Surgical Treatment for Both-Column Acetabular Fractures Using Pre-Operative Virtual Simulation and Three-Dimensional Printing Techniques
Both-column acetabular fractures represent a severe and complex injury pattern, accounting for approximately 21% of all acetabular fractures. These fractures involve the anterior and posterior columns of the acetabulum, disrupting the structural integrity of the pelvic ring and requiring precise anatomical reduction to restore hip joint function and minimize long-term complications such as post-traumatic arthritis. Traditional surgical methods, which rely on intra-operative plate contouring and multiple surgical approaches, often result in prolonged operation times, significant blood loss, and suboptimal fracture reduction. Recent advancements in three-dimensional (3D) printing and virtual simulation technologies offer promising solutions to these challenges by enabling pre-operative planning, personalized plate pre-contouring, and improved surgical accuracy. This study evaluates the clinical efficacy of combining pre-operative virtual simulation with 3D printing techniques for the surgical management of both-column acetabular fractures.
Study Design and Patient Selection
A randomized prospective case-control study was conducted from September 2013 to September 2017, involving 40 patients diagnosed with both-column acetabular fractures. Participants were allocated into two groups using block randomization: the 3D printing group (n=20) and the conventional method group (n=20). Inclusion criteria included patients aged 18–70 years with confirmed both-column fractures (Letournel-Judet classification) and a time from injury to surgery of fewer than three weeks. Exclusion criteria encompassed open fractures, other acetabular fracture types, and delays exceeding three weeks. Demographic data, including age, sex, time from injury to surgery, and associated injuries, showed no significant differences between groups, ensuring comparability.
Pre-Operative Virtual Simulation and 3D Printing Workflow
For the 3D printing group, computed tomography (CT) scans of the pelvis were converted into DICOM files and processed using MIMICS software (version 15, Materialise, Belgium). Fracture fragments were segmented and reconstructed into 3D models. Virtual reduction was performed to simulate anatomical alignment of the fractured acetabulum (Figure 1A–B). The reduced 3D model was exported as a stereolithography (STL) file and refined in Magics 21.0 software (Materialise) to generate a 1:1 scale pelvic model (Figure 1C–D). The Prismlab Rapid400 3D printer was used to fabricate the physical model, which guided pre-contouring of titanium plates and screw length measurements. Pre-contoured plates were sterilized for intra-operative use.
Surgical Techniques
Both groups underwent surgical fixation via the pararectus approach alone or combined with the Kocher-Langenbeck (K-L) approach. In the 3D printing group, pre-contoured plates were directly applied after fracture reduction (Figure 2C), minimizing intra-operative adjustments. Fluoroscopy confirmed proper plate and screw placement (Figure 2D). For the conventional group, plates were contoured manually during surgery, requiring iterative adjustments and prolonged fluoroscopy. Post-operative rehabilitation protocols were identical for both groups, emphasizing early mobilization and progressive weight-bearing.
Outcome Measures and Statistical Analysis
Primary outcomes included operation time, instrumentation time (plate contouring and screw placement), intra-operative fluoroscopy duration, blood loss, and transfusion volume. Secondary outcomes encompassed post-operative fracture reduction quality (assessed via radiographs), hip function (Harris Hip Score at 12 months), and complications. Statistical analyses utilized independent t-tests for normally distributed data, Mann-Whitney U tests for non-parametric data, and chi-squared or Fisher’s exact tests for categorical variables.
Key Findings
Operational Efficiency and Intra-Operative Metrics
The 3D printing group demonstrated significant reductions in operation time (130.8 ± 29.2 vs. 206.3 ± 34.6 minutes; t = -7.5, P < 0.001) and instrumentation time (32.1 ± 9.5 vs. 57.9 ± 15.1 minutes; t = -6.5, P < 0.001). Intra-operative fluoroscopy exposure was markedly lower in the 3D group (4.2 ± 1.8 vs. 7.7 ± 2.6 seconds; t = -5.0, P < 0.001). Blood loss and transfusion volumes were also significantly reduced (500 [400–800] mL vs. 1050 [950–1200] mL; U = 74.5, P < 0.001; 0 [0–400] mL vs. 800 [450–950] mL; U = 59.5, P < 0.001).
Surgical Approach and Fracture Reduction Quality
The 3D printing group required fewer combined surgical approaches (pararectus + K-L: 35% vs. 85%; χ² = 10.4, P < 0.05), reflecting improved pre-operative planning. Post-operative radiographs revealed superior fracture reduction in the 3D group, with 80% achieving <2 mm displacement (vs. 30% in the conventional group; χ² = 10.1, P < 0.05).
Functional Outcomes and Complications
At 12 months, the 3D group exhibited better hip function, with 75% scoring ≥80 on the Harris Hip Score (vs. 30%; χ² = 8.1, P < 0.05). Complication rates were comparable (5% vs. 25%; χ² = 3.1, P = 0.182), including heterotopic ossification, inflammatory responses, and traumatic arthritis.
Discussion
This study highlights the transformative potential of 3D printing and virtual simulation in acetabular fracture surgery. By pre-contouring plates on patient-specific models, surgeons bypass time-consuming intra-operative adjustments, reducing tissue trauma and radiation exposure. The anatomical accuracy of 3D-printed models facilitates optimal plate positioning, which correlates with improved fracture reduction and functional outcomes.
Earlier studies reported mixed results regarding reduction quality, often due to heterogeneous fracture types and surgeon experience. This study’s focus on both-column fractures and standardized surgical protocols strengthens its validity. The 3D workflow’s efficiency is further evidenced by the reduced need for combined surgical approaches, minimizing soft tissue damage and accelerating recovery.
Limitations and Future Directions
Despite its contributions, this study has limitations. The Letournel-Judet classification may not fully capture all fracture variations. Additionally, the cost and accessibility of 3D printing technology may limit widespread adoption. Future studies with larger cohorts and longer follow-ups are needed to validate these findings and explore cost-effectiveness.
Conclusion
Integrating pre-operative virtual simulation with 3D printing technology significantly enhances the surgical management of both-column acetabular fractures. This approach reduces operative time, blood loss, and radiation exposure while improving fracture reduction quality and functional outcomes. As technology advances, personalized 3D-printed models may become standard tools in complex orthopedic trauma care.
doi.org/10.1097/CM9.0000000000000649
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