Technology – between vision and implementation
Real or printed? It is hardly recognizable which of the two shoes is from the 3D-printer. At Delcam's Orthotic Technology Forum in Eindhoven, The Netherlands, it was discussed which role this technology can play within orthopedic shoe technology.
Delcam has regularly organized an English forum dealing with new technologies within orthopedic treatment and care in different places around the world as of 2011. At this year's European event in Eindhoven, more than 100 delegates were informed about topics such as 3D-printers and additive manufacturing. The event was supposed to focus on technology, explained Chris Lawrie from Delcam, who presented the event, at the beginning. And that's what happened. Starting with the first lecture until the joint dinner at the Philips-museum, it was all about different technologies and their use for the treatment with aids and appliances.
The first key aspect of the event was the treatment and care in sports. In his keynote "quantifying musculoskeletal dysfunction using technology", Clifton Bradeley, owner of the British enterprise SUB4, explained how he analyzes athletes and what insight he gains with his technique. He advocated to qualify the dysfunction with measurements – and thus to be able to assess the improvement caused by the treatment. He thinks that locomotion patterns are not enough taken into consideration. Still all collected data had to be evaluated in order to be useful. In his evidence-based practice approach it is not research that is important: "Data do not have to appear in research in order to be useful," Bradeley is convinced. "What you measure does not have to be scientifically based before you intervene." In his own company he applies a systematic approach within the assessment of patients, comparing figures before and after the treatment. In order to implement this approach, he opts for the treatment on the same day. This fast intervention enables the evaluation of early stages of the correction, according to Bradeley.
Scans and CAD/CAM
Dan Swatton, Delcam's technical product manager, summarized how digital technologies have changed the world of aids and appliances in the last century. He feels it is a challenge for these technologies to give inexpensive digital tools to the industry enabling the manufacturers of aids and appliances to work at the same or even higher level than with traditional technologies. To make the changes clearer, he contrasted the steps of the traditional workflow to those of digital processes and measured the time saving for each step. Swatton also analyzed where the development would lead to: Better materials and improved machine technologies are intended to lower the costs. The market for semi-fabricated aids and appliances will grow, because these can be adjusted to the data of clients. He also sees an expansion of direct distribution via retailers in the area of sports and sandals, because in-situ-manufacturing will be easier. With additive production, the finish could be minimized and new markets could be opened, Swatton stated.
Nachiappan Chockalingam from the Staffordshire University in Stoke on Trent, UK, continued with a report on how technologies could be applied in clinical practice, using the example of the treatment and care of diabetes. One of the main goals of his work is the development of an integrated system that helps to assess the diabetic foot and to prescribe treatment and care with shoes. With the understanding of the inner tensions and strains of an individual foot, the material for orthotics can be optimized, according to Chockalingam.
He heads an international research team working at the implementation within the so-called "DiaBSmart"-project. The proposed approach can have consequences on the diagnosis of the diabetic foot and on the prescription of corresponding shoes – and thus it can have considerable consequences on the reduction of ulcerations in diabetic feet, according to the researchers. The first results of the project show that stiffness and thickness of the heel cushion influence the plantar pressure, but they do not have any impact on the optimization of the orthotic's features. But the loading seems to influence these features considerably. According to the present results, parameters like the patient's body measures and the loading of the foot during the stance phase should be considered when selecting the materials for the orthotic.
Miguel Oliveira from the Portuguese CESPU (Cooperativa de Ensino Superior Politécnico e Universitário) talked about his study on the analysis of the gait cycle and the plantar pressure in diabetic patients with "walkinsense" – a portable measuring system that measures the plantar pressure distribution in the shoe in a dynamic state. The goal here is to relate the pressure changes that can be observed with the step frequency, the step duration, speed and plantar pressure in type-2-diabetic patients. According to the results, patients with diabetes have modified kinematics as opposed to non-diabetics and also patients with neuropathy show different kinematics compared to non-affected persons. He said that the average maximal pressure was highest in diabetic patients without neuropathy. Trends concerning the foot pressure during the gait cycle depend very much on the step duration, length and speed and thus have to be further analyzed, as Oliveira emphasizes.
Removing or constructing?
Prof. Jim Woodburn, director of the Glasgow Caledonian University, opposed in the third block the additive production to the subtractive one. We already presented in detail his ideas for new functions with the 3D-printer for custom-made orthotics and the work in the finished "a-foot-print"-project in detail. In his lecture he reached the conclusion that the additive production, such as e.g. 3D-printing, is a feasible technology for the production of custom-made orthotics – combined with the 3D-scan for the shape and with a CAD-basis technology. Here integrated, personalized biomechanics lead to an enhanced functionality. For him the most important challenge is the implementation in the daily work practice.
Dr. Jari Pallari, research and development manager at Peacocks Medical Group, Newcastle, UK, then described how the additive production of custom-made orthotics can find its way into industrial production, using the example of Podfo. With the help of a life cycle of technologies, he compared milling ("late majority" – shortly after the point of culmination) to the additive production ("early application" – on the way to the majority). Pallari sees a big potential in the additive production, but at the same time he warns about the idea that only because we have the technology, we can also manufacture a functional orthotic. He regards these "do-it-yourself-people" as a danger for patients and also for experts.
Direct comparison
Practical demonstrations of the 3D-printer, also of the additive production, and of milling or the subtractive production, could be watched at the stands of Stratasys and BZT/HARDO. In the subsequent plenum advantages and disadvantages of both production technologies were compared and the use of a 3D-printer for orthopedic shoe technology was discussed.
If you wanted to get an impression of both production technologies, you could do so at the stands of the exhibition. Practical presentations of additive and subtractive manufacturing could be watched at the stands of Stratasys and BZT/HARDO. Subsequently advantages and disadvantages of both production technologies were compared and the possibility of the usage of a 3D-printer within orthopedic shoe technology was discussed in the plenum.
Discovering and developing of business areas Roel Weijer, Dutch podotherapist and owner of Podomark, Pododirect and PodoXpert, provided an example with the history of his company of what the path from a traditional to a digital production could be like and what advantages this can have for business.
Jatinder Olk talked about the benefits of new technologies for public institutions. He works for the British Queen Victoria Memorial Hospital as a manager in production, improvement and business operations.
Looking ahead
As a conclusion, Chris Lawrie from Delcam, provided an insight into the vision of a digital orthopedic shoe. He sees the option to design a library of digital shoe design – already today there are programs for the individual construction of realistic-looking shoes at the screen. The choice of colors and materials is already easy here. According to Lawrie, with such systems, you could give the patient the virtual option to design the orthopedic shoe himself the way he likes. There are already manufacturers in the sports shoes area offering that. In the future, these limits could disappear. With the 3D-print, or the additive production, you could have individually designed shoes printed directly in the shop.
The future will show if such ideas will be marketable one day or if they purely remain technological games. The organizers of the Orthotic Technology Forum intend to observe this development attentively. The coming events next year will be held in Australia and in Canada.
by Kathrin Ernsting
