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VOLUME 7, ISSUE 2 

 2024 
 

PROFESSIONAL OPINION 

 

Ratto M, Southwick D. Prosthetist knowledge and 3D printing. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.5. 

https://doi.org/10.33137/cpoj.v7i2.42175 

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Ratto M, Southwick D. Prosthetist knowledge and 3D printing. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.5. 
https://doi.org/10.33137/cpoj.v7i2.42175 

 

 

PROFESSIONAL OPINION 

 

PROSTHETIST KNOWLEDGE AND 3D PRINTING 

Ratto M1*, Southwick D2 

1. Faculty of Information, University of Toronto, Toronto, Canada.  
2. Autodesk inc., San Francisco, California, USA.  
 
  
 

 

 

 

  

 

INTRODUCTION   

In this paper we briefly explored 3D printing and prosthetics, 

understanding 3D printing as connected to but distinct from 

the long history of CAD/CAM technologies in P&O. Work on 

digital production of prosthetics began in the 1960’s but 

despite the development of multiple systems over the last 

70 years, most prosthetic devices are still produced through 

craft processes. If asked, most prosthetists will note the 

existence of automated systems, but highlight their 

inadequacies in coming to terms with the complex 

topologies and textures of a humans and their cost and 

difficulty of use.  

Recent technological developments, including lower cost 

3D scanners with higher accuracies and easier to use 3D 

printers capable of printing in higher tensile strength 

materials offer the possibility of overcoming these stated 

challenges. However, developing digital prosthetic 

toolchains that properly acknowledge and instantiate forms 

of knowledge that constitutes prosthetist expertise is a long-

standing challenge in the development of novel CAD/CAM 

prosthetic systems. 

3D PRINTING AND PROSTHETICS    

In 1990, a research group at Northwestern University, in 

conjunction with Baxter Healthcare, made a single trans-

tibial (TT) socket using a form of 3D printing known as 

stereolithography (SLA).1 Shortly thereafter, the University 

of Texas at Austin and the University of Health Science 

Centre at San Antonio began experimenting with Selective 

Laser Sintering (SLS), which led to an amputee briefly 

wearing a 3D printed socket in a controlled clinical setting in 

1992.2 While quite limited in scope, these early studies in 

the application of 3D printing within the P&O profession had 

a large impact in the profession. In the conclusion of the 

1992 report written by the Department of Veteran Affairs 

(VA) on the Automated Fabrication of Mobility Aids (AFMA), 

which was discussed in detail in the previous chapters, six 

areas of research concentration are suggested. Of these 

six, one specifically called for further research into methods 

for “automating the prosthesis manufacturing process”, and 

the eventual direct prosthesis manufacturing from CAD files 

through “rapid prototyping CAM technologies”.3 The 

reasoning behind this move was that “rapid prototyping 

CAM technologies”, or 3D printing, seemingly allowed for 

the manufacturing of prosthetic devices without the 

interruptive craft methods used in the traditional methods 

during the fabrication of the device.  

A new kind of study into the application of 3D printing in 

P&O work emerged in the late 2000s, which differed from 

earlier studies in that they were a direct response by the 

P&O community to developments in technology and to new 

non-expert actors in the field. The introduction of the 

MakerBot Cupcake CNC and the Thing-O-Matic, in 2009 

and 2010 respectively, marked an important turning point in 

the development of 3D printing technology from both a cost 

and usability perspective.4 Under such slogans as “If you 

can think it, you can make it” Makerbot began to actively 

* CORRESPONDING AUTHOR: 

Matt Ratto, PhD 

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

E-Mail: matt.ratto@utoronto.ca 

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

 
OPEN  ACCESS 

ABSTRACT 

In this paper we briefly explored the history of 3D printing in prosthetics. We 

provided details of our own work developing 3D printing design tools from 2014-

2020 noting how claims around prosthetist experience and knowledge have been 

supported and/or questioned in the development of new device production 

techniques. We ended by arguing for deeper attention to prosthetist knowledge 

and experience in the design of the growing 3D printing ecosystem, seeing this 

focus as necessary and important to preserve and support clinical prosthetist in 

the production of well-fitting and appropriate devices for patients. 

CITATION 

Ratto M, Southwick D. Prosthetist knowledge and 3D printing. 

Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, 

Issue 2, No.5. https://doi.org/10.33137/cpoj.v7i2.42175 

KEYWORDS 

Prosthetics, Orthotics, Fabrication, Additive Manufacturing, 3D 

Printing, Design, Automation, Knowledge, Prosthetist, Orthotist 

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

Volume 7, Issue 2, Article No.5. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i2.42175
https://orcid.org/0000-0002-3554-4513
https://doi.org/10.33137/cpoj.v7i2.42175
https://jps.library.utoronto.ca/index.php/cpoj/index


 

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Ratto M, Southwick D. Prosthetist knowledge and 3D printing. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.5. 
https://doi.org/10.33137/cpoj.v7i2.42175 

PROSTHETIST KNOWLEDGE AND 3D PRINTING 

Ratto M, & Southwick D, 2024 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X 

promote the concept that “desktop manufacturing” was 

leading to a future of de-centralized production. This led to 

various hardware and software developments that not only 

further reduced the costs of 3D printing, but also made the 

technology far more accessible to users without 

backgrounds in engineering. These cheaper and more 

accessible 3D printers created by companies like Makerbot 

effectively addressed the major issue of cost associated 

with the technology. Yet, in doing so, a new type of problem 

was introduced in the form of non-expert actors developing 

digital tools and prosthetics.  

In the late-2000s various organizations with little to no 

connection to the P&O profession began to use 3D printers 

to provide cheap and easily accessible prosthetics for both 

the developed and developing world by allowing users to 

fabricate their own devices.5 These desktop printable 

prosthetic devices were mainly upper extremity prostheses 

such as body-powered “hands” such as the Raptor Hand 

developed by Project E-nable.6 The P&O profession 

responded to these devices by studying them in various 

contexts. While acknowledging that these devices were 

useful for training patients to wear devices, on a functional 

level they were severely lacking. The durability of these 

prosthetics devices also proved problematic, with joints and 

areas of pressure frequently breaking.7,8 Finally, and most 

importantly from the perspective of the P&O profession, was 

the fit of these devices. Most of these devices used simple 

measurements to scale 3D printed components. The Raptor 

Hand, for example, is a device that uses three 

measurements on the wrist and the palm to determine the 

size of the prosthetic device.  

In their critiques of this approach the P&O community note 

that this not only limits the “kinds” of amputations these 

devices can be used for, but it also fails to properly transfer 

the biomechanical forces that act on the limb.7,8 While the 

overall assessment of DIY prosthetics within the P&O 

community is fairly negative, those who have examined 

these devices often acknowledge the potential of 3D 

printing technology for the profession. Thus, the challenge 

going forward is to develop a system that better 

understands the various nuances of the P&O profession, 

while also leveraging the potential benefits of these 

technologies. This, in of itself, is a substantial undertaking. 

What has made this task even harder is the popular 

perception of 3D printing and prosthetics as a “solved 

problem” that formed due to the extensive media coverage 

of DIY prosthetics organizations.9 Unfortunately, this 

popular perception often involves a reduced role for 

prosthetist expertise in a 3D printed future in no small part 

due to a lack of understanding of the clinical and material 

nature of prosthetics themselves.    

3D PRINTABILITY 

Since 2014, the authors of this paper have been part of a 

project called ‘3D PrintAbility’, developing 3D design and 

printing tools for use in rehabilitation clinics in low to middle 

income countries in Sub-Saharan Africa and Southeast 

Asia. Supported initially by a charitable organization and 

later through award-based funders including Grand 

Challenges Canada, Autodesk Foundation, and a Google 

Impact award, the team has created and deployed multiple 

versions of a software and hardware toolchain to produce 

pediatric lower-limb prosthetic and orthotic devices. More 

than 20 prosthetists and prosthetic technicians have 

participated in design exercises and been trained in 3D 

scanning, design, and printing technologies. Clinics that 

have partnered in this work include Comprehensive 

Rehabilitation Services for People with Disability in Uganda 

(CorSU) hospital, Comprehensive Community Based 

Rehabilitation Tanzania (CCBRT) and Tanzania Training 

Centre for Orthopaedic Technologists (TATCOT), and the 

Cambodian School of Prosthetics and Orthotics (CSPO) 

(Figure 1).  

 

Figure 1: Images of patients from Uganda and Tanzania, 2018. 

Nia Technologies (http://www.niatech.org), a non-profit 

organization located in Toronto, Canada currently provides 

support and continues to improve software and hardware 

solutions for P&O. Three clinical trials were carried out 

https://doi.org/10.33137/cpoj.v7i2.42175
http://www.niatech.org/


 

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https://doi.org/10.33137/cpoj.v7i2.42175 

PROSTHETIST KNOWLEDGE AND 3D PRINTING 

Ratto M, & Southwick D, 2024 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X 

during the project, an initial trial at CorSU in Uganda, 

followed by a multi-site trial that included each of the partner 

sites described above. A third and smaller trial was also 

conducted in Canada at St. John’s Rehabilitation 

Clinic/Sunnybrook Hospital in Toronto. A more detailed 

description and accounting of this work can be found in our 

previous publications.10-13 This paper will focus only on the 

3D design software developed during the project.  

The goal of 3D PrintAbility was to extend the traditional 

fabrication and fitting processes for lower-limb prosthetic 

sockets with 3D design software and hardware. As is well-

known to the readers of this journal, the traditional socket 

fabrication and fitting process involves a three-step process. 

In the first step a “negative model” of the residual limb in 

created using plaster wraps. Next, a positive model is 

created by pouring plaster material into the negative model, 

allowing it to harden, and removing the wraps. This positive 

model is then “rectified”, a process where prosthetists add 

and subtract material to create a shape that, when used to 

produce a socket, will properly distribute weight and 

pressure across the residual limb. In the final step, a socket 

is fabricated over the positive model, using thermoplastics 

or lamination processes. Finally, the socket is fitted to the 

patient after some light post-production, such as sanding 

rough edges. During the actual fitting process, minor 

modifications can be made to the socket based on feedback 

from the patient. If, however, major modifications are 

required, the entire process must begin again. Similarly, 

when a patient requires a new socket, the entire process 

begins again. 3D PrintAbility was developed to reduce the 

time to completion of a prosthetic socket and by doing so to 

increase the number of patients that could be treated by 

rehabilitation clinics in low resource areas. This goal has 

many similarities to the reasons for the original development 

of digital fabrication technologies for P&O which included a 

strong desire to better capture the skills and expertise used 

in the development of prosthetic sockets.14-17 

3D PRINTABILITY AND “SOCKET MIXER” 

In 2014, after initial experiments in 3D scanning, design, 

and printing (Figure 2), interviews with prosthetists and 

prosthetic users in Canada and Uganda, the 3D PrintAbility 

team began work on 3D design software made to 

supplement an existing CAD/CAM solution called CanFit, 

made by Vorum inc.18 While CanFit could be used to modify 

3D scans and produce subtractive CNC milling patterns to 

produce positive models, at that time no prosthetist-specific 

software programs existed that could produce 3D printable 

prosthetic sockets. 

The first version of this software we called ‘SocketMixer’. It 

worked as an add-on to the popular Autodesk MeshMixer 

free 3D software package19 and created an additional menu 

panel with custom commands focused on socket 

production. (Figure 3) 

Our goal with this software was to simplify the complex 

chain of commands that could be used by a skilled engineer 

to convert a digital scan to a socket. However, this solution 

did not involve an automatic conversion from digital data to 

3D printable socket, but instead allowed prosthetists to 

make key decisions about the resulting socket, including 

supporting the manipulation of the model to expand or 

reduce specific areas, control the thickness of the socket 

and the shape of the brim, and the location and shape of the 

mounting point for attaching the socket to the rest of the 

prosthetic device. Our goal in creating this simple software 

was to reduce complexity of use while still allowing the 

prosthetists own style and knowledge to be utilized. 

 

Figure 2: Author being scanned and printed socket (Top and 

Middle); CanFit software (Bottom). 

https://doi.org/10.33137/cpoj.v7i2.42175


 

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Ratto M, Southwick D. Prosthetist knowledge and 3D printing. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.5. 
https://doi.org/10.33137/cpoj.v7i2.42175 

PROSTHETIST KNOWLEDGE AND 3D PRINTING 

Ratto M, & Southwick D, 2024 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X 

NIAFIT AND PROSTHETIST KNOWLEDGE 

Our initial work with CanFit and on SocketMixer 

demonstrated the potential of 3D printing for 3D printing 

prosthetic sockets. It also revealed the difficulty for 

prosthetists to use multiple software programs to produce a 

socket. In our initial solution, prosthetists needed to start 

with from one program for scanning, move the resulting file 

to a different program for scan cleanup, still another for 

modeling, and yet another for the actual preparation of a 

printable file. This complexity created many opportunities 

for error and required prosthetists to learn major new skills 

to produce good sockets. To solve this issue, we decided to 

produce a more integrated software solution in which a 

single program provided all capabilities. Extended 

development, many tests and design research with 

prosthetists, and multiple years of testing resulting in NiaFit, 

a scanning, modeling, and printing suite.   

 

Figure 3: SocketMixer, Nia technologies, 2014.  

As is shown in Figure 4, the user flow was separated into 

three main screens. First, a scan taken using an iPad + 

Structure scanner (Occipital inc.) was imported into NiaFit. 

The initial interface focused on tools needed for reducing 

the complexity of the scan and preparing the file for 

modeling activity. Clicking with a mouse on one area of the 

scan selects it (highlighted in orange in Figure 4) and the 

forward and back arrow keys extend the scan to contiguous 

areas. When done, all unselected parts of the scan are 

removed, and the resulting 3D shape is realigned within the 

view window. At this point, modeling tools become 

available, that allow focused and overall smoothing, as well 

as the building up or reducing of regions on the model. 

Other functions are also available, such as the creation of 

trimlines and the taking of measurements. When ready, the 

user moves to the final stage of the process. Here, tools are 

available that reproduce the process of ‘draping’ 

thermoplastics to produce a socket.  

In developing NiaFit, three concerns were paramount. First, 

as noted above, we wanted to create a single application to 

reduce the complexity of the digital socket development 

process. Second, we chose to structure the digital user 

experience to reproduce as much as possible the traditional 

process of prosthetic socket production. By designing the 

experience in this way, the goal was to reduce the retraining 

necessary for prosthetists to transition to a digital workflow 

and to conserve their current knowledge and ways of 

working. Third, we wanted to help prosthetists extend and 

communicate their knowledge. A key insight by early 

developers of CAD/CAM systems in prosthetists was that 

such systems could make prosthetist skill and expertise 

more visible and reproduceable than the destructive craft-

based processes then – and still – in use.16 In NiaFit, all 

prosthetist operations are preserved as separate digital 

‘moves’, allowing for users to move back and forth within the 

prosthetic socket production process. Importantly, such 

‘moves’ allow both the sequential ‘undo’ and ‘redo’ that is 

typical of digital workflows, but also the ability to remove or 

rework operations out of sequence, with the topology of the 

positive model or digital socket adjusting automatically. 

Such processes allow novel forms of ‘branching’ in 

prosthetic design and also foster and support the future 

development of more collaborative forms of prosthetic 

design and production. We developed this functionality 

based on our ongoing collaboration with working 

prosthetists who sought these new capabilities. Only 

recently have more mainstream CAD/CAM design tools 

begun to incorporate similar branching20 and collaboration21 

features.    

CALL TO ACTION 

Despite over 70 years of work on CAD/CAM and over 30 

years since the first 3D printed prosthetic socket, these 

technologies remain undeveloped and of limited current use 

in mainstream P&O. New technical developments, including 

inexpensive scanners and printers capable of higher 

resolutions and stronger materials, are now available, and 

these may increase adoption. However, we strongly believe 

that design software needs to be developed in ways that 

foster, support, and extend prosthetist knowledge and 

expertise. This is best done with the participation of 

prosthetists’ themselves who should drive the creation of 

new systems and platforms to best serve their patients. 

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Ratto M, Southwick D. Prosthetist knowledge and 3D printing. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 2, No.5. 
https://doi.org/10.33137/cpoj.v7i2.42175 

PROSTHETIST KNOWLEDGE AND 3D PRINTING 

Ratto M, & Southwick D, 2024 CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X 

 
Figure 4: Three main screens and functions in NiaFit, 2018. 

ACKNOWLEDGEMENTS 

The work briefly surveyed in this article required the contribution of 

time and energy from prosthetists and other experts in Canada and 

at the many sites when these technologies were trialled. We would 

particularly like to thank Moses Kaweesa, Jennan Taremwa, 

Thearith Heang, Sisary Kheng, Odom Teap, Donald Mchihiyo, Ruth 

Onesmo, Baraka Moshi, Violet Mwaijande for their knowledge and 

prosthetic expertise, and Jerry Evans, Joshua Qua Hiansen, and 

Howie K. Safeer from Nia Technologies. Gordon Ruder, Dan 

Blocka, and Sandra Ramdial provided important perspectives 

throughout the project. In memory of Diane Johnson. Her 

generosity and kindness will not be forgotten. 

DECLARATION OF CONFLICTING INTERESTS 

The lead author was the chief scientist of Nia Technologies, the 

non-profit formed to continue development of 3D design software 

from 2015-2020 and received compensation in this role. He served 

as the PI on all grants associated with its development. 

AUTHORS CONTRIBUTION 

Both authors contributed equally to the research and the writing of 

this manuscript. 

 

SOURCES OF SUPPORT 

This work was supported under the 3D PrintAbility Project funded 

by the Inclusive Design Institute; 2011 Canada Foundation for 

Innovation; 2014 Canada Grand Challenges Stars in Global Health; 

2016 Canada Grand Challenges Transition to Scale; 2016 Google 

Impact Award; 2016 MITACS Award. 

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8.Zuniga JM, Peck J, Srivastava R, Katsavelis D, Carson A. An 

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AUTHORS SCIENTIFIC BIOGRAPHY 

Matt Ratto is Professor and Associate 

Dean, Research in the Faculty of 

Information at the University of Toronto. 

He studies and practices ‘critical making’, 

work that combines humanities insights 

and engineering practices and has 

published extensively on this concept. He 

publishes across a wide range of 

disciplines including recent work on hope 

and interventional digital projects (ACM CSCW 2023), generative 

AI and mental health (JMIR 2023), and additive manufacturing and 

prosthetics (CJPO 2021; JPO 2021). 

Daniel Southwick is a Senior UX 

Researcher at Autodesk, inc. His work 

focuses on the use of CAD/CAM tools in 

manufacturing and the development of 

new AI-based systems. He received his 

PhD in 2019 from the University of 

Toronto. His thesis, “Expertise in the Age 

of Digital Fabrication,” explored the history 

of design and manufacturing with a special 

focus on digital fabrication of prosthetic devices.    

 

 

 

 

 

 

 

 

 

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https://vorum.com/canfit-op-cad-software/
https://meshmixer.com/

