Perceptions of Orthopedic Prespecialists on Patient-Specific 3D Models.
Condition: Educational Problems
Study type: Observational

Summary: 
      Background: Three-dimensional (3D) patient-specific anatomical model guidance is a reliable
      tool in obtaining accurate bony cuts, precise implant placement, and satisfactory surgical
      results. These can enhance surgeon's understanding of their patients' patho-anatomy also
      helping in precise preoperative planning. So, the hypothesis of this study is that, in the
      training of orthopaedic residency, 3D printed models reflecting the patient's individual
      process provide a a foresight and a perception of the bone pathologies and osseous
      relationships before orthopaedic intervention.

      Methods: In this study, the investigators displayed our experience of creating realistic 3D
      models in orthopaedic surgical case scenarios to evaluate the perceptions of fellows in
      orthopaedic surgeon training. The investigators based our study on the comparision of the
      perception of residents who were presented with four-step carousel consisting of different
      scenarios as trauma (calcaneal fracture), deformity (hallux valgus), tumoral mass (sacral
      chondrosarcoma), and reconstructive procedure (multidisciplinary cancer surgery). The X-ray
      images, computed tomography (CT), and 1:1 solid models of the cases were included in each
      step. The orthopaedic residents were asked to compare their perception level of the actual
      scenarios in evaluating the effectiveness of each tool in terms of perceiving the orthopaedic
      problem, understanding the bone pathology, classification of diagnosis and preoperative data
      planning.
    

Detailed description: 
      2.1. Study Group The study group consisted of 11 orthopaedic residents of University
      Hospital. Ethics approval for this study was obtained from our university's Human Research
      Ethics Committee (18-5/41). The work has been reported in line with the STROCSS criteria.

      2.2. Selection of the sample cases The patients were chosen from the MRI examinations of the
      ones who referred to same University Hospital Department of Orthopaedic and Traumatic Surgery
      for diagnosis and treatment between the year of 2016 and 2018. Selection criteria for the 4
      cases was the involved patients (age: 18-62 years) who required orthopaedic surgery, had no
      previous orthopaedic nor traumatic operation, but on the other hand have bone pathology
      leading to deformity, fracture, and suitable radiological imaging results for modeling. 4
      cases that could serve as an example for orthopaedic surgical procedures were determined with
      the consensus of experts in medical education, orthopaedic surgery and anatomy. The selected
      cases were turned into real scenarios with history, medical examination findings, and imaging
      methods. As data collection tool, descriptive grading scale was used to evaluate the
      perceptions of each of these imaging methods in terms of their usefulness in seeing the
      surgical problem, their efficiency in differential diagnosis and presurgical planning.

      2.3.Image post-processing and segmentation Original CT images were converted into in Digital
      Imaging and Communications in Medicine (DICOM) format. Files were transferred to a separate
      workstation with Analyze 12.0 for post-processing and segmentation. Using free 3D Slicer
      (version 4.10.1) software, a smoothing filter was also applied to the segmented volume data
      to improve the surface quality of the model. The STL format for 3D printing was prepared.

      2.4. Creating Life-size Patient-Specific 3D Model Mass Portal Pharaoh xd 20 printer was used
      due to its documented accuracy for producing high-resolution 3D models of orthopaedic cases
      from resin-based polymers.

      2.5. Workshop Data collection shop A grading scale was developed for each case so that the
      residents were able to make a comparison.

        1. The grading scale developed for the trauma case (calcaneus fracture) consisted of 16
           items including the appearance, classification and planning of the fracture surgery.

        2. The scale for the case of deformity (hallux valgus) contained 7 items of classification,
           questioning the degree of deformity and operation planning.

        3. In the grading scale developed for the tumor case (chondrosarcoma), there were 13 items
           questioning the location, size, spread and neighboring pelvic structures.

        4. In the scale for the reconstructive case (thorax localized tumor), there were 13 items
           questioning the location, size, spread and neighboring of intrathoracic structures, the
           occurrence of a postoperative defect, and the reconstructive method in the presence of a
           postoperative defect..

      2.6. Survey A multi-item survey was prepared to assess fellow's perception of residency
      training. The survey utilized by our group, addressed the issues in understanding patient
      bone anatomy, seeing osseous pathology, independent decision-making, differential
      pathological diagnosis, plan on key surgical steps, and preparation for unexpected events.
      Residents who completed their examination in the stations evaluated each imaging method and
      answered the questions on a scale of 10. Scoring in the scale (1 - 10) describes 0 = very low
      and 10= the highest level.

      2.7. Data collection Residents were asked to answer the grading scale by examining the X-ray,
      CT and the 3D model from the first station. In addition, opinions about the models were
      recorded and they were given an average of 10 minutes for each station.

      2.8. Data Analysis Descriptive statistics and Friedman test were used for comparison
      analysis. Data were analyzed using IBM SPSS Statistics, version 24 (IBM Corp., Armonk, NY).
    

Intervention name(s): Survey
Intervention type(s): Behavioral
Intervention description(s): Sequential Assignment
Observational model: Case-Control
Time perspective: Retrospective
Sampling method: Probability Sample
Study population: 
        The study group consisted of 11 orthopaedic residents of University Hospital.