Experimental Study and Preliminary Clinical Application of Mini-invasive Percutaneous Internal Screw Fixation for Scaphoid Fracture under the Guidance of a 3D-printed Guide Plate

A Patient-Specific Three-Dimensional-Printed Surgical Guide for Dorsal Scaphoid Fracture Fixation: A Comparative Cadaver Study

Purpose

This study proposes a patient-specific three-dimensional (3D)-printed surgical guide designed for scaphoid fracture fixation through a limited dorsal approach.

Methods

Computed tomography scans of five cadaveric wrists were modeled in 3D segmentation software and cannulated screw guidewire trajectory was planned. Custom 3D-printed surgical guides for guidewire insertion were designed for each scaphoid. Guidewire placement was performed with and without the surgical guide through a dorsal approach. Postoperative scans were overlaid with the planned trajectory and compared. Five variables were measured: angular deviation, distance between entry points, distance between exit points, embedded guidewire length, and number of attempts.

Results

Mean angular deviation from the planned trajectory was 10.80 ± 6.72° for the guided and 14.08 ± 4.65° for the freehand group. The offset between entry and exit for the guided group was 2.22 ± 1.04 and 3.52 ± 2.80 mm and for the freehand group 2.95 ± 1.31 and 4.91 ± 2.37 mm, respectively. The mean length for the guided group was 23.25 ± 3.33 mm and 23.31 ± 3.07 mm for the freehand group. All guided cases took one attempt and the freehanded cases 2.0 ± 1.0 attempts. A significant positive correlation was found between trajectory and exit. No significance between groups was found between any of the measured variables. A minimum sample size of 28 was determined for follow-up studies.

Conclusions

The use of a custom surgical guide improved guidewire placement in four of five specimens when compared with a freehand approach. Specifically, the trajectory was closer to the planned trajectory. All guidewire placements were clinically acceptable. Therefore, we consider the use of this surgical guide for the dorsal approach feasible to be used in clinical practice.

Clinical relevance

This device could be used to treat nondisplaced scaphoid fractures. The use of a custom surgical guide could allow for accurate and efficient screw placement as well as reduced operating time and fluoroscopy exposure.

3D Bioprinting in Limb Salvage Surgery

With the development of 3D bioprinting and the creation of innovative biocompatible materials, several new approaches have brought advantages to patients and surgical teams. Increasingly more bone defects are now treated using 3D-bioprinted prostheses and implementing new solutions relies on the ability of engineers and medical teams to identify methods of anchoring 3D-printed prostheses and to reveal the potential influence of bioactive materials on surrounding tissues. In this paper, we described why limb salvage surgery based on 3D bioprinting is a reliable and effective alternative to amputations, and why this approach is considered the new standard in modern medicine. The preliminary results of 3D bioprinting in one of the most challenging fields in surgery are promising for the future of machine-based medicine, but also for the possibility of replacing various parts from the human body with bioactive-based constructs. In addition, besides the materials and constructs that are already tested and applied in the human body, we also reviewed bioactive materials undergoing in vitro or in vivo testing with great potential for human applications in the near future. Also, we explored the recent advancements in clinically available 3D-bioprinted constructs and their relevance in this field.

Safety and effectiveness of the three-dimensional-printed guide plate-assisted rotation axis positioning of a hinged external fixator for the elbow

PURPOSE

We aimed to evaluate the safety and effectiveness of three-dimensional (3D)-printed guide plates for assisting in the positioning of the rotation axis of an elbow-hinged external fixator.

METHODS

Terrible triad (TT) patients, who were screened using the predefined inclusion and exclusion criteria, underwent installation of a hinged external fixator on the basis of internal fixation; 3D-printed guide plates, generated from the patient's imaging data, assisted in positioning the rotation axis. All patients received the same peri-operative management and were followed up at six, 12, 24, and 48 weeks postoperatively. The duration of positioning pin placement, the number of fluoroscopies, pin placement success rate, types and incidence of post-operative complications, and the Mayo elbow performance score (MEPS) of the diseased elbow and range of motion (ROM) of both elbows were assessed.

RESULTS

In 25 patients who completed the follow-up, the average time required for positioning pin placement was 329.32 ± 42.38 s (263-443 s), the average number of fluoroscopies was 2.32 ± 0.48 times (2-3 times), and the pin placement success rate was 100%. At the last follow-up, the mean MEPS of the diseased elbow was 97.50 ± 6.92 (75-100), with an excellent and good rate of 100%, and all patients demonstrated stable concentric reduction. The average range of flexion and extension was 135.08° ± 17.10° (77-146°), while the average range of rotation was 169.21° ± 18.14° (108-180°). No significant difference was observed in the average ROM between the both elbows (P > 0.05). Eight (32%) patients developed post-operative complications, including elbow stiffness due to heterotopic ossification in three (12%) patients, all of whom did not require secondary intervention.

CONCLUSION

Utilizing 3D-printed guide plates for positioning the rotation axis of an elbow-hinged external fixator significantly reduced intra-operative positioning pin placement time and the number of fluoroscopies with excellent positioning results. Satisfactory results were also obtained in terms of post-operative complications, elbow ROM, and functional scores.

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.

Minimally Invasive Percutaneous Screw Guided by 3-Dimensional-Printed Guide for the Treatment of Scaphoid Fractures

PURPOSE

This study aimed to explore the feasibility and efficacy of percutaneous fixation of minimally displaced scaphoid waist fractures using a 3-dimensional-printed guide in 10 cases.

METHODS

Fractures were examined using preoperative computed tomography. The skin interface and bone models were reconstructed using computed tomography data. Guidewire insertion was assisted by a guide. Computed tomography was performed 4-6 weeks after surgery until healing of the fracture was confirmed. The mean follow-up period was 7 months (range, 6-9 months). The fracture healing time, grip strength, flexion-extension arc, patient-rated wrist evaluation, and Mayo wrist score were recorded.

RESULTS

A total of 6 hands were in the dominant limb. The mean operation time was 41 minutes (range, 32-70 minutes). Three (30%) scaphoids healed at 6 weeks after surgery, 8 (80%) scaphoids healed at 8 weeks after surgery, and 100% scaphoids healed at 12 weeks after surgery. After correcting for hand dominance, the mean grip strength was 84% (range, 71% to 95%) of that of the contralateral side. The flexion-extension arc was 97% (range, 82% to 100%) of that of the contralateral side. The mean Mayo wrist score was 95 (range, 85-100), and pain decreased to minimal levels. All patients returned to their preinjury activities.

CONCLUSIONS

Three-dimensional printing is an effective and feasible technology that can help guide intraoperative processes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Robot-assisted vs traditional percutaneous freehand for the scaphoid fracture treatment: a retrospective study

PURPOSE

The purpose of this study was to assess the efficiency, safety, and accuracy of cannulated screw fixation using a robot-assisted method compared with a traditional percutaneous freehand method.

METHODS

This retrospective clinical study included 18 patients with scaphoid fracture who underwent cannulated screw fixation by robot-assisted technique or traditional percutaneous freehand technique from June 2018 to June 2020. All patients were divided into the robot-assisted group (9 patients) or the traditional surgery group (9 patients). The operation time, blood loss, number of intra-operative fluoroscopies, fracture healing time, Mayo wrist function score, and screw implantation accuracy were recorded in the two groups.

RESULTS

The average age of the robot-assisted group was 37.9 ± 10.6 years (with a range of 30 to 52 years), there were eight males and one female, and there were six cases of scaphoid fracture on the right side and three on the left side. The average pre-operative time was 2.8 ± 0.7 days (ranging from 1 to 3 days). The average age of the traditional surgery group was 31.6 ± 6.8 years (with a range of 20 to 45 years), there were eight males and one female, and there were five cases of scaphoid fracture on the right side and four on the left side. The average pre-operative time was 2.1 ± 0.8 days (with a range of 2 to 4 days). The number of intra-operative fluoroscopies was 24.4 ± 3.5 in the traditional surgery group, whereas it was only 10.1 ± 1.9 in the robot-assisted group, which was significantly lower (P < 0.05). The average operation time of the traditional operation group was 48.4 ± 12.2 min, and that of the robot-assisted group was 32.6 ± 4.2 minutes, which was significantly shorter (P < 0.05). The angles between the actual screw position and the central axis of the scaphoid on both the coronal and sagittal post-operative CT images were 8.3° ± 2.3° and 8.8° ± 1.6° for the traditional operation group and 3.8° ± 0.8° and 4.3° ± 1.2° for the robot-assisted group, so the accuracy of the robot-assisted group was significantly higher (P < 0.05). There were no significant differences between the two groups in wrist function recovery or fracture healing time.

CONCLUSION

Robot-assisted treatment of scaphoid fracture is more accurate than traditional freehand technology, with shorter operation time and fewer intra-operative fluoroscopies. There is no difference between the two surgical techniques in intra-operative bleeding, post-operative fracture healing, or functional recovery. Robot-assisted surgery is a safe, effective, and accurate method for treating scaphoid fracture.

A Review of the Use of 3D Printing Technology in Treatment of Scaphoid Fractures

Background: Three-dimensional (3D) printing technology is increasingly commercially viable for pre-surgical planning, intraoperative templating, jig creation and customised implant manufacture. The challenging nature of scaphoid fracture and nonunion surgery make it an obvious target. The aim of this review is to determine the use of 3D printed technologies in the treatment of scaphoid fractures. Methods: This is a review of the Medline, Embase and Cochrane Library databases examining studies aimed at therapeutic use of 3D printing, also known as rapid prototyping or additive technology, in the treatment of scaphoid fractures. All studies published up to and including November 2020 were included in the search. Relevant data extracted included modality of use (as template/model/guide/prosthesis), operative time, accuracy of reduction, radiation exposure, follow-up duration, time to union, complications and study quality. Results: A total of 649 articles were identified, of which 12 met the full inclusion criteria. Analysis of the articles showed that 3D printing techniques can be utilised in myriad ways to aid planning and delivery of scaphoid surgery. Percutaneous guides for Kirschner-wire (K-wire) fixation of non-displaced fractures can be created; custom guides can be printed to aid reduction of displaced or non-united fractures; patient-specific total prostheses may recreate near-normal carpal biomechanics and a simple model may help graft harvesting and positioning. Conclusions: This review found that the use of 3D printed patient-specific models and templates in scaphoid surgery can improve accuracy and speed, and reduce radiation exposure. 3D printed prostheses may also restore near-normal carpal biomechanics without burning bridges for potential future procedures. Level of Evidence: Level III (Therapeutic).

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.

Application of 3D navigation for osteotomy of DDH in children: A systematic review and meta-analysis

OBJECTIVE

To systematically review the current articles to compare the efficacy and safety of 3D navigation-assisted osteotomy of DDH with conventional osteotomy of DDH in children. Study design Databases such as PubMed, Embase, Cochrane Library were searched, from inception to April, 2022, for studies applying 3D navigation-assisted osteotomy in DDH children.

METHODS

There were 626 articles identified. According to the search strategy and inclusion criteria, 7 studies were finally included, with a total of 288 cases. Study screening, data extraction, and quality assessment were conducted by two reviewers independently. Data analyses were performed using RevMan 5.4 software.

RESULTS

There were 7 retrospective cohort studies included. Meta-analysis showed that 3D navigation-assisted DDH osteotomy resulted in shorter duration of surgery [I 2   = 88%, REM, MD = 22.86, 95%CI (-27.29, -18.43), p < 0.00001], less radiation exposure during surgery [I 2   = 53%, REM, MD = 2.76, 95%CI (-3.15, -2.37), p < 0.00001], and less intraoperative bleeding [I 2   = 94%, REM, MD = 26.83, 95%CI (-39.24, -14.41), p < 0.0001], compared with conventional DDH osteotomy. There was a significant difference in the number of patients with McKay clinical function graded as poor between the two groups [I 2   = 0%, FEM, RR = 0.20, 95%CI (0.05, 0.74), p = 0.02], whereas there were no significantly statistical differences in the corrected acetabular index angle, postoperative leg length discrepancy, and number of patients with Severin x-ray graded as poor between the two groups (p > 0.05).

CONCLUSION

3D navigation-assisted pelvis and thighbone osteotomy for DDH children could shorten duration of surgery and reduce intraoperative bleeding and x-ray exposure, presenting definite therapeutic effect.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/PROSPERO/#myprospero, identifier: CRD42022333767.

Clinical applications and prospects of 3D printing guide templates in orthopaedics

Background

With increasing requirements for medical effects, and huge differences among individuals, traditional surgical instruments are difficult to meet the patients' growing medical demands. 3D printing is increasingly mature, which connects to medical services critically as well. The patient specific surgical guide plate provides the condition for precision medicine in orthopaedics.

Methods

In this paper, a systematic review of the orthopedic guide template is presented, where the history of 3D-printing-guided technology, the process of guides, and basic clinical applications of orthopedic guide templates are described. Finally, the limitations of the template and possible future directions are discussed.

Results

The technology of 3D printing surgical templates is increasingly mature, standard, and intelligent. With the help of guide templates, the surgeon can easily determine the direction and depth of the screw path, and choose the angle and range of osteotomy, increasing the precision, safety, and reliability of the procedure in various types of surgeries. It simplifies the difficult surgical steps and accelerates the growth of young and mid-career physicians. But some problems such as cost, materials, and equipment limit its development.

Conclusions

In different fields of orthopedics, the use of guide templates can significantly improve surgical accuracy, shorten the surgical time, and reduce intraoperative bleeding and radiation. With the development of 3D printing, the guide template will be standardized and simplified from design to production and use. 3D printing guides will be further sublimated in the application of orthopedics and better serve the patients.

The translational potential of this paper

Precision, intelligence, and individuation are the future development direction of orthopedics. It is more and more popular as the price of printers falls and materials are developed. In addition, the technology of meta-universe, digital twin, and artificial intelligence have made revolutionary effects on template guides. We aim to summarize recent developments and applications of 3D printing guide templates for engineers and surgeons to develop more accurate and efficient templates.

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.

Three-Dimensional Printing of Medical Devices Used Directly to Treat Patients: A Systematic Review

Until recently, three-dimensional (3D) printing/additive manufacturing has not been used extensively to create medical devices intended for actual clinical use, primarily on patient safety and regulatory grounds. However, in recent years there have been advances in materials, printers, and experience, leading to increased clinical use. The aim of this study was to perform a structured systematic review of 3D-printed medical devices used directly in patient treatment. A search of 13 databases was performed to identify studies of 3D-printed medical devices, detailing fabrication technology and materials employed, clinical application, and clinical outcome. One hundred and ten papers describing one hundred and forty medical devices were identified and analyzed. A considerable increase was identified in the use of 3D printing to produce medical devices directly for clinical use in the past 3 years. This is dominated by printing of patient-specific implants and surgical guides for use in orthopedics and orthopedic oncology, but there is a trend of increased use across other clinical specialties. The prevailing material/3D-printing technology used were titanium alloy/electron beam melting for implants, and polyamide/selective laser sintering or polylactic acid/fused deposition modeling for surgical guides and instruments. A detailed analysis across medical applications by technology and materials is provided, as well as a commentary regarding regulatory aspects. In general, there is growing familiarity with, and acceptance of, 3D printing in clinical use.

Role of the orthopaedic surgeon in 3D printing: current applications and legal issues for a personalized medicine

3D printing (I3D) is an additive manufacturing technology with a growing interest in medicine and especially in the specialty of orthopaedic surgery and traumatology. There are numerous applications that add value to the personalised treatment of patients: advanced preoperative planning, surgeries with specific tools for each patient, customised orthotic treatments, personalised implants or prostheses and innovative development in the field of bone and cartilage tissue engineering. This paper provides an update on the role that the orthopaedic surgeon and traumatologist plays as a user and prescriber of this technology and a review of the stages required for the correct integration of I3D into the hospital care flow, from the necessary resources to the current legal recommendations.

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.