Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons.

BACKGROUND: Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons. METHODS: A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes. RESULTS: A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001). CONCLUSION: The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education. LEVEL OF EVIDENCE: Level III - retrospective cohort study.

Setting proficiency standards for simulation-based mastery learning of short antegrade femoral nail osteosynthesis: a multicenter study.

BACKGROUND AND PURPOSE: Orthopedic trainees frequently perform short antegrade femoral nail osteosynthesis of trochanteric fractures, but virtual reality simulation-based training (SBT) with haptic feedback has been unavailable. We explored a novel simulator, with the aim of gathering validity evidence for an embedded test and setting a credible pass/fail standard allowing trainees to practice to proficiency. PATIENTS AND METHODS: The research, conducted from May to September 2020 across 3 Danish simulation centers, utilized the Swemac TraumaVision simulator for short antegrade femoral nail osteosynthesis. The validation process adhered to Messick's framework, covering all 5 sources of validity evidence. Participants included novice groups, categorized by training to plateau (n = 14) or to mastery (n = 10), and experts (n = 9), focusing on their performance metrics and training duration. RESULTS: The novices in the plateau group and experts had hands-on training for 77 (95% confidence interval [CI] 59-95) and 52 (CI 36-69) minutes while the plateau test score, defined as the average of the last 4 scores, was 75% (CI 65-86) and 96% (CI 94-98) respectively. The pass/fail standard was established at the average expert plateau test score of 96%. All novices in the mastery group could meet this standard and interestingly without increased hands-on training time (65 [CI 46-84] minutes). CONCLUSION: Our study provides supporting validity evidence from all sources of Messick's framework for a simulation-based test in short antegrade nail osteosynthesis of intertrochanteric hip fracture and establishes a defensible pass/fail standard for mastery learning of SBT. Novices who practiced using mastery learning were able to reach the pre-defined pass/fail standard and outperformed novices without a set goal for external motivation.

Patellar Fracture Surgery Performed Autonomously by Residents, Yields Similar Short-Term Outcomes to Surgery Performed by Fellowship-Trained Surgeons.

BACKGROUND: Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma. METHODS: A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections). RESULTS: A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001). CONCLUSION: The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

Intertrochanteric Femur Fracture Treatment in Asia: What We Know and What the World Can Learn.

Hip fractures are of great interest worldwide as the geriatric population continues to increase rapidly. Currently, surgeons prefer to use cephalomedullary nail for internal fixation of pertrochanteric/intertrochanteric fractures. This article summarizes 10 concepts in hip fracture treatment over the past 20 years, including fracture line mapping, proximal lateral wall and anterior cortex, posteromedial lesser trochanter-calcar fragment, anteromedial cortex support reduction, changes of fracture reduction after sliding and secondary stability, nail entry point and wedge-open deformity, tip-apex distance and calcar-referenced tip-apex distance, femoral anterior bowing and nail modification, long nails for wide medullary canal and large posterior coronal fragment, and postoperative stability score.

Computer-assisted preoperative planning improves the learning curve of PFNA-II in the treatment of intertrochanteric femoral fractures.

BACKGROUND: Intertrochanteric femoral fractures are prevalent among the elderly, and usually demands surgical treatments. Proximal femoral nail antirotation Asian version (PFNA-II) is widely used for intertrochanteric fracture treatment. The computer-assisted preoperative planning (CAPP) system has the potential to reduce the difficulty of PFNA-II in the treatment of intertrochanteric fractures. The aim of the study was to investigate and compare the learning curves of PFNA-II treatment with CAPP and conventional preoperational planning methods for intertrochanteric femoral fractures. METHODS: A total of 125 patients with intertrochanteric fracture who were treated with PFNA-II between March 2012 and June 2015 were retrospectively analyzed. Patients who underwent surgery with CAPP procedure by a junior surgeon were regarded as group A (n = 53); patients who underwent the conventional surgery by another junior surgeon were regarded as group B (n = 72). Each group was divided into three subgroups (case 1-20, case 21-40, case 41-53 or case 41-72). RESULTS: The average operation time of group A was 45.00(42.00, 50.00) minutes, and in group B was 55.00 (50.00, 60.00) minutes (P < 0.01). Average radiation frequency and blood loss were 13.02 ± 2.32, 160.00 (140.00, 170.00) ml and 20.92 ± 3.27, 250.00 (195.00, 279.50) ml, respectively, with significant differences (P < 0.01). The learning curve of the surgical procedure in group A was steeper than that in group B. There were no significant differences in patient reported outcomes, hospital stay and complication rate between the two groups. Significant differences were observed between group A and B in Harris score at last follow-up in the AO/OTA type 31-A2 intertrochanteric fracture (P < 0.05). CONCLUSION: Compared with conventional preoperative planning methods, CAPP system significantly reduced operation time, radiation frequency and blood loss, thus reshaped the learning curve of PFNA-II treatment with lower learning difficulty. TRIAL REGISTRATION: researchregistry4770. Registered 25 March 2019.

The impact of the AO Foundation on fracture care: An evaluation of 60 years AO Foundation.

OBJECTIVES: Sixty years ago, the Association of Osteosynthesis (AO) was founded with the aim to improve fracture treatment and has since grown into one of the largest medical associations worldwide. Aim of this study was to evaluate AO's impact on science, education, patient care and the MedTech business. DESIGN/METHODS: Impact evaluations were conducted as appropriate for the individual domains: Impact on science was measured by analyzing citation frequencies of publications promoted by AO. Impact on education was evaluated by analyzing the evolution of number and location of AO courses. Impact on patient care was evaluated with a health economic model analyzing cost changes and years of life gained through the introduction of osteosynthesis in 17 high-income countries (HICs). Impact on MedTech business was evaluated by analyzing sales data of AO-associated products. RESULTS: Thirty-five AO papers and 2 major AO textbooks are cited at remarkable frequencies in high ranking journals with up to 2000 citations/year. The number of AO courses steadily increased with a total of 645'000 participants, 20'000 teaching days and 2'500 volunteer faculty members so far. The introduction of osteosynthesis saved at least 925 billion Swiss Francs [CHF] in the 17 HICs analyzed and had an impact on avoiding premature deaths comparable to the use of antihypertensive drugs. AO-associated products generated sales of 55 billion CHF. CONCLUSION: AO's impact on science, education, patient care, and the MedTech business was significant because AO addressed hitherto unmet needs by combining activities that mutually enriched and reinforced each other.

Teaching Cortical-Screw Tightening: A Simple, Affordable, Torque-Directed Training Protocol Improves Resident Performance.

BACKGROUND: Cortical-screw insertion is a fundamental skill in orthopaedic surgery, yet, to our knowledge, no standardized method of teaching this skill exists. The purpose of this study was to evaluate a training protocol that was designed to teach residents how to tighten a cortical screw without causing any stripping. METHODS: Twenty-five residents and 8 attending surgeons from an orthopaedic residency program tightened cortical screws in a synthetic bone model with a digital torque screwdriver using 3 different techniques: percutaneous; open, dominant hand; and open, nondominant hand. The residents then participated in a training protocol during which each tightened additional screws while receiving real-time torque feedback. During training, the residents targeted 50% to 70% of the stripping torque for each screw. They were assessed at baseline, immediately after training, and at 12 to 15 weeks after training. During each assessment, the percentage of screws that were tightened in the target range and the percentage of stripped screws were recorded. The costs of the training protocol were assessed. RESULTS: After training, all of the residents tightened screws with lower insertional torque compared with their baseline, but only the senior residents tightened more screws in the target range and stripped fewer screws. The attending surgeons, when compared with the residents at baseline, tightened more screws in the target range and tended to strip fewer screws, but these differences were absent at final testing. Costs included $1,927 for durable equipment and an estimated $74 per resident per training session for consumable goods. CONCLUSIONS: The senior residents inserted more screws in the target range and stripped fewer screws after participating in this training protocol, but the junior residents did not show significant improvement. Implementation of this training protocol for all residents may improve clinical performance but, because our sample size was limited, additional study is required to assess skill transfer to clinical practice. CLINICAL RELEVANCE: Cortical-screw tightening is a fundamental skill in orthopaedics, and completion of this torque-directed training protocol may accelerate residents' skill acquisition.

Orthopaedic and Plastic Surgery Training Differences Manifested in the Analysis of Distal Radius Fracture Fixation.

All patients undergoing open reduction and internal fixation of a distal radius fracture (DRF) between the years 2010 and 2015 were isolated from the National Surgical Quality Improvement Program database. Patient demographics, respective surgical volume, outcome variables, and complications were extracted. The primary outcomes were surgical time, hospital length of stay, and unplanned reoperation. A total of 6691 patients were included in the study, the majority of whom were treated by orthopaedic surgeons. While there were no significant differences in baseline demographics between the patients treated by orthopaedic and plastic surgeons, the overall operative time was significantly less for DRFs fixed by orthopaedic surgeons. While there was a significant difference for extra-articular fractures, this difference increased significantly for complex intra-articular fractures. Additionally, hospital length of stay was significantly shorter for patients treated by orthopaedic surgeons. To produce well-rounded, technically skilled surgeons, plastic surgery programs should incorporate fixation principles into their training programs. (Journal of Surgical Orthopaedic Advances 28(1):53-57, 2019).

Hip-fracture osteosynthesis training: exploring learning curves and setting proficiency standards.

Background and purpose - Orthopedic surgeons must be able to perform internal fixation of proximal femoral fractures early in their career, but inexperienced trainees prolong surgery and cause increased reoperation rates. Simulation-based virtual reality (VR) training has been proposed to overcome the initial steep part of the learning curve but it is unknown how much simulation training is necessary before trainees can progress to supervised surgery on patients. We determined characteristics of learning curves for novices and experts and a pass/fail mastery-learning standard for junior trainees was established. Methods - 38 first-year residents and 8 consultants specialized in orthopedic trauma surgery performed cannulated screws, Hansson pins, and sliding hip screw on the Swemac TraumaVision VR simulator. A previously validated test was used. The participants repeated the procedures until they reached their learning plateau. Results - The novices and the experts reached their learning plateau after an average of 169 minutes (95% CI 152-87) and 143 minutes (CI 109-177), respectively. Highest achieved scores were 92% (CI 91-93) for novices and 96% (CI 94-97) for experts. Plateau score, defined as the average of the 4 last scores, was 85% (CI 82-87) and 92% (CI 89-96) for the novices and the experts, respectively. Interpretation - Training time to reach plateau varied widely and it is paramount that simulation-based training continues to a predefined standard instead of ending after a fixed number of attempts or amount of time. A score of 92% comparable to the experts' plateau score could be used as a mastery learning pass/fail standard.

Learning Curve in Surgical Treatment of Odontoid Fixation for a Series of Type II C2 Fractures.

The craniovertebral junction (CVJ) is a complex anatomical area upon which most of the motion of the upper cervical spine depends [1]. Because of its unique range of motion, the CVJ is subject to several types of traumatic injury; it has been shown that odontoid fractures are the most common ones in the general population and are the most common isolated spinal fractures [2]. Accounting for up to 18% of all cervical fractures, odontoid fractures are the most common ones in elderly patients [3], in whom they account for up to 60% of spinal cord injuries [4].

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Examination of Skill Acquisition and Grader Bias in a Distal Radius Fracture Fixation Model.

OBJECTIVES: Primary: Assess the ability of faculty graders to predict the objectively measured strength of distal radius fracture fixation. Secondary: Compare resident skill variation and retention related to other knowable training data. DESIGN: Residents were allowed 60 minutes to stabilize a standardized distal radius fracture using an assigned fixed-angle volar plate. Faculty observed and subjectively graded the residents without providing real-time feedback. Objective biomechanical evaluation (construct strength and stiffness) was compared to subjective grades. Resident-specific characteristics (sex, PGY, and ACGME case log) were also used to compare the objective data. SETTING: A simulated operating room in our laboratory. PARTICIPANTS: Post-graduate year 2, 3, 4, and 5 orthopedic residents. RESULTS: Primary: Faculty were not successful at predicting objectively measured fixation, and their subjective scoring suggests confirmation bias as PGY increased. Secondary: Resident year-in-training alone did not predict objective measures (p = 0.53), but was predictive of subjective scores (p < 0.001). Skills learned were not always retained, as 29% of residents objectively failed subsequent to passing. Notably, resident-reported case-specific experience alone was inversely correlated with objective fixation strength. CONCLUSIONS: This testing model enabled the collection of objective and subjective resident skill scores. Faculty graders did not routinely predict objective measures, and their subjective assessment appears biased related to PGY. Also, in vivo case volume alone does not predict objective results. Familiar faculty teaching consistency, and resident grading by external faculty unfamiliar with tested residents, might alter these results.

Does a Learning Curve Exist for the Surgical Treatment of Proximal Humerus Fractures?

BACKGROUND: The complication rate of locked plating for proximal humerus fractures remains stubbornly high. The purpose of this study was to determine if a learning curve exists with the operative treatment of proximal humerus fractures. METHODS: We prospectively followed 161 consecutive patients with proximal humerus fractures treated by a single surgeon with locked plates from 2005 to 2016. Radiographic data, functional outcomes, and complications from the surgeon's first 81 patients were compared to the subsequent 80 patients. RESULTS: There was no statistical difference in the rates of complications (p = 0.29) or screw penetration (p = 0.19). There were no differences in DASH scores (p = 0.64 to 0.79) or tip-apex distance (p = 0.40). Head shaft angles were slightly smaller in patients treated earlier in the surgeon's career (p = 0.02). DISCUSSION: While surgeon experience is certainly a favorable quality, there does not appear to be a significant "learning curve" in the treatment of proximal humerus fractures.

Simulation-Based Educational Module Improves Intern and Medical Student Performance of Closed Reduction and Percutaneous Pinning of Pediatric Supracondylar Humeral Fractures.

BACKGROUND: Simulation-based education has been integrated into many orthopaedic residency programs to augment traditional teaching models. Here we describe the development and implementation of a combined didactic and simulation-based course for teaching medical students and interns how to properly perform a closed reduction and percutaneous pinning of a pediatric supracondylar humeral fracture. METHODS: Subjects included in the study were either orthopaedic surgery interns or subinterns at our institution. Subjects all completed a combined didactic and simulation-based course on pediatric supracondylar humeral fractures. The first part of this course was an electronic (e)-learning module that the subjects could complete at home in approximately 40 minutes. The second part of the course was a 20-minute simulation-based skills learning session completed in the simulation center. Subject knowledge of closed reduction and percutaneous pinning of supracondylar humeral fractures was tested using a 30-question, multiple-choice, written test. Surgical skills were tested in the operating room or in a simulated operating room. Subject pre-intervention and post-intervention scores were compared to determine if and how much they had improved. RESULTS: A total of 21 subjects were tested. These subjects significantly improved their scores on both the written, multiple-choice test and skills test after completing the combined didactic and simulation module. Prior to the module, intern and subintern multiple-choice test scores were significantly worse than postgraduate year (PGY)-2 to PGY-5 resident scores (p < 0.01); after completion of the module, there was no significant difference in the multiple-choice test scores. After completing the module, there was no significant difference in skills test scores between interns and PGY-2 to PGY-5 residents. Both tests were validated using the scores obtained from PGY-2 to PGY-5 residents. CONCLUSIONS: Our combined didactic and simulation course significantly improved intern and subintern understanding of supracondylar humeral fractures and their ability to perform a closed reduction and percutaneous pinning of these fractures.

[Trauma surgery in Pacific Small Island Developing States (SIDS)]. / Unfallchirurgie in den kleinen Inselnationen des Pazifiks.

BACKGROUND: The small developing countries in the Pacific are grouped together as Small Island Development States (SIDS) because they face similar problems which they cannot cope with nationally. They are developing countries, so-called low and lower middle income countries (LMIC), are economically weak and the islands of the different nations are widely scattered. Approximately 80% of the 10 million inhabitants live in rural regions. EPIDEMIOLOGY AND SURGICAL CAPACITY: Over 40% of patients in the surgical departments of hospitals are hospitalized for injuries, and this tendency is increasing. Fractures of the upper extremities are relatively more frequent in the Pacific than in the countries of the North. Long distances, lack of possibilities for treatment and lack of transport often cause complications, such as infected open fractures, pseudarthrosis and posttraumatic malformations. There are too few hospitals with sufficiently competent surgeons, anesthetists and obstetricians (SAO) and appropriate equipment. PACIFIC ISLANDS ORTHOPEDIC ASSOCIATION (PIOA): The PIOA was founded in Honiara, Solomon Islands, and offers surgeons of the Pacific SIDS a comprehensive, structured trauma and orthopedic surgery training in their own countries. It lasts 4 years and leads to an M­Med (orthopaedic surgery) diploma and to a Fellowship of the International College of Surgeons (FICS), which are both recognized by the participating hospitals. It is free for participants. THE AO ALLIANCE FOUNDATION (AOAF): The AOAF is an independent organization with the only aim to enhance trauma surgery capacity in LMICs. The AOAF supports the PIOA program together with the Wyss Medical Foundation. Currently, 18 trainees from 8 Pacific SIDS are participating in the PIOA training program.

Design and evaluation of a new synthetic wrist procedural simulator (Wristsim®) for training of distal radius fracture fixation by volar plating.

Legislation concerning workload of surgical trainees and pressure to reduce learning curves have forced us reconsider surgical training. Our goal was to evaluate a synthetic procedural simulator for teaching open reduction and internal fixation (ORIF) of distal radius fractures (DRF). Twenty surgeons used a synthetic procedural simulator (Wristsim®) made by 3D printing for ORIF of DRF with a volar plate (Newclip Technics®). The evaluation consisted of grading the simulator's realism compared to the surgeons' own experience with surgery on cadavers. The Wristsim® was graded 5.10/10, compared to 8.18/10 for the cadaver specimen for introduction of the plate under pronator quadratus. For fracture reproduction, Wristsim® scored 6.40/10, with the cadaver specimen scoring 7.15/10. For fracture reduction, Wristsim® scored 5.62/10, with the cadaver specimen scoring 7.38/10. Plate application was scored 7.05/10 for Wristsim® and 8.23/10 for the cadaver. Drilling was scored 6.60/10 for the Wristsim® and 8.23/10 for the cadaver. Screw fixation was scored 7.40/10 for the Wristsim® and 8.12/10 for the cadaver. Our results demonstrated that Wristsim® is still inferior to a cadaver specimen for teaching ORIF by volar plating of DRF. A new model of Wristsim® is being developed that will address shortcomings in pronator quadratus thickness, passive ROM in flexion/extension and bone size.

Evaluating Internal Fixation Skills Using Surgical Simulation.

BACKGROUND: Open reduction and internal fixation (ORIF) is an essential skill for an orthopaedic surgeon, yet teaching its components to surgical residents poses challenges in both complexity and cost. Surgical simulation has demonstrated efficacy and is now a mandated component of residency programs, but the techniques and resources required for effective simulation vary greatly. We hypothesized that simulation of ORIF skills could be accomplished in a cost-effective, quantifiable, and reproducible manner and that this experience coupled with didactic learning would increase skill proficiency and enhance ORIF performance. METHODS: Sixteen postgraduate-year-1 orthopaedic surgery interns were assessed on performance of ORIF simulation tasks before and after attending a module designed to introduce and practice internal fixation techniques. Simulation tasks addressed drilling accuracy via oblique drilling through polyvinyl chloride (PVC) cylinders and bisecting wooden dowels and plunge control via drilling through layered boards of varying densities. Fracture fixation simulation involved fixing oblique fractures on synthetic ulnae. Task performance was assessed at 3 time points: immediately before the module, 1 week after the module, and 3 months after the module. Fracture fixation was assessed before and after the module via load-to-failure testing. Success rates for the tasks were analyzed using a repeated-measures analysis of variance, and mechanical properties of the fixed ulnar constructs were compared using paired t tests. RESULTS: In all ORIF simulation tasks, pre-module to post-module improvement in success rates was significant (p < 0.001) and improvements were maintained between the post-module assessment and the 3-month follow-up. The interns also achieved significantly greater strengths in their ulnar fixation constructs, with a mean improvement of 256 N (p = 0.01) after the module. CONCLUSIONS: These results indicate that the technical and sensorimotor skills relevant to internal fixation (with emphasis on the specific skill of using a drill) can be significantly augmented and retained in the short term in surgical residents after exposure to faculty-led lecture and hands-on skills practice using low-cost materials. CLINICAL RELEVANCE: This study provides evidence for an effective, accessible method of enhancing and assessing surgical skills in training.

Critiquing operative fracture fixation: the development of an assessment tool.

PURPOSE: Assessments are fundamentally important for training surgeons. Currently, there are no formal means of assessing operative fracture fixation. An assessment tool has been developed which can be used by trainers to critique the quality of a trainee's operative fracture fixation. The tool is based on the AO principles of fracture management. The reliability and validity of the assessment were tested in a prospective study. METHODS: The assessment tool comprises of 4 domains focusing on the different factors pertinent to fracture fixation (reduction, stability, implant and overall impression). Reliability and validity were evaluated by asking 10 consultant trauma and orthopaedic surgeons to score 20 test cases on two different occasions at least 7 weeks apart. Internal consistency was assessed by Cronbach's alpha. Inter-rater reliability and test-retest reliability were assessed by the inter-class correlation coefficient (ICC) and content validity by the content validity ratio (CVR). RESULTS: Cronbach's alpha was 0.976, with all component criteria correlating well with each other. Total score inter-rater reliability, for a single assessor, as given by the ICC, was 0.708. Overall test-retest reliability was 0.961. The CVR for the assessment tool was 0.65 (which is above the critical value for establishing validity with 10 assessors). CONCLUSIONS: Internal consistency is demonstrated by the excellent Cronbach's alpha with substantial single assessor and excellent test-retest reliability also shown. The CVR above the critical value illustrates that the assessment is valid. The assessment tool has a number of applications within training and service evaluation that could benefit the global orthopaedic community.

Accurate fixation of plates and screws for the treatment of acetabular fractures using 3D-printed guiding templates: An experimental study.

OBJECTIVE: To investigate the feasibility of the use of 3D-printed guiding templates for accurate placement of plates and screws for internal fixation of acetabular fractures. METHODS: 3D models of the pelvises of 14 adult cadavers were reconstructed using computed tomography (CT). Twenty-eight acetabular fractures were simulated and placement positions for plates and screw trajectories were designed. Bending module was obtained by 3D cutting; guiding template was manufactured using 3D printing, and the plate was pre-bent according to the bending module. Plates and screws were placed in cadaveric pelvises using the guiding template, and 3D model was reconstructed using CT. The designed and real trajectories were matched using 3D registration including the coordinates (entry and exit points) of designed trajectory. The number of qualified points with different accuracy levels was compared using Chi-squared test. RESULTS: Sixty-four plates and 339 screws were placed with no cortical breach. The absolute difference of the X, Y, and Z coordinates between the designed and real entry points were 0.52±0.45, 0.43±0.36, and 0.53±0.44mm, respectively. The corresponding values for the exit points were 0.83±0.67, 1.22±0.87, and 1.26±0.83mm, respectively. With an accuracy degree ≥1.9mm for the entry points and ≥3.8mm for the exit points, there was no significant difference between the designed and the real trajectories. CONCLUSION: The 3D-printed guiding template helped achieve accurate placement of plates and screws in the pelvis of adult cadavers.