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Correct classification of fractures according to their patterns is critical for developing a treatment plan in orthopaedic surgery. Unfortunately, for proximal humeral fractures (PHF), methods for proper classification have remained a jigsaw puzzle that has not yet been fully solved despite numerous proposed classifications and diagnostic methods. Recently, many studies have suggested that three-dimensional printed models (3DPM) can improve the interobserver agreement on PHF classifications. Moreover, Virtual Reality (VR) has not been properly studied for classification of shoulder injuries. The current study investigates the PHF classification accuracy relative to an expert committee when using either 3DPM or equivalent models displayed in VR among 36 orthopaedic surgery residents from different hospitals. We designed a multicentric randomised controlled trial in which we created two groups: a group exposed to a total of 34 3DPM and another exposed to VR equivalents. Association between classification accuracy and group assignment (VR/3DPM) was assessed using mixed effects logistic regression models. The results showed VR can be considered a non-inferior technology for classifying PHF when compared to 3DPM. Moreover, VR may be preferable when considering possible time and resource savings along with potential uses of VR for presurgical planning in orthopaedics.

This study aimed to explore the role of the three-dimension (3D) printed models in orthopedic resident training of tibial plateau fractures. A total of 41 residents from our institution were divided into two groups. The intervention group, consisting of 20 residents, had access to 3D-printed models illustrating thirteen tibial plateau fractures. In contrast, the control group, comprising 21 residents, received digital images of thirteen identical tibial plateau fractures. Evaluation of learning outcomes included the accurate identification of tibial plateau fracture patterns, deduction of traumatic mechanisms, preoperative plan, assessment time, and subjective questionnaire responses. The participants with 3D printed models scored significantly higher in both the Schatzker classification and Luo three-column classification compared to those without 3D printed models. Residents in the intervention group performed better in accuracy in deducing traumatic mechanisms compared to the control group. In addition, the sum score of preoperative plan in the intervention group was significantly higher than that in the control group. Specifically, participants with 3D printed models scored higher in surgical approach choice and implants placement than these in the control group. Residents exposed to 3D printed models also spent less time to complete the assessment than those with access only to digital imaging. Subjective assessments indicated that 3D-printed models boosted confidence in fracture identification, improved preoperative plan for fracture management and enhanced the understanding in injury mechanism of tibial plateau fractures. Furthermore, residents agreed that the use of 3D-printed models heightened their interest in learning tibial plateau fractures. Therefore, the addition of 3D printed models significantly contributed to a comprehensive understanding of tibial plateau fractures, the improvement in fracture identification, inferring injury mechanisms and preoperative plan.

Background Juxta-articular giant cell tumors in the talus are very rare and pose a special problem for reconstruction after aggressive tumor curettage. Currently, vascularized iliac bone graft (VIBG) has proven to improve the outcome of partial talus defect, however, technical difficulty occurs when both the three-dimensional fitting for a large cavity and structural support to the articular surface in the talus are needed. Prior publications have demonstrated that the three-dimensional printing technology can improve surgical efficiency on the vascularized bone graft for extremity and mandibular reconstructions in complex clinical scenarios. Case presentation We report the case of a Campanacci grade III giant cell tumor of the right talus, involving the subchondral bone close to four articular surfaces and extending into the medial soft tissue. The tumor was successfully managed with a downgrading strategy that combined microwave ablation and curettage, followed by reconstruction via a VIBG guided by a three-dimensional printed model. Computed tomography scans confirmed bone union at two months postoperatively. Two years after surgery, collapse of the articular surface or evidence of recurrence or osteonecrosis was not observed. The patient achieved a normal gait with 15 degrees of ankle dorsiflexion and 45 degrees of plantar flexion under weightbearing conditions. Conclusion The reconstruction of the large residual cavity in the talus with a VIBG after microwave ablation and aggressive tumor removal of giant cell tumor under the guidance of a three-dimensional printed model enabled the preservation of the ankle function.

Background The simulated three-dimensional (3D) printed anatomical model of the aorta, which has become the norm in medical education, has poor authenticity, tactility, feasibility, and interactivity. Therefore, this study explored the educational value and effect of mixed reality (MR) combined with a 3D printed model of aortic disease in training surgical residents. Method Fifty-one resident physicians who rotated in vascular surgery were selected and divided into traditional (27) and experimental (24) teaching groups using the random number table method. After undergoing the experimental and traditional training routines on aortic disease, both the groups took a theoretical test on aortic disease and an assessment of the simulation based on the Michigan Standard Simulation Experience Scale (MiSSES) template. Their scores and assessment results were compared. The study was conducted at the Department of Vascular Surgery of Peking University People’s Hospital, Beijing, China. Results In the theoretical test on aortic disease, the experimental teaching group obtained higher mean total scores (79.0 ± 9.1 vs. 72.6 ± 7.5, P = 0.013) and higher scores in anatomy/ pathophysiology (30.8 ± 5.4 vs. 24.8 ± 5.8; P  < 0.001) than the traditional teaching group. The differences in their scores in the differential diagnosis (25.8 ± 3.0 vs. 23.3 ± 4.9; P = 0.078) and treatment (22.5 ± 11.8 vs. 24.5 ± 8.2; P = 0.603) sessions were insignificant. The MR-assisted teaching stratified the vascular residents through the MiSSES survey. Overall, 95.8% residents (23/24) strongly or somewhat agreed that the MR was adequately realistic and the curriculum helped improve the ability to understanding aortic diseases. Further, 91.7% residents (22/24) strongly or somewhat agreed that the MR-assisted teaching was a good training tool for knowledge on aortic diseases. All residents responded with “Good” or “Outstanding” on the overall rating of the MR experience. Conclusions MR combined with the 3D printed model helped residents understand and master aortic disease, particularly regarding anatomy and pathophysiology. Additionally, the realistic 3D printing and MR models improved the self-efficacy of residents in studying aortic diseases, thus greatly stimulating their enthusiasm and initiative to study.

ObjectiveTo clarify the usefulness of a personalized three-dimensional (3D) printed model of the kidney for preoperative education among patients who underwent robot-assisted partial nephrectomy (RAPN).MethodsTwenty-nine cases of patients who planned to undergo RAPN and 19 of their families participated in this study. A three-dimensional model consisting of the kidney, tumors, ureter, inferior vena cava, and abdominal aorta in each case was generated using a Z Printer 450 based on the findings of preoperative enhanced CT. After preoperative education using enhanced CT and a 3D-printed model, two anatomy-related issues, three tumor-related issues, and two surgical procedure-related issues were evaluated using a visual analogue scale.ResultsThe median age of all participants was 64 years old. The rate in male patients was significantly higher than that in families. In all three issues in patients and in two of three issues in families, scores in the 3D model were significantly higher than those in CT. In all issues in CT, scores of patients 64 years old or younger were higher than those of patients 65 years old or higher. On the other hand, no significant difference was found in the 3D model for scores on two of three issues regardless of the age of participants.ConclusionOur data indicate that the personalized 3D printed model of the kidney is useful for preoperative education among patients and their families who underwent RAPN, especially in elderly people.

IntroductionThere are several assisted methods for the accurate placement of pedicle screw (PS), including fluoroscopy, a three-dimensional (3D) printed model, a local electrical conductivity measurement device (LECMD), and intraoperative computed tomography (CT) navigation.ObjectivesThis study aimed to investigate the accuracy of PS placement and clinical results using different assisted methods.MethodsThis study included 553 pedicle screws in 31 patients. We divided patients into the fluoroscopy (F) group (n = 79), 3D printed model and fluoroscopy (3D + F) group (n = 150), LECMD, 3D printed model, and fluoroscopy (LECMD + 3D + F) group (n = 171), and the intraoperative CT navigation (N) group (n = 153). We evaluated the operative time, intraoperative bleeding, number of fusion vertebrae, correction rate of the main curve, apical vertebral translation, grade of PS perforation (Grade 0: no perforation; Grade 1: < 2 mm; Grade 2: 2‒4 mm; Grade 3: > 4 mm), and accuracy of PS placement.ResultsThe N group had a significantly longer operative time. There were no significant differences in the clinical results excluding the operative time. The accuracy of PS placement was 93.7%, 91.3%, 93.6%, and 93.5% in the F, 3D + F, LECMD + 3D + F, and N groups, respectively. The Grade 2 perforation rate was 2.5%, 0%, 0.6%, and 0.7% in the F, 3D + F, LECMD + 3D + F, and N groups, respectively.ConclusionsThere were no significant differences in the accuracy of PS placement and clinical results excluding the operative time. The 3D printed model, LECMD, or intraoperative CT navigation would be useful to prevent Grade 2 perforation.

Study Design: Prospective study.Purpose: To evaluate the utility and limitations of using three-dimensional (3D)-printed models for the management of craniovertebral (CV) junction abnormalities.Overview of Literature: In comparison to other bony and vascular anomalies, CV junction abnormalities are difficult to treat. For cases of irreducible atlantoaxial dislocation (AAD), posterior reduction and stabilization have replaced anterior decompression as the standard management protocol. The use of 3D models, such as those described herein, can provide surgeons with in-depth knowledge of the vertebral artery course and bony anomalies associated with CV junction abnormalities.Methods: Clinical and radiological features of 18 patients with CV junction abnormalities were analyzed between March 2017 and February 2019 at Sawai Man Singh Medical College, Jaipur, India. Dynamic computed tomography (CT) of the CV junction and CT angiographies of the neck with respect to the vertebral artery course at the C1–C2 joints were obtained and studied. Customized 3D models of the CV junction were then made based on the CT data, and rehearsal of the surgical procedure was performed using the 3D model one day prior to performing the actual procedure.Results: Seventeen patients had congenital-type AAD, whereas one patient had posttraumatic AAD. Improvements in neck pain and myelopathy were seen in all patients at the follow-up, as analyzed using the Visual Analog Scale and the Japanese Orthopedic Association Scale score, respectively. There were no cases of malpositioning of screws or any direct vertebral artery injury, although in one patient, the distal flow in the dominant vertebral artery was cut off as it got compressed between the bony arch and the screw head.Conclusions: Compared to computer-generated images, 3D-printed models are a more practical approach for dealing with complex CV junction abnormalities. They provide surgeons with deep insights into the complex bony anomalies as well as variations in the vertebral artery courses, thereby improving surgical outcomes.

Purposes We performed a conversation analysis of the speech conducted among the surgical team during three-dimensional (3D)-printed liver model navigation for thrice or more repeated hepatectomy (TMRH). Methods Seventeen patients underwent 3D-printed liver navigation surgery for TMRH. After transcription of the utterances recorded during surgery, the transcribed utterances were coded by the utterer, utterance object, utterance content, sensor, and surgical process during conversation. We then analyzed the utterances and clarified the association between the surgical process and conversation through the intraoperative reference of the 3D-printed liver. Results In total, 130 conversations including 1648 segments were recorded. Utterance coding showed that the operator/assistant, 3D-printed liver/real liver, fact check (F)/plan check (Pc), visual check/tactile check, and confirmation of planned resection or preservation target (T)/confirmation of planned or ongoing resection line (L) accounted for 791/857, 885/763, 1148/500, 1208/440, and 1304/344 segments, respectively. The utterance’s proportions of assistants, F, F of T on 3D-printed liver, F of T on real liver, and Pc of L on 3D-printed liver were significantly higher during non-expert surgeries than during expert surgeries. Confirming the surgical process with both 3D-printed liver and real liver and performing planning using a 3D-printed liver facilitates the safe implementation of TMRH, regardless of the surgeon’s experience. Conclusions The present study, using a unique conversation analysis, provided the first evidence for the clinical value of 3D-printed liver for TMRH for anatomical guidance of non-expert surgeons.

Aim: Three-dimensional (3D) printed models are contemporary volumetric bone graft assessment technique for secondary alveolar bone grafting (SABG) in cleft lip and palate (CLP) patients. The study aimed at evaluation of long-term stability of iliac autograft in SABG using multislice computed tomography (CT) and 3D-printed model-based volumetric analysis. Materials and Methods: Twenty-eight patients were included in this prospective clinical study. CT image (T1) was taken after orthodontic maxillary expansion, correlating with the presurgical image. Furthermore, 3D-printed model was prepared, and volumetric assessment of graft needed was ascertained with water displacement technique. SABG was carried on with the anterior iliac crest autografting procedure. After 1-year follow-up, postoperative CT analysis (T2) was followed upon. Results: The stability of bone graft at the 1-year postoperative was found to be 43.74% with mean bone loss of 56.26% (95% confidence interval; P < 0.005). The moderate scale of CLP cases has shown statistically significant bone stability compared to that of severe and mild cases. Furthermore, the 3D-printed model has shown a significant difference to that of T1 CT imaging (P < 0.005). Conclusion: Within the limitations of the study, it seems appropriate to conclude that 3D-printed models serves as better reference than CT imaging in the context of planning and execution of precise bone grafting in SABG.

Abstract Background Coronary artery fistulae are abnormal communications of coronary arteries with systemic vasculature, pulmonary vasculature, or cardiac chambers. Use of multimodality imaging can be paramount to understanding anatomical and functional features of these complex vascular lesions, therefore optimizing success of potential curative interventions. Case summary We present two patients with incidentally discovered giant aneurysmal coronary arteries with distal fistulous connections to the coronary sinus, which were successfully closed percutaneously with Amplatzer Septal Occluders using the assistance of three-dimensional (3D) printed heart models. Conclusion Computed tomography–guided reconstruction with 3D multiplanar, multicolour printed models can help augment visuospatial understanding of the size, origin, course, and drainage of giant aneurysmal coronary artery-to-coronary sinus fistulae, and with manual bench testing can assist with choosing accurately sized and shaped devices for closure.