Disability and Rehabilitation: Assistive Technology

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3D printing and amputation: a scoping review

Danielle Ribeiro, Stephanie R. Cimino, Amanda L. Mayo, Matt Ratto & Sander
L. Hitzig

To cite this article: Danielle Ribeiro, Stephanie R. Cimino, Amanda L. Mayo, Matt Ratto & Sander
L. Hitzig (2019): 3D printing and amputation: a scoping review, Disability and Rehabilitation:
Assistive Technology, DOI: 10.1080/17483107.2019.1646825

To link to this article: https://doi.org/10.1080/17483107.2019.1646825

Published online: 16 Aug 2019.

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DISABILITY AND REHABILITATION: ASSISTIVE TECHNOLOGY
https://doi.org/10.1080/17483107.2019.1646825

REVIEW

3D printing and amputation: a scoping review

Danielle Ribeiroa, Stephanie R. Ciminob, Amanda L. Mayoc,d, Matt Rattoe and Sander L. Hitzigb,e,f,g
a
Department of Electrical, Computer and Biomedical Engineering, Faculty of Engineering and Architectural Science, Ryerson University, Toronto,
Canada; bSt. John’s Rehab Research Program, Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Canada; cSt. John’s
Rehabilitation Hospital, Sunnybrook Health Sciences Centre, Toronto, Canada; dFaculty of Medicine, University of Toronto, Toronto, Canada;
e
Faculty of Information, University of Toronto, Toronto, Canada; fDepartment of Occupational Science & Occupational Therapy, Faculty of
Medicine, University of Toronto, Toronto, Canada; gRehabilitation Sciences Institute, Faculty of Medicine, University of Toronto,
Toronto, Canada

ABSTRACT ARTICLE HISTORY

Purpose: Three-dimensional (3D) printing is an innovative technology being utilized to create prostheses Received 24 October 2018
for individuals with limb loss. However, there is a paucity of research on the feasibility of using this tech- Revised 11 June 2019
nology to fabricate prostheses. A scoping review was conducted to map the literature on 3D printing Accepted 18 July 2019
and its applications in the field of amputation.
KEYWORDS
Materials and methods: Using a scoping review framework, a systematic literature search was conducted 3D printing; amputation;
in three electronic databases (MEDLINE, EMBASE and CINAHL) for all indexed literature up to 29 prosthetics; prosthet-
June 2018. ist; review
Results: Twenty-eight articles met the inclusion criteria. The majority of studies had small sample sizes
(five participants or less; n ¼ 20) and used a case study design (n ¼ 17). The benefits of 3D printing tech-
nology include higher levels of customization and lower production costs. However, the functionality of
3D printed prostheses is lacking. There is also a need for more robust research designs to obtain a better
understanding of the advantages and disadvantages of 3D printed prostheses and its impact on end-
user outcomes.
Conclusions: The use of 3D printing technology has a number of benefits for improving the manufactur-
ing process of devices for people with lower and upper limb loss. However, more research and techno-
logical advancements are required to fully understand the impact of this technology on patients and
how it will affect their daily life. The long-term effects of this technology will also need to be investigated
in order to produce a more sustainable alternative to traditional prostheses.

ä IMPLICATIONS FOR REHABILITATION

 The use of 3D printing technology for the fabrication of prosthetics for persons with limb-loss has a
number of promising features to improve the fitting and customization of these devices for this
patient population.
 Although the costs of producing 3D printed devices is less expensive and burdensome than trad-
itional approaches to manufacturing techniques, there is a need for additional technological advance-
ments to improve the functionality of these devices.
 Future research needs to adopt more robust research designs with larger sample sizes to provide a
better understanding of the viability of using 3D printing technology to improve patient outcomes.

Introduction
Since 1500 BC, a prosthetic has been the standard approach
towards enabling the individual who has lost a limb to regain
their functional independence [1]. Although the field is centuries
old, the prosthetic industry has only evolved considerably over
the past decade due to the emergence of new technologies [2–5].
As a result of these advances in the fitting and fabrication pro-
cess, modern prosthetics have the potential to significantly
improve the quality of life of persons with limb loss by providing
devices to them with greater ease and comfort [5].
Traditional prosthetics can have several drawbacks as casting
methods involve a considerable amount of manual labour to fab-
ricate, fit and refit each prosthetic. During the traditional
fabrication process, a plaster cast is placed manually onto the
patient’s residual limb to create a first mould of the lost extremity
[6]. This mould is then filled with a cement mixture, which when
set will be destroyed in order to release the positive cement
mould. Prosthetists then rectify and shape the positive mould to
reinforce areas of the limb that endure more pressure, stress and
strain [6]. Once a final representation of the prosthetic is created,
fibre-reinforced resin or thermoplastic material is heated and care-
fully placed over the mould and cured in an oven [2,6]. At this
stage, the positive mould of the lost extremity is destroyed [3].
Destruction of these casts means that the entire fabrication pro-
cess will have to be restarted if the resulting product is not an
adequate fit for the patient [3,6]. Not only are traditional casting

CONTACT Sander L. Hitzig sander.hitzig@sunnybrook.ca St. John’s Rehab Research Program, Sunnybrook Research Institute, 285 Cummer Avenue, Toronto,
Ontario, M2M 2G1, Canada
ß 2019 Informa UK Limited, trading as Taylor & Francis Group
2 D. RIBEIRO ET AL.
methods time-consuming and labour intensive, they can also be
expensive and difficult to modify or re-create [3].
In addition to the fabrication process, there are a number of
end-user (i.e., people with limb loss) concerns about their pros-
thetics, which include dissatisfaction with comfort, weight and
cost of their device [2,3]. These issues are common amongst vari-
ous types of upper extremity prostheses; including myoelectric
prosthesis, body-powered prosthesis and passive prostheses [6].
Although upper extremity prostheses can potentially restore
range of motion and grasp as well as a more life-like cosmetic
appearance, issues of weight, poor sensory feedback and cost are
noted drawbacks [6]. Myoelectric devices are particularly heavy
for both upper- and lower-limb prosthetic users due to actuators
and motors within the prosthetic [7]. Sensory feedback on myo-
electric prostheses can also be problematic as it is difficult to
identify the specific muscle that will efficiently control the device
[8]. Prosthetic costs rise with the complexity and/or aesthetics of
the device, as they require more manual labour, more sophisti-
cated components and costly materials to create an artificial limb
with a more natural appearance [6].
A promising advancement in modern prosthetic fabrication
that alleviates a number of issues noted with traditional fabrica-
tion methods has been the advent of three-dimensional (3D)
printing. This technology encompasses a variety of different print-
ing methods; however, the most effective is rapid prototyping
using an additive manufacturing process.[9] This process involves
heating, excreting and fusing material layer-by-layer slowly build-
ing the object [10]. This differs from traditional prosthetic fabrica-
tion, which primarily employs a plaster cast to create a mould of
the socket, which is then shaped by hand to create a custom fit
for the patient [2,3,6].
The printing process requires that a scan of the extremity be
taken at multiple angles [11], which can be taken via X-ray, mag-
netic resonance imaging (MRI), computed tomography (CT) or by
a hand-held scanner [12]. The images taken are then manipulated
to generate a computerized model that can in turn be 3D printed.
The complexity of the design of the prosthetic is insignificant as
the 3D printer can produce any design or shape necessary at vari-
ous speeds [12]. More general, less customized 3D model files can
be accessed and downloaded for free online, which can make
them available anywhere in the world where Internet access is
available [12].
These 3D files can be designed and printed using a variety of
materials such as polylactic acid (PLA) filament, nylon, thermoplas-
tic, polyvinyl alcohol (PVA) filament, etc. These materials vary in
mechanical strength, flexibility and biocompatibility [5]. The
choice of material will also determine the amount of stress and
strain that can be exerted on the prosthetic. The costs, as well as
the weight of these 3D printed prosthetics, are significantly lower
than in traditional prosthetics [12]. This is due to the type of
material used as well as the reduction in manual labour and man-
ufacturing costs [12]. In general, 3D printing offers a fast, custom-
izable, low-cost and lightweight approach to prosthetic device
design and fabrication [11]. Given these attributes, 3D printing is
becoming a resource to improve accessibility of prosthetics in
rural and developing countries [11,13]. Despite the number of
seemingly positive attributes of this technology, the use of 3D
printing is still in its infancy and there remains much to learn
about the qualities of the prosthetics produced, and the impact
of this technology on patients. To address this gap in knowledge,
the aim of this scoping review paper was to map the literature on
3D printing and its applications in the field of amputation. From
this review, key considerations for future research and clinical
practice were developed to provide concrete suggestions to
advance the use of 3D printing in the field of prosthetics and
rehabilitation.
Methods
The research team conducted this project utilizing the methodo-
logical framework of a scoping review [14]. Scoping reviews are
useful for mapping the existing literature on a topic, to examine
the nature of the research activity, to determine if undertaking a
systematic review of a topic is of value, to disseminate research
findings and identify research gaps in the literature [14]. This
scoping review followed the framework outlined by Arksey and
O’Malley [14], with the five stage refinements proposed by
Levac et al. [15].
Stage 1 – identifying research questions
The guiding research question for the review was: “What is the
state of knowledge about three-dimensional (3D) printing tech-
nology for individuals with an amputation?”. The objectives of
this scoping review were: (1) to identify what types of research
studies have been conducted on this topic; (2) what domains
have been investigated? and (3) what have been the outcomes of
using 3D printing technology in persons with an amputation?
Stage 2 – identifying relevant studies
A computer-assisted search of all literature until 29 June 2018
was conducted. The literature search took place in June 2018 and
electronic databases were utilized to search for articles relevant to
3D prosthetic printing for individuals with an amputation.
Searches were conducted on three large online databases to
reflect the scope of this review. Databases included MEDLINE,
EMBASE and CINAHL. Subsequent searches were conducted by
reviewing the reference list of the selected articles to ensure a
thorough search. The following key terms were used to identify
the pertinent articles: “3D Printing”, “Additive Manufacturing”,
“Rapid Prototyping”, “Amputation”, “Limb Loss”, “Prosthetic”,
“Artificial Limb”, “Prosthetic Limb” and “Joint Prosthesis”.
Stage 3 – selection of relevant studies
Articles considered for inclusion in this scoping review must have
met the following inclusion criteria: (1) any study that had at least
one person with an amputation; (2) articles discussing wearing,
manufacturing or testing of 3D printed devices; (3) any language;
(4) either traumatic or non-traumatic aetiologies and (5) any age
range. Studies were excluded if they were: (1) a review article,
grey literature (e.g., PhD or MSc Theses) or book chapter; (2) con-
ference abstracts or conference materials; (3) an animal study and
(4) a study examining facial prostheses.
After the duplicate abstracts were removed, the full list of
abstracts was assessed by two independent reviewers. These
reviewers screened the article abstracts to determine if they met
the inclusion criteria. Following this step, the reviewers met to
discuss any discrepancies in their inclusion or exclusion of the
articles for full-text review. Once consensus was obtained on the
abstracts, the full-texts were thoroughly analyzed to ensure that
the eligibility criteria were met.

Stage 4 – charting the data
Study characteristics and demographic variables of the included
articles were summarized in descriptive summary tables (see
Table 1). The information extracted included the primary
author(s), year of publication, study design, sample size, study
population and outcome measures.
Stage 5 – collating, summarizing and reporting the results
The full text of the included articles was then examined and the
necessary data were extracted. This data included a descriptive
numerical study and thematic analysis. Two members of the
authorship team (DR and SRC) independently reviewed the
included articles and the descriptive summary. Subsequently, the
two reviewers met with the senior responsible author (SLH) for
consultation meetings to arrive at mutually-agreed upon core cat-
egories, which were: (a) advantages of using 3D printing; (b) dis-
advantages of 3D printing and (c) suggestions for future
improvements. The iterative process to creating these categories
is consistent with a directive content analysis [16].
Results
In total, 28 articles were included following the screening proc-
esses (see Figure 1). The majority of the included studies were
completed in the USA (n ¼ 13) [17–29], which was followed by
the UK (n ¼ 4) [9,30–32]. The remaining studies were spread out
across other countries in Asia (Korea, Japan, China and India,
n ¼ 8) [4,33–39] as well as Portugal, Chile and Australia (n ¼ 3)
[40–42]). The most common study design utilized was a descrip-
tive case study design (n ¼ 17) [4,19–22,24,25,28,30,32,34,35,
37,38,40–42]. Ten studies used an observational study design
[9,17,23,26,27,29,31,33,36,39] and only one study used a cross-
over randomized control trial [18]. Sample sizes for the literature
in this field were small with most studies (n ¼ 20) having five par-
ticipants or less [4,7–42]; 17 of the studies only had a single sub-
ject [4,19–22,24,25,26,30,32,34,35,37,38,40–42]. With regards to
types of amputations, 17 studies were completed on individuals
with upper limb amputations [9,17,18,20,25–28,30,33–35,37–41];
with almost all (n ¼ 16) [9,17,18,20,25–27,30,33–35,37–41] being
on hand prostheses (including fingers) and the other one on the
shoulder socket [28]. The remaining studies were completed in
individuals with a lower limb amputation (n ¼ 11) [4,9,19,
21–24,31,32,36,42]; with most of them involving individuals with a
below knee amputation (n ¼ 9) [4,9,19,21–24,31,36], with one
study looking at above knee amputations [32] and one study
looking at a calcaneal amputation [42].
With regard to the 3D printing technology, there was a lack of
consistency of the type of software, hardware and materials used
in producing the prostheses. The most commonly used software
program across studies was a variant of computer aided design
(CAD) either on its own or in tandem with another program
(n ¼ 17) [4,9,17,19–25,30,31,34,36,38,40,41]. PLA and acrylonitrile
butadiene styrene (ABS) plastic were the most commonly used
materials [18,20,25–28,30,34,36–40].
Advantages of 3D printing
Although there were several noted benefits associated with 3D
printing prosthetic devices, there were three qualities that pre-
vailed as the most advantageous across the included studies:
cost-effectiveness, customization and being more lightweight. In
terms of cost, 14 articles [20,23,26–28,30–35,37,38,41] commented
3D PRINTING AND AMPUTATION 3
on the cost-effectiveness of 3D printing, which was attributed to
having less material, thereby leading to a reduction in material
costs, as well as manufacturing costs since less labour was
required. For instance, Day and Riley [30] noted that designing
and fabricating their 3D printed device was 56% cheaper than a
laminated device, and commented that it also improved cosmesis.
With regard to the customizability, 11 of the included articles
[20,24–26,28,30,34,35,37,40,41] provided commentary regarding
this feature. These devices were deemed extensively customizable
because all the fabrication plans regarding the devices are stored
digitally, and can be modified with ease at any moment and be
printed within days [4,34,35]. This customization enabled a more
accurate representation of the amputated area; thereby allowing
the device to fit the user more comfortably [21,32]. Finally, 11
articles [9,20,25,26,30–32,34,36,38,42] had commented on the
improved usability of the 3D printed device, which were mostly
focused on the fact they were lightweight because of the materi-
als used to manufacture them. Every material varies in strength,
flexibility and biocompatibility, and has a major impact on the
weight of the product.
Disadvantage of 3D printing
Although there were positive aspects to the function of the 3D
printed devices, a number of studies on hand prostheses noted a
lack of functionality in a number of areas [17,18,20,25,28,
35–35,37–40]. For instance, some studies noted a decrease in grip
strength, durability and fine motor skills, which greatly impact
everyday living and activities performed [17,18,20,28,34,38,39].
When fine motor skills are impeded, it can be increasingly difficult
to perform certain tasks such as buttoning a shirt or tying shoes,
which can greatly affect one’s psychological and physical well-
being [7,20,28,34,35,38]. It was also noted by many participants
that it was difficult to lift heavy objects; restricting tasks that can
be performed [25,38,40]. Cosmetic appearance was another qual-
ity that many users were displeased with due to the uncomfort-
able mechanical feeling and appearance [34].
Suggestions for future improvements
The majority of the articles (n ¼ 23) provided suggestions on how
to improve the use of 3D printing technology in order for this
technology to be more widely accepted in the field of prosthetics
and rehabilitation [4,17–24,26–35,37–40]. The three most common
areas for further development that would significantly enhance
the reliability and safety of these devices centred on functionality,
validity and durability of the devices. Six articles suggested that
more research is needed to determine long-term fatigue effects,
as well as whether these devices are capable of weight-bearing
[21,22,24,26,27,31]. There were noted concerns about the safety
and reliability of 3D printed devices, and many suggested future
lines of inquiry to examine this issue [22,27,31]. Overall, several
authors noted that the technology still requires more improve-
ments if it is to make a substantial impact on the field of amputa-
tion [28,39,40].
South et al. [24] reflected upon the lack of peer-reviewed lit-
erature available on 3D printing and amputation. In terms of the
current methodological quality of the included studies, there were
several observed limitations. This included several of the studies
having small sample sizes, and being observational in design
[4,17,18,22]. There was only one study that employed a cross-over
randomized control trial [18]. There were no consistently used
Table 1. Summary of identified articles.

4
Study objective, 3D printing technology
Study (location & design) & materials Clinical characteristics & outcome(s) Main findings

D. RIBEIRO ET AL.
Dass Objective: To develop 3DP MP hand that Sample: Not described. General findings:
(2016) imitates the movement of other hand Amputation type(s): Partial hand  3DP prosthetic mimic’s movement of other hand
Location: India 3DP Technology: Not described amputation  Prosthetic hand can be controlled wirelessly without any
Study: Qualitative Materials: Patient history: Not described difficulties
Design:  3DP Prosthetic Hand Outcome: Prosthetic Hand Manipulation Advantages:
Observational Study Design  AT Mega 328 microcontroller  Capable of performing precise control of movements
based Arduino  Cost efficient & relatively small in size
 Flex Sensors  High degree of accuracy due to servo motors
 Servo Motors Disadvantages:
 RF 433 MHz Transmitter &  Human hand has 27 degrees of freedom while the prosthetic
Receiver module can only provide 6 degrees of freedom
Software: Arduino Future studies:
 To improve upon wirelessly controlled movements with
more ease
Gretsch et al. Objective: To develop an inexpensive 3DP Sample: N ¼ 1(female); 13 years old General findings:
(2016) prosthesis addressing limitations of the Amputation type(s): TRA  There are a limited amount of upper limb prostheses available
Location: USA Robohand Patient history: Not described for children
Study: Qualitative 3DP technology: Not described Outcome: Prosthetic hand manipulation  3DP to fit over ethylene based thermoplastic gel liner
Design: Materials: ABS plastic, motors, Arduino  Shoulder controlled & externally powered prosthesis enabling
Descriptive Case Study Design Microcontroller user to open & close all five fingers & move thumb
Software: Autodesk Inventor, CAD. independently
Advantages:
 Independent thumb was beneficial for grasping objects
 Weighed less than most externally powered prosthesis
 Size is scalable
 Family noted design financial feasibility
Disadvantages:
 # Battery life
 # Grip strength
 # Durability
Future studies:
 To improve upon prototype
Herbert et al. Objective: To investigate the use of a cheaper Sample: N ¼ 2 Amputation type(s): 1 General findings:
(2005) low-end rapid prototyping technology TTA & 1 TRA  Residual limb was scanned, 3DP & dried in a low temperature
Location: UK known as 3DP Patient history: Not described oven, then infiltrated with resin
Study: Qualitative 3DP technology: RP, Z Corporation Z402 3D Outcome: Prosthetic hand manipulation  Socket of prosthesis was wrapped in resin-reinforced carbon
Design: printer fibre allowing the patient to safely weight bear on
Observational study design Materials: Resin their prosthesis
Software: TracerCAD software, SolidView Pro.  Strength & durability of this prosthetic built with this
technology is unproven
Advantages:
 Straight forward to install & use.
 3DP prosthetic socket was as comfortable as
traditional methods.
Disadvantages: Not described.
Future Studies: Not described.
Lee et al. Objective: To compare hand functions of MP & Sample: N ¼ 1 (male); 52 years old General findings:
(2017) 3D-PSP Amputation type(s): TRA on right arm  Tested with a 9-hole pegboard test, BBT & hand strength
Location: Korea 3DP Technology: Artec Eva 3D scanner Patient history: 3D-PSP:
Study: Qualitative Materials: PLA, silicon  Put on medication to control pain,  Fabricated to sense pressure signals from sensor to perform
Design: Software: CAD software phantom pain & sleep disturbance voluntary opening & closing movements
Descriptive Case Study Design  Exercises were performed to  3D-PSP has the potential to positively impact the quality of life
enhance muscle strength for the person with amputation
(continued)
Table 1. Continued.
Study objective, 3D printing technology
Study (location & design) & materials
Swartz et al. (2017) Objective: To create a mechanism that would
Location: USA interact with patient’s residual fingers
Study: Qualitative providing force & tactile feedback
Design: Descriptive case study design 3DP Technology: FDM.
Materials: ABS thermoplastic
Software: SolidWorks CAD software
Clinical characteristics & outcome(s)
 Fitted with myoelectric & 3DP
prosthesis at 2 months after injury
 Wound site was stable & volume
muscle was constant
Outcome: Prosthetic hand manipulation
Sample: N ¼ 1 (male); 50 years old;
Amputation type(s): Partial hand
amputation on index finger & thumb
of left hand (non-dominant hand)
Patient history:
 Traumatic injury
 No functional flexion, extension or
supination of wrist
 Limited flexion & extension
in fingers
 Challenging to use body powered
prosthesis due to length of
remaining fingers
 Previously fitted with
passive device
 Prosthesis model was developed to
have greater force & functionality
as well as to decrease size of
prosthesis compared to traditional
hand prostheses
 Final prosthesis was made out of
7075-T6 aluminium metal for its
Main findings
 3DP is used in medicine: 3D bio-printing for generation &
transplantation of tissues
 13 lbs
 Cost ¼ USD 440
 Fabrication time ¼ 4 days
Myoelectric prosthesis:
 Operated using palmar prehension grasp
 Fabricated to sense voluntary motions of opening & closing
the hand
 30 lbs
 Limitations of 3DP prosthetics can be overcome proving to be
an appropriate method to current prostheses
 Cost ¼ USD 13,000
 Fabrication time ¼ 2 weeks
Advantages: 3D-PSP:
 # Cost, # fabrication time & it was lightweight
 Can easily print new devices when needed at a #cost
Myoelectric prosthesis:
 Patient performed better in MP
 Better hand strength & ability to perform everyday tasks
Disadvantages: 3DP:
 # Grip strength, # dexterity, strong mechanical feeling, difficult
to fabricate delicate parts facing amputation site
 Scanning errors
MP:
 # Battery life, motor noise, repulsed by cosmetic aestheticswas
not pleasing to patients
 # Grip strength, # durability
 Heavy
Future studies:
 To examine functionality, validity & durability of 3DP prosthesis
General findings:
 Plastic is not strong enough which is why the final prosthetic
is made out of aluminium
 Custom prostheses are becoming more readily available due to
easy access to open-source models online
 Could not compare BBT scores as the patient did not have a
previous prosthesis
 Patient no longer used this prosthesis due to lack of strength,
however he has been fit with i-digits system
Advantages:
3D PRINTING AND AMPUTATION
 Patient had " functionality in performing daily tasks,
completing the BBT
 Light weight
Disadvantages:
 Limitations include language barrier, full acceptance of device,
lifting heavy objects & patients also deemed it moderately
difficult to complete tasks
Future studies: Not described
(continued)
5
Table 1. Continued.

6
Study objective, 3D printing technology
Study (location & design) & materials Clinical characteristics & outcome(s) Main findings

D. RIBEIRO ET AL.
strength, wear, lightweight, ease of
manufacturing & corrosion resistant
Outcome: Prosthetic hand manipulation
Zuniga et al. (2017) Objective: To manufacture an inexpensive 3DP Sample: N ¼ 1 (male); 7 years old; General findings:
Location: USA mechanical shoulder prosthesis to assist in Amputation type(s): Congenital shoulder  Weight of prosthetic was customized to replicate the weight or
Study: Qualitative performing bi-manual & unilateral activities disarticulation the other arm
Design: 3DP technology: Not described Patient history: Not described  This device can be used as a transitional device in preparation
Descriptive case study design Materials: PLA, ABS & Taulman Nylon Outcome: Prosthetic manipulation for a more sophisticated prosthesis
Software: Autodesk inventor  Improved technology could compensate for limitations
 Improved technology may compensate for the limitation of #
durability in lower cost devices
Advantages:
 # Cost
 Customization providing different infills & densities
 Correction in patient’s spinal deviation was noted due to
counterweight of the device
 " balance & performance after 2 weeks of using the device
Disadvantages:
 Was not effective for unilateral activities
 # Grip strength
 # Durability
Future studies:
 Improve upon 3DP technology
Yoshikawa et al. Objective: To create a realistic electric 3DP Sample: N ¼ 1 (male); 40 years old; General findings:
(2015) prosthetic hand Amputation type(s): Forearm amputation  Material cost USD $1250 while standard myoelectric prosthesis
Location: Japan 3DP Technology: 3D scanner Patient history: costs USD $15,000
Study: Qualitative Materials: Linear actuator, ABS resin  Right-handed  Non-contact distance sensors, so sweat does not affect the
Design: Descriptive case study design Software: CAD software Arduino Outcome: Prosthetic manipulation signal as well as the metal electrodes do not touch skin
Advantages:
 Person with amputation was able to grasp various objects &
perform various everyday activities
 MP hand gives the appearance of five fingers that are able to
grasp objects
 SHAP test illustrated that the amputee was able to grasp
various objects & perform everyday activities
 3DP to reduce costs, weight & provide ease of maintenance
Disadvantages:
 # Fine motor skills
 Could not pick up heavy objects
Future studies:
 To improve the stiffness of the hand & the size of the
control box
Ferreira et al. (2014) Objective: To create a passive prosthesis in a Sample: N ¼ 1 (male); 21 years old; General findings:
Location: Portugal 3DP silicone band Amputation type(s): Bilateral traumatic  5th finger is needed to properly grasp objects
Study: Qualitative 3DP technology: RP, Axial CT, SLA amputation of both hands  Prosthesis is fully made out of silicone closely matching to
Design: Descriptive case study design Materials: Silicone Patient history: patients skin colour & feeling of the finger
Software: CAD design  Due to accident of crushing both  Prosthesis is not only the fifth finger; it encompasses the palm
hands with a dumbbell, both as well to create suction between hand & prosthesis creating a
hands were amputated & more cosmetic appearance
re-implanted  3D manufacturing approach replaces traditional
 Post-re-implantation the fifth finger manual method
on left hand was fully amputated  Level of satisfaction was dependent on customization
due to necrosis of prosthesis
Advantages:
(continued)
Table 1. Continued.
Study objective, 3D printing technology
Study (location & design) & materials
Hsu et al. (2010) Objective: To determine if resin layer wrapped
Location: China over a 2 mm-thick RP socket increases
Study: Qualitative socket strength & shortens RP fabrication
Design: Descriptive case study design time, using less RP material
3DP technology: RP & FDM
Materials: Polymer layer of polycarbonate, UPR.
Software: CAD/CAM
Imanishi, J. & Choong, P. (2015) Objective: To determine whether 3DP
Location: Australia calcaneus prosthesis is a viable alternative
Study: Qualitative to amputation
Design: Descriptive case study design 3DP technology: EBM 3DP
Materials: Titanium
Software: CT scan
Webber, C. & Davis, B. (2015) Objective: To improve the design of the
Location: USA prosthetic socket restoring a normal thermal
Clinical characteristics & outcome(s)
Outcome: Prosthetic manipulation
& function
Sample: N ¼ 1 (male); 59 years old
Amputation type(s): Unilateral left side
TTA
Patient History:
 31 yrs. experience using PTB
supracondylar prosthesis
 Able to walk without assistance
 No cardiovascular or mental illness
Outcome: Prosthetic fit
Sample: N ¼ 1 (male); 71 years old;
Amputation type(s): Calcaneus
Patient history:
 History of heel pain
 Total calcanectomy followed by
prosthetic reconstruction
Outcome: Prosthetic fit
Sample: Not described
Amputation type(s): Not described
Main findings
 Costs are # due to reduction in material used, "
manufacturing, accuracy & personalization
 # in patient visits
Disadvantages:
 Risk of infection &/or necrosis
 Obligatory use of prosthesis
 Need surgical intervention
Future studies: Not described
General findings:
 Compared to plaster model, the computer aided process could
easily replicate previous devices that were scanned
 Investigation measured interface pressures of an old socket, a
polypropylene sheet socket & a handcrafted UPR socket
 All three sockets illustrated similar pressure distribution
compared to other sockets
 Prosthetist & experienced CAD user is required
Advantages:
 Computer aided process can easily produce a replica socket
Disadvantages:
 Study involves only one participant to date
Future Studies:
 To improve upon the strength of resin-reinforced RP sockets,
with a larger number of participants
General findings:
 Mirror image of left foot calcaneus was used to create a 3DP
right foot calcaneus; Plaster cast; walker boot
 Allografts had high infection rates as well as prolonged
immobilization & weight bearing limitations
 3DP prosthesis was less invasive & reduced time between
designing & the actual surgery
 5 months after surgery the patient was free of pain
Advantages:
 Titanium is light, strong & biocompatible
 Less invasive without donor site problems
 Promotes earlier rehabilitation & discharge
Disadvantages:
 Report follow-up is short term, which might be too early to
draw any conclusions
Future studies: Not described
General findings:
 Socket with the helical cooling channel showed greater

3D PRINTING AND AMPUTATION

Study: Qualitative environment around the residual limb Patient history: Not described temperature differences across the wall of the socket providing
Design: 3DP technology: AM Outcome: Prosthetic fit a cooling effect to the patients residual limb
Observational study design  Overall, the experiment indicated that heat from the inner
Materials: VeroWhitePlus opaque material surface of the socket was drawn to the cooling channel
Software: SolidWorks  VeroWhitePlus performed well & did not leak, warp or melt
during testing
 Socket type & location on the socket were factors affecting
temperature between inner & outer socket walls
Advantages:
 Max inner socket temperature reached 32.2  C, but with
cooling channel the inner temperature dropped slightly
(continued)

7
Table 1. Continued.
Study (location & design)
Alvial et al. (2017)
Location: Chile
Study: Quantitative
Design: Descriptive case study
Day, S. & Riley, S. (2017)
Location: UK
Study: Quantitative
Design: Descriptive case study
Study objective, 3D printing technology
& materials
Objective: Impacts of using 3DP silicone-
embedded prostheses
3DP technology: CT scans
Materials: PLA embedded in silicone
Software: CAD software
Objective: To create & test a 3DP assistive
device to hold patients French horn
3DP technology: FDM
Materials: PLA
Software: Photogrammetry (123 catch
software), & CAD
Clinical characteristics & outcome(s)
Sample: N ¼ 1 male; 51 years old
Amputation type(s): Partial hand
proximal phalanx amputation
Patient history:
 No comorbidities
 Amputation on non-dominant (left)
hand at different levels
Outcome: Object manipulation
Sample: N ¼ 1 (male)
Amputation type(s): Partial hand
amputation of 5th digit at the
metacarpophalangeal joint
Patient history:
 Amputation on left hand
 Limited mobility in both hands due
to Dupuytren contractures
 Amputation due to unsuccessful
fasciotomy to release Dupuytren’s
contracture
 Tried a variety of devices
Outcome: Object manipulation
8
Main findings
D. RIBEIRO ET AL.
 Eight revolution helical cooling channels
Disadvantages:
 The experiment did not perform as well as expected possibly
due to experimental conditions & idealized
modelling conditions
 Thermal conductivity of the socket & the VeroWhitePlus
material may not have been the same, in turn affecting
the results
 Study only represents a short period of time where the patient
is active while using the prosthetic
 Liner in prosthetic was omitted from this study, therefore
affecting the true heat transfer assessment
Future studies:
 To investigate other materials that produce a balance of
thermal & mechanical properties, as well as improve design of
model sockets that are more representative of clinical
applications
General Findings:
Prosthesis 1: 3DP thumb & fifth finger embedded in silicone that
is body powered by tension in metacarpophalangeal joint
Prosthesis 2: 3DP PLA thimble shaped tools embedded in silicone
attached directly to stumps. Each tool had neodymium magnets
at the top
 The prosthesis (Prosthesis 2) that had neodymium magnets
attached to each tool performed better than the prosthesis
(Prosthesis 1) that was body powered by tension in
metacarpophalangeal joint
Advantages:
 Prosthesis 2 was better when manipulating large &
small objects
 Prosthesis 2 was more useful as patient was able to complete
complex tasks
 Customizable & " production rate
Disadvantages:
 Short lifespan of silicone
 Silicone is not suitable for lifting heavy objects
 A multidisciplinary team is required (engineer, physician, etc.)
 Design technique is far from being automated
Future studies:
 To investigate solutions for all types of partial hand
amputations
General findings:
 Proved that 3DP can be an effective method for unique &
custom made assistive devices
 It was possible to design & 3D print a device with limited
knowledge of the CAD software
Advantages:
 Designing & fabricating 3DP device was 56% cheaper than a
laminated device
 Easy to replicate casts
 Reduction in storage space as everything is digitally stored
 Improved cosmesis
 Light weight
Disadvantages:
(continued)
Table 1. Continued.
Study objective, 3D printing technology
Study (location & design) & materials
Dally et al. (2015) Objective: To examine the performance
Location: USA characteristics of 3DP prosthesis for further
Study: Quantitative validation of appropriateness of this
Design: Observational study design prosthesis for the developing world
3DP technology: Additive manufacturing
Materials: Thermoplastic
Software: CAD
Lee et al. (2018) Objective: To assess functionality of 3DP
Location: Korea prosthetic
Study: Quantitative 3DP technology: Artec 3D scanner
Design: Descriptive case study design Materials: Fused flexible thermoplastic
elastomer filament (non-toxic), silicone &
acrylic
Software: Geomagic Freeform
Clinical characteristics & outcome(s)
Sample: N ¼ 40 (males & females) with
no hand amputations
Amputation type(s): Hand amputation
Patient history: Not described
Outcome: Prosthetic hand manipulation
Sample: N ¼ 1 (male); 67 years old
Amputation type(s): Right thumb
amputation above
metacarpophalangeal joint
Patient history:
 Amputation occurred in 1970
 Had gait difficulties with ataxia
 Mild right hand weakness due to
left anterior inferior cerebral
infraction in 1999
 Jebsen-Taylor hand function test
& BBT
Main findings
 Shape capture process is not very accurate
 There are no regulations to assess structural integrity of the
device prior to being given to the patient
Future studies:
 It was recommended that prosthetists be involved in the
designing & development of the device
General findings:
 Participants assessed the hand’s range of abilities by
completing 14 tasks based on SHAP were completed
simulating an amputee bending his/her own wrist to
grip objects
 Tasks were completed by holding the gauntlet with one hand
& applying pressure to the back of the palm with the
other hand
 1=2 of participants used the larger adult sized prosthesis.
 The other 1=2 of participants used the smaller paediatric sized
prosthesis to evaluate effectiveness
 Larger prosthesis could pick up heavier objects while the
smaller hand could not
 Due to limitations, this prosthesis is not applicable for
amputees in low-resource settings
 Studies should be conducted with target audience; amputees
in the developing world to ensure the device can meet the
user’s needs in their day to day lives
Advantages:
 Prosthetic hand was able to pick up several objects, push & lift
objects, as well as turn pages
 Larger prosthesis had more success lifting heavy objects,
opening jar lids & turning door handles
Disadvantages:
 Rotating objects & pouring objects were difficult to perform
 Due to simple flexion in fingers, the device was not able to
tightly grip small objects
 Doors were difficult to open due to the weight of the door
 Majority of tasks showed mixed results as to whether the 3DP
prosthetic hand was beneficial
 Not applicable for persons with amputation in low-resource
settings due to the various limitations of the prosthesis
 Study was not conducted with the target audience
Future studies:
 The prosthesis needs to be able to perform a larger range of
3D PRINTING AND AMPUTATION
tasks & assess the usability of the device with individuals with
target audience
General findings:
 Thumb had a nonslip pattern to prevent slippage of objects
 Prosthetic was designed as a band providing close attachment
to hand
 It took 48 h to produce, at a cost of US $50
 Finger prosthesis was specifically shaped
Advantages:
 Patient adapted easily to prosthesis
 Test scores improved after prosthetic fitting from BBT score
of 17–21
 Faster, cheaper than conventional prosthesis
9
(continued)
Table 1. Continued.
Study objective, 3D printing technology
Study (location & design) & materials Clinical characteristics & outcome(s)
 
Right & left hand was scanned
with 3D scanner at 16 frames/s;
Left thumb flipped to create
right thumb
Outcome: Prosthetic hand manipulation
Xu et al. (2017) Objective: Design & manufacturea 3DP Sample: N ¼ 1 (male); 8 years old
Location: China prosthetic hand Amputation type(s): Wrist amputation
Study: Quantitative 3DP technology: Open-sourced design Patient history:
Design: Descriptive case study design (thingsiverse.com)  Amputation on right wrist
Materials: ABS filament  Diagnosed with MESS
Software: Slic3r  No comorbidities
Outcome: Prosthetic hand manipulation
& function
Zuniga et al. (2015) Objective: To find a low-cost 3DP prosthetic Sample: N ¼ 11 children (two girls &
Location: USA hand & propose a fitting methodology seven boys); 3–16 years old
Study: Quantitative 3DP technology: Makerbot Printer Amputation type(s): Upper-limb
Design: Observational study design Materials: PLA & ABS amputations (one traumatic & eight
Software: Blender 7.2 congenital)
Patient history:
 Nine used the prosthetic for 1–2 h/
day; three used the hand more
than 2 h/day; one used hand only
when needed
 All families & children completed a
survey about quality of life, daily
usage & activities performed after
a 1–3 months of using
the prosthetic
Outcome: Prosthetic hand manipulation
& function
Zuniga et al. (2016) Objective: To identify anthropometric, active Sample: N ¼ 5 (two girls & three boys);
Location: USA range of motion & strength changes after 6 3–10 years old
Study: Quantitative months of using a wrist driven 3DP Amputation type(s): Upper limb
Design: Observational study design transitional prosthetic hand for children amputation
with upper limb deficiencies Patient history:
3DP technology: Makerbot  One traumatic & four congenital
Materials: PLA & ABS  Unilateral carpus upper
Software: Blender software limb reductions
 Wrist active range of motion
greater than 20˚
10
Main findings
D. RIBEIRO ET AL.
Patient gave a QUEST of 36 out of 40 points, being very/quite
satisfied with the prosthesis
 3D image files can be easily modified
Disadvantages:
 Inability to stack objects due to the angle of the
prosthetic thumb
Future studies:
 To adjust the angle of the thumb to ease stacking of objects
for the patient
General findings:
 During 3-month follow-up patient was satisfied with prosthesis
 No complications were reported by patient & their family
Advantages:
 UNB test of prosthetic function for unilateral amputees skill
score increased over the course of 3 months
 Child could function & perform daily activities
 Low-cost (<$20)
 Easy customization
Disadvantages:
 Open-source designs are not regulated
 3DP prosthesis did not function properly in certain
bimanual movements
Future studies:
 Future studies should assess possible disadvantages of 3DP
prosthetics & compare them to traditional methods of
making prostheses
General findings:
 Children used their prosthetic for fun, activities at home, to
play, for school & for sports
 This prosthetic hand is a viable option for children in
developing countries & those with little access to health
care providers
Advantages:
 3DP prosthetic hand is low-cost, light weight, easy to use, easy
fitting, easy assembly & appealing to children
 All subjects reported an increase in quality of life (four were
significant & seven were small & one no change)
 Surveys indicate that this 3DP prosthesis may positively impact
patient quality of life
Disadvantages:
 Inaccurate scaling could affect function or fitting of
the prosthesis
Future studies:
 To investigate functionality, validity, durability & benefit/
rejection rate of 3DP prosthesis
General findings:
 First visit: Fitting procedures & anthropometric measurements
were taken
 Second visit: Six months after using the prosthesis patients
repeated all measurements performed during first visit
 Wrist flexion & extension strength was measured for
both hands
 Average time to print & assemble the prosthesis was 4–7 h
 Prosthesis can be used for activities involving manipulation of
light objects
(continued)
Table 1. Continued.
Study objective, 3D printing technology
Study (location & design) & materials
South et al. (2010) Objective: To use SLS to prosthetic feet with
Location: USA varying stiffness & its influence on gait
Study: Quantitative 3DP technology: SLS
Design: Descriptive case study design Materials: Nylon, carbon fibre
Software: CAD software
Duong et al. (2017) Objective: To test & compare efficiency &
Location: USA functionality of 3DP & MP hand
Study: Quantitative 3DP technology: MakerBot Replicator 2
Design: Cross-over randomized trial Materials: Polypropylene plastic, PLA & TPE
Software: Not described
Clinical characteristics & outcome(s)
Outcome: Prosthetic hand manipulation
& function
Sample: N ¼ 1; 45 years old
Amputation type(s): TTA
Patient history:
 Traumatic, unilateral amputee for
over 16 years
 Proficient walker
 In good physical condition
 No musculoskeletal disorders
or pain
Outcome: Prosthetic foot manipulation
& function
Sample: N ¼ 24 (14 men & 10 women);
22–30 years old
Amputation type(s): Not described
Patient history:
 Healthy.
 Right hand dominant
 Completion of BBT with Limbitless
Arm & i-limb
Outcome: Prosthetic function
Main findings
 Individuals in developing countries are not being treated with
prosthetics due to the lack of trained technicians & lack
of tools
 A licensed prosthetist with a 3D printer could provide 3DP
prosthetics to patients around the world at a very low cost
 3DP is in its early stages & requires a certified prosthetist for
proper development
Advantages:
 There were slight increases in strength, flexion, extension &
range of motion after wearing the 3DP prosthesis for 6 months
 Increase in circumference & wrist range of motion suggests
that 3DP prosthesis is an effective transitional/initial device for
children with traumatic & congenital upper limb deficiencies
Disadvantages:
 Environmental factors (temperature) have to be taken into
consideration when building the prosthetics as three out of the
fivechildren reported breaking or malfunctioning
3DP prosthetic
 There are no standards for manufacturing 3DP prosthetics
which makes it difficult to obtain reliable print
Future studies:
 To examine functionality, durability, safety & 3DP standards for
prosthetic devices
General findings:
 SLS prosthetic produced a similar stiffness characteristic as the
carbon fibre foot
 Kinematic gait & kinetic characteristics were the same
 Mechanical testing verified that the SLS prosthetic performed
similarly to the carbon fibre prosthetic
 There were only minor differences in ankle & knee moments
& angles
Advantages:
 SLS did not fail or leave any permanent damage when inflicted
with high loads
 Versatility of SLS allows for easy scaling
Disadvantages:
 There is also a lack of information available regarding response
of SLS feet to impact loading
 Long-term fatigue characteristics were not assessed
3D PRINTING AND AMPUTATION
Future studies:
 To modify the foot design to reduce ankle & knee moments
during midstance
General findings:
 BBT was used to assess efficiency of prosthetic hand
 BBT using Limbitless Arm then 2 weeks later took BBT using
i-limb
 Two trials were completed
 With better development & technological advancements 3DP
can be a viable option in the future
 Despite the weight of the device the size & shape of the i-limb
was more compatible to the female body influencing
performance
(continued)
11
Table 1. Continued.

12
Study objective, 3D printing technology
Study (location & design) & materials Clinical characteristics & outcome(s) Main findings

D. RIBEIRO ET AL.
i-Limb
 MP hand
 Digits are motorized independently
 One sensor was placed at proximal anterior part of forearm
 One sensor was used to produce a similar function to the
Limbitless Arm
 Used EMG signal
Limbitless Arm
 First 3D printed MP hand
 Uses an Arduino microcontroller, muscle sensors, lithium
polymer batteries, etc.
 Three electrodes were placed on flexor muscles
 Used EMG signal
Advantages:
 The number of blocks successfully transferred by the i-Limb
improved by 53.57% in the first trial & 66.27% in the
second trial
 i- Limb was more efficient & practical
 The difference in the number of blocks moved for trial 2 was
more significant for women than men
 25% of participants reported that the i-limb was heavier than
the Limbitless Arm
Disadvantages:
 Fatigue due to weight
 Sensors did not accurately detect the muscle contractions
 Limbitless Arm used disposable sensors, so they had to change
every time the prosthesis was taken off & had to be placed
back on the arm accurately otherwise the arm will not move
 Joints of Limbitless Arm were limp & lacked rigidity which
affected the individual when grasping objects
 Used a one-size-fits all prosthetic measurement, which had
drawbacks, such as it was too big, & bulky causing pain
Future studies:
 To compare both prosthetic hands on patients with hand
amputations to fully understand functionality of the prosthetic
Tao et al. (2016) Objective: To create a new design process Sample: 240 (120 males & 120 females); General findings:
Location: Korea using topology optimization methods to 25–30 years old  Light weight prosthesis mimicking the natural limb is more
Study: Quantitative develop a new prosthetic foot Amputation type(s): LLA comfortable as well as it reduces stress on the remaining
Design: Observational study design 3DP technology: FDM Patient history: musculature of the patient
Materials: PLA  Ankle height of 80 mm  PLA is lightweight, easy machining, & environmental protection
Software: CAD Outcome: Prosthetic function as it is derived from renewable resources
 Smooth outer surface & rough inner surface (smooth for
aesthetics & rough is insignificant)
 62% weight reduction
 While weight is reduced the structure is maintained
 Safety of this prosthetic was validated using the finite element
analysis using a strain gauge test
Advantages:
 Customization
 Capacity to share designs
 Outsource manufacturing
 Speed & ease of manufacturing
Disadvantages:
 Limited material choice available providing proper structural
support for this model
(continued)
Table 1. Continued.
Study objective, 3D printing technology
Study (location & design) & materials Clinical characteristics & outcome(s) Main findings
Future studies: Not described
Laszczak et al. (2015) Objective: Sample: Not described General findings:
Location: UK To design a sensor to monitor mechanical Amputation type(s): Lower limb  Interfacial stress sensor that has a Flexible sensor frame that
Study: Quantitative stresses at the stump- socket interface Patient History: Not described could potentially accommodate bespoke surface shapes
Design: Observational study design 3DP technology: RP Outcome: Prosthetic fit  TangoBlack has a strain range from 30% to 50% with a stress
Materials: Elastomeric TangoBlack material region of 0.95–0.80 MPa
Software: CAD/CAM  Sensor measures pressure & shear stress up to 350 & 80 kPa
 Sensor demonstrated high linearity (5–8%), high pressure
(1.3 kPa) & shear stress (0.6 kPa) performance
 Pressure of 8 kPa has been shown to cause soft tissue ischemia
reducing blood flux
 Fit, design & comfort of prosthesis is a major issue for persons
with lower limb amputation
 Poor fit results in deterioration of skin & underlying soft tissues
possibly leading to a stump ulcer
Advantages:
 Low-cost versatile solution
 Sensor is a viable tool to evaluate prosthetic socket fitting
preventing stump tissue breakdown
 3DP allows the sensor to be flexible, easy to scale, lightweight
& can be fabricated in many shapes
 RP elastomers provide low-cost manufacturing & potential
improved functionality in clinical applications
Disadvantages:
 Sensors were limited to quasi-static behaviour
Future studies:
 To estimate fatigue to evaluate sensor lifetime
Rogers et al. (2000) Objective: To test the feasibility of using SLS Sample: N ¼ 1 (male); 65 years old General findings:
Location: USA to fabricate a prosthetic socket Amputation type(s): TTA  Monolithic, flexible-double-walled socket
Study: Quantitative 3DP technology: SLS, CAD Patient history:  SLS was acceptable for clinical testing
Design: Descriptive case study design Materials: Nylon  Healthy & mature residual limb  Long-term durability & structural integrity need to be tested
Software: ShapeMaker CAD  Limited community level  This weight was due to the material used, as well as the added
Outcome: Prosthetic fit& function material at regions that endure higher stress
 SLS socket was 450 grams heavier than the conventional
socket (due to material used) however the weight difference
was not very noticeable by the subject
 Joint kinetics & moments did not illustrate large differences

3D PRINTING AND AMPUTATION

between the 3DP & conventional prosthesis
 No software tools available for prosthetists to design sockets in
a shorter period of time
Advantages:
 Socket comfort was 10% higher for the SLS socket
 Small improvements were noted in walking speed &
step length
Disadvantages:
 3DP nylon socket was heavier than the conventional socket
made out of carbon fibre
 SLS computer design requires a high level of engineering
expertise & can be time intensive
(continued)

13
 14
Table 1. Continued.

Study (location & design)
Rogers et al. (2008)
Location: USA
Study: Quantitative
Design: Descriptive case study design
Sanders et al. (2016)
Location: USA
Study: Quantitative
Design: Observational study design
Freeman, D. & Wontorcik, L. (1998)
Location: USA
Study: Quantitative
Design: Descriptive case study design
Study objective, 3D printing technology
& materials
Objective: To assess performance of sockets
with compliant features to relieve in-socket
pressure for TTA
3DP technology: SLS, scanner
Materials: Rilsan D80 polyamide powder (Nylon
11)
Software: GordoDesign prosthetic CAD
software, & ShapeMaker 2000
Objective: To design & fabricate custom plastic
inserts for transtibial prosthesis users
3DP technology: AM
Materials: VeroBlue RGD840 rigid opaque
polymer
Software: CAD/CAM, FaroArm Platinum Scanner
Objective: To manufacture a prosthetic test
socket using SLA & dynamically align it on
a patient
3DP technology: SLA
Materials: Photopolymer epoxy resins
Software: CAD
Clinical characteristics & outcome(s)
Sample: N ¼ 1 (male); 47 years old
Amputation type(s): TTA
Patient history: Not described
Outcome: Prosthetic fit
Sample: Not described
Amputation type(s): TTA
Patient history: Not described
Outcome: Prosthetic fit
Sample: N ¼ 1
Amputation type(s): TTA
Patient history: Not described
Outcome: Prosthetic fit & function
D. RIBEIRO ET AL.
Main findings
 SLS resulted in a less cosmetic appearance
Future studies:
 To investigate long term clinical evaluations of patients
involving larger trials
General findings:
 In-socket pressure was measured
 Less pressure over distal tibia & fibula head than the
conventional socket
 Both sockets were geometrically identical except for
compliant areas
Advantages:
 3DP prosthetic sockets were successful in reducing pressure in
sensitive areas of the residual limb
 Comfortable
Disadvantages:
 Difference in material may contribute to in-socket pressure
differences
 In socket sensors were affected by the curvature of the socket,
reporting higher pressures in higher curvature areas
 Socket is unattractive
Future studies:
 To improve upon long term durability of sockets, cosmetic
appearance & increase number of participants in trials
General findings:
 Subjects wore sockets with inserts for 4 weeks
 Shape of insert was evaluated
 100 min for scanning & designing the insert
 Each of the three insert sections took 6–13 h to fabricate
 Insert shape changes can be digitally tracked to monitor
limb maturation
Advantages:
 Insert shape quality improved after being worn by amputee &
was highly accurate
 Low-cost
 After 4 weeks inserts averaged less than 0.09% volume
difference compared to designed shape
Disadvantages:
 Design software needs to be enhanced to include solid model
generation & manipulation
Future studies:
 To investigate impact of socket shape changes, comfort &
gait features
General findings:
 Plaster Mold; Digitize Mold; 3DP; Cure by laser (80%) & then by
UV oven (20%)
 First test Socket¼$3480 with a build time of 58 h
 Second Test Socket ¼$1560 with a build time of 26 h
 First Test Socket had 0.0625 grooves due to errors in
file conversion
(continued)
Table 1. Continued.
Study (location & design)
Ramakrishnan et al. (2017)
Location: UK
Study: Quantitative
Design: Descriptive case study design
Study objective, 3D printing technology
& materials
Objective: To compare gait of subject using
existing Ossur Total Knee 2000 & 3DP
prosthetic knee
3DP technology: Not described
Materials: Carbon-fibre & nylon
Software: Not described
Clinical characteristics & outcome(s)
Sample: N ¼ 1 (female); 37 years old
Amputation type(s): High functioning
transfemoral amputation
Patient history: Not described
Outcome: Prosthetic fit & function
Main findings
 Socket comfort & fit were similar to sockets made out of co-
polyester via the traditional method
 Photopolymer was strong enough to support the 170 lb
patient during ambulation for 1 h
 Photopolymer is semi-transparent allowing the prosthetist to
view the liner through the socket wall
 SLA eliminates the need for a positive mould
 As new material properties & SLA machining speeds increase,
3DP may become a cost-effective method of manufacturing
prosthetics in the orthotic & prosthetic industry
Advantages:
 Second Test Socket build time decreased by 50% due to the
elimination of the grooves in the socket wall & addition of
photopolymer resin
Disadvantages:
 Time
 Cost
Future studies:
 To reduce production time & cost
General findings:
 Experiment was conducted using a CAREN to capture motion
of leg
 Subjected walked on treadmill for 10 m
 Overall, 3DP is a viable option for prosthetic fabrication
Ossur Total Knee
 Uses hydraulic system to excess flexion assisting in forward
swing of leg
 Human-like gait
 Heavy, costly, cannot personalize, requires maintenance
 More asymmetric gait
3DP Prosthetic
 Subject was forced to use other muscles to support her as she
walked because she was waiting for the terminal impact of
the knee
Advantages:
 Cheap, lightweight
 Higher peak flexion due to lower resistance
 Allows for customization for patient

3D PRINTING AND AMPUTATION

Zang et al. (2017) Objective: To report pre-operative planning
Location: China using 3DP to plan thumb reconstructions
with second toe transplant
Sample: N ¼ 5 (four male & one
female); 16–45 years old
Amputation type(s): Middle of proximal
 More symmetric gait resulting in a more comfortable &
stable gait
Disadvantages:
 Materials used for 3DP do not have the same strength as
moulded plastics
Future studies:
 To examine a less straining prosthetic for the user while
preserving symmetric gait
General findings:
 Rehab; Thumb was reconstructed using mirror technology; 3DP
bone & joint of thumb & 2nd donor toe; Surgery where flap of
(continued)

15
Table 1. Continued.

16
Study objective, 3D printing technology
Study (location & design) & materials Clinical characteristics & outcome(s) Main findings

D. RIBEIRO ET AL.
Study: Quantitative 3D printing technology: CT machine phalanx (one case) & Basilar part big toe & bone of second toe were harvested from the donor
Design: Observational study design Materials: PLA proximal phalanx (four cases) & re-implanted on donors thumb; 3DP bone goes into the
Software: CT scans & Boholo surgical Patient history: thumb & 3DP joint goes in 2nd toe; An iliac artery flap & bone
simulator software  Two cases of machine crush injury were also used to rebuild the donor foot
 Two cases heavy crush injury  The interphalangeal joint of the second toe & bone of the big
 One caserotated & avulsed injury toe under its nail bed were used as donors for the thumb
 Right thumb defects in three cases  All thumb reconstructions were successful
 Left thumb defects in two cases  3D printing of bone & joint are good choices for achieving
 Four cases of injury on dominant thumb reconstructions
side & one case of injury on non-  3DP technology will play an important role in hand
dominant side reconstruction surgery
 Three patients had thumb stumps Advantages:
with moderate stenosis of first web  3–15 months after implantation, all patients were satisfied
Outcome: Prosthetic fit & function  Function & appearance had a success rate of 100%
 3DP is fast, shortening surgical time
Disadvantages:
 Cannot 3D print the whole thumb due to biomechanical
mismatches, cosmetic reasons & reduced flexibility
Future studies:
 Continuing to improve & develop 3DP technology
3DP, three dimensional printing; ABS, acrylonitrile butadiene styrene; AM, additive manufacturing; BBT, box and block test; CAD, computer aided design; CAM, computer aided manufacturing; CAREN, computer-assisted
rehabilitation environment; CT, computerized tomography; EMG, electromyography; FDM, fused filament fabrication; kPA, kilopascal; lbs, pounds; LLA, lower limb amputation; MHz, megahertz; Mm, millimeter; MP, myo-
electric prosthesis; MPa, megapascal; PLA, polylactic acid; PSP, pressure-sensored prosthetics; QUEST, quebec user evaluation of satisfaction with assistive technology; RF, radio frequency; RGD, arginylglycylaspartic acid;
RP, rapid prototyping; Sec, seconds; SHAP, Southampton hand assessment procedure; SLA, stereolithography; SLS, selective laser sintering; TPE, thermoplastic elastomer; TRA, transradial amputation; TTA, transtibial
amputation; UNB, University of New Brunswick; UV, ultraviolet.

Records idenfied
Idenficaon
through database
searching
(n = 177)
Records aer duplicates removed
(n = 119 + 8)
Screening
Records screened
(n = 119 + 8)
Eligibility
Full-text arcles
assessed for eligibility
(n = 42 + 8)
Studies included in
qualitave synthesis
Included
(n = 28)
Figure 1. PRISMA diagram [45].
outcome measures of function, which makes comparisons across
studies difficult.
Discussion
The purpose of the present scoping review was to map the litera-
ture on 3D printing and its applications in the field of amputation,
which demonstrated that the current state of knowledge is lim-
ited. Only 28 studies were identified for this review, and most had
a small sample size with no direct comparison to traditional cast-
ing methods. The number of studies were somewhat evenly split
between lower limb and upper limb amputations; with the major-
ity of the upper limb studies being focused on hand prosthetics.
Although several studies were using CAD (on its own or in tan-
dem with another program) and used PLA or ABS as materials,
the approaches, technologies and materials to fabricate 3D
printed devices were quite diverse. The main findings of this
review indicate there is great potential in the application of 3D
printing in the prosthetics and rehabilitation industry but further
work is need to improve the capability of the technology, stand-
ardize approaches and improve methodological robustness
of studies.
Advantages of 3D printing
The ease of scanning, designing, printing and fitting a prosthetic
within days is beneficial in clinical practice promoting earlier
rehabilitation, reduced hospital length of stay and quicker
3D PRINTING AND AMPUTATION 17
Records idenfied
through other sources
(n = 8)
Records excluded
(n = 77)
Full-text arcles
excluded, with reasons
(n = 22)
Review paper, Abstract,
Poster, No 3D prinng
involved, Animal trial,
not peer reviewed
restoration of function [42]. Patients get fitted with their pros-
thetic in a shorter period of time compared to traditional pros-
thetics and can start rehabilitation earlier preventing further
deterioration and loss of muscle strength. By starting rehabilita-
tion at an earlier time, patients are more likely to get discharged
from the hospital at an earlier date, which is not only beneficial
for the patient but also for the hospital as beds become open to
accommodate more patients [44]. Several of the identified studies
showcased the rapidness of the fitting and manufacturing proc-
esses associated with 3D printing [4,30,34–36,39–41].
Currently, there is a diverse range of materials available for use
with 3D printers when compared to traditional casting methods,
each varying in mechanical strength, flexibility and biocompatibil-
ity [5]. Each material, however, has a limit as to how much stress
and strain can be exerted on the prosthetic. Materials with higher
stress and strain limits are primarily used for lower limb pros-
thetics, as they need to provide more support for the individual
to allow weight bearing. The material used to fabricate the device
has an impact on the weight of the product [12]. As a result,
most of the studies in the review noted that 3D printing produces
lightweight devices [20,25,26,28,30–32,34,38,42]. The included
studies in this review used a wide variety of materials, but with
the most commonly used were many PLA and ABS plastics.
Plastics are known to be lightweight as a result of their many
polymer chains consisting of carbon, oxygen, nitrogen and sul-
phur atoms [45]. In producing 3D printed devices that are lighter
in weight compared to other devices, individuals using these
devices are more likely to perform daily activities with greater
18 D. RIBEIRO ET AL.
ease and balance and posture are improved as a result of a
lighter prosthesis [28]. Furthermore, light weight prostheses are
more comfortable for those with a lower limb amputation, as it
reduces the strain placed on the musculature [36]. Conversely,
heavier prosthetics can negatively affect users by causing more
muscle fatigue [18].
Lightweight devices are also a result of the way the 3D printer
was set up and their thickness and infill settings, as smaller thick-
nesses, infills and densities result in less material used and there-
fore a lighter device [28]. 3D printing not only uses less material
but it also reduces the amount of material wasted contributing to
a reduction in material costs as well as manufacturing costs since
less labour is required [31,41]. This decrease in cost is a major
advantage associated with this technology, as these prosthetic
devices are more affordable to individuals with lower income
[20,26,27]. This was illustrated in a majority of the articles
screened revealing financial feasibility among a wide array of par-
ticipants [20,23,26,28,30–32,34,35,37,38,41]. Traditional custom-
made prosthetics on the other hand can be very costly imposing
financial burden on the person with the amputation and their
family [26]. This can be especially detrimental if the amputation
arises from a congenital condition or is sustained early in life,
which necessitates the growing child to be re-fitted for a pros-
thetic every couple of years [26]. 3D printing has the potential to
reduce the costs associated with the manufacturing of the pros-
thetic, as well as extra parts can be printed within hours to
accommodate growth in a youth with an amputation [26].
Customization of these devices is another advantage of 3D
printing, as all prosthetic 3D scans are stored digitally with all of
the patient’s measurements. These digital scans can be modified
with ease at any moment and be printed within days [4,30,34,35].
In storing these devices digitally, there is a decrease in devices that
need to be placed in a storage space for reference [30].
Customization of this device promotes a more accurate representa-
tion of the amputated area, allowing the device to fit more com-
fortably [25,34]. These advantages also have physical and
psychological effects for the end-users. For instance, an included
study by Zuniga and colleagues [26] reported that almost all their
subjects demonstrated an increase in their quality of life due to
low cost, light weight, customizable 3D printed devices.
Disadvantages of 3D printing
Despite the many benefits of this technology, 3D printing is still
in its infancy requiring much advancement to gain acceptance in
the medical industry. Upon further analysis of the 28 articles (see
Table 1), many of the noted drawbacks associated with 3D print-
ing included inferior grip strength, dexterity and durability for
upper limb prostheses. The human hand has 27 degrees of free-
dom, while a 3D printed hand only has up to 6 degrees of free-
dom [17]. This reduction in mobility can affect the overall
functionality of the prosthesis and the activities that can be per-
formed. Many of the articles found that this reduction in function-
ality and the negative psychological and physical consequences it
had on the patient’s everyday life [17,25,33]. Fine motor skills are
also affected restricting hand rotation, the ability to pick up small
items or heavy items and performing everyday tasks such as but-
toning a shirt [36]. For those who had a lower-limb amputation,
struggles with fit, design and comfort of the prosthesis were
noted to be a major issue [31]. These issues with fit can ultimately
result in compromised viability of the skin and soft tissue, leading
potentially to pressure ulcers [31].
Cosmetic appearance was another quality that many partici-
pants found unfavourable due to the uncomfortable mechanical
feeling and appearance [18,21,22,34,39]. Many prosthetic devices
are constructed out of materials that do not physically and textur-
ally resemble a human appendage. This can be a major concern
for lower limb and upper limb prosthesis, as lower limb prosthe-
ses have limited materials available that would provide enough
structural support that is required for weight bearing [37]. In hav-
ing limited materials available, the cosmetic appearances of these
prostheses are reduced as a result. Lower limb prostheses can be
covered up by clothing and footwear, whereas upper limb pros-
theses are more visible to others. Although upper limb prostheses
have a larger variety of materials available, they still look and feel
mechanical affecting self-esteem and body image [34]. The issue
of appearance is a major concern for some individuals, and
although there are some material alternatives that resemble a
more natural human appendage, they are more expensive and
time and labour intensive to produce [6].
In 3D printing, the designing software can become problem-
atic for novice users. Although, designing on CAD software can
be relatively easy when creating simple products, when designing
prosthetics of certain dimensions, this process can be time inten-
sive and complicated. For instance, Rogers et al. commented that
computer designs for 3D printed devices requires a higher level
of engineering expertise, therefore, an experienced CAD software
designer must be readily available to create such intricate designs
[22]. If an experienced CAD software designer is inaccessible, less
customized 3D model files can be accessed and downloaded for
free online. Although these open-source designs seem like a
favourable alternative to designing products manually, they are a
major concern with this new technology, as designs uploaded are
not regulated [26,27].
According to Day and Riley [30] regulations assessing structural
integrity of 3D printed devices including fatigue levels and weight
bearing stress have not yet been developed [24,34]. This poses as
a significant problem in the future as devices could malfunction
in use and have negative repercussions. Therefore, 3D printing of
prosthetics requires more research and technological advance-
ments in order to produce a more sustainable alternative to trad-
itional prosthetics.
Recommendations for research
Due to the lack of literature available on 3D printing and amputa-
tion, it is difficult to extrapolate definite sources of evidence for
its superiority compared to traditional casting methods. The
majority of the studies were completed using only a 3D printer
and primarily reported on patient satisfaction with the device cre-
ated. A significant issue in terms of the studies was the small
sample sizes, with more than half being a case study with a single
individual. As a result, it is difficult to produce concise unbiased
perspectives as to whether 3D printed devices are more comfort-
able, functional and more cosmetically appealing for patients. It is
recommended that additional trials and studies regarding the
topic of 3D printing and amputation be conducted in comparison
to traditional casting methods, as well as include a larger experi-
mental sample size that are applicable to the study. In doing so,
more data can be compiled and analyzed to evaluate which
method (3D printing or traditional casting) is superior. It is also
recommended that prosthetists should be present during the
development and implementation of the prosthetic to ensure
proper fit on the patient, as the 3D printing technology is not yet
capable of automating such a process [40]. This is one of many

technological issues that this 3D printing technology must
improve upon in order to enhance the overall functionality and
appearance of the device produced. Other advancements include
improving upon durability, strength, comfort and cosmetic
appearance of the device, as well as evaluating the fatigue and
safety of the device while weight bearing [21,22,24,26,27,31].
Another recommendation for future research is to create a 3D
printer that is functional, low cost, fast and applicable for individu-
als with amputations in developing countries. Currently, 3D printers
are slowly being introduced in developing countries providing an
increased quality of care to patients [11,45]. Medical professionals
can either procure these 3D files online or scan them themselves
and print them. Currently, many non-profit medical clinics in these
developing countries rely on governmental support and donations,
making it difficult to procure a 3D printer [11]. Despite this issue,
there are many organizations in the world that will aid medical
clinics and hospitals in the developing world in procuring a 3D
printer as well as teaching medical professionals how to use and
apply this new technology [11]. Therefore, 3D printing is becoming
a viable and accessible option for developing countries to imple-
ment in their healthcare system, however require some advance-
ments to enhance this technology in the future.
Conclusion
3D printing is a fast, customizable, low-cost and lightweight
approach to prosthetic device design and fabrication [11]. It is a
promising advancement in modern prosthetic fabrication that
would alleviate a number of issues noted with the fabrication and
use of prosthetic devices. By supporting increased function with
greater ease and comfort, this technology may contribute to
greater activity and independence, which may ultimately improve
patient’s social and physical wellbeing. Although this technology
has a number of potential benefits, more research and techno-
logical advancements are required to fully understand the impact
of this technology on patients and how it will affect their daily
life. The long-term effects of this technology will also need to be
investigated in order to produce a more sustainable alternative to
traditional prosthetics and enhance the field of 3D printing.
Disclosure statement
No potential conflict of interest was reported by the authors.
References
[1] Norton KM. A brief history of prosthetics. InMotion. 2007;17:
11–13.
[2] Biddiss E, Chau T. Upper-limb prosthetics: critical factors in
device abandonment. Am J Phys Med Rehabil. 2007;86:
977–987.
[3] Dillingham TR, Pezzin LE, MacKenzie EJ, et al. Use and satis-
faction with prosthetic devices among persons with
trauma-related amputations: a long-term outcome study.
Am J Phys Med Rehabil. 2001;80:563–571.
[4] Hsu LH, Huang GF, Lu CT, et al. The development of a
rapid prototyping prosthetic socket coated with a resin
layer for transtibial amputees. Prosthet Orthot Int. 2010;34:
37–45.
[5] Mak AF, Zhang M, Leung AK, et al. Artificial limbs.
Amsterdam, Netherlands: Elsevier Ltd.; 2017.
3D PRINTING AND AMPUTATION 19
[6] Biddiss E, Beaton D, Chau T. Consumer design priorities for
upper limb prosthetics. Disabil Rehabil Assist Technol.
2007;2:346–357.
[7] Dalley SA, Varol HA, Goldfarb M. A method for the control
of multigrasp myoelectric prosthetic hands. IEEE Trans
Neural Syst Rehabil Eng. 2012;20:58–67.
[8] Lai JC, Schoen MP, Perez Gracia A, et al. Prosthetic devices:
challenges and implications of robotic implants and bio-
logical interfaces. Proc Inst Mech Eng H. 2007;221:173–183.
[9] Herbert N, Simpson D, Spence WD, et al. A preliminary
investigation into the development of 3-D printing of pros-
thetic sockets. J Rehabil Res Dev. 2005;42:141–146.
[10] Chimento J, Highsmith MJ, Crane N. 3D printed tooling for
thermoforming of medical devices. Rapid Prototyp J. 2011;
17:387–392.
[11] Ibrahim AMS, Jose RR, Rabie AN, et al. Three-dimensional
printing in developing countries. Plast Reconstr Surg Glob
Open. 2015;3:e443.
[12] Ventola CL. Medical applications for 3D printing: current
and projected uses. P T. 2014;39(10):704–711.
[13] Ratto M, Ree R. Materializing information: 3D printing and
social change. First Monday. 2012;17(7):e3273.
[14] Arksey H, O’Malley L. Scoping studies: towards a methodo-
logical framework. Int J Soc Res Methodol. 2005;8:19–32.
[15] Levac D, Colquhoun H, O’Brien KK. Scoping studies: advanc-
ing the methodology. Implement Sci. 2010;5:69.
[16] Potter WJ, Levine-Donnerstein D. Rethinking validity and
reliability in content analysis. J Appl Commun Res. 1999;27:
258–284.
[17] Dally C, Johnson D, Canon M, et al. Characteristics of a 3D-
printed prosthetic hand for use in developing countries.
Proceedings of the 2015 IEEE Global Humanitarian
Technology Conference (GHTC); 2015 Oct; Seattle,
Washington, USA. p. 66–70.
[18] Duong T, Wagner B, Abraham T, et al. Comparative study
of functional grasp and efficiency between a 3D-printed
and commercial myoelectric transradial prosthesis using
able-bodied subjects: a pilot study. J Prosthetics Orthot.
2017;29:112–118.
[19] Freeman D, Wontorcik L. Stereolithography and prosthetic
test socket manufacture: a cost/benefit analysis. J
Prosthetics Orthot. 1998;10:17–20.
[20] Gretsch KF, Lather HD, Peddada KV, et al. Development of
novel 3D-printed robotic prosthetic for transradial ampu-
tees. Prosthet Orthot Int. 2016;40:400–403.
[21] Rogers B, Bosker G, Faustini M, et al. Case report: variably
compliant transtibial prosthetic socket fabricated using
solid freeform fabrication. J Prosthetics Orthot. 2008;20:1–7.
[22] Rogers B, Stephens S, Gitter A, et al. Double-wall, transtibial
prosthetic socket fabricated using selective laser sintering:
a case study. J Prosthetics Orthot. 2000;12:97–103.
[23] Sanders JE, McLean JB, Cagle JC, et al. Technical note: com-
puter-manufactured inserts for prosthetic sockets. Med Eng
Phys. 2016;38:801–806.
[24] South BJ, Fey NP, Bosker G, et al. Manufacture of energy
storage and return prosthetic feet using selective laser sin-
tering. J Biomech Eng. 2010;132:015001.
[25] Swartz AQ, Turner K, Miller L, et al. Custom, rapid proto-
type thumb prosthesis for partial-hand amputation: a case
report. Prosthet Orthot Int. 2018;42:187–190.
[26] Zuniga J, Katsavelis D, Peck J, et al. Cyborg beast: a low-
cost 3D-printed prosthetic hand for children with upper-
limb differences. BMC Res Notes. 2015;8(1):4304188.
20 D. RIBEIRO ET AL.
[27] Zuniga JM, Peck J, Srivastava R, et al. An open source 3D-
printed transitional hand prosthesis for children. J
Prosthetics Orthot. 2016;28:1.
[28] Zuniga JM, Carson AM, Peck JM, et al. The development of a
low-cost three-dimensional printed shoulder, arm, and hand
prostheses for children. Prosthet Orthot Int. 2017;41:205–209.
[29] Webber CM, Davis BL. Design of a novel prosthetic socket:
assessment of the thermal performance. J Biomech. 2015;48:
1294–1299.
[30] Day SJ, Riley SP. Utilising three-dimensional printing techni-
ques when providing unique assistive devices: a case
report. Prosthet Orthot Int. 2018;42:45–49.
[31] Laszczak P, Jiang L, Bader DL, et al. Development and val-
idation of a 3D-printed interfacial stress sensor for pros-
thetic applications. Med Eng Phys. 2015;37:132–137.
[32] Ramakrishnan T, Schlafly M, Reed KB. Evaluation of 3D
printed anatomically scalable transfemoral prosthetic knee.
Conference Proceedings of the 2017 IEEE International
Conference on Rehabilitation Robotics (ICORR); 2017 July;
London, England. p.1160–1164.
[33] Dass P. Wireless prosthetic hand with RF433MHZ and
ATMEGA328 Arduino controller. Int J Pharm Technol. 2016;
8:20439–20448.
[34] Lee KH, Bin H, Kim K, et al. Hand functions of myoelectric
and 3D-printed pressure-sensored prosthetics: a compara-
tive study. Ann Rehabil Med. 2017;41:875–880.
[35] Lee KH, Kim SJ, Cha YH, et al. Three-dimensional printed
prosthesis demonstrates functional improvement in a
patient with an amputated thumb: a technical note.
Prosthet Orthot Int. 2018;42:107–111.
[36] Tao Z, Ahn HJ, Lian C, et al. Design and optimization of
prosthetic foot by using polylactic acid 3D printing. J Mech
Sci Technol. 2017;31:2393–2399.
[37] Xu G, Gao L, Tao K, et al. Three-dimensional-printed upper
limb prosthesis for a child with traumatic amputation of
right wrist: a case report. Medicine (Baltimore). 2017;96:
e9426.
[38] Yoshikawa M, Sato R, Higashihara T, et al. Rehand: realistic
electric prosthetic hand created with a 3D printer.
Conference Proceedings of the 2015 IEEE Engineering in
Medicine and Biology Society; 2015 August; Milan, Italy.
p. 2470–2473.
[39] Zang CW, Zhang JL, Meng ZZ, et al. 3D printing technology
in planning thumb reconstructions with second toe trans-
plant. Orthop Surg. 2017;9:215–220.
[40] Alvial P, Bravo G, Bustos MP, et al. Quantitative functional
evaluation of a 3D-printed silicone-embedded prosthesis
for partial hand amputation: a case report. J Hand Ther.
2018;31:129–136.
[41] Ferreira NV, Leal N, Correia Sa I, et al. Computer-aided
method and rapid prototyping for the personalized fabrica-
tion of a silicone bandage digital prosthesis. Acta Medica
Portuguesa. 2014;27:775–779.
[42] Imanishi J, Choong PF. Three-dimensional printed calcaneal
prosthesis following total calcanectomy. Int J Surg Case
Rep. 2015;10:83–87.
[43] Fawcett WJ, Mythen MG, Scott M. Enhanced recover: more
than just reducing length of stay? Br J Anaesth. 2012;109:
671–674.
[44] Andrady AL, Neal MA. Applications and societal benefits of
plastics. Phil Trans Roy Soc B Biol Sci. 2009;364:1977–1984.
[45] Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting
items for systematic reviews and meta-s: the PRISMA state-
ment. PLoS Med. 2009;6:e1000097.