3D Printed Prostheses in the Philippines



3D Printed Prostheses in the Philippines: Demand. Dilemma. Direction.

Josephine Robredo-Bundoc, MD

3D printed prosthesis is defined as an artificial limb created or “printed” from a 3-dimensional digital model of the scanned image of the residual limb. By successively “printing” or sequential laying down of thin layers of the material, the prosthesis is formed. Is there a market for it? Is there going to be a demand for 3D printed prostheses?

Demand

No question about it. The increased global demand for prostheses service is attributed to rising population and longer life span. Increase in noncommunicable diseases and higher incidence of musculoskeletal injuries lead to more amputations. More so, once you are an amputee and a prostheses user, you will be a lifetime prostheses user. This need for long term prostheses use further spikes up the demand.

This increased demand for prostheses though is matched by very low access (5-15%) attributed to environmental barriers, inadequate and non-strategically located facilities and lack of trained service providers for prostheses and rehabilitation. Additional factors in the Philippines that limit access are prohibitive cost, limited local suppliers and component manufacturers and the amputees’ beliefs and attitudes.

The PhilHealth benefit packages for prostheses did not only provide a local solution to the prohibitive cost. It also stimulated investors on manufacturing or distributorship of prostheses components and researches on viability of indigenous materials. Nationwide campaign on sensitivity of providers, awareness on the PhilHealth benefit packages and empowering effect of prostheses use have proven effective in increasing access to prostheses services. Despite these and the local initiatives on facility and manpower capacity building, the local challenges of topography, shortfall of strategically located facilities, limited number of trained prosthetists and absence of national certification that will render them employable have not increased the percentage of access significantly.

3D printing provides an “anytime-anywhere” prostheses. With an idea or a model in mind, one only needs to scan the residual limb and digitally model the prostheses design and start printing. Very personalized and customized, designs can be improved rapidly and even the most complex residual limb shapes can be accommodated. All the separate components of a traditional prostheses (e.g., socket, pylon, foot) can be printed out of one part and therefore, little to no assembly is required.

From casting to delivery of the traditional below knee prostheses, 52 hours and 15 minutes of work are utilized at the cost of 30,000 pesos. With a 3D below knee prostheses, casting is replaced by residual limb scanning that only takes 5 minutes and does not require water, plaster of paris bandage roll and stump stocking. Moreover, 12-15 hours of 3D printing replaces 2 days of fabrication and this process does not need an oven, router, vacuum system and tools. Assembly of 12 separate components takes only 30 minutes. Similar to the traditional prostheses, fitting takes 1 hour and initial gait training of 2 hours. The 3D printed below knee prostheses provision entailed only 18 hours and 35 minutes of work with a lower cost of 10,000 pesos. With this comparison, we can indeed say that 3D printed prostheses is a possible solution as it is not only cheaper and faster to produce but also requires less equipment, tools and supplies as compared to traditional prostheses.

Dilemma

3D printed prostheses have its limitations, labeled as “Realistic Constraints”, which are as follows:

  • • prostheses use limited at low to moderate level of functional activity
  • • no guarantee in safety of use for day to day movements
  • • need for high end 3D printer
  • • continuous power supply and precision in machining and printing
  • • short life cycle
  • • cosmesis is not a priority

There are 3 areas of concern which makes us think twice before choosing 3D printed prostheses over traditional prostheses. First, safety is vital as we do not want the prostheses to do more harm to the user. Second, trained prosthetists and rehabilitation medicine services must be available to ensure biomechanical fit and mobility training. Lastly, with the 3D printed prostheses having a shorter life cycle than the traditional prostheses, won’t the higher cost invested in the traditional prostheses, in the long run, prove cheaper than the lower cost 3D printed prostheses which have to be replaced frequently?

Direction

In the light of the above discussions, what direction should 3D printed prostheses take? The direction should be towards improving strength and durability by conducting laboratory and clinical materials testing. Rather than work on improving the design, focus should be on the source of 3D printed materials so life cycle can be longer and safety issues can be ensured. For optimum mobility, the 3D printed prostheses must be comfortable, properly fitted and biomechanically aligned. For safe and functional mobility, the 3D printed prostheses user must undergo proper rehabilitation training.

Based on the results of the Instalimb-PGH Department of Rehabilitation Medicine study, 3D printed prosthesis is recommended as the “interim” or first line of prosthesis service in the succeeding:

  • • GIDA (Geographically isolated and disadvantaged areas), areas of conflict, post-disaster areas
  • • residual limbs undergoing volumetric changes
  • • pediatric amputees
  • Once the residual limbs have stabilized however, the traditional prosthesis is still the optimal choice. Whether it is a 3D printed or traditional prostheses, the emancipatory principle must be in place. As reiterated in the 2017 International Society of Prostheses and Orthoses conference, prostheses service must be people centered. We must never forget that the best recommendations come from the amputees, because they are reason why we are doing this.

Alex Agustin climbs mountains with his traditional prosthesis. He used the 3D printed prostheses during PARM’s RAmp4Life event when it was his turn for the catwalk. Why did Alex favor his 3D printed prostheses over the traditional prostheses in this fashion event?