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With rapid emergence of 3D printing technology, surgeons have recently started to apply this in nearly all areas of orthopaedic trauma surgery. Computed tomography or magnetic resonance images of trauma patients can be utilised for making graspable objects from 3D reconstructed images. Patient specific anatomical models can thereby be created. They enhance surgeons’ knowledge of their patients’ precise patho-anatomy, regarding both traumatized bones and soft tissue as well as normal areas, and therefore help in accurate preoperative planning. 3D printed patient specific instrumentation can help to achieve precise implant placement, and better surgical results.Most importantly, customized implants can be manufactured to match an individual’s anatomy. The role of 3D printing is not limited to the operation theatre as it can also help in the manufacture of better individualized orthoses and prosthetics.
3D printing converts a computer generated 3D image into a physical model. 3D model creation is based on 3D DICOM (digital imaging and communications in medicine) format data derived from CT or MRI. It needs to be converted into a file format which can be recognized by the 3D printer. The DICOM file is therefore uploaded into a program (e.g., Mimics from Materialise for Windows, Osirix(free-open source) for Mac) which enables 3D reconstruction of the image. It is then exported in a file format (stereolithography [STL]) making it readable by software (computer aided design- CAD) which is used to design 3D objects. Defects or errors in the STL file are corrected before exporting to the 3D printer. 3D printers “additively manufacture” or create objects layer by layer. Old manufacturing methods involved the subtraction of layers from raw material, but 3D printing works by “additive manufacturing”, whereby the raw material is “added” layer by layer in a predetermined fashion, thereby achieving precise 3D framework. Industry grade printers utilise lasers to accurately sinter granular substrates such as metal or plastic powders. On completion of each layer, the printer adds a new layer of unfused powder over the previous one and the cycle continues till the entire model is generated. These printers have high print speeds, can recycle unfused powder, and can use stronger materials with higher melting points such as titanium.Layers are joined and final shape is created. One can create unique patient‑specific materials more cost‑effectively than conventional implant manufacturing . 3D printing can make any complex shape and solid and porous sections can be combined for providing optimal strength and performance.
Whilst initially, the products of 3DP were used for complex cases, it is now becoming routine, and is likely to have a significant impact on all of our practices in the coming years, as the have been seen to offer several additional advantages. They can help in the training of novice surgeons in complicated surgical areas like pelvi-acetabular trauma.The model can be sterilized and reviewed intraoperatively if necessary.[6,9,10] Preoperative review of the 3D model allows the surgeon to anticipate intraoperative difficulties, select optimal surgical approach, plan implant placement, visualise screw trajectory etc. and access the need for special equipment. Finally, it can also help in evaluation of restoration of individual anatomy after surgery.In some cases, it can help in making a precise anatomical diagnosis, where it is not otherwise obvious, and in planning subsequent management. 3D printing of individualised artificial cartilage scaffolds and 3D bioprinting are some areas of growing interest. Three dimensional (3D) printing, also called as ‘additive manufacturing’ and ‘rapid prototyping’ is considered as the “second industrial revolution”, and this appears to be especially true for orthopaedic trauma surgery.[1-10] In this paper we have reviewed the literature on applications of 3D printing in orthopaedic trauma, focusing on limb trauma and pelvic injury in particular as other areas like spine and acetabulum have been covered in other papers in the issue.
A literature search was performed in order to extract all papers related to 3d Printing applications in orthopaedics and allied sciences on the Pubmed and SCOPUS databases; using suitable key words and boolean operators (“3D Printing” OR “3 dimensional printing” OR “3D printed” OR “additive manufacturing” OR “rapid prototyping”) AND (‘‘Orthopaedics” OR “Orthopedics’’ ). AND (“Trauma” OR “Injury” )in June, 2018. Search was also attempted in Web of Science, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews(Cochrane library). The search strategy has been depicted in Table 1. Titles and abstracts of these papers were reviewed and duplicate papers and papers not related to Orthopaedic trauma were manually excluded.We also looked at the reference lists of papers for getting more relevant literature.Selected papers were then considered for qualitative synthesis. No limits were set on the time period or level of evidence, as 3D printing in orthopaedics is relatively recent and evidence available is mainly limited to low level studies.
The search on Pubmed retrieved 144 Papers and similar search on SCOPUS retrieved 94 papers.Additional searches did not reveal more relevant papers.After excluding duplicates and unrelated papers,and on screening of titles and abstracts,59 papers were considered for review.
3D printing has been increasingly used by several authors in the field of orthopaedic trauma for the last 2 decades.In 1997, Kacl et al. found that rapid prototyping might be useful for teaching and surgical planning. His paper did not reveal any difference between stereolithography and workstation-based 3-D reformations in the management of intra-articular calcaneal fractures. Brown et al., in 2003, reported that 3-D printing helped in surgical planning and in reducing the exposure of radiation during 117 complex surgical cases. Guarino et al.,in 2007, reported treatment of 10 patients with paediatric scoliosis and 3 complex pelvic fracture patients and concluded that 3-D printing improved the placement accuracy of pedicle and pelvic screws , and therefore decreased the risk of iatrogenic neurovascular trauma. In the past decade the applications of 3D printing technology in orthopaedic trauma has seen a very rapid proliferation, and it now pervades nearly all anatomical areas.
Beliën et al used a 3D model and a distal clavicular reconstruction plate to treat os acromiale and acromion fractures. Initially, a 3D model of the acromion was printed and then a plate was pre-bent to fit the exact curvatures and shape of the acromion. They tested this technique and presented their reports on five patients, three with os acromiales and two with acromial fractures. Patients were evaluated using the Constant–Murley and DASH scores.The fracture or non-union had healed in all cases. If the surgery was performed before additional damage (such as an impingement syndrome) occurred, they saw that the patient’s pain completely disappeared. The surgeon could prepare the entire operation in advance, which reduced the duration of surgery. The model can also be used to inform the patient and the surgical team about the planned operation.[A]
Jeong et al. devised a minimally invasive plating technique for midshaft clavicle fractures using intramedullary indirect reduction and prebent plates made using 3D printed models. This technique allowed easy fracture reduction with accurate prebent plates and minimal soft tissue injury.Kim et al. also used a 3D -printed clavicle model for preoperative planning and as an intraoperative tool for minimally invasive plating of comminuted displaced midshaft clavicular fractures. In this technique, a CT scan of both clavicles was taken in cases with a unilateral comminuted displaced midshaft clavicle fracture. Both clavicles were then 3D printed to get real-size clavicle models. The uninjured clavicle was 3D printed into the opposite side model using mirror imaging technique to create a preinjury replica of the fractured side clavicle.The 3D-printed fractured clavicular model helped the surgeon to observe and manipulate exact anatomical replica of the fractured bone to assist in fracture reduction before surgery. The 3D-printed uninjured clavicular model was used as a template to select the precontoured locking plate which best fitted the model. The plate was inserted through small incisions and fixed with locking screws without fracture site exposure. Seven comminuted clavicular fractures thus treated, achieved good bone union. Authors conclude that this procedure was suitable for a unilateral comminuted displaced midshaft clavicular fracture, when achieving anatomic reduction by open reduction technique seemed difficult.
3D-printed osteosynthesis plates have been utilised in treating intercondylar humeral fractures.Thirteen patients with intercondylar humeral fractures were randomized for open reduction and internal fixation with either conventional plates (n = 7) or 3D-printed plates (n = 6) from March to October 2014. Both groups were compared for operating time and elbow function at minimum 6 month follow-up.All cases were followed-up for an average of 10.6 months (range:6–13 months). The 3D-printing group had a significantly smaller average operating time (70.6-12.1 min) than the conventional plates group (92.3 -17.4 min). At the last follow-up period, no significant difference was found between groups in the rate of patients with good or excellent elbow function, although the 3D-printing group saw a slightly higher rate of good or excellent evaluations (83.1%) compared to the conventional group (71.4%).Custom 3D printed osteosynthesis plates are safe and effective for the treatment of intercondylar humeral fractures and significantly reduce operative time.
To investigate the feasibility and accuracy of a new navigation template for osteotomy in cubitus varus based on computer assistant design and 3D printing technology. The preoperative CT images of 15 children with cubitus varus from June 2015 to June 2016 were collected. According to the above data, the individual osteotomy navigate template match the distal humerus was designed by the software and printed by the 3D printer. Accurate osteotomy was performed with the assistant of the navigate template in the operation. Internal fixation of the osteotomy site was performed with 2 Kirschner wires. After surgery, a long arm plaster was applied with 20° of elbow flexion. All the patients underwent radiographic and clinical evaluations before surgery and at the follow-up examination.During the operation, the navigate template with the individual design of 3D printing technology matched the bony markers of distal humerus. Accurate and simple osteotomy were performed along the resected surface of the navigation template. None of the cases required any kinds of revision surgery or had any complaint of cosmetic appearance. Average union time was 6.7 weeks(ranged, 6 to 8 weeks). Twelve patients got an excellent result and 2 got a good result according to the criteria described by Bellemore. There were no cases with complications of infection or ulnar nerve palsy or joint stiffness.With the help of 3D printing technology, the accurate osteotomy in cubitus varus assisted by individualized navigate template can be realized. This technology can restore normal anatomical structure of the elbow joint to the greatest extent. It is worthy of popularization and application. end
You et al. treated sixty-six old patients aged 61 to 76 years with complicated proximal humeral fractures, who were randomly assigned to two groups – 34 patients in the test group and 32 patients in the control group. In the test group, 3D printing was used to build the 3D fracture model, using data acquired from thin-slice CT scan and processed by Mimics software. It helped in confirmation of diagnosis, designing individual operative plan, simulating surgical procedures and performing surgery as planned. In the control group, only thin-slice CT scan was applied for preoperative planning.Surgery duration, blood loss, fluoroscopy usage and time to union were compared. Screw lengths planned before the surgery and actually measured during the surgery were also compared. The 3D model was able to provide 360 degree visual display and palpatory sense of the direction and severity of the fracture dislocation, which helped in precise preoperative diagnosis, surgical planning and design,implant measurement, preselection of appropriate anatomical locking plate and surgical outcome simulation. Less surgical duration, less blood loss, and less number of fluoroscopy were seen compared with the control group (P < 0.05).
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