Application of virtual overlapping technology for the selection of appropriate metal plate dimensions in rib fracture surgery

Introduction

Rib fractures are a common complication of thoracic trauma, often leading to severe pain, respiratory compromise, and prolonged hospitalization, with risks escalating significantly with advanced age and injury severity (1). Surgical stabilization of rib fracture (SSRF) is recommended as the standard of care for flail chest, with reported favorable outcomes (2). As indications and contraindications have been further delineated, the application of SSRF has expanded to include multiple displaced non-flail rib fractures (3). Although SSRF in this population may provide short-term clinical benefits, demonstrating a reduction in mortality remains challenging (4). Furthermore, conflicting data exist; recent evidence suggests that SSRF may prolong hospital length of stay without providing demonstrable improvement in quality of life at 6 months (5). Consequently, the optimal therapeutic strategy remains a subject of ongoing controversy within the medical community (5,6).

Currently, various osteosynthesis systems are utilized worldwide, with rib-specific locking plate systems (e.g., MatrixRIB) and pure titanium claw-type plates representing two widely utilized types. Unlike locking plates, claw-type plates require precise selection from fixed pre-manufactured dimensions. Despite this limitation, claw-type plates have established a long-standing and widespread presence in clinical practice, attributable to their subjective ease of application and straightforward handling.

For these claw-type devices, determining the appropriate plate size is a subjective process contingent on the surgeon’s intraoperative assessment. Despite being generally manageable, this empirical approach carries an inherent risk of selection error, potentially resulting in implant-anatomy mismatch. Such sizing discrepancies are clinically significant, as they may be associated with postoperative complications, including recurrent fracture displacement and persistent pain at the fracture site.

To address these limitations, this study aimed to assess the feasibility and accuracy of a “virtual overlapping” technology—matching three-dimensional (3D) digital plate templates to patient-specific rib models—to objectively determine the optimal plate size preoperatively.

Methods

Study design and population

This prospective cohort study was conducted at The Affiliated Hospital of Hangzhou Normal University. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of The Affiliated Hospital of Hangzhou Normal University [No. 2023(E3)-HS-048; approval date: February 2, 2024] and all patients provided written informed consent.

Adult patients (age ≥18 years) with blunt thoracic trauma were screened. The inclusion criteria were as follows: (I) all flail chest patients; (II) ≥3 contiguous rib fractures, poor cough; (III) radiographically-verified significant displacement (≥1 shaft width); (IV) chest computed tomography (CT) performed 1–3 days post-injury; and (V) persistent pain [visual analog scale (VAS) score ≥5] despite multimodal analgesia. The exclusion criteria included hemodynamic instability [systolic blood pressure (SBP) <90 mmHg], severe traumatic brain injury [Glasgow Coma Scale (GCS) ≤8], spinal cord injury, or decompensated comorbidities. The final cohort comprised 29 patients (21 men, 8 women; mean age 56.2±14.6 years).

Workflow

The workflow involved: (A) CT acquisition; (B) 3D reconstruction and template import; (C) virtual plate-to-rib matching; (D) optimal size selection; (E) physical plate retrieval; (F) intraoperative application and verification (Figure 1).

Figure 1 The 3D model matching procedure workflow. (A) Chest CT acquisition. (B) In the 3D software environment, 3D rib reconstruction and import of plate templates. (C) Virtual plate-to-rib matching. (D) Selection of the optimal plate size in 3D software. (E) Corresponding physical plate chosen. (F) Intra-operative application and immediate assessment. 3D, three-dimensional; CT, computed tomography.

Image acquisition and 3D reconstruction

The CT datasets utilized in this study were derived from routine admission examinations; patients with scans exhibiting suboptimal resolution were excluded. Admission 3D rib CT was performed using a 64-slice scanner (LightSpeed VCT, GE Healthcare, Chicago, IL, USA). The scanning protocol included a collimation of 64×0.625 mm, a reconstruction slice thickness of 1.25 mm, 120 kV, and a standard bone algorithm. Importantly, these settings constitute the standard institutional protocol for routine rib fracture assessment, requiring no additional special adjustments. Digital Imaging and Communications in Medicine (DICOM) data were then imported into the open-source software platform 3D Slicer (http://www.slicer.org) (7) for segmentation and 3D model generation.

Digital plate models

3D Slicer and models

Two commonly employed models of encircling rib plates were selected for assessment. In the generated 3D models, a consistent color-coding scheme is applied: yellow denotes the plate in its native, as-manufactured configuration (sterile-packaged state), whereas blue indicates its conditioned state (modified or shaped prior to implantation).

Titanium alloy plate

The first model is the Waston Rib Plate (Figure 2), constructed from a malleable pure titanium alloy. The yellow model represents the plate in its original flat state. The blue model represents the plate in its pre-contoured state, where the plate body has been manually bent to a 60-degree angle to better approximate the rib’s curvature. Although the arms can be mechanically spread, if necessary, the blue model specifically highlights the modification of the plate body angle.

Figure 2 Waston Rib Plate (Pure Titanium Rib Plate, YLG02 series, Changzhou Waston Medical Appliance Co., Ltd.). The yellow model represents the plate in its original flat form. The blue model depicts the processed state, with the plate body pre-bent to a 60-degree angle.

Memory alloy plate

The second model is the TiNi Memory Alloy Plate (Figure 3), which utilizes a thermal shape-memory effect. The yellow model depicts the plate in its original factory state, where the arms are contracted (resting state). The blue model depicts the plate in its expanded state, achieved after the plate is cooled in ice water and the arms are mechanically widened using a spreader to facilitate placement over the rib.

Figure 3 Memory Alloy Plates (TiNi Encircling Plate, 6H series, Shanghai XinChang Memory Co., Ltd.). The yellow model indicates the plate in its original, contracted form (factory state). The blue model indicates the expanded configuration (processed in ice water and widened for implantation).

Virtual overlapping technology procedure

Due to the significant displacement characterizing the fracture, the rib is structurally divided into two distinct segments. This malalignment often precludes simultaneous virtual fitting of the plate to both ends in the static model. Consequently, a sequential matching strategy is employed: for fractures with significant displacement, the same plate model is utilized to separately match the two sides of the fracture ends. Specifically, the plate template is initially aligned with one fracture segment to establish the preliminary size. Once the fit is confirmed, the same template model is then repositioned to verify its geometric compatibility with the opposing fracture segment. This ensures the selected plate curvature accommodates the anatomy of both ends once reduction is achieved.

In the 3D modeling software, the rib fracture model is imported alongside the digital plate library. Initially, a medium-sized template (representing the intermediate dimension) is selected to assess compatibility. The digital plate (depicted in blue) is positioned such that its body runs parallel to and contours tightly against the rib’s outer cortex (Figure 4A). The longitudinal axis of the plate body (Figure 4A, red arrow) must coincide with the central midline of the rib’s outer surface. Crucially, the junctions of the plate arms and body (the shoulders; Figure 4A, yellow arrow; edges of the rib, green arrow) must align precisely with the superior and inferior edges of the rib (Figure 4B, green arrow). Finally, the length of the plate arms on the inner aspect of the rib (Figure 4C, blue arrow) is assessed to ensure optimal sizing—verifying that the arms are neither excessively long (causing mutual interference during closure) nor excessively short (compromising grip strength).

Figure 4 Virtual overlapping procedure. (A) The central axis of the plate body aligns perfectly with the midline of the rib’s outer surface (red arrow). The green arrows in (A) and (B) indicate that the shoulders (roots, yellow arrows) of the plate arms should align with the rib edges (green arrows). (C) Assessment of the plate arm length on the inner aspect of the rib (blue arrows) to prevent sizing errors (excessive protrusion or inadequate encirclement). The green arrows in (C) indicates the rib edges.

Statistical analysis

Data management and statistical analysis were performed using Microsoft Excel (Microsoft Corp., Redmond, WA, USA). Continuous variables are presented as mean ± standard deviation (SD) and range. Categorical variables are expressed as frequencies and percentages (%).

Results

During the study period, a total of 29 consecutive patients presenting with rib fractures were included in this prospective cohort. The demographic analysis revealed a male predominance, with 21 male patients (72.4%) and 8 female patients (27.6%). The mean age of the cohort was 56.2±14.6 years, ranging from 27 to 87 years. For all 29 patients, the described 3D virtual overlapping and sizing workflow was successfully implemented preoperatively, and all patients underwent SSRF without severe procedure-related complications.

To provide a step-by-step illustration of the proposed 3D modeling workflow, we selected two representative cases from our consecutive cohort: one utilizing a pure titanium plate and the other a memory alloy device. The demographic data, injury mechanisms, radiological findings, and perioperative metrics are comprehensively outlined in Table 1.

Case #1: application of a pure titanium claw-shaped rib fracture plate model

Case #1 involved a 52-year-old female who sustained multiple right-sided rib fractures and hemopneumothorax following a motor vehicle accident, necessitating surgical stabilization. The posterior fractures of the 9th and 10th ribs were selected as representative examples.

Strategy for displaced fracture ends

Due to the significant displacement characterizing the fracture, the rib is structurally divided into two distinct segments. This malalignment often precludes simultaneous virtual fitting of the plate to both ends in the static model. Consequently, a sequential matching strategy is employed: the plate template is initially aligned with one fracture segment to establish the preliminary size. Once the fit is confirmed, the same template model is then repositioned to verify its geometric compatibility with the opposing fracture segment. This ensures that the selected plate curvature accommodates the anatomy of both ends once reduction is achieved.

Figure 5A presents the preoperative 3D CT reconstruction, clearly depicting the displaced fracture sites of the 9th and 10th ribs adjacent to the spine (indicated by yellow arrows). Following the virtual sizing and surgical fixation, Figure 5B displays the postoperative 3D CT reconstruction, confirming that the selected Waston titanium plates achieved precise anatomical alignment and secure fixation on the ribs (indicated by yellow arrows). Specifically, the green plate in Figure 5, C1 is oversized, with the corners of the plate arms (orange arrow) protruding significantly beyond the rib edges (green arrow). Figure 5, C2 further indicates that the plate arm is excessively long (blue arrow). In contrast, Figure 5, C3 demonstrates an appropriately sized blue plate (one size smaller), where the corners of the plate arms (orange arrow) precisely align with the rib edges (green arrows).

Figure 5 Virtual overlapping and sizing procedure for Waston rib plates. The yellow arrows indicate the locations of the rib fractures. (A) Preoperative 3D CT reconstruction showing the displaced fractures (yellow arrows). (B) Postoperative 3D CT reconstruction showing the ribs after SSRF (yellow arrows). (C1-C3) Comparison of plate sizing. (C1) An oversized plate (Model 45×19, depicted in green) is aligned with the rib midline. The shoulders of the plate arms (orange arrow) protrude beyond the superior and inferior rib edges (green arrows). (C2) View from the inner aspect of the rib showing that the length of the unilateral plate arm exceeds half the width of the rib’s inner surface (blue arrows), indicating a risk of interference during closure. (C3) The appropriate plate (Model 45×15, depicted in blue) demonstrates optimal fit. The shoulders of the plate arms (orange arrow) align flush with the rib edges (green arrows) without protrusion. Additionally, the length of the unilateral plate arm is less than half the width of the rib’s inner surface, ensuring secure fixation without interference. 3D, three-dimensional; CT, computed tomography; SSRF, surgical stabilization of rib fractures

Case #2: application of the memory alloy plate model

Case #2 involved a 51-year-old male who sustained multiple left-sided rib fractures and pulmonary contusion following a fall. The fractures of the 9th through 11th ribs, indicated by green arrows in Figure 6A, served as the representative examples. The patient underwent surgical stabilization utilizing memory alloy plates. Postoperative 3D CT reconstruction following internal fixation is shown in Figure 6B (indicated by green arrows). To illustrate the selection process, a smaller plate model (Type 6H12) was initially chosen for assessment, depicted in green (Figure 6, C1). As illustrated in Figure 6, C1, when utilizing a plate one size smaller than the optimal model, aligning the plate arm corners (yellow arrow) with the rib edges (green arrows) results in an excessively short unilateral plate arm (blue arrow), which is prone to detachment post-fixation. Conversely, Figure 6, C2 demonstrates an appropriately sized plate with a suitable arm length (blue arrow). Figure 6, C3 depicts the red plate after it has retracted to its original shape. Finally, Figure 6, C4 confirms the secure anatomical engagement of the plate on the inner aspect of the rib.

Figure 6 Virtual overlapping and sizing procedure for Memory Alloy Plates (TiNi Encircling Plate). The green arrows indicate the locations of the rib fractures. (A) Preoperative 3D CT reconstruction showing the fracture sites. (B) Postoperative 3D CT reconstruction confirming secure fixation after SSRF. (C1-C4) Comparison of plate sizing and simulation. Note that these panels illustrate the matching process on one fracture segment; the same selection logic applies to the opposing fracture end. (C1) An undersized plate (Model 6H12, colored in green). Although the midline is aligned, the length of the unilateral plate arm (blue arrow) is less than one-third of the rib’s inner width, indicating insufficient encirclement and inadequate grip strength. (C2) An appropriate plate (Model 6H13, colored in blue). The shoulders of the plate arms (yellow arrow) align perfectly with the rib edges, and the length of the plate arm (blue arrow) is suitable for secure fixation. (C3) Simulation of the 6H13 plate in its contracted state (colored in red) at body temperature, demonstrating the clamping effect. The shoulders of the plate arms (yellow arrow) align with the rib edges (green arrow). (C4) View from the inner aspect of the rib, showing the final engagement of the plate arms. The length of the unilateral plate arm covers less than half the width of the rib’s inner surface (blue arrow). The green arrow indicates the rib edges. 3D, three-dimensional; CT, computed tomography; SSRF, surgical stabilization of rib fractures.

Discussion

This study demonstrates that utilizing 3D virtual overlapping technology for preoperative planning in SSRF is feasible and results in accurate plate sizing. Although SSRF is the established standard for flail chest, its therapeutic benefit for non-flail fractures—particularly regarding mortality reduction and quality of life—remains a subject of controversy, with recent high-level evidence presenting conflicting data (4-6). However, regardless of the debate surrounding indications, precision in rib-encircling implant selection constitutes a pivotal link in determining surgical success. Ill-fitting implants may compromise stability and lead to instability at the fracture site, potentially serving as a source of postoperative pain.

Currently, rib-encircling (claw-type) systems remain widely utilized. However, as distinct plate models are designed to accommodate specific ranges of rib diameters, selecting an ill-fitting plate may necessitate intraoperative implant exchange, thereby exacerbating trauma to the fracture site. Furthermore, such mismatches may result in mechanical failure and recurrent displacement postoperatively. Therefore, precise preoperative selection provides a valuable reference for preventing these adverse occurrences.

In recent years, 3D CT reconstruction has gained widespread application in thoracic preoperative planning, particularly in the domain of precision pulmonary surgery (8,9). This technology has demonstrated favorable clinical outcomes, providing direct support for the refinement of surgical techniques (10). Building on these advancements, we integrated 3D CT imaging into the precise preoperative planning for rib fractures, aiming to mitigate intraoperative uncertainty and enhance surgical efficacy.

The unique and complex geometry of ribs renders preoperative sizing via standard two-dimensional (2D) CT scans inherently difficult. To address this, our approach employs 3D imaging software on personal computers to achieve precise reconstructions of rib fractures, into which 3D models of various metal plates are integrated. Through this “virtual overlapping” technology, the optimal plate size is determined via model matching within the software environment. This method effectively circumvents subjective limitations by establishing an objective sizing standard, thereby minimizing the risk of inaccuracies arising from intraoperative assessments. Although the approximate 40-minute planning time may preclude its use in immediate emergency settings, it serves as an ideal adjunct for stable patients scheduled for surgery ≥2 days post-injury, effectively capitalizing on the necessary preoperative observation window. Ultimately, this approach significantly enhances preoperative planning, facilitating safer and more informed intraoperative decision-making.

Feasibility: hardware requirements, data acquisition, and workflow integration

Hardware and data prerequisites

The computational demands of the proposed approach are minimal; a standard laptop equipped with an integrated graphics card is sufficient for implementation, obviating the need for high-end workstations. However, the quality of the input data is paramount. High-resolution, thin-slice chest CT data is a strict prerequisite. Specifically, ensuring appropriate breath-holding or respiratory phase control, alongside rapid acquisition times, is critical to minimize motion artifacts, whereas thin-slice reconstruction (slice thickness ≤1.5 mm) enhances the geometric fidelity of the resulting 3D model. Without high-quality DICOM data, the accuracy of both the reconstruction and the subsequent fitting process would be compromised.

Software and operational efficiency

The described workflow is fundamentally designed to be surgeon-led. In this study, we utilized the open-source 3D Slicer software to generate 3D rib models and perform virtual plate matching. It should be noted that, given its open-source nature, this 3D Slicer-based workflow is currently recommended primarily as an adjunctive tool for clinical research and preoperative visualization. To ensure optimal patient safety, the virtual simulation does not replace clinical judgment; the surgeon always makes the definitive determination regarding the specific plate model and size based on actual intraoperative conditions.

Regarding operational efficiency, processing and virtually simulating a single rib takes approximately 5–10 minutes. However, the comprehensive preoperative planning for a routine clinical case—which includes DICOM data import, initial full-chest 3D reconstruction, and the targeted simulation of 2–3 critical fracture sites—typically requires a total of 1.5–2 hours. Furthermore, in patients presenting with multiple rib fractures (e.g., >3), it is generally unnecessary to perform virtual simulation for every individual fracture site. Due to the inherent morphological similarities among adjacent ribs, surgeons typically only need to focus their preoperative planning on the fracture ends located at the most severely displaced or anatomically complex segments. For the remaining fractures with comparable morphology, surgeons can directly reference the successfully matched plate models during surgery or simply proceed with standard intraoperative fixation. This targeted approach significantly optimizes preoperative preparation time while fully satisfying practical clinical needs.

Accessibility and cost-effectiveness

Crucially, this methodology is flexible regarding software selection. All analytical steps, including segmentation, reconstruction, and virtual fitting, can be executed using open-source platforms such as 3D Slicer. In addition to these free platforms, commercial software such as the Mimics Innovation Suite v21 (Materialise NV, Leuven, Belgium) (11) offers enhanced operational convenience and is currently widely utilized. It is important to acknowledge that although open-source platforms are robust research tools, they may lack specific Food and Drug Administration (FDA) or Conformité Européenne (CE) certification for clinical diagnosis. Consequently, in this workflow, the software functions strictly as an adjunctive preoperative tool for visualization and sizing estimation. The final selection of the implant is ultimately subject to the surgeon’s judgment and must be validated by intraoperative verification to ensure patient safety. Complementing this software accessibility, manufacturers provided digital plate templates (in “.STL” format) at no cost. This combination of standard hardware, versatile software options, and accessible digital assets ensures the workflow is practically efficient and financially viable for a wide range of institutions.

Clinical validation

The clinical reliability of this technology was validated by cross-referencing postoperative 3D CT imaging with physical examinations. A potential concern in SSRF is the discrepancy between radiological appearance and mechanical stability—where a plate appears well-positioned on CT, yet bony crepitus (indicating micromotion) persists at the fracture site. In our review of 30 cases, no such discrepancies were observed. The virtual planning accurately predicted the intraoperative fit, demonstrating high feasibility and reliability for enhancing surgical precision.

Limitations

During the model matching procedure, rib dimensions may occasionally fall precisely between two consecutive plate sizes (e.g., #11 and #12). In such borderline instances, we routinely prioritize the larger size (e.g., #12). If the selected plate appears marginally oversized relative to the rib diameter intraoperatively, the “hugging arms” of the plate can be forcibly clamped or mechanically compressed to reduce their encircling dimension. This manipulation effectively tightens the grip on the rib, ensuring secure fixation and preventing hardware loosening, whereas an undersized plate (#11) risks inadequate coverage that cannot be corrected.

This study also has limitations inherent to its design. It was a single-center prospective cohort study with a relatively small sample size (n=29) and lacked a randomized control group. However, despite the limited sample size, qualitatively, this method facilitated the preoperative decision-making process, particularly in scenarios where visual assessment was ambiguous. This clinical utility was supported by the immediate intraoperative verification of secure fixation and further corroborated by postoperative CT scans confirming precise anatomical apposition. Consequently, although definitive conclusions regarding its superiority over conventional methods require validation in larger trials, the current data support its feasibility.

The integration of 3D rib reconstruction with patient surface imaging enhances the ability to accurately locate fracture ends on the skin, thereby facilitating a precise surgical incision plan. Regarding the workflow timing, we acknowledge that international guidelines recommend SSRF within 72 hours. However, in cases of high-energy trauma, the timing of surgery is often constrained by concomitant injuries (e.g., subarachnoid hemorrhage, pulmonary contusion) or hemodynamic instability that require initial medical optimization. In our institutional workflow, the virtual overlapping planning is typically completed within 1–2 days after admission utilizing the initial diagnostic CT data. This parallel workflow ensures that plate sizing is finalized during the compulsory observation period, allowing surgeons to proceed immediately once the patient is physiologically cleared for anesthesia. Thus, the application of this technology utilizes the necessary medical stabilization window and does not inherently delay surgical intervention.

In summary, despite the requisite planning time, this technology offers a feasible and objective strategy to enhance preoperative precision and reduce intraoperative uncertainty in rib fracture stabilization.

Conclusions

In this prospective cohort study, we demonstrated that virtual overlapping of patient-specific 3D rib models with digital plate templates is a feasible and accurate method for preoperative sizing. The technique achieved 100% concordance between the virtually selected and surgically implanted plates, ensuring precise anatomical fit without the need for intraoperative exchange. Integrating 3D imaging into the surgical workflow provides a precision-medicine tool that effectively mitigates empirically derived sizing uncertainty. Further high-quality comparative research is warranted to establish its clinical benefits over standard intraoperative sizing techniques.

Acknowledgments

We would like to express our sincere gratitude to all the staff at the Department of Thoracic Surgery, The Affiliated Hospital of Hangzhou Normal University, for their invaluable clinical and administrative support throughout this study. We also extend our deepest appreciation to the patients and their families who participated in this research; this study would not have been possible without their trust and cooperation.

Footnote

Data Sharing Statement: Available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1-2509/dss

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1-2509/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of The Affiliated Hospital of Hangzhou Normal University [No. 2023(E3)-HS-048; approval date: February 2, 2024], and all patients provided written informed consent.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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