Does 3D-Assisted Acetabular Fracture Surgery Improve Surgical Outcome and Physical Functioning?-A Systematic Review

Abstract

Three-dimensional technology is increasingly being used in acetabular fracture treatment. No systematic reviews are available about the added clinical value of 3D-assisted acetabular fracture surgery compared to conventional surgery. Therefore, this study aimed to investigate whether 3D-assisted acetabular fracture surgery compared to conventional surgery improves surgical outcomes in terms of operation time, intraoperative blood loss, intraoperative fluoroscopy usage, complications, and postoperative fracture reduction, and whether it improves physical functioning. Pubmed and Embase databases were searched for articles on 3D technologies in acetabular fracture surgery, published between 2010 and February 2021. The McMaster critical review form was used to assess the methodological quality. Differences between 3D-assisted and conventional surgery were evaluated using the weighted mean and odds ratios. Nineteen studies were included. Three-dimensional-assisted surgery resulted in significantly shorter operation times (162.5 ± 79.0 versus 296.4 ± 56.0 min), less blood loss (697.9 ± 235.7 mL versus 1097.2 ± 415.5 mL), and less fluoroscopy usage (9.3 ± 5.9 versus 22.5 ± 20.4 times). The odds ratios of complications and fracture reduction were 0.5 and 0.4 for functional outcome in favour of 3D-assisted surgery, respectively. Three-dimensional-assisted surgery reduces operation time, intraoperative blood loss, fluoroscopy usage, and complications. Evidence for the improvement of fracture reduction and functional outcomes is limited.

Keywords: 3D; 3D print; acetabular fracture; surgical planning; systematic review; three-dimensional.

Figure 1

PRISMA flow diagram.

Figure 2

Three-dimensional-assisted surgery. Three-dimensional-assisted surgery encompasses a spectrum of modalities, including 3D visualisation, 3D printing, and patient-specific surgical guides or implants. The steps required for 3D printing, 3D printing and pre-contouring of the implant, or the manufacturing of patient-specific implants are illustrated. In the 3D printing process (top row) a virtual 3D model is created from a CT scan, e.g., using Mimics Medical software in which a threshold for bone tissue is selected based on the Hounsfield Units of the CT scan. The 3D models are split into the separate fragments, indicated by the different colours. This virtual model can be 3D printed and used for preoperative planning and surgical guidance. For 3D printing and pre-contouring of the implant (middle row), a virtual 3D model is created from a CT scan. Then, the contralateral healthy hemipelvis is mirrored, e.g., using 3-matic Medical software, and it is used as a template for the virtual fracture reduction. The fracture fragments are virtually reduced to their original anatomical position. The mirrored or virtually reduced hemipelvis can be 3D printed and this 3D print is used for pre-contouring of the implant. One study performed virtual plating and printed the contour of a plate, which was then used for pre-contouring the implant [44]. Next, the pre-contoured implant is sterilised and used for intraoperative fracture fixation. Finally, patient-specific implants (bottom row) are designed, based on the virtual 3D model from the CT scan. Either the mirrored contralateral pelvis or the fracture reduction can be used as a model for the implants. The screw directions and positions are predetermined and then the implant is designed based on the shape of the pelvis of the individual patient and based on the fracture type. The implant is accompanied by a surgical guide, to ensure that the screws are positioned and directed as planned. The implants and surgical guides are sterilised and used for intraoperative fracture fixation within four days.

Figure 3

Forest plot of operation time. *: Good-quality study.

Figure 4

Forest plot of blood loss. *: Good-quality study.

Figure 5

Forest plot of the complications. *: Good-quality study.

Figure 6

Forest plot of the postoperative reduction, where the events indicate a poor reduction. *: Good-quality study.

Figure 7

Forest plot of the functional outcome, where the events indicate a poor functional outcome. The Harris Hip score was used by Huang et al. [38] and Wan et al. [46]. The Merle d’Aubigné score was used by Wang et al. [32] and Wu et al. [34]. *: Good-quality study.