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      3D-printed patient-specific applications in orthopedics

      Orthopedic Research and Reviews
      Dove Medical Press Ltd.

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          Abstract

          With advances in both medical imaging and computer programming, two-dimensional axial images can be processed into other reformatted views (sagittal and coronal) and three-dimensional (3D) virtual models that represent a patients’ own anatomy. This processed digital information can be analyzed in detail by orthopedic surgeons to perform patient-specific orthopedic procedures. The use of 3D printing is rising and has become more prevalent in medical applications over the last decade as surgeons and researchers are increasingly utilizing the technology’s flexibility in manufacturing objects. 3D printing is a type of manufacturing process in which materials such as plastic or metal are deposited in layers to create a 3D object from a digital model. This additive manufacturing method has the advantage of fabricating objects with complex freeform geometry, which is impossible using traditional subtractive manufacturing methods. Specifically in surgical applications, the 3D printing techniques can not only generate models that give a better understanding of the complex anatomy and pathology of the patients and aid in education and surgical training, but can also produce patient-specific surgical guides or even custom implants that are tailor-made to the surgical requirements. As the clinical workflow of the 3D printing technology continues to evolve, orthopedic surgeons should embrace the latest knowledge of the technology and incorporate it into their clinical practice for patient-specific orthopedic applications. This paper is written to help orthopedic surgeons stay up-to-date on the emerging 3D technology, starting from the acquisition of clinical imaging to 3D printing for patient-specific applications in orthopedics. It 1) presents the necessary steps to prepare the medical images that are required for 3D printing, 2) reviews the current applications of 3D printing in patient-specific orthopedic procedures, 3) discusses the potential advantages and limitations of 3D-printed custom orthopedic implants, and 4) suggests the directions for future development. The 3D printing technology has been reported to be beneficial in patient-specific orthopedics, such as in the creation of anatomic models for surgical planning, education and surgical training, patient-specific instruments, and 3D-printed custom implants. Besides being anatomically conformed to a patient’s surgical requirement, 3D-printed implants can be fabricated with scaffold lattices that may facilitate osteointegration and reduce implant stiffness. However, limitations including high cost of the implants, the lead time in manufacturing, and lack of intraoperative flexibility need to be addressed. New biomimetic materials have been investigated for use in 3D printing. To increase utilization of 3D printing technology in orthopedics, an all-in-one computer platform should be developed for easy planning and seamless communications among different care providers. Further studies are needed to investigate the real clinical efficacy of 3D printings in orthopedic applications.

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          Most cited references42

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          Fabrication methods of porous metals for use in orthopaedic applications.

          Implant stability is not only a function of strength but also depends on the fixation established with surrounding tissues [Robertson DM, Pierre L, Chahal R. Preliminary observations of bone ingrowth into porous materials. J Biomed Mater Res 1976;10:335-44]. In the past, such stability was primarily achieved using screws and bone cements. However, more recently, improved fixation can be achieved by bone tissue growing into and through a porous matrix of metal, bonding in this way the implant to the bone host. Another potentially valuable property of porous materials is their low elastic modulus. Depending on the porosity, moduli can even be tailored to match the modulus of bone closer than solid metals can, thus reducing the problems associated with stress shielding. Finally, extensive body fluid transport through the porous scaffold matrix is possible, which can trigger bone ingrowth, if substantial pore interconnectivity is established [Cameron HU, Macnab I, Pilliar RM. A porous metal system for joint replacement surgery. Int J Artif Organs 1978;1:104-9; Head WC, Bauk DJ, Emerson Jr RH. Titanium as the material of choice for cementless femoral components in total hip arthroplasty. Clin Orthop 1995;85-90]. Over the years, a variety of fabrication processes have been developed, resulting in porous implant substrates that can address unresolved clinical problems. The advantages of metals exhibiting surface or bulk porosity have led researchers to conduct systematic research aimed at clarifying the fundamental aspects of interactions between porous metals and hard tissue. This review summarises all known methods for fabricating such porous metallic scaffolds.
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            One-step reconstruction with a 3D-printed, biomechanically evaluated custom implant after complex pelvic tumor resection.

            Resection of a pelvic tumor is challenging because of its complex three-dimensional (3D) anatomy and deep-seated location with nearby vital structures. The resection is technically demanding if a custom implant is used for reconstruction of the bone defect as the surgeon needs to ensure the resection margin is sufficiently wide and the orientation of intended resection planes must match that of the custom implant. We describe a novel workflow of performing a partial acetabular resection in a patient with pelvic chondrosarcoma and reconstruction with a custom pelvic implant in a one-step operation. A multi-planar bone resection was virtually planned. A computer-aided design implant that both matched the bone defect and biomechanically evaluated was prefabricated with 3D printing technology. The 3D-printed patient-specific instruments (PSIs) were used to reproduce the same planned resection. The histology of the tumor specimen showed a clear resection margin. The errors of the achieved resection and implant position were deviating (1-4 mm) from the planned. The patient could walk unaided with a good hip function. No tumor recurrence and implant loosening were noted at 11 months after surgery. The use of this novel CT-based method for surgical planning, the engineering software for implant design and validation, together with 3D printing technology for implant and PSI fabrication makes it possible to generate a personalized, biomechanically evaluated implant for accurate reconstruction after a pelvic tumor resection in a one-step operation. Further study in a larger population is needed to assess the clinical efficacy of the workflow in complex bone tumor surgery.
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              Direct metal fabrication of titanium implants with tailored materials and mechanical properties using electron beam melting technology

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                Author and article information

                Journal
                Orthopedic Research and Reviews
                ORR
                Dove Medical Press Ltd.
                1179-1462
                2016
                October 2016
                : Volume 8
                :
                : 57-66
                Article
                10.2147/ORR.S99614
                a1d5211e-f6a5-4d87-8921-21c9e592e3e1
                © 2016

                http://creativecommons.org/licenses/by-nc/3.0/

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