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Nov 02, 2024

Application of a customized 3D-printed osteotomy guide plate for tibial transverse transport | Scientific Reports

Scientific Reports volume 14, Article number: 22771 (2024) Cite this article 335 Accesses Metrics details Enhance the efficiency of tibial transverse transport by employing customized 3D-printed

Scientific Reports volume 14, Article number: 22771 (2024) Cite this article

335 Accesses

Metrics details

Enhance the efficiency of tibial transverse transport by employing customized 3D-printed osteotomy guide plates and striving to improve precision through CT evaluation for enhanced guide design. 17 diabetic foot patients were treated with the plate for tibial transverse transport. Preoperatively, we collected DICOM data from the affected tibia’s CT and designed the geometric parameters of the tibial cortical bone window. A customized 3D-printed osteotomy guide plate was then fabricated using 3D printing technology. Postoperative X-ray and CT evaluations, conducted at two and five weeks post-surgery, assessed five crucial geometric parameters of the bone window. Measurements included the distance from the upper edge of the tibial cortical bone window to the tibial plateau, the distance from the anterior edge of the tibial cortical bone window to the bone ridge, the height of the tibial cortical bone window, the center-to-center distance between the 4.0 mm diameter Schanz pin and the osteotomy Kirschner pin, and the center-to-center distance of the 4.0 mm diameter Schanz pin. These measured parameters were subsequently compared to the preoperative design parameters. The Clinical trial registration number is ChiCTR2400087174. CT measurements showed no significant differences (P > 0.05) from preoperative design parameters across the five evaluated aspects. The average osteotomy duration was 35 ± 15 min with no bone window fractures. The bone window aligned effectively with the tibial shaft, achieving complete incorporation after distraction. A 4 to 8-month postoperative follow-up confirmed full healing of the tibial surgical wound and diabetic foot wounds. Utilizing customized 3D-printed osteotomy guide plates in tibial transverse bone transport surgery enables accurate translation of preoperative virtual designs into real-time procedures, enhancing surgical efficiency and quality.

Diabetic foot (DF) is among the most severe ischemic complications of diabetes, featuring a prolonged course, high costs, and a tendency to persist without improvement1. Tibial transverse transport (TTT) has demonstrated favorable efficacy in treating ischemic conditions of the lower limbs, including DF2. TTT surgery involves creating a tibial cortical bone window on the medial side of the tibia. As the bone window is gradually elevated, there is active regeneration of the microvascular network within the elevation gap. This process achieves the reconstruction of microcirculation in damaged tissues, enhancing wound healing capabilities3.

The amputation of the tibial cortical bone window is a crucial step in TTT surgery4, and currently, the following challenges exist: ①Determine the precise osteotomy position. Proximity to the proximal end of the tibia may lead to goosefoot irritation, while closeness to the distal tibia may result in bone window splitting or tibial fracture due to medullary cavity stenosis. ②Optimal bone window size. An overly large bone window may damage the tibial crest, causing fractures, while a too-small bone window during drilling may lead to window cracking. ③Precise osteotomy to ensure the smooth outward and inward movement of the bone window. Through digital simulation surgery, it is possible to visualize the desired effects of tibial cortical bone window osteotomy, including the appropriate height, precise alignment of the anterior and posterior edges of the cortical bone window with the medial side of the tibial medullary cavity, and the proper height of the tibial cortical bone window. However, existing osteotomy methods, such as customized guide plate osteotomy, continuous osteotomy can’t accurately and conveniently transfer the simulated surgical effects to the actual surgery5. Although we can precisely plan the relevant parameters of the tibial cortical bone window area through virtual surgery, further research is needed to determine how to accurately guide numerous subsequent surgical steps, apply 3D virtual design to actual surgery, and assess the conduction effect in digital form to obtain quantifiable compliance indicators. This will help further enhance the 3D-printed osteotomy guide plate-assisted surgery6.

Given this, this study developed a customized 3D-printed osteotomy guide plate for TTT in accordance with the osteotomy requirements and actual surgical procedures. The study retrospectively reviewed 17 diabetic foot patients treated with these guides, assessing the technology’s effectiveness through clinical and imaging data. The aim was to explore and assess the clinical advantages and application value of the customized 3D-printed osteotomy guide plate for performing tibial transverse transport surgery in diabetic foot cases. The study also sought to investigate the feasibility and evaluation methods of employing 3D printing technology to complete a virtual-to-real-to-virtual process7.

This study comprised 17 patients with diabetic foot who underwent tibial transverse transport utilizing customized 3D-printed osteotomy guide plates. The osteotomy guide plate was designed based on preoperative CT data and subsequently printed in 3D. Preoperative CT scans and postoperative X-rays and CT scans were utilized for a three-dimensional analysis of the osteotomy plane. Measurements were taken to assess the planned and achieved tibial cortical bone windows.

This study has been approved by the Medical Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, and all patients have informed consent and signed informed consent forms(The IEC approval letter number is [2024] (0121)). And completed the filing in the National Medical Research Registration and Filing Information System (the record number is MR-42-24-010375). The Clinical trial registration number is ChiCTR2400087174, registered on 22/07/2024. All research was performed in accordance with relevant guidelines/regulations, and consent was obtained from all participants and/or their legal guardians. Research involving human research participants has been performed in accordance with the Declaration of Helsinki.

The patient’s affected or unaffected lower limb underwent spiral CT thin-slice scanning to obtain continuous cross-sectional DICOM data files.

Using MIMICS medical 3D reconstruction software, a new project was created, and the patient’s CT scan data was imported. The bone tissue algorithm was employed to select the tibial region and obtain the region of interest mask. Based on the two-dimensional contour mask of the transverse section, a digital three-dimensional virtual model that matched the patient’s skeletal morphology in a 1:1 ratio was reconstructed. Simultaneously, the soft tissue algorithm threshold was used to reconstruct a three-dimensional digital model of the skin of the affected limb.

The reconstructed bone tissue model was rendered semi-transparent. In the coronal view, measurements were taken using a 2D plane measurement method to assess the medullary cavity diameter below the tibial tuberosity and the outer diameter of the tibial cortical bone. Simultaneously, measurements were made of the vertical distance from the tibial cortical bone on the medial side to the epidermis in the bone’s transverse plane.

To acquire diverse dimensional parameters of bone transport surgical instruments and reconstruct the overall structure using mechanical design software. Concurrently, formulate a standardized bone transport guide with a core structure resembling a rectangular prism. Two central guiding columns assist in directing the Schanz pins responsible for pulling the bone window. The arrangement depends on the spacing between the Schanz pins in the bone transport instrument fixture. Along the longitudinal axis, the guide is segmented into two joinable parts, employing the diameter of the tibial medullary cavity as the width between the anterior and posterior edges. Both edges have a predetermined hole width of 1.5 mm, designed for closely guiding Kirschner pins along the anterior and posterior walls during osteotomy. The spacing between upper and lower holes on the guide is determined by adding the Schanz pin spacing, Schanz pin diameter, and an extra 1 cm. Each anterior and posterior edge of the guide hosts an elongated positioning rod with a 1 mm diameter elongated positioning guide hole at its end. Through these holes, 1 mm diameter Kirschner pins are inserted, aligning closely with the anterior and posterior edges of the tibial cortex, ensuring the longitudinal axis of the guide aligns with the center of the tibial anatomical axis. A positive and negative connecting rod is employed at the connection point between the anterior and posterior guide sections, and the primary division seam traverses the central axis of the Schanz pins, facilitating swift removal after intraoperative navigation module assistance in positioning.

Import the modular structure of the virtual surgical instrument apparatus and navigation module into 3matic. Use the translation and rotation functions to place the instruments and guide on the medial plane of the tibia. The positioning criterion ensures that the end of the guide’s Schanz pin guiding hole barely contacts the inner cortical bone of the tibia.

Design an extension rod on one side of the plate, aligning it with the height of the tibial plateau joint surface. Establish a vertical reference plane along the guide’s central axis. Utilize this reference plane to generate a two-dimensional projection of the tibial plateau joint surface contour. Design a continuous guide groove, 1 mm in width, following the contour line. This groove facilitates positioning the guide at the correct height on the medial side of the tibia, preventing the bone window from being excessively high or low (Figs. 1, 2, 3, 4 and 5).

Design flowcharts.

CT images of the affected limb were obtained and 3D reconstruction was performed.

The height of the osteotomy area from the tibial plateau, the size of the tibial cortical bone window, and the minimum medullary cavity diameter were measured.

Modeling of bone transport instruments.

Guide plate design and format output.

The plate is 3D printed using photosensitive resin, with a thickness of approximately 10 mm and a longitudinal length of about 70 mm. After printing, evaluate the plate’s integrity, inspect holes for deformities or fractures, and confirm the distribution of Schanz pin guiding columns for compatibility with the tibial transport apparatus. Finally, sterilize the plate using low-temperature plasma (hydrogen peroxide) (Fig. 6).

3D printing guide plate printing forming.

①Height Adjustment: Insert a 1 mm Kirschner pin into the medial knee joint space. Place the plate groove over the end of the Kirschner pin, aligning the guide in the tibial head-to-tail direction, and secure it to the inner side of the tibial skin. ②Anterior-Posterior Adjustment: Insert two 1.0 mm Kirschner pins into the elongated positioning guide holes on each side of the plate. Insert the Kirschner pins along the gap between the tibial cortical bone and soft tissues, positioning the plate in the tibial anterior-posterior direction. ③Osteotomy Incision Placement: Open the plate at the connection point of the anterior and posterior pieces. Remove the rear components, excluding the guiding groove. Create a longitudinal incision on the inner side of the tibia along the posterior edge of the front component. Separate all layers from subcutaneous tissue to periosteum, mobilize the periosteum forward and backward, and insert the plate into the incision. The incision size must allow for complete placement of the plate. ④Schanz Pin Placement: Following the plate’s Schanz pin guiding columns, insert two 4.0 mm Schanz pins into the bone window. Subsequently, use a 1.5 mm Kirschner pin to drill continuous holes according to the pre-determined osteotomy holes on the plate. ⑤Bone Block Removal: Use a thin-bladed bone knife to cut the bone, creating a tibial cortical bone window that is fully detached. ⑥Schanz Pin Placement and Finalization: Insert a 5.0 mm Schanz pin above and below the osteotomy area. Install the tibial transport apparatus and verify that the tibial cortical bone window can be fully transported outward and inward. Close all layers using sutures1 ( Fig. 7).

Illustration of surgical steps. (a) Guide plate adhering to the skin; (b,c) Insert a 1.0 mm diameter Kirschner pin (a) from any point in the medial gap of the knee joint. Pass the guide plate through the guiding groove onto the tail of Kirschner pin (a), confirming the position of the guide plate along the longitudinal axis of the limb. Move the guide plate along the anterior-posterior direction of the tibia. Based on the alignment of the guide plate with the contour of the skin on the medial surface of the tibia, preliminarily position the guide plate in the anterior-posterior direction of the limb. Along the anterior-posterior direction of the guide plate, insert two 1.0 mm diameter Kirschner pins (b,c) closely against the anterior and posterior edges of the tibia through the extended positioning guide holes. Further determine the position of the guide plate in the anterior-posterior axis of the limb, completing the relative positioning of the guide plate and the medial surface of the tibia. Intraoperative fluoroscopy confirms the accurate insertion of Kirschner pin (a) into the medial gap of the knee joint and the close contact of Kirschner pins (b,c) with the anterior and posterior edges of the tibia. (d,e) Split the front part (a) and back part (b) of the guide plate. Make a longitudinal incision along the posterior edge of part (a) on the medial surface of the tibia (arrow indicates the incision). Push the skin, subcutaneous tissue, and bone membrane aside in both anterior and posterior directions. For ease of operation, temporarily move Kirschner pins (b,c) and part (a) of the guide plate. After completing the osteotomy incision, reassemble and position part (a) and part (b) of the guide plate. (f–i) After inserting Schanz pins into the guide holes, drill two 4.0 mm diameter Schanz pins into the cortical bone window of the planned osteotomy area. Then, using a 1.5 mm Kirschner pin, consecutively drill holes in the osteotomy site under the guidance of the osteotomy holes (arrow indicates 1.5 mm drilling with Kirschner pin). Check the integrity of the drilled holes. (j) Install the tibial transport apparatus. (k) Use a thin-bladed bone knife to cut out the bone window, severing the bone column in the area of non-continuous drilled holes. Check if the bone window is completely detached and if it can be smoothly transported outward and inward. (l) Suture the skin.

①Distance from the upper edge of the tibial cortical bone window to the tibial plateau: From the apex of the intercondylar eminence of the tibial plateau to the midpoint of the upper edge of the tibial cortical bone window.②Distance from the anterior edge of the tibial cortical bone window to the bone ridge: From the midpoint of the anterior edge of the tibial cortical bone window to the bone ridge.③Height of the tibial cortical bone window: From the midpoint of the upper edge to the midpoint of the lower edge of the tibial cortical bone window.④Center-to-center distance between the 4.0 mm diameter Schanz pin and the osteotomy Kirschner pin: From the midpoint of the anterior edge of the tibial cortical bone window to the center distance between the Schanz pin.⑤Center-to-center distance of the 4.0 mm diameter Schanz pin: Center distance between the 4.0 mm diameter Schanz pin (Fig. 8).

Postoperative X-ray measurements. (a,b) Measurements at 2 weeks postoperatively; (c,d) Measurements at 5 weeks postoperatively.

Based on the postoperative X-ray measurement data and a comparison with preoperative virtual design, taking into account X-ray measurement errors, errors in bone absorption at the edge of the bone window, deviations in 3D printing, and bone loss due to Kirschner wire drilling and osteotomy, this study conducted postoperative CT data measurements on subsequent cases for further comparison with preoperative virtual design (Fig. 9).

Postoperative CT versus preoperative virtual design.

Statistical analysis was performed using SPSS 26.0 software to analyze the preoperative virtual design and postoperative X-ray and CT actual measurements of five parameters: distance from the upper edge of the tibial cortical bone window to the tibial plateau, distance from the anterior edge of the tibial cortical bone window to the bone ridge, height of the tibial cortical bone window, center-to-center distance between the 4.0 mm diameter Schanz pin and the osteotomy Kirschner pin, and center-to-center distance of the 4.0 mm diameter Schanz pin.

Intraoperative visual and fluoroscopic assessments were employed to evaluate the effectiveness of osteotomy and nail placement. The evaluation criteria included: ① No occurrence of splintering in the tibial cortical bone window; ② Intraoperative measurements using a sterile steel ruler indicated no significant deviation in the actual size of the tibial cortical bone window compared to the preoperative design; ③ Fluoroscopy confirmed the central positioning of the Schanz pin within the medullary cavity; ④ Fluoroscopy demonstrated the close placement of the Schanz pin against the cortical bone.

Regular postoperative follow-up to assess the healing of the patient’s skin wound.

Statistical analysis was conducted to assess the differences between preoperative design values and postoperative X-ray actual measurements. Parameters included the distance from the upper edge of the tibial cortical bone window to the tibial plateau, the distance from the anterior edge of the tibial cortical bone window to the bone ridge, the height of the tibial cortical bone window, the center-to-center distance between the 4.0 mm diameter Schanz pin and the osteotomy Kirschner pin, and the center-to-center distance of the 4.0 mm diameter Schanz pin. Significant differences were found in four groups of data with P < 0.05. Possible factors contributing to these differences include 3D printing deviations, misplacement of the guide plate, the presence of soft tissue, and errors in the Kirschner pins, all of which could introduce significant discrepancies (Table 1; Figs. 10, 11, 12, 13 and 14). However, no statistically significant difference was observed in the comparison between preoperative design and postoperative CT actual measurements (P > 0.05), suggesting no significant disparities between the two sets of data (Table 2).

Preoperative design and actual postoperative X-ray measurements of the distance from the upper edge of the tibial cortical bone window to the tibial plateau.

Preoperative design and actual postoperative X-ray measurements of the distance from the anterior edge of the tibial cortical bone window to the bone ridge.

Preoperative design and actual postoperative X-ray measurements of the height of the tibial cortical bone window.

Preoperative design and actual postoperative X-ray measurements of the center-to-center distance between the 4.0 mm diameter Schanz pin and the osteotomy Kirschner pin.

Preoperative design and actual postoperative X-ray measurements of the center-to-center distance of the 4.0 mm diameter Schanz pin.

17 patients underwent TTT surgery guided by the customized 3D-printed osteotomy guide plate. During the procedure, one lateral fluoroscopy was performed for the Schanz pin placement. It revealed that the Schanz pin was centrally positioned within the medullary cavity and tightly placed against the cortical bone. The osteotomy process proceeded smoothly, with no splintering observed in any of the tibial cortical bone windows. Complete inward and outward bone transport was achieved (Fig. 15).

The practical application of customized 3D-printed osteotomy guide plate in tibial transverse transport. (a–c) First, insert 1.0 mm Kirschner pins tightly against the medial gap of the knee joint to set the height of the guide plate. Then, affix the customized 3D-printed osteotomy guide plate to the skin of the tibia, ensuring that the guide plate conforms to the bony landmarks and the skin of the lower leg. Insert two 1.0 mm Kirschner pins into the extended positioning guide holes on either side of the guide plate, snugly fitting them into the bone and the soft tissue gap, fixing the relative position of the guide plate to the medial side of the tibia. (d,e) Take advantage of the guide plate’s detachable feature for easier skin incision. Open the guide plate along the disassembly assembly parts, then make a longitudinal incision along the central axis of the guide plate on the medial side of the tibia. Separate the subcutaneous tissue down to the periosteum, cut the periosteum open on both sides, and place the guide plate into the incision. (f) Insert two 5.0 mm Schanz pins through the Schanz pin guide columns. (g,h) Use 1.5 mm Kirschner pins to drill holes sequentially along the center-to-center distance. (i,j) Then, use a thin-blade bone knife to cut the bone block, ensuring that the cut bone block is completely detached. During the bone-cutting process, pay attention to protecting the periosteum to avoid damage to surrounding important neurovascular structures. (k,l) Measure the size of the bone block during the surgery, install the tibial bone transport apparatus, and close all layers with sutures.

Regular outpatient follow-ups included imaging examinations for observation. The follow-up duration varied between 4 and 8 months, averaging 5.8 months. There were no instances observed where the tibial cortical bone window could not be fully relocated to its original position. Satisfactory healing of the tibial cortical bone window was observed after relocation, and the wound exhibited good recovery (Figs. 16, 17 and 18).

(a) Upon a review 2 weeks postoperatively, it is observed that the bone block is intact, and the Schanz pin is located at the central medullary canal. (b) After a 4-week postoperative review, it is observed that the bone block has been smoothly transported without any fractures.

(a) Preoperative CTA; (b) CTA three months postoperatively.

(a) Preoperative diabetic foot ulcer, with visible tendon exposure. (b) Three months postoperatively, the wound shows regenerated skin.

3D printing technology in orthopedics is mainly applied in three areas: producing 1:1 physical models, printing orthopedic surgical auxiliary materials, and printing orthopedic implants. In terms of clinical usage, 3D-printed orthopedic surgical guides fall into three categories: fixation guides, osteotomy guides, and other specialized guides. Presently, these 3D-printed guides find application in corrective osteotomy incisions for deformity healing, guiding spinal and pelvic screws, aiding in prosthetic placement, joint replacements, ligament reconstruction, tumor tissue resection, and other surgical procedures8.

Customized 3D-printed osteotomy guide plates aim to meticulously follow preoperative plans, ensuring accurate implant positioning and precise bone correction. In cases involving the spine, trauma, joints, and bone tumors, 3D surgical guides facilitate the exact execution of digital surgical plans at the operation site. Besides enhancing accuracy, they can also decrease radiation exposure and reduce operation time9,10.

The customized 3D-printed osteotomy guide plate is an instrument used to guide the placement of internal fixations such as screws, assist in bone repositioning, and determine the range of osteotomy11. In both cadaveric and clinical research, the template has garnered increasing attention from clinicians due to its position independence and the reduction of surgical procedures12. With the assistance of the guide plates, the surgeon can easily determine the direction and depth of screw paths, select the angle and scope of osteotomy, and enhance the precision, safety, and reliability of the surgery11. It simplifies challenging surgical steps, shortens the learning curve for physicians, and accelerates the growth of young and mid-career physicians. Reduced radiation exposure can decrease surgical complications, improving the quality of orthopedic surgeries12. Compared to surgical navigation systems, surgical guides are more convenient and user-friendly13. Additionally, surgical guides can be used under minimally invasive conditions, reducing time in the operating room, saving significant costs for hospitals, and lowering patient risks14.

In the execution of TTT, traditional methods such as chiseling the bone window, fixing pins, and inserting transfer pins often rely on the surgeon’s experience15. However, limited exposure of the field has its constraints, making it difficult to achieve precise positioning and uniform chiseling during the creation of the bone window. Any slight error in this process could potentially damage the periosteum, affecting the later recovery of blood circulation in the affected limb16. Additionally, during the insertion of the transfer pin, relying on the naked eye to gauge the pin angle can easily result in deviations. If the angle of the transfer pin is not completely perpendicular to the bone flap plane, then after the bone flap movement in the postoperative period, asymmetric tilting displacement may occur on both sides. This can lead to uneven growth of the vascular network between the two sides of the bone fracture ends or even the absence of vessel growth in the gap on the highly tilted side17. Furthermore, traditional TTT, involving a large incision on the anterior inner side of the leg and conventional instrument drilling for bone cutting, has several disadvantages: ①uneven bone cutting during surgery, leading to bone block splitting and fractures; ②time-consuming and labor-intensive bone cutting during the surgery17.

This study utilized preoperative CT data of the affected or healthy limb to design the customized 3D-printed osteotomy guide plate. During the surgery, tibial transverse transport was performed based on the preoperative design of the osteotomy area. Postoperatively, X-ray and CT follow-up data of the patient were compared with the preoperative design to assess the accuracy of the procedure18. This research demonstrated that the customized 3D-printed osteotomy guide plate can achieve precise and safe bone cutting in tibial transverse bone displacement surgery. The digital evaluation showed no significant differences between the actual bone cutting and the preoperative design. The patients exhibited good wound healing postoperatively, and there were no instances of tibial cortical bone window splitting within two months of the follow-up examinations.

For the design of the 3D-printed plate, precision positioning is achieved through the use of Kirschner guide columns on the guide. These guide columns allow for accurate and repeatable positioning. The design features a detachable structure for ease of skin incision, with proximal and distal markings on the guide for reference. Beneath the guide, the Schanz pin guide column can be broken, and the extended column can be percutaneously cut, allowing for a change in the surgical approach if needed.

The design incorporates both continuous and non-continuous bone drilling to prevent cortical bone debris from falling into the marrow cavity before external fixation is applied. Vertical truncation of the cortical bone window ensures that the window remains connected to the trabecular bone inside the marrow cavity. Vibrating the bone window is necessary to fracture the trabecular bone and smoothly lift the cortical bone window.

The guide can be directly placed in the surgical incision, adhering to the bone surface for bone cutting. During bone cutting, minimal debris is generated from the friction between the Schanz pin and its guide column, as well as the Kirschner pin and the bone-cutting guide hole. The generated debris is non-toxic and harmless to the human body, and the guide itself does not interfere with the healing of the bone-cutting incision. The guide is easily removable and not prone to fragmentation.

The degree of conformity between virtual surgery and the actual surgical procedures and outcomes is a crucial evaluation indicator for assessing the transformation or guidance of real surgical outcomes by virtual surgery. The conformity assessment of 3D-printed guide-assisted surgery includes aspects such as the alignment between clinical lesions and virtual surgery, the alignment between virtual surgery and guide design, the alignment between virtual surgery and guide manufacturing, the alignment between the guide and surgical procedures, and the alignment between surgical procedures and outcomes. Conducting conformity assessments is a key element in enhancing the effectiveness of translating virtual surgery into real surgical outcomes, improving procedures, and adhering to relevant industry standards. For TTT, we have introduced, for the first time, specific targets related to the tibial cortical bone window. This enables a comprehensive evaluation of the geometric parameters of the tibial cortical bone window between virtual surgery and actual surgery, achieving a thorough assessment of conformity.

For the first time, this study evaluated the conformity between each link of digital design, 3D printed guide plate assisted real surgery, and digital evaluation, and used 3D printed guide plate as the carrier to conduct virtual surgical operation into real surgery, so as to achieve accurate positioning and convenient operation, obtain a good degree of consistency between virtual design and real use, and explore new paths for further improving surgery19. This study is the first to apply 3D-CT to evaluate the accuracy of personalized 3D printed osteotomy guides in transverse tibial bone transfer surgery. We describe a reproducible method to accurately measure the level of the osteotomy plane achieved by imaging calculations20.

This research marked the first application of 3D-CT evaluation to assess the accuracy of customized 3D-printed osteotomy guide plates in tibial transverse transport. We described a repeatable method that utilizes imaging calculations to precisely measure the horizontal plane of the achieved osteotomy. The findings indicate that 3D-printed guides can assist in tibial transverse transport with a high level of planning accuracy9,10.

The presence of outliers clearly indicates that the use of customized 3D-printed osteotomy guide plates during surgery may still lead to errors. Possible factors contributing to this situation include 3D printing deviations, misplacement of the guide, the presence of soft tissue, and errors in Kirschner pins, which may introduce significant inaccuracies. Additionally, the perfect fit of customized 3D-printed osteotomy guide plates at multiple locations on the medial side of the tibia may lead to deviations from the surgical plan.

This study has the following limitations: ① The number of cases included is relatively small, and there is some individual variability in surgical strategies. ②It is a retrospective study with a short follow-up period. Cases were grouped based on whether personalized 3D-printed osteotomy guides were used, and the surgeries were performed by the same surgeon. The lack of randomization and blinding may introduce data bias, and further prospective randomized controlled studies are needed for validation. ③ The study exclusively used personalized 3D-printed osteotomy guides for tibial transverse bone transport surgery, lacking a control group of patients who did not use guides for clinical effectiveness comparison.

Preoperative precise osteotomy has been achieved using CT virtual data, and postoperative CT has been employed to compare and assess the accuracy of osteotomy against preoperative plans. The study will continue to explore how to convert real-time intraoperative X-ray fluoroscopy into three-dimensional CT images. Efforts will be made to utilize computer algorithms to transform intraoperative two-dimensional fluoroscopy from multiple angles into three-dimensional images, allowing more accurate observation of osteotomy effects. This approach can potentially be extended to other orthopedic surgeries. We acknowledge further limitations. Although CT provides higher accuracy compared to traditional X-rays, it is susceptible to metal artifacts that may hinder the precise definition of the achieved osteotomy plane. Nevertheless, we have implemented a metal artifact reduction algorithm, significantly improving the results. Overall, the implemented method involves an automated process aimed at eliminating variability in result measurements. However, accurate measurement of result values relies on successful registration of preoperative and postoperative CT scans.

The customized 3D-printed osteotomy guide plate in tibial transverse transport is relatively new, and there is a lack of long-term clinical studies raising questions about its contribution to improving patient clinical outcomes. Currently, there is no evidence suggesting a direct correlation between more accurate tibial osteotomy and improved clinical outcomes or reduced postoperative complications. Future research should aim to determine the long-term impact of radiation exposure on patient functional outcomes and assess the associated costs of 3D planning.

Clinical validation of a customized 3D-printed osteotomy guide plate in tibial transverse transport is important to assess whether the plan is achieved intra-operatively. In this study, we proposed a method using 3D-CT analysis to measure the achieved horizontal osteotomy of the tibial cortical bone window. We quantified the differences between the achieved and planned levels of tibial cortical bone window osteotomy.

All data generated or analysed during this study are included in this published article [and its supplementary information files].

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These authors contributed equally: Dongxuan Wei, Wei Zhou and Jiahui Huang.

Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China

Dongxuan Wei, Wei Zhou, Xianglong Zhou, Hui Song & Liming Xiong

Department of Ophthalmology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China

Jiahui Huang

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Dongxuan Wei: conceptualization; data curation; formal analysis; investigation; writing-original draft. Wei Zhou: investigation; validation; writing-review. Jiahui Huang: investigation; validation. Xianglong Zhou: investigation; validation. Hui Song: conceptualization; supervision; writing-review & editing. Liming Xiong: conceptualization; supervision; writing-review & editing. All authors reviewed the manuscript.

Correspondence to Hui Song or Liming Xiong.

The authors declare no competing interests.

This study has been approved by the Medical Ethics Committee of Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, and all patients have informed consent and signed informed consent forms.

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Wei, D., Zhou, W., Huang, J. et al. Application of a customized 3D-printed osteotomy guide plate for tibial transverse transport. Sci Rep 14, 22771 (2024). https://doi.org/10.1038/s41598-024-73715-y

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Received: 09 January 2024

Accepted: 20 September 2024

Published: 01 October 2024

DOI: https://doi.org/10.1038/s41598-024-73715-y

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