







































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 

Gutierrez A.R. Exploring the future of prosthetics and orthotics: harnessing the potential of 3D printing. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, 
Issue 2, No.7. https://doi.org/10.33137/cpoj.v6i2.42140 

 

 

STAKEHOLDER PERSPECTIVES 

 

EXPLORING THE FUTURE OF PROSTHETICS AND ORTHOTICS: HARNESSING THE 

POTENTIAL OF 3D PRINTING 

Gutierrez A.R* 

Bionic Prosthetics and Orthotics Group LLC, Merrillville, Indiana, USA. 
 
 

 

 

 

  

 

 

 

 

 
 

INTRODUCTION 

In the last decade, Prosthetics and Orthotics (P&O) have 

embraced technological progress, particularly in bionic 

advancements, boosting patient mobility outcomes. 

Recently, focus has turned to enhancing the P&O interface, 

crucial for effective clinical interventions. Over the past 6+ 

years, 3D printing has transformed accessibility, workflow, 

and implementation, impacting prosthetic and orthotic 

procedures. 3D printing in general, is a robust tool for 

fabricating complicated objects in a cost-effective and timely 

manner.1 Despite initial challenges, collaborative efforts 

between technical printer manufacturers, software 

developers, and clinicians have streamlined digital 

workflows, promoting increased adoption of this technology 

in clinical practices.  

Our clinical group, Bionic Prosthetics and Orthotics Group 

(www.bionicpo.com), has been at the forefront of 

implementation of 3D printing into our clinical practice, 

primarily in Prosthetic cases, utilizing FDM (Fused 

Deposition Modeling). 

We were attempting to standardize and improve the 

timeliness of our clinical workflow and overcome the 

traditional time-consuming fabrication methods of hand 

casting, plaster model modifications, thermoforming and 

lamination to enable our clinicians to spend more time 

focusing on patient care. Rapid production in 3D printed 

sockets may shorten the time from evaluation to delivery of 

the prosthesis,2 socket modifications after limb shape 

changes; which could improve clinical outcomes in 

prosthesis use3 and limit any negative effects of socket 

disuse.4 For this transformation to occur, we had to 

demonstrate outcomes of printed devices could match 

those attained with standard fabrication devices. The key 

challenges to penetrating this space in our practice were 

digital scanning technology, printing materials and strength, 

printing time, and digital workflow efficiency.  

DIGITAL SHAPE CAPTURE 

During this period, the P&O field had access to CAD/CAM 

technology with white light scanners, offering heightened 

accuracy. Yet, the integration across multiple clinic 

locations was challenging due to financial, hardware, and 

reliability limitations. Despite having a few white light 

scanners within our practice, the consistency and efficiency 

were burdensome, often exceeding the time of traditional 

methods; additionally, lacking an in-house carver, we 

resorted to costlier central fabrication for diagnostic sockets. 

 
OPEN  ACCESS 

ABSTRACT 

This paper explores the transformative impact of 3D printing on Orthotics and Prosthetics, focusing 

on enhancing patient outcomes and clinical efficiency. Over the past decade, the integration of 

additive manufacturing has revolutionized device fabrication, particularly in diagnostic socket 

production, leading to significant time reductions in patient care. This article addresses challenges 

such as material limitations and the need for equivalent strength to traditional sockets, exploring the 

use of PETG filaments and advanced printers. It emphasizes the role of digital scanning and model 

modification technology, highlighting affordable solutions like Structure Sensor Scanners and 

iPhone-based capture systems in shaping the digital workflow. The importance of a standardized 

digital workflow in clinical settings is discussed, showcasing reduced practitioner time and improved 

patient care. The paper concludes by outlining ongoing efforts to enhance patient care through 

automation and flexible prints. In summary, this paper provides a concise overview of the impactful 

advancements in Orthotics and Prosthetics through 3D printing, highlighting its potential for 

improved clinical efficiency and patient outcomes. 

CITATION 

Gutierrez A.R. Exploring the future of 

prosthetics and orthotics: harnessing the 

potential of 3D printing. Canadian 

Prosthetics & Orthotics Journal. 2023; 

Volume 6, Issue 2, No.7. 

https://doi.org/10.33137/cpoj.v6i2.42140 

KEYWORDS 

Orthotics, Prosthetics, 3D Printing, 

Additive Manufacturing, Digital Workflow, 

Diagnostic Sockets, Material Strength, 

Clinical Efficiency, Prosthetic Interface 

* CORRESPONDING AUTHOR: 

Anthony R Gutierrez, CP/LP 

Bionic Prosthetics and Orthotics Group LLC, Merrillville, Indiana, USA. 

E-Mail: tony@bionicpo.com  

ORCID ID: https://orcid.org/0009-0002-2215-1750 

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

Volume 6, Issue 2, Article No.7, 2023 

 

 

Special Issue 

https://doi.org/10.33137/cpoj.v6i2.42140
http://www.bionicpo.com/
https://doi.org/10.33137/cpoj.v6i2.42140
https://orcid.org/0009-0002-2215-1750
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Gutierrez A.R. Exploring the future of prosthetics and orthotics: harnessing the potential of 3D printing. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, 
Issue 2, No.7. https://doi.org/10.33137/cpoj.v6i2.42140 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X HARNESSING THE POTENTIAL OF 3D PRINTING IN P&O 
Gutierrez A.R, 2023 (Special Issue) 

A pivotal shift occurred when Structure Sensor Scanners, 

coupled with an Apple iPad, entered the scene, providing 

affordable scanning. This enabled our practitioners to do 

quick limb scanning with a familiar technology, a crucial 

efficiency lesson for our journey towards standardized 3D 

printing integration.  

The importance of consistent shape capture across a large 

team is vital to the program's success. Our group has 

traditionally used the Structure Sensor and iPad interface, 

but recently the availability of new Structure Sensors has 

been limited and has created a challenge as our technology 

is aging and accuracy issues were realized. We have 

recently transitioned to Orten capture software (Orten 3D 

Cam 6.0.1 (588)) (https://orten.proteor.com/orten), utilizing 

the iPhone front camera system. All clinicians on our team 

utilize the same phone for clinical purposes, and this was 

an ideal solution to create uniformity across all scans 

coming into the fabrication team, which has led to more 

consistent output. 

MATERIAL LIMITATIONS 

At the time that we started this work, PLA (Polylactic Acid) 

and ABS (Acrylonitrile Butadiene Styrene) were plastic 

filaments that were widely available and utilized by hobby 

printers and were the first materials utilized in the P&O 

space. While these filaments are easy to print with, the 

material was not familiar to the P&O clinician to utilize in a 

clinical sense. In the prosthetic clinical workflow, a vital part 

of the process is the diagnostic socket fitting. These sockets 

are utilized as a platform to create the definitive fabrication 

of the prosthesis. Clinicians are often modifying the socket 

shape via heat and removal of material to create the 

customized socket that will be implemented as a long-term 

solution for the patient. The problem with printed sockets 

was that PLA and ABS do not behave like traditional 

thermoplastic materials used by the field in the modification 

process necessary during diagnostic fittings, thus our 

clinicians struggled with implementing 3D printed solutions 

into their practice. In time, we were able to find more 

suitable PETG filaments that could be utilized and 

manipulated with similar methods to traditional fabrication. 

However, our initial printers were standard flow FDM 

printers (with a nozzle dimension of .6mm utilizing 1.25 mm 

filament), and in order to print a diagnostic socket which was 

strong enough withstand socket donning and static weight 

bearing, we needed to print a socket with sufficient material 

thickness to ensure strength during weight-bearing and 

dynamic alignment of the prosthesis. To accomplish this, we 

had to print with an inner shell, an internal honeycomb 

structure, and an outer shell to complete the socket shape. 

While this was able to create a socket that was strong 

enough for fittings, it was opaque, and thus not an 

equivalent process to traditional fabrication as modification 

of the material was still a challenge due to the dual wall 

design with 25-50% infill based on patient activity 

characteristics. 

PRINTING TIME 

In our traditional workflow, a limb impression is taken, filled 

with plaster, hand modified, thermoformed, and trimmed. 

This process would involve about 1 hour of practitioner time 

and 1.5 hours of technician time. In our initial digital 

workflow, with a standard flow printer, we could capture the 

limb impression and digitally modify it in about 15 minutes, 

then the socket could be designed for printing in about 10 

minutes. However, depending on the size of the residual 

limb, it takes about 8-12 hours to 3D print a PETG or Nylon 

socket with 25-50% infill percentage using a Filament 

Innovations ICARUS GEN 1.0 Printer. While practitioner 

time was greatly reduced, we were still behind on the 

technical timeline and still had not created a more efficient 

process, as we had one standard flow printer servicing nine 

clinics. The first breakthrough of printed sockets in mass 

adaptation into our workflow was when we partnered with 

Filament Innovations and their High-Flow Kratos, which was 

able to utilize a 2.5 mm nozzle and 2.85 mm filament. The 

output of this machine gave us the closest replica of a 

standard fabrication diagnostic socket. The printer was able 

to produce a diagnostic socket of a PETG material that was 

a solid piece with a 4 mm wall thickness (no infill) in 1.5 

hours and 15 minutes technical post processing of the 

socket for patient use. This material was able to be modified 

during the fitting appointment with the same processes as 

traditionally fabricated materials and was able to be used in 

both static and dynamic fittings. Reaching this benchmark 

enabled our practice to fully adopt a digital workflow. We 

were able to drop our practitioner’s time from 1 hour to 15 

minutes and our technician’s hands-on time from 1.5 hours 

to 15 minutes. This was an incredible efficiency booster on 

both our clinical and technical sides and led to mass 

adoption in our practice.   

STRENGTH TESTING IN 3D PRINTING 

One of the biggest questions we had in the initial 

implementation of 3D printing prosthetic sockets with High-

Flow printers was: Are they equivalent in strength compared 

to a traditionally fabricated socket? Anecdotally within our 

clinics, we saw that the strength of the PETG sockets we 

were producing were similar to that of traditional diagnostic 

sockets.  To explore this further, we partnered with Rosalind 

Franklin University in North Chicago, Illinois by collaborating 

on a Department of Defense funded grant, under the 

Orthotics and Prosthetics Outcomes Research program. 

We conducted a systematic review to better understand the 

current state of this newer fabrication method, with a focus 

on the structural integrity of 3D printed sockets and factors 

that can affect the strength of 3D printed sockets when 

tested using ISO 10328 standards.  Based on our search, 

we determined that direct comparison between studies was 

https://doi.org/10.33137/cpoj.v6i2.42140
https://orten.proteor.com/orten
https://www.filamentinnovations.com/
https://www.filamentinnovations.com/


 

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Gutierrez A.R. Exploring the future of prosthetics and orthotics: harnessing the potential of 3D printing. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, 
Issue 2, No.7. https://doi.org/10.33137/cpoj.v6i2.42140 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X HARNESSING THE POTENTIAL OF 3D PRINTING IN P&O 
Gutierrez A.R, 2023 (Special Issue) 

challenging based on methodological differences including 

limited sample size, different testing conditions, infill 

percentages, and reinforcements near the socket pylon 

interface. Regardless, our systematic review results did 

show that 3D printed sockets were trending towards 

producing similar failure forces as those observed in 

laminated sockets.5 We complemented this review with 

empirical data collected by our group in which we performed 

ultimate failure testing of 3D printed composite sockets 

using some of the latest filaments available.For 3D printed 

sockets, three different material filaments were used: PETG 

(Filament Innovations, Pennsylvania, USA); polycarbonate 

or PC (Polymax-PC, Polymaker, Changshu, China); and co-

polymer polypropylene or CPX (Filament innovations, 

Pennsylvania, USA). CPX is a specific co-polymer 

polypropylene filament that, as per manufacturer 

information, has higher strength characteristics than 

standard co-polymer propylene. We refer to the filament 

using the manufacturers name, CPX, rather than the 

generic co-polymer propylene to highlight this difference) 

and compared the results to that of a standard laminated 

composite (Nano Resin, Paceline Advanced Medical 

Solution) and a lay-up consisting of braided carbon fiber 

(ST&G USA Corp.), Nyglass Stockinette (Paceline 

Advanced Medical Solution), and Nysert (SPS).  

In this case, the layup consisted of a layer each of (in this 

order) carbon braid, nyglass, nysert, nyglass, carbon braid 

and feather stretch nylon stocking. Another polyvinyl alcohol 

bag was placed over the layup. The thermosetting resin, 

activated with the promoter or hardener, was then poured 

into the bag and was subjected to vacuum to evenly spread 

the resin throughout the layup on the mold. Manual stringing 

of the resin was performed from the outside of the PVA bag 

to ensure the lay-up was fully saturated. The resin started 

thermosetting shortly after and was left to cure for several 

hours before it was ready to be cut and trimmed) socket.  

The mechanical strength of prosthetic sockets was 

investigated in accordance with ISO 10328 standards. The 

loading configurations as specified in ISO 10328 reflects 

loading that occurs either during heel strike (loading 

condition I), in which the load axis passes from the anterior 

side of the proximal leg to the posterior side of the distal leg, 

or toe-off (loading condition II), in which the load axis passes 

way towards the anterior side to the distal end of the socket. 

Condition II is the most commonly used testing condition for 

ultimate failure of 3D printed sockets since it places the 

socket in its “worst case scenario”, where failure loads are 

lower due to higher bending moments generated at the 

distal end of the socket. 

Our failure test results performed at Condition II with a 2-

inch pylon at P5 loading level (P5 load level of the ISO 

standards, which targets patients with a body mass of 100 

kg and corresponds to 920 N (settling test), 2013 N (proof 

test), and 4025 N (ultimate test, upper limit) for the tests)  

showed 3D printed composite sockets had 32% reduced 

ultimate failure strength when compared to laminated 

sockets.  

However, they may still be safe to use at the prescribed 

loading levels. Based on the cumulative results of our 

testing and literature review, we believe that improving the 

pylon socket interface and inclined layer printing might help 

improve the strength to match that of laminate composite 

sockets.6 

OPTIMIZATION OF THE DIGITAL WORKFLOW 

The implementation of the full digital workflow within our 

practice group has been an exciting and challenging task. 

Our goal was to replicate the traditional process and 

improve both clinical and technical efficiencies. Our practice 

is currently utilizing printing for diagnostic sockets (PETG- 

Filament Innovations), co-poly sockets (CPX - Filament 

Innovations), and flexible inner sockets (TPU- Matter 

Hackers). 

Our clinical workflow model works as follows for our 

clinicians: 

1. Shape Capture (15 minutes) 

a. Clinician will cast patient and scan outside of fiberglass 

cast, as this is simpler than scanning inside of cast, and a 

uniform fiberglass cast is thin enough to capture limb 

shape and easily be modified out (75%) 

b. Clinician will scan limb directly (15%) 

c. Clinician will cast patient and mail cast to fabrication 

team (10%) 

● We currently utilize structure scanners with an iPad and 

the Willowood Omega Scan Application (Version 4.2.0) or 

the Orten Capture Front Camera Scanners (Orten 3D 

Cam 6.0.1 (588)) on iPhone. 

2. Digital modifications (10 minutes) 

a. Digital technicians modify scan from clinician (85%) 

b. Clinicians modify scan and send to digital technicians 

(15%) 

● We primarily utilize Willowood Omega Software 

(Version 1.7.2 (1.7.19281.01)) for socket modification. We 

are currently testing Ossur Design Studio (Version 

unavailable) and Orten Fly Shape (Version 1.3.1 (588)). 

3. Digital Socket design (10 minutes) 

a. Digital technicians create sockets with desired 

suspension: Pin lock Lanyard, Suction, Vacuum, or Seal-

in 

b. Socket is entered into a slicer to create G-code for 

printing. We currently utilized Odin (Filament Innovations, 

Version 1.2.2) and Simplify 3d (Version 4.1.2) 

https://doi.org/10.33137/cpoj.v6i2.42140


 

4 

Gutierrez A.R. Exploring the future of prosthetics and orthotics: harnessing the potential of 3D printing. Canadian Prosthetics & Orthotics Journal. 2023; Volume 6, 
Issue 2, No.7. https://doi.org/10.33137/cpoj.v6i2.42140 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X HARNESSING THE POTENTIAL OF 3D PRINTING IN P&O 
Gutierrez A.R, 2023 (Special Issue) 

Note: We utilize Meshmixer (Autodesk Version 3.5.474) 

for all design. 

4. Socket is printed and trimmed by digital technicians 

(1.5-2.5 hours shape dependent) 

a. We currently utilize Filament Innovations Icarus printers, 

Kratos Printers, and a PVA med Printer for these prints.  

CONCLUSION 

In conclusion, our initiatives have successfully provided 

clinicians with additional time to dedicate to patient care and 

improved outcomes. Our ongoing endeavors are directed 

towards further enhancing patient care through the 

identification of additional procedural efficiencies. The 

implementation of diagnostic sockets has streamlined initial 

care processes and accelerated prescription timelines. 

Notably, co-poly prints (CPX) have emerged as a reliable 

solution for prolonged diagnostic socket usage and 

preparatory devices for new individual with amputation, 

demonstrating sustained efficacy for up to six months. The 

integration of flexible prints alongside traditional lamination 

techniques has not only improved material consistency and 

reduced waste but has also been seamlessly incorporated 

into the production of definitive sockets. Through the 

strategic implementation of automation, our practice has 

effectively lightened the time burden on clinicians, ultimately 

contributing to enhanced patient outcomes. 

CALL TO ACTION 

Take proactive steps to revolutionize the field of Prosthetics 

and Orthotics through 3D printing. Embrace this 

transformative technology to streamline workflows, reduce 

fabrication time, and ultimately enhance the lives of 

individuals in need of prosthetic and orthotic devices. 

Collaborate with technical printer manufacturers, software 

developers, clinicians, and researchers to expand the 

capabilities of 3D printing, fostering knowledge sharing and 

research partnerships. Invest in research and development 

efforts to overcome material limitations and socket strength 

challenges, introducing new materials and techniques 

validated through studies. Establish and disseminate best 

practices for digital shape capture, design, and printing 

processes, standardizing workflows for reduced practitioner 

time and increased consistency across clinics. Prioritize 

education and training for clinicians, equipping them with 

the necessary skills for effective 3D printing technology 

utilization. Maintain a patient-centric approach, directing 

efforts towards improving clinical outcomes and enriching 

the patient experience through 3D-printed devices. 

Together, we can unlock the full potential of 3D printing in 

Prosthetics and Orthotics. 

ACKNOWLEDGEMENTS 

I extend my gratitude to Sagar Shetty for initiating our exploration 

of 3D Printing, the entire Bionic Prosthetics and Orthotics Group for 

actively participating in the adoption of a digital clinical workflow, 

our digital manufacturing partners, and our patients for embracing 

this transformative shift in technology. 

DECLARATION OF CONFLICTING INTERESTS 

The author is an employee of Bionic Prosthetics and Orthotics 

Group. 

SOURCES OF SUPPORT 

This work was supported by the Department of Defense under the 

Orthotics and Prosthetics Outcomes Research Program, award 

number W81XWH2010175.  

REFERENCES 

1.McHugh KJ, Nguyen TD, Linehan AR, Yang D, Behrens AM, 

Rose S, et al. Fabrication of fillable microparticles and other 

complex 3D microstructures. Science (New York, NY). 

2017;357(6356):1138–42. DOI: 10.1126/science.aaf7447 

2.Ventola CL. Medical applications for 3D printing: current and 

projected uses. P & T. 2014;39(10):704–11. PMID: 25336867; 

PMCID: PMC4189697 

3.Mayo AL, Gould S, Cimino SR, Glasford S, Harvey E, Ratto M, et 

al. A qualitative study on stakeholder perceptions of digital 

prosthetic socket fabrication for transtibial amputations. Prosthet 

Orthot Int. 2022;10.1097. DOI: 10.1097/PXR.0000000000000157  

4.Rosenblatt NJ, Stachowiak A, Reddin C. Prosthetic disuse leads 

to lower balance confidence in a long-term user of a transtibial 

prosthesis. Adv Wound Care (New Rochelle). 2021;10(9):529–33. 
DOI: 10.1089/wound.2019.1086 

5.Kim S, Yalla S, Shetty S, Rosenblatt NJ. 3D printed transtibial 

prosthetic sockets: A systematic review. PLoS One. 

2022;17(10):e0275161. DOI: 10.1371/journal.pone.0275161 

6.Sunjung K, Sai Y, Sagar S, Noah R. Structural integrity of custom-

designed additive manufactured prosthetic sockets compared to 

traditional sockets. Available at SSRN: 

https://ssrn.com/abstract=4571479  

AUTHOR SCIENTIFIC BIOGRAPHY 

Tony Gutierrez has been with Bionic 

Prosthetics and Orthotics Group since 

2015, currently serving as their 

National Clinical Specialist for 

Advanced Prosthetic Solutions. In his 

role, he leads the group's adoption of 

digital workflows and 3D printing 

technology, focusing on enhancing 

clinical research in socket design, 

strength testing, and adjustable above-the-knee prosthetic socket 

fittings. Gutierrez's educational background includes a bachelor's 

degree in Mathematics Education from Indiana University–Purdue 

University Indianapolis (IUPUI), a Master's in Biomechanics from 

the University of Wisconsin, and a Postgraduate Certificate in 

Prosthetics from The Northwestern University Prosthetics and 

Orthotics Center (NUPOC). His dedication to the field is evident 

through past publications in biomechanics, gait mechanics, and 

prosthetic socket design. 

 

https://doi.org/10.33137/cpoj.v6i2.42140
https://www.filamentinnovations.com/filament
https://ssrn.com/abstract=4571479

