Anatomical knowledge underpins the practice of healthcare professions and 3D visuospatial appreciation is an important part of medical and veterinary education [21]. However, while cadaveric specimens are used to demonstrate realistic anatomy, high cost, reforms in medical education, ethical considerations, and limited accessibility can limit their availability and suitability for use in teaching [10, 28]. Web deployable anatomical simulations or "virtual reality learning objects" have been adopted as a substitute, but their use for online and mobile learning is being limited by the declining support for web browser plug-ins for personal computers and unavailability on popular mobile devices like Apple iPad and Android tablets. Widespread application of Virtual/ Augmented reality is relatively restricted, largely due to the high cost and limited accessibility associated with the necessary software and hardware, as well as the interdisciplinarity required to develop these tools [10, 37, 41]. And, while HTML5 VR learning objects would make VR learning more accessible across devices, these are in the early stages of development [30]. Moreover, questions have been raised about the reproducibility of augmented reality learning tools on a larger scale [10].

Anatomical physical models offer an effective tool for understanding the spatial arrangements of anatomical organs and teaching gross anatomy due to their easy accessibility and educational effectiveness. Such models could be a practical tool to bring up the learners' level of gross anatomy knowledge at a low cost [39]. Three-dimensional (3D) printing technology has advanced greatly over the past decade and has many applications in the field of medicine. Orthopaedic surgeons have demonstrated that 3D printing technology can improve patient care and physician education and that this technology can be used to improve surgical techniques, plan for difficult surgeries, and create patient-specific instrumentation and implants [13]. In addition, 3D printing is being used in tissue/organ fabrication, creation of customised prosthetics and implants, medical teaching/training, including procedural skill acquisition and patient-physician communication [24]. A recent review of the role of 3D printed anatomical models in teaching human anatomy, suggested that in the test of anatomical knowledge, the post-training test results from 3D models were higher than those in the cadaver or 2D training and that more students were satisfied with their learning [40].

Cases such as foot and ankle pathology can be complex, with the 3D anatomy challenging to appreciate [13]. Deformity can occur in several planes simultaneously and appreciating complex 3D spatial relationships requires a strong foundational understanding of anatomy and mental 3D visualization skills [21]. Physical models that can be manipulated in a 3D space can significantly benefit the visuospatial understanding of structures with complex spatial relationships [21]. Models can accurately demonstrate bony foot and ankle anatomy [10]. Some have proposed that colour and multi-material 3D printed anatomical models can have the same visual and tactile properties as anatomical specimens and could therefore complement or supplement them in anatomy teaching to compensate for the shortage of cadavers [28]. Moreover, whilst there is a need for studies to investigate the effectiveness of 3D printing in comparison to cadavers, there is also need for research to explore if 3D printing is effective as a supplementary tool in a blended anatomy learning approach [6].

Avoiding models and using computers is a possibility. However, a study found that although computer-based learning resources, including virtual reality, can have a positive impact on learning outcomes, they appear to have significant limitations in comparison to physical models, particularly in areas where the anatomy is complex and students have a lower spatial ability [14]. The authors warn against assuming that greater control and interactivity of computer-based modalities would lead to better learning. We believe combining a physical model with gaming avoids these problems and benefits from the advantages of both of these learning aids.

3D model printing has its own difficulties. Existing segmentation software tools are variable, and segmentation requires experienced readers, is time-consuming and prone to intra-and inter-observer variability [31, 34]. Although obtaining accurate and consistent 3D shape segmentation is challenging, even for human workers, novel semi-supervised learning approaches have been proposed and show promising results accuracy and consistency [27]. Research is required to determine the extent to which alternatives to cadaveric anatomy accurately demonstrate the anatomy and ascertain whether they are effective for teaching anatomy [10].

Several reviews, including meta-analyses, have consistently found that the use of games for educational purposes, promote learning and/or reduce instructional time across multiple disciplines and ages [32]. Several theories have been proposed to explain why games are effective learning tools, but essentially play is a primary socialization and learning mechanism common to all human cultures and many animal species [32]. A study found that an interactive game, which allowed users to manipulate a virtual anatomical 3D model of part of the nervous system, provided a greater understanding of the complex structures [35].

There is lack of uniformity in the definition of gamification [33]. The terms gamification, game-based learning and serious games are sometimes used interchangeably, for some authors they mean slightly different things: Gamification is the application of game concepts (e.g. points, leader boards, prizes) to the learning process to make it more enjoyable and engaging, Game-based learning involves modifying a game to teach a specific skill or learning result, and Serious games, are ones created where education is the primary goal, rather than entertainment [11, 15, 33]. All of these three game-related mechanisms seek to make learning more interesting and inspiring [15]. Many studies have shown that utilizing gamified media in medical education may confer advantages, however most of these are virtual and computer-based [15]. A study conducted at the Glasgow Science Centre used a science communication app on 3D anatomy for public engagement activities involving skull anatomy and cycling helmet safety. They found that by integrating the fun and enjoyable elements of a game with educational objectives (gamification), players could learn complex scientific concepts through active exploration. They also proposed that the development and inclusion of serious games in public engagement activities would be a useful adjunct [36].

Mounting evidence suggests that educational games can provide an enjoyable way of learning, improve student engagement, stimulate the motivation of students to learn, and contribute to improvements in teaching outcomes [38]. Gamification can provide alternative approaches for educators and in most cases, these are well-received and can create an immersive experience, and are effective, engaging, easy to understand, interesting, and educational [38].

Educational games should never disrupt the learning process and when they are introduced into the classroom, it is important to incorporate them into the pedagogy [2]. We believe that students learning must align with learning objectives/outcomes and the 3D foot and ankle puzzle session had clear learning outcomes and was embedded in the curriculum. It has been proposed that educational games are able to create a social constructivist learning environment, where learners construct their knowledge by interacting with peers and instructors. This cooperative learning concept can support learners to achieve learning outcomes and promote social skills [3].

Dissection is often termed as destructive, rather than constructive process [22]. The disassembly process inherent in dissection does not allow for repeated explorations, particularly ones that are guided by different objectives. Similarly, it could be argued that a cadaveric foot skeleton (or skeleton model) could have been used in teaching, however these are usually wired or fixed. The advantage of using a 3D printed puzzle in teaching anatomy is that it allows the building up of the structures from its components which is constructive and creative and enhances the learning experience.

The effectiveness of combining 3D printed models and gamification in undergraduate medical education has not yet been investigated. This study aims to investigate if using a 3D printed foot and ankle puzzle, combing these two learning aids, can enhance the learning experience and be effective for teaching anatomy.