Abstract
Background
Given the novelty of three-dimensional (3D) printing-assisted fracture surgery in orthopaedics, surgeon familiarity is limited and learning curve is high. As such, it is unclear how the introduction of 3D printing into clinical practice for pelvic and acetabular fracture surgery would impact perioperative outcomes. The aim of this study was to determine the impact of introducing 3D printing-assisted surgery on perioperative outcomes for traumatic pelvic and acetabular fractures.
Methods
We retrospectively identified consecutive patients who underwent surgical fixation of traumatic pelvic and acetabular fractures from 2018 to 2022 at a single tertiary hospital. The patients included in the study were divided into two groups: (1) 3D printing-assisted surgery and (2) conventional surgery. Baseline demographics and perioperative outcomes of total surgical duration, estimated blood loss, blood transfusion, number fluoroscopy images, fluoroscopy duration and postoperative disposition were recorded and compared between the two groups.
Results
In total, 26 patients were included in the present study, with 3D printing-assisted surgery being used in 34.6 % (n = 9) of cases. There were no significant differences in baseline demographics or fracture type between the 3D printing group and conventional group. As compared to patients who underwent conventional surgery, those that underwent 3D printing-assisted surgery had, on average, shorter surgical duration (299.8 ± 88.2 vs 309.1 ± 143.1 min), lesser estimated blood loss (706.3 ± 330.0 vs 800.0 ± 584.2 ml), lower transfusion rates (50.0 % vs 52.9 %), lower number of intraoperative fluoroscopy images (62.8 ± 74.5 vs 71.6 ± 47.9 images) and shorter fluoroscopy duration (235.0 ± 79.2 vs 242.3 ± 83.5 min), although statistical significance was not achieved. None of the patients in the present study developed surgical complications postoperatively.
Conclusion
The introduction of 3D printing-assisted surgery in clinical practice for pelvic and acetabular fractures is a safe and viable adjunct in pelvic and acetabular surgery, achieving comparable perioperative outcomes in the initial phase.
Keywords: 3D-printing assisted surgery, Trauma, Pelvis fracture, Acetabulum fracture, Perioperative outcomes
1. Introduction
The management of pelvic and acetabular fractures poses significant challenges due to their complex anatomy, affecting perioperative factors such as surgical duration, intraoperative blood loss, and postoperative results.1 The key objective of surgical intervention in such fractures is to reconstruct the articular surface to mitigate complications arising from the fracture.2 Orthopedic surgeons must possess a comprehensive grasp of the fracture pattern and the unique anatomy of each patient to achieve optimal fracture reduction.3 Additionally, custom contouring of implants tailored to individual patients is essential for effective fracture reduction, considering the unique nature of each pelvic or acetabular fracture case.4
Three-dimensional (3D) printing-assisted fracture surgery is being increasing utilised by surgeons for the management of complex fractures such as pelvic fractures, acetabular fractures, and complex comminuted fractures.5 Its applications in Orthopaedic surgery include characterizing fracture anatomy, preoperative planning, patient education, and designing patient-specific implants and instruments.2 Utilizing 3D-printed bone models depicting fracture patterns enables surgeons to gain enhanced insights into fracture morphology and facilitate pre-contouring of implants, potentially enhancing intraoperative precision and overall surgical outcomes.
Existing literature, including previous studies and systematic reviews, suggests that the integration of 3D printing into surgery for pelvic and acetabular fractures correlates with notably reduced intraoperative surgical duration, estimated blood loss, fluoroscopy exposure, and improved postoperative fracture reduction and functional scores compared to traditional surgical approaches.6,7 However, the widespread adoption of 3D printing technology in many healthcare institutions is still in its nascent stages, characterized by a considerable learning curve in its implementation and application in complex surgeries.8 Consequently, the initial impact of introducing 3D printing into clinical practice for pelvic and acetabular fracture surgeries on perioperative outcomes remains uncertain.
The aim of this study was to determine the impact of introducing 3D printing-assisted surgery on perioperative outcomes for traumatic pelvic and acetabular fractures. We hypothesise that the introduction of 3D printing-assisted surgery into clinical practice for traumatic pelvic and acetabular fractures would lead to comparable outcomes as compared to patients undergoing conventional surgery.
2. Methods
2.1. Study design
We conducted a retrospective analysis involving consecutive patients who underwent operative management of traumatic pelvic or acetabular fractures from 2018–2022 at a single tertiary hospital. The introduction of 3D printing-assisted surgery for pelvic and acetabular fracture fixation commenced at our institution in 2018.
We included participants with traumatic acetabular or pelvic fractures diagnosed by computed tomography (CT), and who underwent open reduction and internal fixation (ORIF) with plates. Exclusion criteria comprised patients with both pelvic and acetabular fractures, those with pathological or nontraumatic fractures, and individuals who solely underwent sacroiliac screw insertion. Patients undergoing revision surgery or additional surgeries due to polytrauma were also excluded.
The study participants were categorized into two groups: (1) those subjected to 3D printing-assisted surgery and (2) those who underwent conventional surgery without 3D printing. The study was conducted following local ethical and institutional guidelines, with approval obtained (DSRB Ref: 2022/00618).
2.2. Surgical technique
The CT images in 3D printing group were saved as DICOM images and uploaded to a Slicer software for segmentation of the pelvic and acetabular fractures, creating a 3D model. Both the femoral heads were subtracted, and the 3D image was finalised with the clinician. The image was then exported in STL format and printed on a Fused Deposition Modeling (FDM) 3D Printer. Following 3D printing and post-processing, the models were then used for preoperative planning9 and precontouring of plates if required. (Fig. 1).
Fig. 1.
3D printed model of the pelvis and acetabulum of a patient (Right), with reconstructed acetabulum with the fracture pattern marked out with black marker (Left).
The fractured 3D hemipelvis was used to better understand the fracture configuration, the optimal reduction technique, surgical approach and for preoperative contouring of the surgical plates according to the unique fracture anatomy (Fig. 2). In patients with unilateral fractures, the contralateral pelvis was mirrored to simulate the reduced pelvis and the plate was contoured to the mirrored side. In patients with bilateral fractures, the fragments were printed separately and reduced in the 3D software, prior to printing. Once the size and position of the implants were confirmed, they were precountoured, labelled and sterilised for use in surgery. For patients who underwent conventional surgery instead, contouring of the plates was done intraoperatively using a malleable template.
Fig. 2.
Preoperative contouring of the plate for a patient who underwent 3D printing-assisted surgery.
Standard surgical approaches to pelvis and acetabulum were used in both the groups by the operating surgeon. Intraoperative fluoroscopy was used to confirm fracture reduction and contact of the implants with the cortical surface. Reduction was considered anatomical9 when, in all projections, the joint line was restored within 2 mm (Fig. 3). Postoperatively, prophylactic antibiotics and Deep Vein Thrombosis (DVT) prophylaxis were instituted as per local institutional guidelines for all patients.
Fig. 3.
Preoperative (left) and final postoperative (right) plain radiographs showing good fracture reduction in a patient who underwent 3D printing-assisted surgery.
2.3. Perioperative outcomes
Baseline patient demographics of age, gender, race, Body Mass Index (BMI) and American Society of Anaesthesiologists' (ASA) grade were recorded. Fracture classification was determined from preoperative radiographs, using the Young–Burgess Classification10 for pelvic fractures and Letournel Classification11 for acetabular fractures.
Perioperative outcomes such as total surgical duration, estimated blood loss, transfusion requirements, postoperative hemoglobin and hematocrit levels, number of fluoroscopy images, fluoroscopy duration, and postoperative disposition were retrospectively recorded. Differences in baseline demographics and outcomes were compared between the two groups.
2.4. Statistical analysis
Continuous variables were presented as mean ± standard deviation, whereas categorical variables were represented as percentages and counts. A Student's independent t-test was employed to assess the differences between the two groups for continuous variables, including age, BMI, and surgical duration. For categorical variables such as gender, analysis was conducted using either the Pearson chi-square test or Fisher's exact test. Statistical analyses were carried out utilizing SPSS software package, version 20.0 (SPSS Inc, Chicago, IL). Statistical significance was set at p < 0.05.
3. Results
3.1. Patient demographics
A total of 75 consecutive patients who underwent surgical management of traumatic pelvic and acetabular fractures from 2018 to 2022 were identified. Of these patients, 49 were excluded for undergoing only sacroiliac screw insertion (n = 39), pathological fracture due to tumor (n = 1), revision surgery (n = 1), having both pelvic and acetabular fractures (n = 6) and undergoing additional surgeries in the same setting for polytrauma (n = 2).
Of the 26 patients who were eventually included in the present study, 34.6 % (n = 9) underwent 3D printing-assisted surgery while 65.4 % (n = 17) underwent conventional fixation surgery. In the present cohort, 80.8 % (n = 21) of patients underwent surgery for acetabular fracture, while 19.2 % (n = 5) of patients underwent surgery for pelvic fracture. There were no significant differences in baseline demographics or preoperative factors between the 3D printing group and conventional group in the present study cohort (Table 1).
Table 1.
Comparison of baseline demographics and preoperative factors between 3D printing-assisted surgery and conventional surgery.
| 3D Printing Method (n = 9) | Conventional Method (n = 17) | P-value | |
|---|---|---|---|
| Demographics | |||
| Age (years) | 36.9 ± 18.8 | 45.7 ± 20.5 | 0.294 |
| Gender | |||
| Male | 77.8 (7) | 76.5 (13) | 0.940 |
| Female | 22.2 (2) | 23.5 (4) | |
| Race | |||
| Chinese | 55.6 (5) | 41.2 (7) | 0.757 |
| Malay | 11.1 (1) | 29.4 (5) | |
| Indian | 22.2 (2) | 17.6 (3) | |
| Others | 11.1 (1) | 11.8 (2) | |
| BMI (kg/m2) | 24.8 ± 7.4 | 21.7 ± 5.1 | 0.576 |
| ASA Grade | |||
| 1 | 22.2 (2) | 17.6 (3) | 0.073 |
| 2 | 77.8 (7) | 41.2 (7) | |
| 3 | 0 | 41.2 (7) | |
| 4 | 0 | 0 | |
| Fracture Classification | |||
| Side | |||
| Right | 55.6 (5) | 64.7 (11) | 0.648 |
| Left | 44.4 (4) | 35.3 (6) | |
| Fracture Type | |||
| Acetabular | 77.8 (7) | 82.4 (14) | 0.778 |
| Pelvic | 22.2 (2) | 17.6 (3) | |
| Acetabular Fracture Type | |||
| Both Column | 0 | 21.4 (3) | 0.690 |
| Transverse & Posterior Wall | 14.3 (1) | 7.1 (1) | |
| T-type | 14.3 (1) | 14.3 (2) | |
| Anterior column - Posterior hemitransverse | 42.9 (3) | 42.9 (6) | |
| Posterior column & wall | 28.6 (2) | 14.3 (2) | |
| Pelvic Fracture Type | |||
| Anterior-posterior compression | 0 | 33.3 (1) | 0.361 |
| Lateral compression | 100 (2) | 66.7 (2) | |
| Vertical sheer | 0 | 0 | |
BMI: Body Mass Index; ASA: American Society of Anaesthesiologists.
3.2. Intraoperative and postoperative outcomes
Intraoperatively, as compared to patients who underwent conventional surgery, those that underwent 3D printing-assisted surgery had, on average, lower surgical duration (299.8 ± 88.2 vs 309.1 ± 143.1 min), lower estimated blood loss (706.3 ± 330.0 vs 800.0 ± 584.2 ml) and lower transfusion rates (50.0 % vs 52.9 %), although statistical significance was not reached. Similarly, number of intraoperative fluoroscopy images (62.8 ± 74.5 vs 71.6 ± 47.9 images) and fluoroscopy duration (235.0 ± 79.2 vs 242.3 ± 83.5 min) was, on average, lower in the 3D printing group, although statistical significance was also not achieved (Table 2).
Table 2.
Comparison of intraoperative and postoperative surgical outcomes between 3D printing-assisted surgery and conventional surgery.
| 3D Printing Method (n = 9) | Conventional Method (n = 17) | P-value | |
|---|---|---|---|
| Intraoperative | |||
| Surgical duration (mins) | 299.8 ± 88.2 | 309.1 ± 143.1 | 0.860 |
| Estimated total blood loss (ml) | 706.3 ± 330.0 | 800.0 ± 584.2 | 0.678 |
| Transfusion rate | 50.0 (4) | 52.9 (9) | 0.891 |
| Fluoroscopy (number of shots) | 62.8 ± 74.5 | 71.6 ± 47.9 | 0.759 |
| Fluoroscopy (total duration) | 235.0 ± 79.2 | 242.3 ± 83.5 | 0.859 |
| Postoperative | |||
| Postoperative Hemoglobin (g/dL) | 10.2 ± 1.9 | 10.2 ± 1.4 | 0.953 |
| Postoperative Hematocrit (%) | 30.6 ± 6.0 | 30.3 ± 4.3 | 0.869 |
| Disposition | 0.103 | ||
| General Ward | 88.9 (8) | 47.1 (8) | |
| High Dependency | 11.1 (1) | 35.3 (6) | |
| Intensive Care Unit | 0 | 17.6 (3) | |
Postoperatively, there was no significant difference between the groups in terms of disposition, postoperative haemoglobin or postoperative haematocrit (Table 2). None of the patients in the present study developed surgical complications postoperatively.
4. Discussion
The primary finding of our study indicates that patients undergoing 3D printing-assisted surgery for pelvic and acetabular fractures demonstrate perioperative outcomes similar to those undergoing conventional surgery, particularly in the early phase following the integration of 3D printing into clinical practice.
Addressing traumatic pelvic and acetabular fractures presents significant challenges to orthopedic surgeons due to the complexity of anatomy and limited visibility during surgical approaches.2,7 Achieving proper fracture reduction and restoring stability and congruity to the pelvic ring and acetabulum necessitates a surgeon's comprehensive understanding, experience, and familiarity with these intricate fractures. Technological advancements, including the integration of 3D printing-assisted surgery, have facilitated enhanced understanding of fracture anatomy and preoperative planning.12
Prior studies have suggested that utilizing 3D printed bone models for acetabular and pelvic fractures enhances understanding of fracture anatomy and preoperative planning, potentially leading to improved surgical outcomes.13,14 These studies have reported reductions in surgical duration, blood loss, transfusion rates, and intraoperative fluoroscopy exposure time with the incorporation of 3D printing in pelvic and acetabular fracture surgery.6,9 Consistent with these findings, our study observed similar trends in patients undergoing 3D printing-assisted surgery, although statistical significance was not achieved.
In a prospective study by Downey et al.15 of 20 patients undergoing pelvic or acetabular fracture surgery, it was reported that the use of 3D models (which was used in half of the cohort) provided additional information regarding fracture patterns, but no significant improvements were observed in various surgical parameters, including surgical duration, estimated blood loss, fracture reduction or infection rates. Another study by Hung et al.16 found that 3D printing-assisted surgery did not affect length of hospitalisation stay among 18–60-year-old male patients with traumatic pelvic or acetabular fractures. Length of hospitalisation was instead influenced by other factors such as Injury Severity Score (ISS), initial haemoglobin levels and duration from fracture to admission. In our study, the lack of statistically significant differences between 3D printing-assisted surgery and conventional surgery groups may be attributed to possible confounding factors such as surgeon familiarity and injury severity.
Common causes of surgical complications in complex orthopedic cases include prolonged operative time, intraoperative bleeding, and extended anesthesia time due to inaccurate preoperative planning.17 Despite the potential of 3D printing-assisted surgery to enhance preoperative planning and mitigate surgical complications, its adoption in clinical practice is still in its early stages, with a steep learning curve for surgeons.8
On the use of 3D printing in free flap jaw surgery, Zhu et al.18 described a three-stage learning curve of primary outcome: initial learning, plateau, and overlearning. In the initial learning phase, stabilisation of proficiency was only achieved after 23 cases. Total operation time and length of hospital stay stabilized after 8–17 cases. While no targeted studies have been performed assessing the learning curve in 3D printing-assisted pelvic or acetabular surgery, it is likely that the stages of the learning curve involved would be similar, given the complexity of pelvic and acetabular fracture fixation.7 We postulate that with increasing usage and experience, it is possible that the benefits of 3D printing-assisted surgery, such as shorter surgical duration and reduced blood loss, may become more pronounced and achieve statistical significance.
The present study has several limitations. First, this was a retrospective study with a limited sample size. Second, the present study did not include functional outcomes scores of the patients as the study primarily aimed to look at intraoperative outcomes. Future prospective, randomized, long-term, and multicentric studies are warranted to better evaluate the impact of 3D printing on the treatment of traumatic pelvic and acetabular fractures.9 Despite its benefits, 3D printing-assisted surgery also has its limitations9: It requires high-quality CT images for precise 3D reconstruction of bone models, 3D models do not provide information about surrounding soft tissue or neurovascular injury, and the printing of such 3D models itself may incur additional time. The surgical approach and reduction would depend on fracture displacements and vector pull by muscles and other soft tissue structures - which cannot be simulated accurately outside the body in 3D printed models. Nonetheless, the use of the 3D models allowed the authors to have a better understanding of the fracture fragments, methods of reduction and areas of best bone for fixation.
In conclusion, the introduction of 3D printing-assisted surgery in clinical practice for pelvic and acetabular fractures is a safe and viable adjunct in pelvic and acetabular surgery, achieving comparable perioperative outcomes in the initial phase.
Funding
None.
Funding/sponsorship
None.
Informed consent
Not applicable.
Institutional ethical committee approval (for all human studies)
Institutional review board's approval (DSRB Ref: 2022/00618).
CRediT authorship contribution statement
Vikaesh Moorthy: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing. Ivan Tjun Huat Chua: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing. Sze Ern Tan: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing. Anand Pillai: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing. Bryan Yijia Tan: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing. Michael Gui Jie Yam: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
None.
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