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      How 3D patient-specific instruments improve accuracy of pelvic bone tumour resection in a cadaveric study

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          Abstract

          Objectives

          To assess the accuracy of patient-specific instruments (PSIs) versus standard manual technique and the precision of computer-assisted planning and PSI-guided osteotomies in pelvic tumour resection.

          Methods

          CT scans were obtained from five female cadaveric pelvises. Five osteotomies were designed using Mimics software: sacroiliac, biplanar supra-acetabular, two parallel iliopubic and ischial. For cases of the left hemipelvis, PSIs were designed to guide standard oscillating saw osteotomies and later manufactured using 3D printing. Osteotomies were performed using the standard manual technique in cases of the right hemipelvis. Post-resection CT scans were quantitatively analysed. Student’s t-test and Mann–Whitney U test were used.

          Results

          Compared with the manual technique, PSI-guided osteotomies improved accuracy by a mean 9.6 mm (p < 0.008) in the sacroiliac osteotomies, 6.2 mm (p < 0.008) and 5.8 mm (p < 0.032) in the biplanar supra-acetabular, 3 mm (p < 0.016) in the ischial and 2.2 mm (p < 0.032) and 2.6 mm (p < 0.008) in the parallel iliopubic osteotomies, with a mean linear deviation of 4.9 mm (p < 0.001) for all osteotomies. Of the manual osteotomies, 53% (n = 16) had a linear deviation > 5 mm and 27% (n = 8) were > 10 mm. In the PSI cases, deviations were 10% (n = 3) and 0 % (n = 0), respectively. For angular deviation from pre-operative plans, we observed a mean improvement of 7.06° (p < 0.001) in pitch and 2.94° (p < 0.001) in roll, comparing PSI and the standard manual technique.

          Conclusion

          In an experimental study, computer-assisted planning and PSIs improved accuracy in pelvic tumour resections, bringing osteotomy results closer to the parameters set in pre-operative planning, as compared with standard manual techniques.

          Cite this article: A. Sallent, M. Vicente, M. M. Reverté, A. Lopez, A. Rodríguez-Baeza, M. Pérez-Domínguez, R. Velez. How 3D patient-specific instruments improve accuracy of pelvic bone tumour resection in a cadaveric study. Bone Joint Res 2017;6:577–583. DOI: 10.1302/2046-3758.610.BJR-2017-0094.R1.

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          Most cited references27

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          Resection and reconstruction for primary neoplasms involving the innominate bone.

          Edward Dunham, W F Enneking (1978)
          Using described criteria for the selection of patients for excision or resection of tumors involving various portions of the innominate bone, as opposed to hemipelvectomy, fifty-seven out of the more than 200 patients evaluated were judged to be candidates for a curative procedure. Of these, twenty-five were selected for hemipelvectomy and thirty-two, for non-amputative procedures. Depending on the location and extent of the lesion as determined by complete preoperative work-ups, three types of procedures were performed singly or in combination:(1) wide excision or radical resection of the iliac wing; (2) periacetabular wide excision or radical resection; or (3) wide excision or radical resection of the pubis. Reconstruction was accomplished when the hip joint was excised by fusion or the creation of a pseudarthrosis either medially in relation to the pubis or laterally in relation to the ilium or wing of the sacrum. The results after follow-ups of one to seventeen years were assessed in terms of the immediate goals of surgery, control of the disease, and function. The findings were as follows: With the preoperative assessment and operative techniques described, an oncologically adequate procedure was performed in two-thirds of the cases. In the remaining cases, the adequacy of the procedure was compromised by poorly planned biopsies, occult microextensions, and surgical errors. The recurrence rate was high after the inadequate procedure (100 per cent) and low (4 per cent) after the adequately accomplished procedures. Function was nearly normal when the hip joint was preserved. If the hip joint was removed and fusion was obtained, the results were good, but fusion was obtained in only 50 percent of the cases in which it was attempted. If the hip joint was removed and pseudarthrosis resulted, the results ranged from good to poor. Sciatic-nerve involvement necessitating resection of the nerve was not a contraindication to a non-amputative procedure.
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            Osteosarcoma of the pelvis: experience of the Cooperative Osteosarcoma Study Group.

            M Salzer-Kuntschik, Matthias Kevric, Rudolf Schwarz … (2003)
            To define patients and tumor characteristics as well as therapy results, patients with pelvic osteosarcoma who were registered in the Cooperative Osteosarcoma Study Group (COSS) were analyzed. Sixty-seven patients with a high-grade pelvic osteosarcoma were eligible for this analysis. Fifteen patients had primary metastases. All patients received chemotherapy according to COSS protocols. Thirty-eight patients underwent limb-sparing surgery, 12 patients underwent hemipelvectomy, and 17 patients did not undergo definitive surgery. Eleven patients received irradiation to the primary tumor site: four postoperatively and seven as the only form of local therapy. Local failure occurred in 47 of all 67 patients (70%) and in 31 of 50 patients (62%) who underwent definitive surgery. Five-year overall survival (OS) and progression-free survival rates were 27% and 19%, respectively. Large tumor size (P =.0137), primary metastases (P =.0001), and no or intralesional surgery (P <.0001) were poor prognostic factors. In 30 patients with no or intralesional surgery, 11 patients with radiotherapy had better OS than 19 patients without radiotherapy (P =.0033). Among the variables, primary metastasis, large tumor, no or intralesional surgery, no radiotherapy, existence of primary metastasis (relative risk [RR] = 3.456; P =.0009), surgical margin (intralesional or no surgical excision; RR = 5.619; P <.0001), and no radiotherapy (RR = 4.196; P =.0059) were independent poor prognostic factors. An operative approach with wide or marginal margins improves local control and OS. If the surgical margin is intralesional or excision is impossible, additional radiotherapy has a positive influence on prognosis.
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              Is Open Access

              3D-printed patient-specific applications in orthopedics

              Kwok Chuen Wong (2016)
              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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                Author and article information

                Contributors
                A. Sallent: Role: Orthopaedic Surgeon
                M. Vicente: Role: Orthopaedic Surgeon
                M. M. Reverté: Role: Orthopaedic Surgeon
                A. Lopez: Role: Researcher
                A. Rodríguez-Baeza: Role: Professor of Anatomy
                M. Pérez-Domínguez: Role: Orthopaedic Surgeon
                R. Velez: Role: Orthopaedic Surgeon
                Journal
                Journal ID (nlm-ta): Bone Joint Res
                Title: Bone & Joint Research
                ISSN (Electronic): 2046-3758
                Publication date Collection: October 2017
                Publication date (Electronic): 4 November 2017
                Volume: 6
                Issue: 10
                Pages: 577-583
                Affiliations
                [1 ]Department of Orthopedic Surgery, Hospital Vall d’Hebron, Barcelona, Spain and Vall d’Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
                [2 ]Department of Orthopedic Surgery, Hospital Vall d’Hebron, Barcelona, Spain
                [3 ]Musculoskeletal Tissue Engineering Department, Vall d’Hebron Research Institute (VHIR), Barcelona, Spain
                [4 ]Department of Morphological Science, Universitat Autonoma de Barcelona, Barcelona, Spain
                [5 ]Department of Orthopedic Surgery, Hospital Vall d’Hebron, Barcelona, Spain and Vall d’Hebron Research Institute (VHIR), Universitat Autonoma de Barcelona, Spain
                Author notes
                [*]A. Sallent; email: andreasallent@ 123456gmail.com
                Article
                Publisher ID: 10.1302_2046-3758.610.BJR-2017-0094.R1
                DOI: 10.1302/2046-3758.610.BJR-2017-0094.R1
                PMC ID: 5715211
                PubMed ID: 29054990
                SO-VID: db2e41a9-9362-4634-8fcf-0e391ee51fc8
                Copyright © © 2017 Sallent et al.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attributions licence (CC-BY-NC), which permits unrestricted use, distribution, and reproduction in any medium, but not for commercial gain, provided the original author and source are credited.

                History
                Date received : 5 April 2017
                Date accepted : 31 July 2017
                Categories
                Subject: Oncology
                Subject: 7
                Subject: Pelvic tumour
                Subject: Patient-specific instruments
                Subject: 3D printing
                Subject: Computer-assisted planning
                Subject: Cadaveric study

                Keywords: pelvic tumour,patient-specific instruments,3d printing,computer-assisted planning,cadaveric study
                Data availability:
                Keywords: pelvic tumour, patient-specific instruments, 3d printing, computer-assisted planning, cadaveric study

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