SLR - December 2022 - Adam Bhatti, DPM
Title: Percutaneous reduction, cannulated screw fixation and calcium sulfate cement grafting assisted by 3D printing technology in the treatment of calcaneal fractures.Reference: Dai G, Shao Z, Weng Q, Zheng Y, Hong J, Lu X. Percutaneous reduction, cannulated screw fixation and calcium sulfate cement grafting assisted by 3D printing technology in the treatment of calcaneal fractures. J Orthop Sci. 2021 Jul;26(4):636-643.
Level of Evidence: II Scientific Literature Review
Reviewed By: Adam Bhatti, DPM
Residency Program: Eastern Virginia Medical School, Norfolk, VA
Podiatric Relevance:
Calcaneal fractures account for approximately 1-2% of all fractures, and up to 60% of all tarsal fractures. With a high degree of difficulty involved in surgical treatment options, mismanagement of these injuries can easily result in postoperative complications such as, deformity, posttraumatic arthritis, incision healing problems, infection, hematoma, sural nerve injury. The concept of percutaneous reduction in order to reduce soft tissue trauma in high- energy trauma injuries has been previously introduced. Similarly the concept of 3D printed implants has earned a spotlight in the field of orthopedic surgery. The study analyzes several areas of high interest within the field of podiatry including minimally invasive techniques, use of orthobiologics, and use of 3D printing for operative planning. The goal of this study was to apply 3D printing technology to preoperative planning and surgery of displaced intra-articular calcaneal fractures (DIACFs), and to evaluate its effectiveness, feasibility and safety in fracture repair.
Methods:
81 patients with DIACFs (Sanders II/III) were evaluated from August 2015 to August 2017. All patients were divided into 3D printing group (40) and conventional group (41). Both groups underwent reduction and fixation percutaneously prior to injection with CSC. Procedure time, estimated blood loss, and time under fluoroscopy, radiographs were all evaluated. AOFAS score was utilized to assess functional outcomes. The authors designed a questionnaire aimed at measuring the usefulness of the three-dimensional (3D) printed model for surgeons and patients.
Results:
No significant differences were found between affected limb, age, fracture classification, mechanism of injury. The 3D printed group had a slightly longer time from injury to surgery compared to the conventional group (5.0 vs 3.6). The surgery duration, blood loss volume and the number of fluoroscopy images in the 3D printing group were significantly less than that in the conventional group. Although no significant difference was noted in the radiographic analyses between the two groups pre-operatively, the 3d printed group yielded significantly better radiographic results post-operatively. Furthermore, AOFAS scores reported by the 3D printed group also demonstrated significantly better results in comparison to the conventional group. Both the surgeons and patients reported higher satisfaction with the 3D printed group. No statistical significance was found between complication rates between both groups. The 3D printed group reported 2 superficial infections, 1 sural nerve damage, 2 STJ stiffness. The conventional group reported 1 superficial infection, 2 sural nerve damage, 2 STJ stiffness.
Conclusions:
Despite the high degree of technical difficulty, this study presents a safe and effective alternative approach to calcaneal fracture fixation in populations at high risk for developing postoperative complications. Although routine diagnostic imaging plays an important role in surgical planning, 3D printed models have become an invaluable tool in pre-operative planning by adding an extra dimension. The 3D printed models allow surgeons to simulate the surgery in vitro resulting in less operative time, and accurate hardware selection/placement. Regardless of the aforementioned benefits, the 3D models do not take into account soft tissue components and there is still limited use for 3D printed models in emergent situations.