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Three Dimensional Printing as an Aid for Pre-operative Planning in Complex Cases of Total Joint Arthroplasty: A Case Series
, Juan Barrigab, Solomon Dadiaa,c, Omri Merosea,c, Amir Sternheima,c, Nimrod Snira,d
∗Corresponding author: Samuel Morgan. samuelmorgan@mail.tau.ac.il
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Digital templating is an essential aspect of pre-operative planning for total joint arthroplasty procedures. For complex cases of joint reconstruction, the standard templating software is insufficient to achieve the desired accuracy. 3D printing significantly aids the pre-operative planning in complicated cases of joint reconstruction and offers immense potential towards improving outcomes in these cases. The purpose of the present study is to present the various ways in which 3D printing has aided our department in facilitating complex cases of lower extremity reconstruction.
Data was retrospectively retrieved for all patients that underwent total hip arthroplasty (THA) and total knee arthroplasty (TKA) with the aid of 3D printing technology at our institution between January 2016–February 2021. Patient pain was determined before and after surgery using the visual analogue scale (VAS). Patient reported outcome measures (PROMs) were additionally analyzed using the hip disability and osteoarthritis outcome score (HOOS) and knee injury and osteoarthritis outcome score (KOOS).
The final study population consisted of 39 patients that underwent TKA or THA procedures with the use of 3D printing. Twenty-four (61.5%) of the surgeries in the study were THA procedures, whereas 15 (38.5%) were TKA procedures. The average VAS for patients reduced from 8.4% before surgery to 5.4% after surgery (p < 0.001). The mean KOOS of patients that underwent TKA was 17.33 ± 9.33 (43%) and the mean HOOS of patients that underwent THA was 13.79 ± 6.6 (42%).
The following series demonstrates the ability by which 3D printing facilitates complex cases of hip and knee reconstruction. 3D printing offers an improvement in understanding of patient specific anatomy, enhancing patient outcomes. Departments should consider the use of 3D printing technology as an adjunct when performing complex cases of lower extremity reconstruction.
1 Introduction
Digital templating is an essential aspect of pre-operative planning for total joint arthroplasty (TJA), as it aids in the prediction of implant sizes and reduces post-operative complications.1,2 Component, type and size prediction is less accurate for complex cases of lower extremity reconstruction.3 As pre-operative templating takes into consideration osseous morphology in order to determine proper component size and position, it is logical that inferior results are noted in pathologies with deficient bone stock and distorted anatomy. In such cases, 2-D templating may not be sufficient in order to achieve the desired accuracy.
Recently, several reports have substantiated the effectiveness of three dimensional printing technology in arthroplasty procedures, highlighting its promising potential for improving reconstructive technique.4–6 By modeling a joint that is specific to a patient, this allows surgeons the ability to understand the specific joint limitations and anatomic intricacies as it pertains to each individualized case, so that they can meticulously plan for unique problems that they may encounter intra-operatively.
In complicated cases of hip and knee reconstruction with distorted anatomy and deficient bone stock, 3D printing offers significant aid in surgical planning. Despite studies which support the use of 3D printing technology in departments, reports detailing the ways by which 3D printing may be used as an adjunct to complex cases are decidedly lacking.7–10 Presenting the various applications by which this technology may be applied offers significant contribution towards improving reconstructive technique and musculoskeletal oncology across departments worldwide. Thus, we devised the present case series with the following objective: to describe the various applications by which 3D printing has been used in our department, allowing us to achieve good outcomes in challenging cases of oncological reconstruction, by improving our understanding of patient-specific anatomy.
2 Methods
The following case series is a retrospective cohort study that included 39 patients that underwent complex arthroplasty procedures in our institution between January 2016–February 2021 with the aid of 3D printing technology. 3D printing was carried out pre-operatively at the Levin Center Surgical 3D Printing Innovation Laboratory. Post-operative management included modulated non-weight bearing using walking aids, early immobilization and thrombo-prophylactic treatment. Anterior posterior (AP) x-rays were additionally obtained post-operatively. Data gathered from the patients’ electronic records included demographics such as age, gender, side of operation, and indication for surgery. Patients were contacted at 1–2 years post-operatively to complete surveys and questionnaires in order to measure their pain and functional outcomes.
2.1 Outcomes measured
Pain and quality of life were measured with the visual analogue scale (VAS) questionnaire. The VAS is a validated method for scoring acute and chronic pain, whereby patients record their pain score on a 10-cm line, where a score of 0 represents no pain and a score of 10 represents worst pain.11 VAS scores were obtained pre-operatively and post-operatively. Functional outcomes for patients undergoing TKA and THA were measured with the knee injury and osteoarthritis outcome score (KOOS) and the hip injury and osteoarthritis outcome score (HOOS), respectively. The KOOS and HOOS are validated scoring from 0 to 100 where 0 represents total knee disability (KOOS) and total hip disability (HOOS), and 100 represents perfect knee health (KOOS) and perfect hip health (HOOS).12,13 HOOS and KOOS were obtained post-operatively at 1–2 years.
3 Results
The final study population consisted of 39 patients. The mean age of patients in our study was 47 ± 23 years. Twenty-four (61.5%) of the surgeries in the study were THA procedures, whereas 15 (38.5%) were TKA procedures. Twenty-two (56.4%) of patients in the study were female. Twenty-four patients (63.2%) underwent left-sided operations, while 14 (36.8%) underwent right-sided operations (Table 1). The indications for surgery included: reconstruction following primary or secondary tumor resection (69.2%), multiple revision procedures (17.9%), conversion from open reduction internal fixation (ORIF) (7.7%), and avascular necrosis (AVN) (2.6%). The indication for surgery was unknown for 2.6% of patients (Fig. 1).
| Mean Age (years) | 47 ± 23 |
| Knee Surgery (n) | 15 (38.5%) |
| Hip Surgery (n) | 24 (61.5%) |
| Gender (female: male) | 22:17 |
The average VAS of all patients was 8.4% before surgery and 5.4% after surgery, a finding that was found to be statistically significant (p < 0.001). Following surgery, the mean KOOS of patients that underwent TKA was 17.33 ± 9.33 (43%) and the mean HOOS of patients that underwent THA was 13.79 ± 6.6 (42%) (Table 2).
| VAS Before Surgery | VAS After Surgery | |
| All patients (n = 39) | 8.4% | 5.4%** |
| KOOS (out of 28) | ||
| Knee (n = 15) | 17.33 (43%) | |
| HOOS (out of 24) | ||
| Hip (n = 24) | 13.79 (42%) | |
In regards to the patients’ ambulatory status following surgery, 2 patients (5.1%) were unable to walk and required a wheelchair. Of the patients who were able to ambulate, 4 (10.3%) required a cane, 1 (2.6%) required a customized shoe orthotic, 2 (5.1%) required crutches, 3 (7.7%) required a walker and 20 (51.3%) were able to ambulate on their own without an assisted ambulatory device. Seven of the patients (17.9%) did not have a formal follow up to determine ambulatory status (Table 3).
| Ambulatory Status | Number of Patients (Total = 39) |
| Ambulates without assistance | 20 (51.3%) |
| Ambulates with assist of cane | 4 (10.3%) |
| Ambulates with assist of crutches | 2 (5.1%) |
| Ambulates with assist of walker | 3 (7.7%) |
| Wheelchair: non-ambulatory | 2 (5.1%) |
| Unknown | 7 (17.9%) |
4 Discussion
Digital templating has made significant contributions to orthopaedics over the years. Despite the proven efficacy of digital templating in component prediction, such a method is not adequate in complex cases of joint reconstruction. In recent years, 3D printing has emerged as an aid in complex surgical cases within orthopaedics. Several studies in the current body of literature validate our findings regarding the effectiveness of 3D printing, through its role as an aid in pre-operative planning.14–18 However, reports that present in detail the ways by which this technology may be applied to complex cases are scarce. The following case series aimed to present in detail the ways by which 3D printing has facilitated pre-operative planning for complex cases of oncological reconstruction in our department.
4.1 Case 1: Inadequate soft tissue coverage and proximal tibial deficiency
The current case describes a 39-year old female who presented to our institution in 2005 with a diagnosis of giant cell tumor of the left proximal tibia. The patient subsequently underwent curettage and cryosurgery, with cementation of the void and augmentation with a plate. During a visit to our clinic in 2018, she was diagnosed with infection of her hardware, with staphylococcus capitis. Consequently, a 2-stage revision was planned. During the first stage of the revision, all of the hardware which included the plate, pins and the cement were removed. Curettage of the bone was performed and re-cementation with antibiotics was performed. A total knee replacement was planned for February of 2019, in which our 3D printing technology would be used to facilitate the procedure (Fig. 2).
From mapping out the joint, we noted a large void and cortical window that occurred from resecting the tumor, which resulted in significant deficiency at the medial cortex of the bone. Such a deficiency could lead to tilting of the tibial baseplate. There was additional concern related to the medial joint stability and the function of the MCL given the cortical window. In order to overcome the deficient bone stock, we needed to provide several augments, while simultaneously ensuring a maximal stable fixation. To prevent tilting of the tibial baseplate, we used a long tibial stem extension, which contributes to joint stability by reducing forces of compression, shear, axial torque and varus/valgus moments, normally generated during movement of the knee.19 Modelling this joint allowed us to understand its anatomy in order to provide appropriate alignment of the tibial stem, ensuring it would not contact the tibial cortex and lead to inappropriate positioning of the baseplate.20
Our 3D model additionally allowed us to understand the extent of the large and uncontained bone defect. We planned on metal filling augments (cones and metaphyseal sleeves) in order to fill the void created by previous surgeries and impacted a combination of morcellized and strut allograft of the fibula.
Currently at almost 3 years following surgery, the patient has returned to daily work, ambulates without any aid and climbs stairs regularly.
4.2 Case 2: acetabular insufficiency
The current case describes a 21-year old female who presented to our institution in April 2017 with a diagnosis of osteosarcoma to her left pelvis. Following her diagnosis, the patient underwent a surgical hip dislocation in order to perform a type II/III internal hemi-pelvectomy, which included the medial acetabulum, the anterior column and the pubic bone. During the procedure, a plate and an allograft were added to the medial wall of the acetabulum. In March 2019, MRI findings confirmed a suspected diagnosis of avascular necrosis (AVN) of the left hip, following which a THA was planned (Fig. 3).
The two main advantages 3D printing provides in cases with deficient acetabular bone stock is the ability to model trial implants and the ability to perform a dry run. As we were faced with deficient bone stock in the medial acetabulum, the anterior column and the pubic bone, we were challenged with finding an appropriate acetabular location and cup size that would allow for sufficient bony ingrowth, while providing the minimal amount of constraint.
During THA, one of the main objectives is to restore normal hip anatomy and preserve the center of rotation (COR). Preserving the COR is important as it reduces the risk of impingement and dislocation in addition to improving the range of motion.21 The degree of acetabular reaming affects relocation of the COR.22 This technique is particularly complicated in cases of acetabular deficiency. Through 3D modeling of the patient's acetabulum, we performed a dry run where we simulated reaming in order to understand the extent that we would be able to perform this technique intra-operatively. After modeling several trial implants to match the patients' anatomy and simulating reaming, we placed the acetabular cup 2 cm superior to the COR in order to get maximal cup support from the native acetabular bone. Such a strategy would not have been possible without modeling our patient's joint in three dimensions. Currently, at almost 3 years following her surgery, the patient walks without any aid, noted no pain during her follow up visits and has almost no daily limitations.
4.3 Economic impact
One final consideration that warrants discussion is the cost of this technique. While significant costs may be incurred by implementing 3D printing labs into hospitals, such a technology also has the potential to lessen costs, due to its associated shorter operational time over a broad range of surgeries in addition to complex joint replacements.23 In an analysis by Ballard et al.24 the authors proposed that the shortened operating time that is a result of 3D models, can potentially cover the costs required to maintain a 3D printing lab. While little is known regarding the cost-effectiveness associated with 3D printing, surgeons should consider the economic implications associated with the implementing this technology into their departments.
The following case series should be interpreted in light of certain limitations. We acknowledge that this is a single-centre study with a small sample size, which may have confounded our results. As the complex cases in our study were carried out by two experienced senior surgeons, our study did not consider the learning curve associated with operating with the aid of 3D printing. Finally, as our study did not include a statistical comparison between functional outcomes pre-operatively and post-operatively, it is difficult to draw conclusions regarding the efficacy of this technology at improving functional outcomes.
5 Conclusion
The following case series demonstrates the ability by which 3D printing facilitates complex cases of hip and knee reconstruction. Such a technology offers immense potential towards orthopedic departments worldwide, by improving reconstructive technique as well as musculoskeletal oncology. Future large prospective studies are warranted to investigate the cost-effectiveness of this technology and additional ways it can be applied to facilitating complex surgical cases.
Funding
None of the authors in this study received any funding and do not have any proprietary interests in the materials described in the article.
Ethics approval
This study was approved by the institutional review board.
Availability of data and material
Not applicable.
Code availability
Not applicable.
Consent to participate
Informed consent was obtained from all participants in the study.
Consent to publish
Consent to publish was obtained from all the participants in the study.
Informed consent
Informed consent was obtained from all patients.
Institutional ethical committee approval
Obtained for study.
Authors contribution
Morgan: writing – original draft, Barriga: data curation, Dadia: Investigation, Merose: validation, methodology, Sternheim: conceptualization, writing – review and editing, Snir: conceptualization, writing – review.
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