PROTHESES AROUND THE WORLD

Whereas in industrialised countries prostheses have become increasingly sophisticated high-tech devices capable of performing complex movements, in other countries there is a lack of basic provision for those with physical disabilities requiring prostheses. Heinz Trebbin has spent half his life in developing countries, providing medical aid, setting up workshops and training locals in the manufacture of prostheses. Today, he is back home in the Allgäu region of southern Germany. The 61-year-old has launched a pilot project that aims to make 3D-printed prostheses available to people in countries where medical care is lacking.

Studies show that 80 per cent [2] of people with physical disabilities live in so-called “low-income countries”. Prostheses are usually prohibitively expensive there. What’s the best way to help those affected?

Heinz Trebbin: Medical care is a huge problem in poorer countries. Few people have health insurance. While the presence of international aid organisations means there’s often a better supply of prostheses to patients in war-zones, there’s a lack of options for treatment in most developing countries. This is where we urgently need to find solutions. One of the most important causes of amputations worldwide is diabetes. In Latin America, this metabolic disease is particularly common. There, the population not only needs better access to information, it also needs better health care.

What needs to happen for patients in developing countries to be given the chance to get a prosthesis?

Trebbin: Professionally trained orthopaedic technicians are often scarce in poorer countries. Most of them only work in the big cities. To travel to the big cities, patients have to find the money to cover the high cost of the journey and they’re also faced with not being able to earn anything during this period. That’s why we need to find a way to help more people outside the metropolitan areas. An alternative could be prostheses from the 3D printer.

How is a prosthesis produced with the aid of a printer?

Trebbin: First, the stump of an amputated leg is measured exactly to the millimetre by means of a 3D scanner. The next step is to use a computer software to produce a virtual three-dimensional prosthesis stem, which is the most important part of a functional prosthesis. The prosthesis stem is printed in the 3D printer and connected to the other elements of the artificial leg.

And can this be done just about anywhere in the world?

Trebbin: In principle, yes. The traditional way of creating a fitting socket with a plaster cast is a real art. It takes years of experience to get it right. The prosthesis mustn’t cause pressure at the stump interface or lead to skin chafing. 3D printing makes the process easier – and there’s no need for orthopaedic technicians to be present on the ground. Together with the Fraunhofer Institute, we’re planning a pilot project to train specialists centrally in developing countries. Via the Internet, they’ll receive the 3D impression from an assistant in the patient's region and use it to model a connecting piece on the computer. The data is then returned and the prosthesis printed out on site. In this way, a small number of specialists can help a great number of people.

How are the prostheses fitted remotely?

Trebbin: One possibility is to have the orthopaedic technicians participate in the fitting session via video. They can assess the gait pattern and give instructions to the support staff.

Are 3D prostheses already widely used in developing countries?

Trebbin: In terms of the materials used, 3D printing is still in its infancy, but the technology has great potential for the future. Another advantage of 3D printing is that it’s possible to produce customised prosthetic limbs, such as for feet with complex joints. So far, however, only a few projects in developing countries are using 3D printing.

You’ve said that the 3D projects to date have not functioned in a sustainable manner. Why is that?

Trebbin: Many projects are just about printing out cheap prostheses. Of course, that’s better than nothing. But we need experts to provide high-quality treatment. In addition, it’s vital to establish a service structure in these countries that functions well, even after the foreign development workers have long returned home. What’s needed here is to help people help themselves – and not the creation of new dependencies.

What’s the difference between the prostheses that have been used to date in developing countries and those used in industrialised countries?

Trebbin: In countries like Germany, there are more high-tech prostheses. In principle, however, a functional lower-leg prosthesis, for example, can be built for a mere 200 to 300 dollars. Just to put this in context: in Germany, a model with similar functions costs 5,000 to 10,000 euros. Above all, however, it’s important that prostheses for developing countries are stable, cost-efficient and durable. And in certain regions, the material must be able to withstand high humidity and strong sunlight.

What does development policy need to deliver in the future in order to improve the supply of prostheses in poorer countries?

Trebbin: I’d really like to see greater efforts being made for people outside of war zones too. We need many small projects on the ground that are sustainable and that run over longer periods of time. Some projects just seem to be about spending vast sums of development aid quickly – regardless of whether it makes sense or not. In cases such as these it would be preferable to take a closer look at how the money can be used in the best possible way.

THE VICIOUS CYCLE BETWEEN DISABILITY AND POVERTY

Poverty, disability and need are mutually dependent. Whoever has a disability quickly falls into poverty, and those in poverty find it difficult to escape their condition: our graphic shows the consequences of this cycle, for example, on economic and social development.

SOURCES

[1] World Health Organization / World Bank. The World Report on Disability. Geneva: WHO, http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf (2011), p. 102.

[2] Prosthetics an Orthotics 2012, 37 (5)353-361: Provision of prosthetic and orthotic services in low-income countries: A review of the literature, Colette S Harkins, Anthony McGarry and Arjan Buis