BACKGROUND: Ankle-foot orthoses (AFOs) are medical devices supporting individuals with pathological gait. Manufacturing fully customized AFOs with a carbon dorsal leaf spring (C-AFOs) traditionally relies on manual processes involving material waste and resource consumption. Additive manufacturing (AM), commonly referred to as 3D printing, offers potential pathways toward a more sustainable production, yet its impact on sustainability-related metrics in orthosis manufacturing remains insufficiently examined. OBJECTIVE: In this study a partially digital C-AFO manufacturing workflow was developed using AM, initially tested and it was investigated how the partial digitalization affects selected sustainability-related metrics compared to the established manual manufacturing workflow. METHODOLOGY: An exploratory study was conducted at a German orthotic workshop, where a partially digital workflow for C-AFO manufacturing was developed and implemented. Two C-AFOs were produced using the traditional manual and the new partially digital workflow, while both workflows were analyzed and compared by means of a gate-to-gate life cycle inventory analysis in accordance with ISO 14040/44. Data collection encompassed the consumed material mass (divided into material incorporated into the C-AFO, in-house reusable material, potentially externally recyclable material, and disposable material), electrical energy consumption, and process water usage. RESULTS: Partial digitalization substantially reduced total material use by 4.59 kg (21%) and process water consumption by 12 L (83%), primarily by reducing the use of non-recyclable plaster models. Additionally, the proportions of in-house reusable and potentially externally recyclable materials increase, while the proportion of disposable material decreases. Conversely, electrical energy consumption increased by 15.96 kWh (172%), largely attributable to the 3D printing processes employed. CONCLUSION: Although the exploratory nature and limited scope of this study preclude general conclusions regarding overall workflow sustainability, the findings indicate that transitioning from manual to partially digital C-AFO manufacturing presents possible sustainability potential. A comprehensive evaluation within the framework of a complete life cycle assessment is recommended to substantiate these initial results. Layman's Abstract Ankle-foot orthoses (AFOs) are medical devices supporting individuals with pathological gait. Their manufacture is currently predominantly manual. In recent years, additive manufacturing (AM), also known as 3D printing, has increasingly been applied in AFO production. While this technology is expected to offer sustainability benefits, data-based comparisons of resource consumption between manual and partially digital manufacturing of fully customized AFOs with a carbon dorsal leaf spring (C-AFOs) remain insufficiently examined. In this study a partially digital C-AFO manufacturing workflow was developed through replacement of manual steps with 3D scanning and 3D printing. The workflow was initially tested and it was investigated how partial digitalization affects selected resource consumption metrics. Two C-AFOs were produced at a German orthotic workshop using both a traditional and partially digital workflow. Both workflows were analyzed in accordance with ISO 14040/44 regarding material mass consumption (divided into material incorporated into the C-AFO, in-house reusable material, potentially externally recyclable material, and disposable material), electrical energy and process water use. Partial digitalization reduces total material throughput by 4.59 kg (21%) and process water consumption by 12 L (83%), primarily through reducing the amount of non-recyclable plaster models. In addition, the proportion of materials reusable in-house and potentially recyclable externally is increased, while the proportion of disposable material is reduced. Electrical energy consumption increases by 15.96 kWh (172%), largely attributable to 3D printing. While the exploratory nature and limited scope of this study preclude general conclusions regarding overall sustainability, the findings suggest that the transition toward digital AFO manufacturing may hold sustainability potential. A comprehensive life cycle assessment is recommended to substantiate these initial results. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47795/35345 How To Cite: Strenge O, Krieger C, Dilthey C, Nasilowski L, Frei J, Hochmann D. Towards more sustainable AFO manufacturing: An exploratory life cycle inventory of partially digital production. Can Prosthet Orthot J. 2026;9(2):6. https://doi.org/10.33137/cpoj.v9i2.47795 Corresponding Author:Ole Strenge, M.Sc. Affiliations: Biomechatronics Research Laboratory, FH Münster University of Applied Sciences, Steinfurt, Germany. E-Mail: ole.strenge@fh-muenster.de ORCID ID: https://orcid.org/0009-0007-7739-3438
BACKGROUND: Additive manufacturing (3D printing) has been proposed as a means of improving customization, accessibility, and production efficiency in prosthetic fabrication. However, clinical outcomes remain incompletely characterized, with existing evidence limited by heterogeneous study designs, small samples, and inconsistent outcome reporting. OBJECTIVE: To conduct a scoping review to map the available evidence on clinical outcomes of 3D-printed prosthetic devices in individuals with limb loss or congenital limb difference. METHODOLOGY: JBI (formerly Joanna Briggs Institute) methodology and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines were followed. MEDLINE, Embase, CINAHL, CENTRAL, and Web of Science were searched from inception to December 31, 2025. Studies were eligible if they reported clinical outcomes, assessed using an identifiable method of measurement, for a functional limb prosthesis directly fabricated using additive manufacturing. RESULTS: Of 1,396 records screened, 42 studies were included. Thirty-one (73.8%) were case reports or case series; no randomized controlled trials were identified. Thirty-two studies (76.2%) involved upper-limb prostheses and ten (23.8%) involved transtibial devices. Fused deposition modeling (FDM) was the most reported additive manufacturing method (76.2%). In upper-limb studies without a comparator, participants frequently reported improved gross motor function compared with using no prosthesis, while fine motor performance and device durability were common limitations. Where a conventional device was used as a comparator, findings were mixed rather than uniformly favoring either fabrication approach. In lower-limb studies, gait and patient-reported outcomes were generally comparable between 3D-printed and conventionally fabricated devices. CONCLUSION: The literature describes 3D-printed prostheses being fabricated, fitted, and used across a range of clinical contexts, including for customized and activity-specific designs, but the evidence base remains limited. Future work should prioritize larger comparative studies, longer follow-up, and more standardized outcome assessment to better define the role of additive manufacturing in prosthetic care. Layman's Abstract Prosthetic limbs help people who have lost a limb, or were born with a limb difference, move and carry out everyday activities. Traditionally, prostheses are manually made using techniques that take time, skill, and clinical resources. 3D printing, which builds an object layer by layer from a digital file, has been suggested as a customizable approach to prosthetic fabrication with possible workflow advantages, though it also carries its own trade-offs. It remains unclear how well 3D-printed prostheses work for the people who use them. This review searched multiple databases to identify published studies examining how people experience 3D-printed prosthetic arms or legs, including how well the devices perform, how comfortable they are, and how satisfied users feel. We identified and reviewed 42 relevant studies, most of which were small reports describing only a handful of patients rather than large trials. In arm prosthesis studies, users often reported improvements in everyday tasks compared to using no prosthesis, though fine motor performance and durability were common weaknesses; results were mixed when compared with conventionally made devices. Studies of leg prostheses generally found comparable outcomes between 3D-printed and conventional devices. Overall, the studies describe 3D-printed prostheses being made, fitted, and used in a range of clinical settings, including custom devices made for specific activities, but the evidence base remains limited. Larger, higher-quality studies with longer follow-up and more consistent outcome measures are needed to better define the role of 3D printing in the production of prostheses. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47836/35342 How To Cite: Bhatla C, Ho M, Devion C, Gao R.Z, Mayo A.L. Additive manufacturing of prosthetic devices: A scoping review of clinical outcomes. Can Prosthet Orthot J. 2026;9(2):5. https://doi.org/10.33137/cpoj.v9i2.47836 Corresponding Author: Dr. Amanda L. Mayo, MD, MHSc, FRCPC, Affiliations: 1) Division of Physical Medicine and Rehabilitation, Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; 2) Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. E-Mail: Amanda.Mayo@sunnybrook.ca ORCID ID: https://orcid.org/0000-0001-7061-2529
BACKGROUND: Recent advancements in digital workflows, including the use of 3D printing, are transforming the prosthetics and orthotics (P&O) field. Digital technologies offer opportunities to deliver P&O services that are more efficient by reducing design and fabrication times, are less wasteful through the elimination or reduction of consumables, including plaster, foam and other materials, and are more repeatable by having digitally saved designs. Despite known advantages, the adoption of digital workflows in P&O has been inconsistent, underscoring the need for cross-sector collaboration to guide the field using evidence-informed approaches. OBJECTIVE: To collaborate with key interest groups to identify priority areas for advancing the adoption and implementation of digital workflows in the P&O field. METHODOLOGY: A modified Delphi approach was used to inform the structure of a Canada-wide initiative and involved participation of 79 representatives from key interest groups, including prosthetists, orthotists, technicians, biomedical engineers, researchers, and people with limb absence/difference. Research priorities were identified through online surveys followed by a hybrid meeting during which attendees engaged in small- and large-group discussions to refine and select priorities. RESULTS: Five key digital P&O research priorities were identified: (1) strengthening evidence on device quality and system performance compared to traditional methods; (2) developing economic and reimbursement models to support clinical integration; (3) improving education and training for digital workflows; (4) establishing standardized practice guidelines; and (5) increasing key interest group engagement to better understand user needs and perspectives. While the general components of digital workflows are now broadly understood, future efforts should focus on more specific contexts, and discussions should be more targeted and disaggregated (e.g., by device type, patient population, or care setting) and include experts with context-specific experience. CONCLUSION: This collaboration initiative provides a strategic roadmap for advancing the adoption of digital workflows in the P&O field and supports the development of national collaborations aimed at fostering innovations and evidence-based practice. Layman's Abstract Recent advances in digital technologies, including three-dimensional (3D) printing, are changing how prostheses and orthoses are designed and fabricated. Digital workflows are the processes of using digital technologies to design and create prostheses or orthoses. These approaches may improve prostheses and orthoses care by reducing design and fabrication time, decreasing waste by reducing the use of plaster and other materials, and improving consistency by allowing designs to be digitally stored and reused. Despite these potential benefits, digital workflows are not yet widely used in clinical practice. Barriers such as limited evidence, gaps in education and training, cost and reimbursement challenges, and a lack of shared standards have slowed adoption. To help address these challenges, a Canada-wide initiative was conducted to bring together key interest groups and develop a shared research agenda. Using a structured consensus-building approach, 79 invitees (including prosthetists, orthotists, biomedical engineers, researchers, and people who use prostheses and/or orthoses) contributed through online surveys and a hybrid meeting that included group discussions. Five main research priorities were identified: generating stronger evidence comparing digitally produced prostheses or orthoses with traditionally made devices, improving education and training for digital workflows, developing economic and reimbursement models that support routine clinical use, creating baseline guidelines to promote consistent and safe practices, and increasing engagement with key interest groups to better understand their perspectives and needs. Overall, this work provides a roadmap to guide future initiatives and collaboration, supporting innovation and evidence-informed use of digital workflows in prostheses and orthoses care. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46848/35280 How To Cite: Andrysek J, Mayo A.L, Ngan C.C, Blocka D, Pendse V, Calovini E, et al. Developing a research agenda in digital workflows for the fabrication of prostheses and orthoses. Can Prosthet Orthot J. 2026;9(2):4. https://doi.org/10.33137/cpoj.v9i2.46848 Corresponding Author: Prof. Jan Andrysek, PhD Affiliation: 1) Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto, Ontario, Canada; 2) Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada. E-Mail: JAndrysek@hollandbloorview.ca ORCID ID: https://orcid.org/0000-0002-4976-1228
BACKGROUND: Spinal curvature in adolescent idiopathic scoliosis (AIS) is associated with a reduction in standing height. While height loss due to scoliosis and height gain following surgical correction are well described, little is known about immediate height change during scoliosis brace fitting and its relationship to in-brace skeletal correction. In-brace Cobb angle correction remains a primary indicator of brace effectiveness; however, no radiation-free clinical tool exists to support early assessment during fitting. OBJECTIVE: To investigate whether immediate standing height change during scoliosis brace fitting is associated with in-brace Cobb angle correction. METHODOLOGY: A retrospective audit was conducted on 60 adolescents with idiopathic scoliosis (13 males, 47 females; mean age 12.4 ± 1.7 years; mean standing height 156.6 ± 10.7 cm) treated at The London Orthotic Consultancy in Kingston, UK. Clinical data were collected between January and October 2022. Standing height was measured immediately before and after brace fitting, and Cobb angles were assessed at baseline and in-brace. Correlation and simple linear regression analyses were performed to explore the relationship between height change and in-brace correction. RESULTS: The mean baseline Cobb angle was 38.0 ± 10.7°, correcting to a mean in-brace Cobb angle of 10.3 ± 9.4°, corresponding to a mean absolute Cobb angle correction of 27.8 ± 9.9° and mean percentage correction of 74.3 ± 19.2%. Mean height gain at fitting was 1.24 ± 0.74 cm (range −0.2 to 3.5 cm). Descriptive analyses included the full cohort (n = 60), including participants demonstrating radiographic over-correction (n = 6). Following exclusion of cases demonstrating radiographic over-correction (>100%), a moderate positive association was observed (R = 0.45, p = 0.001). Sex-specific subgroup analysis was not performed due to limited statistical power. CONCLUSION: Immediate height gain during scoliosis brace fitting demonstrates a moderate association with in-brace skeletal correction and may serve as a simple, radiation-free clinical indicator of mechanical brace response. Height measurement should be interpreted as an adjunct to, rather than a replacement for, radiographic assessment. Prospective studies using multivariable predictive models are warranted to further evaluate its clinical utility. Layman's Abstract Scoliosis is a condition in which the spine curves sideways. In children and adolescents, this curvature can make a person appear slightly shorter because the spine is not fully upright. One of the main goals of brace treatment is to straighten the spine as much as possible while the child is still growing. Currently, the main way to check how well a brace is working is by taking an X-ray, but repeated X-rays expose young patients to radiation. This study explored whether a simple measurement, standing height, could provide useful information during a brace fitting appointment without using radiation. We reviewed the clinical records of 60 adolescents with idiopathic scoliosis (13 males and 47 females) who were treated at The London Orthotic Consultancy in Kingston, UK. The average age of the patients was 12.4 years, and their average standing height was 156.6 cm. The data were collected between January and October 2022. During the brace fitting appointment, each patient’s height was measured immediately before and after putting on the brace. X-rays were also taken to measure how much the spinal curve improved while wearing the brace. On average, patients became about 1.24 cm taller when the brace was first fitted, although the change ranged from a decrease of 0.2 cm to an increase of 3.5 cm. The average spinal curve improved from 38° before bracing to 10° while wearing the brace, corresponding to an average absolute correction of 28° and an average percentage correction of 74%. In general, larger increases in height were associated with greater straightening of the spine seen on X-rays. These findings suggest that measuring height during a brace fitting appointment may provide clinicians with a quick, safe, and radiation-free way to gain early insight into how well a brace is working. Although height measurement cannot replace X-rays, it may help clinicians make better decisions during brace fitting and potentially reduce unnecessary radiation exposure for young patients with scoliosis. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/46645/35062 How To Cite: Courtney A, Walmsley S, Bishop T, Bernard J, Darren L, Jones R.K, et al. Immediate height gain during scoliosis brace fitting as a predictor of in-brace skeletal correction: A non-radiographic clinical indicator. Can Prosthet Orthot J. 2026;9(2):3. https://doi.org/10.33137/cpoj.v9i2.46645 Corresponding Author: Anna Courtney, Affiliation: The London Orthotic Consultancy, Kingston upon Thames, United Kingdom. E-Mails: anna.courtney@londonorthotics.co.uk ORCID ID: https://orcid.org/0009-0009-0726-1186
Despite major advances in prosthetic components, digital workflows, and manufacturing technologies, substantial variability continues to exist in prosthetic interface outcomes. Socket fit, tissue tolerance, user comfort, and long-term functional success remain difficult to predict and standardize across individuals and clinical settings. While contemporary technologies such as CAD/CAM, pressure scanning, additive manufacturing, and emerging artificial intelligence applications may improve manufacturing precision and reproducibility, they do not fully address the biological and biomechanical complexities that influence interface performance. Residual limb tissues, suspension systems, gait mechanics, skin adaptation, and individual user characteristics interact dynamically throughout prosthetic use, limiting the ability of shape capture and manufacturing processes alone to determine successful outcomes. This perspective paper argues that prosthetic interface management should be viewed as a dynamic biological and biomechanical process rather than primarily a manufacturing challenge. Building upon a systems-based understanding of the interface, the paper proposes that successful outcomes emerge from the interaction between socket design, liner characteristics, suspension mechanisms, tissue biology, gait dynamics, and clinical decision-making. The paper further highlights the unique role of the prosthetist in observing long-term outcomes and emphasizes the continued importance of clinical expertise in an increasingly digital environment. Future progress in prosthetic interface management will likely depend on integrating technological innovation with rehabilitation science, biomechanics, tissue biology, and outcome-focused clinical practice. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/47748/35116 How To Cite: Johannesson A.G. Beyond shape capture: The dynamic transtibial prosthetic interface and the continuing role of clinical expertise. Can Prosthet Orthot J. 2026;9(2):1. https://doi.org/10.33137/cpoj.v9i2.47748 Corresponding Author: Dr. Anton G. Johannesson, PhD, CPO Affiliations: Össur Clinics EMEA, Stockholm, Sweden. E-Mail: ajohannesson@ossur.com ORCID ID: https://orcid.org/0000-0001-8729-458X
