







































VOLUME 6, ISSUE 2 

 2023 
 

Articles in this special issue has been invited and reviewed by Dr. Silvia Ursula Raschke and Dr. Hossein Gholizadeh. 

 

D E S I G N I N G  T H E  F U T U R E :  3 D  P R I N T I N G ' S  

R E V O L U T I O N  I N  P R O S T H E T I C S  &  O R T H O T I C S  

S T A K E H O L D E R  P E R S P E C T I V E S   

PRINTING 

3D 

PUBLISHER: CANADIAN ONLINE PUBLICATION GROUP   

S P E C I A L  I S S U E  

CPOJ 

ISSN: 2561-987X 

https://jps.library.utoronto.ca/index.php/cpoj/EDitorinchief


 

1 

Andrysek J, Ramdial S. Transforming P & O care with 3D printing – more than meets the eye. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 2, 
No.3. https://doi.org/10.33137/cpoj.v6i2.42138 

 

 

STAKEHOLDER PERSPECTIVES 

 

TRANSFORMING P & O CARE WITH 3D PRINTING– MORE THAN MEETS THE EYE 

Andrysek J1,2*, Ramdial S3  

1 Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada. 
2 Institute of Biomedical Engineering, Faculty of Applied Science and Engineering, University of Toronto, Toronto, Canada. 
3 Orthotics and Prosthetics Department, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Canada. 

 
 

 

 

 

  

 

 

 

 

 

 
 

 

INTRODUCTION 

With custom care being a prominent focus in the Prosthetics 

and Orthotics (P&O) industry, the ability to create unique 

assistive devices suggests 3D printing is the ideal solution. 

The appeal of additive manufacturing is its ability to produce 

one-off parts relatively quickly and inexpensively. While 3D 

printing has been around for decades, recent technological 

advancements have made it more relevant, meeting the 

design and functional requirements of the P&O field.  But is 

3D printing poised to transform P&O practices, and replace 

our traditional methods? This paper provides insight on this 

by examining the state-of 3D printing technology as it 

applies to P&O, and highlighting important considerations in 

bringing 3D printing into mainstream practice. The paper 

draws from recent published literature, as well as our 

learnings of 4+ years of work to implement digital workflows 

and 3D printing into the clinical services within our own 

rehab hospital. The intention of this paper is to provide 

useful information and guidance to the P&O sector including 

practitioners (i.e. clinicians and technicians implementing 

3D printing in their practices), manufacturers (those 

developing digital workflows and 3D printers), researchers, 

health care funders and policy makers, users, educators, 

and the media, which has not always presented the topic in 

an accurate way.  

3D PRINTING TECHNOLOGY 

3D printing allows for the construction of three-dimensional 

objects from a digital model by joining or solidifying 

materials. Many different 3D printing methods exist, utilizing 

a variety of materials. Common printing methods include 

fused deposition modeling (FDM), whereby an object is 

built-up with an extruded filament, sintering, where a 

powder is fused together, or stereolithography, in which 

liquid resin is hardened into the desired object. Polymers 

(plastics such as PVA, PLA, PET, ABS, nylon) are the most 

commonly printed materials and relevant to P&O, but 

metals, resins, and even composites can also be 3D printed. 

 
OPEN  ACCESS 

ABSTRACT 

Many within the prosthetics and orthotics (P&O) industry are embracing 3D printing technology to produce 

better devices more efficiently, cost-effectively and to improve patient outcomes. 3D printing is here to stay, 

but how much will it transform P&O practices? This paper explores the state-of 3D printing technology as it 

applies to P&O and aims to highlight important considerations for bringing 3D printing into mainstream practice. 

The paper draws from recent published literature, as well as experiences stemming from ongoing efforts 

focused on implementing digital workflows and 3D printing into P&O care. The paper examines the topic from 

the technological, research, economics, funding, and clinical perspectives. While 3D printing and digital 

workflows have advantages over traditional methods (i.e. ability to design more complex parts, reprinting and 

reproduction of parts, less labour intensive) there are also challenges limiting adoption. First, despite recent 

advancements in 3D printing technology, gaps still exist in terms of the materials and processes. For example, 

cost-effectively fabricating devices that are concurrently strong and durable, allow for colourful designs, and 

are thermoformable are still being developed. Cost-wise, 3D printing may currently be more viable for small, 

or paediatric devices. There are also limited technical standards to ensure safe and durable devices are 

produced, as well as a lack of evidence and information about patient outcomes and operating costs. 

Nevertheless, a great amount of enthusiasm and momentum exists within the industry to innovate, and with it 

the potential for 3D printing to one day be central to mainstream P&O care. Given the many aspects of the 

P&O industry, collaboration and partnerships will facilitate learning from each other to advance and realize the 

potential of 3D printing sooner. 

CITATION 

Andrysek J, Ramdial S. 

Transforming P & O care with 

3D printing– more than meets 

the eye. Canadian Prosthetics 

& Orthotics Journal. 2023; 

Volume 6, Issue 2, No.3. 

https://doi.org/10.33137/cpoj.v

6i2.42138 

KEYWORDS 

Prosthetics, Orthotics, 

Fabrication, Additive 

Manufacturing, 3D Printing, 

Digital Workflows, Scanning, 

Socket 

* CORRESPONDING AUTHOR: 

Jan Andrysek, PhD 

Bloorview Research Institute, Holland Bloorview Kids Rehabilitation 
Hospital, Toronto, Canada. 

E-Mail: jan.andrysek@utoronto.ca 

ORCID ID: https://orcid.org/0000-0002-4976-1228 

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

Volume 6, Issue 2, Article No.3. 2023 

 

 

Special Issue 

 

https://doi.org/10.33137/cpoj.v6i2.42138
https://doi.org/10.33137/cpoj.v6i2.42138
https://doi.org/10.33137/cpoj.v6i2.42138
mailto:jan.andrysek@utoronto.ca
https://orcid.org/0000-0002-4976-1228
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Andrysek J, Ramdial S. Transforming P & O care with 3D printing – more than meets the eye. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 2, 
No.3. https://doi.org/10.33137/cpoj.v6i2.42138 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X TRANSFORMING P & O CARE WITH 3D PRINTING– MORE THAN MEETS THE EYE 
Andrysek J, and Ramdial S, 2023 (Special Issue) 

Each printing method is unique in terms of the materials that 

can be used, the characteristics of the fabricated parts (i.e. 

part geometries and size, surface finish, colors, strength, 

cost), and general usability (i.e. cost of or access to printer, 

printing time, and post processing requirements). It is 

crucial to highlight that no single printing technology can do 

it all, and the most likely scenario is that clinics will need 

access to a multitude of different printers, depending on 

their applications. For example, implementation efforts may 

rely on the use of a low-cost FDM printer for fabricating 

check or diagnostic sockets while a sintering printer such as 

the Hewlett Packard (HP) Multi Jet Fusion (MJF) is used for 

the final prosthesis or orthosis requiring high strength and 

durability.  

3D PRINTING IN P&O 

Before diving further into 3D printing in P&O, it is important 

to recognize that 3D printing is closely integrated with digital 

workflows (i.e. the process of developing the digital models 

that are ultimately printed). Typically, this includes some 

method of scanning the user’s body part and using 

Computer-Aided Design (CAD) software to develop the 

digital model. For decades, these digital workflows have 

included carving at the latter end to make a foam positive 

for molding a brace or socket, however, 3D printing has the 

potential to replace this final step. Within our own work, it 

has taken considerable time and effort to figure out the 

digital processes for different devices (determining what 

scanner and design software are best, learning how to 

effectively use them, establishing file management etc.). 

Applying digital workflows into P&O practice has its 

challenges and benefits. Challenges include: incomplete 

solutions, inability to work with physical models, and the 

costs and investment needed to implement them, among 

others.1 However, these can be viewed as short-term 

hindrances as there are also benefits — the first of which 

being the possibility of more efficient processes for making 

and remaking devices.  Once a digital model is developed, 

it can be easily adjusted (digitally) and/or printed as many 

times as needed. If a user breaks their device, another one 

can be reprinted and sent to them. Within our work, users 

have expressed their desire to have fabrication processes 

that require fewer visits to the clinic or hospital. Another 

benefit is the opportunity for large data sets of digital models 

to inform best clinical practices around the design of 

devices, and to advance the design processes to be more 

scientifically driven.1 This could help in teaching and 

training, or to automate aspects of the design process to 

improve usability and efficiency of CAD programs; 

ultimately improving outcomes by allowing devices to be 

fabricated more consistently.  

Beyond developing and implementing workflows for making 

sockets and orthoses, our group has also explored the use 

of 3D printing in a number of other ways. The first among 

these is the design of terminal devices that do not exist 

commercially, including a custom hand,2 as well as 

recreational devices (such as a hockey stick attachment for 

a youth with a transradial prosthesis). We have also used 

3D printing in the design and development of commercial 

prosthetic components such as the All-Terrain prosthetic 

knee joint. The versatility of 3D printing makes it possible to 

explore applications that were not previously possible. For 

example, a market has evolved around 3D printed 

personalized cosmetic prosthetic covers, enabling disability 

to be fashionable rather than something that people try to 

conceal. Similarly, greater personalization and 

customization of prosthetic liners is now possible with the 

advent of 3D printing of silicone. A liner can be printed with 

varying materials and thicknesses, to better conform and 

transfer the loads to the limb to improve comfort and 

function. Variable thickness also enables orthotic and 

prosthetic interfaces to be designed to have compliance in 

certain areas and provide greater support in others, to 

improve comfort and load bearing capabilities.  

As previously mentioned, implementing digital workflows 

and 3D printing in P&O practice presents some unique 

challenges, and many are related to 3D printing technology 

itself. Until recently and before the introduction of 3D 

printing technology such as the HP MJF, cost-effectively 

printing larger parts that met their strength requirements 

was a major limitation.3 However, the capital investments of 

acquiring a MJF printer are substantial, as are operational 

costs which can include such aspects as hiring a trained 

technician to run the equipment. At present, there is limited 

information on the economic aspects of using digital 

workflows and 3D printing as compared to traditional 

workflows, making it a leap of faith for those interested in 

implementing these new technologies.4 An additional 

financial consideration which remains a gray area in some 

health care systems, is reimbursement. However, 

professionals and the P&O industry are advocating for 

approval of new and proven technologies.    

Beyond the economic aspects, concerns also persist about 

the suitability of existing 3D printing technology for use in 

P&O. An important aspect is strength and durability, given 

the critical role that P&O devices play in the lives of their 

users. Strength is determined not only by the material used, 

but also the printing process. For example, FDM printed 

parts are prone to weakness between printed layers, 

resulting in potential fracture points. Sintered parts (such as 

with the MJF) are much more isotropic and avoid this but 

come at a much higher cost as previously mentioned. A 

related challenge is the absence of standards or protocols 

for strength testing components such as sockets and 

orthoses. The design of custom P&O devices such as 

sockets or orthoses is largely based on best practices and 

the practitioner’s experience, and such experiential 

evidence is still limited for non-traditionally made devices. 

Structural testing standards such as ISO 10328 do not cover 

P&O components beyond prosthetic knee joints and feet. 

https://doi.org/10.33137/cpoj.v6i2.42138


 

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Andrysek J, Ramdial S. Transforming P & O care with 3D printing – more than meets the eye. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 2, 
No.3. https://doi.org/10.33137/cpoj.v6i2.42138 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X TRANSFORMING P & O CARE WITH 3D PRINTING– MORE THAN MEETS THE EYE 
Andrysek J, and Ramdial S, 2023 (Special Issue) 

Further, the diversity of printing materials and methods, as 

well as device requirements, complicates the establishment 

of accepted standards and practices. Nevertheless, general 

guiding principles for 3D printing medical devices are being 

established. The standards identify important technical 

considerations for manufacturing and testing of 3D printed 

medical devices including point-of-care and patient-

matched (custom) devices which are relevant to the P&O 

industry.5  

Other characteristics are also important, but not easy to 

achieve with existing 3D printers. Printed materials should 

ideally be thermoformable to allow for both immediate 

adjustments to parts such as sockets and orthoses during 

fitting and future adjustments due to growth or other 

physiological changes. However, the most promising 

printing methods (such as the HP MJF) are not ideal in this 

respect. The sintered MJF Nylon material has limited 

thermoformability, and the application of heat has the 

unfortunate effect of changing the color and finish of the 

surface, thus compromising aesthetics of the finished piece 

as well as possibly the mechanical properties. The MJF 

printer is also limited in terms of colors that can be printed, 

with dark grey being the default. HP previously sold a printer 

that gave us a variety of choices, but these colour features 

are no longer available. This is unfortunate, as many users 

(kids and adults alike) see color as an important aspect of 

device personalization. In contrast, FDM printers can easily 

print in color, however, as noted earlier the strength and 

surface finish are questionable. In the case of diagnostic 

sockets that need to be transparent in addition to being 

thermoformable, the options are even more limited. Curable 

resins that are transparent are not thermoformable. Plastics 

used in FDM are thermoformable, but the FDM process 

limits transparency due the way the filament is layered to 

make the parts.  Optimization of printing parameters and 

surface treatments can help to increase transparency, but 

currently there is little guidance on how to achieve 

acceptable results in practice. Trade-offs exist, and many of 

these unique challenges are left up to the P&O industry to 

find solutions. 

Unraveling more of the details, there are other challenges 

to overcome. For example, currently there is no simple way 

to digitally capture the changes made by heat forming a 

diagnostic socket for the finalization of the model and 

printing of the definitive socket. Scanners that can 

effectively capture the inside shape of a socket, especially 

small sockets, are not available. We even went as far as 

trying dental scanners, but these are not designed to 

reconstruct topologies relevant to P&O devices. One could 

fill the diagnostic socket with plaster or alginate and then 

digitally scan in this positive model, but it would be ideal if 

this “traditional workflow” step could be avoided. Another 

restriction is size. Not only does the cost of the printed part 

increase with size, but most printers have print volumes that 

cannot accommodate larger devices. For example, current 

MJF printers have a build volume that can print a smaller 

AFO, but not a large adult one. Joining two printed parts to 

make a larger device is possible but requires extra steps 

and may compromise strength. 3D printing at present may 

be best suited for smaller devices such as foot orthotics, and 

also pediatric over adult care. 

The possibilities that 3D printing offer are exciting. One only 

needs to go to any P&O forum or congress, to see all of the 

innovation that companies, researchers, and health care 

are driving. From improvements to digital design and data 

management software and new printing technologies, to 

service bureau models for central fabrication and beyond. 

However, current 3D printing technology does not fully meet 

the needs of the P&O industry and as such, the future 

remains uncertain. The ideal 3D printer would be cost-

effective and not only produce strong and durable parts with 

a good finish, but also colors and designs that users desire. 

Processes and materials that are concurrently able to 

provide the important features (strength, durability, good 

finish, thermoformability, colors, biocompatibility etc.) are 

needed. Additionally, reduced print times (i.e. < 1 hour) 

would allow devices to be fabricated and tested during a 

single session, thus reducing the number of appointments 

and overall healthcare costs and burden on users. It is a lot 

to ask for and expect from 3D printing to meet all these 

criteria. The alternative is that clinical practices continue to 

adapt to best utilize the existing tools. The mainstream 

adoption of 3D printing in P&O would change practice, and 

it must not compromise quality of devices, treatment and 

services. Given the diversity of P&O care, it will continue to 

take ingenuity and craftiness to address the many practice 

nuances over time as was done with traditional processes. 

One important aspect of this, is that we are able to learn 

from each other. In our efforts to implement digital 

technology workflows, we have been very fortunate at the 

willingness of other clinics, hospitals, researchers and even 

companies to share their expertise and learnings with us. 

These partnerships help us move forward with greater ease 

and to apply digital workflows in our care. It is our goal to 

reciprocate and support others. We need to strive to 

continue to bring the communities interested in digital 

workflows and 3D printing together. Some considerations 

include establishing special interest groups, forums or 

networks and to collaborate globally (i.e. International 

Society for Prosthetics and Orthotics - ISPO). The 

discussions must also involve manufacturers, who can 

ultimately help address the limitations of existing printing 

technology, and policymakers and funders, who can help to 

remove funding and regulatory barriers in how we can 

implement 3D printing in practice.  

CALL TO ACTION 

Is 3D printing the future of P&O care? Will it continue to be 

a way that we make the occasional one-off device, or will it 

more profoundly transform our practice? It is too early to 

https://doi.org/10.33137/cpoj.v6i2.42138


 

4 

Andrysek J, Ramdial S. Transforming P & O care with 3D printing – more than meets the eye. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, Issue 2, 
No.3. https://doi.org/10.33137/cpoj.v6i2.42138 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X TRANSFORMING P & O CARE WITH 3D PRINTING– MORE THAN MEETS THE EYE 
Andrysek J, and Ramdial S, 2023 (Special Issue) 

know and will depend on the future advancements in the 

technology itself, the P&O ecosystem, the validation from all 

involved — especially our users, and also our continued 

willingness and ability to work toward implementing it. The 

driving elements, and metrics to indicate that we are on the 

right track, will boil down to whether the needs of clients can 

be served more efficiently and effectively. This will require 

shared learnings from the users, clinical, technical and 

research groups, and utilizing available evidence about the 

quality of care and cost-effectiveness in comparison to the 

status quo.  

ACKNOWLEDGEMENTS 

We would like to acknowledge all those that have contributed to this 

work over the years including many members of the clinical and 

technical teams within the Orthotics and Prosthetics Department at 

Holland Bloorview, and most notably Elaine Ouellette, Neil Ready, 

Kerri Kelland and Amy Richardson.  Other contributors to the work 

that informed this paper include Calvin Ngan and Harry Sivasambu 

from the Bloorview Research Institute. We also thank Boundless 

Biomechanical Bracing for their insights on the HP MJF printing. 

Last but not least, many thanks to the clients of Holland Bloorview 

that have participated in trialing digitally made devices.   

DECLARATION OF CONFLICTING INTERESTS 

The authors have no conflicts of interest to declare related to this 

paper. 

AUTHORS CONTRIBUTION 

Both authors contributed equally to the research and the writing of 

this manuscript. 

SOURCES OF SUPPORT 

Holland Bloorview Foundation Grants from 2021 to 2023. Natural 

Sciences and Engineering Council (NSERC) Discovery Grant 

493032. NSERC Alliance Grant 514883. The War Amps.   

REFERENCES 

1.Ngan C, Sivasambu H, Kelland K, Ramdial S, Andrysek J. 

Understanding the adoption of digital workflows in orthotic & 

prosthetic practice from practitioner perspectives: a qualitative 

descriptive study. Prosthet Orthot Int. 2022;46(3):282-289. DOI: 

10.1097/PXR.0000000000000107 

2.Eshraghi A, Yoo J, Klein J, Mckenzie I, Sebaldt G, Leineweber M, 

et al. A custom, functional and lifelike passive prosthetic hand for 

infants and small toddlers: clinical note. Prosthet Orthot Int. 

2020;44(3):180-184. DOI: 10.1177/0309364620909276 

3.Ribeiro D, Cimino SR, Mayo AL, Ratto M, Hitzig SL. 3D printing 

and amputation: a scoping review. Disabil Rehabil Assist Technol. 

2021;16(2):221-240. DOI: 10.1080/17483107.2019.1646825 

4.Roberts A, Wales J, Smith H, Sampson CJ, Jones P, James M. 

A randomised controlled trial of laser scanning and casting for the 

construction of ankle-foot orthoses. Prosthet Orthot Int. 

2016;40(2):253–61. DOI: 10.1177/0309364614550263 

5.Technical considerations for additive manufactured medical 

devices: Guidance for Industry and Food and Drug Administration 

Staff [Internet]. Food and Drug Administration. 2017. [cited Sep 22, 

2023]. Available from: https://www.fda.gov/regulatory-

information/search-fda-guidance-documents/technical-

considerations-additive-manufactured-medical-devices 

AUTHORS SCIENTIFIC BIOGRAPHY 

Dr. Jan Andrysek is a Senior Scientist at 

the Bloorview Research Institute of Holland 

Bloorview Kids Rehabilitation hospital and 

an Associate Professor at the Institute of 

Biomedical Engineering, University of 

Toronto. His research program focuses on 

the development of treatments and 

assistive technologies for children and 

youth with physical disabilities. Specific 

areas of study include prosthetic and 

orthotic limb design and control, bio sensing, biofeedback and gait 

training systems, and understanding the global need for prosthetic 

and orthotic technology and its impact on mobility, physical 

function, and quality of life. He is the recipient of awards including 

the 2017 Ontario Profession Engineers Engineering Medal for 

Research and Development.  In 2019 Dr. Andrysek was elected an 

American Institute for Medical and Biological Engineering (AIMBE) 

fellow. He is also the co-founder and Chief Scientific Officer at 

Legworks Inc., a social for-profit enterprise focused on improving 

prosthetic technologies and care for individuals globally. 

Sandra Ramdial is a certified prosthetist.  

She is the past operations manager for the 

Orthotic and Prosthetic Department at 

Holland Bloorview Kids Rehabilitation 

Hospital where she led a group of clinical 

and technical professionals and had direct 

involvement in client care. She has over 35 

years of experience in the field including 22 

years at Holland Bloorview and was part of 

the Professional and Clinical Services 

team at Otto Bock Healthcare Canada where she managed the 

Custom Silicone Group and a key clinical ambassador and 

educator for upper limb prosthetics. Sandra is the past president of 

the Canadian Association of Prosthetics & Orthotics and the 

International Society for Prosthetics & Orthotics (ISPO) Canada 

and the past secretary-treasurer for the Association of Children’s 

Prosthetic-Orthotic Clinics. She continues to be involved in 

Orthotics & Prosthetics and is presently the President Elect for the 

International Board of ISPO. In addition to her extensive 

experience, she brings an even greater amount of enthusiasm and 

passion for research and development, and new technologies to 

the field.   

https://doi.org/10.33137/cpoj.v6i2.42138
https://www.fda.gov/regulatory-information/search-fda-guidance-documents/technical-considerations-additive-manufactured-medical-devices
https://www.fda.gov/regulatory-information/search-fda-guidance-documents/technical-considerations-additive-manufactured-medical-devices
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