Contemporary use of 3D printed jigs and guides for osteotomies around the knee: a systematic review

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Abstract

Background. With improved accessibility of imaging and additive manufacturing, custom targeting guides and jigs are now widely accepted across many areas of orthopaedics. During orthopedic surgery, patient-specific guides assist in the accurate drilling and cutting of bone in conjunction with meticulous pre-operative planning. Given their increased uptake, it is important to define the lessons learned from recent clinical experience, and to document the reported benefits when using this technology intra-operatively.

The aim of this review is to evaluate the potential benefits of patient-specific guides for osteotomies about the knee, and to clarify what evidence currently exists to support their use.

Methods. A systematic review of PubMed, Embase, and Web of Science was performed for studies investigating the use of intra-operative patient-specific guides for realignment osteotomies about the knee. Randomised controlled trials, non-randomised studies, observational studies, case series, and case reports, as well as in vitro studies, were included. Screening was conducted with the Covidence software, and risk of bias was assessed with the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I) tool.

Results. A total of 38 studies satisfied the inclusion criteria: 21 of these included patient-specific instrumentation (PSI) for high tibial osteotomy, 6 with distal femoral osteotomy, 4 — for combined tibial/femoral rotational corrective osteotomies, 4 — in double-level osteotomies, and 6 — for intra-articular osteotomies. The main outcomes reported were accuracy of surgical correction, typically with reference to pre-operative plans, and execution accuracy based on radiographic measurements. Other common outcomes were operative time, intra-operative fluoroscopy, and operative costs. Many studies were observational in nature, with no control groups available for suitable comparison.

Conclusions. For corrective osteotomies about the knee, the literature suggests PSI has very strong potential to improve accuracy in achieving pre-operative targets. This was reported for both opening and closing wedge osteotomies of the femur, and for high tibial osteotomy. Some contradictory results have been reported for high tibial osteotomy, based on limited evidence from small studies that in many instances lacked controls for comparative analysis. Additional controlled trials are necessary to confirm the benefits of PSI for osteotomies about the knee, considering it has not yet been conclusively validated. The literature currently available indicates PSI can improve the accuracy of corrective osteotomies about the knee.

About the authors

Jared Walker

The Royal Brisbane and Women’s Hospital; Herston Biofabrication Institute; University of Queensland

Author for correspondence.
Email: jared.walker@uqconnect.edu.au
ORCID iD: 0009-0000-8281-8380

MD

Australia, Brisbane, QLD; Herston, QLD; Saint Lucia, QLD

Yuheng Wang

Herston Biofabrication Institute; University of Queensland

Email: wangyuheng1996@hotmail.com

MD

Australia, Herston, QLD; Saint Lucia, QLD

Nicholas Green

The Royal Brisbane and Women’s Hospital; Herston Biofabrication Institute; Orthopaedic Research Centre of Australia

Email: Nicholas.Green@health.qld.gov.au
ORCID iD: 0000-0003-2841-3141
Australia, Brisbane, QLD; Herston, QLD; Brisbane, QLD

Deniz Erbulut

The Royal Brisbane and Women’s Hospital; Herston Biofabrication Institute; University of Queensland; Orthopaedic Research Centre of Australia

Email: Deniz.Erbulut@health.qld.gov.au
ORCID iD: 0000-0002-5700-3515
Australia, Brisbane, QLD; Herston, QLD; Saint Lucia, QLD; Brisbane, QLD

Mustafa Alttahir

Macquarie University Hospital

Email: Mustafa.alttahir@gmail.com
ORCID iD: 0000-0002-4944-5540
Australia, Sydney, NSW

Kevin Tetsworth

The Royal Brisbane and Women’s Hospital; Herston Biofabrication Institute; University of Queensland; Orthopaedic Research Centre of Australia; Macquarie University Hospital

Email: ktetsworthmd@gmail.com
ORCID iD: 0000-0002-3069-4141
Australia, Brisbane, QLD; Herston, QLD; Saint Lucia, QLD; Brisbane, QLD; Sydney, NSW

References

  1. Higgins J.P., Thomas J., Chandler J., Cumpston M., Li T., Page M.J. et al. Cochrane handbook for systematic reviews of interventions. John Wiley & Sons; 2019. 694 p. doi: 10.1002/9781119536604.index.
  2. Moher D., Shamseer L., Clarke M., Ghersi D., Liberati A., Petticrew M. et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. doi: 10.1186/2046-4053-4-1.
  3. Sterne J.A., Hernán M.A., Reeves B.C., Savović J., Berkman N.D., Viswanathan M. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016;355:i4919. doi: 10.1136/bmj.i4919.
  4. Pérez-Mañanes R., Burró J.A., Manaute J.R., Rodriguez F.C., Martín J.V. 3D Surgical Printing Cutting Guides for Open-Wedge High Tibial Osteotomy: Do It Yourself. J Knee Surg. 2016;29(8):690-695. doi: 10.1055/s-0036-1572412.
  5. Kim H.J., Park J., Shin J.Y., Park I.H., Park K.H., Kyung H.S. More accurate correction can be obtained using a three-dimensional printed model in open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2018;26(11):3452-3458. doi: 10.1007/s00167-018-4927-1.
  6. Tardy N., Steltzlen C., Bouguennec N., Cartier J.L., Mertl P., Batailler C. et al. Francophone Arthroscopy Society. Is patient-specific instrumentation more precise than conventional techniques and navigation in achieving planned correction in high tibial osteotomy? Orthop Traumatol Surg Res. 2020;106(8S):S231-S236. doi: 10.1016/j.otsr.2020.08.009.
  7. Abdelhameed M.A., Yang C.Z., AlMaeen B.N., Jacquet C., Ollivier M. No benefits of knee osteotomy patient’s specific instrumentation in experienced surgeon hands. Knee Surg Sports Traumatol Arthrosc. 2023;31(8):3133-3140. doi: 10.1007/s00167-022-07288-6.
  8. Fayard J.M., Saad M., Gomes L., Kacem S., Abid H., Vieira T.D. et al. Patient-specific cutting guides increase accuracy of medial opening wedge high tibial osteotomy procedure: A retrospective case-control study. J Exp Orthop. 2024;11(1):e12013. doi: 10.1002/jeo2.12013.
  9. Predescu V., Grosu A.M., Gherman I., Prescura C., Hiohi V., Deleanu B. Early experience using patient-specific instrumentation in opening wedge high tibial osteotomy. Int Orthop. 2021;45(6):1509-1515. doi: 10.1007/s00264-021-04964-z.
  10. Savov P., Hold M., Petri M., Horstmann H., von Falck C., Ettinger M. CT based PSI blocks for osteotomies around the knee provide accurate results when intraoperative imaging is used. J Exp Orthop. 2021;8(1):47. doi: 10.1186/s40634-021-00357-8.
  11. Chaouche S., Jacquet C., Fabre-Aubrespy M., Sharma A., Argenson J.N., Parratte S. et al. Patient-specific cutting guides for open-wedge high tibial osteotomy: safety and accuracy analysis of a hundred patients continuous cohort. Int Orthop. 2019;43(12):2757-2765. doi: 10.1007/s00264-019-04372-4.
  12. Yang J.C., Chen C.F., Luo C.A., Chang M.C., Lee O.K., Huang Y. et al. Clinical Experience Using a 3D-Printed Patient-Specific Instrument for Medial Opening Wedge High Tibial Osteotomy. Biomed Res Int. 2018;2018:9246529. doi: 10.1155/2018/9246529.
  13. Munier M., Donnez M., Ollivier M., Flecher X., Chabrand P., Argenson J.N. et al. Can three-dimensional patient-specific cutting guides be used to achieve optimal correction for high tibial osteotomy? Pilot study. Orthop Traumatol Surg Res. 2017;103(2):245-250. doi: 10.1016/j.otsr.2016.11.020.
  14. Jacquet C., Sharma A., Fabre M., Ehlinger M., Argenson J.N., Parratte S. et al. Patient-specific high-tibial osteotomy’s ‘cutting-guides’ decrease operating time and the number of fluoroscopic images taken after a Brief Learning Curve. Knee Surg Sports Traumatol Arthrosc. 2020;28(9):2854-2862. doi: 10.1007/s00167-019-05637-6.
  15. Fucentese S.F., Meier P., Jud L., Köchli G.L., Aichmair A., Vlachopoulos L. et al. Accuracy of 3D-planned patient specific instrumentation in high tibial open wedge valgisation osteotomy. J Exp Orthop. 2020;7(1):7. doi: 10.1186/s40634-020-00224-y.
  16. Van Genechten W., Van Haver A., Bartholomeeusen S., Claes T., Van Beek N., Michielsen J. et al. Impacted bone allograft personalised by a novel 3D printed customization kit produces high surgical accuracy in medial opening wedge high tibial osteotomy: a pilot study. J Exp Orthop. 2023;10(1):24. doi: 10.1186/s40634-023-00593-0.
  17. Zaffagnini S., Dal Fabbro G., Lucidi G.A., Agostinone P., Belvedere C., Leardini A. et al. Personalised opening wedge high tibial osteotomy with patient-specific plates and instrumentation accurately controls coronal correction and posterior slope: Results from a prospective first case series. Knee. 2023;44: 89-99. doi: 10.1016/j.knee.2023.07.011.
  18. Zhu X., Qian Y., Liu A., Xu P., Guo J.J. Comparative outcomes of patient-specific instrumentation, the conventional method and navigation assistance in open-wedge high tibial osteotomy: A prospective comparative study with a two-year follow up. Knee. 2022;39:18-28. doi: 10.1016/j.knee.2022.08.013.
  19. Jeong S.H., Samuel L.T., Acuña A.J., Kamath A.F. Patient-specific high tibial osteotomy for varus malalignment: 3D-printed plating technique and review of the literature. Eur J Orthop Surg Traumatol. 2022;32(5): 845-855. doi: 10.1007/s00590-021-03043-8.
  20. Lau C.K., Chui K.H., Lee K.B., Li W. Computer-Assisted Planning and Three-Dimensional-Printed Patient-Specific Instrumental Guide for Corrective Osteotomy in Post-Traumatic Femur Deformity: A Case Report and Literature Review. J Orthop Trauma Rehabil. 2018;24(1):12-17. doi: 10.1016/j.jotr.2016.11.002.
  21. Donnez M., Ollivier M., Munier M., Berton P., Podgorski J.P., Chabrand P. et al. Are three-dimensional patient-specific cutting guides for open wedge high tibial osteotomy accurate? An in vitro study. J Orthop Surg Res. 2018;13(1):171. doi: 10.1186/s13018-018-0872-4.
  22. Miao Z., Li S., Luo D., Lu Q., Liu P. The validity and accuracy of 3D-printed patient-specific instruments for high tibial osteotomy: a cadaveric study. J Orthop Surg Res. 2022;17(1):62. doi: 10.1186/s13018-022-02956-2.
  23. MacLeod A.R., Mandalia V.I., Mathews J.A., Toms A.D., Gill H.S. Personalised 3D Printed high tibial osteotomy achieves a high level of accuracy: ‘IDEAL’ preclinical stage evaluation of a novel patient specific system. Med Eng Phys. 2022;108:103875. doi: 10.1016/j.medengphy.2022.103875.
  24. Rosso F., Rossi R., Neyret P., Śmigielski R., Menetrey J., Bonasia D.E. et al. A new three-dimensional patient-specific cutting guide for opening wedge high tibial osteotomy based on ct scan: preliminary in vitro results. J Exp Orthop. 2023;10(1):80. doi: 10.1186/s40634-023-00647-3.
  25. Arnal-Burró J., Pérez-Mañanes R., Gallo-Del-Valle E., Igualada-Blazquez C., Cuervas-Mons M., Vaquero-Martín J. Three dimensional-printed patient-specific cutting guides for femoral varization osteotomy: Do it yourself. Knee. 2017;24(6):1359-1368. doi: 10.1016/j.knee.2017.04.016.
  26. Jacquet C., Chan-Yu-Kin J., Sharma A., Argenson J.N., Parratte S., Ollivier M. “More accurate correction using “patient-specific” cutting guides in opening wedge distal femur varization osteotomies. Int Orthop. 2019;43(10):2285-2291. doi: 10.1007/s00264-018-4207-1.
  27. Shi J., Lv W., Wang Y., Ma B., Cui W., Liu Z. et al. Three dimensional patient-specific printed cutting guides for closing-wedge distal femoral osteotomy. Int Orthop. 2019;43(3):619-624. doi: 10.1007/s00264-018-4043-3.
  28. Huang Y.C., Chen K.J., Lin K.Y., Lee O.K., Yang J.C. Patient-Specific Instrument Guided Double Chevron-Cut Distal Femur Osteotomy. J Pers Med. 2021;11(10):959. doi: 10.3390/jpm11100959.
  29. Jud L., Vlachopoulos L., Beeler S., Tondelli T., Furnstahl P., Fucentese S.F. Accuracy of three dimensional-planned patient-specific instrumentation in femoral and tibial rotational osteotomy for patellofemoral instability. Int Orthop. 2020;44(9):1711-1717. doi: 10.1007/s00264-020-04496-y.
  30. Micicoi G., Corin B., Argenson J.N., Jacquet C., Khakha R., Martz P. et al. Patient specific instrumentation allow precise derotational correction of femoral and tibial torsional deformities. Knee. 2022;38:153-163. doi: 10.1016/j.knee.2022.04.002.
  31. Sabatini L., Nicolaci G., Giachino M., Risitano S., Pautasso A., Massè A. 3D-Printed Surgical Guiding System for Double Derotational Osteotomy in Congenital Torsional Limb Deformity: A Case Report. JBJS Case Connect. 2021;11(1):e20.00468. doi: 10.2106/jbjs.Cc.20.00468.
  32. Imhoff F.B., Schnell J., Magaña A., Diermeier T., Scheiderer B., Braun S. et al. Single cut distal femoral osteotomy for correction of femoral torsion and valgus malformity in patellofemoral malalignment – proof of application of new trigonometrical calculations and 3D-printed cutting guides. BMC Musculoskelet Disord. 2018;19(1):215. doi: 10.1186/s12891-018-2140-5.
  33. Grasso F., Martz P., Micicoi G., Khakha R., Kley K., Hanak L. et al. Double level knee osteotomy using patient-specific cutting guides is accurate and provides satisfactory clinical results: a prospective analysis of a cohort of twenty-two continuous patients. Int Orthop. 2022;46(3):473-479. doi: 10.1007/s00264-021-05194-z.
  34. Pioger C., Mabrouk A., Siboni R., Jacquet C., Seil R., Ollivier M. Double-level knee osteotomy accurately corrects lower limb deformity and provides satisfactory functional outcomes in bifocal (femur and tibia) valgus malaligned knees. Knee Surg Sports Traumatol Arthrosc. 2023;31(7):3007-3014. doi: 10.1007/s00167-023-07325-y.
  35. Gómez-Palomo J.M., Meschian-Coretti S., Esteban-Castillo J.L., García-Vera J.J., Montañez-Heredia E. Double Level Osteotomy Assisted by 3D Printing Technology in a Patient with Blount Disease: A Case Report. JBJS Case Connect. 2020;10(2):e0477. doi: 10.2106/jbjs.Cc.19.00477.
  36. Fürnstahl P., Vlachopoulos L., Schweizer A., Fucentese S.F., Koch P.P. Complex Osteotomies of Tibial Plateau Malunions Using Computer-Assisted Planning and Patient-Specific Surgical Guides. J Orthop Trauma. 2015;29(8):e270-276. doi: 10.1097/bot.0000000000000301.
  37. Wang H., Newman S., Wang J., Wang Q., Wang Q. Corrective Osteotomies for Complex Intra-Articular Tibial Plateau Malunions using Three-Dimensional Virtual Planning and Novel Patient-Specific Guides. J Knee Surg. 2018;31(7):642-648. doi: 10.1055/s-0037-1605563.
  38. Yang P., Du D., Zhou Z., Lu N., Fu Q., Ma J. et al. 3D printing-assisted osteotomy treatment for the malunion of lateral tibial plateau fracture. Injury. 2016;47(12):2816-2821. doi: 10.1016/j.injury.2016.09.025.
  39. Pagkalos J., Molloy R., Snow M. Bi-planar intra-articular deformity following malunion of a Schatzker V tibial plateau fracture: Correction with intra-articular osteotomy using patient-specific guides and arthroscopic resection of the tibial spine bone block. Knee. 2018;25(5):959-965. doi: 10.1016/j.knee.2018.05.015.
  40. Zaleski M., Hodel S., Fürnstahl P., Vlachopoulos L., Fucentese S.F. Osteochondral Allograft Reconstruction of the Tibia Plateau for Posttraumatic Defects-A Novel Computer-Assisted Method Using 3D Preoperative Planning and Patient-Specific Instrumentation. Surg J (N Y). 2021;7(4):e289-e296. doi: 10.1055/s-0041-1735602.
  41. Hsu C.P., Lin S.C., Nazir A., Wu C.T., Chang S.S., Chan Y.S. Design and application of personalized surgical guides to treat complex tibial plateau malunion. Comput Methods Biomech Biomed Engin. 2021;24(4): 419-428. doi: 10.1080/10255842.2020.1833193.
  42. Van den Bempt M., Van Genechten W., Claes T., Claes S. How accurately does high tibial osteotomy correct the mechanical axis of an arthritic varus knee? A systematic review. The Knee. 2016;23(6):925-935. doi: 10.1016/j.knee.2016.10.001.
  43. Cerciello S., Ollivier M., Corona K., Kaocoglu B., Seil R. CAS and PSI increase coronal alignment accuracy and reduce outliers when compared to traditional technique of medial open wedge high tibial osteotomy: a meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2022;30(2):555-566. doi: 10.1007/s00167-020-06253-5.
  44. Aman Z.S., DePhillipo N.N., Peebles L.A., Familiari F., LaPrade R.F., Dekker T.J. Improved Accuracy of Coronal Alignment Can Be Attained Using 3D-Printed Patient-Specific Instrumentation for Knee Osteotomies: A Systematic Review of Level III and IV Studies. Arthroscopy. 2022;38(9):2741-2758. doi: 10.1016/j.arthro.2022.02.023.
  45. Dewilde T.R., Dauw J., Vandenneucker H., Bellemans J. Opening wedge distal femoral varus osteotomy using the Puddu plate and calcium phosphate bone cement. Knee Surg Sports Traumatol Arthrosc. 2013;21(1):249-254. doi: 10.1007/s00167-012-2156-6.
  46. Zarrouk A., Bouzidi R., Karray B., Kammoun S., Mourali S., Kooli M. Distal femoral varus osteotomy outcome: Is associated femoropatellar osteoarthritis consequential? Orthop Traumatol Surg Res. 2010;96(6):632-636. doi: 10.1016/j.otsr.2010.04.009.
  47. Duivenvoorden T., Brouwer R.W., Baan A., Bos P.K., Reijman M., Bierma-Zeinstra S.M. et al. Comparison of closing-wedge and opening-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee: a randomized controlled trial with a six-year follow-up. J Bone Joint Surg Am. 2014;96(17):1425-1432. doi: 10.2106/JBJS.M.00786.
  48. Saithna A., Kundra R., Modi C.S., Getgood A., Spalding T. Distal femoral varus osteotomy for lateral compartment osteoarthritis in the valgus knee. A systematic review of the literature. Open Orthop J. 2012;6:313-319. doi: 10.2174/1874325001206010313.
  49. Moore J., Mychaltchouk L., Lavoie F. Applicability of a modified angular correction measurement method for open-wedge high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2017;25(3):846-852. doi: 10.1007/s00167-015-3954-4.
  50. Girotto J.A., Koltz P.F., Drugas G. Optimizing your operating room: or, why large, traditional hospitals don’t work. Int J Surg. 2010;8(5):359-367. doi: 10.1016/j.ijsu.2010.05.002.

Supplementary files

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2. Figure 1. PRISMA flow diagram [2]

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3. Figure 2 (a, b, c). High tibial osteotomy (unilateral opening wedge/valgizing). Read the Case 1 description in the article text above

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4. Figure 3. Bilateral opening wedge/varizing DFO. Read the Case 2 description in the article text above

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5. Appendix
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