University of Hong Kong: Sterilization & Infection Rates in 3D Printed Models & Guides Used Intra-operatively

Hong Kong researchers explore the use of 3D printed medical models but advance in a more unique direction with concerns over infection. Detailing their findings in the recently published ‘A review of the manufacturing process and infection rate of 3D-printed models and guides sterilized by hydrogen peroxide plasma and utilized intra-operatively,’ the authors discuss the use of innovative bespoke devices for surgical planning.

As 3D printing has made impacts within the medical field, medical professionals, patients, and their families benefit due to better avenues for diagnosis, treatment, and education for everyone involved. But there are even more specific uses for 3D printed medical models today in promoting patient-specific treatment with improved pre-operative planning procedures and even intra-operative processes.

“In the specialty of orthopedics, 3D models can allow for visualization of bony anatomy and implant contouring, whilst guides can be created to direct osteotomies as well as screw entry sites,” explained the researchers.

Much attention is paid to the strides being made due to 3D printing, but outside issues such as sterility are critical to the health of patients also. Typical methods include ethylene oxide (EtO) gas and hydrogen peroxide plasma, which is a result of excitation beyond the gaseous phase—with free-radical formation allowing for sterility.

Patient eligibility and exclusion. More than 300 models were rendered by computer software from 2015 – 2019. The numbers of models proceeding to manufacturing, sterilization and intraoperative use amounted to 124. A further ten patients were excluded from analysis due to use of materials other than ABS (7 patients) as well as failure to reach 3-months of follow-up subsequent to surgery (3 patients), leaving a total of 114 patients eligible for analysis.

To date, the University of Hong Kong has produced over 300 3D models and guides. Beginning in 2015, their orthopedic academic unit began 3D printing models and guides on-site; and while they were at first fabricating models exclusively for orthopedics, over time they also began 3D printing for ‘other surgical contexts’ too. The authors confirm that out of the 300 models produced, 114 have been used for intra-operative purposes. Their review goes on to cite details regarding cases using models and guides, identifying those in which infections occurred, and highlighting risk factors.

3D printed models and guides were designed using Meshmixer and printed on a Fortus 450mc 3D printer with ABS-M30i.

Aspects of model/guide manufacturing unique to intra-operative usage. a 3D-rendering of pelvis model with initials engraved upon the left ilium to allow for correct patient identification. b Photos taken by instrument nurse demonstrating proper grouping and assembly of a surgical guide for pedicle screw placement so corresponding components may be packaged and sterilized together. The assembled guide was contoured to fit upon bony surface landmarks of the posterior spinal vertebra, as demonstrated during testing upon a 3D-model of the same patient c and during the definitive surgery (d)

3D prints were sterilized with hydrogen peroxide plasma, and low temperatures prevented deformation in material.

“A surgical time-out procedure ensured that the printout was used for the correct patient, anatomical region and procedure, in accordance to initials upon the surface,” explained the authors. “Post-operatively, printouts were similarly subject to low temperature disinfection then returned to the surgeon in charge.”

Application of 3D printouts. a Intended purpose of 3D printout showing 59/114 (51.8%) of printouts being utilized as anatomical models and 55/114 (48.2%) as guides/jigs intra-operatively. b The 124 cases utilized intraoperatively spanned different regions of the body as well as surgical specialties. The numbers relevant to each region and their percentages in relation to the whole patient cohort is shown

The researchers examined 3D prints from 124 patients with models used intra-operatively during surgical planning and management.

“Seven cases were excluded as printouts were not constructed from ABS, of which four cases utilized nylon, two case utilized polyetherimide (Ultem1010 CG), and one case utilized cobalt chrome,” explained the authors.

“Three cases were excluded because of inadequate follow-up. A total of 114 models remained for subsequent analysis. Fifty nine out of 114 (51.8%) were anatomical models utilized on-table for planning and / or implant contouring. The remaining 55/114 (48.2%) were utilized as guides or jigs specific to patient anatomy to facilitate corrective osteotomies, screw insertion or pin placement.”

Ultimately, 10.9 percent of the guides or jigs developed infections, while 3.3 percent of the models developed infections at the surgical sites.

“All six cases of guides/jigs with infection were utilized to facilitate osteotomies. Both models with infection were utilized for implant contouring, one during fixation of a pilon fracture and the other for an orbital floor blowout fracture,” stated the researchers.

Pointing out that while the infection rate of 7 percent was comparable to previous literature published regarding traditional techniques, the authors realize the importance of users to ‘be aware of potential caveats,’ despite the overall safety of the application. There are also intrinsic challenges in the fabrication of patient-specific devices and ensuring the safety of tissue biocompatibility.

Cross-section of pelvis 3D model demonstrating irregular luminal spaces. a Arrows indicate surface openings upon the posterior ilium on a 3D model of the pelvis. The dotted line and arrowhead demonstrates the level of transverse sectioning subsequently performed. Cross-sectional appearance following software rendering b and physical sectioning c of the same pelvis model demonstrating irregular trabecular spaces contained within

Intraoperative use of osteotomy guide. a Software rendered image of guide intended for corrective osteotomy and shown upon the tibial shaft (b) with the osteotomy site marked in teal. c Intra-operative photo with the guide secured and oscillating saw engaged in preparation for osteotomy and (d) upon completion. e Intra-operative x-ray demonstrating reduction and fixation of the tibial shaft following corrective osteotomy. f Similar guide retrieved post-op demonstrating damage to ABS over the osteotomy slit with the potential to release debris

“It is worth noting that prior studies detailing infection-related outcomes of 3D printouts have not explicitly utilized them intra-operatively, and this is one of the first studies to have done as such. Our overall impression was that our process of sterilization and on-table usage is safe, and that surgical complexity and tissue manipulation as reflected by increased operating time were the main culprits for infection,” concluded the authors.

“In detailing the design, printing, and sterilization of 3D printouts as well as infection-related outcomes amongst this sizable cohort, we demonstrate that our production process is safe for continuation and may be adopted elsewhere.”

What do you think of this news? Let us know your thoughts! Join the discussion of this and other 3D printing topics at 3DPrintBoard.com.

[‘A review of the manufacturing process and infection rate of 3D-printed models and guides sterilized by hydrogen peroxide plasma and utilized intra-operatively’]

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Olaf Diegel’s Latest 3D Printed Guitar, the Xenomorph

“Here’s lookin’ at you, kid.” “Hasta la vista, baby.” “Life is like a box of chocolates.” “Game over, man, game over!” These are all memorable lines from iconic films, though some people may not recognize the last one. This is a line from one of my absolute favorite movies, the 1986 Aliens, and was uttered by Private Hudson, played by Bill Paxton, after (most of) the group narrowly escapes with their lives from a close encounter with the film’s titular creatures.

(Image: IMDB)

Needless to say, I was pretty excited about multi-talented Swedish design engineer Olaf Diegel’s latest 3D printed guitar: the Xenomorph, which is what “the Company” dubbed the fully-grown alien life form in the movie.

“Yes, this was a fun little project that really got the creative juices flowing,” Diegel told me in an email.

Formerly a professor at Lund University in Sweden, Diegel is now in charge of the Creative Design and Additive Manufacturing Lab at the University of Auckland in New Zealand, as well as a professor of additive manufacturing and product development. He is also a DfAM expert and loves completing creative 3D printed projects, like a tiny desktop distillery, a Skeletor microphone, a saxophone, and of course, guitars.

Olaf Diegel (Image: ODD Guitars)

Diegel also founded ODD Guitars, which focuses on making, according to the website, “personalisable, customisable guitars that explore the limits of 3D printing technologies and applications.” ODD uses Selective Laser Sintering (SLS) technology to make its guitars, and finishes the instruments with top quality off-the-shelf hardware.

ODD makes all kinds of guitars – there’s a Steampunk one, the Spider, American Grafitti, Beatlemania, and now the Xenomorph. I told Diegel how much I love the Alien franchise, and asked if he could tell me a little more about the making of his Alien-themed guitar.

“It started way back, about 3 years ago, when Fredrik Thordendal, from Swedish extreme metal band Meshuggah, suggested the idea of designing a biomechanical inspired guitar. And I also had a friend in the robotics field who had a lot of biomechanical tattoos, so those got me started on the guitar,” Diegel told me. “But other projects got in the way and I forgot about it until around 3 months ago, and picked the project up again, but that’s when it got morphed somewhere between a biomechanical and an Alien themed guitar which, indeed, were awesome movies…”

Diegel used mostly SOLIDWORKS, with “a bit of help from Meshmixer,” to sculpt some of the guitar’s more organic parts. He got some of the “rough details and proportions” for these parts from different Thingiverse models.

In response to a question from one of his LinkedIn followers, he said, “I did a very rough crude shape of the head and teeth, mainly trying to get the head carapace right in Solidworks and exported that as an STL, and then had to modify and massage the STL a whole heap in Meshmixer to make it look like the Alien.”

Then, he put it all together in Materialise Magics so he could merge all of the individual STL files into a single file. The body of the Xenomorph guitar was 3D printed in white nylon by i.materialise in Belgium, and its neck is a high-quality Warmoth maple neck, with a rosewood Fretboard, and a machined maple inner core that joins it to the bridge. The hardware includes Seymour Duncan hot-rodded humbuckers, a Schaller bridge and guitar strap locks, and Gotoh tuners, all in black for a good Alien vibe.

Diegel received the guitar back from Belgium right before Christmas, so he took advantage of the holidays to begin priming, sanding, and painting it.

“When I got to the colour, I started it off with ‘Hammerite’ paint, to give it almost the ‘worn’ grey metallic look of the spaceships in the Alien movies. But I then thought it needed a bit more colour to highlight the Alien bits, so took it to Ron Van Dam, the NZ airbrush artist who does the ‘fancy’ paint jobs on most of my guitars. He did an awesome job at giving it just the touch of colour it needed, as well as the glistening clearcoat that mimics the sliminess of the Alien Xenomorph,” Diegel told me.

He’s tried it out, and the 3D printed Xenomorph guitar “plays and sounds awesome.”

“This is guitar number 80, and I have one of each design in my collection, so have sold somewhere around 66 of them, so this is also makes a nice example of using 3D printing for low-volume high-value production,” Diegel said.

Other LinkedIn comments on his original post provide Diegel with some ideas for his next guitar. Harry Potter was one option, but I agree with the second one – a 3D printed Predator guitar, so the two can battle it out.

Discuss this story and other 3D printing topics at 3DPrintBoard.com or share your thoughts in the Facebook comments below.

[Images: Olaf Diegel, ODD Guitars, unless otherwise noted]

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3D Printing News Sliced: Linde Gases, Techniplas, Autodesk, America Makes

Today in Sliced, the 3D Printing Industry news digest, a 3D inkjet printer for electronics; the latest hardware and software releases at Formnext 2018; 3D printing helps improve cancer treatment and more. Formnext 2018 previews Linde Gases, a division of the Linde Group, a German engineering company, will present its ADDvance powder cabinet for metal materials used […]

3D Printing Strong and Sturdy Models

Sometimes a digital 3D design looks great in your software, but just can’t make it in reality. Here in the real world, a 3D model can only be so thin or fragile; models with very skinny wires or delicate parts might break after printing, or worse, not be able to 3D print at all. In this post, we’ll examine how auto-checks, human checks, and prototyping can help you design models that print successfully and are sturdy enough to handle repeated use or handling.

Auto-Checks

Shapeways provides guidelines and auto-checks to ensure that your uploaded models are printable in each material. For example, models created at Shapeways in Versatile Plastic are 3D printed in a durable nylon material in large batches using an industrial Selective Laser Sintering (SLS) printer. Versatile plastic has an intense post production process that includes extraction from powder and other models, cleaning and polishing, and even dying in different colors. Thin or narrow models can be easily broken or separated during post production. You can refer to the Design Guidelines for Versatile Plastic to determine how thin you can make the wires in your model. Here’s what those guidelines say about two success parameters, wall thickness and wire thickness:

In the guidelines above, “walls” are flat surfaces in your model and “wires” are more like strands. Notice that the recommended minimum for supported wires (those that connect to your model nearby on both ends) is 0.8mm. Processed models are put through a polisher, and Premium models are polished even more, so their minimum is higher: 0.9mm. Finally, the minimum for unsupported wires (which don’t inherit as much stability from the rest of the model) is even larger, at 1.0mm.

After you upload your model, Shapeways will perform a series of auto-checks to measure the thickness of walls and wires, among other things. If you click on “View 3D Tools” (or “View Issues”, if your uploaded model failed any checks) from within any Material view of your model, Shapeways will show you the results of these auto-checks. Here’s what that looked like for an early demo version of our Deltoidal Icositetrahedron model:

Although this model passed the Wire Thickness check, it fails the Wall Thickness check. The flattened notes at the vertices, and even some of the long wires, are considered “walls” here, and they aren’t thick enough to get over the 0.7mm minimum thickness requirement.

Checking and Fixing Thickness Issues

You can check the thickness of your model in whatever design software you used to create it. Or, another easy way to determine the minimum thicknesses of your design is to import your model to Meshmixer and use the Thickness tool in the Analysis menu. You can then use Meshmixer to make your design thicker, if needed, by selecting the model and then using Edit > Extrude (using the Normal Direction) or Edit > Offset to expand your model outwards or inwards. To thicken only selected parts of your model, you can take the more targeted approach described in our previous article Tutorial Tuesday 50: Using Meshmixer to Make 3D Models Thick Enough to 3D Print.

Prototyping

Even if your model passes printability checks, it’s worth printing a demo model to make sure that everything is okay. Sometimes, weak geometry can’t be determined until a model is actually printed and in your hand. Even if the print comes out successfully, it may be too delicate to hold up to its intended use. After our example model failed printability checks, we redesigned it so that it would just barely pass the checks and print successfully. It was a beautiful model, but it wasn’t long before it broke and warped:

I guess the moral of this story is: For best results, don’t try to just *barely* meet the print requirements; rather, make sure you are safely above them.

It’s worth pointing out that the size of the model itself matters as much as the thickness; the two go hand-in-hand. In the image above, the smaller model has the same wire thickness but is actually quite sturdy. The larger model is weaker because the wires are longer and have to hold up to greater stress when the model is handled. This means when prototyping, you can’t always get an accurate impression of the strength of your model by shrinking your model down, or designing a smaller version. Think about it this way: a wireframe model the size of your head will need a larger wire thickness than a model the size of your pinky!

In the end, we decided to thicken up our Deltoidal Icositetrahedron model significantly. The final version looks like the blue model on the right in the image below. It’s much stronger, and the cost of printing was only increased by a few dollars.

Human Checks

Sometimes models pass the online checks at Shapeways, but then fail a secondary check when they are actually ordered for printing. That’s because actual human beings at Shapeways check your model manually while they prepare it for 3D printing. They check for things that require a lot more expertise than the automatic computer checks, like how large your model is, how the different pieces of it fit together, and a lot of things that you or I might not think of. If they notice a problem then they will email you, and try to suggest ways that you can modify your model to increase the likelihood that it will print successfully.

Keep in mind that the printing engineers at Shapeways want to make sure that your model can print correctly not just once, but over and over. A model that passes the auto-checks and listed guidelines may have weak areas that may not break on the first print, but are likely to break the second or third time. This means that even if your print comes out well in a “Print it Anyway” situation, it still might not be stable enough to offer as an item in the Marketplace. Variations in print stability can arise from small differences in the printing and finishing process, like how the models are packed or oriented in the machines, or how it interacts with other models in the polisher.

As an example, consider our Hoop Knot Earring:

According to the Design Guidelines for Silver, we needed to make the wires at least 1mm in diameter. However, it’s best to exceed that significantly; consider that Silver models from Shapeways are 3D printed in wax, cast in Silver using lost wax casting, and then finished and polished. All of those procedures could damage a model with weak geometry. When we uploaded our Hoop Knot Earring for printing, it passed all of the auto-checks. But when we tried to order a print of it in Silver, the kind and knowledgeable human engineers at Shapeways said that the geometry of our model was too weak. They suggested adding connectors and even emailed me this helpful illustration:

Of course, in this case I couldn’t add connectors since that would have ruined the design; instead I had to make the wires thicker to give the model more stability. That resulted in the print shown below on the right. Later I tried to make a larger version, shown on the left, but an interesting thing happened; since the wires had to travel further, they were more prone to bending and becoming misshapen when I opened and closed the earring. Even though the larger model had thicker wires, in the end it didn’t work as well as a functional item.

In the end, you’ll have to use a combination of your own design analysis, automatic printability checks, manual printability checks, and physical prototyping to successfully print delicate or geometrically complex models. If you’ve got your own tips and tricks that help you through this process, let us know!

 

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Is your 3D model a mess? Make it printable!

What do you do when your 3D model is broken? I mean really broken, like “can’t even upload it” broken, or “half of my triangles are disappearing” broken? In this post we’ll talk about what to do when your usual mesh-repairing strategies fail and you need to bring out the big guns.

Let’s do this by example. So that we can follow exactly what’s going wrong, we’ll create a bad mesh by modifying an existing 3D model, my Deltoidal Hexecontahedron Catalan Bracelet:

We’re going to turn this into a tealight ring and add some solid faces to the wireframe to create a partially-enclosed look. The screenshot below shows what it looked like when I did this in TopMod; I added the closed triangle faces, and everything seems fine:

Nice! But when we try to upload to Shapeways, we get this error message:

First line of defense: Meshmixer

Meshmixer is a great first tool for modifying 3D meshes; for an in-depth example see our previous article Tutorial Tuesday 50: Using Meshmixer to Make 3D Models Thick Enough to 3D Print. But, in this case, when we open our broken file in Meshmixer to see what’s going wrong, the faces don’t load in. Although Meshmixer knows something is wrong here, its Inspector cannot repair it:

Second line of defense: MeshLab

Another great mesh-manipulation tool is MeshLab; for a primer on making simple mesh fixes with MeshLab, check out our previous article Tutorial Tuesday 5: Quick Fixes With MeshLab. It’s more complicated than Meshmixer, but can often take care of bad geometry like reversed normals and non-manifold faces. However, when we try to open our broken file in MeshLab we get this error:

After opening the file and looking through some of the Cleaning & Repairing filters, we see that there are some non-manifold faces:

The problem lies with where the new faces intersect. When we added those new triangles, we created some bad geometry where the pairs of coincident faces meet.  Alas, although MeshLab can identify these problems, it’s not able to actually fix them; usual MeshLab repair menu options such as “Remove Faces from Nonmanifold Edges” and “Remove T-Vertices by Edge Flip” are unsuccessful here.

The big guns: MakePrintable

If you have a Windows machine, you can try using the professional software Netfabb to repair this model. Netfabb is free for students, but for the rest of us it costs $30, per month. For professionals in industry this is probably reasonable, but for smaller businesses and hobbyists it’s pretty steep.

Luckily, with any platform and for no money at all you can have access to the extremely powerful mesh-repair services at MakePrintable. MakePrintable’s free cloud-based repair service lets you upload models to repair on their servers, and then download up to three repaired models per month. If you need more repairs than that, then for just $10 per month you can upgrade to their Pro service to get access to more features and unlimited downloads. Since Meshmixer and MeshLab can handle lots of simple mesh problems, the three-a-month restriction is not so bad. But does it work? The answer is YES, and in fact in my experience I have NEVER had a model that MakePrintable couldn’t repair. That includes successfully repairing my Tentacle Bowl, which was made from thousands of recursively-generated overlapping spheres that resulted in very broken internal geometry.

Let’s see what MakePrintable can do with our model. MakePrintable is a cloud-based service that works entirely in your browser, so to get started you just go to makeprintable.com:

Opening and repairing models is free in MakePrintable; it’s only the final download that counts against your monthly total. This means that we can upload our file and see if MakePrintable will fix our file without risking anything. When we upload our model, MakePrintable immediately recognizes its 20 non-manifold edges. Along the right sidebar are a number of fancy options for the Pro/Paid version, but for our purposes we can just use the default free settings.

So, can MakePrintable fix this bad geometry? Yes! Note in the image below that the right-hand model has no non-manifold edges anymore, so we should be in the clear. To download the repaired mesh, choose Save/Export, then 3D Model, then your filetype, then save the file to your computer. This action will reduce your three-a-month download count, so be sure you are happy with the repair before downloading.

In this case our initial broken mesh was very simple, and MakePrintable’s repaired mesh was much finer, with many more triangles. We could have controlled that if we were using the Pro/Paid version, but in this case we can reduce the mesh in Meshmixer and then run through mesh styling TopMod to get exactly the blocky-smooth style we want, which looks like this:

Fixed and ready for Shapeways

Our repaired and remeshed model now uploads to Shapeways, and we can order 3D prints of fancy Deltoidal Hexecontahedron Tealight Rings. Here’s what they look like after printing and photographing for our geekhaus store:

This was just a simple example with a handful of faces and edges causing bad geometry; it can of course get much, much worse. Do you have a broken model? Give these tools a try then upload your model again. Let us know how it goes!

Upload My Model button

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