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    In keeping with our move to bring Orthopedics Today readers more than pure app reviews and keep readers up to date on some of the bigger technology trends in orthopedics, this month’s column will touch upon an emerging tech trend that seems poised to materially alter the orthopedic world for years to come: 3-D printing.

    Specifically, 3-D printing is a type of manufacturing process that uses a digital model to create a 3-D object out of virtually any material. The process is distinct from traditional manufacturing techniques in that it is an “additive” rather than a “subtractive” process. Subtractive processes carve away excess material from blanks. Additive processes build objects using layering techniques. There are many types of additive manufacturing processes, but for the sake of simplicity, think of the 3-D printing process like an ink-jet printer accurately dispensing targeted layers of ink. A 3-D printer successively lays down fine layers of the chosen material in a way that is dictated by a sophisticated computer-aided design (CAD) program.

    Imagine downloading a set of plans from the Internet for just about any solid object that you desire, adding the correct base materials to your 3-D printing machine and printing the object at your home or business. This is what 3-D printing may potentially deliver.

    The technology dates back about 30 years, so it is not new. What makes it exciting, however, is that costs have come down drastically making it much more accessible to the general public.

    Matthew DiPaola

    Orrin I. Franko

    Rapid innovation and price declines brought the microcomputer and the smartphone to the masses, unleashing life-altering changes to how we live and work. Potentially, 3-D printers may be next. One can only imagine the implications. Below we will highlight a few uses that have recently made headlines and speculate on some ways that 3-D printing may alter the practice of the orthopedic surgeon.

    Rapid prototyping

    Creating inexpensive models of products is a process that is extensively used in industry to test new designs in nearly all aspects of manufacturing. From total joint implants to surgical instruments, there is hardly a solid manufactured product in the orthopedic field that does not benefit from a model to help one better understand its form and function. Rapid prototyping helps the engineer better collaborate with the physician in the development of new iterations for implant and instrument design.

    Some surgeons are already using 3-D printing to create plastic models for difficult-to-visualize fractures and deformities. At the American Academy of Orthopaedic Surgeons Annual Meeting, a group at the Medical College of Wisconsin lead by Rick Papendrea, MD, presented a cheap and efficient way to fabricate plastic models of scapula and distal humeri for complex shoulder and elbow problems using 3-D printing. For less than $100, a custom scapula model could be printed with readily available apps (Osirix) and a CT scan by one of a number of companies specializing in 3-D printing (Shapeways and 3-D Systems are two). The surgeon can use the model for presurgical planning or can sterilize and use it in the operating room (OR) for intraoperative guidance. A “negative” mold of the implant could be made to guide the surgeon in shaping bone grafts during surgery if so desired. One wonders whether such inexpensive technology will disrupt the complex, computer-guided surgery systems on the market.

    Of course, creating prototypes requires less stringent structural standards than final manufacturing, but technology is improving to the point where 3-D printing will regularly meet those standards as well.

    Quicker manufacturing

    While there may be some regulatory hurdles to clear for implants to be made on the spot, the rapid creation of custom surgical instruments and non-disposables might soon be within reach for the average surgeon. Many of us have been in a case where we wished that we had a specific instrument, but it might have been hard to justify the cost to purchase it for a rare indication.

    Rapid manufacturing promises to change that. As the availability of durable raw materials and printing techniques improves, it soon may be possible to print up specific instruments on location based off of a CAD blueprint. Imagine custom modification of retractors, and the creation and testing of specific jigs and instruments. With the aid of a good CAD designer, a surgeon may be able to directly go to the OR or market with an instrument design.

    Recently, a newly minted graduate student in New Zealand, inspired by his own uncomfortable experience with a cast, developed a 3-D printed exoskeleton-like cast that is light-weight, strong and breathable. He is working on commercially developing the “Cortex” cast with the use of 3-D printing patterns from radiographic imaging.

    What about implants and biologics? The case for (or against) custom implants is beyond the scope of this column. What we can say, however, is that the groundwork is being laid to manufacture a host of biological and non-biological implants in a variety of medical disciplines.

    Researchers at Oxford Performance Material in Connecticut have created a 3-D printed cranial prosthesis meant to replace lost bone in the skull. Recently, one of these implants was used to reconstruct a skull defect in a patient in the United States. Lawrence Bonassar, PhD, at the Cornell University Department of Biomedical Engineering recently used 3-D printers to create a human earlobe. A group led by Anthony Atala, MD, has successfully implanted mouse dermal skin grafts printed on 3-D printers into host recipients.

    Washington State University boasts a Materials Research Group that is pushing the boundaries of 3-D printing by creating bioceramic composites and custom titanium implants for load-bearing purposes. In addition, a Massachusetts Institute of Technology group is now creating synthetic bone-like materials with 3-D structures that are much more consistent with those seen in nature than other previous man-made materials. According to their group, “the possibilities are endless.”

    No biologic implants have been placed into humans at this point. However, one can imagine that this may not be far off.

    We are only beginning to realize some of the applications that may come out of 3-D printing in orthopedics. Market forces will shape which 3-D print solutions eventually reach widespread applicability and which will be relegated to tech novelty. Regardless, it will be interesting to see the creativity that follows as this technology becomes more widespread.

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