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Yale Begins 3D Orthopaedic Surgical Procedures That Are Fully In-house

May 28, 2024
by John Ready

Lisa Lattanza, MD, chair and Ensign Professor of Orthopaedics & Rehabilitation, has performed the first fully in-house 3D surgical case at Yale.

Lattanza performed the world’s first elbow transplant prior to joining Yale School of Medicine as chair in 2019. She has long maintained ambitious goals for melding her world-renowned expertise in 3D surgical planning with emerging innovations in 3D technology to establish Yale as a destination for orthopaedic care.

The first in-house, custom, personalized 3D surgical procedure repaired a distal radius malunion, which is caused when a broken forearm heals incorrectly, resulting in misaligned or deformed bones. Lattanza worked alongside a Yale team to develop a 3D surgical plan for the patient, 3D printed personalized surgical guides, and 3D printed anatomically precise models of the bone structure. By using advanced imaging software with 3D modeling and printing, Lattanza was able to identify the best outcomes possible through a non-standardized surgical approach without having to make an incision. This latest endeavor represents the ever-converging synergy between orthopaedics and engineering, and also is creating new opportunities in personalized medicine.

Visualizing orthopaedics in 3D

“Orthopaedic surgery is geared toward functionality and returning patients to normal life, and to that end, ‘one size fits all’ is no longer a phrase that applies for us,” Lattanza said. “Our priority is to fully understand each patient and develop a plan of care based on their specific needs, long-term goals, and achievable outcomes. Since every person has a unique anatomy with individualized motion patterns and functions, as well as unique injuries, 3D surgical procedures are tailored specifically for each patient.”

Surgeons are often tasked with reviewing two-dimensional images such as X-rays, which leave considerable room for interpretation as it relates to the degree and direction of deformity. Innovations in 3D surgical planning are allowing surgeons such as Lattanza to provide unmatched care to patients who have been suffering from injuries or congenital problems that did not heal appropriately, leading to pain and musculoskeletal dysfunction.

Using specialized software, engineers can convert images from CT or MRI scans into 3D digital anatomy. Surgeons can plan their surgery using these digital models prior to making a cut, making the operation safer and more efficient. While this technology is a game-changer, the surgeon still needs to rely on their training and expertise to effectively execute the plan. This technology can also be vital in repairing previous surgeries that did not solve the patient's problem.

The detailed digital models enable surgeons to identify various conditions by categorizing them into types and subsets, allowing for a much more accurate surgical intervention. By using this 3D technology in advance of pediatric, adult, musculoskeletal oncology, and other cases, the surgery can be optimized to the best possible outcome.

Planning surgeries using 3D computer modeling before even entering the operating room is a tremendous benefit for physicians and enables surgeons to comprehensively understand every case so they can plan which approach or permutation of each procedure is most appropriate. In some cases, new approaches and techniques are used based on information learned from the planning.

3D printing for orthopaedic surgery

In addition to 3D planning, Yale surgeons, clinicians, and researchers can now utilize the 3D Collaborative for Medical Innovation (3DC), which is based in the Department of Orthopaedics & Rehabilitation, to create 3D printed patient-specific models and tools. These precise anatomical prints allow surgeons to physically manipulate the exact portions of bone they will see in the operating room and offer a tactile reference for how surgical guides and jigs will fit beforehand, which can be extraordinarily helpful in complex deformity cases.

3DC Program Director and Lead Engineer Alyssa Glennon has spent more than the past decade working with some of the world’s preeminent orthopaedic surgeons to create 3D virtual surgical plans and patient-specific instrumentation for use in surgery for both upper and lower extremities. She explained more about how this new initiative is bringing advanced 3D technologies to Yale.

“Our primary objective is to support our clinicians and their cases by bringing engineering expertise into their surgical planning, and technology like 3D printing, artificial intelligence, and virtual reality into the operating room,” Glennon said. “With our in-house 3DC team, we offer patient-specific solutions wherever and whenever needed. This leads to benefits such as reduced operating times, reduced intra-operative fluoroscopy, enhanced precision, improved consistency, minimized complications, lowered costs to the hospital, and better patient outcomes, among others.”

Yale surgeons have typically worked with third parties in the past to design surgical plans or custom-print components to be used in surgery based on a patient’s unique anatomy. This would often be limited, however, by patient pathology, challenging timelines, and requirements for more complicated communication and delivery pathways. The goal of the 3DC is to offer those same services, and more, right here at Yale.

“With an in-house lab, we have many more options,” Glennon added. “Because the 3DC is within Yale School of Medicine, we are adjacent to the physicians and the operating rooms. We can make rapid changes based on real-time feedback from the clinicians, and we can work with faster lead times since no shipment is required. We can also support more pathology types and patient age brackets, circumventing any limitations of third parties. We can have engineering staff present in the operating room at the time of surgery, or we are just a short walk away.”

The first in-house 3D surgical case

The patient who underwent Lattanza’s first procedure had an injury to the forearm leading to functional impairment of the wrist, loss of strength, a reduced range of motion, pain, and cosmetic concerns. Malunions typically occur because of inadequate immobilization, poor fracture reduction, or underlying medical conditions that impact the process of healing bone.

The most common surgical procedure to repair a malunion is called an osteotomy. During the operation, a surgeon will cut the affected bones and move them into a better position and hold them in place with a plate and screws intended to keep the forearm stable while it heals. In the past, these cases were corrected “freehand” using the surgeon’s best judgment and X-rays to reposition the bone. However, realigning in all three planes of the deformity is not possible based on X-rays alone. Now, with the use of 3D planning, the deformity and anatomy can be corrected back to exactly how they were before the injury.

To accomplish this, the engineer and surgeon collaborate to review the case and plan together on the computer. This process involves using the patient’s unique anatomy from CT imagery. The mirrored, healthy arm is overlaid on top of the surgical side to comprehensively analyze the deformity and compare it to the healthy anatomy.

The surgeon focuses on anatomy, understanding of function, and what must be corrected, as well as a surgical approach and the hardware involved. The engineer does the processing of the CT or MRI, plus the 3D analysis, and recommends an osteotomy type and location to correct the deformity, and also virtually simulates the osteotomy and hardware placement for approval by the surgeon.

For this first case, Lattanza and Glennon discussed the possible correction strategies and collaborated to finalize the custom pre-surgical plan. Glennon then designed and 3D-printed patient-specific jigs and surgical guides and created 3D-printed anatomical models of the patient’s arm bones, which Lattanza was able to further examine, manipulate, and refer to during surgery.

Surgery was performed in April. First the radius, which is the forearm bone that runs from the thumb side of the wrist to the elbow, was corrected and plated based on the plan, and then the ulna — the other long forearm bone — was adjusted to make sure the wrist joint was fully restored.

3D applications beyond orthopaedics

While the 3DC specializes in supporting clinical cases, engineers like Glennon can collaborate on other projects in medicine. Engineering services of the 3DC include medical imaging data segmentation, the creation and/or modification of digital anatomical models and 3D analysis of such models, computer aided design (CAD) of medical devices and/or test devices, preparation and/or deployment of 3D digital models into extended reality, 3D printing, and other similar tasks.

“We want to offer the best patient experience possible through the 3DC, while enabling surgeons to achieve what seems impossible,” Glennon said. “With technology constantly evolving, we are in a unique position to help clinicians rapidly adapt so everyone benefits —most important, the patients.”

“Surgeons are like race car drivers, steering the case and driving the surgery to the finish line for the patient,” Glennon added. “Winning a race, though, requires support to empower the drivers to do what they do best. Engineering is part of the pit crew for the healthcare team.”

“We help physicians visualize pathology, offer new perspectives and in-depth analysis on surgical plans, streamline surgery to ensure operations run smoothly, and innovate on medical devices to improve the experiences for both the surgeons and their patients,” she continued. “We recognize that every single body is different and, by bringing technology like this into the hospital, it equips our health care teams with what they need to customize every case to best fit the individual.”

To date, the 3DC has supported five orthopaedic surgical cases involving both upper and lower extremities. Glennon is also in discussions with plastic surgery, radiation oncology, and other departments about the many opportunities to bring engineering and technology to support surgeon effectiveness and patient care.

Personalized medical education is a new frontier

Driven by rapid technological advancements in 3D printing and advanced imaging visualization techniques, personalized patient care is quickly becoming mainstream in medicine. Dedicated in-house engineering services can reduce production times, support unique innovation initiatives, and reduce the overall costs for health systems.

There are also untold uses for training sessions, educational opportunities, and further convergence with artificial intelligence and augmented reality to continue to develop the skillsets of both emerging and experienced surgeons.

Although this surgical case represents a first of its kind at Yale, work has been well underway to develop this niche of medical engineering professionals capable of supporting health care systems. Through a collaboration between Yale School of Medicine, the Yale School of Engineering & Applied Sciences, and the Department of Orthopaedics & Rehabilitation, Yale created the nation’s first master’s degree in personalized medicine and applied engineering in 2022, conceived by Lattanza and Glennon with the collaboration and hard work of Daniel Wiznia, MD, associate professor of orthopaedics & rehabilitation, and Steven Tommassini, PhD, a research scientist in the department.

The one-year advanced degree program is training the next generation of engineers, computer scientists, and medical professionals in using new technologies in 3D medicine and imaging. As it enters its third academic year this fall, dozens of students have learned how to develop and apply 3D technology to address surgical and medical conditions, with the goal of personalizing healthcare treatments to improve clinical outcomes.

“This technology allows us to treat every patient as an individual to formulate a treatment plan, whether it’s a surgical plan or a medical plan that is devised specifically for that individual rather than something that is more broad or general,” Lattanza said. “It is also a powerful learning and research tool that is breaking down assumptions that we have made about various orthopaedic problems when we could only see and study them in two dimensions."

“There are multiple ways that this is going to impact patient care, whether it’s from the 3D cellular printing aspect or the individualized surgery. It also could lead to projects that would involve better ways of educating students coming through either the medical school side or the engineering side in terms of accessing three-dimensional anatomy.”

Submitted by John Ready on May 23, 2024