3D-printed Bone Models in Addition to CT Imaging for Intra-articular Fracture Repair (SPRINT)

Sterilised 3D-PRINTed Bone Models in Addition to Conventional CT Imaging for Operative Visualisation in Complex Intra-articular Fracture Repair - A Multi-centre, Double-blind Randomised Controlled Trial

The purpose of this study is to compare the effectiveness of 3D-printed bone models in addition to CT imaging versus CT imaging alone on surgical quality and operation time for patients undergoing surgical repair of intra-articular fractures.

Study Overview

• Status: Recruiting
• Conditions: Proximal Humeral Fracture; Distal Humerus Fracture; Distal Femur Fracture; Distal Tibia Fracture
• Intervention / Treatment: Other: 3D printed (3DP) bone models + CT imaging; Other: CT imaging

Detailed Description

Surgical fixation of intra-articular fractures is a technically demanding task that poses significant challenges to orthopaedic surgeons. Articular fragments may be comminuted, depressed, or impacted, and neighbouring soft tissue is often heavily compromised. Furthermore, aggressive surgical dissection is typically necessary to achieve adequate visualisation, and anatomical reduction often devitalises bone fragments and invites deep infection. The management of intra-articular fractures requires a well-designed preoperative plan and a skilfully executed surgical tactic to guarantee the best possible outcome. Multiplanar reformation (CT-MPR) and three-dimensional reconstruction (CT-3DR) are imaging techniques that have enhanced intraoperative visualisation, however, accurate analysis of complex fractures remains challenging.

3D printing is a rapidly developing, low-cost technology that is already being applied across numerous contexts in orthopaedics and traumatology. 3D printed bone models can be produced from digitised CT data in a matter of hours, providing a dimensionally accurate representation of the patient's skeleton which approximates real-life visual and tactile experiences. When used in preoperative planning, these models have shown to improve surgeon communication and shorten surgical duration. Despite positive early results, few clinical studies have studied the effect of 3D bone model use on surgical outcome. The purpose of this randomised controlled trial is to compare the effectiveness of intraoperatively utilised 3D bone models in addition to conventional CT imaging on reduction quality and surgical duration versus CT imaging alone for patients undergoing surgical fixation of complex intraarticular fractures.

Patients providing informed consent will be screened for eligibility. All eligible patients will be randomly assigned in a double-blind manner (participant and outcome assessor) to receive surgical fracture fixation with or without the addition of sterilised 3D-printed bone models to standard CT imaging for intraoperative visualisation.

• Study Type: Interventional
• Enrollment (Anticipated): 80
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Christian Fang; Phone Number: 22554581; Email: cfang@hku.hk

Study Locations

• Hong Kong
  • Hong Kong, Hong Kong
    • Recruiting
    • Queen Mary Hospital, the University of Hong Kong
    • Contact: Christian Xinshuo Fang; Phone Number: 22554581
    • Principal Investigator: Christian Xinshuo Fang

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 16 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. age 18 years or older
2. with intra-articular fracture of the proximal or distal humerus, proximal ulna, proximal radius, distal femur, or proximal or distal tibia (pilon fracture)
3. requiring anticipated surgical repair of fracture
4. with pre-operative CT scan already available as part of routine assessment

Exclusion Criteria:

1. pathological fracture
2. multiple fractures requiring simultaneous or staged operations
3. fractures around the hip, pelvis and acetabulum, and any other fracture types not specified in the inclusion criteria
4. requiring surgery within 24 hours of admission
5. unable or unwilling to give consent to participate

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: 3D-printed models plus CT imaging; Fracture repair surgery using sterilized 3DP models, CT-MPR and CT-3DR for planning and intraoperative visualization	Other: 3D printed (3DP) bone models + CT imaging; In addition to CT-MPR and CT-3DR, 3DP models will be used for surgical planning and intraoperative visualization.
Active Comparator: CT imaging alone; Fracture repair surgery using CT-MPR and CT-3DR for planning and intraoperative visualization	Other: CT imaging; CT-MPR and CT-3DR used for surgical planning and intraoperative visualization.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Quality of articular surface reduction grading assessed by three-point scale	The quality of articular surface reduction will be rated by two surgeons blinded to intervention allotment assessing post-operative and intraoperative fluoroscopic images. The Kappa value will be recorded for inter-observer agreement between two observers (1. Perfect reduction, 2. Observable imperfections 1-2mm, 3. Significant imperfections >2mm)	Immediately post-operation
Skin to skin duration of surgery (minutes)	The skin to skin duration of the surgery will be recorded.	Immediately post-operation

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Total fluoroscopy time (seconds)	The total intraoperative fluoroscopy time will be recorded in seconds.	Immediately post-operation
Intraoperative blood loss (mL)	The patient's blood loss during the surgery will be recorded.	Immediately post-operation
Total length of skin incision (mm)	The total length on the incision will be measured post operation.	Immediately post-operation
Total tourniquet time (minutes)	Total time the tourniquet was applied will be recorded.	Immediately post-operation
Incidence of surgical complications	Incidence of infection, neurological deficit, wound breakdown, loss of fixation, revision surgery will be recorded at follow up.	3 months post-operation
Quality of articular surface reduction grading assessed by three-point scale	The quality of articular surface reduction will be rated by two surgeons blinded to intervention allotment assessing post-operative and intraoperative fluoroscopic images. The Kappa value will be recorded for inter-observer agreement between two observers (1. Perfect reduction, 2. Observable imperfections 1-2mm, 3. Significant imperfections >2mm)	3 months post operation
Health-related quality of life measured by SF-12 Chinese (HK) version	12-item Short Form Health Survey (SF-12), a patient-reported outcome measure of HRQOL comprised of a mental component (MCS) and physical component (PCS), each with a final score ranging from 0 (worst outcome) to 100 (best outcome).	3 months post-operation

Collaborators and Investigators

• Sponsor: The University of Hong Kong
• Investigators: Principal Investigator: Christian Fang, Dept of Orthopaedics and Traumatology, Queen Mary Hospital

Publications and helpful links

General Publications

• Suresh K. An overview of randomization techniques: An unbiased assessment of outcome in clinical research. J Hum Reprod Sci. 2011 Jan;4(1):8-11. doi: 10.4103/0974-1208.82352.
• Jupiter JB, Fernandez DL, Toh CL, Fellman T, Ring D. Operative treatment of volar intra-articular fractures of the distal end of the radius. J Bone Joint Surg Am. 1996 Dec;78(12):1817-28. doi: 10.2106/00004623-199612000-00004.
• Kang HW, Lee SJ, Ko IK, Kengla C, Yoo JJ, Atala A. A 3D bioprinting system to produce human-scale tissue constructs with structural integrity. Nat Biotechnol. 2016 Mar;34(3):312-9. doi: 10.1038/nbt.3413. Epub 2016 Feb 15.
• You W, Liu LJ, Chen HX, Xiong JY, Wang DM, Huang JH, Ding JL, Wang DP. Application of 3D printing technology on the treatment of complex proximal humeral fractures (Neer3-part and 4-part) in old people. Orthop Traumatol Surg Res. 2016 Nov;102(7):897-903. doi: 10.1016/j.otsr.2016.06.009. Epub 2016 Aug 9.
• Yang L, Shang XW, Fan JN, He ZX, Wang JJ, Liu M, Zhuang Y, Ye C. Application of 3D Printing in the Surgical Planning of Trimalleolar Fracture and Doctor-Patient Communication. Biomed Res Int. 2016;2016:2482086. doi: 10.1155/2016/2482086. Epub 2016 Jul 3.
• Kacl GM, Zanetti M, Amgwerd M, Trentz O, Seifert B, Stucki H, Hodler J. Rapid prototyping (stereolithography) in the management of intra-articular calcaneal fractures. Eur Radiol. 1997;7(2):187-91. doi: 10.1007/s003300050132.
• Yan CH, Chiu KY, Ng FY, Chan PK, Fang CX. Comparison between patient-specific instruments and conventional instruments and computer navigation in total knee arthroplasty: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2015 Dec;23(12):3637-45. doi: 10.1007/s00167-014-3264-2. Epub 2014 Sep 13.
• Yang J, Cai H, Lv J, Zhang K, Leng H, Sun C, Wang Z, Liu Z. In vivo study of a self-stabilizing artificial vertebral body fabricated by electron beam melting. Spine (Phila Pa 1976). 2014 Apr 15;39(8):E486-92. doi: 10.1097/BRS.0000000000000211.
• Peltola SM, Melchels FP, Grijpma DW, Kellomaki M. A review of rapid prototyping techniques for tissue engineering purposes. Ann Med. 2008;40(4):268-80. doi: 10.1080/07853890701881788.
• Brown GA, Firoozbakhsh K, DeCoster TA, Reyna JR Jr, Moneim M. Rapid prototyping: the future of trauma surgery? J Bone Joint Surg Am. 2003;85-A Suppl 4:49-55. No abstract available.
• Hurson C, Tansey A, O'Donnchadha B, Nicholson P, Rice J, McElwain J. Rapid prototyping in the assessment, classification and preoperative planning of acetabular fractures. Injury. 2007 Oct;38(10):1158-62. doi: 10.1016/j.injury.2007.05.020. Epub 2007 Sep 19.
• Bizzotto N, Tami I, Tami A, Spiegel A, Romani D, Corain M, Adani R, Magnan B. 3D Printed models of distal radius fractures. Injury. 2016 Apr;47(4):976-8. doi: 10.1016/j.injury.2016.01.013. Epub 2016 Feb 6. No abstract available.
• Li Z, Li Z, Xu R, Li M, Li J, Liu Y, Sui D, Zhang W, Chen Z. Three-dimensional printing models improve understanding of spinal fracture--A randomized controlled study in China. Sci Rep. 2015 Jun 23;5:11570. doi: 10.1038/srep11570.
• Fang C, Fang B, Wong TM, Lau TW, Pun T, Leung F. Fixing a fractured arthrodesed hip with rapid prototype templating and minimal invasive plate osteosynthesis. Trauma Case Rep. 2015 Nov 14;1(9-12):79-83. doi: 10.1016/j.tcr.2015.10.005. eCollection 2015 Dec.
• Wong TM, Jin J, Lau TW, Fang C, Yan CH, Yeung K, To M, Leung F. The use of three-dimensional printing technology in orthopaedic surgery. J Orthop Surg (Hong Kong). 2017 Jan;25(1):2309499016684077. doi: 10.1177/2309499016684077.
• Fedorov A, Beichel R, Kalpathy-Cramer J, Finet J, Fillion-Robin JC, Pujol S, Bauer C, Jennings D, Fennessy F, Sonka M, Buatti J, Aylward S, Miller JV, Pieper S, Kikinis R. 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging. 2012 Nov;30(9):1323-41. doi: 10.1016/j.mri.2012.05.001. Epub 2012 Jul 6.
• Rennie D. CONSORT revised--improving the reporting of randomized trials. JAMA. 2001 Apr 18;285(15):2006-7. doi: 10.1001/jama.285.15.2006. No abstract available.
• Zarin DA, Tse T, Williams RJ, Califf RM, Ide NC. The ClinicalTrials.gov results database--update and key issues. N Engl J Med. 2011 Mar 3;364(9):852-60. doi: 10.1056/NEJMsa1012065.

Study record dates

Study Major Dates

• Study Start (Actual): March 13, 2020
• Primary Completion (Anticipated): December 31, 2023
• Study Completion (Anticipated): December 31, 2023

Study Registration Dates

• First Submitted: February 5, 2021
• First Submitted That Met QC Criteria: February 5, 2021
• First Posted (Actual): February 10, 2021

Study Record Updates

• Last Update Posted (Actual): July 20, 2022
• Last Update Submitted That Met QC Criteria: July 19, 2022
• Last Verified: July 1, 2022

More Information

Terms related to this study

• Keywords: 3D Printing; Intra-articular Fracture; Patient-specific instrumentation
• Additional Relevant MeSH Terms: Wounds and Injuries; Leg Injuries; Shoulder Injuries; Arm Injuries; Femoral Fractures; Fractures, Bone; Tibial Fractures; Humeral Fractures; Shoulder Fractures; Intra-Articular Fractures
• Other Study ID Numbers: UW 18-480

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Plan Description: Anonymized dataset to be included as supplementary data in final publication
• IPD Sharing Time Frame: Within 1 year of study completion
• IPD Sharing Access Criteria: Additional information available upon reasonable request of principal investigator
• IPD Sharing Supporting Information Type: Study Protocol; Statistical Analysis Plan (SAP); Informed Consent Form (ICF)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No