Ankle foot orthoses (AFOs) are traditionally manufactured using vacuum thermoforming as shaping technology. Additive manufacturing has the potential to disruptively change the way these orthopaedic devices are produced. In this study, AFOs are developed which are virtually designed and produced with laser sintering as shaping technology. The mechanical and clinical performances of these laser-sintered AFOs are compared with traditionally manufactured AFO by asking seven patients (both children and adults) to walk with each type of AFO

Deckers, Jan Patrick

Forward, Malcolm

Geldhof, Jeroen

Plasschaert, Frank

Vasiliauskaite, Egle

Vermandel, Miguel

Jan Patrick Deckers

Miguel Vermandel

Jeroen Geldhof

Egle Vasiliauskaite

Malcolm Forward

Frank Plasschaert

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Plastics Rubber and Composites

Development and clinical evaluation of laser-sintered ankle foot orthoses

Ghent University Academic Bibliography

Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=yprc20Plastics, Rubber and CompositesMacromolecular EngineeringISSN: 1465-8011 (Print) 1743-2898 (Online) Journal homepage: http://www.tandfonline.com/loi/yprc20Development and clinical evaluation of laser-sintered ankle foot orthosesJan Patrick Deckers, Miguel Vermandel, Jeroen Geldhof, Egle Vasiliauskaite,Malcolm Forward & Frank PlasschaertTo cite this article: Jan Patrick Deckers, Miguel Vermandel, Jeroen Geldhof, Egle Vasiliauskaite,Malcolm Forward & Frank Plasschaert (2018) Development and clinical evaluation oflaser-sintered ankle foot orthoses, Plastics, Rubber and Composites, 47:1, 42-46, DOI:10.1080/14658011.2017.1413760To link to this article:  https://doi.org/10.1080/14658011.2017.1413760Published online: 14 Dec 2017.Submit your article to this journal Article views: 25View related articles View Crossmark dataDevelopment and clinical evaluation of laser-sintered ankle foot orthosesJan Patrick Deckersa, Miguel Vermandela, Jeroen Geldhofa, Egle Vasiliauskaiteb, Malcolm Forwardb andFrank PlasschaertbaV!go Group N.V., Wetteren, Belgium; bGait & Movement Analysis Laboratory, Cerebral Palsy Reference Centrum, University Hospital Ghent,Gent, BelgiumABSTRACTAnkle foot orthoses (AFOs) are traditionally manufactured using vacuum thermoforming asshaping technology. Additive manufacturing has the potential to disruptively change theway these orthopaedic devices are produced. In this study, AFOs are developed which arevirtually designed and produced with laser sintering as shaping technology. The mechanicaland clinical performances of these laser-sintered AFOs are compared with traditionallymanufactured AFO by asking seven patients (both children and adults) to walk with eachtype of AFO.ARTICLE HISTORYReceived 2 June 2017Revised 31 October 2017Accepted 3 December 2017KEYWORDSPatient; gait; orthotics; anklefoot orthosis; additivemanufacturing; selectivelaser sintering; polyamide 12;mechanical propertiesLiterature surveyAn ankle foot orthosis (AFO) is a device that can be pre-scribed to individuals with movement impairments. Thespecific aim of an AFO depends on an individual: his/hermedical condition, functional needs and activity level. Ingeneral an AFO can support weak muscles and/orrestrain spastic muscles, ultimately leading to asmoother, more stable and more energy efficient loco-motion. Today patients can choose between standardoff the shelf AFO and custom-made AFO. StandardAFOs are cheaper but might offer less comfort to apatient than custom-made AFO. On the other hand, pro-duction of custom-made AFO is a labour-intensive taskrequiring highly skilled personnel [1]. Today plastic cus-tom AFOs are typically produced from polypropylene(PP) sheets using the vacuum thermoforming technique.Recent advances in medical imaging and in additivemanufacturing (AM) technology might change the waycustom AFOs are produced. The following AFO AMproduction scheme is suggested: (1) patient’s anatomyis captured by laser scan, (2) captured data is used torecreate the patient’s anatomy in three-dimensional(3D) space and (3) using 3D patient data a personalisedAFO is designed, analysed (virtually) and prepared forAM [1]. Once AM technology matures, the productionof custom AFO might become cheaper, faster, morecontrollable and more accurate than using currenttechnology [2].Different aspects of AM of custom AFO havealready been researched. Some researchers carriedproof of concept studies [3,4]; some investigateddimensional accuracy of AM AFO [2], while othersinvestigated material characteristics and prototypeAM AFO performance on a small sample of healthyor impaired subjects [4–7].In 2007 Milusheva et al. [3] suggested an early con-cept of AFO production by AM using a modular designAFO with exchangeable elastic springs. Milusheva et al.used laser scanning and laser sintering (LS, SLS®) toproduce the prototype conceptual AFO, not reportingon AFO fit or performance. In 2012, Telfer et al. [4]suggested a new concept of modular AFO with adjus-table stiffness in sagittal plane. Telfer et al. produceda prototype AFO from PA 12 powder by LS and testedit on a healthy subject in a gait analysis laboratory.They found that by adjusting AFO, stiffness in thesagittal plane ankle kinematics could be varied. Thus,Telfer et al. suggested that in the future custom AFOwith superior features to current AFO might be pro-duced by AM.Dimensional accuracy and fit of 3D printed AFO ontwo healthy subjects have been investigated by Schrankand Stanhope [2]. Four half scale AFO and two fullscale AFO were printed for the purpose of the study.Schrank and Stanhope found that dimension discre-pancies between actual LS AFO and their CAD modelswere below 2 mm and that LS build orientation andposition did not have a significant influence on dimen-sional accuracy. Two full scale AFO that were designedfor two healthy subjects, by subjective visual judgment,provided a good fit on those subjects.Faustini et al. [5] investigated energy release andstorage properties of three polyamide (PA)-basedmaterials: DuraFormTM PA (glass-filled PA 12),© 2017 Institute of Materials, Minerals and Mining Published by Taylor & Francis on behalf of the InstituteCONTACT Jan Patrick Deckers jan.deckers@vigogroup.eu V!go Group N.V., Biezeweg 13, 9230 Wetteren, BelgiumPLASTICS, RUBBER AND COMPOSITES, 2018VOL. 47, NO. 1, 42–46https://doi.org/10.1080/14658011.2017.1413760DuraFormTMGF (PA 12), RilsanTMD80 (PA 11) andcompared them to carbon fibre (CF), material that isalso often used to produce traditional AFO. RilsanTMD80 (PA 11) proved to have the lowest mechanicaldamping characteristics out of the three LS materialstested; however mechanical damping in the RilsanTMD80 AFO was still appreciably greater (36%) than inCF-AFO. RilsanTM D80 was the only material out ofthree materials tested to withstand large deformations.Mavroidis et al. [1] used 3D laser scanning and astereolitography (SLA) process to produce customAFO for a healthy subject. Two types of materialswere used for SLA AFO production: (1) Accura 40resin for the production of rigid SLA AFO and (2)Somos 9120 resin for the production of flexible SLAAFO. The performance of LS AFO was compared toa prefabricated plastic posterior leaf spring AFO inthe gait analysis laboratory. Mavroidis et al. foundthat both rigid and flexible SLA AFO performed simi-lar to prefabricated AFO. The minor differences in per-formance of different AFO were attributed todifference in their stiffness. However, stiffness of theAFO was not reported in this study.Harper et al. [6] carried out a study to compare theperformance of modular AFO with CF strut and LSproduced PA 11 strut. The study involved 10 subjectswith unilateral limb impairments. Harper et al.reported that the differences between gait performancewhile walking with LS PA 11 and CF struts were mini-mal. Thus, authors concluded that PA 11 is a materialsuitable for use in orthotics.Creylman et al. [7] compared the performance of LSAFO to the performance of custom PP AFO in eightsubjects with unilateral foot drop in the gait analysislaboratory. They did not find significant differencesbetween performance of LS AFO and PP AFO, thusconcluding that LS AFO can perform as well as cus-tom-made PP AFO.The results achieved to date support the use of AMtechnology in orthotics. However, more extensive clinicalstudies are still needed for AM technology acceptance.MethodologyIn this study, seven patients (both children and adults)are selected. The pathologies considered were trauma,neuro-muscular disorder and cerebral palsy. Beforeparticipation in the study, the patients are screenedby a team of medical specialists. In order to participatein the study, the patients have to be able to walk with-out walking aids. Among others, exclusion criteriawere: insufficient hip and knee power, severe obesity,stiff knee gait and muscle tone of Ashworth 3 ormore in psoas, hamstrings, adductors, rectus femoris,gastrocnemius or soleus.Before production, the team of medical specialistsprescribed the stiffness of the AFO devices aroundthe ankle joint, according to the pathology of thepatients (Table 1). Further, some AFO were prescribedwith leather boots to ensure adequate foot support andto ensure that heel contact with the AFO is maintained.Owing to growing of the patients, normal wearingtimes for AFO in Belgium is 1 year for patients youngerthan 14 years, 2 years for patients between 14 and 21years, and 5 years for patients older than 21 years.During the clinical study the patients were asked towear the laser-sintered AFO for 6 weeks and the tra-ditionally manufactured AFO for another 6 weeks(with order randomised). All patients wore the samesemi-orthopaedic shoes for both types of AFO.Manufacturing of orthotic devicesFigure 1 schematically depicts how both the tradition-ally manufactured and selective laser-sintered AFOwere produced. The production process of both AFOstarted with 3D scanning of the leg of the patient,using Artec Studio® alongside standard physicalmeasures (which are the height of the fibula, heelwidth, meta width, ankle width, foot length, heel tometa length). When the pathology of the patients wastoo severe, a plaster cast was also taken in addition tothe 3D laser scan. In these cases, the plaster cast wasalso scanned. When comparing the physical measure-ments, it was found that the direct scan of the leg cap-tured best the meta width and the scan of the plastercast captured best the heel width.As a second step, the scans were virtually correctedusing specialised orthopaedic software (Rodin 4D®).The result of this correction (i.e. an .STL file) is usedas a step in producing both the traditionally manufac-tured AFO and the laser-sintered AFO.Traditionally manufactured AFOThe corrected positives were milled out of wood, usinga five axes milling machine. These positives were usedas a mould in a vacuum thermoforming process using4 mm heated PP sheet to create a classic AFO.The ankle trim lines (i.e. the way the polypropyleneshell was cut around the ankle) were adjusted accord-ing to the clinical prescription for the flexibility ofthe AFO around the ankle. If the clinical prescriptionTable 1. AFO ankle stiffness prescriptions for patients of theclinical study.Left RightPatient 1, child Rigida RigidaPatient 2, child Semi-flexible Semi-flexiblePatient 3, adult Semi-flexiblea FlexiblePatient 4, child Semi-flexible Semi-flexiblePatient 5, adult FlexiblePatient 6, adult FlexiblePatient 7, adult FlexibleaaThese AFO include a leather boot to compensate for foot pathologies.PLASTICS, RUBBER AND COMPOSITES 43was rigid, semi-rigid, flexible or very flexible, the trimlines were respectively anterior to (in front of),through, or posterior to (behind), or very posteriorlyto the lateral malleolus (Table 2).Selective laser-sintered AFOThe corrected scan files were used as a starting point inthe computer-aided design of the AFO, whichconsisted of a calf part of 3.0 mm thickness, a footpart of 3.0 mm thickness and two carbon fibre rodsconnecting them. In order to design the AFO, a combi-nation of the following design software programs wasused: 3-Matic® (Materialise N.V.) and SolidWorks®(Dassault Systemes) & Rhinoceros® (Robert McNeel& Associates). The resulting calf and foot parts werelaser sintered out of ther polyamide 12 (PA12) material(3D Systems and/or EOS LS machines).The diameter of the two carbon fibre rods wasadjusted according to the clinical prescription for theflexibility of the AFO around the ankle. Where theclinical prescription was ‘rigid’, a rod diameter of10 mm for adults and 8 mm for children was selected.When the clinical prescription was ‘semi-rigid or flex-ible’, a rod diameter of 8 mm for adults and 6 mm forchildren was selected. The exception was one adultpatient who was provided with a very flexible AFO,having rods of 6 mm diameter. For all laser-sinteredAFO, the ankle trim lines were through the lateral mal-leolus (Table 2).Patient fitting and finishingIn a next step, a Certified Prosthetist Orthotistadjusted the devices (e.g. adding foot supportmaterial where needed) according to their experience.Finally, the device was finished with the placement ofpadding, a thin insole, the attachment of hook andloop fasteners and the placement of leather boots(if prescribed, Table 1).Results and discussionAll patients walked with both laser-sintered and tra-ditionally manufactured AFO.The time required for the patient fitting was less forthe laser-sintered AFO (rough estimation of savedtime: 10–20%). During the the virtual (CAD) designof the laser-sintered AFO, the trim lines were alreadydefined. For the traditionally manufactured AFO, theFigure 1. Production of traditionally manufactured (left) andlaser-sintered (right) AFO.Table 2. Definitions of ankle stiffness of both traditionally manufactured and laser-sintered AFO.Traditionally manufactured Laser sinteredChildrenFlexible • Trim line behind lateral malleolus • Trim line through lateral malleolus• 6 mm rodsSemi-flexible/semi-rigid • Trim line through lateral malleolus • Trim line through lateral malleolus• 6 mm rodsRigid • Trim line in front of • Trim line throughlateral malleolus lateral malleolus• 8 mm rodsAdultsVery flexible • Trim line a lot behind lateral malleolus • Trim line through lateral malleolus• 6 mm rodsFlexible • Trim line behind lateral malleolus • Trim line through lateral malleolus• 8 mm rodsSemi-flexible/semi-rigid • Trim line through lateral malleolus • Trim line through lateral malleolus• 8 mm rodsRigid • Trim line in front of lateral malleolus • Trim line through lateral malleolus• 10 mm rods44 J. P. DECKERS ET AL.trim lines are manually defined/refined during thepatient fitting.All traditionally manufactured AFO survived the 6weeks of clinical trial without any failure or noticeablewear. Nevertheless, the strength of the laser-sinteredAFO developed for the clinical study needs to beoptimised:(1) Patient 1: After 1 day, the plastic shell of the laser-sintered AFO broke when the patient (child) wasrunning around and playing ‘catch’. The strengthof this AFO seemed to be insufficient (Figure 2(a)).(2) Patient 2 wore the laser-sintered AFO for the 6weeks trial period with no failure. In this case,the strength of the AFO was sufficient.(3) Patient 3: The carbon rods of the right laser-sin-tered AFO broke at their lowest point after 3days of use (Figure 2(b)). This was probably dueto inaccurate cutting and grinding of the rodsintroducing a crack/notch at a critical point.(4) Patient 4: After 4 weeks, the plastic shell of the leftlaser-sintered AFO broke (Figure 2(c)) during asudden impact while the patient (child) was play-ing soccer. It seems that a combination of fatiguefailure (4 weeks of walking) and high stressesduring the sudden impact caused the AFO to fail.(5) Patient 5: After 3 weeks, the plastic shell of thelaser-sintered AFO broke while the patient walkedup stairs. Probably this happened due to a fatiguefailure (Figure 2(d)).(6) Patient 6 wore the laser-sintered AFO for the 6weeks trial period. Nevertheless, the AFO becamedirty and a cracking began at the metatarsal pha-langeal joint (Figure 2(e)). Further investigationof the fatigue behaviour of the PA12 materialand investigating stain release post-processingmethods are mandatory to solve these issues.(7) Patient 7: After 5 weeks, the plastic shell ofthe laser-sintered AFO broke during hiking.Probably this happened due to fatigue failure(Figure 2(f)).ConclusionsCompared to the traditionally manufactured AFO, thetime needed for patient fitting is less for the laser-sin-tered AFO (rough estimation of saved time: 10–20%).However, long-term clinical studies are mandatory totest the behaviour of the laser-sintered AFO in dailyuse conditions. The clinical pilot study reported hereto develop/evaluate the process of producing laser-sin-tered AFO, highlights the importance of more exten-sive mechanical characterisation tests (such asstrength, fatigue, impact) both on coupon-levelmaterial samples and on the final product, processingof carbon material (if used) and stain release post-pro-cessing methods. As such, it also highlights the need touse finite element modelling and simulation, includingappropriate material models, when producing a laser-sintered AFO for a patient.Disclosure statementNo potential conflict of interest was reported by the authors.FundingThis research was funded by VLAIO (Flanders Innovation &Entrepreneurship) by the A_STREAM_AFO (Applied Struc-tural Engineering of AM Materials for Ankle Foot Orthosis;project numbers: 140164 and 140165) project under the SIM(Strategic Initiative Materials in Flanders) research programmeFigure 2. Breaking of right AFO of patient 1 ((a) breaking ofplastic shell), right AFO of patient 3 ((b) breaking of rods),left AFO of patient 4 ((c) breaking of shell), right AFO of patient5 ((d) breaking of shell), right AFO of patient 6 ((e) fatigue crackat location of metatarsal phalangeal joint) and right AFO ofpatient 7 ((f) breaking of shell).PLASTICS, RUBBER AND COMPOSITES 45STREAM (STRuctural Engineeringmaterials through AdditiveManufacturing).References[1] Mavroidis C, Ranky RG, Sivak ML, et al. Patient specificankle-foot orthoses using rapid prototyping. J NeurengRehabil. 2011;8(1):1.[2] Schrank ES, Stanhope SJ. Dimensional accuracy ofankle-foot orthoses constructed by rapid customizationand manufacturing framework. J Rehabil Res Dev.2011;48(1):31–42.[3] Milusheva S, Tosheva E, Tochev D, et al. Personalizedankle foot orthosis with exchangeable elastic elements.J Biomech. 2007;25(6):90–95.[4] Telfer S, Pallari J, Munguia J, et al. Embracing addi-tive manufacture: implications for foot and ankle ortho-sis design. BMCMusculoskelet Disord. 2012;13(1):1287.[5] Faustini MC, Neptune RR, Crawford RH, et al.Manufacture of passive dynamic ankle-foot orthosesusing selective laser sintering. IEEE Trans BiomedEng. 2008;55(2):784–790.[6] Harper NG, Russell EM, Wilken JM, et al. Selective lasersintered versus carbon fiber passive-dynamic ankle-footorthoses: a comparison of patient walking performance.J Biomech Eng. 2014;136(9):091001.[7] Creylman V, Muraru L, Pallari J, et al. Gait assessmentduring the initial fitting of customized selective laser sin-tering ankle foot orthoses in subject with drop foot.Prosthet Orthet Int. 2013;37(2):132–138.46 J. P. DECKERS ET AL.

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Development and clinical evaluation of laser-sintered ankle foot orthoses

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