Utility of 3D printed models in acetabular fracture teaching for Orthopaedic trainees

doi:10.21203/rs.3.rs-1352606/v1

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Research Article

Utility of 3D printed models in acetabular fracture teaching for Orthopaedic trainees

https://doi.org/10.21203/rs.3.rs-1352606/v1

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Objective

To evaluate the utility of 3-D printed models of acetabular fractures as a teaching and assessment tool compared to conventional lecture based teaching among orthopaedic trainees.

Methods

This was randomised prospective study conducted in a tertiary hospital setting which was consisted of 16 Orthopaedic residents. Ten different cases of acetabular fracture patterns were identified and printed as 3-D models. Baseline knowledge of acetabular fracture classification and surgical approach was determined by an x-ray based pre-test. Trainees were then randomly assigned into two groups. Group I received only lectures. Group II were additionally provided with 3-D printed models during the lecture. Participants then received a post-test and were assessed for comprehension and retention of teaching.

Results

Sixteen trainees participated in the trial. Both Group 1 and Group 2 improved post teaching with mean score of 2.5 and 1.9 to 4.4 and 6 out of 10 respectively. Post test score for fracture classification and surgical approach were significantly higher for 3-D model group (p<0.05). Trainees felt physical characteristics of the 3-D models were good representation of acetabular fracture configuration, and should be used routinely for teaching and surgical planning.

Conclusion

3-D printed model of real clinical cases have significant educational impact compared to lecture based learning in improving young trainees understanding of complex acetabular fractures.

Acetabular fracture

3D printed Model

Orthopaedic trainees

Teaching and assessment tool

A fundamental component of trauma management training for an orthopaedic resident is to understand classification of fracture patterns. Classification helps in pre-operative planning and execution of optimal treatment. Acetabular fractures are complex with multiple fracture lines in three-dimensional planes posing a significant challenge to young trainees, both in diagnosis and management. In 1964, Robert Judet and Emile Letournel used pelvis radiographs and proposed the classification scheme of these fractures that is still most widely used today [1–2]. Modern technology like computed tomography (CT) and 3D reconstruction technology has provided a better understanding of acetabular fracture patterns and aid in evaluating acetabular fractures and its classification [2–3].

Traditional teaching method involves didactic lectures with 2D images (both XR and CT scan) or various algorithms and flowcharts for acetabular fracture classification [4]. But these methods are non-intuitive and to bridge the learning gap in less experienced surgeons 3D understanding of these fractures is required [5]. For learning purpose descriptions are often in simplest form, however fracture lines seldom follow classic patterns in clinical scenario (Fig. 1). Besides the complexity of these fractures, low incidence coupled with regulation of training hours result in learning opportunities becoming far and few [6–7]. This has necessitated alternative education tools like computer-based simulator modules and other skills training models, employed in different medical speciality curriculum with varying degree of success [8].

Use of 3D technology to teach complex surgical anatomy is making its presence felt in the field of education for different surgical specialities [9–13]. 3D printed models of brain, heart, liver and complex bone structures have already shown that 3D printing of complex areas of human body can be accurate and is useful in trainee and patient education as well as for pre-operative planning and practice [14–21]. Both undergraduate and post-graduate students are favouring use of 3D printed models as educational aids in teaching anatomy including acetabular fractures [18, 22–25].

3D printing of acetabular fractures and its application including in education has increased with improved technology, reduced cost and better availability [24, 26–27]. These type of models have shown improved understanding of fracture patterns for trainees but did could provide advantage of assessment of the clinical application of knowledge [20, 22–23]. The purpose of this study is to determine the usefulness of 3D printed models of acetabular fractures as an adjunct to routine lectures for orthopaedic resident education to improve understanding of classification and assess their ability to select appropriate surgical management approach. The secondary objective of this study is to evaluate residents’ perception on the use of this novel technology.

Participants and Study design

This randomised prospective study was approved by the institutional review board (reference number 2017/00104) and supported by internal department funds through the ‘4th Orthopaedic Research Fund Grant Call’.

The study participants consisted of 16 orthopaedic residents from our university training program. During residency a trainee spends 25% of prescribed orthopaedic training time (4 out of 16 rotations) in musculoskeletal trauma. Routine educational methods include apprenticeship model of learning combined with regular lectures, hands-on surgical training and simulator-based learning. For this study the participants were randomised into 2 groups after obtaining written informed consent.

Group 1 received a traditional lecture via power-point slides including the basics of acetabular fracture anatomy, classification scheme and algorithms, surgical approaches and treatment using relevant diagrams, x-rays and other images. Group 2, in addition, was provided with 3D printed models of acetabular fractures during the course of the lecture. Judet and Letournel classified acetabular fractures in 5 elementary and 5 associated fracture types [28]. All the fractures were taught to residents during the lecture using pertinent radiological images (X-ray and CT scan) of real unidentified patients similar to what they would encounter in clinical practice and during assessments or examinations.

Before the lectures, both groups completed an x-ray based pre-test of 10 cases to assess baseline knowledge of the topic. Appropriate radiographs were shown for 10 different fracture types and participants had to comment on the fracture classification and preferred surgical approach. This was followed by segregating the groups into 2 different rooms. Subsequently, a 45-minute lecture was given to each group one after the other, the difference being that of exposure of Group 2 to the 3D printed models during the lecture. To avoid immediate recall bias the post-test similar to pre-test was conducted 3 weeks after to assess the learners' retention of knowledge and understanding of the topic. This followed a feedback survey and comments on the teaching method. Responses were rated on a 5 point Likert scale from "1 - strongly agree, 2 - agree, 3 - neutral, 4- disagree and 5 - strongly disagree". The models were then given to all participants to handle and subjective feedback of individuals and the groups’ perceptions on the 3D models were also obtained.

Patient and public involvement

No patients involved.

Case selection for the study and printing of 3D models

Ten cases were selected from pelvis and acetabular fracture registry of our hospital by a fellowship-trained surgeon that could represent the described patterns of acetabular fracture. The images were de-identified and subsequently analysed by two senior orthopaedic trauma specialists who routinely manage acetabular trauma and are designated faculty for postgraduate teaching. They discussed and agreed on appropriateness of each image in terms of adequate fracture pattern representation that is necessary for junior trainees to diagnose and classify the fracture. Both senior surgeons also conducted discussions and agreed on a single preferred correct answer for test questions on fracture classification and choice of appropriate surgical approach. The same cases were also used for printing the 3D models which were examined by the senior surgeons for fidelity to images and fracture types.

Different methods and technique are available for 3D printing of medical models. In our study, original fine cut (< 1mm) the CT scans of the selected cases were obtained as DICOM (Digital Imaging and Communications in Medicine) images were then provided to a third party for printing maintaining all data privacy. They reconstructed computer generated 3D images using ScanIP (Synopsis) software and obtained the models made out of photopolymer using custom-built SLA (Stereolithography) 3D printer (Fig. 2) with each model costing between US$ 350–400.

Statistical Analysis

The data was analysed using Microsoft Excel 2013 and SPSS (Ver 20.0, IBM Corp. NY, USA). The homogeneity of data was assessed and Wilcoxon signed rank test was used to determine differences in pre and post-test scores for the two groups. Post hoc analysis could not be performed as comparative numbers in some groups was less than three. The difference is reported as being statistically significant if p value was < 0.05. Qualitative feedback is represented as median score and per cent participants favouring a response. Certain subjective perceptions and feedback are also included in the results.

There were 16 participants with 12 male and 4 females. In total 9 junior (years 1 to 3) and 7 senior (years 3 to 6) residents were included and randomised into two groups matched in age, and years of experience (Table 1). Both, Group1 (Conventional lecture group) and Group 2 (3D model group) had 8 residents each.

Table 1

Study participants characteristics
	Group 1 (n = 8)	Group 2 (n = 8)	Total (n = 16)
Age (Range in years, mean)	30–36 (34.1)	28–37 (31.7)	28–37 (32.8) p = 0.19
Sex (M:F)	7:1	5:3	12:4
JR : SR ratio	4:4	5:3	9:7
PG year experience (mean)	6.88	4.38	5.62 p = 0.15
JR – Junior Residents (year 1 to 3), SR – Senior Resident (years 4 to 6), PG – post graduate

As expected, higher post-test scores were recorded compared to pre-test scores both for fracture classification with improvement to mean score of 5.2 from 2.2 (p = 0.001) and for correct surgical approach from the mean score of 5.1 to 6.9 (p = 0.004). Although the scores in diagnosis improved statistically (p = 0.028) for Group 1, the mean score remained below 50% (4.8 out of 10) even after teaching. The scores for correct surgical approach among Group 1 did not show a significant improvement (p = 0.170). For group 2, the mean post-test score not only improved to 60% (6 out of 10) and 80% (8 out of 10) for correct fracture classification and surgical approach it was also statistically significant for both variables (p = 0.011, p = 0.016) (Table 2).

Table 2

Comparison of pre and post-test scores of participants (comparison of means, median)
	Pre-test score (Fracture classification)	Post-test score (Fracture classification)	p value	Pre-test score (Surgical approach	Post-test score (Surgical approach)	p value
Group 1 - lecture group (mean ± SD, median)	2.5 ± 1.85 2.5	4.4 ± 1.91 4.7	0.03	4.8 ± 2.90 5.0	5.8 ± 1.80 5.5	0.17
Group 2–3D model group (mean ± SD, median)	1.9 ± 1.64 1.5	6.0 ± 1.90 4.5	0.01	5.2 ± 2.05 6.0	8.0 ± 1.51 8.0	0.01
Total (mean ± SD, median)	2.2 ± 1.72 2.0	5.2 ± 2.1 5.5	0.001	5.1 ± 2.43 5.5	6.9 ± 1.94 7.5	0.004

Transverse and both column fractures were easiest to diagnose. The number of candidates who could correctly identify each fracture type in post-test was higher in the 3D model group when compared to the conventional lecture group especially for more complex 'associated' fractures (Fig. 2). Posterior column fracture diagnosis improved from 0 in either group to 50% (4 out of 8) and 75% (6 out of 8) in respective groups (Fig. 2). When clubbed into 'elementary' and 'associated' fractures for analysis, 40% improvement incorrect diagnosis was seen for group 2 (Table 3).

Table 3

Comparison for improvement in correct identification of fracture type during the pre-test and post-test between groups
	Elementary fractures (5 simple)			Associated fractures (5 complex)
	Pre-test	Post-test	% improvement (p value)	Pre-test	Post-test	% improvement (p value)
Group 1 (n = 40*)	11	19	20% (p = 0.10)	8	16	20% (p = 0.04)
Group 2 (n = 40*)	13	29	40% (p = 0.04)	10	24	35% (p = 0.03)
* Elementary and Associated types have 5 subtypes each; ref footnote Fig. 2. Thus, for 8 participants in each group (n = 8) the total correct answers = 40 (5x8)

The ability to plan the correct surgical approach depends not only on the correct identification of fracture but understanding the fracture pattern. Candidates were deemed proficient if they could propose a correct surgical approach for least 75% of cases; which in our study was considered as of 7 out of 10 cases. Fifty per cent (4 out of 8) in Group 1 showed this proficiency compared to 100% (8 out of 8) in Group 2 after exposure to the teaching method (Figs. 3 and 4).

Participants were asked to provide perceptive feedback on their teaching method based on a 'Likert' scale of 1 to 5 (1 – strongly agree, 2 agree, 3 – neutral, 4 – disagree and 5 – strongly disagree) (Table 4).

Table 4

Perceptive feedback of participants to their teaching method
No.	Feedback questions	Group 1 - lecture group (median)	Group 2–3D model group (median)	p value
1	This method teaches clinically relevant anatomy	2	1	0.10
2	This method accurately depicts acetabular fracture types	2	1	0.10
3	This method improved 3D spatial comprehension of acetabular fractures	2	1	0.40
4	This method improves Xray interpretation	2	1	0.26
5	This method helps to improve CT scan interpretation	3	2	0.19
6	This method helps to better learn acetabular fracture classification	2	1	0.31
7	This method helps to understand surgical approach	3	1	0.05
8	This method helps to understand fracture reduction and surgical fixation	3	1	0.12
9	I would use this method to prepare for acetabular surgery	2	1	0.10
10	This method should be extended to teach other fractures	3	1	0.03
based on ‘likert’ scale of 1–5 (1 – strongly agree, 2 – agree, 3 – neutral, 4 – disagree and 5 – strongly disagree)

Although both groups responded favourably to their teaching method, residents in group 1 were unsure of using lecture teaching for practical application (Table 4). Group 2 strongly agreed that 3D models helped to learn classification, surgical approach and planning, while also appreciating the perceived need for 3D models in teaching other fractures as well. Six out of eight (75%) participants strongly agreed while other 2 agreed that they preferred 3D models to be incorporated in regular curriculum for teaching acetabular fractures. In subjective feedback from Group 1, six participants said that did not prefer the lecture-based teaching after they were provided with the 3D models to play with upon completion of the study. Some comments from the participants in favour of the 3D printed models were –

"Models improved my 3D understanding of fracture lines and patterns seen on X-ray"
"Lectures can become confusing but the models allow for simultaneous correlation to images on X-ray and CT scan"
"I am now more confident in the diagnosis and classification of acetabular fractures"

Management of acetabular fractures are a subject of interest for trauma surgeons and orthopaedic residents often find them daunting to understand [22–23]. Classification of these fractures are complex and dictate surgical approach, hence it is important for orthopaedic residents to understand then well and our study, of 16 orthopaedic trainees demonstrated this difficulty when they could correctly classify on average only 2 out of 10 different fracture types in the pre-test. Not only did they correctly diagnose more than 50% cases correctly the feedback responses also showed that all residents felt more confident about acetabular fractures after teaching.

Efforts have been made in past to introduce algorithms for classification of acetabular fractures [4]. In our study, we compared the conventional lecture-based teaching method using these algorithms to same lecture augmented with 3D models and showed improvements in learners' ability to classify fracture and propose suitable surgical approach. Few studies have employed a similar model but have either used artificially created fracture or limited fracture types [22–23, 29]. We obtained data from actual patients as the fracture lines seldom follow the textbook description in real life. Also, we felt it is important to visualise variations in different fracture patterns, hence we made efforts to obtain all 10 fracture types described by Judet and Letournel for our residents. One can argue that when teaching or assessment of classification ability is required, the subjects should have access to all options. Awan et al. obtained models for five most common acetabular fractures whereas Lim and colleagues, in their study method, did not choose single column or wall fractures assuming that it would not adequately test the ability of 3D models to help residents with classification [22–23]. Our study not only shows that elementary fractures were difficult to identify for residents but also that this ability improved significantly for those who had access to 3D printed models (Table 3).

Incidence of acetabular fractures is low and good surgical execution affects the functional outcome [7]. We believe that handling of 3D models while learning the descriptions on 2D images (X-ray and CT scans) helped our residents to better understand the orientation of fracture fragments in relation to anatomic landmarks. This is shown by significant improvement number of participants who were able to provide correct surgical approach when given 3D models to aid learning. The ability to manipulate models present the opportunity to understand the depth and direction of fracture and allow matching them like jigsaw puzzles to understand reduction manoeuvres and surgical steps. Previous authors have shown similar results of improvement in test score for correct classification of acetabular fractures but were not able to show this extension of the diagnostic knowledge to clinical application [22–23]. Also, the study by Awan et al. was for radiological residents only where diagnosis is endpoint.

ACGME (Accreditation Council for Graduate Medical Education) from North America and other European medical education accreditation systems has shifted focus on developing core competencies for resident training in surgical training to assess competency is now being incorporated to be incorporated into the curriculum [30–32]. In our study, surgical approach assessment shows that 3D printed models can also be used to assess one of the core competencies i.e. practice-based learning. The results of our study suggest an overall deficiency in young trainee's ability to identify acetabular fractures which improved with the use of 3D printed models from real patients and also improved their application of this knowledge. We suggest that this model can also be used as an additional tool to tick the checklist of EPAs.

Feedback is an essential tool in educational methods. As much as the trainees require feedback on their performance, so does the system on the methods of teaching. Even though both groups showed a positive response to their teaching method, digital images cannot resolve the difficulty of understanding 3D orientation of fractures. After showing the 3D models to whole group 100% participants favoured 3D printed models to only lecture-based learning. Throughout the feedback and post-study discussions 3D models were favoured method to understand acetabular fracture anatomy, improved orientation in XR and CT images as well as a need for use in surgical planning. The models provide operating surgeon with visual and tactile model of fracture to appreciate the personality of fracture, and manoeuvre them to understand surgical reduction techniques.

Limitations

A recent systemic review has demonstrated multiple shortcomings in studies about the use of 3D technology for the training of surgical trainees [33]. We aimed to perform a well-designed trial but the use of 3D printing technology in medical education is new and standardised assessment methods are constantly being developed. Our groups were matched for trainee years and postgraduate experience, however, the small sample size was one of the limitations. A multi-centre simultaneous trial with a large sample size would power the study immensely. Secondly, our post-test was done only once at 3 weeks from teaching and while repeated assessments over a period of time with regular use of the models would provide more accurate data on their utility as education and assessment tool. We tried to limit certain bias like pro-innovation bias in pre-test by obtaining informed consent immediately before randomisation for the lecture. Immediate recall bias was also limited by conducting the post-test after 3 weeks and avoiding interim make up lectures.

In terms of 3D models themselves, only osseous anatomy was printed in our pilot study. Use of variable materials to add on soft tissues and body surface in future would allow ‘real feel’ of the cases. This would allow candidates to be to perform ‘real’ practice surgery and has potential to develop into more sophisticated education tools. The 3D printed models can not only be used for orthopaedic trainees’ teaching and assessment of knowledge, they can be produced routinely as representative specimen of everyday complex fractures. Virtual and augmented reality technology can be combined with these models to do pre-operative planning and even perform practice surgery and refine skills of trainees. Kim et al and Zeng et al have shown this is possible as per results from their respective papers [34–35].

Use of 3D printed models of acetabular fractures as an adjunct to conventional lectures to improve orthopaedic residents understanding of the classification and application to surgical planning. 3D printed models provide a feel of fracture patterns appreciation of variability in human body as concluded by our trainees’ preferred method for learning. Incorporating this model to assess surgical planning can make it a useful assessment tool for educators. The new generation of surgical trainees have various modern technology at their disposal in everyday life which should be incorporated into regular training at all levels.

The field of education has suffered when it comes to innovation in teaching method and even in medical education we are only recently and using modern technologies for improving upon traditional methods like didactic lectures and the apprenticeship model. Landmark Italian educator Maria Montessori had demonstrated how powerful it can be to let children see, touch, hear, smell or taste what they are learning but the ways of early childhood teaching changed only after half a century later [36]. We are all multi-sensory learners and the introduction of multimodal techniques e.g. simulators and 3D models would enhance learning ability to understand complex forms and concepts in medical science.

Ethics approval and Consent to participate

The methodology for this randomised prospective study was carried out in accordance with the Institutional Review Board (IRB). The experimental protocols were approved by the IRB (IRB reference number 2017/00104)

Informed consent for participation was obtained from all participants in this study and publication of results.

- A statement to confirm that all methods were carried out in accordance with relevant guidelines and regulations(e.g. Declaration of Helsinki).

- A statement to confirm that all experimental protocols were approved by a named institutional and/or licensing committee.

- Must include a sentence confirming that informed consent was obtained from all subjects and/or their legal guardian(s).

Consent for publication

Not applicable in this study

Availability of data and materials

The dataset generated and analysed during the current study are not publicly available as the data is non digital but are available from the corresponding author on reasonable request.

Competing interest / Conflict of interest statement

All authors certify that we have no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

Funding

This study was supported by internal department funds through the ‘4^th Orthopaedic Research Fund Grant Call’. Grant / award number: N/A

Author contribution and acknowledgement

SG conceived the study, participated in the study design, performed the statistical analysis and drafted the manuscript. CXK contributed to the statistical interpretation and drafted the manuscript. YS participated in the study design and oversaw the manuscript. DM participated in the study design and oversaw the manuscript. GK conceived the study, participated in the study design and oversaw the manuscript. All authors read and approved the final manuscript.

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No competing interests reported.

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Editorial decision: Major revision
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Utility of 3D printed models in acetabular fracture teaching for Orthopaedic trainees

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Abstract

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Introduction

Methods

Participants and Study design

Patient and public involvement

Case selection for the study and printing of 3D models

Statistical Analysis

Results

Discussion

Limitations

Conclusion

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References

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