3D printing improves preoperative decision making for patient positioning and surgical approach selection for tibial plateau fractures

Abstract

Treatment of complex tibial plateau fractures remains a challenging task in clinical practice. Sufficient and appropriate preoperative decision making is essential for optimal treatment success and ultimately influences patient outcomes. Recently, the novel technique of 3D printing has proven to be beneficial for the preoperative management in other joint regions. To investigate the impact of point-of-care 3D printing on the preoperative management of tibial plateau fractures, we asked 5 students, 10 surgical residents, 3 junior surgeons and 4 senior surgeons, to simulate the preoperative planning of 22 tibial plateau fractures (11 AO B and 11 AO C fractures) regarding the treatment concept, patient positioning, operative approach and implant selection and positioning. First with CT scans only, second with 3D volumetric reconstructions, and finally with 3D printed fracture models. We analyzed the inter- and intraobserver agreement and the subjective perceived confidence of the rater regarding his decision with the different imaging modalities across the different levels of professional experience. Statistics were performed using kappa values, percentage match (PM) analysis and a univariate one-way analysis of variance. The use of 3D printing had no effect on the interobserver reliability of treatment concept selection (PM CT 83% > 3DCT 83% > 3D 82%). However, descriptively higher kappa and percentage match values increased for agreement on patient positioning and surgical approach using 3D printed fracture models. In addition, the raters selected the implants that were actually used to treat the fractures in 63% of the cases. The subjective perceived certainty of the raters increased with the use of 3D printing technology from 45% (CT and 3DCT) to 60% (3D). Additionally, raters changed their treatment plan in 36% of the cases and gained additional information 76% of the time when using the 3D printed specimen. The use of 3D printed fracture models showed a trend toward higher interrater reliability of patient positioning and surgical approach for medical students and surgical residents, while experienced surgeons show less benefit. In addition, 3D-printed models supported implant pre-selection and increased subjective confidence, positively influencing preoperative planning.

Keywords: 3D printing; Implant selection; Patient positioning; Preoperative management; Surgical approach; Tibial plateau fracture.

Fig. 1

Threshold-based semi-automated segmentation using Materialise’s interactive medical image control system (Mimics Innovation Suite v24; Materialise, Leuven, Belgium) (A,B), post processing using Materialise 3-Matic (Materialise 3-Matic Medical v16; Materialise, Leuven, Belgium) (C), slicing process using Cura (Ultimaker Cura v4.10; Ultimaker, Utrecht, Netherlands) (D).

Fig. 2

3D-printing station with a Ultimaker S5 FDM 3D printer (A,B,D) and a support dissolving station (C).

Fig. 3

Multifragmentary lateral tibial plateau fracture shown as a CT-scan (A–C), a 3D volumetric reconstruction (D) and as a 3D-printed model (E).

Fig. 4

The different aspects and their options to choose from of the surgical concept.

Fig. 5

Online questionaire (A,B) and plate selection (C).