Introduction: Additive manufacturing (AM), also known as rapid prototyping (RP) or Three-

Dimensional printing (3D Printing), was defined by the ASTM International Committee as the
“process of joining materials to make objects from 3-dimensional (3D) model data, usually layer
by layer, as opposed to subtractive manufacturing methodologies.” For 3D printing, the original
data required can be gathered from Computed Tomography (CT) scanning or Magnetic
Resonance Imaging (MRI), and 3D modeling design can be achieved with the aid of 3D
Computer-Aided Design (CAD) software. Once the preparation procedures are completed, the
printing process can be done bottom-up in one step. Unlike conventional manufacturing, 3D
printing is a material-specific and design-specific system, thus making it possible to fabricate
components with complex geometric shapes without requiring tooling or molds when printing.
In the 1990s, the advent of tissue engineering led to the application of biomedical scaffold
implants with appropriate structural design for repairing or replacing injured or diseased tissues.
However, manufacturing scaffolds with complex geometric structures for individual patients
using traditional machining methods was challenging. The possibility of using medical images to
create customized implants with controlled gradient structure, porosity, and pore size
demonstrated the potential of 3D printing technology in biomedical applications, especially in
orthopedic surgery. Today, many clinical trials have been conducted with 3D printed implants
in orthopedic applications. Surgeons and engineers are attracted to this technology and have
made considerable efforts to improve clinical outcomes.

3D printing offers benefits such as precise and personalized manufacturing, reduced waste, cost
efficiency, and faster production times, making it an attractive medical solution. The healthcare
sector's global monetary expenditure is growing at an alarming rate due to factors such as an
aging population, the increasing prevalence of chronic diseases, and technological
advancements. The estimated global healthcare spending in 2021 was $9.6 trillion, with a
significant portion going toward biomedical device design and development. The annual
spending on biomedical device design and development is estimated at $350 billion globally.
Proper and economical design, and production of biomedical devices and equipment can
positively impact societies by leading to cost savings, improved quality of care, better patient
outcomes, and a more sustainable future for the healthcare sector. Affordable and accessible
medical devices can help diagnose and treat diseases early, improving patient outcomes and
reducing healthcare costs in the long run. Additive manufacturing revolutionizes biomedical
engineering by enabling the creation of custom implants tailored to individual patient anatomy. It
offers improved fit, functionality, and comfort compared to traditional implants, and reduces
surgical times and facilitates rapid prototyping and iterative design.

Literature Review on AM in Orthopedics

Various authors have discussed the techniques and the technologies used in additive
manufacturing, the materials needed for an implant based on their cell-material interactions,
processing methods, mechanical properties, and chemical properties. Titanium (Ti) has excellent
mechanical properties and is considered biocompatible for implantation. They have also
discussed other materials that can also be used in 3D printing and bioprinting, such as natural
polymers, bio-ceramics, synthetic, and metals. Materials for 3D printing are needed to be
carefully chosen based on the proposed application of the construct. Some articles also discussed
the various dimensions of application of 3D printing in orthopedics, including implants and
prostheses for support, designing, and printing customized equipment for surgical planning, and
regenerating musculoskeletal tissues, including bone, cartilage, and soft tissues such as tendon,
ligament, and muscles. Researchers have also discussed the techniques and the technologies
used, the materials needed for an implant based on their cell-material interactions, processing
methods, mechanical properties, and chemical properties. Titanium (Ti) has excellent
mechanical properties and is considered biocompatible for implantation.

Wong et al.,[1] reviewed the application of 3D printing and its applications in orthopedic surgery.
The 3D printing technique is different from conventional methods in terms of design freedom
and flexibility. It has been applied successfully in bone tissue engineering for the manufacturing
of structurally advanced bio-scaffolds, surgical planning for complicated cases, and in the
manufacture of instruments for specific patients and implants to match individuals’ anatomy and
to achieve error-free resection.

The current status shows growing research work in the field of AM and its applications and
various challenges in the orthopedics field. This technology provides education about implant
designing and preoperative planning and also creates manufacturing flexibility. It allows the
fabrication of customized prosthetic implants as per the patient’s specific requirements in terms
of shape, size, dimension, and mechanical properties. Advancement of AM in orthopedics helps
in the printing of bones which are made accurately up of CaP and collagen. This technology can
overcome the challenges of engineers encountered in bone tissue engineering and regenerative
medicine fields.

Zheng et al.,[2] presented the repairing of critical-size defects, which are a challenge for
orthopedics’ surgeons. In the research article “3D bioprinting in orthopedics” translational
research” it has been carried out that 3D bioprinting is a technology that connects biomaterial
and living cells and is an important method that can be used in tissue engineering projects. 3D
bioprinting is a technology which can be used to create various scaffolds with a broad range of
advanced material and cell types. In the orthopedic field, the smallest bone defect that cannot be
repaired by itself is called a critical size defect, which will not heal without interference. The
maturity of 3D bioprinting technology helps us with a new way to promote bone regeneration
and also enables biomaterials and tissue engineering to be more closely integrated. As 3D
printing technology continues to become faster, affordable, and more accurate, its use in medical
research and biological manufacturing is likely to become routine, especially in the research
field.

Zamborsky et al.,[3] in their paper “perspectives of 3D printing technology in orthopedic surgery”

reviewed rapid prototyping technologies in medicine focusing on surgery, preoperative model
printing in fractures and patient-specific surgical guides, custom orthopedic implants,
instruments and plastic or metal implant prototypes, printing bone constructs-bone grafts,
periprosthetic infection, and spinal fusion. A detailed review of the topics, as mentioned above,
was done. Science, called regenerative medicine, has already succeeded in the engineering of
skin, cartilage, bladders, urine tubes, and blood vessels and so on can be successfully implanted
in patients.

Bedo et al.,[4] in their paper “method for translating 3D bone defects into personalized implants
made by AM,” has suggested a method for translating 3D bone defects into personalized
prosthetic implants, to be further produced by AM methods, based on CT imaging. This method
consists of delimiting bone defect areas in CT, isolation of defects, and the construction of a
virtual implant that is saved in the .stl format for 3D printing.

Surgical planning is the method used before the operation for pre-visualization of surgical
intervention, performed by using CT planning software. It is used to predefine the surgical steps
and to understand the details about surgical anatomy. Surgical planning has gone through
different stages in the evolution of modern medicine. AM is identified for better preoperative
planning, and the chances of exposure of radiation during surgeries can be reduced using this
technology. Surgical planning using 3D printing technology might reduce perioperative blood
loss and operation time, but there was the same complication rate.

Methods Followed to Construct Three-dimensional Model are:

Image acquisition and computed tomography scan preprocessing for three-dimensional

printing:

The foremost step for 3D printing is the acquisition of images. The image data are acquired from
computerized CT scan, MRI, or any other imaging methods. However, the most common one is
CT images for 3D printing in orthopedics surgery. Mimics software is developed for medical
preprocessing of images and used for the partitioning of 3D medical images (coming from
ultrasound, CT, MRI, etc.), and the result will be perfectly precise 3D models of a patient’s
anatomy. Mimics software converts Digital Imaging and Communications in Medicine format
files containing sliced CT images into sliced digital images. Various tools are used for afterward
processing of 3D models, including visualized tools and cutting tools. The cutting tool is used to
separate the single target region, whereas the visualized tool is used for maximal/minimal
projection, surface/volume rendering, and multiplane improvement.

Slicing and resizing the model:

Cura is powerful but easy to use 3D slicing software. The software is used for slicing 3D files
for different 3D printers. Cura supports STL, OBJ, and 3MF 3D file format. It also has a function
of importing and converting 2D images (.JPEG, .JPG, .PNG, .GIF, and .BMP) to 3D extruded
models. Using Cura, we can also adjust the size of the model. It also shows the exact time that
will be taken for printing the 3D model. Cura software has different printing parameters, mainly
printing speed, layer thickness, filling rate, printing temperature, support, and platform
attachment, and they can be set for a particular model.

Three-Dimensional Printing:
After slicing a 3D object, it generates a readable language for the 3D printer called G-code. The
3D printer reads G-code only, and the 3D object is printed using co-ordinates. 3D printers have
inbuilt 3D Printing software for the creation of actual 3D physical objects. The commands are
given by 3D printing software to 3D printers and material comes out of a nozzle in the form of
thread or wire, which is then joined together layer upon layer and solidifies to create a real 3D
object. The limitation of 3D modeling software is that it can only create a virtual model of an
object. Therefore, 3D printing software is used to translate the 3D model into a readable format,
such as G-code for the 3D printer. Figure 2 shows the printing of orthopedics parts using FDM
3D printing. The quality of the model is determined by the critical parameter, i.e., printing speed.
If the printing speed is high, then the quality of the model will be reduced, and it can cause
machine failure too. Furthermore, faster printing speed means that there is not enough time for
each layer to cool down and solidify to a particular shape. This will result in overheating, and
this will further lead to easy deformation of the model. The nozzle temperature is determined by
the type of material used for 3D printing.

Design and Printing of Patient-Specific Fracture Bone Implant:

For the printing process, the CT scanning of the fractured bone is used, which is most
appropriate for preoperative planning in orthopedic surgery and trauma. This method is also
useful for defining the fracture in intricate bone anatomy and studying geometry. The primary
step used in this process is as under: 1. CT of a patient-specific fractured bone 2. Conversion of
CT data into the CAD model using Mimics software 3. 3D printing of fracture bone using FDM
3D printing 4. Surgical planning. The scanned CT data are converted into a virtual 3D model
using the Mimics software. The use of 3D modeling facilitates the implementation of fracture
operative techniques. The main purpose of printing this object is to facilitate better geometry,
shape, and size for surgical planning. The accuracy, surface finish, and the strength of the object
also depend on the material used for the printing.

Post-processing:
Apply post-processing techniques like heat treatment, surface modification (e.g., polishing,
sandblasting), and machining to assess changes in material properties and surface quality.

Mechanical and Structural Analysis:

Using simulation tools to perform mechanical tests (e.g., tensile strength, fatigue, and impact
resistance) on both pre- and post-processed implants.
Then we analyze the structural integrity of the implants, taking into account stress distribution
and potential failure points and simulate surface treatments to evaluate roughness, finish, and
osseointegration potential using surface analysis tools within the software.

Biocompatibility Estimation:
Although biocompatibility is generally tested experimentally, simulations can provide insights
into how surface modifications might improve biological responses based on existing research.

Implantation of patient-specific implant

A 20-year-old male patient, who is right hand dominant, presented to the clinic with fracture of
distal-end radius of the right side. He was a musician by profession. He was very anxious about
the proper functionality of his hand after the surgery. Thus, the concern of the patient for his
future in the field becomes a prime concern for us. The various benefits in the latest
advancements in medicine (3D printing) were discussed with the patient such as preoperative
accurate assessment of the bony injury, technique, and ease of reduction of the multiple fracture
fragments and preparation of patient-specific jig, that can facilitate accurate surgery to
reconstruct the fractured bone like the one before the fracture was amongst the few advantages
described. Furthermore, the plate to be implanted could be chosen and premolded before the
actual surgical day. All these processes not only helped us to achieve an accurate reduction but
also provided an excellent functional outcome, which is indirectly a result of reduced surgical
time, lesser anesthesia time, and lower blood loss. The patient returned to the activities of daily
living in 3 weeks with a full range of motion. After 3 months, he was able to play his musical
equipment.

Thus, we may conclude that AM enables personalized implants, prosthetics, and implantation,
which is valuable in the field of orthopedics. This technology fabricates the implants of any
desired shape rapidly. It increases the patient’s safety and satisfaction and also helps to give
training to medical students and doctors for better understanding of various types of
patient-specific pathology, fractures, and anatomy. In the FDM process, PLA was used to create
the bone. The temperature of the material was increased so that it comes out from the nozzle in
the molten form. It increases the accuracy and strength of the bone implant. A comprehensive
evaluation of a patient’s anatomy is made by using 3D printing. It is done before the actual
surgery and therefore helps to develop more accurate surgical plans. The anatomy of every
patient is different; therefore, 3D printing of PSI seems more beneficial than traditional
mass-production methods of implant manufacturing.

Limitations
The major limitation of AM is the huge cost of software, hardware, skilled operators,
maintenance, as well as printing material. Furthermore, AM includes the timescale model
production, which varies according to different parameters such as density, porosity, and
dimensions. Furthermore, data processing and image accomplishment take time. In orthopedics,
sometimes mechanical strength is not achieved that is required and thus makes the object
unusable for long-term use. In the case of FDM 3D printing, one of the significant disadvantages
is that the process must be uninterrupted, if once the machine is disturbed, then the entire process
is to be repeated. While the machine is working, the operator must take care that the material is
appropriately fed to the nozzle. The study in this field requires a much higher type of machines.
While printing the bone (object), many factors of 3D printing technology are still not considered.
The printing of defected bone is limited only for the use of surgical planning and not for the
implementation of the human body.

Future Scope
Nowadays, AM is also used in orthopedics. In this field, it is used for various applications in
surgical planning, manufacturing of PSI, bone tissue engineering, drug delivery, traumatology,
bioprinting, and orthopedics’ corsets. We need more biocompatible material available for 3D
printing at lesser rates. Also, bio meta-materials are going to be used to make deployable
implants. As the implant reaches the intended implantation site, it will take a full size and full
load-bearing due to the activation of the deployment mechanism. Available machines of 3D
printing take more time for jobs needing intricate detailing and better finishing. The time taken
for the 3D printing of a better surface finish product needs to be reduced. The future study to
focus on the risk of implant-associated infections in orthopedics’ implants.
References
1. Wong, T. M., Jin, J., Lau, T. W., Fang, C., Yan, C. H., Yeung, K., ... & Leung, F. (2017).
The use of three-dimensional printing technology in orthopaedic surgery: a review. Journal
of Orthopaedic Surgery, 25(1), 2309499016684077.
2. Zheng, X., Huang, J., Lin, J., Yang, D., Xu, T., Chen, D., ... & Wu, A. (2019). 3D bioprinting
in orthopedics translational research. Journal of Biomaterials Science, Polymer
Edition, 30(13), 1172-1187.
3. Zamborsky, R., Kilian, M., Jacko, P., Bernadic, M., & Hudak, R. (2019). Perspectives of 3D
printing technology in orthopaedic surgery. Bratislava Medical Journal/Bratislavské
Lekárske Listy, 120(7).
4. Bedo, T., Munteanu, S. I., Popescu, I., Chiriac, A., Pop, M. A., Milosan, I., & Munteanu, D.
(2019). Method for translating 3D bone defects into personalized implants made by additive
manufacturing. Materials Today: Proceedings, 19, 1032-1040.
5. Ariz, A., Tasneem, I., Bharti, D., Vaish, A., Haleem, A., & Javaid, M. (2021). Is additive
manufacturing of patient-specific implant is beneficial for orthopedics. Apollo
Medicine, 18(1), 33-40.

6. https://typeset.io/