 3D–printed models can lead to a better intervention strategy, which is beneficial for patients because it decreases the risks, procedure times, and recovery times.
Background:
Three-dimensional (3D) printing is becoming increasingly important in medicine and especially in surgery. The aim of the present work was to identify the advantages and disadvantages of 3D printing applied in surgery.
Methods:
We conducted a systematic review of articles on 3D printing applications in surgery published between 2005 and 2015 and identified using a PubMed and EMBASE search. Studies dealing with bioprinting, dentistry, and limb prosthesis or those not conducted in a hospital setting were excluded.
Results:
A total of 158 studies met the inclusion criteria. Three-dimensional printing was used to produce anatomic models (n = 113, 71.5%), surgical guides and templates (n = 40, 25.3%), implants (n = 15, 9.5%) and molds (n = 10, 6.3%), and primarily in maxillofacial (n = 79, 50.0%) and orthopedic (n = 39, 24.7%) operations. The main advantages reported were the possibilities for preoperative planning (n = 77, 48.7%), the accuracy of the process used (n = 53, 33.5%), and the time saved in the operating room (n = 52, 32.9%); 34 studies (21.5%) stressed that the accuracy was not satisfactory. The time needed to prepare the object (n = 31, 19.6%) and the additional costs (n = 30, 19.0%) were also seen as important limitations for routine use of 3D printing.
Conclusion:
The additional cost and the time needed to produce devices by current 3D technology still its widespread use in hospitals. The development of guidelines to improve the reporting of experience with 3D printing in surgery is highly desirable.
Elbow instability remains a challenging surgical problem. Most commonly, isolated reconstructions of the medial collateral ligament or lateral collateral ligament are performed; however, on occasion, there can be deficiency that requires reconstruction of both ligaments. The senior author has developed a method to reconstruct both the medial and lateral collateral ligaments using 1 graft. This technique uses a "box-loop" design, whereby the donor tendon is passed through the humerus and ulna and tied back to itself, creating a loop.
Fourteen cases with mean follow-up of 64 months were reviewed. Nine patients returned to the clinic and were evaluated both clinically and radiographically. An additional 5 patients participated by phone questionnaire.
Average follow-up time was 64 months (range, 19-109 months). According to the Summary Outcome Determination given by the patients, 7 elbows were normal or nearly normal, 4 were greatly improved, 2 were improved, and 1 was worse compared with before surgery. The Summary Outcome Determination score average was 7 (range, -2 to 10). American Shoulder and Elbow Surgeons scores (including both clinic patients and phone questionnaire patients) ranged from 36 to 100, with an average of 81; of 14 patients, 8 had an American Shoulder and Elbow Surgeons self-satisfaction score of 10. The average Quick Disabilities of the Arm, Shoulder, and Hand score was 13 (range, 0-64). The average Mayo Elbow Performance Index score was 88 (range, 60-100), with 4 excellent (90-100), 3 good (75-89), and 3 fair (60-74) results and no poor results.
This technique was found to have excellent midterm results. Compared with separate medial- and lateral-sided reconstruction, there is simplification of bone tunnel formation as well as graft fixation.
Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.
Three‐dimensional (3D) printing, or additive manufacturing, is now a widely used tool in pre‐operative planning, surgical teaching and simulator training. However, 3D printing technology that produces models with accurate haptic feedback, biomechanics and visuals for the training surgeon is not currently available. Challenges and opportunities in creating such surgical models will be discussed in this review paper. Surgery requires proper tissue handling as well as knowledge of relevant anatomy. To prepare doctors properly, training models need to take into account the biomechanical properties of the anatomical structures that will be manipulated in any given operation. This review summarises and evaluates the current biomechanical literature as it relates to human tissues and correlates the impact of this knowledge on developing high fidelity 3D printed surgical training models. We conclude that, currently, a printer technology has not yet been developed which can replicate many of the critical qualities of human tissue. Advances in 3D printing technology will be required to allow the printing of multi‐material products to achieve the mechanical properties required.
Background:
Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. The purpose of this study was to examine the clinical outcomes of glenohumeral arthrodesis.
Methods:
Twenty-nine patients with 29 affected shoulders underwent primary glenohumeral arthrodesis between 1992 and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients.
Results:
All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes, and an arthrodesis position of ≥25° yielded better functional outcomes.
Conclusions:
Glenohumeral arthrodesis is associated with a high rate of patients with complications (41%). Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function.
Level of evidence:
Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) has been introduced to obtain consistent alignment, prevent instrumentation of the medullary canal and improve operating room efficiency. This article compares simultaneous bilateral TKA performed with and without the use of PSI in terms of surgical time; blood loss and transfusion requirements; length-of-stay, early thromboembolic events and complication rates. There was a trend to reduced total blood loss (as measured by drop in hemoglobin values) and lower transfusion rate after surgery. Further research in the form of high quality randomized trials and cost-benefit analyses may help in further consolidation of these findings.
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In orthopaedic surgery, resection of pelvic bone tumors can be inaccurate due to complex geometry, limited visibility and restricted working space of the pelvis. The present study investigated accuracy of patient-specific instrumentation (PSI) for bone-cutting during simulated tumor surgery within the pelvis. A synthetic pelvic bone model was imaged using a CT-scanner. The set of images was reconstructed in 3D and resection of a simulated periacetabular tumor was defined with four target planes (ischium, pubis, anterior ilium, and posterior ilium) with a 10-mm desired safe margin. Patient-specific instruments for bone-cutting were designed and manufactured using rapid-prototyping technology. Twenty-four surgeons (10 senior and 14 junior) were asked to perform tumor resection. After cutting, ISO1101 location and flatness parameters, achieved surgical margins and the time were measured. With PSI, the location accuracy of the cut planes with respect to the target planes averaged 1 and 1.2 mm in the anterior and posterior ilium, 2 mm in the pubis and 3.7 mm in the ischium (p < 0.0001). Results in terms of the location of the cut planes and the achieved surgical margins did not reveal any significant difference between senior and junior surgeons (p = 0.2214 and 0.8449, respectively). The maximum differences between the achieved margins and the 10-mm desired safe margin were found in the pubis (3.1 and 5.1 mm for senior and junior surgeons respectively). Of the 24 simulated resection, there was no intralesional tumor cutting. This study demonstrates that using PSI technology during simulated bone cuts of the pelvis can provide good cutting accuracy. Compared to a previous report on computer assistance for pelvic bone cutting, PSI technology clearly demonstrates an equivalent value-added for bone cutting accuracy than navigation technology. When in vivo validated, PSI technology may improve pelvic bone tumor surgery by providing clinically acceptable margins.
Stereolithography, a new technique of prototype fabrication developed for the aerospace industry, offers a unique way to display patient anatomy. Like current computer aided design (CAD) systems, it uses digital image data from computed tomography (CT) and magnetic resonance (MR) to produce a physical model. Unlike conventional CAD it does not require a cutting tool and, therefore, CAD toolpath limitations do not exist. The stereolithography apparatus uses an ultraviolet laser to selectively polymerize and solidify a polymeric liquid plastic solution under computer control. The device was used to produce a model of cranial bony anatomy from CT image data, providing full internal detail in the constructed model, including encased sinuses, foramen, and potentially complete internal anatomy within a closed skull. The advantages and disadvantages of this technology are reviewed with an emphasis on future development.
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Fifteen patients with symptomatic malunions of the distal radius were treated with osteotomies, corticocancellous bone grafting, and plate and screw fixation. We investigated the ability of precise preoperative planning of the size and shape of the corticocancellous bone graft to restore alignment of the radius to within 5 degrees angular deformity and 2 mm ulnar variance as compared with the opposite uninjured wrist. Only six of 15 patients (40%) satisfied these criteria. Inter-rater reliability of radiographic assessment was greater than 0.85. Five patients had residual radial inclination or sagittal tilt greater than 10 degrees with respect to the uninvolved wrist. Four patients had a residual ulnar variance greater than 2 mm with respect to the uninvolved wrist. Residual shortening (three of four patients), but not residual angulation, was associated with unsatisfactory pain and stiffness an average of 19.5 months after osteotomy (range, 11-32 months). We conclude that a distal radius osteotomy using a precisely planned and measured interpositional corticocancellous graft does not restore distal radius alignment in most patients, and that failure to restore length is associated with continued pain and stiffness.
Level of evidence:
Therapeutic study, Level IV (case series).
The purpose of this study was to determine if three-dimensional computed tomography (3-D CT) scans of the glenoid can be used to accurately quantify, by means of a glenoid index, bone loss in patients with anterior glenohumeral instability, and to compare the results with arthroscopic measurements to determine if the 3-D CT scan can preoperatively predict which patients with anterior glenohumeral instability will benefit from a bone grafting procedure.
From 2003 to 2006, 188 patients with anterior glenohumeral instability underwent arthroscopic evaluation and treatment by the senior author (S.S.B.). Of 188 total patients, there were 25 patients ranging in age from 15 to 43 years (median, 19 years) who underwent 3-D CT evaluations of both shoulders followed by arthroscopy of the unstable shoulder. For an arthroscopically measured bone loss of less than 25% of the inferior glenoid diameter, an arthroscopic Bankart repair was performed; for a glenoid bone loss of greater than or equal to 25%, an open Latarjet reconstruction was performed. We defined the glenoid index as the ratio of the maximum inferior diameter of the injured glenoid compared to the maximum inferior diameter of the uninjured contralateral glenoid as calculated from the 3-D CT scans. If the glenoid index was greater than 0.75, the patient was predicted to benefit from an arthroscopic Bankart repair (the need for surgery and the type of surgery having been determined on the basis of arthroscopic measurements). However, if the glenoid index was less than or equal to 0.75, the patient was predicted to benefit from an open Latarjet procedure. The results of each patient's glenoid index were compared with the arthroscopic decision to perform either an arthroscopic Bankart repair or an open Latarjet procedure.
Of the 25 patients included in this study, 13 patients underwent an open Latarjet procedure and 12 patients underwent an arthroscopic Bankart repair. The 3-D CT scans accurately predicted the arthroscopic decisions to perform an arthroscopic Bankart repair or open Latarjet in 24 (96%) of 25 cases (Fisher exact test; P < .001).
The glenoid index as calculated from the 3-D CT scan accurately predicted the requirement of a bone grafting procedure for 24 (96%) of 25 patients when the benchmark value of 0.75 was used. The 3-D CT scan can therefore be used by surgeons as an additional diagnostic tool for preoperative planning and patient counseling.
Level III, development of diagnostic criteria with universally applied reference (nonconsecutive patients).
Integrating 3D Visualisation Technologies in Undergraduate Anatomy Education
- Keenan
Technical considerations for additive manufactured medical devices.
- FDA U.S.