Integration of technologies into the practice of a trauma surgeon: from robotic surgical systems to 3D printing of implants

Daria M. Orlova, Roza R. Abdullaeva, Daria D. Kozlova, Daria M. Gubina, Alina R. Khafizova. Integration of technologies into the practice of a trauma surgeon: from robotic surgical systems to 3d printing of implants. Cardiometry; Issue No. 30; February 2024; p. 103-108; DOI: 10.18137/cardiometry.2024.30.103108; Available from:

Over the past decade, the use of digital tools in the activities of trauma surgeons and orthopedists has increased dramatically. Research has shown that the use of digital technologies can improve the accessibility, efficiency and capabilities of medical services[1]. In particular, orthopedic digital care can provide more personalized, data-driven care and can assist physicians with assistive diagnostic functions based on medical principles and data analysis models, thereby encouraging more effective and efficient diagnosis and treatment decisions ranging from prevention to rehabilitation. Since the introduction of mechanization during the first industrial revolution, technologies and innovations have been actively used in healthcare [2]. Industry 4.0, through the integration of the Internet and new technologies (for example, communication technologies (ICT), digitization, artificial intelligence (AI), Internet of Things (IoT), cloud technologies, cloud computing, additive manufacturing (AM) and big data), marked the beginning of a “paradigm shift” in how to help patients It is available worldwide in all specialties, including surgical traumatology and orthopedics.

In traumatology and orthopedics, new technologies help doctors in the early diagnosis of various conditions, faster development of innovative treatment methods and perioperative patient monitoring. The overall goal of the technologies used by trauma surgeons is to increase surgical accuracy and accelerate postoperative rehabilitation, as well as provide optimized services to patients.

MATERIALS AND METHODS

In the process of preparing the review article, an array of literature was analyzed, the study of the content of which made it possible to achieve the purpose of the study – to study the features of integrating modern technologies into the practice of a trauma surgeon. Both theoretical studies of specialists and clinical cases were considered. Comparative and analytical research methods were used in the research process.

RESULTS

Technological innovations play a very important role in preoperative surgical planning, accurate intraoperative implant placement, restoration of biomechanical parameters and effective surgical procedures [3]. In the field of trauma care, the use of computer virtual reality, 3D printing methods for planning surgical treatment of fractures, real-time navigation, as well as computer and robotic surgery for total hip replacement and tumors has increased exponentially [4].

Self-monitoring and reporting (SMART) technology and sensory implants contributed to the clarification of diagnoses, objective intraoperative assessment of the balance of soft tissues, for example, during total knee replacement and postoperative monitoring of patients.

Additive manufacturing (AM), also known in the specialized literature as three-dimensional (3D) printing, is a process of combining materials to create objects from a digital 3D model layer by layer [5]. Over the years, this technology has been used in many industries, such as jewelry, mechanical engineering, textiles, etc. Since the end of the twentieth century, this technology has been increasingly used due to its versatility, ease of use and precise control both in terms of the production process and in terms of the possibility of manufacturing complex shapes and structures. Thus, printed templates may have properties that are in demand in biomedical applications. In the medical field, AM technology is used to create customized medical instruments, drug delivery systems, engineered tissues, skeletons for bone regeneration, orthoses or guides, as well as surgical implants.

In the last decade, there has been a growing trend towards customizing business models and technological advances, which has led to lower costs and knowledge required to use the AM. Computer-aided design (CAD) has also begun to be used in the medical field [6].

There are various methods of measuring and modeling existing objects to create digital models that can be worked on using CAD software. The most commonly used methods include computed tomography (CT) and 3D scanning. Three–dimensional scanning is the most practical and convenient solution for surveying topography.

Digital reconstruction, CAD modeling and conversion to the required format are performed using the appropriate software. In the biomedical field, the 104 | Cardiometry | Issue 30. February 2024

use of AM technology is expanding, it is especially widespread in the manufacture of orthoses. The advantages of orthoses made using AM technology are as follows: production is possible with lower costs, the possibility of prompt changes, faster production. Patients usually feel more comfortable with prosthetic sleeves made with AM devices than with traditional handmade sleeves [7].

AM technology makes it possible to manufacture spine orthoses, knee orthoses, ankle orthoses, wrist orthoses, foot orthoses, etc. Individual wrist orthoses for chronic wrist pain or for splinting a healing broken bone can also be made using AM technology. So, some experts evaluated the 3D printing of the orthosis on the wrist in case of a Collis fracture. Wrist radiographs were periodically performed to observe the angle of inclination of the palm, the angle of cubital deviation and the height of the beam.

Three-dimensional technologies are increasingly used in the work of a trauma surgeon. Exponential growth of digital applications in this field of activity is expected in the coming years. Until recently, surgical intervention planning was usually performed manually using X-ray images. They are currently being replaced by advanced scheduling software that includes multimodal and customized medical data. In addition to preoperative planning, digital technologies have become increasingly active in supporting the work of physicians. For example, it has been shown that during arthroplasty procedures, computer methods are superior to traditional implantation methods in terms of their consistency and accuracy [8].

While robotic technologies are mainly aimed at supporting doctors in performing precise and planned mechanical actions, augmented reality (AR) technology improves the surgeon’s work by increasing the amount of available medical information. AR refers to the real world augmented with virtual information, as opposed to virtual reality (VR), where the user experiences a completely virtual environment.

The growing interest in AR in traumatology is confirmed by practice. Surgical procedures in orthopedic surgery often use visual data, such as medical images obtained both before and during surgery, and often involve mechanical steps such as installing a screw or implant, so such technical tasks activate the use of AR in this area.

It is extremely important today to introduce the use of innovations already at the stage of training fu- ture doctors. Recent research shows that using virtual reality tools in residency can improve and transfer surgical skills to the operating room. In addition, virtual reality also allows you to standardize and objectively evaluate various parameters during training, including the accuracy of surgical techniques or the time required for various surgical steps.

Especially in the practice of arthroscopy, the use of virtual reality has aroused great interest and has become the subject of research in recent years [9]. Arthroscopic simulators can not only display three-dimensional anatomy, simulate surgical instruments and pathologies, but can also simulate realistic events, including cartilage damage or bleeding. Virtual reality simulator training can improve basic arthroscopic skills and reduce surgical time for residents.

Other possibilities of using virtual reality in orthopedic surgery residency include the practice of installing intramedullary rods and transpedicular screws, arthroplasty and fracture fixation [10]. Experts note that immersive virtual reality contributes better to the development of technical and non-technical skills compared to traditional methods of teaching in orthopedic residency.

Artificial intelligence-based techniques have made a significant contribution to improving medical imaging through data collection, reconstruction, analysis and interpretation. Artificial intelligence identifies the imaging examination required by the patient by including information extracted from the patient’s medical record and determines the appropriate protocol for it. The area where artificial intelligence is most often used is image interpretation, where AI is used to prevent human error and improve diagnostic accuracy.

Artificial intelligence-based algorithms were used to recognize the arthroplasty component on conventional radiographs, thereby providing a set of images and key imaging functions that a radiologist usually uses to distinguish between different types and brands of implants [11]. Thus, the artificial intelligence-based system tries to compare the known characteristics with the parameters of the implant, thus making an assessment. After completing this process, the accuracy of the system is established by comparing the established and known (correct) results, and inaccuracies or additional information can be entered into the system manually, and thus the process can be repeated.

Some studies have shown that in traumatology, AI is able to more easily and quickly detect wrist frac- tures, as well as spinal compression on radiographs (unlike medical specialists). Artificial intelligence can help automate the assessment of lumbar disc pathology on MRI using various assessment systems with almost 100% accuracy [12]. AI provides automatic segmentation of the area of interest, thereby improving the quality of image analysis, with many studies focusing on knee cartilage segmentation. Artificial intelligence-based image interpretation can be very accurate, but requires large sets of training data.

The advantage offered by AI in the field of medicine is the ability to predict clinical outcomes for patients based on datasets as well as medical images [13]. Risk assessment and predicting outcomes have always been a challenge in clinical medicine. Artificial intelligence can improve diagnostic accuracy, which reduces the risk of misdiagnosis.

DISCUSSION

Robotics used in the activities of a trauma surgeon can be divided into two categories: tactile and active systems. Tactile navigation systems are passive, synergistic, controlled by a surgeon and complement manual movement along a planned trajectory with the help of “virtual devices” to improve results [14]. For example, quantitative THR surgery is performed with advanced real-time soft tissue balancing using a navigation system to visualize, plan and control all stages and their effects on soft tissues.

Active robotic systems are fully automated, based on a preoperative plan, and performed without any surgical intervention. In the future, the “telemanipulated” master-control and slave-robot systems may play an important role in orthopedic surgery [15]. They physically separate the surgeon from the patient using a console that provides information (a 3D operating field) to the surgeon, who then uses master controllers capable of filtering, scaling and converting the movements of the surgeon’s hands into robotic arms (output data), which reduces possible tremor. This type of system can be used, especially in remote, hard-to-reach places, for example, with minimally invasive arthroscopic procedures. However, one of the main obstacles for this type of system is the lack of a tactile feedback channel to provide force or position information or potentially augmented information such as planned trajectories. The considered type of robotic system can make a radical revolution in orthopedic surgery in terms of minimal surgical access, elimina tion of critical anatomical structures, increased alignment accuracy, reduced workload on the surgeon in terms of ergonomics, as well as less exposure to radiation and, ultimately, improved patient treatment outcomes [16]. However, it should be noted that the integration of robotics into clinical and surgical workflows may require additional time and resources, which could potentially lead to a temporary decrease in surgical effectiveness at the initial stage of training, since surgeons and medical personnel require special training to work effectively with orthopedic robots.

The interaction of more advanced sensor technologies and technologies such as artificial intelligence, big data analysis and machine learning has also allowed the development of orthopedic devices with self-monitoring analysis and reporting technology [17]. These devices, such as braces, prostheses and implants with built-in sensors, can measure movement, strength and posture, aiming to improve and individualize patient care. It has been shown that for the upper extremities, the settings of wearable sensors provide important data on the results of rehabilitation of patients after surgery, for example, for fractures of the humerus head. The use of such telemedicine technologies provides advantages in postoperative monitoring, not only due to the ability to reach more patients and reduce costs, but also especially applicable to groups of patients in remote areas.

One of the specific applications of SMART devices is intelligent implants (II), which can be used to assess fracture healing and detect aseptic loosening in total joint replacement, periprosthetic infections and other infections of the musculoskeletal system. Assessment of the stage of fracture healing is crucial for providing patients with an adequate postoperative plan, taking into account load restrictions, as well as for early detection of non-joints [18]. Implantable data logger (attached to the plate) collects various fracture healing parameters that are transmitted wirelessly to the patient’s smartphone, which allows the attending physician to conduct a remote assessment. It has been shown that in addition to the treatment of fractures, II makes it possible to detect implant loosening and osseointegration during total hip replacement (THR) under experimental conditions by detecting mechanoacoustic waves and transmitting them to an external unit [19]. In total knee replacement, tibial component strain gauges can be used to understand intraoperative biomechanics, determine the alignment and size 106 | Cardiometry | Issue 30. February 2024

of implants, as well as to plan a postoperative care and rehabilitation regimen.

Sensors based on microelectromechanical systems (MEMS) attached to an implant are also used in the field under consideration, which can detect the presence of bacteria before biofilm formation by analyzing certain bacterial compounds. Other sensor technologies can detect active infections by detecting changes in pH, oxygen levels, and temperature, and therefore also allow monitoring of antibiotic treatment.

Orthoses and splints are made using 3D scanning and 3D printing technology. The main advantage is improved adaptation to the patient’s anatomy, which makes it possible to increase the effectiveness of treatment of injuries of the lower and upper extremities [20].

Orthoses made using 3D technology are a worthy alternative to traditional ones made by molding thermoplastic materials. Although their use is not yet very widespread, it provides numerous benefits such as reduced production time, reduced costs and increased patient satisfaction [21].

Individual implants made using 3D technologies allow reconstructing bone defects after surgery. The fixation and stability of individual implants are highly effective, so the clinical results, even in the short term, are quite favorable.

With regard to additive bone production, functional prototypes of clinically significant bone tissue, mechanically stable and with functional bone marrow, have been developed thanks to bioprinting. In the experimental field, synthetic polymer hydrogels are successfully used to create an extracellular matrix to which mesenchymal stem cells are added. They differentiate into mature bone tissue when stimulated by ceramics such as hydroxyapatite or bioactive crystals. The main problem at present is the vascularization of bioprinted bone tissue.

The combination and integration of imaging tests with bioprinting of cartilage and bone tissues will make it possible in the future to manufacture individual autografts for the treatment of cartilage and bone defects [22]. Thanks to autografts made by bioprinting, it will be possible to avoid both problems of autografts (accessibility and morbidity) and problems of allografts (compatibility and osteogenic ability).

Currently, artificial intelligence-based systems are used in various ways, for example, to detect fractures and osteoarthritis, determine bone mineral density and assess bone age [23]. The activity of trauma surgeons largely depends on the conducted imaging study, so they can make the correct diagnosis and prescribe treatment only after analyzing the images under consideration [24]. In this case, artificial intelligence can optimize the acquisition, reconstruction, analysis and interpretation of images, thereby providing effective assistance to orthopedic doctors.

The COVID-19 pandemic has greatly affected the work of doctors. They had to treat patients in special conditions, and very often they had to use digital technology to get in touch with patients who were far away. Trauma surgeons also had to deal with the existing pressures during the Covid-19 period. The complications that arose due to contact with the new virus put the medical staff in a difficult position, which is why they had to resort to additional solutions to cope with these difficulties. New technologies have facilitated the work of specialists, making it easier to perform surgical interventions [25]. Thus, doctors have the opportunity to save time and financial resources during these interventions.

CONCLUSIONS

In recent years, digital tools and applications have been rapidly developed and implemented in the field of traumatology and orthopedic surgery and are beginning to shape this medical field at all levels – clinical and logistical processes, patient care, research and education. Examples of technologies and digital tools that have flourished in recent years include the Internet of Things (IoT), next-generation telecommunications networks, artificial intelligence (AI), big data analysis, blockchain technologies and sensors. These technologies have significantly changed the possibilities of providing medical care, supporting and enhancing human cognitive functions and decision-making. They are closely linked and together can contribute to the formation of digital ecosystems. Digital applications that have already been implemented in healthcare systems include, among others, electronic medical records, telemedicine solutions, robotic operations, three-dimensional (3D) modeling, virtual modeling and visualization. Interactive virtual 3D visualization (combined with robotics) replaces standard two-dimensional (2D) imaging techniques, which improves preoperative planning and intraoperative functionality and, consequently, patient treatment outcomes.

Medical specialists should be ready to use new technologies, for which they need to undergo special training. Trauma surgeons should integrate new tech- nologies into modern medical practice, therefore they should constantly cooperate with scientists, providing them with the data necessary for their implementation in various applications. New technologies may revolutionize the field of orthopedics and provide optimized patient care in the near future. In the future, these technologies are expected to reduce burnout of doctors, as well as the time required to analyze a specific case or perform surgery, which will increase the number of visits or operations performed per day.