Meta-Analysis
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Jan 18, 2020; 11(1): 57-67
Published online Jan 18, 2020. doi: 10.5312/wjo.v11.i1.57
Use of three-dimensional printing in preoperative planning in orthopaedic trauma surgery: A systematic review and meta-analysis
Catrin Morgan, Chetan Khatri, Sammy A Hanna, Hutan Ashrafian, Khaled M Sarraf
Catrin Morgan, Chetan Khatri, Khaled M Sarraf, Trauma and Orthopaedics, Imperial College NHS Trust, London W2 1NY, United Kingdom
Sammy A Hanna, The Royal London Hospital, Barts Health NHS Trust, London E1 1BB, United Kingdom
Hutan Ashrafian, Department of Surgery and Cancer, Imperial College London, London W2 1NY, United Kingdom
Author contributions: Morgan C, Khatri C, Ashrafian H and Sarraf K designed research; Morgan C, Khatri C and Ashrafian H performed research; Ashrafian H and Hanna SA contributed new reagents or analytic tools; Morgan C, Khatri C and Ashrafian H analyzed data; Morgan C, Khatri C, Hanna SA, Ashrafian H and Sarraf K wrote the paper.
Conflict-of-interest statement: All authors declare that they have no conflicts of interest.
PRISMA 2009 Checklist statement: Manuscript meets requirements of PRISMA statement
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Catrin Morgan, BSc, MBBS, MRCS, Trauma and Orthopaedics, Imperial College NHS Trust, Praed Street, London W21NY, United Kingdom. catrin.morgan@nhs.net
Received: June 11, 2019
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
Processing time: 212 Days and 5.3 Hours
ARTICLE HIGHLIGHTS
Research background

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.

Research motivation

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.

Research objectives

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.

Research methods

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.

Research results

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.

Research conclusions

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.

Research perspectives

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.