Journal of Orthopaedic Translation 42 (2023) 94–112

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Journal of Orthopaedic Translation

journal homepage: www.journals.elsevier.com/journal-of-orthopaedic-translation

Review Article

3D printing metal implants in orthopedic surgery: Methods, applications

and future prospects
Meng Meng a, b, Jinzuo Wang a, b, Huagui Huang a, b, Xin Liu a, b, Jing Zhang a, b, Zhonghai Li a, b, *
a
Department of Orthopedics, First Affiliated Hospital of Dalian Medical University, Dalian, PR China
b
Key Laboratory of Molecular Mechanism for Repair and Remodeling of Orthopedic Diseases, Liaoning Province, PR China

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Currently, metal implants are widely used in orthopedic surgeries, including fracture fixation, spinal
3D printing fusion, joint replacement, and bone tumor defect repair. However, conventional implants are difficult to be
Custom metal implants customized according to the recipient's skeletal anatomy and defect characteristics, leading to difficulties in
Patient-specific orthopedics
meeting the individual needs of patients. Additive manufacturing (AM) or three-dimensional (3D) printing
technology, an advanced digital fabrication technique capable of producing components with complex and precise
structures, offers opportunities for personalization.
Methods: We systematically reviewed the literature on 3D printing orthopedic metal implants over the past 10
years. Relevant animal, cellular, and clinical studies were searched in PubMed and Web of Science. In this paper,
we introduce the 3D printing method and the characteristics of biometals and summarize the properties of 3D
printing metal implants and their clinical applications in orthopedic surgery. On this basis, we discuss potential
possibilities for further generalization and improvement.
Results: 3D printing technology has facilitated the use of metal implants in different orthopedic procedures. By
combining medical images from techniques such as CT and MRI, 3D printing technology allows the precise
fabrication of complex metal implants based on the anatomy of the injured tissue. Such patient-specific implants
not only reduce excessive mechanical strength and eliminate stress-shielding effects, but also improve biocom-
patibility and functionality, increase cell and nutrient permeability, and promote angiogenesis and bone growth.
In addition, 3D printing technology has the advantages of low cost, fast manufacturing cycles, and high repro-
ducibility, which can shorten patients' surgery and hospitalization time. Many clinical trials have been conducted
using customized implants. However, the use of modeling software, the operation of printing equipment, the high
demand for metal implant materials, and the lack of guidance from relevant laws and regulations have limited its
further application.
Conclusions: There are advantages of 3D printing metal implants in orthopedic applications such as personaliza-
tion, promotion of osseointegration, short production cycle, and high material utilization. With the continuous
learning of modeling software by surgeons, the improvement of 3D printing technology, the development of metal
materials that better meet clinical needs, and the improvement of laws and regulations, 3D printing metal im-
plants can be applied to more orthopedic surgeries.
The translational potential of this paper: Precision, intelligence, and personalization are the future direction of
orthopedics. It is reasonable to believe that 3D printing technology will be more deeply integrated with artificial
intelligence, 4D printing, and big data to play a greater role in orthopedic metal implants and eventually become
an important part of the digital economy. We aim to summarize the latest developments in 3D printing metal
implants for engineers and surgeons to design implants that more closely mimic the morphology and function of
native bone.

* Corresponding author. Department of Orthopedics, the First Affiliated Hospital of Dalian Medical University, No. 5, Longbin Road, Dalian Development Zone,
Dalian, Liaoning Province, PR China.
E-mail address: lizhonghai@dmu.edu.cn (Z. Li).

https://doi.org/10.1016/j.jot.2023.08.004
Received 21 May 2023; Received in revised form 28 July 2023; Accepted 2 August 2023
Available online 01 September 2023
2214-031X/© 2023 The Authors. Published by Elsevier B.V. on behalf of Chinese Speaking Orthopaedic Society. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Meng et al.
1. Introduction
With the progressive aging of the world's population, many elderly
populations are prone to orthopedic diseases such as fractures due to
advanced age and metabolic diseases, resulting in pain or loss of function
[1]. By 2050, it is expected that the population aged 65 or elder will
increase to about 20% of the global population [2]. This increase in the
elderly population, coupled with changes in work and lifestyle, has also
led to an increasing number of young people suffering from degenerative
diseases such as osteoarthritis and osteoporosis. Solving these diseases
usually requires replacement or repair of the body's skeleton, so the de-
mand for orthopedic implants is growing rapidly [3].
Orthopedic implants can be made of metal, bioceramic, biopolymer,
or composite biomaterials [4]. With the mechanical strength re-
quirements of orthopedic surgical implants, surgeons often choose im-
plants made of metal to provide support which enables early movement
of the patient and prevents complications [5]. Although metal implants
have been used in surgeries such as fracture fixation, spinal fusion, joint
replacement, and bone tumor defect repair, traditional methods of
implant fabrication have many limitations that make it difficult to meet
the individual needs of patients [3,4]. It is important to match the me-
chanical properties between the metal implant and the bone, as higher
elastic modulus tends to produce stress shielding, leading to subsequent
bone resorption and eventual implant failure [6].
Precision, intelligence, and personalization are the future direction of
orthopedics [7]. After fulfilling all the requirements for an ideal ortho-
pedic implant, the diseased area can produce healthy and functional bone
with the help of metal biomaterials [2]. To obtain such ideal bio-
materials, advanced manufacturing techniques are required that can
precisely fabricate complex geometries, reduce excessive mechanical
strength, increase cell and nutrient permeability, and promote angio-
genesis and bone growth [8,9]. Three-dimensional (3D) printing tech-
nology, also known as additive manufacturing (AM), or rapid prototyping
(RP), has revolutionized the biomedical field as an advanced digital
manufacturing technology [10]. In the clinic, physicians can use the
patient's medical imaging data, such as computed tomography
Figure 1. The process of 3D printing metal implants (A) Personalized acquisition of patient imaging data, such as X-rays, CT, or MRI, (B) The orthopedic surgeon and
engineer use CAD software to create a data model of the implant based on the patient's needs, which is converted into a series of 2D layer slices and saved as
stereolithography (STL) data, (C Computer-controlled fabrication of the appropriate 3D printing technology melts the metal material layer by layer to print the molded
model, and (D) Final finishing of the implant, such as grinding, coating, and surface oxidation techniques.
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Journal of Orthopaedic Translation 42 (2023) 94–112
(CT)/magnetic resonance imaging (MRI), to individually design and
fabricate patient-specific orthopedic implants to fit the patient's surgical
requirements [1,2,5]. With the development of digital technology,
computer-aided design (CAD) techniques, and surgical technology, there
is an increasing interest in patient-specific metal implants with similar
structural and functional properties to natural bone [1,11]. Furthermore,
3D printing technology has the advantages of low cost, fast
manufacturing cycle, and high reproducibility, shortening the time of
patient surgery and hospitalization [5,12]. In this paper, we review the
characteristics of 3D printing methods and biometals and summarize the
properties of 3D printing metal implants and their clinical applications in
orthopedic surgery. Based on this, we systematically discuss the potential
possibilities for their further promotion and improvement.
2. Metal 3D printing methods
Metal 3D printing methods have been available for at least 20 years
and are widely used in the biomedical field [5]. Traditional
manufacturing methods are limited to the fabrication of complex bone
implants, and it is difficult to simulate the structure of cortical and
cancellous bone in real bone tissues [2]. Compared to traditional
manufacturing methods, metal 3D printing methods have unparalleled
advantages in terms of high production accuracy, the ability to print
controlled microporous structures, and achieving perfect replication of
real bone tissue [8,11]. The process of fabricating 3D printing metal
implants can be divided into four parts (Fig. 1). (1) Personalized acqui-
sition of patient imaging data, such as CT or MRI. (2) The orthopedic
surgeon and engineer use CAD software to create a data model of the
implant based on the patient's needs, which is converted into a series of
2D layer slices and saved as stereolithography (STL) data. (3)
Computer-controlled fabrication of the appropriate 3D printing tech-
nology melts the metal material layer by layer to print the molded model,
and (4) Final finishing of the implant, such as grinding, coating, and
surface oxidation techniques. In this section, the currently used methods
for metal 3D printing are introduced and summarized in Fig. 2 and
Table 1.
M. Meng et al. Journal of Orthopaedic Translation 42 (2023) 94–112

Figure 2. Metal additive manufacturing (A) selective laser sintering [13], (B) selective laser melting [14], (C) electron beam melting [15], (D) laser direct metal
deposition [16], (E) laser induced forward transfer [17], (F) atomic diffusion additive manufacturing [18], reproduced with permission.

Table 1
The detailed classification of 3D printing methods for biometals.
Technique types Description Materials Cost Advantages Limitations

Selective laser The laser selectively scans and melts a layer Titanium (Ti) alloys; $$ 1 Fast print speed, up to 25.4 1 Powdery surface finish
sintering (SLS) [2] of material powder at a set speed and energy cobalt-chromium mm/h;
density (Co–Cr); stainless steel 2 High material utilization, no 2 Requiring post-printing
(SS); nickel (Ni)–Ti alloys sintered powder can be process
recycled repeatedly;
3 No significant need for support 3 Process with odor
structures generation
Selective laser melting Using a high-powered laser to completely Almost all metal alloys $$$ 1 Higher accuracy than SLS 1 Low speed
(SLM) [19] melt each layer of metal powder, rather than (0.02 mm);
just sinter it, results in a very dense and 2 Variety of materials; 2 Possible delamination and
strong printed object porosity
3 Smooth surface 3 High temperature gradients
4 Suitable for complex internal can lead to stress and
structures misalignment within the
final product
Electron beam melting Similar to SLM, it is capable of producing a Ti alloys; Co–Cr $$$ 1 High forming efficiency; 1 Less accurate
(EBM) [20] dense metal structure. The difference 2 High product strength and less 2 Poor surface finish and
between these two techniques is that EBM impurity due to vacuum requires the post-printing
uses an electron beam rather than a laser to melting; process
melt the metal powder 3 Fabrication of brittle materials 3 Expensive equipment
due to reduced cooling rate 4 Long printing time
Laser direct metal During the process, a nozzle aggregates Almost all metal alloys $$ 1 Localized heat input and 1 Poor surface roughness
deposition (LDMD) powder on its working plane, while its laser consequently, low distortion,
[21] beam centers to a point. The laser solidifies allowing printing of metal with
the powder which it shines on, creating a high melting point;
stacked entity at that position 2 Fabricate functional gradient 2 Uncontrollable composition
materials and parts and microstructure
3 Perform surface defect repair 3 Complex residual stress
of parts
Laser-induced forward The laser is exposed to a thin layer of metal Chromium, tungsten, $$ 1 Very small-scale part 1 Small-batch production
transfer (LIFT) [22] material, resulting in a thermal stress wave or gold, Ni, aluminum processing;
evaporation that subsequently yields the 2 Easy operation and without 2 Small size and thin layers
ejection of a liquid micron-sized droplet onto vacuum environment or
a transparent substrate cleanroom;
3 Wide range of printed 3 Weak structural support
materials;
4 High accuracy
Atomic diffusion Processes use a wire which is made of metal Sinterable metal powder: $ 1 The density of parts can reach Longer lead time to a strong
additive powders enclosed in a thermoplastic polymer SS, Ti alloys about 95–99%; part
manufacturing that works as a binder for the metallic 2 Low cost;
(ADAM) [23] particles 3 High-quality surface;
4 Precise-complex structure;
5 Excellent isotropic
performance;
6 Batch production

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M. Meng et al.
2.1. Selective laser sintering
Selective laser sintering (SLS) is a type of powder bed melting tech-
nology, patented in 1989 [2,13]. In this process, the powder is first
preheated to a temperature below the sintering point so that the powder
does not melt completely. Then the powder is evenly distributed and
dispersed using a powder spreading roller, which focuses the laser beam
precisely on the powder layers and scans the cross section of the part.
Lower the print platform and repeat the process until all layers are sin-
tered [24]. The outstanding feature o f SLS is that the powder can be used
as support without laser sintering, so there is no need to print additional
support materials [25]. Furthermore, SLS has the advantage of a wide
selection of molding materials [26]. Although it can reduce the heat of
material molding to a certain extent, it directly leads to the problems of
porousness, low density, high surface roughness, and insufficient me-
chanical properties of the implant due to the presence of solid-phase
particles, which require post-printing treatment [27]. In addition,
odors are generated during the production process. Li et al. [28] found
that the microstructure and mechanical properties of Ti alloy bone
scaffolds fabricated by SLS technology were more similar to cancellous
bone without significant stress shielding, and could be more effective in
achieving early stability after implantation in vitro and in vivo. In
addition, Kawaguchi et al. [29] used the SLS technique to fabricate a
bone scaffold for implantation into the dog femur and found it could
promote bone formation and vascularization at the site of the bone
defect.
2.2. Selective laser melting
Selective laser melting (SLM) is also a type of powder bed melting
technology and was first proposed in 1995 [2,14]. The technology was
developed based on SLS, so the basic principles of both are similar. The
difference is that the laser temperature of SLM is higher and will
completely melt all the metal powder unformed. Therefore, the entire
printing process in SLM needs to be carried out in a chamber protected by
an amorous gas to avoid oxidation of the metal [19]. Compared to metal
products fabricated with SLS, SLM has better molding properties, higher
density, better mechanical properties, and higher dimensional accuracy
[30]. The subsequent processing required in conventional processes such
as casting and machining is not required. At the same time, this tech-
nology allows the processing of a wide range of medical metals, such as
stainless steels (SS), titanium (Ti) alloys, and cobalt-based alloys, to form
implants with complex structures [31]. Because of these, SLM has
become an ideal method for fabricating complex or functional gradient
structures with precise dimensions. This encourages its use in the prep-
aration of metallic implants and scaffolds. However, it has some disad-
vantages. The process parameters of SLM are complex and the
manufacturing speed is very low. Thinner layer thicknesses are required
for greater accuracy, especially when faced with complex parts that
require a large number of support structures, the printing cost and time
for SLM will increase significantly, making it difficult to be used in
large-scale manufacturing [32]. Residual stress is the common phe-
nomenon that may cause interlayer debonding and stress cracking. These
cracks may decrease the mechanical properties and dimensional accu-
racy [33]. The heating/cooling rate of the SLM process is high, which
leads to high residual stress in final products. It is difficult to deposit
metallic powder on the former layer uniformly, which may lead to
delamination and porosity. Thus, it is important to minimize the balling
effect, such as increasing laser power or reducing scan speed. SLM has
been utilized to fabricate orthopedic implants such as replacements for
zygomatic bone and finger [34]. Wang et al. [35] designed a novel
trabecular acetabular cup by SLM technique and performed compression
tests. The results showed that the compressive strength and elastic
modulus were consistent with the mechanical properties of human
cortical bone. Przekora et al. [36] found that SLM-fabricated mesh
Ti6Al4V cages have all the characteristics of an optimal spinal implant,
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Journal of Orthopaedic Translation 42 (2023) 94–112
such as a low risk of implant subsidence and providing good osseointe-
gration at the bone-implant interface.
2.3. Electron beam melting
Similar to SLS and SLM, electron beam melting (EBM) is a common
3D printing technique for metal implants that uses a high-energy, high-
speed electron beam to bombard metal powders, melt the powdered
material and form the product [20,15]. EBM is one of the most common
3D printing techniques applied for orthopedic metal implants, such as
acetabular cups with outer porous mesh structure regions, femoral knee
implants, and intramedullary rods [2]. The electron beam is controlled by
a set of electromagnetic coils that precisely point the electron beam at the
area to be melted. The electron beam selectively moves as it melts the
powder, leaving the metal powder unfused. Since EBM uses electron
beam heating to produce higher temperatures, it is mostly used to print Ti
and cobalt-chromium (Co–Cr) alloys [20]. Moreover, compared to laser
beam melting of metal powders, EBM can create a vacuum environment
very well by the properties of the high-energy electron beam itself,
without having to set up an environment specifically for isolating the
material powder from the outside air. The electron beam has the ad-
vantages of a high energy utilization rate, a high material absorption rate,
better stability, and low operation and maintenance costs. This also al-
lows EBM to print parts with high density, high strength, and low risk of
deformation [37]. However, the processing time of EBM could be longer
than SLM in order to cool down the implants to room temperature.
EBM-built implants also exhibit rough surfaces because of the attachment
of a large amount of partially melted particles, which is similar to SLM
[38]. What's more, it still has deficiencies that need to be improved such
as low accuracy and expensive equipment. Liu et al. [39] prepared
personalized porous bone plates by EBM and coated them with tantalum
(Ta) metal. The bone plates exhibited a similar elastic modulus to cortical
bone and did not generate stress shielding. Notably, EBM has many
unique clinical applications in the field of bone repair, ranging from a
simple acetabular cup to the fifth toe, from the hand–wrist complex to the
shoulder, and from vertebral replacement to cranio-maxillofacial recon-
struction [39]. Implants manufactured by EBM, such as acetabular cups,
are also approved by the U.S. Food and Drug Administration (FDA) and
were CE certified in 2010 and 2007, respectively [34].
2.4. Laser direct metal deposition
Laser direct metal deposition (LDMD) is a metal 3D printing tech-
nology developed on the basis of laser cladding technology combined
with SLS [16]. It was first proposed by Sandia National Laboratories in
the 1990s [21]. Many universities and institutions have independently
studied LDMD, leading to various names for the technology, such as laser
engineered net shaping (LENS), directed energy depositioin (DED), laser
rapid forming (LRF), etc. Similar to SLS, the laser system is also the
heating element, but the difference is that the LDMD heats and melts the
metal substrate [40]. Due to the large laser focused spot, the printing
accuracy is generally above 1 mm. Although the molding efficiency is
greatly improved, the dimensional accuracy and surface finish are not
ideal, and further mechanical processing is required before actual use.
LDMD requires thermal cycling of the metal several times at melting and
lower temperatures, and this thermal behavior leads to complex micro-
structural changes. As a result, it is difficult to control the composition
and structure of the part [41]. At the same time, during implant fabri-
cation, the metal experiences rapid heating and cooling, which can easily
generate complex residual stress distributions that can lead to cracking
and deformation of the metal implant. This high residual stress also af-
fects the mechanical properties and corrosion resistance [42]. The un-
controllability of composition and microstructure, and the formation of
residual stresses are two major disadvantages of LDMD technology [43].
In 2007, Krishna et al. [44] fabricated Ti hip stems by LENS technology,
which improves the machining flexibility of complex shaped implants
M. Meng et al.
and reduces the stiffness of load-bearing implants. Balla et al. [45] suc-
cessfully deposited a Ta coating on Ti using LENS to enhance the
osseointegration properties. Samuel et al. [46] described the corrosion
resistance of bone implants made of laser-deposited Ti–Nb–Zr–Ta alloys
as superior to Ti–6Al–4V alloys with enhanced cell differentiation
properties.
2.5. Laser induced forward transfer
For most of the cases, metal printing has been limited to materials
with low melting points. Until now, 3D printing of metals such as copper
or gold has proven to be very difficult or extremely expensive [17]. For
this reason, laser induced forward transfer (LIFT) was developed [22]. It
is a direct printing method that deposits various metals after laser
interaction. The technique does not require metal powders and works
differently from conventional metal 3D printing techniques. The method
has been successfully applied to print chromium, gold, Ti, nickel (Ni),
and aluminum [47]. However, LIFT also has some disadvantages, such as
the inability to generate overhanging large 3D implants, weak structural
support, and the inability to carry out mass production [48]. These
limitations stem from the nature of LIFT and may require the sacrifice of
support material.
2.6. Atomic diffusion additive manufacturing
The principle of atomic diffusion additive manufacturing (ADAM) is
almost identical to the fused deposition 3D printing technology of the
extrusion molding process [18]. The plastic binder can be removed in a
sintering furnace after printing, and the metal powder is sintered with a
density of 95–99%. Only the raw materials used in this technology are
not plastics and thermoplastic resins for fused deposition, but metal
materials such as Ti, aluminum, and iron (Fe) [23]. The Matel X metal 3D
printer from Markforged is a prime example of this technology [18]. The
main advantages of ADAM are as follows: 100 times faster than tradi-
tional machining methods, one-tenth the cost of traditional metal 3D
printing, produces high-quality part surfaces without post-processing,
creates precise, complex structures, has excellent isotropic properties,
and is suitable for mass production. However, ADAM has the problem of
long time to manufacture parts.
3. Metal materials
Although metals have been used in medicine since ancient times,
metal implants were largely unsuccessful until the development of
aseptic surgical techniques in the 1860s, which facilitated the use of
metals in implants [3,11]. In 1896, Ni-plated steel screws were used for
the treatment of bone dissection. In the 1920s, SS was developed with
characteristics resistant to corrosion by body fluids. In the 1930s, Co–Cr
alloys, originally developed for the aerospace industry, were first used in
medical implants. Pure Ti implants were introduced in the mid-1950s,
followed decades later by Ti alloys with superior mechanical properties
[49]. In the 1970s, the clinical application of nickel-titanium (Ni–Ti)
shape memory alloys (SMA) spurred further development of biomedical
metals. As metal printing technology and materials science continue to
mature, more and more metals can be safely implanted in the human
body, and metal materials are receiving more and more attention.
In orthopedic surgery, the surgeon selects different types of biometal
depending on the patient's clinical requirements [3,50]. Among the inert
biometals, SS 316L, Co–Cr alloys, and Ti alloys are the most commonly
used metals for fracture fixation and bone remodeling [5,51–54]. This is
mainly due to their long-term stability under highly reactive in vivo
conditions and their excellent mechanical properties [55]. However, it is
known that during the process of wear and slow erosion, the implants
release metal ions, which may induce local tissue damage and inflam-
matory response [56,57]. Degradability is the preferred choice for tem-
porary implant support in bone healing, such as plates and screws, thus
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Journal of Orthopaedic Translation 42 (2023) 94–112
eliminating unnecessary surgical risks and excessive costs for a second
surgery [58]. Currently, magnesium (Mg), Fe, and zinc (Zn) alloys are the
best biodegradable metals for orthopedics because they have good in
vivo biocompatibility, controlled degradation profiles, and sufficient
mechanical strength to support bone during regeneration [59–62]. The
mechanical properties of biomedical metal materials and natural human
bone are listed in Fig. 3 and Table 2.
3.1. Stainless steel
SS remains one of the most commonly used alloys for the manufacture
of surgical implants and instruments, and at least half of all orthopedic
implants in the U.S. are made of it [63]. SS implants are inexpensive,
simple to fabricate, and affordable for many patients, but they are
gradually being replaced by other alloys, particularly Co-Cr and Ti [76,
77]. Because of its general biocompatibility and corrosion resistance, SS
is used in fracture treatment in the form of screws and plates to provide
temporary support in anticipation of complete bone tissue regeneration,
which can be surgically removed again after the bone tissue has healed
[78]. Compared to other methods, the SLM method solidifies faster and
therefore produces 316L parts with a fine honeycomb dendritic structure
for higher strength.
The antioxidation and anti-corrosion properties of SS are gained from
the addition of Cr and Ni [63]. Most orthopedic implant applications of
SS 316L consist of reduced carbon (less than 0.03%), Cr (16–18%), and
Ni (10–14%) with additions of molybdenum (2–3%), manganese (Mn)
(approximately 2%) and minor additives of sulfur, silicon, phosphorus,
and nitrogen [79]. Cr forms a protective oxide membrane on the surface
of SS implants, and this membrane provides protection from implants
and does not interfere with the metabolic processes occurring in vivo
[80]. However, we should consider that SS 316L is prone to stress
cracking and is susceptible to corrosion by chlorides [63]. Therefore, SS
316L is probably only used for implants that do not require long-term
placement in the body, such as steel plates [81]. It should be
mentioned that Cr and Ni are apparently harmful to human cells due to
their presence in SS. If released due to corrosion, it may irritate tissues
and cause an immune response that can seriously lead to cancer. Nitrogen
is typically alloyed with Ni-free SS to maintain a low Ni content [82,83].
Wang et al. [84] manufactured cubic, octahedral, and triple-period
minimum surface (TPMS) gyroscopes of SS316L at a relative density of
40/50/60% with appropriate Young's modulus and excellent biocom-
patibility for use in implants.
3.2. Titanium alloy
Ti has been known since the late 19th century for its ideal mechanical
capacity and ability to bond with the adjacent bone, improving the sta-
bility of the implant [85]. Moreover, Ti has a monopoly in the orthopedic
implant market because it has the remarkable advantage of not inter-
fering with MRI [86]. The excellent biocompatibility of Ti is mainly due
to the reaction of their surface with oxygen to form a dense TiO2 oxide
membrane. In this family, Ti–6Al–4V was identified as one of the most
useful Ti alloys [66]. Since the 1970s, Ti and its alloys have been widely
used in artificial joints, bone trauma products (intramedullary nails,
fixation plates, screws, etc.), and orthopedic internal fixators of the spine
because of their excellent biocompatibility, good corrosion resistance,
and high specific strength [87].
The first generation of Ti alloys: Commercially pure Ti (CP–Ti),
Ti–3Al-2.5V, Ti–6Al–4V. In the 1940s, CP-Ti was first used for non-load-
bearing, corrosion-resistant applications. Subsequently, Ti–3Al-2.5V was
gradually used as an orthopedic implant material, but its use in ortho-
pedics was limited due to its poor wear resistance [64,65]. Ti–6Al–4V
was successfully developed in the United States in 1954 and has a high
strength [88,89]. Compared to CP-Ti, Ti–6Al–4V has a 50% increase in
mechanical strength, which allows Ti–6Al–4V to be used in load-bearing
implants such as fracture fixation plates, hip stems, and screws [90]. The
M. Meng et al. Journal of Orthopaedic Translation 42 (2023) 94–112

Figure 3. Properties of 3D printing metal materials (A) Stainless steel [51], (B) Titanium alloy [52], (C) Cobalt-chromium alloy [53], (D) Tantalum alloy [52], (E)
Shape memory alloy [54], (F) Zinc alloy [60], (G) Iron alloy [61], (H) Magnesium alloy [62], reproduced with permission.

Table 2
Mechanical properties of biomedical metal materials and natural human bone.
Material Yield strength (Mpa) Modulus of Biocompatibility Applications Reference
elasticity (Gpa)

Stainless Steel 220–260 ~190 High biocompatibility Acetabular cups, bone screws, bone [63]
plates, pins, etc.
CP-titanium (Ti) 240–550 100 High biocompatibility Bone screws, bone plates, etc. [64,65]
Ti–6Al–4V 950 112 High biocompatibility [66]
Cobalt-chromium 450–660 ~210 Low biocompatibility Bone screws, bone plates, femoral stems, [5]
(Co–Cr) alloy total hip replacements, etc.
Tantalum 205–480 3 High biocompatibility Socket cups, pads, rods, and [67]
intervertebral fusion devices
Nickel (Ni)–Ti 195–690 (austenitic phase); 48 High biocompatibility Intervertebral fusion devices [68,69]
70–140 (martensitic phase)
Magnesium based 160~200 10–45 High biocompatibility, H2 evolution Bone screws, bone plates (non-load [70,71]
alloy bearing parts), etc.
Iron based alloy 100–200 188–215 Low biocompatibility Bone screws, bone plates, etc. [72,73]
Zinc based alloy 150–180 — Cytotoxicity, no gas production, Bone screws, bone plates (load-bearing [74,75]
high biocompatibility parts), etc.
Cortical bone 188–222 15–35 Natural skeleton Natural skeleton [1,11]
Trabecular bone 2–70 0.01–3 Natural skeleton Natural skeleton [1,11]

highest relative density reported for SLM Ti6Al4V is 99.80% and fully
dense parts for Ti6Al4V by EBM were obtained by Arcam AB. The dif-
ference between EBM and SLM in processing Ti6Al4V lies in the final
microstructure which in turn, affects the mechanical properties [91].
However, there are some concerns because Ti contains cytotoxic
aluminum and vanadium. In addition, CP-Ti and Ti–6Al–4V have a much
higher modulus of elasticity than human bone, which may lead to stress
shielding and bone resorption [85].
With the finding that metal allergy can cause damage to the respi-
ratory system, nervous system, gastrointestinal tract, and hematopoietic
system, long-term use has potentially harmful effects on the human body
[92]. The development of low or non-toxic Ti alloys became the next hot
spot, that is, Nb, Fe, and other elements instead of toxic vanadium ele-
ments, which is called the second generation of medical Ti alloys, with
Ti–5Al-2.5Fe, Ti–6Al–7Nb (TC20) as representatives [93]. However, the
second-generation Ti alloy performance of Ti–6Al–4V is not significantly
improved, the elastic modulus and human bone elastic modulus gap are
still large, easy to produce stress shielding [87].
The third generation of Ti implants is β-type Ti alloys with high
strength, low elastic modulus, and corrosion resistance, which are more
suitable as internal human implants [94]. For instance, Parthasarathy
et al. [95] found that Ti–35Nb–7Zr–5Ta alloy exhibited good bioactivity
and low elastic modulus for use as orthopedic metal implants by EBM
methods. In addition, Hein et al. [96] developed Ti–24Nb–4Zr–8Sn by

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M. Meng et al.
the SLM method with an elastic modulus of only 50 GPa, a tensile
strength of 706 MPa, and excellent corrosion resistance. FDA has
approved the 3D printing Ti implants, which are known as emerging
implant technologies (EIT) cellular Ti produced by a German medical
device manufacturer, for spinal applications [5].
3.3. Cobalt-chromium alloy
Co–Cr alloys are high-strength alloys with Co and Cr as the main
components, with high-temperature oxidation resistance and good
biocompatibility [5]. An example of an alloy classification for medical
purposes is ASTM F75 Co–Cr alloy [97]. Compared to SS and Ti alloys,
Co–Cr alloys have higher wear resistance and corrosion resistance
because of high content of Co and Cr [81]. Since the 1930s, Co–Cr alloys
have been ideal for weight-bearing implants and are widely used in
artificial joints (hip and knee joints), etc. [34,98,99]. Vitallium intro-
duced one of the most popular CoCrMo alloys for joint replacements in
1939 [100]. Compared to bone, Co–Cr alloys have a higher modulus of
elasticity, density, and hardness, and suffer from stress shielding and
bone resorption problems [99]. 3D printing can help reduce the elastic
modulus of Co–Cr alloys and minimize the stiffness difference between
the alloy and bone [101]. Currently, EBM has been successfully used to
create Co–Cr implants with desired macro-geometry and bulk inter-
connected pore architecture [102]. Compared to Ti alloys, Co–Cr alloys
are less biocompatible and osseointegrated than Ti [103]. Therefore, in
clinical practice, they are the material of choice for implants that do not
come into contact with the bone interface (e.g., rods in spinal fixation)
[104]. Besides, Co–Cr alloys are still associated with wear and corrosion
problems after implantation in the human body [105]. In surgeries such
as total hip replacement, knee implantation, and spinal fixation, the
resulting release of metal ions can lead to various medical complications
that greatly limit the application of the implant [5]. When prepared by
the SLM method, the strong temperature gradient during melting leads to
a fine cellular microstructure of the Co–Cr implant, which enhances the
corrosion resistance of the implant [106]. Currently, the direction of
Co-based alloy development is further alloy strengthening (such as the
addition of hydrogen and tungsten elements) to obtain higher-strength
alloys.
3.4. Tantalum alloy
Since 1940, Ta was first used in orthopedics, it has been used in
clinical applications for more than 80 years. Ta has excellent biological
inertness, corrosion resistance, and biocompatibility, with properties
similar to cancellous bone [67]. In the field of bone and joint, porous Ta
technology, such as socket cups for primary hip replacement, pads for hip
and knee defect sites, and porous Ta rod implantation for the treatment of
early femoral head necrosis, has been used extensively and has been
reported to be safe and effective in long-term follow-up [107–109]. There
are also reports of good results with Ta as an intervertebral fusion in-
strument [110]. Ta can be used as a coating on SS and Ti implants to
enhance corrosion resistance and osseointegration [39]. However, the
high density and melting temperature of Ta make it difficult to process
using conventional techniques and the inventory costs are high. 3D
printing technologies such as directed energy deposition make it possible
to fabricate Ta. Recently, Bandyopadhyay et al. [111] demonstrated the
feasibility of processing porous Ta structures using LENS to maintain
processing parameters close to those of Ti64. 30% porous Ta structures
showed in vivo biological properties similar to those of 30% porous Ti64
nanotube surface modifications. Computational fluid dynamics (CFD)
analysis proved that 3D printing porous Ta scaffolds with pore sizes of
400–600 μm hold appropriate permeability and surface area, which
facilitated cell adhesion and proliferation [112]. These findings provide
new evidence for further application of porous Ta scaffolds for bone
defect repair.
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3.5. Shape memory alloy
The shape memory effect is a unique phenomenon in which deformed
materials can be restored to their original shape and dimensions by
heating in a certain temperature range or by reversible martensitic
transformation [113]. Ni–Ti alloys are the most promising SMA because
of their mechanical stability, low stiffness, and thermoelectricity [114,
115]. Although the Young's modulus of Ni–Ti is higher than that of
natural bone, it can be reduced to 11–20.5 GPa for porous NiTi implants
using 3D printing techniques [116]. The 3D printing porous Ni–Ti skel-
etal fixation device provides adequate fixation stiffness over a 6–9 month
healing period and has the flexibility to return to normal stress distri-
bution after the bone is fully remodeled [117]. Based on the properties of
SMA, Ni–Ti alloys are used in orthopedic implants such as spinal im-
plants, intramedullary nails, scoliosis correction devices, and spinal
spacers [68,69]. In addition to the interesting shape memory effect, Ni–Ti
SMA has good corrosion resistance, wear resistance, and ideal biocom-
patibility due to the formation of a Ti oxide layer on its surface [118].
This protective membrane prevents the toxic and allergenic effects of Ni
release, so we wanted to increase the formation and thickness of TiO2
[119]. Typically, SLM methods are commonly used to print SMA [120,
121]. Intervertebral fusion devices are one of the recently identified
applications for porous Ni–Ti in spine surgery, with one commercial
product commercially available since 2002 under the trade-name Acti-
pore (from Biorthex, Canada) for lumbar and cervical interbody devices
[122]. Assad et al. [123] proved that porous Ni–Ti provides higher bone
ingrowth stimulation (which further increases with time), due to its
cellular, bone-like architecture, and a bone apposition rate two orders of
magnitude higher, but still performs similarly to traditional Ti–6Al–4V
fusion cages, without the need of bone grafting.
3.6. Absorbable metal materials
The use of inert metals in orthopedic surgery may require secondary
implant removal if unexpected clinical complications occur, such as pain
or impaired function [2]. Also, the diagnostic accuracy of X-ray and CT
images is severely compromised by imaging artifacts produced by metals.
Currently, the most widely studied biodegradable metals include Mg, Fe,
and Zn and their alloys. During the early stages of bone defect regener-
ation, the entire mechanical support is dependent on the implant. The
mechanical integrity of the implant should be maintained for approxi-
mately 3–12 weeks to support the healing process in the upper extremity,
while the lower extremity requires approximately 12–24 weeks [124]. As
the regenerated bone slowly regains its strength, the implant material can
gradually degrade. Therefore, the rate of biodegradation of metal im-
plants should be controlled so that the loss of load-bearing capacity of the
resorbable metal material is balanced by the increase in structural
integrity of the bone [125].
3.6.1. Magnesium alloy
Mg and its alloys are widely favored by researchers in the field of
bone regeneration because of their good biocompatibility, suitable me-
chanical strength, and biodegradability [70]. The density and natural
modulus of elasticity of Mg-based metals are very similar to human bone,
with a modulus of elasticity of 45 GPa and a density as low as 1.74 g/cm3
[71]. Compared to Ti and SS, the stress shielding effect of Mg-based
metals is negligible [126]. It can be used to make screws and rods that,
when implanted, provide mechanical support and gradually degrade to
provide space for growing bone tissue [127]. Ultimately, the implant
degrades completely, thus minimizing the incidence of metal allergy to
permanent implants [128].
The greatest advantage of Mg is its biodegradability [129]. Among
the cations in the human body, Mg ranks fourth and is mainly stored in
bone tissue, involved in many metabolic processes in the body [130]. In
vivo, Mg is degraded to Mg2þ, which can be excreted through urine [71].
M. Meng et al.
More importantly, there is growing evidence that Mg ions released from
implants can promote bone regeneration and accelerate the healing of
bone disease [129]. In the treatment of challenging bone diseases, it may
have a significant advantage over non-Mg-based counterparts [124].
However, due to rapid degradation after implantation, Mg and its alloys
cannot maintain sufficient mechanical strength and are now mainly
alloyed with other elements to modify their properties [126,130]. For
example, Mg–Mn alloys have improved corrosion resistance, and Mg–Zn
alloy has higher strength [131,132]. Yang et al. [133] prepared novel
Mg–Ti composites by 3D printing and subsequent acid treatment, which
significantly improved the morphology of MC3T3-E1 cells, reduced the
apoptosis rate, and enhanced osteogenic activity. Rapid degradation of
Mg releases large amounts of hydrogen, which may lead to the separation
of tissues and tissue layers, delayed repair of bone defects and tissue
necrosis [71,130,134]. According to recent studies, the new degradable
Mg alloy ZEK100 and tricalcium phosphate coated Mg alloy AZ31 both
have good biocompatibility and biodegradability [135,136]. Xie et al.
[137] fabricated a porous 3D-printed Mg-Nd-Zn-Zr implant using SLM
technology and the implant exhibited cytocompatibility and excellent
osteoinductivity in vitro. Furthermore, the implant demonstrated excel-
lent antibacterial ratios of 90.0% and 92.1% for methicillin-resistant
Staphylococcus aureus (MRSA) and Escherichia coli, respectively.
3.6.2. Iron alloy
Fe is one of the essential trace elements and is involved in many
physiological reactions. It was shown that Fe is biocompatible and has
excellent mechanical properties close to those of SS 316L, making it a
good candidate for implants that require high structural strength, such as
bone defect repair [71]. In addition, Fe is relatively easy and affordable
to obtain and does not release hydrogen during biodegradation after
implantation [72]. Currently, Fe-based materials are considered to be
promising candidates for the manufacture of biodegradable implants due
to their excellent mechanical properties and degradability [73].
Among the biodegradable metals, Fe has the lowest tendency to
dissolve. Although the superior mechanical properties and the slow
corrosion process are positive attributes, they may also have some un-
desirable consequences [72]. For orthopedic applications, too slow a
degradation rate may impede tissue regeneration, limit force transfer to
growing bone, and result in stress shielding [138]. More importantly, the
recommended human intake of Fe is 6–20 mg daily, too excessive con-
centrations can produce toxicity, including inflammation, increased free
radicals, and damage to lipid membranes, proteins, and DNA [139,140].
An increase in surface to volume ratio may also increase the degradation
rate of this metal, keeping it in line with the respective regeneration rates
of bone and vascular tissues [139]. Therefore, research efforts have
focused on the development of porous structures made of Fe-based
compounds to maximize surface area, reduce stress shielding, improve
degradation rates, and promote natural tissue growth [141]. Yang et al.
[142] showed that 3D printing Fe scaffolds with hydroxyapatite (HA)
coatings achieved compressive mechanical properties in the range of
those of natural bone and significantly improved the survival and oste-
ogenic differentiation of bone marrow mesenchymal stem cells (BMSCs)
on the scaffolds. Putra et al. [143] demonstrated that 3D printing Fe
Mn-akermanite scaffolds could fulfill all the requirements for bone sub-
stitution in vitro, namely, adequate biodegradation rate, mechanical
properties in the range of bone trabeculae even after 4 weeks of
biodegradation, paramagnetic properties, cytocompatibility, and most
importantly, osteogenic properties.
3.6.3. Zinc alloy
Similar to Fe, Zn is one of the essential trace elements in the human
body and plays an important role in many physiological activities (e.g.
growth, immunity, and wound healing) and is essential for the catalytic
function of more than 300 enzymes [144]. Approximately 85% of Zn is
reported to be found in muscle and bone, making Zn essential for bone
development and growth [74]. To maintain normal body requirements
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Journal of Orthopaedic Translation 42 (2023) 94–112
for Zn, the recommended daily intake of Zn is 15–40 mg [75]. Although
there is still concern about whether the utilization of Zn metal in the
human body can lead to adverse effects, studies have shown that zinc has
negligible toxicity [145]. A series of studies in vitro have shown that Zn
ions can promote stem cell osteogenesis, increase mineralization capac-
ity, as well as promote osteoblast adhesion, proliferation, and differen-
tiation [146]. In addition, Zn has been shown to have antibacterial
activity [147].
However, due to the soft texture and low mechanical strength of pure
Zn, there are few reports on the use of pure Zn scaffolds for bone tissue
engineering. Zn alloys prepared by adding other metal elements (e.g. Mg,
Ca, and Sr) show significant improvements in mechanical properties and
biocompatibility compared to pure Zn [148,149]. Zn and Zn alloys are
being investigated for fracture fixation, and the Mg–Zn–Ca alloy scaffold
prepared by Kim [150] et al. has good corrosion resistance and osteo-
genic properties and has shown satisfactory bone repair. Li et al. [151]
proposed a novel bone repair bioscaffold by adding Zn submicron par-
ticles to PLGA/β-TCP using 3D printing technology. A series of in vitro
and in vivo experiments demonstrated that the scaffold has no adverse
effect on the viability of BMSCs and promotes their adhesion and oste-
ogenic differentiation, as well as higher osteogenic and
anti-inflammatory properties compared with PLGA/β-TCP scaffolds
without Zn particles.
3.7. Limitations of metal materials and enhancement strategies
3D printing porous implants can reduce stress shielding effects and
reduce implant loosening and fractures [152]. However, with the
increased demand for metallic implants, the currently available materials
and techniques cannot meet the needs of modern orthopedic implants,
and scholars have begun to experiment with various enhancement stra-
tegies to improve the osteogenic capacity, osteoconductivity, bacterial
inhibition, and biocompatibility of bone implants to varying degrees
[153–155].
One of the challenges that plague metal implants is corrosion [156].
When in contact with tissue, due to the oxygen diffusion limit contrib-
uted by the fast leakage of metal ions in the body, these ions create a high
toxicity level, thereby causing adverse effects on the cells [9]. The
accumulation of heavy metals in the cells over time can lead to toxicity
and death, called metallosis, which can lead to the development of sar-
coma [25,83]. Incorporating elements that self-passivate (Ti, Cr, Al) is
the most common method to prevent corrosion [157]. One method of AM
that has garnered much attention for its capability in producing
compositionally complex materials, as well as its ability to modify
existing surface microstructure is LENS. Laser surface modification (LSM)
using LENS of Ti–6Al–4V to modify granular structure thereby changing
the hardness while creating a passive oxide layer that significantly re-
duces the in vivo wear when compared to as-received Ti–6Al–4V samples
[158]. In studies by Roy et al. [159], the LENS processing technique was
again used to create compositionally gradient Ti/HA and Ta/MgO im-
plants. The studies showed that differences in microstructure can be
elicited by varying the processing parameters such as laser scan speed
and thickness of the gradient layer.
Another key challenge is the inability to interact with the surrounding
tissue, called bioinert. Without proper implant-host tissue interaction, a
thin fibrotic lining, or scar tissue, forms at the interface and the implant
tends to loosen over time [160,161]. It has been found that osteoblasts
prefer to aggregate on rough surfaces, while non-osteoblasts prefer
smooth surfaces. Zhang et al. [162] showed the 3D printing Ti6Al4V
implant presented a distinct fluctuant macroscale rough surface and
relatively better hydrophilicity which enhanced the adhesion, prolifer-
ation, osteogenic differentiation, and angiogenetic factor expression of
BMSCs. However, the most desirable surface roughness has not been
determined. In addition, Zhang et al. [163] introduced submicron-scale
pits on the original surface by acid etching to obtain a hierarchical
micro/submicro-textured surface and the results suggested the adhesion,
M. Meng et al.
proliferation, and osteogenic differentiation of BMSCs were significantly
improved. EBM and SLM have less inherent surface roughness compared
to laser sintering or powder bed printing [39,164]. These processes have
been utilized to print microscale porous structures while achieving
stiffness and strength values in between that of trabecular and cortical
bone [9]. Nano-scale topography has been shown to improve wettability,
which increases the adhesion of cells [165]. However, it must be noted
that these changes to surface topography may also have a direct effect on
the nature of the interaction between pathogenic microorganisms and
surfaces [166]. The beneficial effects of nano-pattering shown in in vivo
studies comprise increased hydrophilicity, fast neovascularization at the
bone implant site, early osseointegration, and as well osseointegration in
compromised bone compared to micro rough surfaces [167,168]. Zhang
et al. [169] successfully constructed a hierarchical micro-/-
submicro-/nanostructured surface feature of Ti6Al4V implants by 3D
printing. The microscale topography and sub-micro pits increased the
space for the cell growth and mechanical stability of implants, while the
modification of nanotubes dramatically improved the surface hydrophi-
licity, protein adsorption, and biomineralization.
In particular, 3D printing is one of the most promising methods for
introducing complex interconnected architectures and curved channels
with controlled distribution into metal materials [170]. Adequate
porosity with interconnecting pores allows the formation of vasculari-
zation as a transport pathway for nutrient diffusion and metabolic waste,
which help functional key cellular activities and tissue survival. High
surface-area-to-volume ratio, pore shape, and pore size are essential for
cell attachment and growth. However, with the increase in porosity, the
mechanical strength is jeopardized in terms of compressive strength. 3D
printing has provided flexibility for designers and engineers to adapt the
mechanical behavior of bone tissue accordingly [171].
Despite the fact that the bulk of the implant is made from metal
material, the coating layer exhibits a bioceramic component that forms
on the metal surface. For materials such as Ti, readily forming a passive
layer alone is not enough for tissue integration. For this reason, HA
coating has been extensively researched and is known for its ability to
match bone mechanical strength, hence preventing osteoclasts, and its
chemical bonding to bone, and has shown clinical success in inducing
bone-growth fixation rather than fibrous connective tissue formation
[172]. In addition, the bone support capabilities of biomolecules are
being investigated, including peptides, bone morphogenetic protein
(BMP) growth factors, non-BMP growth factors, collagens, and other
extracellular matrix-related components (e.g. hyaluronic acid). Chitosan
is a cationic polysaccharide that demonstrates excellent characteristics
namely biocompatibility, non-toxicity, biodegradability, antimicrobial
characteristics, and availability. Chitosan scaffolds enhance cell adhe-
sion, proliferation, osteoblast differentiation, and mineralization [173].
Next to these groups, the effects of antiresorptive drugs (zoledronic acid,
alendronic acid), osteoanabol drugs (teriparatide), chemotherapeutic
agents (selenium), and different antibacterial agents (vancomycin,
gentamicin) are explored [174]. Wang et al. [175] fabricated a poly-
dopamine coating on a 3D-printed implant surface via the in situ poly-
merization method, which improved the hydrophilicity and osteogenic
capacity of the implants.
4. Clinical applications
Many orthopedic conditions require implants to restore function at
the site of the lesion. In clinical practice, metals are the preferred implant
material due to their excellent biomechanical properties, but there is still
the problem of unacceptable failure rates [176,177]. The availability of
metal implants for patient is dependent on two main factors: mechanical
stability and biological response to host bone [50]. Computational
methods such as CAD, finite element analysis (FEA), and CFD can be used
for the mechanical testing of implants by simulating tension, compres-
sion, bending, shear, torsion, and biomechanical/physiological loading
conditions in vivo [178]. Compression is the most common loading
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Journal of Orthopaedic Translation 42 (2023) 94–112
condition for bone design, so among the various mechanical properties,
the elastic modulus is the most important and frequently found in the
literature. Ribeiro et al. [179] found that the prediction of the FEA
showed a good agreement with conventional mechanical test results,
revealing the areas more affected under compression load. Kang et al.
[180] designed a multi-segment artificial vertebral implant by opti-
mizing parameters such as pore diameter and porosity, and FEA showed
that the optimized implant was about 2 times to trussed implant in terms
of the maximum compression load and compression stiffness per unit
mass and achieved good results in subsequent clinical trials. After the
implant was fabricated by 3D printing, the mechanical properties such as
unidirectional compression testing, strain energy density, and flexural
performance or behavior of the material were evaluated by comparing
the strength and strain energy density of the implants in four-point
bending test or three-point bending test [181]. Extensive testing and
evaluation are performed during the pre-market phase, often including
mechanical testing such as fatigue and wear studies [182].
3D printing metal implants can be personalized to suit the different
disease states and surgical conditions of the patient in order to balance
the contradiction between porosity and stiffness [183]. The biological
response to the host bone, on the other hand, is usually achieved by
monolithic or surface modification of such implants [9]. In just the past
few years, metal 3D printing technology in the medical field, especially
the application of orthopedics has been highly valued, and its innovative
potential and application prospects are more generally favored [50,108,
184–188]. Several metal 3D printing orthopedic implant applications are
shown in Fig. 4. However, will it bring disruptive changes to the future of
orthopedics, as many colleagues expect? It is important to truly under-
stand and objectively evaluate the value of metal 3D printing technology
in orthopedics. To date, research on the clinical application of
patient-specific implants has focused on bone tumor surgery, joint
replacement surgery, spinal implants, and traumatic fracture fixation and
reconstruction as listed in Tables 3–6.
4.1. Spinal surgeries
Recently, 3D printing implants have become of interest in the
manufacture of internal fixation implants, spinal cages for interbody
fusion procedures, vertebral body replacements (VBR), and disc implants
for total disc replacement (TDR) [231,232]. In the atlantoaxial spine due
to the complex anatomy, surgical accuracy is crucial. Thayaparan et al.
[190] designed a 3D printing manufactured Ti posterior fixation implant
by SLS printer to cure three female patients with unilateral atlantoaxial
osteoarthritis. No screw malposition and no neural or vascular injuries
were observed. What's more, Thayaparan et al. [193] described a novel
method for occipitocervical fixation using a 3D printing Ti
patient-specific implant by SLM method. At 6-month follow-up, the pa-
tient reported resolution of symptoms and demonstrated satisfactory
occipitocervical alignment without evidence of implant dysfunction.
Current spinal cages for interbody fusion procedures may lead to
endplate fractures and collapse. Due to the particular usefulness of 3D
printing in reconstructing complex geometries, they can be used in areas
where current implants are not suitable to replace local anatomical
structures [233]. In anterior cervical discectomy fusion (ACDF), 3D
printing cages could significantly relieve symptoms, restore the curvature
of the cervical spine, effectively maintain the intervertebral height for a
long time, and prevent complications related to postoperative subsidence
[234]. Arts et al. [194] found that 3D printing porous Ti cervical implants
by SLM resulted in significant clinical improvement after ACDF. The
fusion rate of porous Ti compared with polyetheretherketone (PEEK)
with autograft at 12 months was similar, although porous Ti resulted in
faster consolidation. Spetzger et al. [189] performed a pilot project of the
first implantation with an anterolateral standard approach of a
custom-designed cervical Ti cage, made of trabecular Ti and manufac-
tured with direct metal printing. The improved load-bearing surface will
lower the rate of implant dislocation and subsidence. Siu et al. [191]
M. Meng et al. Journal of Orthopaedic Translation 42 (2023) 94–112

Figure 4. Clinical application of metal 3D printing orthopedic implants (A) Radial head prosthesis [184], (B) Porous scaffolds in femoral defect [108], (C) Total talus
implant [185], (D) Spine fusion device [186], (E) Trabecular acetabular cup [187], (F) Cones in total knee arthroplasty [188], reproduced with permission.

Table 3
The main clinical application of spinal surgeries.
Year Authors Journal Case Type of surgery Results

2016 Spetzger et al. Eur Spine J 1 3D-printed cervical fusion titanium (Ti) cage The improved load-bearing surface will lower the rate of implant
[189] dislocation and subsidence
2018 Thayaparan J Clin 3 Atlantoaxial transarticular screw fixation No screw malposition and no neural or vascular injuries were observed
et al. [190] Neurosci
2018 Siu et al. [191] World 1 A minimally invasive lateral lumbar interbody Postoperative CT scan confirmed excellent implant-end plate matching
Neurosurg fusion at L2-3 and L3-4 and restoration of lost disk space
2019 He et al. [192] Oper 1 3D printed microporous prosthesis (3D-PTMP) for The patient had an uneventful recovery, regaining ambulatory status 3
Neurosurg the anterior column of the cervical spine between wk after the 2 operations without ventilator support or other severe
C1 and T1 complications
2020 Thayaparan J Clin 1 3D printed patient-specific implant (PSI) for There were no intraoperative or postoperative complications
et al. [193] Neurosci occipitocervical fixation
2020 Arts et al. [194] Spine J 49 Anterior cervical discectomy with an interbody cage 3D printed porous Ti cervical implants resulted in significant clinical
(ACDF) improvement after surgery
2020 Wei et al. [195] Ann Transl 9 3D printed vertebral body for spinal reconstruction The tailored shape matching with the contact surfaces and the porous
Med with primary tumors involving C2. structure conducive to osseointegration provide both short- and long-
term stability to the implant
2021 Thayaparan Eur Spine J 1 3D-printed lumbosacral fixation implant secured by No evidence of implant dysfunction was observed on radiography.
et al. [196] L2-L5, S2, and iliac screws
2021 Fang et al. Med Sci 12 3D-printed artificial vertebral body in repairing The 3D-printed artificial vertebral body helps maintain intervertebral
[197] Monit bone defects for single-level anterior cervical height and cervical physiological curvature and is a good candidate for
corpectomy and fusion (ACCF). ACCF
2021 Tang et al. Orthop Surg 27 3D printed modular prosthesis for spinal At the latest follow-up, in 23 alive patients, 19 can walk independently
[198] reconstruction after multilevel thoracolumbar total and two can achieve outdoor activities by walking aid
en bloc spondylectomy (TES)
2022 Sun et al. [199] Orthop Surg 8 3D printed artificial vertebral body for multilevel X-rays showed that the 3D printed artificial vertebral body of all cases
total en bloc spondylectomy (TES) matched well, and the fixation was reliable. Hardware failures such as
loosening, sinking, breaking, and displacement weren't observed during
the follow-up period
2022 Hu et al. [200] Int J Bioprint 8 3D printed artificial vertebral body for multilevel Combined with neoadjuvant and adjuvant therapy, these patients had
total en bloc spondylectomy (TES) excellent postoperative outcomes, long-term normal spinal function,
and associated low local recurrence probability
2022 Girolami et al. J Clin Med 2 3D-printed personalized implants for reconstructing Three dimensional printing allowed the reported authors to design
[201] the anterior column patient-specific solutions, not only for shape and size of the implants but
also for the method to achieve proximal fixation
2022 Zhou et al. J Neurosurg 23 3D printed artificial vertebral body for spinal The low incidence of prosthesis subsidence of 3D-printed
[202] Spine reconstruction after en bloc resection of endoprostheses can provide good stability instantly.
thoracolumbar tumors

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Table 4
The main clinical application of joint surgeries.
Year Authors Journal Case Type of surgery Results

2013 Colen et al. Acta Orthop Belg 8 A modified custom-made triflanged acetabular None of the reconstructions failed or had to be revised. Clinical results
[203] reconstruction ring (MCTARR) for revision hip were satisfactory. Radiographs showed good screw positioning.
arthroplasty
2015 Mao et al. Int Orthop 23 Customized cage with a hook, crest, and flange The mean Harris hip score improved from 39.6 pre-operatively to 80.9 at
[204] or braids for severely compromised acetabulum the final follow-up. There were no instances of deep infection, severe
in revision THA venous thrombosis, and nerve palsy.
2016 Li et al. [205] Clin Orthop Relat 26 Custom acetabular cages for revision THA with Individualized custom cages resulted in the generally reliable restoration
Res severe bone defects of the hip center. No revisions have been performed.
2017 Wang et al. Exp Ther Med 17 3D printing hip arthroplasties in THA The 3D printing approach provides a better short-term curative effect that
[206] is more consistent with the physiological structure and anatomical
characteristics of the patient.
2020 Geng et al. J Orthop Surg Res 92 3D printing porous trabecular acetabular cup The satisfaction rate (prevalence of satisfied or very satisfied) was 91.3%.
[187] for primary total hip arthroplasty (THA) No acetabular cup failures occurred. The overall survival rate of
implantation is 99.1% (cup survival rate 100%).
2020 Tetreault Bone Joint J 139 3D printed metaphyseal cones in revision total Survivorship free of cone revision for aseptic loosening was 100% and
et al. [207] knee arthroplasty (TKA) survivorship free of any cone revision was 98%
2020 Wang et al. J Int Med Res 1 3D printed porous tantalum (Ta) prosthesis for The surgery went smoothly and the patient achieved a satisfactory
[208] TKA recovery after surgery.
2020 Faldini et al. J Orthop 1 3D printed ankle prosthesis for total ankle The complete customization process for total ankle arthroplasty provided
[209] Traumatol arthroplasty (TAA) accurate and reliable implant positioning, with satisfactory short-term
clinical outcomes.
2021 Mac
ak et al. Acta Chir Orthop 3 3D printed titanium acetabular component of The three-point fixed 3D printed acetabular component combined with
[210] Traumatol Cech THA impaction grafting of the acetabular base is a good alternative in
managing the advanced bone defects of acetabulum after the failure of
THA
2022 Ao et al. Front Bioeng 6 3D printed porous Ta cones in TKA Radiological examination at the final follow-up showed that cones
[188] Biotechnol implanted into the joint were stable and bone defects were effectively
reconstructed
2022 Zhang et al. ACS Omega 7 3D printed revision prostheses for ankle For complex bone defects and revision prostheses, matching implants can
[211] osteoarthritis be printed individually, which could realize the personalized precise
treatment.

Table 5
The main clinical application of bone tumor surgeries.
Year Authors Journal Case Type of surgery Results

2017 Liang et al. Bone Joint 12 3D-printed pelvic endoprostheses after The application of 3D-printing technology can facilitate the precise matching and
[212] J resection of a pelvic tumour osseointegration between implants and the host bone
2017 Luo et al. Med Sci 4 3D printed tibia block for treating giant No sign of prosthesis fracture, loosening, or other relevant complications were
[213] Monit cell tumors (GCT) of the proximal tibia. detected.
2019 Lu et al. BMC Surg 1 3D printed porous implant for GCT in the At the last follow-up at 29 months postoperatively, the patient had satisfactory limb
[214] proximal tibia function and no further damage was seen to the subchondral area and articular surface.
2019 Feng et al. Yonsei Med 1 3D printed prosthesis replacement for During the follow-up, the presence of bone ingrowths on the porous surface of some
[215] J limb salvage segments of the prosthesis suggested good outcomes for long-term biological
integration between the prosthesis and host bone.
2020 Chen et al. J Int Med 1 3D printed implant for reconstruction of The patient recovered with significant pain relief and good functional recovery after
[216] Res the pelvic bone the surgery. No implant-related complications occurred during the 12-month follow-
up.
2021 Wu et al. J Surg 28 3D-printed pelvic endoprostheses after The mean follow-up period was 32.2 months, during which 16 patients had disease-
[217] Oncol resection of a pelvic tumour free survival, 3 survived with the disease, and 9 died. The prostheses were stable, and
the mean offset of the center of rotation was 5.48 mm.
2021 Park et al. J Orthop 12 3D-printed bone-cutting guides and In all patients, independent gait was recovered except for a patient who underwent
[218] Sci implants n pelvic bone tumor surgery hindquarter amputation 4 months postoperatively because of local recurrence.
2021 Zhang et al. J Orthop 8 3D printed porous implants for GCT in the No degeneration of the knee joint was found. Osseointegration was observed in all
[219] Surg Res proximal tibia patients.

performed a minimally invasive lumbar interbody fusion on a 74-year--
old woman with osteoporotic fractures at L2 and L3. The design was
converted to implantable Ti cages through AM. At surgery, a tight fit
between the implants and the targeted disk space was achieved. For
revision lumbar fusion surgery, Thayaparan et al. [196] chose an EIT
Cellular Ti interbody cage using an SLS printer to replace the existing
PEEK interbody cage at L5–S1. No evidence of implant dysfunction was
observed on radiography.
For the reconstruction of irregular vertebral body defects in special
locations, 3D printing artificial vertebral bodies also had unique advan-
tages [235,236]. In single-level anterior cervical corpectomy and fusion
(ACCF), the 3D printing artificial vertebral body performs better in
maintaining intervertebral height and cervical physiological curvature
compared with the Ti mesh cage [197]. For reconstruction of bone de-
fects after multilevel total en bloc spondylectomy (TES), 3D printing
artificial vertebral bodies could greatly reduce the risk of prosthesis
collapse and loosening, and its advantages were more significant [199,
198]. Combined with neoadjuvant and adjuvant therapy, these patients
had excellent postoperative outcomes, long-term normal spinal function,
and associated low local recurrence probability [200]. A 3D printing Ti
microporous prosthesis was designed by He et al. [192] to reconstruct the
anterior column of the cervical spine between C1 and T1 for stability. A
postoperative CT scan indicated a good position of the 3D printing
construct between the endplates with no sign of tumor recurrence or
implant subsidence. The location of spinal tumors in the spine provides
challenges both for tumor excision, since satisfactory exposure is difficult

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M. Meng et al. Journal of Orthopaedic Translation 42 (2023) 94–112

Table 6
The main clinical application of trauma surgeries.
Year Authors Journal Case Type of surgery Results

2017 Mai et al. Zhonghua Wai Ke 8 3D printed acetabular wing-plate for complex Surgical management of complex acetabular fracture via lateral-rectus
[220] Za Zhi acetabular fractures approach combined with 3D printing personalized acetabular wing-plate
can effectively improve reduction quality and fixation effect
2018 Zhang et al. Medicine 6 3D printed titanium metal trabecular bone Hip-preserving rates were 100% for IIA, 100% for IIB, and 50% for IIC.
[221] reconstruction systems for osteonecrosis of the The effect of TMTBRS treatment for early ONFH in ARCO IIA and ARCO
femoral head IIB is satisfactory.
2019 Zhao et al. Orthop Surg 1 Porous tantalum (Ta) metal plates in the The resulting porous Ta metal exhibited excellent mechanical and
[222] treatment of tibial fracture biological properties and improved the therapeutic effects for the
treatment of a tibial fracture nonunion.
2020 Luenam J Orthop Surg 1 3D printed implant for severe open distal Due to the favorable result at a 2-year follow-up, this modality is a
et al. [223] humerus fracture potentially viable surgical option in treating the severe open distal
humeral fracture associated with entire lateral condylar damage.
2020 Wang et al. BMC 15 3D printed patient-specific (3DPPS) Ti–6Al-4 V The 3DPPS Ti-6AL-4 V plate is a feasible, accurate, and effective implant
[224] Musculoskelet plates to treat complicated acetabular fractures for acetabular fracture treatment.
Disord
2020 Hou et al. J Mater Sci Mater 3 3D printed micro-porous prosthesis for large X-ray demonstrated good osseous integration of the implant/bone
[225] Med metaphyseal segmental femoral bone defect interface. No complications occurred such as implant loosening,
subsidence, loss of correction, and infection.
2020 Kadakia 3D Print Med 4 3D printed implants in complex lower extremity This technology provides surgeons with tools to better tackle some of the
et al. [226] reconstruction more challenging clinical cases, especially within the field of foot and
ankle surgery.
2020 Steele et al. J Foot Ankle Surg 11 3D Printed spherical Implants for Custom 3D printed sphere implant is safe in patients with severe bone loss
[227] tibiotalocalcaneal arthrodesis undergoing TTC arthrodesis with a retrograde intramedullary nail and
may result in improved rates of successful arthrodesis.
2021 Hussain J Foot Ankle Surg 1 3D Printed total talus replacement At the 12-month mark the foot function index (FFI) score improved from
et al. [228] 95.9% pre-op to 4.7% post op and the American orthopedic foot and ankle
score was 0 pre-op to 94 post-op
2022 Wu et al. J Orthop Surg Res 9 3D printed porous Ta scaffolds for infective The 3D-printed porous Ta prosthesis was an acceptable alternative
[108] segmental femoral defect treatment, that could achieve satisfactorily reconstruct an infective broad
bone defect in the femur when other biological techniques were not
suitable.
2022 Liu et al. J Mater Sci Mater 10 3D printed porous Ti6Al4V scaffolds for The implantation of a 3D printed Ti6Al4V scaffold was feasible and
[229] Med diaphyseal defects of lower limbs effective to reconstruct critical bone defects of lower limbs without
additional bone grafting.
2022 Grau et al. J Foot Ankle Surg 1 3D Printed talus for the treatment of a chronic After a 2-year follow-up, a good clinical evolution was achieved, with no
[230] infection of the ankle signs of reactivation of the infection, no pain, good skin condition, and
optimal functionality

to achieve, and reconstruction, especially for proximal fixation [201]. For
C1/C2 chordoma, Mobbs et al. [237] discovered that the use of 3D
printing individualized prostheses was easy to put into the required po-
sition, facilitates surgery, shortens the operative time, and avoids further
complex reconstruction. In 9 patients with primary tumors involving C2,
Wei et al. [195] found that the 3D printing vertebral bodies using an EBM
printer were all stable with no sign of displacement or subsidence, evi-
dence of implant osseointegration was observed in the imaging studies.
Zhou et al. [202] considered that the use of a 3D printing artificial
vertebral body for anterior reconstruction after en bloc resection of the
thoracolumbar spinal tumor is useful. The low incidence of prosthesis
subsidence of 3D printing endoprostheses can provide good stability
instantly.
Along with interbody and vertebral body cages, the feasibility of
manufacturing disc implants for TDR by means of 3D printing technol-
ogies has been recently studied. Intervertebral disc end plates were
successfully designed by De Beer and colleagues and the end plate ge-
ometry of disc implants reduced the risk and potential for subsidence into
the vertebral bone end plate [238]. Domanski et al. [239] have recently
conducted preliminary research on 3D printing intervertebral disc im-
plants. The endoprosthesis prototype was made of CoCrMo alloy with the
use of selective laser technology. FEA demonstrated restoration of full
range of motion of the spine in all anatomical planes and restoration of
the normal height of the intervertebral space and curvature of the ante-
rior spinal convexity.
4.2. Joint surgeries
In joint surgery involving the shoulder, hip, knee, and ankle, the use
of 3D-printed articular prostheses to reconstruct joint function has
yielded good therapeutic results. When treating severe bone defects in
the joint after total shoulder arthroplasty, the 3D printing shoulder gle-
noid prosthesis with its porous structure fills the bone defect well and the
additional threaded holes in the component allow for conversion to a
reverse structure, achieving good functional scores at an average follow-
up of 2.5 years [240].
Personalized patient prostheses have been reported to be a valuable
option for total hip arthroplasty (THA), with high-precision printed
cancellous bone structures that aid bone growth and fixation strength
and improve surgical success [241,242]. Geng et al. [187] analyzed 92
consecutive patients and found that 3D printing porous trabecular Ti
acetabular cup by EBM method may provide good initial stability and
secondary fixation because of its highly interconnected, porous structure.
Wang et al. [206] assessed the use of 3D printing hip replacements with
Ti alloys in THA. In 17 patients, the time to postoperative weight bearing
and the Harris scores were better than the traditional method. Colen et al.
[203] reported on the use of a modified custom-made triflanged
acetabular reconstruction ring in 6 patients with severe acetabular bone
defects with acceptable to good results in all. Revision hip arthroplasty is
conducted when a primary THA fails due to a variety of reasons, such as
aseptic loosening (50%), instability (16%), infection (15%), debilitating
pain, periprosthetic fractures, or component failure [243]. Mac
ak et al.
[210] concluded that the implantation technique of a three-point fixed
custom-made 3D printing acetabular component combined with impac-
tion grafting of the acetabular base is a good alternative in managing the
advanced bone defects of acetabulum with pelvic discontinuity after the
failure of THA. Li et al. [205] found that individualized custom cages by
the SLS method appeared to provide stable fixation and improved hip
scores in 26 patients with a massive acetabular defect. Mao et al. [204]
designed a customized cage with a hook, crest, and flange or braids, and

105
M. Meng et al.
then utilized it to reconstruct severely compromised acetabulum in
revision THA. The mean Harris hip score improved from 39.6
pre-operatively to 80.9 at the final follow-up. There were no instances of
deep infection, severe venous thrombosis, and nerve palsy.
Total knee arthroplasty (TKA) is potentially difficult when using
historical designs of cones [244]. The patient-customized 3D-printed
metaphyseal cone is a useful technique for reconstructing massive
proximal tibial bone defects, with encouraging clinical and radiological
outcomes in TKA [245]. Tetreault et al. [207] found that 3D-printed Ti
cones, with a reamer-based system, yielded excellent early survivorship
and few complications in patients with severe bone loss undergoing
difficult revision TKA. Hua et al. [109] treated patients with Charcot
arthropathy by preparing 3D printing porous Ta implants, which could
effectively restore the range of motion of the knee joint, and lower ex-
tremity alignment, and eventually achieve good functional results of
walking without crutches after surgery. Ao et al. [188] demonstrated that
3D-printed porous Ta cones could effectively reconstruct bone defects
and offer anatomical support in TKA revision. Radiological examination
at the final follow-up showed that cones implanted into the joint were
stable and bone defects were effectively reconstructed. The bone defect
left by infection after artificial knee arthroplasty is large and irregular,
and the prognosis for revision surgery is poor. Wang et al. [208] found
that the 3D printing porous prosthesis can be used to reconstruct tibial
bone defects in patients with chronic inflammation after joint replace-
ment surgeries. The surgery went well and the patient achieved a satis-
factory recovery after surgery. Yin et al. [246] used a uniquely shaped
and highly porous 3D printing knee prosthesis during revision surgery.
The porous structure of the tibia and femur provided micro-anchoring of
the host bone and induced bone ingrowth, with mechanical strength
(35.8 MPa) similar to cancellous bone and low modulus of elasticity
(0.74 GPa) reducing the risk of stress masking. The 6-month post-
operative follow-up showed better knee function.
Total ankle arthroplasty (TAA) has been proposed in an effort to
improve functional outcomes. However, the outcomes of TAA are
generally unsatisfactory compared to other arthroplasties, such as those
of the hip and knee. Based on this, Faldini et al. [209] reported the metal
prosthesis components using Co–Cr powders and immediate post-
operative X-rays showed good implant positioning and alignment. Zhang
et al. [211] found that 3D printing porous Ta has good histocompati-
bility, and its interface structure and porosity are more conducive to bone
ingrowth for ankle osteoarthritis.
4.3. Bone tumor surgeries
In bone tumor surgery, 3D printing implants may be an ideal option to
accurately reconstruct the unique anatomy of patients with specific bone
defects [247]. The traditional treatment for osteosarcoma is amputation,
but patients have a low long-term postoperative survival rate and
accompanying limb dysfunction [248]. 3D printing metal implants
significantly improve the treatment of bone tumors, restoring bone
appearance and function [249]. Vitiello et al. [250] evaluate the appli-
cation of 3D printing custom-made prostheses in different sites. The
prosthesis was printed using the EBM method, by sintering Ti powder
(Ti–6Al–4V). They found that preoperative and postoperative quality of
life were comparable. The patients preserved their autonomy on daily life
activities with no functional impairment and they were able to carry out
normal activities and work.
Due to the lack of individual design, high incidence of prosthetic
mismatching, and loosening were reported in pelvic reconstruction sur-
gery with conventional modular prostheses [251]. Liang et al. [212]
found that the use of 3D printing pelvic prostheses for the reconstruction
of the bony defect was safe, without additional complications, and gave
good short-term functional results. Additionally, 28 pelvic tumor patients
were enrolled by Wu et al. [217] and achieved good early postoperative
efficacy and functional recovery. Park et al. [218] filled cavitary bone
defects with structural allobone graft precisely trimmed by the 3D
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Journal of Orthopaedic Translation 42 (2023) 94–112
printing allograft-shaping guide and 3D-printed mesh-style Ti spacer
using EBM technology. The patient's independent gait was recovered.
Chen et al. [216] described a 29-year-old woman with giant chon-
drosarcoma treated with a personalized 3D Ti implant. The surgery was
successful, and the patient recovered with significant pain relief and good
functional recovery after the surgery.
In patients with tibial plateau osteomegaloblastoma, the conventional
hinged knee prosthesis has some problems, such as poor mobility, stress
concentration, susceptibility to prosthesis fracture, loosening, and sink-
ing. If the replacement is performed with a surface prosthesis, it cannot
handle the large bone defect that occurs after the lesion is scraped away,
and the joint stability is poor when the tumor segment is removed and
then replaced with a conventional surface knee joint [252]. Based on the
above considerations, Luo et al. [213] designed a 3D printing block made
of Ti alloy (Ti–6Al–4V) through the use of the EBM method for
semi-limited knee replacement after tumor resection. In all 4 cases, the
3D printing block fitted the bone defect precisely. In cases of giant cell
tumour (GCT) of theproximal tibia, the application of 3D printing porous
prosthesis combined autograft could supply enough mechanical support
and enhance bone ingrowth [253]. Lu et al. [214] fabricated a person-
alized porous implant by the EBM method to mechanically support the
graft and subchondral area and help avoid degenerative changes and
mechanical failure. At the last follow-up at 29 months postoperatively,
the patient had satisfactory limb function and no further damage was
seen to the subchondral area and articular surface. Feng et al. [215] re-
ported a case of radical resection of ameloblastoma in the mid-distal tibia
combined with limb salvage using a Ti alloy prosthesis replacement.
Computer-assisted 3D-printing technology allowed for more volume and
structural compatibility of the prosthesis, thereby ensuring a good
operation and initial prosthetic stabilization.
4.4. Trauma surgeries
The treatment of complex post-traumatic skeletal defects and de-
formities can benefit from 3D printing technology [254]. The application
of 3D printing prostheses to repair bone defects and deformities in areas
such as the extremities and pelvis can lead to excellent restoration of limb
function, thus enabling patients to perform normal daily activities [255].
For patients with open fractures of the distal humerus with severe loss of
articular surfaces and bony structures, Luenam et al. [223] used the SLM
method to print metal powders to make prostheses. At the 24-month
follow-up, radiographs showed good radiocapitellar and ulnar articular
spaces.
Fractures involving the acetabulum require repair of the articular
surface and anatomy to achieve a satisfactory clinical outcome. However,
surgery involving the acetabulum has been challenging due to the
complexity of the peripelvic anatomy and neurovascular structures [256,
219]. The use of a personalized 3D printing dynamic anterior plate-screw
system for the quadrilateral area (DAPSQ) Ti plate has potential advan-
tages in reducing the operation time and blood loss during the treatment
of double-column acetabular fractures [257]. Wang et al. [224] found
that patient-specific Ti–6Al-4 V plate by SLM method is a feasible, ac-
curate, and effective implant to treat complicated acetabular fractures
involving quadrilateral plate (QLP) disruption. Mai et al. [220] reported
8 cases with complex acetabular fractures. The acetabular wing-plate was
designed and printed with Ti. Postoperative X-ray and CT examination
showed an excellent or good reduction of anterior and posterior column,
without any operation complications.
The use of 3D printing metal implants is feasible and effective for
reconstructing critical bone defects of the femur [229]. For early osteo-
necrosis of the femoral head (ONFH), especially in young patients, hip
preservation becomes an important therapeutic principle. Zhang et al.
[221] applied a new 3D printing Ti trabecular bone implant by the EBM
method to replace the necrotic bone of patients with early ONFH. The
results show that 3D printing Ti metal trabecular bone may be effective in
delaying ONFH progression. For segmental irregular bone defects of the
M. Meng et al.
femur, Hou et al. [225] treated all patients with 3D printing micro-porous
prosthesis by EBM method combined with intramedullary nail. No
complications occurred such as implant loosening, subsidence, loss of
correction, and infection. For infective segmental femoral defect, Wu
et al. [108] combined the 3D printing porous Ta prosthesis and Mas-
quelet's induce membrane technique to reconstruct bone defect for 9
patients. There were no deep infections, refractures, sensorimotor dis-
order, vascular injury, ankylosis and recurrence of infection occurred in
all cases.
Fractures of the tibia represent a common class of injuries in ortho-
pedics. The blood supply to the tibia is poor due to the small subcu-
taneous muscle tissues inside. Consequently, the tibia is prone to delayed
fracture healing and nonunion of the fracture after surgery. Zhao et al.
[222] used a porous Ta metal plate to treat nonunion of a tibial fracture.
The resulting porous Ta metal exhibited excellent mechanical and bio-
logical properties and improved the therapeutic effects for the treatment
of a tibial fracture nonunion. Hamid et al. [258] reported a 46-year-old
woman who sustained a left open distal intra-articular tibia fracture
with substantial distal tibia bone loss at the scene of the injury. The
implant was made of Ti–6Al–4V with patented truss structure and
roughened texture of the cross members to facilitate osteointegration.
Plain radiographs and CT scans demonstrated successful bone incorpo-
ration of the talus, calcaneus, and 3 of 4 cortices of the tibia. Tibiotalo-
calcaneal (TTC) arthrodesis in the setting of a large bony defect remains a
significant challenge for orthopedic surgeons. Yao et al. [259] found that
personalized plates (P-Plates) could provide improved clinical outcomes
in joint fusion by enabling perfect geometric matching between irregular
bone and implants. Steele et al. [227] demonstrated that the use of a
custom 3D printing sphere implant is safe in patients with severe bone
loss undergoing TTC arthrodesis with a retrograde intramedullary nail
and may result in improved rates of successful arthrodesis.
Total talar arthroplasty is a viable treatment option for talar injuries
and pathologies. Hussain et al. [228] reported that the patient underwent
surgical resection of the pathologic talus with implantation of the custom
talar prosthesis. The current results are very favorable. In a patient with a
chronic ankle infection, Grau et al. [230] implanted a custom Ti talus
with an articular fixation nail. After a 2-year follow-up, a good clinical
evolution was achieved, with no signs of reactivation of the infection, no
pain, and good skin condition. Kadakia et al. [226] described that the 3D
printing cage was used to provide structural support and match the
anatomy of the patient with a collapsed native talus with a large bone
defect. They also presented a case of total talus arthroplasty in the setting
of talar avascular necrosis. This implant is designed based on CT images
of the talus from the contralateral limb. The implant is made from cobalt
chrome and is smooth to allow for gliding at adjacent articulations.
4.5. Adverse events
Postoperative monitoring of patients with 3D printing implants
revealed that adverse events were mainly divided into material issues
and implant design issues [260]. Chung et al. [261] reported a case of
vertebral reconstruction with 3D printing implants, and the patient had
increased eosinophils after surgery without further clinical symptoms,
which was postulated to be an allergic-type hypersensitivity response to
Ti powder particles. Hence, post-print processing to ensure the removal
of powder particles may be important for surgeons of 3D printing im-
plants to consider, as suggested by the FDA [260]. Li et al. [262] used Ti
implants for the reconstruction of orbital defects and removed the im-
plants in two patients after implant exposure due to infection. This sug-
gests that orthopedic surgeons should take fully into account the patient's
age, health status, medical history, localized infections, location and
extent of bone defects, and remaining soft tissue volume when using
metal implants. In addition, implant insertion may be difficult due to the
complex anatomy of the surgical approach [263]. A few surgeons failed
to achieve the midline union of the two-piece interbody cage and intra-
operative discrepancy to the anticipated defect geometry and relative
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Journal of Orthopaedic Translation 42 (2023) 94–112
positioning of the posterior rods [261]. Therefore, multiple implant
heights/sizes can be required to accommodate for variable resection
defects and dimensions of the surgical insertion-window mandate
consideration during design-rendering.
5. Advantages, limitations, and future
A serious analysis of the process characteristics of metal 3D printed
implants reveals the following significant advantages in the field of or-
thopedic applications: 1) Personalization. By taking the CT or MRI scan
data of the patient's patient's bones, the clinician personalizes the product
according to the characteristics of the native bones and manufactures a
product that exactly matches the native bones, thus reducing the impact
of the implant on the human body and restoring the normal function of
the human bones to the maximum extent. 2) Osseointegration. It is well
known that bone fusion is one of the most important topics that has been
highly focused and intensively studied in orthopedics ever. 3D printing
technology can print rough mesh structures. The ability of the bone tissue
adjacent to the implant to grow into the micropores means direct fusion
of the patient's bone with the endosseous implant, which was previously
unattainable with most endosseous implants. In addition, the density,
strength, and elastic modulus of the implant is adjusted by adjusting the
pore size and porosity to make the implant shape and mechanical
properties similar to the natural cancellous and cortical bone of the
human body. 3) The short cycle time and high material utilization. 3D
printing technology can take a product from design to fabrication in as
little as 24 h, significantly reducing delivery time, and the printing pro-
cess is usually carried out under vacuum or inert gas protection, making
the material recyclable.
However, it is important to realize that, at least at this stage, there are
still some problems limiting the use of 3D printed metal implants. First,
most orthopedic surgeons are unfamiliar with the various software and
equipment used to make 3D printed implants, and expensive equipment
purchases, maintenance costs, consumable costs, as well as in-
compatibility of printing software, severely limit the popularity and
development of 3D printing technology. An integrated and unified
computer platform should be developed to facilitate communication
among different professions such as radiologists, orthopedic surgeons,
and engineers.
Next, 3D printing requires more high-quality metal materials. Mate-
rials for clinical use have extremely stringent requirements. Currently,
only a few mature materials are available for 3D metal printing, such as
Ti, SS, and Co–Cr alloys. Safety, biocompatibility, degradation proper-
ties, and bioactivity of materials before and after printing need to be
considered to meet the requirements for industrialization and clinical
use. For example, for medical implants made from Ti alloys, the printing
process and product properties should be evaluated before and after
printing to ensure that they are not teratogenic and carcinogenic after
implantation. The strict sterilization of 3D printing implants is one of the
key aspects to ensure a successful placement. Incorrect sterilization
processes can negatively affect the surface properties of orthopedic im-
plants and joint prostheses, which can lead to implant failure. Therefore,
it is critical that metal materials can withstand the effects of sterilization.
In addition, as the use of 3D printing implants becomes more wide-
spread, appropriate laws and regulations need to be put in place to
regulate the use of customized implants. In the U.S., 3D printing implants
generally fall under the same regulatory class as similar orthopedic im-
plants, most of which belong to the class III category [264]. Regardless of
the manufacturing method, implants must pass regulatory standards
based on the class of device (class I, II, or III) in order to come to market.
For custom devices, the FDA may offer exemptions under section 520(b)
of the Food, Drug, and Cosmetic Act (Fd & C Act) which allows for the
distribution of devices which are “not generally available”, “modified to
fit the order of the physician”, and related to “special need” or for “suf-
ficiently rare conditions or unique pathology” [265]. In 2014, the FDA
held a public working group that summarized best practices for quality
M. Meng et al.
control and safety in AM. On January 1, 2020, China officially imple-
mented the "Regulations on the Supervision and Administration of
Customized Medical Devices " to regulate 3D printing devices under the
filing system. However, an international standard assessment system for
such issues is not yet in place, and there are still some outstanding ethical
issues [12]. In summary, those who chose to manufacture customized
implants are held to the same standards as every other manufacturer of
metallic implants.
Despite these limitations to the use of 3D printing metal implants in
orthopedics, 3D printed metal implants will offer unprecedented op-
portunities as the metal materials industry and 3D printing technology
continue to evolve and improve. Smart stimulus-responsive biomaterials
have attracted increasing attention from researchers over the past 5 years
[266]. They differ from conventional biomaterials in their ability to
respond to external physical triggers (e.g., light irradiation, electric and
magnetic fields, ultrasound, appropriate mechanical stimulus) or
endogenous disease microenvironments (e.g., overexpressed ROS, mild
acidity, endogenous electric fields, specific ionic concentrations, secreted
enzymes or specific immune environments), or a combination of the
above. Artificial intelligence, 4D printing, big data, and other digital
technologies are constantly being updated, making metal orthopedic
implants increasingly personalized and intelligent.
6. Conclusion
Precision, intelligence, and personalization are the future directions
of orthopedics. 3D printing is an exciting technology which is considered
to revolutionize patient-specific orthopedic implants. With the help of 3D
printing techniques and advanced biometals, orthopedic implants can
precisely fabricate complex geometries, reduce excessive mechanical
strength, increase cell and nutrient permeability, and promote angio-
genesis and bone growth. It is reasonable to believe that 3D printing
technology will be more deeply integrated with artificial intelligence, 4D
printing, and big data to play a greater role in orthopedic metal implants
and eventually become a major part of the digital economy.
Declaration of competing interest
The authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a
potential conflict of interest.
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