Unveiling the ultimate advantage: a meta-analysis of 3D visualization and problem-based learning in orthopedic education

Abstract

Background

Three-dimensional (3D) visualization has become increasingly prevalent in orthopedic education to tackle the distinct anatomical challenges of the field. However, there is a conspicuous lack of systematic reviews that thoroughly evaluate both the advantages and drawbacks of integrating 3D with problem-based learning (3D + PBL).

Methods

A rigorous search of English databases (Cochrane Library, Embase, PubMed, Scopus, and Web of Science) and Chinese databases (National Knowledge Infrastructure: CNKI, Chongqing VIP: VIP, and Wan Fang) were performed up to July 2024 to identify relevant studies. Relevant studies were selected based on established eligibility criteria, with clinical data carefully extracted for analysis. Eighteen randomized controlled trials involving a total of 1,077 participants were included in the analysis.

Results

The findings indicated that 3D + PBL instruction significantly outperformed traditional lecture-based learning (LBL) in terms of theoretical knowledge (SMD = 1.62, 95% CI: 1.14–2.10, P < 0.00001) and practical operational scores (SMD = 2.29, 95% CI: 1.41–3.16, P < 0.00001). Furthermore, students exposed to 3D + PBL teaching exhibited a significantly better understanding of orthopedic anatomical structures compared to those receiving LBL (SMD = 1.18, 95% CI: 0.71–1.65, P < 0.00001). Additionally, students in the 3D + PBL group achieved higher theoretical grades (OR = 2.95, 95% CI: 1.57–5.55, P = 0.0008) and reported greater overall satisfaction (OR = 3.26, 95% CI: 1.91–5.54, P < 0.0001) compared to their LBL counterparts.

Conclusion

Given the unique demands of orthopedic education, 3D + PBL emerges as a highly effective teaching method. It not only improves students' theoretical scores but also enhances their communication skills and comprehension of complex concepts. Furthermore, students exhibit greater satisfaction with this approach.

Introduction

Lecture-based learning (LBL) is traditionally teacher-centered, often relying on a "spoon-feeding" approach that transmits knowledge directly to students, and this method can impede students' problem-solving and analytical skills and reduce their interest and motivation [1]. In contrast, PBL, introduced by McMaster University in the UK in 1995, has become a cornerstone in many UK medical schools and is gaining traction in China, featuring prominently in numerous training programs [2]. PBL emphasizes active learning and problem-solving, addressing the complexities of orthopedic education, which requires a thorough understanding of human anatomy and practical skills. Particularly for intricate areas such as pelvic and acetabular anatomy, advanced spatial visualization is essential due to irregular shapes and complex fracture patterns [3]. To meet these challenges, 3D models based on radiographic data have been developed, allowing for the reconstruction of typical and atypical orthopedic scenarios, thereby enhancing students' comprehension of diseases and retention of theoretical knowledge [4].

However, PBL does not uniformly outperform traditional teaching methods for all students. Some studies suggest that PBL can be particularly challenging for faculty and trainees constrained by time [5,6,7]. Additionally, the impact of integrating 3D anatomical models into PBL on students’ learning engagement and comprehension remains unclear [8]. Prior research has primarily focused on the individual effects of 3D visualization tools and PBL in educational settings but has not adequately evaluated their combined impact. This gap in the literature underscores the need for a more integrated approach to understanding how 3D visualization and PBL can synergistically enhance learning outcomes. The primary objective of this study is to investigate the combined impact of 3D visualization tools and PBL on curriculum improvement in orthopedic education, particularly in terms of knowledge retention and practical skill development. This research aims to provide evidence-based insights to inform the development of more effective and engaging educational strategies, ultimately enhancing the quality of orthopedic training programs. To address this gap, we conducted a systematic review and meta-analysis of existing literature to evaluate the effectiveness of combining 3D visualization with PBL in orthopedic education.

Materials and methods

Study design

This meta-analysis is in accordance with PRISMA statement [9].

Literature retrieval strategy

The search strategy encompassed electronic databases including English databases (Cochrane Library, Embase, PubMed, Scopus, and Web of Science) and Chinese databases (National Knowledge Infrastructure: CNKI, Chongqing VIP: VIP, and Wan Fang) were performed up to July 2024. We conducted a comprehensive identification and review of all randomized controlled trials (RCTs) that compared teaching using 3D + PBL to LBL. Our search strategy incorporated both subject headings and free-text keywords: ([PBL OR problem-based learning] AND [3D OR Three-dimensional]) AND (Orthopedics). There were no restrictions based on language for the articles included in our review.

Inclusion and exclusion criteria

Inclusion criteria

Studies were included based on the following PICOS criteria: 1) Population (P): Medical students included trainee and resident doctors. 2) Intervention (I): The experimental group employed 3D + PBL. 3) Comparison (C): The control group utilized LBL. 4) Outcome (O): Metrics included theoretical scores, practical skills assessments, case analysis evaluations, problem-solving abilities, and overall satisfaction. 5) Study Design (S): Only RCTs were considered for inclusion.

Exclusion criteria

Studies were excluded based on the following criteria: 1) Population (P): No-medical students, such as teachers, undergraduates, and so on. 2) Intervention (I): In the experimental group, the 3D + PBL teaching approach was not employed. Instead, other methods such as CBL (Case-Based Learning) or TBL (Team-Based Learning) were used, or only 3D or only PBL was applied. 3) Comparison (C): In the experimental group, the LBL teaching approach was not employed. 4) Outcome (O): Absence of relevant outcome measures. 5) Study Design (S): No-RCTs were excluded.

Data extraction

This process was carried out independently by two reviewers (Li and Hu) in accordance with the Cochrane Collaboration guidelines for systematic reviews, while another two authors (Xiao and Liu) verified the articles selected based on the predefined inclusion and exclusion criteria. Any disagreements between the reviewers were resolved by consultation with a third reviewer. Data extraction emphasized fundamental sample characteristics (authorship, year, age of participants, experimental group, control group, teaching subjects, and study duration, etc.). When information was lacking, we tried to reach out to the primary author via email to obtain clarification or to exclude the study.

Risk of bias assessment

Two authors independently assessed the risk of bias (ROB: http://handbook-5-1.cochrane.org/), in accordance with the Cochrane Handbook version 5.1.0 tool for assessing ROB (The methodological quality was assessed based on several criteria: random sequence generation, concealment of allocation sequences, participant and personnel blinding, outcome assessment blinding, completeness of outcome data, selective reporting, and potential other biases. Each criterion was categorized as “low risk of bias,” “unclear risk of bias,” or “high risk of bias.”) in RCTs [10]. The evaluation of bias was performed by two independent researchers, and the overall quality assessment was carried out by the same two reviewers. In cases where disagreements arose that could not be resolved, discussions were held, or a third reviewer was brought in for an additional assessment.

Statistical analysis

The meta-analysis was conducted using RevMan 5.4 software (freely available online). For continuous outcomes, we reported the standardized mean differences (SMD), and dichotomous outcomes were expressed as odds ratios (OR) with 95% confidence intervals (CI). To evaluate the heterogeneity of the included studies, we applied the Chi-square test. A lack of heterogeneity was indicated by P ≥ 0.1 and I2 ≤ 50%, which led to the use of a fixed-effect model. Conversely, a random-effects model was adopted when P < 0.1 or I2 > 50% indicated the presence of heterogeneity. Additionally, we evaluated publication bias by generating funnel plots corresponding to each category of failure mode.

Results

Search result

The initial search yielded 1,684 records, from which 628 were removed due to duplication. Following a review of titles, abstracts, and full-text articles, 18 studies were identified as potentially suitable for inclusion criteria [4, 11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27]. Post the application of these criteria, one English-language trial and 17 Chinese-language trials were incorporated into the meta-analysis were found to have been published. Figure 1 illustrates the selection process and the number of included and excluded studies. However, this study includes both Chinese and English literature, which may introduce some bias. Therefore, for the Chinese studies, we ensure accurate translation to maintain the integrity of the data and reduce bias.

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Study characteristic

This meta-analysis included 18 RCTs with a total of 1,077 patients, evaluating the effects of 3D + PBL teaching versus LBL teaching in orthopedic education. Participants' ages ranged from 14 to 53 years, and the sample sizes ranged from 28 to 106. Most studies focused on trainees (n = 14), with 4 studies targeting resident doctors. Nine studies lacked participant age information, five did not specify teaching subjects, and ten were missing data on study duration. The basic characteristics of the included studies are detailed in Table 1.

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The bias risk assessment results of the included studies

The risk of bias in the RCTs was assessed using the Cochrane tool. The results for each quality item were presented as percentages across studies. One study did not report RCT design details, 10 studies had ambiguous random sequence generation, and 7 studies explicitly stated RCT design. One study did not report details of allocation concealment, 15 studies provided unclear descriptions of allocation concealment, and 2 studies explicitly detailed the specifics of allocation concealment. Two studies did not report details of the blinding method, nine studies provided unclear descriptions of the blinding, and seven studies explicitly detailed the specifics of the blinding method. The quality assessment of the included studies is illustrated in Fig. 2 The quality assessment at the outcome level, conducted using the GRADE methodology, is summarized in Table 2. The overall evidence quality, evaluated according to GRADE criteria, was determined to be very moderate to very low.

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Primary meta-analysis results

Theoretical scores and operational scores

Twele [4, 12,13,14,15,16, 18, 21, 23,24,25, 27] studies (N = 751) reported the theoretical scores, and outcome level quality for theoretical scores assessed by GRADE was “very low”. Significant heterogeneity was observed (P < 0.00001, I2 = 88%), prompting the use of a random-effects model. The analysis revealed that 3D + PBL teaching resulted in higher theoretical scores compared to LBL teaching (SMD = 1.62, 95% CI: 1.14–2.10, P < 0.00001; see Fig. 3). A sensitivity analysis was conducted to explore potential sources of heterogeneity, but no specific source was identified. Through the included basic information tables, we identified differences in participant characteristics (participants in the studies by Sun, Yang, and Zhang were Resident doctors, while participants in the remaining nine studies were Trainees). We also observed variations in teaching subjects across each study, which could be a primary source of heterogeneity. Additionally, we noted that the duration of 3D + PBL teaching varied across studies, which is another significant source of heterogeneity.

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Nine [12, 14,15,16, 21, 23,24,25, 27] studies (N = 565) reported the operational scores, and outcome level quality for operational scores assessed by GRADE was “very low”. Significant heterogeneity was detected (P < 0.00001, I2 = 94%), necessitating the use of a random-effects model. The analysis indicated that 3D + PBL teaching yielded higher operational scores compared to LBL teaching (SMD = 2.29, 95% CI: 1.41–3.16, P < 0.00001; see Fig. 4). A sensitivity analysis was performed to identify potential sources of heterogeneity but found no specific source. Through the included basic information tables, we identified differences in participant characteristics (participants in the studies by Yang and Zhang were Resident doctors, while participants in the remaining 7 studies were Trainees). We also observed variations in teaching subjects and duration of 3D + PBL teaching across each study, which could be a primary source of heterogeneity.

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Understanding ability and communication ability

Seven [14, 15, 17, 18, 20, 23, 27] studies (N = 354) reported on understanding ability, and outcome level quality for understanding ability assessed by GRADE was “very low”. High heterogeneity was observed (P = 0.0007, I2 = 74%), requiring a random-effects model. The meta-analysis indicated that 3D + PBL teaching improved students' understanding of orthopedic anatomical structures compared to LBL teaching (SMD = 1.18, 95% CI: 0.71–1.65, P < 0.00001; see Fig. 5). A sensitivity analysis indicated that the heterogeneity was potentially influenced by the study by Wu AM et al., which reduced I2 from 74 to 50%. Through a detailed analysis of the study by Wu AM et al., it was found that this research lacks the average age of the participants. Additionally, the teaching subjects in this study focus on 3D spinal models, which differs from the other included studies. This discrepancy could be a major source of heterogeneity.

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Six [4, 14, 15, 22, 23, 27] studies (N = 340) reported on communication ability, and outcome level quality for communication ability assessed by GRADE was “very low”. High heterogeneity was observed (P = 0.02, I2 = 64%), necessitating the use of a random-effects model. The analysis demonstrated that 3D + PBL teaching improved communication ability compared to LBL teaching (SMD = 1.10, 95% CI: 0.70–1.51, P < 0.00001; see Fig. 6). A sensitivity analysis indicated that the heterogeneity was potentially influenced by the study by Zhang BW et al., which reduced I2 from 64 to 0%. Through a meticulous analysis of the study by Zhang BW et al., it was found that this research not only lacks the average age of the participants but also does not provide information on Teaching subjects and the duration of 3D + PBL teaching. These omissions could be primary sources of heterogeneity.

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Teaching interest and teaching satisfaction

Seven [4, 14, 15, 17, 18, 23, 27] studies (N = 370) reported teaching interest, and outcome level quality for teaching interest assessed by GRADE was “very low”. High heterogeneity was observed (P = 0.006, I2 = 67%), so a random-effects model was applied. The meta-analysis showed that students exhibited greater teaching interest with 3D + PBL teaching (SMD = 1.48, 95% CI: 1.05–1.90, P < 0.00001; see Fig. 7). sensitivity analysis indicated that the heterogeneity was potentially influenced by the study by Shi LJ and Zhang XD et al., which reduced I2 from 67 to 31%. Through a careful analysis of the basic information tables of the included studies, it was found that the participants in these two studies were all Resident doctors, while the participants in the remaining studies were Trainees. This could be a major source of heterogeneity.

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Four [4, 17, 18, 20] studies (N = 274) reported on teaching satisfaction., and outcome level quality for teaching satisfaction assessed by GRADE was “very low”. No significant heterogeneity was found (P = 0.12, I2 = 49%). The meta-analysis indicated that 3D + PBL teaching led to higher teaching satisfaction (SMD = 0.85, 95% CI: 0.49–1.22, P < 0.00001; see Fig. 8).

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Orthopedic skill

Six [4, 14, 15, 22, 23, 27] studies (N = 340) reported the orthopedic skill of students, and outcome level quality for orthopedic skill assessed by GRADE was “very low”. High heterogeneity was observed (P = 0.02, I2 = 62%), so a random-effects model was applied. The analysis showed that 3D + PBL teaching resulted in better orthopedic skills compared to LBL teaching (SMD = 1.21, 95% CI: 0.81–1.61, P < 0.00001; see Fig. 9). A sensitivity analysis suggested that the heterogeneity might be attributed to the study by Zhang BW et al., which reduced I2 from 62 to 0%. Through a meticulous analysis of the study by Zhang BW et al., it was found that this research not only lacks the average age of the participants but also does not provide information on Teaching subjects and the duration of 3D + PBL teaching. These omissions could be primary sources of heterogeneity.

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Excellent theoretical grades

Four [19, 22, 25, 26] studies (N = 229) reported excellent theoretical grade for students, and outcome level quality for excellent theoretical grades assessed by GRADE was “moderate”. No heterogeneity was observed (P = 0.77, I2 = 0%), so a fixed-effect model was used. The meta-analysis showed that students achieved higher excellent theoretical grades with 3D + PBL teaching (OR = 2.95, 95% CI: 1.57–5.55, P = 0.0008; see Fig. 10).

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Overall satisfaction

Four [19, 21, 26, 27] studies (N = 230) reported the overall satisfaction, and outcome level quality for overall satisfaction assessed by GRADE was “moderate”. No significant heterogeneity was observed (P = 0.32, I [2] = 14%), so a fixed-effect model was applied. The meta-analysis indicated that students had higher overall satisfaction with 3D + PBL teaching compared to LBL teaching (OR = 3.32, 95% CI: 1.84–5.99, P < 0.0001; see Fig. 11).

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Secondary meta-analysis results

Self-learning ability and analyzing and solving problem ability

Four [14, 15, 23, 27] studies (N = 186) reported self-learning ability, and outcome level quality for operation time assessed by GRADE was “very low”. No significant heterogeneity was observed (P = 0.71, I2 = 0%), so a fixed-effect model was used. The meta-analysis found that students demonstrated stronger self-learning abilities with 3D + PBL teaching compared to LBL teaching (SMD = 1.28, 95% CI: 0.96–1.60, P < 0.00001; see Figure S1).

Four [14, 15, 23, 27] studies (N = 186) reported students’ ability to analyze and solve problems, and outcome level quality for operation time assessed by GRADE was “very low”. No significant heterogeneity was observed (P = 0.48, I2 = 0%), so a fixed-effect model was applied. The meta-analysis showed that 3D + PBL teaching significantly enhanced students' problem-solving abilities compared to LBL teaching (SMD = 1.26, 95% CI: 0.94–1.58, P < 0.00001; see Figure S2).

Learning motivation

Two [15, 27] studies (N = 98) reported on learning motivation, and outcome level quality for operation time assessed by GRADE was “very low”. No significant heterogeneity was observed (P = 0.80, I2 = 0%). The meta-analysis demonstrated that 3D + PBL teaching significantly improved learning motivation compared to LBL teaching (SMD = 1.10, 95% CI: 0.67–1.53, P < 0.00001; see Figure S3).

Passing rate of exam

Two [16, 17] studies (N = 128) reported the passing rate of the examinations, and outcome level quality for operation time assessed by GRADE was “very low”. No significant heterogeneity was observed (P = 0.51, I2 = 0%). The analysis found that 3D + PBL teaching significantly improved the passing rate of exams compared to LBL teaching (OR = 8.13, 95% CI: 2.44–27.10, P = 0.0006; see Figure S4).

Publication bias

A funnel plot was employed to evaluate publication bias. In the studies that reported theoretical scores, the funnel plot displayed asymmetry (see Fig. 12), moreover, Egger’s test (see Figure S5) yielded a P-value of 0.009, indicating the presence of publication bias, indicating a possible occurrence of publication bias.

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Discussion

PBL (Problem-Based Learning) has been a global educational method for over 50 years [28], aimed at developing students' critical thinking, problem-solving, teamwork, and innovation skills [29, 30]. Compared to traditional teaching methods, PBL promotes active exploration, collaboration, and participation, which enhances learning motivation and deepens understanding, while also fostering comprehensive skills. Orthopedics, a complex surgical field, covers a broad range of topics such as trauma, sports injuries, and bone tumors [29]. The complexity of orthopedic anatomy, particularly the acetabulum, which involves intricate blood vessels and nerves, makes it challenging for students to grasp the related concepts [31]. Integrating 3D printing technology into clinical teaching offers a more visual and realistic depiction of fractures and anatomical structures, aiding students in comprehending fracture mechanisms, severity, and treatment options [32]. Despite these advancements, the impact of combining 3D models with PBL teaching on students' learning and understanding remains unclear. There has been no systematic review specifically addressing the effectiveness of 3D + PBL in orthopedic education.

This systematic review investigated the impact of 3D + PBL teaching in orthopedics, and it revealed that 3D + PBL teaching not only improves students' learning and understanding but also boosts their interest and satisfaction. Traditional teaching methods, often criticized as "spoon-feeding," tend to be simplistic and may lead to passive learning, where students acquire strong theoretical knowledge but lack practical skills [1]. This approach hampers their ability to master new orthopedic knowledge and technologies. In contrast, 3D + PBL focuses on solving professional problems and designing learning content, which enhances students’ motivation, proactivity, and independent thinking. This method significantly improves their ability to recall and apply knowledge, making it more effective than traditional methods for testing theoretical knowledge [33, 34]. Our meta-analysis showed higher theoretical and operational scores with 3D + PBL teaching. The integration of 3D printing technology further enhances this approach by providing tangible, three-dimensional models of complex anatomical structures and fractures. This allows students to interact with and explore detailed representations of orthopedic conditions, improving their spatial understanding and clinical skills. 3D models can simulate various scenarios and treatments, offering a realistic and immersive learning experience. While previous studies also found PBL superior in exam scores compared to traditional methods (P < 0.05) [4]. Factors such as motivation, learning skills, and study techniques, as noted by Feeley et al [35]. influence academic performance, complicating the comparison between PBL and traditional teaching methods. Despite this heterogeneity, evidence supports that the PBL teaching model, combined with 3D printing technology, significantly enhances students' overall abilities and practical skills [36, 37].

Anatomy is a fundamental and essential discipline in medical education, and a meta-analysis encompassing 22 randomized controlled trials suggests that the supplementary use of 3D-printed models reconstructed from radiographic images is recommended to achieve optimal anatomical education. 3D-printed models offer unique advantages in the field of anatomy [38]. Current medical education has been profoundly impacted, with the effects being most pronounced in the field of anatomy. A deep understanding of anatomical structures is crucial for comprehending injury mechanisms, especially in orthopedics, where the analysis of mechanical properties is essential for designing effective reduction techniques and treatment plans. This approach can significantly reduce surgical errors [39, 40]. Accurate anatomical knowledge is indispensable for students to grasp these concepts fully. 3D printing technology offers significant advantages by creating highly realistic, proportional models of anatomical structures. These three-dimensional representations enhance students' visual understanding of anatomy and provide valuable resources for orthopedic clinical teaching [40, 41]. By addressing common challenges faced by learners, such as inadequate comprehension of anatomical knowledge and discrepancies between theoretical concepts and actual structures, 3D printing stimulates students' interest and motivation. This technology improves their understanding and practical skills in orthopedics. Our meta-analysis indicates that 3D + PBL teaching significantly improves students' understanding of orthopedic knowledge compared to LBL teaching (SMD = 1.18, 95% CI: 0.71–1.65, P < 0.00001). Supporting this, Shayna et al [42]. demonstrated that 3D teaching was more effective than 2D teaching in enhancing students' understanding of orthopedic concepts. While both teaching methods improved performance and confidence, students using 3D models reported a better overall learning experience compared to those using 2D images. Enhanced understanding of orthopedic knowledge correlates with improved orthopedic skills and higher passing rates in examinations. Additionally, our research found that 3D + PBL teaching also enhances students' communication skills. However, there was high heterogeneity in the results related to orthopedic skills and communication skills. Further analysis revealed that Zhang et al.'s study incorporated a bedside 3D teaching mode with case-based learning (CBL), which could contribute to the observed variability. Furthermore, Zhang et al [22]. did not specify the duration of learning or the teaching subjects. In conclusion, this meta-analysis demonstrates that 3D + PBL teaching improves students' academic performance, communication skills, and practical abilities, with a notable enhancement in their understanding of orthopedic anatomical structures.

Student satisfaction with teaching methods is a crucial metric for evaluating educational approaches, reflecting students' overall experience and attitudes towards the teaching process and outcomes [43, 44]. High levels of satisfaction suggest that students appreciate the teaching method, which may correlate with better knowledge mastery and application skills. Our meta-analysis demonstrated that 3D + PBL teaching significantly increased students' teaching interest and overall satisfaction. This method addresses the limitations of traditional teaching by actively engaging students, emphasizing skill development, and fostering a greater enthusiasm for learning. The use of 3D printing technology to create detailed anatomical models provides students with a comprehensive understanding of orthopedic structures, thereby enhancing their interest and involvement in clinical learning. Lahner et al [45]. reported that 3D printing technology improved the engagement of medical students by providing realistic bone models for preoperative planning in trauma surgery. Additionally, a review highlighted that PBL enhances students' learning interest, self-learning abilities, and long-term retention [46]. Consistent with these findings, our study revealed that 3D + PBL teaching led to higher overall satisfaction among students (OR = 3.32, 95% CI: 1.84–5.99, P < 0.0001). Therefore, by integrating advanced 3D technology with PBL, we provide new insights into how these tools optimize educational outcomes, effectively addressing the current challenges faced by students in mastering complex surgical skills and anatomical understanding. Additionally, by leveraging 3D + PBL to explore the potential for personalized learning experiences, we can more effectively meet the needs of individual learners, thereby enhancing each student's interest in learning. Our study findings contribute to the growing evidence supporting the integration of 3D + PBL in medical education, particularly in orthopedic education, and provide a foundation for further research and clinical application.

While 3D + PBL teaching offers numerous benefits, it also presents several challenges. Implementing 3D + PBL teaching methods necessitates significant investment in resources such as advanced educational technology, software, and specialized training. This financial burden can be substantial for some institutions, potentially limiting accessibility and long-term sustainability. Additionally, the 3D + PBL approach demands considerable time and effort. PBL emphasizes real-world problem-solving, requiring students to engage deeply in independent thinking, self-directed learning, and collaborative problem-solving. This can potentially impact the pace of learning in other subjects, leading to increased stress and anxiety among students [47, 48]. Moreover, the successful integration of 3D + PBL teaching requires coordinated efforts from various stakeholders, including educational institutions, healthcare facilities, educators, and students. Addressing these challenges effectively necessitates collective teamwork and cooperation from all involved parties.

Current limitation

Our study has several limitations that should be acknowledged: 1) We have only included studies published in English and Chinese, which may introduce language bias and lead to heterogeneity among sources. In subsequent steps, we should further search databases in other languages, increase the inclusion of literature in different languages, and ensure accurate translation of these studies to minimize potential bias. 2) All studies included in our meta-analysis were conducted in China, which could lead to subjectivity in some results. Future research should incorporate larger, more diverse samples from various regions. 3) Significant heterogeneity was observed in some results. Despite performing sensitivity analyses to identify potential sources, some clinical outcomes still lacked clear explanations for their variability. Several of the included studies lack information on randomization, allocation concealment, and blinding, which increases the risk of bias. Furthermore, the measurement of outcome indicators is inconsistent across studies. Although we have standardized the outcome measures, some bias remains, and further efforts are needed to address the inconsistency in outcome indicators. To address these issues, further large-scale RCTs are needed to reduce bias and confirm clinical outcomes.

Conclusion

Given the unique demands of orthopedic education, 3D + PBL proves to be a highly effective teaching method. It not only enhances students' theoretical scores but also improves their communication and understanding abilities, leading to greater overall satisfaction with the learning experience. In the future, there should be an integration of 3D + PBL into existing orthopedic training programs, which includes selecting appropriate 3D content, designing PBL scenarios, and integrating these elements into the curriculum. This will provide a comprehensive framework for implementing 3D + PBL in orthopedic education, further enhancing teaching methodologies.

Data availability

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

References

Alamrani MH, Alammar KA, Alqahtani SS, Salem OA. Comparing the effects of simulation-based and traditional teaching methods on the critical thinking abilities and self-confidence of nursing students. J Nurs Res. 2018;26:152–7.

Neufeld VR, Barrows HS. The “McMaster Philosophy”: an approach to medical education. J Med Educ. 1974;49:1040–50.

Howe A, Campion P, Searle J, Smith H. New perspectives–approaches to medical education at four new UK medical schools. BMJ. 2004;329:327–31.

Sun M, Chu F, Gao C, Yuan F. Application of the combination of three-dimensional visualization with a problem-based learning mode of teaching to spinal surgery teaching. BMC Med Educ. 2022;22:840.

Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med. 1993;68:52–81.

Berkson L. Problem-based learning: have the expectations been met? Acad Med. 1993;68:S79-88.

Vernon DT, Blake RL. Does problem-based learning work? A meta-analysis of evaluative research. Acad Med. 1993;68:550–63.

Peng WS, Wang L, Zhang H, et al. Application of virtual scenario simulation combined with problem-based learning for paediatric medical students. J Int Med Res. 2021;49:300060520979210.

Li T, Yan J, Liu X, Hu J, Wang F. Efficacy and safety of conservative treatment compared with surgical treatment for thoracolumbar fracture with score 4 thoracolumbar injury Classification and Severity (TLICS): a systematic review and meta-analysis. Clin Spine Surg. 2023;37(5):230–41.

Li T, Yan J, Hu J, Liu X, Wang F. Efficacy and safety of electroacupuncture for carpal tunnel syndrome (CTS): A systematic review and meta-analysis of randomized controlled trials. Front Surg. 2022;9:952361.

Chang J, Wang H, Wu Y. Application of PBL teaching method combined with 3D anatomical model in orthopedic clinical teaching. J Anhui Med College. 2018;17:100–4.

Guo Z, Huang M, Li X. Application of 3D printing technology in clinical teaching of PBL in department of orthopedics. China Continuing Med Educ. 2017;9:19–21.

Kang L, Fan L, Cui J. Application of 3D printing combined With PBL teaching in orthopedic teaching for clinical interns. China Continuing Med Educ. 2021;13:35–8.

Li F, Wang D, Cheng J. Application of the PACS and 3D printing technology combined with PBL in orthopedic clinical teaching. China Med Educ Technol. 2015;29:288–90.

Liu C, Zhang F, Yang H. Application of 3D Printing Technique in PBL teaching of complicated femoral intertrochanteric fractures. J Tissue Eng Reconstruc Surg. 2017;13:360–2.

Liu K, Li M, Bian W. The effect of three-dimensional printing technology in clinical PBL teaching of Tibial Plateau Fracture. China Continuing Med Educ. 2020;12:16–8.

Shi L, Gao F, Sun W. The effect of three-dimensional finite element technology combined with problem-based learning teaching model in clinical teaching of orthopaedic graduate students. New Med. 2021;31:400–4.

Sun L, Li B, Pan W. Application of 3D printing model combined with PBL teaching method for standardized training of residents in clinical teaching of pelvic bone tumor. Zhejiang Med Educ. 2021;20:24–6.

Wang X, Jiao J, Pan W. Using improved PBL combined with 3D printing technology in the novitiate of orthopedic for clinical students. China Higher Med Educ. 2018;10:84–5.

Wu A, Wang K, Wang J. Application of 3D printing technology in assisting problem-based learning teaching method in teaching of orthopedic diseases for undergraduate medical students. E-J Transl Med. 2017;4:90–2.

Yang M, Zhou L. Application of question guided teaching combined with 3D printing in standardized training of orthopedic residents. Chinese J Clin Res. 2019;32:850–2.

Zhang B, Zhang H, Peng K. Practical application of 3D bedside teaching in clinical teaching of bone surgery. Ningxia Med J. 2021;43:188–9.

Zhang X, Niu W, Wang B. Application of 3D printing technology in spinal operation PBL teaching for the clinical professional master of Chinese orthopedics and traumatology. Med Health Educ. 2016;13:113–5.

Zhao F, Wang X, Dou Y. Integration effectiveness of three-dimensional finite element and problem-based learning in teaching of orthopedic traumatology. China Med Educ Technol. 2018;31:82–4.

Zhao Y, Yang X, Xing S. Application of 3D anatomy teaching software combined with PBL teaching method in orthopedics clinical teaching. China Continuing Med Educ. 2023;15:57–61.

Zhou P. Application of 3D printing technology combined with PBL teaching mode in orthopedic clinical teaching. J Chifeng University(Natural Science Edition). 2023;39:91–3.

Zhu J, Liu Z, Zhang Z. Application of 3D printing technique in PBL teaching of tibial plateau fracture. China Continuing Med Educ. 2018;10:31–4.

Lim WK. Dysfunctional problem-based learning curricula: resolving the problem. BMC Med Educ. 2012;12:89.

Li T, Song R, Zhong W, et al. Use of problem-based learning in orthopaedics education: a systematic review and meta-analysis of randomized controlled trials. BMC Med Educ. 2024;24(1):253.

Tudor Car L, Kyaw BM, Dunleavy G, et al. Digital problem-based learning in health professions: systematic review and meta-analysis by the digital health education collaboration. J Med Internet Res. 2019;21:e12945.

Citak M, Gardner MJ, Kendoff D, et al. Virtual 3D planning of acetabular fracture reduction. J Orthop Res. 2008;26:547–52.

Bae JY, Kwak DS, Park KS, Jeon I. Finite element analysis of the multiple drilling technique for early osteonecrosis of the femoral head. Ann Biomed Eng. 2013;41:2528–37.

Wormley ME, Tovin MM, Lusardi M, Wilson S. Students’ perspectives of core value development in a modified problem-based learning program. Physiother Theory Pract. 2019;35:1061–77.

Fan C, Jiang B, Shi X, et al. Update on research and application of problem-based learning in medical science education. Biochem Mol Biol Educ. 2018;46:186–94.

Feeley AM, Biggerstaff DL. Exam success at undergraduate and graduate-entry medical schools: is learning style or learning approach more important? A critical review exploring links between academic success, learning styles, and learning approaches among school-leaver entry (“Traditional”) and Graduate-Entry (“Nontraditional”) medical students. Teach Learn Med. 2015;27:237–44.

Lestari E, Stalmeijer RE, Widyandana D, Scherpbier A. Does PBL deliver constructive collaboration for students in interprofessional tutorial groups? BMC Med Educ. 2019;19:360.

Stentoft D. Problem-based projects in medical education: extending PBL practices and broadening learning perspectives. Adv Health Sci Educ Theory Pract. 2019;24:959–69.

Asghar A, Naaz S, Patra A, Ravi KS, Khanal L. Effectiveness of 3D-printed models prepared from radiological data for anatomy education: a meta-analysis and trial sequential analysis of 22 randomized, controlled, crossover trials. J Educ Health Promot. 2022;11(1):353.

Asghar A, Patra A, Naaz S, Kumar R, Babu CR, Singh B. Investigating the integration of anatomical variabilities into medical education as a potential strategy for mitigating surgical errors. J Anat Soc India. 2024;73(1):70–81.

Patra A, Asghar A, Chaudhary P, Ravi KS. Integration of innovative educational technologies in anatomy teaching: new normal in anatomy education. Surg Radiol Anat. 2022;44(1):25–32.

Weldon M, Poyade M, Martin JL, et al. Using interactive 3D visualisations in neuropsychiatric education. Adv Exp Med Biol. 2019;1138:17–27.

Youman S, Dang E, Jones M, Duran D, Brenseke B. The use of 3D printers in medical education with a focus on bone pathology. Med Sci Educ. 2021;31:581–8.

Kar SS, Premarajan KC, Subitha L, Archana R, Iswarya S, Sujiv A. Student-centred learning in community medicine: an experience from jawaharlal institute of postgraduate medical education and research. Puducherry Natl Med J India. 2014;27:272–6.

Santos G, Marques CS, Justino E, Mendes L. Understanding social responsibility’s influence on service quality and student satisfaction in higher education. J Clean Prod. 2020;256:120597.

Lahner M, Kandler C, Stadler M, Bäumlein M. 3D printing of anatomical models for preoperative planning of trauma surgery: Lessons learned from a case series of sternoclavicular fractures. Eur J Trauma Emerg Surg. 2018;44:381–8.

Jorge RM, Jorge RM, Lerma NL, Alagón JP. Applications of 3D printing in medical education: a surgical perspective. Biomed Sci Instrum. 2016;52:480–7.

Jones RW. Problem-based learning: description, advantages, disadvantages, scenarios and facilitation. Anaesth Intensive Care. 2006;34:485–8.

Seneviratne RD, Samarasekera DD, Karunathilake IM, Ponnamperuma GG. Students’ perception of problem-based learning in the medical curriculum of the Faculty of Medicine, University of Colombo. Ann Acad Med Singap. 2001;30:379–81.