Use of a real-size 3D-printed model as a preoperative and intraoperative tool for minimally invasive plating of comminuted midshaft clavicle fractures
© Kim et al. 2015
Received: 12 November 2014
Accepted: 24 May 2015
Published: 10 June 2015
Open reduction and plate fixation is the standard operative treatment for displaced midshaft clavicle fracture. However, sometimes it is difficult to achieve anatomic reduction by open reduction technique in cases with comminution.
We describe a novel technique using a real-size three dimensionally (3D)-printed clavicle model as a preoperative and intraoperative tool for minimally invasive plating of displaced comminuted midshaft clavicle fractures. A computed tomography (CT) scan is taken of both clavicles in patients with a unilateral displaced comminuted midshaft clavicle fracture. Both clavicles are 3D printed into a real-size clavicle model. Using the mirror imaging technique, the uninjured side clavicle is 3D printed into the opposite side model to produce a suitable replica of the fractured side clavicle pre-injury.
The 3D-printed fractured clavicle model allows the surgeon to observe and manipulate accurate anatomical replicas of the fractured bone to assist in fracture reduction prior to surgery. The 3D-printed uninjured clavicle model can be utilized as a template to select the anatomically precontoured locking plate which best fits the model. The plate can be inserted through a small incision and fixed with locking screws without exposing the fracture site. Seven comminuted clavicle fractures treated with this technique achieved good bone union.
This technique can be used for a unilateral displaced comminuted midshaft clavicle fracture when it is difficult to achieve anatomic reduction by open reduction technique.
Level of evidence V.
Open reduction and plate fixation is the standard operative treatment for displaced midshaft clavicle fracture . This procedure provides biomechanically stable construction allowing for early mobilization and the accommodation of fracture compression. However, extensive stripping of the fracture site results in an increased risk of infection and a potential decrease in cosmetic satisfaction. Complications associated with plate fixation, such as implant failure or re-fracture after implant removal, have been reported [2, 3]. The elastic intramedullary nailing technique was developed to preserve the periosteal blood supply of the fracture area. It has the advantage of maintaining an intact fracture hematoma, which may increase the rate of fracture healing [4–7]. However, an intramedullary device may migrate with the movements of the bone and can therefore result in medial protrusion, thus causing irritation or skin perforation. Telescoping and shortening are common in comminuted fractures treated with elastic intramedullary nailing, and early motion is limited due to its suboptimal stability .
A minimally invasive plate osteosynthesis (MIPO) has been introduced to overcome the limitations of the two commonly used operative techniques, as it can provide excellent biological healing and optimal stabilization strength [1, 8–11]. However, it is more technically demanding than standard open reduction and plate fixation as the fracture site remains closed. There are numerous manufacturers that supply anatomically designed precontoured locking plates for use in the minimally invasive approach. However, it is challenging to select the right plate for each clavicle fracture due to the bones’ individual size and shape characteristics. It is difficult to check if the plate fits well on the clavicle unless the clavicle is fully exposed and the plate is inserted into position. If the plate does not attach suitably to the fractured clavicle, adequate screw fixation for optimal stability may not be possible. This may cause the plate to protrude and therefore lead to skin irritation. A plate can be molded to fit the clavicle, but this process is difficult if the clavicle is not fully exposed.
In this article, we describe a novel technique using a real-size three dimensionally (3D)-printed clavicle model. The 3D-printed clavicle is utilized as a template to select the anatomically precontoured locking plate for the minimally invasive approach for a superior fit to the clavicle prior to surgery. A computed tomography (CT) scan is taken of both clavicles in patients with a unilateral displaced comminuted midshaft clavicle fracture. Using the mirror imaging technique, the contralateral uninjured clavicle is printed into a real-size model of the fractured side clavicle. This replica is employed as a template and utilized intraoperatively as a reference for anatomic reduction of the fracture.
This technique is indicated for a unilateral displaced comminuted midshaft clavicle fracture that requires operative treatment. Comminuted fractures that are difficult to achieve anatomic reduction by open reduction technique may benefit the most with this process. Fractures with poor soft tissue condition that may lead to wound problems after opening the fracture site may benefit with this minimally invasive technique without injuring the compromised soft tissue. The contralateral uninjured clavicle should not present with fracture, deformity, or history of surgery to be deemed suitable as an anatomically precontoured locking plate template. The template will be utilized as a reference for anatomic reduction during the operation.
Model production by 3D printing
Selection of the anatomically precontoured locking plate
Ethical standards were followed in the content and dissemination of the study.
Seven comminuted clavicle fractures treated with this technique achieved good bone union. The 3D-printed fractured clavicle model allowed the surgeon to observe and manipulate accurate anatomical replicas of the fractured bone to assist in fracture reduction. The 3D-printed uninjured clavicle model could be utilized as a template to select the anatomically precontoured locking plate which best fits the model. The plate could be inserted through a small incision and fixed with locking screws without exposing the fracture site.
The 3D printing technologies are common in product design industries, and their use is growing in all fields including medicine [12–17]. As the popularity of 3D printing is increasing, it is becoming financially feasible and accessible to use in orthopedic surgery [18, 19]. Use of 3D printing for acetabular fracture surgery has been reported, and its application to other fracture surgery is expected to increase as actual osseous anatomy can be reproduced that can help surgeons understand the characteristics of fractures [20, 21]. Although a bony surface structure can also be visualized by the 3D reconstructed CT images, it can only be visualized on the computer screen and the images have to be memorized for use during fracture reduction. 3D-printed fracture models can be utilized in the surgical field to assist surgeons with obtaining the correct fracture configuration during reduction. The uninjured side clavicle model printed as a mirror image can be utilized as a reference for anatomic reduction during fracture surgery. 3D printing is especially useful for non-extremity fractures, such as clavicle, acetabulum, and pelvis, as it is difficult to perform the C-arm manipulations required to obtain suitable fluoroscopic views for a 3D orientation of the fractured or uninjured sites. These views are critical as they provide surgeons with key images to use as a reference for anatomical reduction. Precontouring the plate or selecting the plate that will best fit the fractured bone is difficult without the 3D-printed model unless the fracture is exposed.
3D models can be invaluable for a precise preoperative plan as the plate can be attached to the 3D-printed fracture model prior to surgery. This allows the surgeon to select the correct screw holes to use or to perform a surgery on the 3D model prior to the real fracture surgery. The 3D models can also be utilized to educate residents and can enhance communication with patients.
The disadvantage of this technique is that considerable time and cost are required from the acquisition of the CT data to manufacturing and receiving the real-size 3D-printed model. However, the use and popularity of 3D printing in industry is growing at an exponential rate. This growth can be associated with lower printing costs and subsequently greater accessibility to printing technologies in the future.
Compared to open reduction for simple clavicle fractures, closed reduction requires increased fluoroscopic time and radiation exposure. During MIPO, it is sometimes difficult to reduce the fracture using a closed technique. Intramedullary nailing followed by plate fixation was introduced to make closed reduction easier . However, this technique still requires longer operative time and increases the patient’s exposure to radiation, compared to open reduction. As CT scanning is not routinely used for simple clavicle fractures, obtaining CT scans for 3D printing in these cases increases radiation exposure. However, for comminuted clavicle fractures or fractures with poor skin conditions, for which open reduction could increase the risk of nonunion or wound complications, we believe our technique of using 3D printing for MIPO outweighs the risk of radiation exposure or prolonged operative time, compared to open procedures. CT scanning is helpful in these cases not only for 3D printing but also for obtaining the fracture configuration especially when MIPO is used for comminuted clavicle fractures. Compared to the standard technique for MIPO, our approach of using the 3D printed clavicle model to assist surgeons in obtaining the fracture configuration can make closed reduction easier and reduce fluoroscopy time, which lowers radiation exposure. However, our recommendation is only limited to MIPO used for comminuted fractures. For simple, displaced fractures of the clavicle, we believe open reduction and plate fixation should be the standard operative treatment.
The 3D-printed fractured clavicle model allows the surgeon to observe and manipulate accurate anatomical replicas of the fractured bone to assist in fracture reduction prior to surgery. Using the mirror imaging technique, the uninjured clavicle model can be used as a template to select or pre-shape the anatomically designed locking plate for the minimally invasive plate osteosynthesis of the displaced comminuted midshaft clavicle fracture. The 3D-printed clavicle model can also be used intraoperatively as a reference for anatomic reduction.
All authors certify that this study was approved by the Institutional Review Board of Hallym University Kangnam Sacred Heart Hospital and that patients' informed consent was obtained.
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