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VOLUME 4, ISSUE 2  
 2021 

 

STAKEHOLDER  PERSPECTIVES 

Ratto M. Designing a digital toolchain for prosthetics: A retrospective. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.16. 

https://doi.org/10.33137/cpoj.v4i2.36188 

This article has been invited and reviewed by Co-Editor-In-Chief, Dr. Silvia Ursula Raschke. 
English proofread by: Karin Ryan, M.A., B.Sc., P.T. 
Managing Editor: Dr. Hossein Gholizadeh 
 

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Ratto M. Designing a digital toolchain for prosthetics: A retrospective. Canadian Prosthetics & Orthotics Journal. 2021; Volume 4, Issue 2, No.16. 
https://doi.org/10.33137/cpoj.v4i2.36188 

 

 

 
STAKEHOLDER  PERSPECTIVES 

 

DESIGNING A DIGITAL TOOLCHAIN FOR PROSTHETICS: A RETROSPECTIVE 

Ratto M.* 
 

Faculty of Information, University of Toronto, Toronto, Canada. 
 
 
 

 

 

  

 

 

 

 

INTRODUCTION 

From 2014 until 2020, I participated in the development of a 

novel CAD/CAM system for lower-limb prosthetics sockets. 

That project, initiated by CBM Canada, a charitable 

organization that supports hospitals in the developing world, 

and funded by corporate, non-profit, and governmental 

sources, was successful insofar as it developed multiple 

software and hardware solutions, deployed these into 

multiple clinical settings in different countries, and had a 

direct impact on the quantity and quality of prosthetic 

interventions in those clinics.  

A non-profit organization, Nia Technologies, was founded to 

support this ongoing work, and has been continually funded 

through philanthropic donations and corporate and non-

profit grants since 2015. The specifics of that work have 

previously been published1-3 and interested readers can 

refer to those publications for details regarding clinical 

outcomes, trial data, and for more information about our 

specific hardware and software solutions. This paper 

provides an overview of the work from a broader 

perspective, highlighting how the health economic 

framework, that  is  key to this special issue, well describes  

 

the design choices we made to attend to the multiple levels 

of concerns and stakeholders in the health economic 

framework.  

PROJECT OVERVIEW 

Founded in 2015, Nia Technology is a non-profit 

organization that has developed and deployed a digital 

scanning, design and fabrication system for the production 

of trans-tibial prosthetic sockets and simple orthotic 

devices. Designed to be used in Lower and Middle Income 

Countries (LMIC) orthopaedic clinics, the system has been 

built to integrate with the current International Committee of 

the Red Cross (ICRC) polypropylene Prosthetic and 

Orthotic (P&O) system and thus concentrates only on the 

socket component. This system primarily makes use of a 

single laptop computer, modified commodity 3D scanners 

and printers, and custom 3D scanning and design software 

called NiaScan and NiaFit respectively. The resulting 

system, including all software and hardware costs under 

US$10,000, with paediatric and adult 3D printed prosthetic 

sockets material costs of less than $10 per unit. The system 

was designed to be used in LMIC contexts by orthopaedic 

technicians and prosthetists trained within the ICRC training 

programs. It has been tested and deployed in four clinics: 

the Comprehensive Rehabilitation Services for People with 

Disability in Uganda (CoRSU), the Comprehensive 

Community Based Rehabilitation Clinic in Tanzania 

(CCBRT), the Tanzania Training Centre for Orthopaedic 

Technologists (TATCOT) and the Cambodia School of 

 
OPEN  ACCESS Volume 4, Issue 2, Article No.16. 2021 

 

 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

 

ABSTRACT 

From 2014 until 2020, I participated in the development of a novel CAD/CAM 

system for lower-limb prosthetic sockets for use in Lower and Middle Income 

Countries (LMIC) orthopaedic clinical settings. This article provides an overview 

of the value principles that guided that work and the ways in which we attempted 

to support the clinical needs of our prosthetists and others in the clinical contexts. 

It will highlight how the health economic framework that is key to this special issue 

well describes the design choices we made in order to attend to the multiple levels 

of concerns and stakeholders we identified as key to success.     

CITATION 

Ratto M. Designing a digital toolchain for prosthetics: A 

retrospective. Canadian Prosthetics & Orthotics Journal. 

2021; Volume 4, Issue 2, No.16. 

https://doi.org/10.33137/cpoj.v4i2.36188 

KEYWORDS 

Health Economic Framework, 3D Printing, Innovation, 

LMIC, Values, Prosthetics, Orthotics, Rehabilitation 

 

 

* CORRESPONDING AUTHOR 

Matt Ratto, PhD  

Faculty of Information, University of Toronto, Canada. 

E-mail: matt.ratto@utoronto.ca 

ORCID ID: https://orcid.org/0000-0002-3554-4513  

Special Issue: Health Economics in Prosthetics & Orthotics 

https://doi.org/10.33137/cpoj.v4i2.36188
https://jps.library.utoronto.ca/index.php/cpoj/index
https://doi.org/10.33137/cpoj.v4i2.36188
mailto:matt.ratto@utoronto.ca
https://orcid.org/0000-0002-3554-4513


 

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https://doi.org/10.33137/cpoj.v4i2.36188 

ISSN: 2561-987X 
DESIGNING A DIGITAL TOOLCHAIN FOR PROSTHETICS  

Ratto M., 2021 CPOJ 

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Prosthetics and Orthotics (CSPO). For each site, Nia 

Technologies personnel traveled to the clinical site for one 

week, installing or updating equipment and carrying out 

three days of training with the technicians and clinicians on 

site. Following this, Nia Technologies provides digital 

support via email and teleconference. As of February 2021, 

the system remains in use at CoRSU, CCBRT and 

TATCOT.  

Nia Technologies has iteratively developed a design values 

framework which has guided our work. Briefly, this 

framework is as follows:     

• Design with local needs in mind as described by 

stakeholders in local clinical setting.  

• Develop collaboratively and field-test/evaluate in 

target clinical settings. 

• Encourage adoption and adaptation of technologies 

and workflow by orthopaedic technicians and 

clinicians in target setting.  

• Manage and maintain locally (with ongoing technical 

support from Nia) 

• Focus on benefits to local stakeholders including 

people with disabilities, clinicians, and hospital 

administrators.  

Our work has been shaped by these design values some of 

which were first proposed based on initial research work on 

P&O and in consultation with experts during workshops 

organized early in the project4 and iterated as our project 

progressed. As this framework demonstrates, an important 

aspect of our work has been to emphasize local agency and 

ownership of the P&O process and resulting technological 

intervention, even when doing so increased the 

technological complexity of the system. For example, early 

on in our design process we rejected the idea of a system 

where the operating of the design software was outsourced 

to an external CAD specialist. Instead, we focused on 

creating design software made to emphasize and support 

the knowledge of the P&O professional. While we 

recognized the added complexity in training and in software 

design this decision entailed, abiding by our design 

principles made such a decision necessary. Our overall goal 

of increasing the capacities of the LMIC orthopaedic clinics 

therefore included not just making the process of prosthetic 

production more efficient, but adjacent goals that relate to 

the overall context of P&O work in these settings.   

HEALTH ECONOMIC FRAMING 

Our values framework connects loosely to the Health 

Economic Framing (HEF) described in this special issue. 

The HEF emphasizes the need to consider the patients, 

prosthetist/orthotist, and payers as important stakeholders 

and the relevant contexts of prosthetic use, the clinical 

practices in which devices are made and patients engage in 

rehabilitation and training, and the institutions that provide 

the organization and funding (Table 1).      

Our design principles - encouraged us to attend to these 

aspects of P&O in our design process. Creating a 

successful P&O intervention requires attending to the 

multiple relationships and needs this entails. Given that our 

primary users were P&O professionals working in LMIC 

contexts, our design principles put the orthopaedic 

technician and prosthetist/orthotist at the center (Figure 1). 

Table 1: Stakeholders and contexts in Health Economic Framing. 

Stakeholders Contexts  

Patients Uses of Devices 

Prosthetists Clinical and Rehabilitation practices 

Payers Health care institutions 

 

This paper provides three specific ways our work 

incorporated our values framework and the key 

relationships highlighted above.  

EXAMPLE: RELATIONS TO LOCAL 

COMMUNITY CAPACITIES 

The aim of Nia’s work was to speed up the process of 

producing and fitting a prosthetic or orthotic device within a 

LMIC clinical context.  We designed our system to mirror 

and connect to the ICRC polypropylene process (first 

developed by the ICRC in 1979) for producing custom 

prosthetics and orthotics in order to make the most use of 

professional knowledge and skills already held by the 

clinicians. Our focus was on enhancing their capacity as 

opposed to developing a parallel process that might bypass 

existing professionals. Training on and access to 3D 

printing technology increases existing clinical capacity by 

providing the means for prosthetists/orthotists to make   

prosthetics and orthotic devices more quickly. It does not 

PROSTHETIST 

Patient 

Other clinicians 

P&O colleagues 

Payers and Administrators 

Local community 

Orthopaedic Workshop 

Health Care institution 

Profession 

Figure 1: Centering of prosthetist in HEF 

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ISSN: 2561-987X 
DESIGNING A DIGITAL TOOLCHAIN FOR PROSTHETICS  

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reduce or remove the need for clinicians in a clinical or 

rehabilitation setting. 

By building on clinical skills and expertise, the technologies 

we developed enabled clinicians to minimise time spent on 

manual production and maximise time on decisions about 

device design, fit, and patient care. Rather than offload this 

work to external western partners, the 3D technology 

becomes another tool in the orthopaedic workshop. As an 

example, the team decided on using a 3D printer that is 

relatively easy to maintain and repair in situ, as opposed to 

the easiest to use printer available. This decision required 

the team to trust the technical capacity of the orthopaedic 

clinicians (as professionals already working with a range of 

tools and equipment), but significantly enhanced the 

durability of the innovation. Finally, rather than try to 

produce all parts of the prosthetic device, our system only 

replaces the custom parts; the mass-produced parts – such 

as connectors, pylons and feet – are cheaper if sourced 

through ICRC rather than 3D printed. 

We applied our design values by working within the pre-

existing social, professional and technical context by 

building on existing efforts, systems and local capacities. 

This stands in opposition to many other 3D printing 

prosthetic innovation projects that are more motivated by 

the application, or scaling, of a purely technological solution 

without the due consideration of the context that would 

make it viable. The former motivation offers a greater 

chance of implementing a long-term solution to a problem; 

the latter motivation can result in interventions that are not 

possible to sustain without the physical presence of outside 

short-term ‘technical experts’ (who may displace the 

building of more permanent capacity). 

EXAMPLE: RELATIONS TO OTHER 

CLINICIANS 

One realization we had was a need to help our LMIC 

prosthetist/orthotist users represent themselves as expert to 

other professional groups. While highly valued for the 

patient results prosthetists generated in their clinical 

settings, ethnographic work carried out with the 

prosthetists/orthotists and technicians revealed a 

systematic lack of understanding on the expert nature of 

their work by others.5 Some of our prosthetist respondents 

highlighted the materiality of their work as part of the reason 

for this; other clinician personnel saw them mostly as 

‘makers’ since they were often covered in plaster and 

working with the heavy vacuum pumps, grinders, and 

manual tools present in their workshops. The prosthetists 

we interviewed highlighted the ways in which the move to 

digital systems worked to recharacterize them as more 

‘expert.’ In order to support this more fully, we encouraged 

the set up and design of special workstation areas, 

connected to but discrete from the P&O clinical setting in 

order to reinforce the digital aspects of their practice. Our 

respondents found that these settings, when witnessed by 

other clinical care-givers helped support the similarity of 

their care-giving practice to other experts in the hospital.       

Here, our design work again extended beyond the specific 

digital scanning, design, and printing tasks to incorporate 

the prosthetists’/orthotists’ relations to others in the clinical 

setting. Equally, our design work was not just about the 

software and hardware that we produced, but also included 

the settings in which it operated. Again, successful adoption 

of our system was supported by our understanding the full 

work flow and the complex health frameworks in which this 

P&O work was situated.  

EXAMPLE: RELATIONS TO FUNDERS AND 

PAYERS 

Finally, a key aspect of the development work was in 

generating an innovation which helped support the overall 

work of the clinic and the funders who provided the 

resources necessary for its operation. In the LMIC contexts 

in which we deployed our solution, this is often non-profit 

and charitable organizations. For all new innovations, it is 

important to build up an evidence base to ‘prove’ the 

efficacy of the innovation, especially since it integrated 

technology which is new and relatively unfamiliar to the 

sector. Therefore, a key aspect of our work has been 

continual clinical evaluation of our solutions, ultimately 

resulting in testing over 200 patients at four clinical sites in 

three different countries. The goal of these trials was to be 

able to make statistically significant claims about the 3D 

printed device with regards to durability, fit, accuracy and 

overall use when directly compared to traditional devices. 

Nia set this goal for multiple reasons including both 

functional and symbolic needs.   

Functionally, we needed to more fully evaluate and improve 

our processes in order to validate the (at the time) novel use 

of 3D printing in lower-limb prosthetics. Symbolically, our 

continued investment and engagement in collaborative 

trials with the hospitals demonstrated Nia’s commitment to 

improving the clinical process to the clinicians and other 

stakeholders, thereby strengthening key relationships. In 

particular, funders of clinical P&O work required clinical 

evidence in order to continue to support this work. We also 

found that the trials served to draw new funding into the 

orthopaedic clinic, supporting attention and interest in an 

area of work that required additional investment.  

As in the above cases, we took the need to link P&O work 

to funders and payers into consideration as we developed 

and deployed our software and hardware interventions. In 

particular, we worked directly with the LMIC hospitals to 

develop forms of survey and reporting which served to 

provide clinical oversight and evaluation of the capacities 

and problems with our solutions, but also resulted in two 

additional forms of evidence. First, and most importantly, we 

generated economic evidence that used very situated 

material, labour, and support costs to define the potential 

economic benefits of our system. These typically required 

deep dives into the specifics of the LMIC clinics, including 

working with the clinical staff to access actual numbers 

associated with orthopaedic clinical work. This often 

required putting relatively complex economic stories 

together, where the economics of the clinic including device 

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ISSN: 2561-987X 
DESIGNING A DIGITAL TOOLCHAIN FOR PROSTHETICS  

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production, rehabilitation, and education costs were 

connected to more general expenses associated with 

housing and transportation of prosthetic patients and their 

families during treatment. These stories assisted the 

hospitals in funding the use of our systems, but also often 

resulted in new forms of funding for the orthopaedic clinic 

and in some cases the hospital itself.        

DISCUSSION 

The above story and examples may make it seem that the 

processes through which Nia Technologies developed and 

deployed a new 3D scanning, design, and printing solution 

were straight-forward and clear, and the results guaranteed. 

Nothing could be further from the truth. The work did not 

follow a straight-forward path, nor has acceptance of our 

solutions been complete. While our solution does continue 

to be utilized in some of the clinical settings I mentioned, in 

at least one of them, it was not adopted despite concerted 

efforts. However, the lack of adoption of Nia’s solutions and, 

of 3D printing in P&O more generally, should not be 

understood as simply an issue in the capacity of 3D printing 

and digital systems to meet the needs of P&O. Nor should 

this slowness be understood as the result of recalcitrant 

P&O professionals unwilling to adopt novel tools. While it is 

true that convincing orthopaedic clinicians of the merits and 

potential of 3D technologies has required a longer 

evidentiary process than we initially assumed, adoption or 

its lack is better understood as ‘lack of fit’ into the full 

framework of P&O work A key aspect that is often 

undervalued in contexts of emerging technologies like 3D 

printing and CAD is the provision of training and support that 

must attend actual implementation. We found that both in-

person and distributed forms of support were key to 

successful adoption, including periodic connections to other 

institutional actors outside the direct orthopaedic context, 

such as hospital administrators. Developing innovations in 

this space requires attending to the full socio-technical 

context of P&O work, including the various relationships 

well described in the Health Economic Framework which is 

the focus of this special issue.  

Key to overcoming this challenge was helping the 

profession understand that 3D printing technologies would 

not replace clinicians with CAD designers in Canada (or 

elsewhere), nor would their craft and expertise be 

transformed into manual labour with the remainder being 

done automatically by a computer or by a different set of 

professional CAD designers. Retaining the clinician at the 

centre of the design and production process by integrating 

3D technologies into the profession remains a major aspect 

of Nia’s work. In doing so, our goal is to strengthen the 

profession and assist P&O professionals in better 

communicating the complexity of their care-giving work to 

others within their clinical contexts. To be clear, the need 

and clinical importance of strengthening and clarifying the 

role of the prosthetist was not initially apparent to us. 

Instead, the surfacing of these aspects occurred through 

our sustained connection to clinical contexts and the 

qualitative data-gathering and analysis we carried out as 

part of an ethnographic process. Finally, investment in 

professional development, quality and patient care takes 

time and significant resources. Technology funders in 

particular have grown accustomed to a specific notion of 

scale, i.e. that technology innovations can be scaled 

quickly, leading to quick and large scale results, providing 

opportunities for funders that require a relatively short-term 

commitment. Innovation within P&O as in any health care 

context requires more than just material and technical 

development, it also requires analysis of the deep web of 

relations through which the profession provides its care.  

CONCLUSION 

Media coverage of prosthetics and 3D printing has often 

focused on the impacts and value to the patient, while 

ignoring the prosthetic profession and clinical contexts of 

this work. Personally, I continue to receive requests for 

‘legs’ from people all over the world, including many 

requests from prosthetic wearers here in Canada who, 

typically for economic reasons, have difficulty securing 

devices for their use. Such requests, although well-

meaning, misconstrue the role of new technical innovations 

like 3D printing in the established field of prosthetics and the 

socio-technical contexts that guarantee clinically valid 

results for prosthetic users. Too often, engineers and 

innovators from outside the field of P&O help reinforce this 

mistake, building systems intended to ‘transform the field’ 

but which typically fall flat. This paper describes an 

alternative innovation approach, that the team that 

participated in the Nia technologies project ‘backed into’ as 

we became more knowledgeable about P&O. The values 

principles we developed and the HEF relations to which we 

attended account for our relative successes; our inability in 

some cases to fully support the complexities of local 

relations equally accounts for a lack of adoption. The goal 

of this brief article has been to anecdotally describe the 

ways in which we attempted to incorporate a more complex 

understanding of P&O contexts as part of our project in the 

hopes that these experiences will provide support for others 

seeking to innovate.       

CALL TO ACTION  

Many technically sophisticated tools exist that can benefit 

the P&O community. When adoption is slow, prosthetists 

and clinics are often blamed, with innovators claiming that 

the issue is primarily the conservative nature of the P&O 

discipline. Our experiences developing Nia Technologies’ 

digital toolchain for lower-limb prosthetic sockets highlights 

the ability of P&O clinics and clinicians to be early adopters 

of new technologies if and when the solutions being 

developed address the many needs and stakeholders that 

exist in the field. I encourage all innovators in P&O to first, 

incorporate a deep dive into specific P&O contexts (public 

health, private providers, LMIC clinics, developed world 

contexts, etc.) prior to developing their initial solution 

requirements, and second, to plan to work directly and 

iteratively with clinicians in their planned context of 

deployment. In doing so, P&O innovators will be able to 

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ISSN: 2561-987X 
DESIGNING A DIGITAL TOOLCHAIN FOR PROSTHETICS  

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better address the complexity of the P&O context, including 

the stakeholders identified within the Health Economic 

Framework.      

ACKNOWLEDGEMENTS 

I would like to acknowledge the essential and important input 

provided during the course of the Nia project by the many 

prosthetists, orthopaedic technicians, support staff, and 

administrators at CorSU, CCBRT, TATCOT, and the Cambodian 

School of Prosthetics and Orthotics (CSPO). I would also like to 

personally thank Ed Epp, president of Helping Hands, Intl. for their 

ongoing commitment and support to Nia Technologies and to the 

overall health and wellbeing of children in the developing world. 

Finally, I’d like to emphasize the shared and committed work of the 

Nia team, first and foremost CEO Jerry Evans, and also Head of 

Programs, Joshua Qua Hiansen, lead developer Howie Safeer, 

designer Kaveh Nia, and the many volunteers who have 

participated.   

DECLARATION OF CONFLICTING 

INTERESTS 

During the time that my research on prosthetics and digital systems 

was being carried out, I was paid a consultancy fee by Nia.  At the 

time of writing this paper, I was no longer receive any financial fees 

or incentives from Nia. 

SOURCES OF SUPPORT 

I have been Chief Science Officer of Nia Technologies, the non-

profit organization described in this article since 2015. This role has 

involved consultancy payment. The writing of work was not directly 

supported by Nia, nor any of the grants Nia uses for current or past 

support. 

REFERENCES 

1.Ratto M, Qua Hiansen J, Kaweesa M, Taremwa J, Heang T, 

Kheng S, et al. An international multi-center clinical study: gauging 

patient experience with digitally designing, 3D trans-tibial prosthetic 

devices compared to manually produced prosthetic devices. 

International Society for Prosthetics and Orthotics World Congress 

(ISPO), 2017, Capetown, SA, May 8-11, 2017. 

2.Schmidt R, Coons G, Chen V, Gmeiner T, Ratto M. 3D-printed 

prosthetics for the developing world. InSIGGRAPH 2015: Studio 

2015. DOI:10.1145/2785585.2792535  

3.Ratto M, Qua Hiansen J, Marshall J, Kaweesa M, Taremwa J, 

Heang T, et al. An International, Multicenter Field Trial Comparison 

Between 3D-Printed and ICRC-Manufactured Transtibial Prosthetic 

Devices in Low-Income Countries. J Prosthet Orthot. 2021;33(1): 

54–69. DOI:10.1097/JPO.0000000000000349 

4.Record, M. Ratto, A. Ratelle, A. Ieraci and N. Czegledy, "DIY 

Prosthetics Workshops: ‘critical making’ for public understanding of 

human augmentation," 2013 IEEE International Symposium on 

Technology and Society (ISTAS): Social Implications of Wearable 

Computing and Augmediated Reality in Everyday Life, 2013, 117-

125, DOI: 10.1109/ISTAS.2013.6613110 

5.Southwick D. Expertise in the Age of Digital Fabrication [Doctoral 

Thesis]. University of Toronto. 2019; Available from: 

https://tspace.library.utoronto.ca/handle/1807/95985 

AUTHOR SCIENTIFIC BIOGRAPHY 

Matt Ratto is an 

Associate Professor in the 

Faculty of Information at 

the University of Toronto 

and the Bell University 

Labs Chair in Human-

Computer Interaction. His 

current work explores the 

co-design and adoption of 

new digital technologies in 

health care. He coined the 

term ‘critical making” in 

2007 to describe work that combines humanities insights and 

engineering practices and has published extensively on this 

concept. A current project involves the development of a cost-

effective software and hardware toolchain for the scanning, design, 

and 3D printing of lower-limb prostheses for use in the developing 

world. This work is being carried out in partnership with Hope and 

Healing International, and rehabilitation hospitals in Canada, 

Uganda, and Tanzania. 

 

 

https://doi.org/10.33137/cpoj.v4i2.36188
https://tspace.library.utoronto.ca/handle/1807/95985

