| The Surgical Technologist | JUNE 2022 272 reducing simulated operative time [264]. Moreover, 3DP instruments have been found to not only have higher quality than conventional tools but also to be cost-effective [252]. 3D-printed models can help assess the degree of anatomy restoration postoperatively [251]. Additionally, customized sockets and prostheses have been made for use after lower limb amputation surgery [265, 266]. 3DP has even been used for rapid production of custom-fit anklefoot orthoses following subject gait analysis; this custom-fit model was found to at least be comparable to the prefabricated ankle foot orthoses (AFOs) and has been especially helpful in children who are rapidly growing [241, 267]. From preoperative planning to patient-specific models, instruments, and implants; from microscopically engineered bone graft to orthoses, 3DP has quickly been picked up by and applied by orthopaedic surgeons. While the evidence supporting 3DP in orthopaedics is both reflected in recent publication trends and remains promising, there remains room for improvement [240]. Further investigations can focus on maximizing high-value patient care, surgeon education, and patients’ functional outcomes related to 3DP technologies. As the field continues to advance—now with 4- and 5D-printing—these different printing modalities have vast potential for simultaneously producing “smarter,” stronger products and enabling excellent patient care [268]. 4. Exponential Innovations 4.1. 3D Printing Integration with Augmented, Mixed, and Virtual Reality. The pressing necessity for the continuous improvement of medical imaging technologies has driven the use of new advanced visualization techniques such as augmented reality (AR), mixed reality (MR), virtual reality (VR), and 3DP in the field of surgery. The goal of these innovative applications is to integrate data found in the medical images into the OR in order to offer patients more precise and personalized treatments [269]. To date, most research has mainly only demonstrated the feasibility of implementation; but the results are quite promising [270]. To visualize or print an anatomical reconstruction from the images, the creation of a 3D-digital model (3DDM) is required [271]. The workflow to build it involves several sequential steps, including (1) 3D data acquisition, (2) anatomical segmentation, (3) conversion DICOMfiles to a 3D mesh file format, and (4) creation of a computer-aided design (CAD) file [272]. From herein, the resulting model can be uploaded into a virtual space and/or printed as a physical 3D mirror. This process requires dedicated and trained personnel, expensive tools, and time-consuming software [273]. For these reasons, its current implementation in clinical practice remains limited. In surgery, there are three areas in which the integration of 3DP with AR, MR, and VR is gaining special attention: preoperative planning, intraoperative support, and education training. For example, it has been applied on prostate and kidney cancer, showing improvements in clinical outcomes, surgical planning and intraoperative guidance, and training (Figure 11) [274]. The benefits of these technologies in preoperative planning lie in the increased awareness of anatomical details in complex surgical cases and the ability to identify risks and challenges before surgery, allowing the planning of a safe surgical strategy and potentially avoiding the occurrence of unexpected events [275], a surgical “Mental Map.” As an intraoperative support tool, 3DDM has also proven their usefulness, reducing the dependence on preoperative interpretation of imaging data and providing an anatomically correct, “twin” model in real time [276]. AR platforms superimpose 3D virtual models on physical objects in real space, allowing simultaneous interaction with both [277]. In this regard, even though, the main limitation remains the lack of accuracy in spatial registration, in Orthopaedic Oncology, it could be beneficial in tumor resection surgeries. Additionally, this technology could be advantageous to guide osteotomy cutting planes [278]. Recently, there have been developments of systems that, from selected anatomical segments in the 3DDM, allow printing and incorporation into the operative field, of a customized patient reference that provides an automatic registration of the image in real space through a smartphone augmented reality application [279]. Today, advanced 3D modeling (3DDM) and visualization technologies have an exciting and most promising range of applications in the fields of simulation, education, and training. The integration of AR, MR, VR, and 3D printing enables efficient training of physicians [280]. Preoperative evaluation and simulation using 3D imaging data allow surgeons to gain valuable experience and preoperatively practice surgical steps in a safe setting [281]. Additionally, these technologies allow real surgeries to be supervised by telepresence [282]. There is no doubt that recent progress in the integration of simulation and virtual modeling into the OR has highlighted the potential benefits of these technologies, however, the concrete clinical impact on operative and postoperative outcomes remains to be defined [283]. 4.2. 3D Printed Medical Devices and Tools for Space Surgery. Human space activities in recent decades have mostly taken place on the International Space Station (ISS); however, there is growing interest in exploring beyond low Earth orbit (LEO), such as the Moon and Mars. Operational requirements and constraints are closely linked to mission objectives, destination, duration, and necessary resources, influencing the scope of human activity and technology needed to complete missions. Sustaining and supporting the human presence in space require the use of medical devices compatible with the space environment and artificial environments of a spacecraft or planet-based habitat, also considering operational limitations [284]. Preserving human health in space is primarily done through telemedicine-compatible equipment, allowing ground-based experts to be part of examinations. However, the great distances in planetary exploration lead to time delays in communication with medical personnel on Earth, affecting the application of telesurgery in space missions, a technique already shown as a useful tool when there is the need to invasively treat patients who are geographically separated from their physicians [285]. 16 BioMed Research International
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