Langerhuizen David W G, Doornberg Job N, Janssen Michiel M A, Kerkhoffs Gino M M J, Jaarsma Ruurd L, Janssen Stein J
D. W. G. Langerhuizen, G. M. M. J. Kerkhoffs, S. J. Janssen, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, Amsterdam University Medical Centre, Amsterdam, the Netherlands.
J. N. Doornberg, M. M. A Janssen, R. L. Jaarsma, Department of Orthopaedic & Trauma Surgery, Flinders University, Flinders Medical Centre, Adelaide, Australia.
Clin Orthop Relat Res. 2020 Dec;478(12):2901-2908. doi: 10.1097/CORR.0000000000001356.
For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined.
QUESTIONS/PURPOSES: (1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model?
We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test.
We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09).
Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius.
Level II, diagnostic study.
在骨折治疗中，X线片以及二维（2-D）和三维（3-D）CT主要用于术前规划和术后评估。桡骨远端关节内骨折的治疗在技术上具有挑战性，细致的术前规划对于改善患者预后至关重要。三维打印的手持模型可能会改善外科医生术前对特定骨折特征和类型的解读，因此可能具有临床价值；然而，对于桡骨远端骨折这种因关节内结构导致的高发病率且通常较为复杂的骨折，三维打印手持模型的附加价值尚未确定。
问题/目的：（1）使用三维打印手持模型是否能提高评估桡骨远端骨折手术决策所依据的特定骨折特征的可靠性？（2）使用三维打印手持模型是否能提高外科医生对骨折总体分类的一致性？（3）增加三维模型评估骨折总体结构时，外科医生的信心是否会提高？
我们连续纳入了2018年5月至2018年11月在一级创伤中心治疗的20例桡骨远端关节内骨折。10名外科医生评估特定骨折特征（掌侧边缘骨折、冲模骨折、掌侧月骨面、背侧粉碎、台阶>2mm和间隙>2mm）的有无，根据AO/骨科创伤协会（OTA）分类方案进行骨折分类，以及他们根据分类方案评估骨折总体情况的信心，评分范围为0至10分（0分=完全没有信心至10分=非常有信心）。在10名经常治疗桡骨远端骨折的参与者中，7名是骨科创伤外科医生，3名是上肢外科医生，完成住院医师培训后的经验年限从1年到25年不等。骨折评估进行了两次，每次评估间隔1个月。最初，使用X线片以及二维和三维CT图像进行骨折评估（传统评估）；第二次评估时，基于X线片以及二维和三维CT图像，并增加一个三维手持模型（三维打印手持模型评估）。在这两种情况下，骨折特征均由外科医生自行解读进行评估，评估前不给予具体指导。在每次评估前，我们提供一张展示AO/OTA分类方案的表格。使用多评分者Fleiss卡方检验来确定外科医生评估骨折特征和分类的可靠性。使用配对t检验评估对骨折总体分类评估的信心。
我们发现，桡骨远端关节内骨折的三维打印模型在所有特征的可靠性方面，卡方值没有变化：掌侧边缘（传统卡方值0.19[95%CI 0.06至0.32]，三维手持模型卡方值0.23[95%CI 0.11至0.36]，卡方值差异0.04[95%CI -0.14至0.22]；p = 0.66），冲模骨折（传统卡方值0.38[95%CI 0.15至0.61]，三维手持模型卡方值0.50[95%CI 0.23至0.78]，卡方值差异0.12[95%CI -0.23至0.47]；p = 0.52），掌侧月骨面（传统卡方值0.31[95%CI 0.14至0.49]，三维手持模型卡方值0.48[95%CI 0.23至0.72]，卡方值差异0.17[95%CI -0.12至0.46]；p = 0.26），背侧粉碎（传统卡方值0.36[95%CI 0.13至0.58]，三维手持模型卡方值0.31[95%CI 0.11至0.51]，卡方值差异-0.05[95%CI -0.34至·0.24]；p = 0.74），台阶>2mm（传统卡方值0.55[95%CI 0.29至0.82]，三维手持模型卡方值0.58[95%CI 0.31至0.85]，卡方值差异0.03[95%CI -0.34至0.40]；p = 0.87），间隙>2mm（传统卡方值0.59[95%CI 0.39至0.79]，三维手持模型卡方值0.69[95%CI 0.50至0.89]，卡方值差异0.10[95%CI -0.17至0.37]；p = 0.48）。尽管某些骨折特征的卡方值似乎有分类上的改善，但重叠的置信区间表明没有变化。骨折分类没有改善（传统诊断：卡方值0.27[95%CI 0.14至0.39]，增加三维手持模型的传统诊断：卡方值0.25[95%CI 0.15至0.35]，卡方值差异：-0.02[95%CI -0.18至0.14]；p = 0.81）。在评估过程中增加三维模型时，在评估骨折总体结构的自我评估信心方面没有改善（传统诊断7.8[标准差0.79{95%CI 7.2至8.3}]，三维手持模型8.5[标准差0.71{95%CI 8.0至9.0}]，得分差异：0.7[95%CI -1.69至0.16]，p = 0.09）。
增加三维模型并没有提高外科医生评估桡骨远端关节内骨折特征和分类的可靠性。进一步的研究应该评估三维打印手持模型对教学外科住院医师和医学实习生的附加价值，以确定三维打印在桡骨远端骨折治疗中的未来作用。
II级，诊断性研究。
