The Journal of Foot & Ankle Surgery xxx (2016) 1–5

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The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Case Reports and Series

Three-Dimensional Printing and Surgical Simulation for Preoperative

Planning of Deformity Correction in Foot and Ankle Surgery
James R. Jastifer, MD 1, Peter A. Gustafson, PhD 2
1
Borgess Orthopedics, Kalamazoo, MI
2
Western Michigan University, Kalamazoo, MI

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 4 A paucity of published data is available describing the methods for the integration of 3-dimensional (3D)
printing technology and surgical simulation into orthopedic surgery. The cost of this technology has decreased
Keywords:
computer modeling and the ease of use has increased, making routine use of 3D printed models and surgical simulation for
deformity correction difficult orthopedic problems a realistic option. We report the use of 3D printed models and surgical simu-
3-dimensional printing lation for preoperative planning and patient education in the case of deformity correction in foot and ankle
virtual osteotomy surgery using open source, free software.
Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.

The creation of a physical model from a computer-generated data
set is a manufacturing concept called rapid prototyping. The
application of this concept within medicine is not new, and the
adoption of this technology thus far has largely been in the setting of
patient-specific instrumentation in joint arthroplasty, preoperative
planning, procedure rehearsal, educational tools, and patient
communication (1–9). It is particularly useful when complex 3-
dimensional (3D) spatial relationships are important. In recent years,
the cost of 3D printing has decreased significantly. The purpose of the
present project is to report and describe the potential for application
of this technology within foot and ankle surgery.
Case Report
A 46-year-old male patient presented with chronic pain of
12 months’ duration after a motorcycle accident in which he had
sustained multiple cervical and thoracic spine fractures and a left
bimalleolar ankle fracture. The ankle fracture had been treated non-
operatively by the referring orthopedic surgeon. His pain was located
medially and laterally and elicited a score of 8 on a 10-point visual
analog scale. His preoperative American Orthopaedic Foot and Ankle
Society ankle-hindfoot score was 47 of 100 (10,11). The radiographs
are shown in Fig. 1. Nonoperative management failed, and the patient
elected to undergo corrective osteotomy of the fibula and excision of
the medial malleolus fragments.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: James R. Jastifer, MD, Borgess Orthopedics, 2490 South
11th Street, Kalamazoo, MI 49009.
E-mail address: jrjast@gmail.com (J.R. Jastifer).
Weightbearing radiographs and bilateral computed tomography
(CT) scans were obtained. The CT scan data were created using stan-
dard Digital Imaging and Communications in Medicine and imported
into a free, open source software program capable of performing
reconstruction algorithms for bone and soft tissue (3D Slicer; www.
slicer.org). A 3D surface model and compatible file were created,
and surface imperfections were smoothed using MeshLab (MeshLab,
version 1.3.3; www.meshlab.sourceforge.net). The CT data for the
contralateral ankle were similarly modeled and mirrored to show
the ideal shape of the abnormal side postoperatively. Both models
were printed using a commercially available 3D printing service
(Shapeways Inc, New York, NY; www.Shapeways.com). The printed
3D models allowed manipulation and a thorough understanding of
the deformity (Fig. 2).
A preoperative plan was developed to perform a corrective Z-sha-
ped osteotomy (Fig. 3). The surface models were converted into 3D
solid models. Subsequently, the osteotomy was simulated using
Boolean operations and translation and rotation of the distal fibular
fragment with a freely available CAD software program, FreeCAD,
version 0.14 (www.freecadweb.org) from the previously created 3D
model file. From these manipulations, we noted that the deformity
magnitude was 7 of external rotation, a 6-mm loss of fibular length,
and 5 mm of posterior translation (Fig. 4). It was determined that 7 of
internal rotation could be achieved with a posteriorly based 3-mm
wide bone wedge (Fig. 5).
The surgery was performed as planned, and the patient achieved
union at the osteotomy site (Figs. 6 and 7). At the final follow-up visit
at 7 months postoperative, the patient’s visual analog scale score had
improved to a score of 2 of 10, depending on the activities performed;
his American Orthopaedic Foot and Ankle Society ankle-hindfoot
scale score was 89 of 100.

1067-2516/$ - see front matter Ó 2016 by the American College of Foot and Ankle Surgeons. All rights reserved.
http://dx.doi.org/10.1053/j.jfas.2016.01.052
2 J.R. Jastifer, P.A. Gustafson / The Journal of Foot & Ankle Surgery xxx (2016) 1–5

Fig. 1. (A) Anteroposterior and (B) lateral radiographs of the preoperative deformity.

Discussion
3D printing was first used in foot and ankle surgery in 1997 for
the evaluation of intra-articular calcaneal fractures (12). Although
in this seminal work the 3D printed models were not found to be
statistically superior to software-based 3D reconstructions, we, and
others, feel that the physical models are helpful in preoperative
planning (9). In the present study, we report a method to create
virtual and physical 3D models from CT data sets using open source
software, open data formats, and a commercially available printing
source for use in foot and ankle surgery. We believe these types of
models will be invaluable for the preoperative planning of difficult

Fig. 2. (A) Lateral view of the abnormal and (B) normal sides demonstrating malunion of the fibula with posterior translation relative to the talus (white arrows) and loss of fibular length
(black arrows).
 J.R. Jastifer, P.A. Gustafson / The Journal of Foot & Ankle Surgery xxx (2016) 1–5 3

Fig. 3. Z-shaped osteotomy with removal of bone and creation of a free distal fibular fragment for manipulation.

Fig. 4. (A) Lateral view of normal and (B) abnormal sides after mobilization of the Z-shaped osteotomy.

Fig. 5. Screenshots demonstrating (A) restoration of the talar–fibular relationship (black arrows) and mesh imperfection from early osteophyte formation (white arrow). (B) After internally
rotating the distal fibular segment, the posterior bone wedge width could be measured to be 3 mm (black arrows).
4 J.R. Jastifer, P.A. Gustafson / The Journal of Foot & Ankle Surgery xxx (2016) 1–5

Fig. 6. Intraoperative image demonstrating (A) the 3-mm iliac crest bone wedge and (B) mobilization of the distal fibular fragment.

deformities and for patient education. To our knowledge, only 2
other descriptions of the use of 3D printing in foot and ankle sur-
gery have been published, other than the seminal work by Kacl et al
(12). The first study was by Chung et al (9), who used 3D printed
calcaneal fractures for the creation of preshaped calcaneal plates.
The second study was a case report by Giovinco et al (8), who
similarly used CT data for preoperative planning of Charcot foot
reconstruction.
We believe a couple of considerations are worth noting. First,
this technique can be performed using a standard computer,
available to most surgeons. Second, in an era of large capital ex-
penditures for electronic medical record and picture archiving and
communication system software, all the software used in the
technique we have presented is free and widely available to
community surgeons. Third, for surgeons with little interest in the
technicalities of performing this technique, we found the software

Fig. 7. (A) Anteroposterior and (B) lateral radiographs of the postoperative correction.
 J.R. Jastifer, P.A. Gustafson / The Journal of Foot & Ankle Surgery xxx (2016) 1–5
package OsiriX, version 6.5.2 (www.osirix-viewer.com) to be very
useful and easy to use for basic 3D reconstruction and surface
modeling.
In conclusion, we believe these techniques are useful in the pre-
operative planning of operative deformity correction of the foot and
ankle. We also believe this technology is becoming easier to use and
that low-cost commercial 3D printing has made this technology
available outside of academic medical centers.
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