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Table of Contents
REVIEW ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 51-54

Three-dimensional printing for complex orthopedic cases and trauma: A blessing


1 Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi, India
2 Department of Orthopaedics, Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India

Date of Web Publication5-Jul-2018

Correspondence Address:
Vipul Vijay
Department of Orthopaedics, Indraprastha Apollo Hospital, New Delhi - 110 067
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_51_18

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  Abstract 


Three-dimensional (3D) printing technology is penetrating the health-care field at an astonishing rate. In the clinical settings, 3D printing, as a novel additive manufacturing technique, is mainly applied in orthopedics. A group of 3D printing-based patient-specific osteotomy instruments, orthopedic implants, and dental implants have been available for clinical use. The uses of 3D printing have been explored in the field of arthroplasty, sports medicine, spine, pediatric orthopedics, and trauma. The 3D printing technology may provide a chance for the Indian orthopedists and technicians to independently develop innovative medical devices to catch up with their Western counterparts. Its role in patient as well as medical education is also worth exploring. With these myriad applications, 3D printing holds great promise to improve patient as well as surgeon satisfaction in the near future. We discuss the process, applications, and advantages of 3D printing in this review article.

Keywords: Arthroplasty, orthopedics, three-dimensional printing, trauma


How to cite this article:
Vaishya R, Vijay V, Vaish A, Agarwal AK. Three-dimensional printing for complex orthopedic cases and trauma: A blessing. Apollo Med 2018;15:51-4

How to cite this URL:
Vaishya R, Vijay V, Vaish A, Agarwal AK. Three-dimensional printing for complex orthopedic cases and trauma: A blessing. Apollo Med [serial online] 2018 [cited 2018 Nov 14];15:51-4. Available from: http://www.apollomedicine.org/text.asp?2018/15/2/51/236005


  Introduction Top


Three-dimensional (3D) printing is a rapidly evolving technology with the potential for significant contributions to surgical practice, especially in complex orthopedic and trauma problems. This technology has applications in preoperative planning, education, custom manufacturing (implants, prosthetics, and surgical guides), and serves exciting potential for biological applications. 3D technology was first introduced two decades ago, when it was seen as unobtainable, expensive, and futuristic with limited clinical application.[1],[2],[3] In recent times, there has been an explosion in 3D printing technology applications. Its use is becoming more widespread in surgery, and the technology will likely play a pivotal role in orthopedic practice.

3D printing converts a computer-generated 3D image into a physical model. 3D printing is also referred to as rapid prototyping or additive manufacturing, wherein the physical model is built one thin layer at a time.[4] Typically, the manufacturing of 3D models is based on 3D digital imaging and communications in medicine (DICOM) format data from computed tomography (CT) or magnetic resonance imaging (MRI). The printer builds the model by a series of cross-sectional layers of liquid, powder, or sheet material such as plastics/polymers and metals. The final shape is created when the layers are joined. This process can be used to create unique patient-specific materials which may be more cost-effective than the conventional manufacturing of implants.[4],[5] 3D printing can create any complex shape and allows solid and porous sections to be combined to provide optimal strength and performance.[4]


  Three-Dimensional Printing Technique Top


What is three-dimensional printing?

Technological developments have lowered the cost of 3D printers such that their use has expanded into areas not traditionally associated with rapid prototyping, such as patient education, surgical training, and research.

Image acquisition

To begin the process of 3D printing, an image portraying the desired object must be collected. This image is then converted into a format that the 3D printer software can use to template the object. For medical applications, this raw image can be acquired from CT or MRI scans. Advancements in medical imaging have resulted in scan resolution that far surpasses 3D printer resolution.

Image processing

The radiological scan dataset (often in the DICOM file format) must then be converted into a file format recognized by the 3D printer. The DICOM file is uploaded into a program (e.g., OsiriX) that allows for 3D reconstruction of the image. The file is exported in a file format (stereolithography [STL]) that makes it readable to software (computer-aided design) which is used to design the 3D objects. Defects or errors in the STL file can be corrected using readily available software. The corrected STL file is then sent to the 3D printer.

Three-dimensional printing

3D printers use a variety of technologies to “additively manufacture” or construct objects layer by layer. Whereas the old manufacturing methods included the subtraction of layers from raw material, 3D printing works on the model of “additive manufacturing.” In additive manufacturing, layer by layer of the raw material is “added” in a predetermined manner, hence achieving accurate and excellent 3D framework.

Industrial-grade printers use lasers to precisely sinter granular substrates (e.g., metal or plastic powders). After each layer of the structure is completed, the printer adds a new layer of unfused powder on the top of the old one, and the subsequent round of sintering builds the next cross-section fused to the previous one. The advantages of these printers are high print speeds, the ability to easily recycle unfused powder, and the ability to use stronger materials with higher melting points (e.g., titanium, which had been challenging to sculpt by standard subtractive methods).


  Uses in Orthopedics Top


Currently, 3D printing is widely available in surgical planning for a variety of orthopedic procedures. These cases vary from complex fracture patterns to revision arthroplasty surgery [Table 1].
Table 1: Various advantages of three-dimensional printing in orthopedics

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Complex trauma

3D printing is especially useful in complex trauma cases. The 3D-printed models provide a visual and tactile aid in conceptualizing complex fracture patterns. The model can be sterilized and reviewed intraoperatively as required.[6],[7] Preoperative reviews of the 3D model can allow the surgeon to anticipate intraoperative difficulties, selection of optimal surgical approach, and the need for specific equipment. Challenging pelvic fractures provide an example of these concepts.[7],[8]

There are published examples where 3D technology has been utilized in complex cases of the upper-limb and lower-limb osteotomies.[9],[10],[11] These articles support the notion that this technology simplifies complicated surgery, providing confidence that the goals of surgery are being achieved and operative time is reduced. Trials comparing routine preoperative planning with the use of 3D printing are required.[12]

Arthroplasty

Most implant companies have 3D-printed guides available to assist in standard knee joint arthroplasty.[13] A guide to assist with hip resurfacing has been described.[14] This process is commonly called patient-specific instrumentation. Patients have either CT scan or MRI scan to produce DICOM images. 3D images are then created, and a preoperative surgical plan is constructed to achieve perfect implant placement. Disposable cutting blocks are then fabricated to match and conform to the patient's anatomy using 3D printing technology. The proposed benefits include improved reproducibility of component alignment, reduced surgical time, and optimized efficiency and cost-effectiveness. Despite these proposed benefits, it is yet to be proven to be better than the standard techniques.[15],[16]

3D printing has allowed the emergence of custom implants.[17] Customized implants for joint arthroplasty are useful when the patient does not fit the standard range of implant size or their disease.

Spinal surgery

Preoperative computer-assisted planning and custom 3D-printed guides have also been described in pedicle screw placement.[18]

Pediatric orthopedics

Pediatric orthopedic surgeons have utilized 3D-printed models to assist in the management of complex spine scoliosis, the coalition in the foot, and Perthes' and Blount's disease.[6],[19] The models were used to assist in preoperative planning, communication with the patient, reference during surgery with reported improvements in the safety of the procedure, and reducing operative time. Simple and complex osteotomies can be planned using models preoperatively. The surgeon can study the deformity and plan the surgery with a computer model. It includes the exact placement of implants and the ideal osteotomy site. 3D printing can produce jigs to allow for predrilling of holes for customized plates with built-in osteotomy guides.[9]

Education

3D printing has a role in patient as well as surgeon training. It helps the patient and the relatives identify the exact pathology in greater detail and also to identify the ways to deal with the pathology. It also helps students to understand the exact anatomy of the tissue involved and hence helps in better training. A 3D-reconstructed model of any pathology also helps the surgeon to have a tactile feeling of the problem and better understand its relationship with other vital structures.[20],[21]

Bio-engineering

3D printing can also help in manufacturing implants which have a significantly improved coating of bio-active materials. These implants tend to have significantly improved bone incorporation and technically may lead to improved implant longevity. Implants such as the Tantalum-coated acetabular component are available for use in osteoporotic bone and bones with poor structural support for their better bony incorporation.


  An Illustrative Case Top


A 36-year-old male sustained right proximal tibial fracture following road traffic accident. Radiographs were suggestive of a proximal tibial fracture with intra-articular extension. There was a suspicion of a depressed fragment in the proximal tibia. The patient underwent CT of the proximal tibia with 3D reconstruction [Figure 1]. The CT scan was suggestive of type 2 Schatzker proximal tibial fracture (split depression fracture).
Figure 1: Three-dimensional reconstructed computed tomography image of a Schatzker-type proximal tibial fracture with a split depression of the articular surface

Click here to view


Given the intra-articular nature of the fracture, the patient was planned for a 3D-printed model. The CT images were converted to DICOM and sent for 3D printing. The model was able to delineate the fracture pattern clearly and was also able to define the displaced intra-articular fragments [Figure 2]. The 3D-printed model also helped to identify the exact placement of the plate and the direction of the screws for the fixation of all the fragments.
Figure 2: The three-dimensional-printed model of the same patient. The front and the top views of the tibia are shown. This three-dimensional-printed model helped in delineating the fracture pattern and also helped define the various fragments which need to reduced and fixed

Click here to view


By the 3D-printed model, it was decided that the fracture requires an extra screw from above the proximal extent of the plate to adequately fix the fragments. This plan was also discussed with the patient and the relatives, and they were able to understand the complexity of the fracture pattern better.

The fracture was fixed using the minimally invasive technique (less invasive stabilizing system) using a 3.5-mm proximal tibial locking compression plate. As planned preoperatively, the level of the plate from the articular surface was fixed, and an extra 7-mm partially threaded cancellous screw was used for the fixation of the fracture. The reduction was satisfactory in the postoperative radiographs [Figure 3].
Figure 3: The postoperative anteroposterior and lateral radiographs showing a locking plate inserted using minimally invasive technique. In addition, note the use of a separate partially threaded screw (arrow), from outside the plate, to buttress the articular depression

Click here to view


3D printing helped the surgeon to fix this complex fracture using the minimally invasive technique. It helped in achieving anatomic reduction without significant soft-tissue dissection and blood loss. It also helped the surgeon to discuss the plan preoperatively with the patient. This helped in proper surgical planning and satisfactory outcome.


  Conclusion Top


3D printers have been used successfully in various fields, such as craniofacial, plastic, urology, dental surgery, and aerospace, but its use in orthopedics is relatively recent and not well known to most surgeons, although it has tremendous implications and benefits. It is known that the operative complications in the majority of the complex orthopedic cases are due to prolonged operative time, intraoperative bleeding, extended anesthetic time, and high doses of medications, and it happens due to inaccurate preoperative planning. These problems can be avoided by preoperative planning using a 3D-printed model. A 3D-printed model can help the surgical team to understand the problem accurately and also plan the procedure to be performed in vitro with precision. It not only improves the execution of a surgical procedure, but also helps in making the necessary arrangements such as equipment and implants, in advance. 3D printing technology not only helps patients with the complex problem, but also assists the doctors to perform surgery accurately which may save from unnecessary medicolegal problems.

3D printing technology is in its primitive form in the field of orthopedics as the knowledge is limited, the learning curve is high, and the cost is a factor. However, we believe that the future holds bright for it. Orthopedic surgeons would not only be able to use 3D-printed model for surgical planning, but would also be able to use 3D-printed implants for their complicated cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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Leong NL, Buijze GA, Fu EC, Stockmans F, Jupiter JB; Distal Radius Malunion (DiRaM) collaborative group. Computer-assisted versus non-computer-assisted preoperative planning of corrective osteotomy for extra-articular distal radius malunions: A randomized controlled trial. BMC Musculoskelet Disord 2010;11:282.  Back to cited text no. 12
    
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Sassoon A, Nam D, Nunley R, Barrack R. Systematic review of patient-specific instrumentation in total knee arthroplasty: New but not improved. Clin Orthop Relat Res 2015;473:151-8.  Back to cited text no. 15
    
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Victor J, Dujardin J, Vandenneucker H, Arnout N, Bellemans J. Patient-specific guides do not improve accuracy in total knee arthroplasty: A prospective randomized controlled trial. Clin Orthop Relat Res 2014;472:263-71.  Back to cited text no. 16
    
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Abstract
Introduction
Three-Dimensiona...
Uses in Orthopedics
An Illustrative Case
Conclusion
References
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