November 2020

Postcards From Main Street: Missives From the 3D Front Lines

iStockphoto.com #1021334542

3D printing has been making countless inroads into everyday work routines.  Here, O&P professionals share their use of the technology.

By Janice T. Radak and Friends

Answer This Months Question

As this month’s cover conveys, three-dimensional (3D) printing has created breakthrough opportunities across the spectrum of lower extremity challenges. 3D printing is allowing healthcare providers from surgeons to shoemakers to dare to dream of patient-specific therapeutic options for conditions once thought untreatable: crushing traumas and nonunions. This disruptive manufacturing process is also helping with neuromotor issues.

Since its discovery in the early 1980s, 3D printing or additive manufacturing (so called because products are built by adding layers of raw material versus traditional machine manufacturing which uses subtraction) has been evolving as a technology as end-users continue to find new uses for it and experiment with new materials.

Custom orthotics, a field that hadn’t seen true disruption since the 1950’s introduction of vacuum-forming plastics, began to see major integration of 3D printing starting in 2018. Indeed, the price of orthotics was already trending in the wrong direction at $9.80/unit in 2017 down from $10.70/unit in 2013. However, as recently as October of this year, the Research and Markets Report projected that the global foot orthotic insoles market will reach $5.464.57 million by 2027 up from $3,560.00 million in 2019. Key drivers behind the market growth are the aging of the population and the increasing incidence of both diabetes and obesity, as well as the increasing use of orthotics in sports to achieve higher performance metrics.

To find out more about what’s happening the real world, LER asked readers to share their thoughts on 3D printing in their part of the world. Here is a sampling of their responses:


Joe Fairley, BEP, Orthotic Resident, MPO, with Sampson’s Prosthetics & Orthotics Laboratory in Schenectady, NY, (Sampsons.com) writes:

At Sampson’s Prosthetics and Orthotics Lab, 3D printing has become an everyday staple in our prosthetic fabrication workflow. Over the last four years, we have been pushing the boundaries of what can be feasibly and usefully 3D-printed for prosthetic applications. We are currently utilizing the PVA Med Emergence Pro 3D printer to quickly and reliably fabricate lower limb prosthetic diagnostic sockets. By integrating 3D scanning with the Structure Sensor or Comb app, then performing 3D modifications with Ossur’s Design Studio or PVA Med’s RapidPlaster, we have drastically shortened appointment times as well as the technical hands-on time. We have tested our hand casts and plaster modifications against our 3D scans and 3D modifications, resulting in our patients preferring the 3D diagnostic socket in most cases. When comparing Socket Comfort Scores with clinical observations of total contact and dynamic gait mechanics, our 3D printed sockets have been surpassing the traditional sockets.

Other benefits we have seen involve lower material costs, time-saving convenience for our clinicians, and a quantitative way to document limb volume and shape changes over time. We have also dabbled with 3D printing prosthetic covers among other prosthetic componentry. So far, we have not found a consistent application for our orthotic workflow, but it is only a matter of time and more testing before we dive into using 3D printing for orthotics.


Bryan Craft with Additive America in Kinston, NC, (additiveamerica.com) writes:

We are a digital manufacturer who has placed an immense focus on the prosthetics and orthotics field. In fact, 2 of our co-founders are CP and CPO themselves. From our perspective, we’re seeing that clinicians who use our technology spend less time in the dusty shop and more time out seeing patients. Their challenges start with the digital workflow, so we meet them where they are and go from there. We allow clinicians to keep their existing traditional casting process or move quicker into 3D printed check sockets. Either way they choose they’re saving time.

Patient feedback is why we do what we do. We hear how the lighter weight, more customized 3D-printed sockets feel like they are a part of the patient’s body. The built-in flex zones move with them and keep them from feeling the pain of walking that once haunted them. This is truly incredible feedback.

Those that are using the multi-jet fusion 3D printing technology are finding these results exciting. This raises the water level for clinicians to take advantage of the benefits of additive manufacturing (AM). As more clinicians come on board with AM, more patients see the end-user benefits of this technology.

What separates our business model from others is the way we think. Optimizing for 3D, fabricating for patients, and time-saving for clinicians are all very important things to make AM progress.


David Gerecke, CPO, FAAOP, with Maughan Prosthetic & Orthotic, in Burien, WA, (maughanpno.com) sent case examples:

3D printing has revolutionized my prosthetic practice. I routinely deliver a reinforced test socket on definitive components for transtibial amputees in one day. I use the Symphonie Aqua System with Vector Control to take a full weight-bearing plaster cast, which I then digitize. After making almost no modifications to the shape other than correcting for the thickness of the print and adding a brim, I 3D print on my PVA Med/Create 1400 printer, epoxy on a distal connector and reinforce with Delta-Lite conformable casting tape. After alignment on definitive components, the patient walks out on a new prosthesis on the same day. After using this temporary socket for a few days, I re-assess fit and make necessary changes to the shape (seldom needed), then 3D print another socket to send to our fabrication facility for duplication in definitive materials.

Case 1

41 y/o male left trans-tibial amputation who lives about 290 miles from my clinic in Burien, WA. He usually arrives by car or train on a Wednesday night and comes in Thursday morning then leaves Friday afternoon when we are finished. Our challenge is his weight-loss program where he has lost about 40 pounds over the last year. This has resulted in a few socket changes. He has been in a series of Delta-Lite reinforced test sockets which are aligned on his componentry and delivered same day. These reinforced test sockets are durable enough for several months of use. He is close to his target weight of 165-170 lbs. where we will then create a definitive socket for him.

CAD/CAM software and 3D-printing allow me to check in with him by phone before he comes to my clinic to see where he is in residual limb volume. Number of ply, pressure points, and his recurrent lateral patellar bursa are reviewed. Zoom meetings provide needed visual information. If needed modifications are minor, I print a socket for him prior to his arrival. Socket changes take mere minutes, and he is often on his way home on the same day. If re-casting is needed, same-day turn-around is routine.

Case 2

Transtibial foam covers are easily produced by scanning the sound side, mirror imaging, then merging with a scan of the prosthesis. The resulting 3D printed mold interfaces intimately with the prosthetic socket and the foot shell allowing minimal finishing for the 2-part expanding foam. Prosthetic skin can then be applied over the resulting shape, producing a foam cover that is a mirror image of the uninvolved side. There are many possible variations with this technique, including the need to accommodate components or create a removable cover.

All in all, 3D printing has changed my practice philosophy. Rather than requiring multiple visits over the course of several weeks, I can provide a comfortable and functional definitive prosthesis in as little as a few days, with the patient routinely walking out same day on a prosthesis with a reinforced test socket. During these COVID-19 Pandemic times, this approach also minimizes infection risk for patients, families and providers by requiring fewer visits.

I see the potential for a same-day definitive prosthesis!


Alex Olsen, CPO, with Great Lakes Prosthetics & Orthotics, (greatlakespando.com), in Ypsilanti, MI, writes:

We integrated 3D-printing into our practice a little over a year ago and it has been a game changer. We are now able to reduce turnaround time on prosthetic devices dramatically, which enables our patients to be in their devices much sooner than with traditional fabrication methods.

We have used 3D printing extensively for check sockets for prosthetics, and even printed a few custom orthotic devices, from wrist/hand orthoses to custom humeral fracture orthoses. We are also using it to print protective cosmetic covers for lower extremity prostheses, and the flexible inner socket portions of the socket. This one is particularly beneficial because if the flexible socket tears or is otherwise unusable, it is very easy to just reprint it to the exact size and thickness of the original, which in traditional fabrication is very difficult.

 


Brian Greer, CP, BOCO, with Mobility Prosthetics (mobilityprosthetics.com) in Murray, UT, writes:

We have been using digital scanning and 3D printing for prosthetics for over 4 years now. These technologies have completely improved the patient experience and outcomes. First, taking a scan of a residual limb is far superior to taking a plaster or fiberglass cast because it is faster, cleaner, and more precise. Also, I will add that patients, family members, doctors, and physical therapists are mesmerized by the scanning process and the accuracy of the scan once it is taken.

Next, computer-aided design is far superior to model modification with plaster of paris because it is also faster, cleaner, much more precise, and fully replicable. Really, there is no comparison between plaster model modification and computer-aided design…it would be like comparing painting a portrait to taking a photograph.

Lastly, 3D-printing of a diagnostic or definitive socket has dramatically improved the process because it can be printed overnight, it can be fabricated to any specification (eg, wall thickness thinner in some regions for flexibility while thicker in others for strength), and it is completely and totally replicable. If a patient breaks a socket, a new one that is identical to (or even better than) the broken one can be printed before they arrive back at the office.

Honestly, scanning, computer-aided designing, and 3D-printing prosthetics are the way that it should be done in this day and age. You wouldn’t talk on a phone from 50 years ago and you wouldn’t watch a television from 50 years ago…why would you make a prosthesis using techniques from 50 years ago? 3D-printing is a 21st century tool for a 21st century professional.

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