Published online Jan 18, 2020. doi: 10.5312/wjo.v11.i1.57
Peer-review started: June 11, 2019
First decision: September 21, 2019
Revised: September 25, 2019
Accepted: November 25, 2019
Article in press: November 25, 2019
Published online: January 18, 2020
With the increasing complexity of operations and surgical decision-making, three-dimensional (3D) printing is a novel modality with the potential to make a huge impact in the surgical field. In orthopaedics, the use of 3D printing can be broadly split into three categories. This includes: (1) The use of 3D printing in pre-operative planning; (2) 3D implants; and (3) 3D patient-specific instrumentation. In pre-operative planning, 3D printed models of the fracture configuration or pathology can allow surgeons to visualise relevant anatomy and help aid executing complex operations. It is however not clear how best to utilise the technique and whether this results in better outcomes.
The focus of this study is the use of 3D printing in preoperative planning in orthopaedic trauma surgery. Studies comparing the use of 3D printing with conventional approaches have suggested an improvement in orthopaedic operative outcomes, as measured by blood loss, use of fluoroscopy and operative time. However, the systematic assessment and meta-analysis of 3D printing in orthopaedic trauma as a single entity has not been performed. The increased application of this technology has the potential to revolutionize orthopaedic practice and enhance clinical outcomes.
The aim of this research was to draw evidence from all studies across all areas of orthopaedic trauma, irrespective of age and gender, to assess the overall role of 3D printing in orthopaedic preoperative planning and core surgical outcomes. The primary outcome measures in this review were (1) Operation time; (2) Intra-operative blood loss; and (3) Fluoroscopy used.
This study was performed in accordance to PRISMA guidelines for the reporting of systematic reviews. The study protocol was pre-defined and registered on PROSPERO. A search of Medline, Ovid and Embase from inception to February 8, 2018 was carried out and citations were imported into EndNote X7 (New York, United States) reference manager software. Two authors independently assessed the quality of included papers. FFor randomised controlled trials, the Jadad score was used and for all other study types, the Newcastle-Ottawa scale was used. Meta-analysis was performed through the inverse-variance, random-effects model of DerSimonian and Laird for both continuous and categorical outcomes.
Seventeen studies (922 patients) met our inclusion criteria and were reviewed. The use of 3D printing across all specialties in orthopaedic trauma surgery demonstrated an overall reduction in operation time of 19.85% [95% confidence interval (CI): -22.99, -16.71], intra-operative blood loss of 25.73% (95%CI: -31.07, -20.40) and number of times fluoroscopy was used by 23.80% (95%CI: -38.49, -9.10). Overall, the quality of the studies was low and it was not possible to carry out a subgroup analysis due to the limited number of studies in the different subspecialties of orthopaedic trauma.
This meta-analysis and systematic review on the use of 3D printing in preoperative planning in orthopaedic trauma suggests that 3D printing reduces operative time, intraoperative blood loss and the number of times fluoroscopy is used. 3D printing is a rapidly evolving field and it allows surgeons to gain better understanding of complex trauma cases and aid in surgical planning. 3D printing should be considered as an adjunct to improve patient care by minimising operative insult in orthopaedic trauma surgery.
The study highlights the potential impact 3D printing can have in orthopaedic trauma surgery. Further studies, in particular more randomised control trials in similar areas of orthopaedics are required to further enhance our knowledge of the role of 3D printing in orthopaedics and its application to daily clinical practice. There is also the need for an in-depth cost-analysis for the use of 3D printing in surgery, taking into account the production cost vs potential savings made by improved intra-operative outcomes.