{"paper_id":"34eb4f71-b435-4ff6-82e6-7921fba219e3","body_text":"Reconstruction of Traumatic Proximal Femoral Bone Defects with Personalized 3D-Printed Porous Ti-6Al-4V Prosthesis: A Case Report and Literature Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Reconstruction of Traumatic Proximal Femoral Bone Defects with Personalized 3D-Printed Porous Ti-6Al-4V Prosthesis: A Case Report and Literature Review Jiangang Cheng, Yang Gao, Guolin Meng, Jinkang Zhang, zhuoyu Long, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8098190/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background Reconstruction of critical-sized proximal femoral defects caused by high-energy trauma remains a formidable orthopedic challenge due to compromised mechanical stability, anatomical complexity, and limited biological integration capacity. Traditional methods (allografts, Ilizarov techniques, vascularized grafts) often fail to address dual requirements of load-bearing and long-term osseointegration. Methods This case report details a 55-year-old male miner with a 111 mm post-traumatic femoral defect following open comminuted fracture. A two-stage protocol was implemented: 1) Initial stabilization via external fixation and defect temporization; 2) Definitive reconstruction using a patient-specific 3D-printed porous Ti6Al4V prosthesis featuring dual-functional design - hollow architecture for autologous/allogeneic bone grafting and optimized screw trajectories mirroring contralateral femoral anatomy. The implant incorporated biomechanical enhancements including microporous inner surfaces (600–700µm pore size, 70–80% porosity) for osseointegration and multidirectional locking screw fixation. This study was approved by our Institutional Review Board, and informed consent was obtained. Results At 49-month follow-up, radiographic evaluation demonstrated complete bony union and extensive bone ingrowth into the porous structure. The patient achieved full weight-bearing with Harris Hip Score of 92 points, resuming occupational activities without implant-related complications. CT confirmed stable osseointegration without loosening or stress shielding. Conclusion This case validates the efficacy of 3D-printed prostheses with integrated biological/mechanical solutions for traumatic femoral defects. Key innovations include: 1) Dual-phase reconstruction: Mechanical stabilization via topology-optimized porous structure + biological integration through bone-graftable chambers; 2) Anatomic precision: Mirror-image modeling combined with calcar femorale-aligned screw trajectories; 3) Long-term durability: 70–80% porosity balancing stress distribution and fatigue resistance. Compared to conventional methods, this approach reduced treatment duration while achieving superior functional outcomes. Future directions should focus on gradient-porosity designs and bioactive coatings to enhance osseoconduction. Traumatic femoral defect 3D-printed prosthesis Staged reconstruction Dual-phase reconstruction Mechanical stability Biological integration Figures Figure 1 Figure 2 Figure 3 Introduction The repair of critical-sized bone defects secondary to open comminuted fractures, osteomyelitis, and bone nonunion remains a formidable challenge in orthopedic surgery [ 1 ] . Current clinical strategies primarily encompass these modalities: allograft transplantation, Ilizarov bone transport and vascularized fibular grafting [ 1 , 2 ] . However, each approach presents distinct limitations that compromise clinical outcomes [ 3 ] . Allograft transplantation faces challenges regarding mechanical stability, immune rejection and bone resorption [ 4 ] . Ilizarov bone transport, while effective in gradual defect resolution, is associated with prolonged treatment duration (typically 6–12 months), high complication rates including pin tract infections, limb length discrepancies, and docking site nonunion [ 5 – 7 ] . Vascularized fibular grafts demand specialized microsurgical expertise and carry risks of donor site morbidity, stress fractures and pseudarthrosis formation [ 8 ] . Emerging 3D-printing technologies have revolutionized bone defect reconstruction by enabling precise anatomical restoration [ 9 ] . While 3D-printed prostheses have demonstrated success in oncological limb salvage surgery [ 10 ] , their application in non-neoplastic conditions remains underexplored. Current implants primarily focus on structural support, yet long-term stability remains uncertain due to inadequate biological integration and prosthetic loosening due to fatigue [ 11 ] . To address this dual challenge of immediate mechanical competence and sustained osteogenesis, we propose a novel composite reconstruction strategy: a patient-specific porous titanium prosthesis with optimized topology, combined with autologous bone grafting to facilitate biological fixation. This case report validates this concept through a 49-month follow-up of a critical-sized proximal femoral defect (111 mm) caused by open comminuted fractures. We reconstructed with a 3D-printed porous Ti6Al4V prosthesis combined with autologous/allogeneic bone successfully. The patient achieved radiographic union and resumed full weight-bearing activities without implant-related complications. This dual-phase reconstruction paradigm may represent a viable solution for complex non-oncological bone defects. Case presentation 1.Chief complaint A 55-year-old male miner was admitted to our hospital due to a proximal femoral bone defect of more than six months caused by open comminuted fractures. His right thigh was accidentally hit by a huge rock during work, resulting in an open comminuted fracture, with severe soft tissue damage and heavy contamination of the wound. He underwent debridement surgery multiple times at the local hospital. The patient underwent debridement, bone cement spacer placement, and external fixator fixation of the right proximal femur over three months ago. Postoperatively, the wound healed well, but a residual proximal femoral bone defect remains to be addressed. The patient was subsequently transferred to our hospital for further management. The patient had no history of any diseases. 2.Physical examination An external fixator spanning the right hip joint was applied to the proximal femur. The pin sites appeared dry without signs of erythema or exudate. A 20cm old surgical scar was visible over the lateral aspect of the proximal right thigh, with no elevation in skin temperature. The right thigh was significantly shortened, with local varus deformity, and the right hip joint movement was restricted. Distal circulation and sensation of the affected limb were intact. 3. Preoperative Preparation Three weeks preoperatively, the femoral external fixator was removed and replaced with tibial tuberosity skeletal traction. Laboratory investigations including complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin levels all fell within normal reference ranges. Radiographic evaluation confirmed a 111 mm proximal femoral bone defect with retained bone cement spacer, accompanied by coxa vara deformity demonstrating a neck-shaft angle of 108°. 4.Prosthesis fabrication During this waiting period, we proceed with the design and fabrication of the prosthesis. Based on the mirror principle, we obtained the missing data from the contra-lateral part of the femur to fabricate the irregular prosthesis. The prosthesis fabrication was designed by Shaanxi Dongwang Technology Company [12] . The prosthesis was a hollow tubular structure, the interior of which can be used for bone grafting. The prosthesis can be divided into an inner wall and an outer wall. The outer wall provided mechanical support, while the inner wall was a porous layer that facilitates the osteointegration of bone tissue into the prosthesis. The proximal end of the prosthesis was designed with two screw holes along the direction of the femoral neck, and there are several screw holes extending towards the greater trochanter. The distal end was designed with three screw holes perpendicular to the direction of the diaphysis. All of these provided sufficiently stable mechanical properties (Fig. 1). 5.Operative procedure Under general anesthesia, surgical exposure was achieved through the previous incision at the proximal right femur. Following cement spacer identification, the induced membrane was incised and complete cement removal was performed. Radical debridement was conducted to excise fibrotic tissue and sequestrum at the fracture site, with sclerotic bone resection continued until punctate bleeding was observed on bone surfaces. Sequential medullary canal reaming preceded definitive measurement of the proximal femoral defect, quantified as 111 mm in length. In accordance with preoperative digital templating, a 3D-printed titanium porous prosthesis was anatomically positioned and rigidly fixed at both metaphyseal and diaphyseal segments. Autologous iliac crest bone grafts harvested bilaterally were milled into 3 mm × 3 mm corticocancellous particles. These were combined with freeze-dried allogeneic bone granules at a 5:1 ratio (autograft: allograft) and 1 g vancomycin powder, forming an osteoconductive composite. The bone mixture was strategically implanted through dedicated grafting windows in the prosthetic body. Final intraoperative fluoroscopy confirmed appropriate hardware positioning and bone graft distribution prior to drainage tube placement (Fig. 2). 6.Postoperative management Standard prophylactic measures were implemented immediately postoperation, including intravenous cefazolin sodium 1 g every 8 hours (tid) for 48 hours, combined with multimodal analgesia and mechanical thromboprophylaxis. The surgical drain was removed on postoperative day 2. Early rehabilitation protocol initiated 24 hours postoperatively included active/passive range-of-motion exercises for the hip and knee joints under physiotherapist supervision. Blood routine tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin, and D-dimer tests were checked weekly. Three months after surgery, the patient started partial weight-bearing exercises with the assistance of crutches, gradually transited to full weight-bearing exercises based on radiographic consolidation evidence. Follow-up evaluations of radiographic assessment of the femur and hip joint function using Harris Hip Score (HHS) were conducted at 1 month, 3 months, 6 months and annually after surgery. 7.Outcome and evaluation During the 49-month follow-up period, the surgical wound demonstrated favorable healing progression without clinical signs of infection. The patient maintained asymptomatic status with no significant hip pain or discomfort throughout the observation period. Serial laboratory analyses consistently showed inflammatory markers and D-dimer concentrations within physiologically normal ranges. Postoperative radiographic evaluations revealed optimal prosthesis positioning with stable screw fixation, showing no evidence of component loosening or periprosthetic osteolysis. Notably, the bone defect interfaces achieved complete osseous union, with evident bone ingrowth into the porous prosthesis structure documented at the 6-month postoperative evaluation (Fig. 3). At the final follow-up assessment, the patient exhibited satisfactory hip functional outcomes with a Harris Hip Score of 92 points, demonstrating preserved joint mobility and successful return to occupational activities. Discussion Reconstruction of large-segment bone defects caused by open comminuted fractures remains a significant challenge in orthopedics, characterized by prolonged treatment duration, low success rates, and high disability rates [ 1 – 3 ] . This case presented a particularly complex scenario involving a 111 mm irregularly shaped segmental bone defect at the right proximal femur, where conventional reconstruction strategies proved inadequate. Effective bone regeneration coupled with sustained mechanical stability constitutes the dual imperative in such cases, yet no existing modality satisfactorily addresses both requirements. Traditional approaches exhibited critical limitations in this clinical context. Allograft transplantation carries substantial risks of immune rejection and progressive graft resorption, particularly problematic in geometrically complex defects where creeping substitution fails to achieve complete osseous integration [ 4 ] . The Ilizarov bone transport technique, while theoretically applicable, was precluded by the proximal femoral location's insufficient residual bone stock for fixation and the unacceptable risks of hip joint stiffness and progressive varus deformity development [ 5 – 7 ] . Vascularized fibular autografts, though providing biological viability, demonstrated insufficient load-bearing capacity for weight-bearing reconstruction and introduced donor-site morbidity, with additional concerns regarding diameter mismatch at the recipient site and late stress fracture potential [ 8 ] . In this case, we innovatively employed a 3D-printed hollow titanium alloy prosthesis, achieving anatomical restoration and functional recovery, thereby providing new insights for managing complex bone defects [ 13 ] . While 3D-printed titanium prostheses have been primarily reported for oncological defect reconstruction [ 10 , 14 ] , critical distinctions exist in their application to post-traumatic bone defects. In oncological limb salvage surgery, the primary objective centers on restoring structural continuity to preserve ambulatory function and quality of life, often with compromised long-term biomechanical durability due to limited patient survival expectations. In contrast, traumatic bone reconstruction necessitates dual-phase biomechanical considerations: (1) Primary stability requiring rigid mechanical support to withstand physiological loads during early bone regeneration, and (2) Secondary biological remodeling demanding gradual load transfer to neoformed bone to prevent stress shielding and implant fatigue failure over decades of expected use [ 15 – 17 ] . Zhuo Chen et al. evaluated 3D-printed porous prostheses for reconstructing femoral defects secondary to osteomyelitis in 11 patients and showed that the 3D-printed implants demonstrated rapid anatomical restoration with mechanical stability, significantly reducing treatment duration while achieving favorable functional outcomes in complex femoral defects [ 18 ] . Bingchuan Liu et al. evaluated 3D-printed prostheses for reconstructing critical-sized tibial diaphysis defects (> 10 cm) in 14 patients with chronic osteomyelitis (10 cases) or aseptic non-union (4 cases) and reported that 3D-printed porous Ti6Al4V prostheses effectively restore anatomical integrity and optimize stress conduction in the lower limbs, resulting in substantial functional recovery [ 19 ] . However, since these prostheses do not require bone grafting and cannot facilitate bone ingrowth into the implant, their long-term stability and fatigue resistance necessitate further investigation. The proximal femoral defect in our case, located near the hip joint with complex stress distribution, necessitated enhanced fatigue resistance and long-term stability. Our prosthesis design incorporated several key innovations: First, the hollow structure reduces mass and stress shielding effects. The microporous internal architecture (pore size 600 ~ 700µm, porosity 70%~ 80%) mimics human bone mechanics while optimizing stress distribution and theoretically improving fatigue resistance [ 20 , 21 ] . Second, the slightly oversized inner diameter maximizes contact area with host bone. The hollow chamber serves as a graft space for autologous/allogeneic bone mixed with vancomycin powder, enhancing biological integration and long-term stability. Third, the prosthesis features multiple locking screw trajectories designed using mirroring principles from the contralateral femur: two screw paths along the calcar femorale, multidirectional fixation at the greater/lesser trochanters, and three vertical distal locking screws. Additional suture holes facilitate soft tissue reattachment, collectively achieving both immediate mechanical stability and biological anchorage through bone ingrowth. At 49-month follow-up, CT confirmed bony union, extensive prosthesis osseointegration, and absence of loosening. The patient resumed normal gait and occupational activities. This study has limitations including single-case reporting and relatively short follow-up. Future directions include: (1) Developing gradient-porosity prostheses with reinforced density in load-bearing regions; (2) Optimizing topological structures through finite element analysis to balance strength and elastic modulus; (3) Exploring bioactive coatings (e.g., BMP-2 delivery systems) to accelerate osseointegration. Conclusion This case validates using 3D-printed porous titanium prostheses for reconstructing critical proximal femoral defects caused by open comminuted fractures. The custom prosthesis, featuring a hollow porous structure, optimized fixation, and integrated bone grafting, addressed mechanical stability and biological integration. Compared to traditional methods, this approach reduces treatment duration, enhances stability, and combines antibiotic-impregnated grafting for biological integration, circumventing limitations of allografts and Ilizarov techniques. Although single-case reporting necessitates caution, the results underscore 3D-printing's potential in non-oncological reconstruction. Future studies should optimize implant topology, integrate bioactive coatings, and validate outcomes in larger cohorts for standardized protocols. Declarations Acknowledgements Not applicable. Author contributions Cheng Jiangang and Gao Yang were responsible for case collection, performing the surgeries, and drafting the manuscript. Meng Guolin was responsible for experimental design, prosthesis design, and development. Zhang Jinkang was responsible for formulating the surgical plan. Long zhuoyu was responsible for prosthesis development, as well as the collection and summarization of case data. Liu xianggui was responsible for patient management. Huang Hong was responsible for prosthesis manufacturing, quality inspection, and guiding the installation. Funding We sincerely acknowledge the financial support from the Shaanxi Provincial Key Research and Development Program (2024SF-YBXM-198) and National Natural Science Foundation of China (81400859). Data availability The datasets generated and analysed during the current case report are not publicly available due to patient confidentiality and privacy concerns. However, anonymized data may be made available from the corresponding author upon reasonable request and with permission of the involved patient. Consent for publication The patient involved in this case report provided written informed consent for the publication of their personal and clinical details, as well as any identifying images included in this study. Competing interests The authors declare no competing interests. Conflict of interest No competing financial interests exist. Ethical Considerations Ethical approval was not needed for writing a case report in our settings. Clinical trial number: not applicable. References Migliorini F, La Padula G, Torsiello E, et al. Strategies for large bone defect reconstruction after trauma, infections or tumour excision: a comprehensive review of the literature. EUR J MED RES. 2021;26(1):118. Vidal L, Kampleitner C, Brennan MÁ, et al. Reconstruction of Large Skeletal Defects: Current Clinical Therapeutic Strategies and Future Directions Using 3D Printing. Front Bioeng Biotechnol. 2020;8:61. Feltri P, Solaro L, Di Martino A, et al. Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis. Sci Rep. 2022;12(1):9098. Evrard R, Manon J, Maistriaux L, et al. Decellularization of Massive Bone Allografts By Perfusion: A New Protocol for Tissue Engineering. TISSUE ENG PT A. 2023;30(1–2):31–44. Zhu YL, Guo BF, Zang JC, et al. Ilizarov technology in China: a historic review of thirty-one years. INT ORTHOP. 2022;46(3):661–8. Ren C, Li M, Ma T, et al. A meta-analysis of the Masquelet technique and the Ilizarov bone transport method for the treatment of infected bone defects in the lower extremities. J ORTHOP SURG-HONG K. 2022;30(2):10225536221102685. Liu K, Shi L, Liu Y, et al. Ilizarov bone transport versus Masquelet technique for the treatment of bone defects caused by infection: A meta-analysis. ASIAN J SURG. 2023;46(12):6109–11. Toros T, Ozaksar K. Reconstruction of traumatic tubular bone defects using vascularized fibular graft. Injury. 2021;52(10):2926–34. Wixted CM, Peterson JR, Kadakia RJ, et al. Three-dimensional Printing in Orthopaedic Surgery: Current Applications and Future Developments. J Am Acad Orthop Surg Glob Res Rev. 2021;5(4):e20. Timofticiuc IA, Dragosloveanu S, Caruntu A, et al. 3D Bioprinting in Limb Salvage Surgery. 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Hou G, Liu B, Tian Y, et al. An innovative strategy to treat large metaphyseal segmental femoral bone defect using customized design and 3D printed micro-porous prosthesis: a prospective clinical study. J MATER SCI-MATER M. 2020;31(8):66. Liu B, Tan Q, Wang Z, et al. Applying 3D-Printed Porous Ti6Al4V Prostheses to Repair Osteomyelitis-Induced Partial Bone Defects of Lower Limbs: Finite Element Analysis and Clinical Outcomes. ORTHOP SURG. 2023;17(1):115–24. Chen Z, Xing Y, Li X, et al. 3D-printed titanium porous prosthesis combined with the Masquelet technique for the management of large femoral bone defect caused by osteomyelitis. BMC Musculoskelet Disord. 2023;25(1):474. Liu B, Wang L, Li X, et al. Applying 3D-printed prostheses to reconstruct critical-sized bone defects of tibial diaphysis (> 10 cm) caused by osteomyelitis and aseptic non-union. J Orthop Surg Res. 2023;19(1):418. Taniguchi N, Fujibayashi S, Takemoto M, et al. Effect of pore size on bone ingrowth into porous titanium implants fabricated by additive manufacturing: An in vivo experiment. Volume 59. MAT SCI ENG C-MATER; 2016. pp. 690–701. Zhong L, Chen J, Ma Z, et al. 3D printing of metal-organic framework incorporated porous scaffolds to promote osteogenic differentiation and bone regeneration. NANOSCALE. 2020;12(48):24437–49. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8098190\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Case Report\",\"associatedPublications\":[],\"authors\":[{\"id\":557523678,\"identity\":\"97803637-7fde-45f6-981a-7cf0ed4cd41f\",\"order_by\":0,\"name\":\"Jiangang Cheng\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Air Force Military Medical University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jiangang\",\"middleName\":\"\",\"lastName\":\"Cheng\",\"suffix\":\"\"},{\"id\":557523679,\"identity\":\"e32bca76-9798-4469-bf8d-22a8315d1df2\",\"order_by\":1,\"name\":\"Yang 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16:42:40\",\"extension\":\"xml\",\"order_by\":19,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":59765,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"0c444b389d43448ab0d3596e297eea7b1structuring.xml\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/c5983ba5a7cd7abb5c8dc685.xml\"},{\"id\":98429134,\"identity\":\"1850f7e3-3617-46fd-995d-bab1d1a8be75\",\"added_by\":\"auto\",\"created_at\":\"2025-12-17 16:42:50\",\"extension\":\"html\",\"order_by\":20,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"acdc-reference\",\"size\":70816,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"earlyproof.html\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/f0bdee9b351172ab52f93dc5.html\"},{\"id\":98430129,\"identity\":\"8ba8b8e6-a466-45ba-9b44-386ca9fa6cfe\",\"added_by\":\"auto\",\"created_at\":\"2025-12-17 16:44:51\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":100814,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eViews of the patient-specific 3D-printed titanium prosthesis. (1,2,4,5) Computer-generated design models illustrating the prosthetic geometry and fixation screw trajectories. (3,6) Photographs of the manufactured prosthesis from the anterior (3) and posterior (6) aspects.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig.1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/ffc03610a08a0b870a412cd3.jpg\"},{\"id\":98429880,\"identity\":\"30b0e5d8-8378-4571-93b0-126a8da3eecb\",\"added_by\":\"auto\",\"created_at\":\"2025-12-17 16:44:16\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":142491,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eIntraoperative photographs: (1) bone cement filling the bone defect; (2) after removal of the bone cement and debridement of local scar tissue; (3, 4) prosthesis implantation and sufficient bone grafting through the bone grafting window.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig.2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/14b4ecf0e6369a5eb9446498.jpg\"},{\"id\":98074754,\"identity\":\"e2c750be-2424-4b99-a17f-19bad790f85d\",\"added_by\":\"auto\",\"created_at\":\"2025-12-12 13:28:45\",\"extension\":\"jpg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":140391,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eRadiographic images of the femoral bone defect at different time points.\\u003c/p\\u003e\\n\\u003cp\\u003e1: Preoperative anteroposterior radiograph of the femur showing the bone cement spacer.\\u003c/p\\u003e\\n\\u003cp\\u003e2: Intraoperative imaging after removal of the bone cement.\\u003c/p\\u003e\\n\\u003cp\\u003e3-4: Anteroposterior radiograph and coronal CT scan of the femur at 7 months postoperatively, indicating no signs of prosthesis or screw loosening, and showing integration of the implanted bone granules with the surrounding bone tissue.\\u003c/p\\u003e\\n\\u003cp\\u003e5: Anteroposterior radiograph of the femur at 13 months postoperatively, demonstrating a well-positioned prosthesis without evidence of loosening.\\u003c/p\\u003e\\n\\u003cp\\u003e6-8: Anteroposterior radiograph and CT images of the femur at 49 months postoperatively, revealing satisfactory bony healing in the bone defect area and no signs of prosthesis or screw loosening.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig.3.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/6bc42c15310b1e46578c5a64.jpg\"},{\"id\":98444508,\"identity\":\"b969063c-eb51-445f-9263-2a39050dd856\",\"added_by\":\"auto\",\"created_at\":\"2025-12-17 17:16:08\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":889737,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/457b058e-fe77-4487-8383-8b586a814e28.pdf\"},{\"id\":98429327,\"identity\":\"7171f9e0-f3f0-429d-b02b-8c7f4ea1e739\",\"added_by\":\"auto\",\"created_at\":\"2025-12-17 16:43:13\",\"extension\":\"jpg\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":3908658,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"CAREchecklist.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8098190/v1/8eabc0c44c9ba3e0da8bc84f.jpg\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Reconstruction of Traumatic Proximal Femoral Bone Defects with Personalized 3D-Printed Porous Ti-6Al-4V Prosthesis: A Case Report and Literature Review\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eThe repair of critical-sized bone defects secondary to open comminuted fractures, osteomyelitis, and bone nonunion remains a formidable challenge in orthopedic surgery \\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e]\\u003c/sup\\u003e. Current clinical strategies primarily encompass these modalities: allograft transplantation, Ilizarov bone transport and vascularized fibular grafting \\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/sup\\u003e. However, each approach presents distinct limitations that compromise clinical outcomes \\u003csup\\u003e[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]\\u003c/sup\\u003e. Allograft transplantation faces challenges regarding mechanical stability, immune rejection and bone resorption \\u003csup\\u003e[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]\\u003c/sup\\u003e. Ilizarov bone transport, while effective in gradual defect resolution, is associated with prolonged treatment duration (typically 6\\u0026ndash;12 months), high complication rates including pin tract infections, limb length discrepancies, and docking site nonunion \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]\\u003c/sup\\u003e. Vascularized fibular grafts demand specialized microsurgical expertise and carry risks of donor site morbidity, stress fractures and pseudarthrosis formation \\u003csup\\u003e[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]\\u003c/sup\\u003e. Emerging 3D-printing technologies have revolutionized bone defect reconstruction by enabling precise anatomical restoration \\u003csup\\u003e[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]\\u003c/sup\\u003e. While 3D-printed prostheses have demonstrated success in oncological limb salvage surgery \\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]\\u003c/sup\\u003e, their application in non-neoplastic conditions remains underexplored. Current implants primarily focus on structural support, yet long-term stability remains uncertain due to inadequate biological integration and prosthetic loosening due to fatigue \\u003csup\\u003e[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e]\\u003c/sup\\u003e. To address this dual challenge of immediate mechanical competence and sustained osteogenesis, we propose a novel composite reconstruction strategy: a patient-specific porous titanium prosthesis with optimized topology, combined with autologous bone grafting to facilitate biological fixation. This case report validates this concept through a 49-month follow-up of a critical-sized proximal femoral defect (111 mm) caused by open comminuted fractures. We reconstructed with a 3D-printed porous Ti6Al4V prosthesis combined with autologous/allogeneic bone successfully. The patient achieved radiographic union and resumed full weight-bearing activities without implant-related complications. This dual-phase reconstruction paradigm may represent a viable solution for complex non-oncological bone defects.\\u003c/p\\u003e\"},{\"header\":\"Case presentation\",\"content\":\"\\u003ch3\\u003e1.Chief complaint\\u003c/h3\\u003e\\n\\u003cp\\u003eA 55-year-old male miner was admitted to our hospital due to a proximal femoral bone defect of more than six months caused by open comminuted fractures. His right thigh was accidentally hit by a huge rock during work, resulting in an open comminuted fracture, with severe soft tissue damage and heavy contamination of the wound. He underwent debridement surgery multiple times at the local hospital. The patient underwent debridement, bone cement spacer placement, and external fixator fixation of the right proximal femur over three months ago. Postoperatively, the wound healed well, but a residual proximal femoral bone defect remains to be addressed. The patient was subsequently transferred to our hospital for further management. The patient had no history of any diseases.\\u003c/p\\u003e\\n\\u003ch3\\u003e2.Physical examination\\u003c/h3\\u003e\\n\\u003cp\\u003eAn external fixator spanning the right hip joint was applied to the proximal femur. The pin sites appeared dry without signs of erythema or exudate. A 20cm old surgical scar was visible over the lateral aspect of the proximal right thigh, with no elevation in skin temperature. The right thigh was significantly shortened, with local varus deformity, and the right hip joint movement was restricted. Distal circulation and sensation of the affected limb were intact.\\u003c/p\\u003e\\n\\u003ch3\\u003e3. Preoperative Preparation\\u003c/h3\\u003e\\n\\u003cp\\u003eThree weeks preoperatively, the femoral external fixator was removed and replaced with tibial tuberosity skeletal traction. Laboratory investigations including complete blood count (CBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin levels all fell within normal reference ranges. Radiographic evaluation confirmed a 111 mm proximal femoral bone defect with retained bone cement spacer, accompanied by coxa vara deformity demonstrating a neck-shaft angle of 108°.\\u003c/p\\u003e\\n\\u003ch3\\u003e4.Prosthesis fabrication\\u003c/h3\\u003e\\n\\u003cp\\u003eDuring this waiting period, we proceed with the design and fabrication of the prosthesis. Based on the mirror principle, we obtained the missing data from the contra-lateral part of the femur to fabricate the irregular prosthesis. The prosthesis fabrication was designed by Shaanxi Dongwang Technology Company \\u003csup\\u003e[12]\\u003c/sup\\u003e. The prosthesis was a hollow tubular structure, the interior of which can be used for bone grafting. The prosthesis can be divided into an inner wall and an outer wall. The outer wall provided mechanical support, while the inner wall was a porous layer that facilitates the osteointegration of bone tissue into the prosthesis. The proximal end of the prosthesis was designed with two screw holes along the direction of the femoral neck, and there are several screw holes extending towards the greater trochanter. The distal end was designed with three screw holes perpendicular to the direction of the diaphysis. All of these provided sufficiently stable mechanical properties (Fig. 1).\\u003c/p\\u003e\\n\\u003ch3\\u003e5.Operative procedure\\u003c/h3\\u003e\\n\\u003cp\\u003eUnder general anesthesia, surgical exposure was achieved through the previous incision at the proximal right femur. Following cement spacer identification, the induced membrane was incised and complete cement removal was performed. Radical debridement was conducted to excise fibrotic tissue and sequestrum at the fracture site, with sclerotic bone resection continued until punctate bleeding was observed on bone surfaces. Sequential medullary canal reaming preceded definitive measurement of the proximal femoral defect, quantified as 111 mm in length. In accordance with preoperative digital templating, a 3D-printed titanium porous prosthesis was anatomically positioned and rigidly fixed at both metaphyseal and diaphyseal segments. Autologous iliac crest bone grafts harvested bilaterally were milled into 3 mm × 3 mm corticocancellous particles. These were combined with freeze-dried allogeneic bone granules at a 5:1 ratio (autograft: allograft) and 1 g vancomycin powder, forming an osteoconductive composite. The bone mixture was strategically implanted through dedicated grafting windows in the prosthetic body. Final intraoperative fluoroscopy confirmed appropriate hardware positioning and bone graft distribution prior to drainage tube placement (Fig. 2).\\u003c/p\\u003e\\n\\u003ch3\\u003e6.Postoperative management\\u003c/h3\\u003e\\n\\u003cp\\u003eStandard prophylactic measures were implemented immediately postoperation, including intravenous cefazolin sodium 1 g every 8 hours (tid) for 48 hours, combined with multimodal analgesia and mechanical thromboprophylaxis. The surgical drain was removed on postoperative day 2. Early rehabilitation protocol initiated 24 hours postoperatively included active/passive range-of-motion exercises for the hip and knee joints under physiotherapist supervision. Blood routine tests, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), procalcitonin, and D-dimer tests were checked weekly. Three months after surgery, the patient started partial weight-bearing exercises with the assistance of crutches, gradually transited to full weight-bearing exercises based on radiographic consolidation evidence. Follow-up evaluations of radiographic assessment of the femur and hip joint function using Harris Hip Score (HHS) were conducted at 1 month, 3 months, 6 months and annually after surgery.\\u003c/p\\u003e\\n\\u003ch3\\u003e7.Outcome and evaluation\\u003c/h3\\u003e\\n\\u003cp\\u003eDuring the 49-month follow-up period, the surgical wound demonstrated favorable healing progression without clinical signs of infection. The patient maintained asymptomatic status with no significant hip pain or discomfort throughout the observation period. Serial laboratory analyses consistently showed inflammatory markers and D-dimer concentrations within physiologically normal ranges. Postoperative radiographic evaluations revealed optimal prosthesis positioning with stable screw fixation, showing no evidence of component loosening or periprosthetic osteolysis. Notably, the bone defect interfaces achieved complete osseous union, with evident bone ingrowth into the porous prosthesis structure documented at the 6-month postoperative evaluation (Fig. 3). At the final follow-up assessment, the patient exhibited satisfactory hip functional outcomes with a Harris Hip Score of 92 points, demonstrating preserved joint mobility and successful return to occupational activities.\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eReconstruction of large-segment bone defects caused by open comminuted fractures remains a significant challenge in orthopedics, characterized by prolonged treatment duration, low success rates, and high disability rates \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR2\\\" citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e]\\u003c/sup\\u003e. This case presented a particularly complex scenario involving a 111 mm irregularly shaped segmental bone defect at the right proximal femur, where conventional reconstruction strategies proved inadequate. Effective bone regeneration coupled with sustained mechanical stability constitutes the dual imperative in such cases, yet no existing modality satisfactorily addresses both requirements.\\u003c/p\\u003e\\u003cp\\u003eTraditional approaches exhibited critical limitations in this clinical context. Allograft transplantation carries substantial risks of immune rejection and progressive graft resorption, particularly problematic in geometrically complex defects where creeping substitution fails to achieve complete osseous integration \\u003csup\\u003e[\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]\\u003c/sup\\u003e. The Ilizarov bone transport technique, while theoretically applicable, was precluded by the proximal femoral location's insufficient residual bone stock for fixation and the unacceptable risks of hip joint stiffness and progressive varus deformity development \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR6\\\" citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e]\\u003c/sup\\u003e. Vascularized fibular autografts, though providing biological viability, demonstrated insufficient load-bearing capacity for weight-bearing reconstruction and introduced donor-site morbidity, with additional concerns regarding diameter mismatch at the recipient site and late stress fracture potential \\u003csup\\u003e[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]\\u003c/sup\\u003e. In this case, we innovatively employed a 3D-printed hollow titanium alloy prosthesis, achieving anatomical restoration and functional recovery, thereby providing new insights for managing complex bone defects \\u003csup\\u003e[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003cp\\u003eWhile 3D-printed titanium prostheses have been primarily reported for oncological defect reconstruction \\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e]\\u003c/sup\\u003e, critical distinctions exist in their application to post-traumatic bone defects. In oncological limb salvage surgery, the primary objective centers on restoring structural continuity to preserve ambulatory function and quality of life, often with compromised long-term biomechanical durability due to limited patient survival expectations. In contrast, traumatic bone reconstruction necessitates dual-phase biomechanical considerations: (1) Primary stability requiring rigid mechanical support to withstand physiological loads during early bone regeneration, and (2) Secondary biological remodeling demanding gradual load transfer to neoformed bone to prevent stress shielding and implant fatigue failure over decades of expected use \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR16\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003cp\\u003eZhuo Chen et al. evaluated 3D-printed porous prostheses for reconstructing femoral defects secondary to osteomyelitis in 11 patients and showed that the 3D-printed implants demonstrated rapid anatomical restoration with mechanical stability, significantly reducing treatment duration while achieving favorable functional outcomes in complex femoral defects \\u003csup\\u003e[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]\\u003c/sup\\u003e. Bingchuan Liu et al. evaluated 3D-printed prostheses for reconstructing critical-sized tibial diaphysis defects (\\u0026gt;\\u0026thinsp;10 cm) in 14 patients with chronic osteomyelitis (10 cases) or aseptic non-union (4 cases) and reported that 3D-printed porous Ti6Al4V prostheses effectively restore anatomical integrity and optimize stress conduction in the lower limbs, resulting in substantial functional recovery \\u003csup\\u003e[\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e]\\u003c/sup\\u003e. However, since these prostheses do not require bone grafting and cannot facilitate bone ingrowth into the implant, their long-term stability and fatigue resistance necessitate further investigation.\\u003c/p\\u003e\\u003cp\\u003eThe proximal femoral defect in our case, located near the hip joint with complex stress distribution, necessitated enhanced fatigue resistance and long-term stability. Our prosthesis design incorporated several key innovations: First, the hollow structure reduces mass and stress shielding effects. The microporous internal architecture (pore size 600\\u0026thinsp;~\\u0026thinsp;700\\u0026micro;m, porosity 70%~ 80%) mimics human bone mechanics while optimizing stress distribution and theoretically improving fatigue resistance \\u003csup\\u003e[\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]\\u003c/sup\\u003e. Second, the slightly oversized inner diameter maximizes contact area with host bone. The hollow chamber serves as a graft space for autologous/allogeneic bone mixed with vancomycin powder, enhancing biological integration and long-term stability. Third, the prosthesis features multiple locking screw trajectories designed using mirroring principles from the contralateral femur: two screw paths along the calcar femorale, multidirectional fixation at the greater/lesser trochanters, and three vertical distal locking screws. Additional suture holes facilitate soft tissue reattachment, collectively achieving both immediate mechanical stability and biological anchorage through bone ingrowth. At 49-month follow-up, CT confirmed bony union, extensive prosthesis osseointegration, and absence of loosening. The patient resumed normal gait and occupational activities.\\u003c/p\\u003e\\u003cp\\u003eThis study has limitations including single-case reporting and relatively short follow-up. Future directions include: (1) Developing gradient-porosity prostheses with reinforced density in load-bearing regions; (2) Optimizing topological structures through finite element analysis to balance strength and elastic modulus; (3) Exploring bioactive coatings (e.g., BMP-2 delivery systems) to accelerate osseointegration.\\u003c/p\\u003e\"},{\"header\":\"Conclusion\",\"content\":\"\\u003cp\\u003eThis case validates using 3D-printed porous titanium prostheses for reconstructing critical proximal femoral defects caused by open comminuted fractures. The custom prosthesis, featuring a hollow porous structure, optimized fixation, and integrated bone grafting, addressed mechanical stability and biological integration. Compared to traditional methods, this approach reduces treatment duration, enhances stability, and combines antibiotic-impregnated grafting for biological integration, circumventing limitations of allografts and Ilizarov techniques. Although single-case reporting necessitates caution, the results underscore 3D-printing's potential in non-oncological reconstruction. Future studies should optimize implant topology, integrate bioactive coatings, and validate outcomes in larger cohorts for standardized protocols.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003eAcknowledgements\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eAuthor contributions\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eCheng Jiangang and Gao Yang were responsible for case collection, performing the surgeries, and drafting the manuscript. Meng Guolin was responsible for experimental design, prosthesis design, and development. Zhang Jinkang was responsible for formulating the surgical plan. Long zhuoyu was responsible for prosthesis development, as well as the collection and summarization of case data. Liu xianggui was responsible for patient management. Huang Hong was responsible for prosthesis manufacturing, quality inspection, and guiding the installation.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eFunding\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eWe sincerely acknowledge the financial support from the Shaanxi Provincial Key Research and Development Program (2024SF-YBXM-198) and National Natural Science Foundation of China (81400859).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eData availability\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and analysed during the current case report are not publicly available due to patient confidentiality and privacy concerns. However, anonymized data may be made available from the corresponding author upon reasonable request and with permission of the involved patient.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConsent for publication\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe patient involved in this case report provided written informed consent for the publication of their personal and clinical details, as well as any identifying images included in this study.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eCompeting interests\\u003c/strong\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare no competing interests.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConflict of interest\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNo competing financial interests exist.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eEthical Considerations \\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eEthical approval was not needed for writing a case report in our settings. Clinical trial number: not applicable.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eMigliorini F, La Padula G, Torsiello E, et al. Strategies for large bone defect reconstruction after trauma, infections or tumour excision: a comprehensive review of the literature. EUR J MED RES. 2021;26(1):118.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eVidal L, Kampleitner C, Brennan M\\u0026Aacute;, et al. Reconstruction of Large Skeletal Defects: Current Clinical Therapeutic Strategies and Future Directions Using 3D Printing. Front Bioeng Biotechnol. 2020;8:61.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eFeltri P, Solaro L, Di Martino A, et al. Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis. Sci Rep. 2022;12(1):9098.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eEvrard R, Manon J, Maistriaux L, et al. Decellularization of Massive Bone Allografts By Perfusion: A New Protocol for Tissue Engineering. TISSUE ENG PT A. 2023;30(1\\u0026ndash;2):31\\u0026ndash;44.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eZhu YL, Guo BF, Zang JC, et al. Ilizarov technology in China: a historic review of thirty-one years. INT ORTHOP. 2022;46(3):661\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eRen C, Li M, Ma T, et al. A meta-analysis of the Masquelet technique and the Ilizarov bone transport method for the treatment of infected bone defects in the lower extremities. J ORTHOP SURG-HONG K. 2022;30(2):10225536221102685.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLiu K, Shi L, Liu Y, et al. Ilizarov bone transport versus Masquelet technique for the treatment of bone defects caused by infection: A meta-analysis. ASIAN J SURG. 2023;46(12):6109\\u0026ndash;11.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eToros T, Ozaksar K. Reconstruction of traumatic tubular bone defects using vascularized fibular graft. Injury. 2021;52(10):2926\\u0026ndash;34.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eWixted CM, Peterson JR, Kadakia RJ, et al. Three-dimensional Printing in Orthopaedic Surgery: Current Applications and Future Developments. J Am Acad Orthop Surg Glob Res Rev. 2021;5(4):e20.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eTimofticiuc IA, Dragosloveanu S, Caruntu A, et al. 3D Bioprinting in Limb Salvage Surgery. J Funct Biomater. 2023;15(12):383.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eDong J, Ding H, Wang Q, et al. A 3D-Printed Scaffold for Repairing Bone Defects. Polym (Basel). 2023;16(5):706.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eCheng J, Gao Y, Long Z, et al. Repair of distal fibular and lateral malleolus defects with individualized 3D-printed titanium alloy prosthesis: The first case report from China. Int J Surg Case Rep. 2022;94:107057.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAbar B, Kwon N, Allen NB, et al. Outcomes of Surgical Reconstruction Using Custom 3D-Printed Porous Titanium Implants for Critical-Sized Bone Defects of the Foot and Ankle. FOOT ANKLE INT. 2022;43(6):750\\u0026ndash;61.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eYen WW, Baksh N, Gallo V, et al. Current Concepts and Advances of Three-Dimensional Printing in Reconstructive Musculoskeletal Oncology: A Systematic Review. J LONG-TERM EFF MED. 2021;31(4):59\\u0026ndash;71.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eTaniguchi N, Fujibayashi S, Takemoto M, et al. Effect of pore size on bone ingrowth into porous titanium implants fabricated by additive manufacturing: An in vivo experiment. Volume 59. MAT SCI ENG C-MATER; 2016. pp. 690\\u0026ndash;701.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eHou G, Liu B, Tian Y, et al. An innovative strategy to treat large metaphyseal segmental femoral bone defect using customized design and 3D printed micro-porous prosthesis: a prospective clinical study. J MATER SCI-MATER M. 2020;31(8):66.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLiu B, Tan Q, Wang Z, et al. Applying 3D-Printed Porous Ti6Al4V Prostheses to Repair Osteomyelitis-Induced Partial Bone Defects of Lower Limbs: Finite Element Analysis and Clinical Outcomes. ORTHOP SURG. 2023;17(1):115\\u0026ndash;24.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eChen Z, Xing Y, Li X, et al. 3D-printed titanium porous prosthesis combined with the Masquelet technique for the management of large femoral bone defect caused by osteomyelitis. BMC Musculoskelet Disord. 2023;25(1):474.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eLiu B, Wang L, Li X, et al. Applying 3D-printed prostheses to reconstruct critical-sized bone defects of tibial diaphysis (\\u0026gt;\\u0026thinsp;10 cm) caused by osteomyelitis and aseptic non-union. J Orthop Surg Res. 2023;19(1):418.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eTaniguchi N, Fujibayashi S, Takemoto M, et al. Effect of pore size on bone ingrowth into porous titanium implants fabricated by additive manufacturing: An in vivo experiment. Volume 59. MAT SCI ENG C-MATER; 2016. pp. 690\\u0026ndash;701.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eZhong L, Chen J, Ma Z, et al. 3D printing of metal-organic framework incorporated porous scaffolds to promote osteogenic differentiation and bone regeneration. NANOSCALE. 2020;12(48):24437\\u0026ndash;49.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-musculoskeletal-disorders\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bmsd\",\"sideBox\":\"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://author-welcome.nature.com/12891\",\"title\":\"BMC Musculoskeletal Disorders\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Traumatic femoral defect, 3D-printed prosthesis, Staged reconstruction, Dual-phase reconstruction, Mechanical stability, Biological integration\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8098190/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8098190/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cb\\u003eBackground\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eReconstruction of critical-sized proximal femoral defects caused by high-energy trauma remains a formidable orthopedic challenge due to compromised mechanical stability, anatomical complexity, and limited biological integration capacity. Traditional methods (allografts, Ilizarov techniques, vascularized grafts) often fail to address dual requirements of load-bearing and long-term osseointegration.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eMethods\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis case report details a 55-year-old male miner with a 111 mm post-traumatic femoral defect following open comminuted fracture. A two-stage protocol was implemented: 1) Initial stabilization via external fixation and defect temporization; 2) Definitive reconstruction using a patient-specific 3D-printed porous Ti6Al4V prosthesis featuring dual-functional design - hollow architecture for autologous/allogeneic bone grafting and optimized screw trajectories mirroring contralateral femoral anatomy. The implant incorporated biomechanical enhancements including microporous inner surfaces (600\\u0026ndash;700\\u0026micro;m pore size, 70\\u0026ndash;80% porosity) for osseointegration and multidirectional locking screw fixation. This study was approved by our Institutional Review Board, and informed consent was obtained.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eResults\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eAt 49-month follow-up, radiographic evaluation demonstrated complete bony union and extensive bone ingrowth into the porous structure. The patient achieved full weight-bearing with Harris Hip Score of 92 points, resuming occupational activities without implant-related complications. CT confirmed stable osseointegration without loosening or stress shielding.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eConclusion\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eThis case validates the efficacy of 3D-printed prostheses with integrated biological/mechanical solutions for traumatic femoral defects. Key innovations include: 1) Dual-phase reconstruction: Mechanical stabilization via topology-optimized porous structure\\u0026thinsp;+\\u0026thinsp;biological integration through bone-graftable chambers; 2) Anatomic precision: Mirror-image modeling combined with calcar femorale-aligned screw trajectories; 3) Long-term durability: 70\\u0026ndash;80% porosity balancing stress distribution and fatigue resistance. Compared to conventional methods, this approach reduced treatment duration while achieving superior functional outcomes. Future directions should focus on gradient-porosity designs and bioactive coatings to enhance osseoconduction.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Reconstruction of Traumatic Proximal Femoral Bone Defects with Personalized 3D-Printed Porous Ti-6Al-4V Prosthesis: A Case Report and Literature Review\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-12-12 13:28:40\",\"doi\":\"10.21203/rs.3.rs-8098190/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-02-05T06:32:25+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-24T23:02:54+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"113565337796734669375552180890180234127\",\"date\":\"2026-01-19T14:10:26+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-16T14:57:48+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"273929526061921196235151388360400478019\",\"date\":\"2026-01-14T15:46:33+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-01-10T02:01:38+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"269389503338248538661327990797356009745\",\"date\":\"2026-01-04T01:18:55+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-12-09T09:06:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-12-09T09:03:35+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-12-08T07:22:44+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-12-06T16:09:28+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Musculoskeletal Disorders\",\"date\":\"2025-12-06T16:04:20+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-musculoskeletal-disorders\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"bmsd\",\"sideBox\":\"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://author-welcome.nature.com/12891\",\"title\":\"BMC Musculoskeletal Disorders\",\"twitterHandle\":\"BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"stoa\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"71709493-aa83-48df-bf51-c3326cc3945d\",\"owner\":[],\"postedDate\":\"December 12th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-22T11:53:20+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-12-12 13:28:40\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8098190\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8098190\",\"identity\":\"rs-8098190\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}