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• W3043268241 abstract "Where Are We Now? Three-dimensional (3-D) printing is the layer-by-layer or “additive manufacturing” of an object from a computer-generated 3-D image. Orthopaedic surgeons use this technology to create anatomic models, patient-specific instrumentation, and permanent implants. Most models of bone anatomy are generated from Digital Imaging and Communications in Medicine® (known as DICOM®, Arlington, VA, USA) data provided by a CT image. Given the endless variety of bone injuries and the inherent complexity of certain fracture patterns, 3-D printing has seen rapid growth in orthopaedic trauma. Three-dimensional printing models, typically made of polylactic acid, provide a tactile and visual experience that may help surgeons with fracture classification, presurgical planning, patient communication, and trainee education. In the study by Langerhuizen et al. [9], the addition of a handheld distal radius fracture model did not make a difference in fellowship-trained surgeons’ recognition of or confidence in the injured anatomy when compared with 2-D or 3-D CT images and radiographs. The authors speculated that 3-D models of distal radius fractures might be useful as a teaching aid for more-junior doctors. Two-dimensional and 3-D CT images make fracture classification more reliable and can change a surgeon’s preoperative plan, including plans for treating fractures of the distal radius [2, 5, 6]. In contrast to the findings of Langerhuizen et al. [9], several studies have shown that a 3-D model allows some improvement in identifying important features of the underlying trauma [1, 7, 12]. In a cohort of 20 patients with acetabular fractures, full-sized models promoted better interobserver agreement in fracture classification for consultants and trainees, with the greatest improvement for less-experienced doctors [7]. Studies comparing the treatment of elbow fractures [12] and distal radius fractures [3] with and without a preoperative 3-D model have shown improvements in surgical and fluoroscopy times when a model was used beforehand. So, although Langerhuizen et al. [9] tell us that a surgeon’s ability to identify key anatomy may not improve with a 3-D model, the ability to see, feel, and manipulate a fracture model may limit the time needed to understand the fracture in the operating room. Beyond Langerhuizen et al.’s [9] study of distal radius fractures, only two studies have specifically explored whether a physical model is better than 3-D CT in terms of classifying fractures and planning an operation. A study of distal humerus fractures found a benefit to 3-D CT and 3-D printing models for identifying specific fracture characteristics; however, there was no specific advantage to making a 3-D printing model [2]. An analogous study on radial head fractures reported that the addition of 3-D CT models improved the reliability of fracture classification and characterization, with less variability in treatment [5]. The addition of a physical model improved the observers’ agreement with respect to treatment but did not affect fracture classification or the observers’ understanding of fracture characteristics. Perhaps the greatest advantage of a 3-D model for our patients is that surgeons, especially less-experienced ones, will make more treatment decisions before the patient is on the operating table. The tradeoff, highlighted in a study of distal radius fractures [3], may be the preoperative time and effort required of the surgeon. Where Do We Need to Go? The application of 3-D technology to planning challenging corrective osteotomies (for example, osteotomies of the forearm) seems intuitive and has been described [11]; however, a widespread means to incorporate 3-D printing into training or routine practice has not been defined. The overarching question raised by Langerhuizen et al. [9] is, for which fractures and/or in which specific practitioner population would the routine fabrication of a 3-D printing model improve the physician’s ability to understand the fracture and maximize patient care? Under which circumstances and for whom is an investment in this technology worthwhile? Two systematic reviews [8, 10] reported that surveys reveal patient and surgeon satisfaction with 3-D printing technology. Surgeons are pleased to gain a better appreciation of the 3-D geometry of complex fractures and, in some cases, simulate the surgery in vitro. Patients find that the models improve communication regarding their injury and the surgical plan. Nonetheless, these reviews demonstrated no clear benefit to patient outcomes from the direct application of 3-D printing technology. The next step is finding a way to move from general satisfaction with the novel technology to where the models not only limit patient time in the operating room but also improve patient outcomes. Applying 3-D printing technology to trainee education may be a crucial, albeit indirect, way to improve patient outcomes. Unlike the experts who participated in Langerhuizen et al.’s [9] study, physicians in training programs or younger attending physicians may be able to better characterize fractures and plan surgery if they are given a 3-D model. Experts spend many hours correlating preoperative imaging findings with the actual intraoperative 3-D findings. Trainees could acquire experience outside the operating room by learning to treat challenging fractures through 3-D printing simulation. Arthroscopy models have been designed and validated for a similar reason [4]. Expedited learning outside the operating room might translate to better surgical performance and ultimately to improved outcomes for patients. How Do We Get There? The most straightforward way to expand on the work of Langerhuizen et al. [9] is to compare fracture characterization, classification, and surgeon confidence in trainees with and without a 3-D printing model. If trainees see a substantial benefit to 3-D printing, then training-program directors can ensure that residents have access to models when discussing difficult fractures and treating them. Taken a step further, surgical simulation platforms on 3-D printing models could be designed and validated for skills such as repairing a comminuted distal radius fracture. An ambitious project would determine the subset of practicing surgeons and fracture patterns that will benefit from the inexpensive preoperative printing and manipulation of a model. Young attending surgeons at academic centers treating less-common but complex fractures (for example, comminuted fractures of the distal humerus) could be randomized to one of two groups: routine treatment versus surgical simulation (including reduction and fixation) on a 3-D printing model. To achieve adequate numbers, the study would likely require the cooperation of several centers and a large group of young surgeons willing to participate in a time-intensive “dry run.” Groups would be compared with respect to operative metrics (time or fluoroscopy use), radiographic outcomes, and clinical parameters. If there is a clear benefit to 3-D printing, then less-experienced surgeons might be motivated to incorporate this technology into routine practice. Further, doctors could ask implant vendors to print 3-D models of complex fractures before surgery in the same way that vendors are expected to deliver patient-specific instrumentation based on CT data for complex arthroplasties." @default.
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• W3043268241 date "2020-06-30" @default.
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• W3043268241 title "CORR Insights®: Do 3-D Printed Handheld Models Improve Surgeon Reliability for Recognition of Intraarticular Distal Radius Fracture Characteristics?" @default.
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• W3043268241 doi "https://doi.org/10.1097/corr.0000000000001404" @default.
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