Role of Virtual preoperative planning and

3D printing in the management of

complex orthopaedic trauma

Presenting author : Dr Abhishek Vaish

Authors: Abhishek Mishra, Tarun Verma, Abhishek Vaish, Raju Vaishya, Lalit
Maini
 3 D Printing
• 3DP technology was introduced two decades ago

• It is a rapidly evolving technology.

• Helpful in complex Orthopaedic and Trauma

• Has applications in:

a) preoperative planning
b) education
c) custom manufacturing (implants, prosthetics and surgical guides)
d) biological applications.

Cai H. Application of 3D printing in orthopedics: status quo and opportunities in China. Ann Ttransl Med. 2015; 3 (Suppl 1): S12. doi:
10.3978/j.issn.2305- 5839.2015.01.38.

2. Lal H, Patralekh MK. 3D printing and its applications in orthopaedic trauma: A technological marvel. J Clin Orthop Trauma. 2018;9:260-268. doi:
10.1016/j.jcot.2018.07.022.
 3 D printing - Why??
Translating Revolution in Medicine
Surgical
planning and
Training
 Freedom to design and
Pharmaceutica Devices manufacture
l
 Customization/personalization
3D printing in
Medicine objects

3D
 Ease of access (anyone can do it)
Implants
Tumors
modelling  Cost effectiveness

Artificial organs  Precision

 Excellent peer education tool
 Counseling is easier
 Steps to print a 3D model

a) Scan to print [CT or MRI Scans

for bones]

b) Scan  3D image

c) 3D image STL format

d) STL image G Code

e) G code  3D Model Via AM

Printing
 Aims and objectives

• To study the clinical and functional outcomes of virtual

planning and 3D printing in complex trauma cases

• To evaluate the complications of this technique

• To understand the limitations and pitfalls of 3DP

 Materials and methods
• Retro-prospective study
• Study duration 2 years
• Cohort of 91 cases, study in 2 hospitals
• Divided into 12 categories: respectively:
Acetabular fracture, n=60
Tibial plateau fracture, n=10
Carpo-metacarpal fr/dislocation
n=1
Shoulder fracture dislocation, n=4
Posttraumatic elbow deformity, n=1
Posttraumatic knee deformity, n=2
F M
Nonunion distal tibia, n=1
Cervical spine fracture, n=3
Malunited fracture acetabulum, n=4
Complex intra-articular elbow
fracture, n=2
Comminuted distal radius fracture,
n=2
Femoral head fracture, n=1.
 Materials and methods

Questionnaire with six questions

So, the scale of response for every case was from 0 to 6

Yes response was awarded as 1 No response was awarded as 0

Responses to these questions asked to surgeons after surgery were recorded.

Question 1. Do you think this process helped in reducing the surgical time?
Question 2. Did it change or influence surgical plan?
Question 3. Did it improve inventory management?
Question 4. Was the application of 3DP feasible?
Question 5. Did postoperative X-ray deviate from planned?
Question 6. Would you recommend the use of 3DP in the future?
Results: Clinical and functional outcomes

• Average score of the questionnaire was 4.5, out of a

maximum of 6.

• In all the 91 cases, the surgeons were satisfied with the

outcome which they got intraoperatively and postoperatively.

• 3D models of complex fracture were helpful in understanding

the anatomy and sketching out the plans for optimum
reduction and fixation.
Results: Clinical and functional outcomes

• Better surgical outcomes: complex anatomy of acetabular and proximal

tibial fractures were simplified due to pre-contoured patient-specific plates
designed from 3DP. Accurate anatomical reduction in reduced surgical
time turned out to attain better surgical outcomes.

• Surgical duration was reduced significantly in our case series in about

75.0% of case categories

• A modification of surgical plan after using 3DP was needed only in 3

cases
 Limitations
•It is an observational study

•Lack a control group and inclusion of heterogeneous cases.

• A comparative study is warranted to objectify the differences

and further validate the usefulness of these techniques.

•Like any other skill, VPP and 3DP also have a learning curve.

•Initial setup cost is still high ( Machine, software,

technician, electricity). However, this reduces with volume
and time.
Case 1: 40 M, with Cubitus valgus
3-D models
Pre-op contouring of the plates
Follow up X-rays
Functional outcome
Case 2: 45M RTA
3-D Planning and model
Post-op X-rays
Follow-up X-rays
Clinical outcome @ 3 months
 Discussion
• 3DP was introduced initially in the engineering and technology
sector, but now its scope has penetrated the medical field.

•There are two technologies Additive manufacturing (AM) and

Subtractive manufacturing (SM)

Several materials can be used to make a 3D model, like

Acrylonitrile-butadiene-styrene (ABS) printable polymers,
plastics (PLA, TPTE, resin, high detail resin flexible, nylon) and
metal composite (aluminum, bronze, copper, brass, gold, titanium)

Chen H, Sun J, Hoemann CD, et al. Drilling and microfracture lead to different bone structure and necrosis during bone-
marrow stimulation for cartilage repair. J Orthop Res. 2009; 27(11):1432-1438.
 Discussion
•Maini et al have designed pre-contoured templates for plates used in acetabular
fracture fixation with the help of VPP and 3DP and studied its efficacy and accuracy.

•Benefits of VPP and 3DP:

Better understanding of anatomy of a complicated Access the need for special equipment
fracture

Training of the surgeons in complicated and challenging Intraoperative review of the sterilized 3-D printed
surgical areas like pelvi-acetabular trauma, intra-articular model is possible
fractures and spinal surgery

Preoperative planning, surgical rehearsal and simulation Help in the evaluation of restoration of individual
anatomy after surgery

Anticipate intraoperative difficulties May help in making a precise anatomical diagnosis,

where it is not otherwise
obvious, and in planning subsequent management

Select optimal surgical approach Allow intraoperative referencing and navigation, reduce
time, increased accuracy

Plan implant selection and placement Visualize screw trajectory

 Conclusion:

•VPP and 3DP aid in efficient management of complex orthopaedic trauma.

• Helps in the better understanding of fracture Patho-anatomy and subsequent

planning & in designing patient-specific templates or jigs for accurate placement of
implants.

•VPP and 3DP reduce surgical duration and invasiveness and deliver better
surgical outcomes.

•Initial learning curve, with more experience of using these techniques, the time and
efforts required become much lesser than initial cases.

• With improving technologies and advancements, the utility of these techniques is

going to increase.
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