3D-printed, ‘high-tech’ prosthetics change the lives of children and teenagers amputees

When she was just seven years old, Caroline Pereira Nunes, from Rio de Janeiro, had to have her right arm amputated. The radical condition came from a bone tumour, which chemotherapy was unable to assuage. The risk of the disease spreading was very high.

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“I thought it would be better not to have an arm than for me to die. After the amputation, I fully recovered and adapted to this one-handed life,” says Caroline, now 19 years old.

Shortly after the surgery, she started a rehabilitation treatment and received an aesthetic prosthesis, but she says that she did not adapt.

— As I was very young, I didn’t have the willpower to use the prosthesis. She was heavy and made it difficult for me to play,” she explains. Before long, she gave up on the device.

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“I’d spent more time without an arm than with it, so I found a way to do whatever I wanted. I just didn’t stay without doing it because then it would be a frustration – he says in a relaxed tone.

Only at the age of 18, he thought about the possibility of prosthesis again, for appearance and to try to reduce back pain. She turned to the National Institute of Traumatology and Orthopedics (Into), of the Ministry of Health, in Rio de Janeiro, where she had started rehabilitation treatment with her first prosthesis in 2010. The scenario was different. This time, it was a 3D device, manufactured on site using printers.

“This prosthesis is spectacular. She’s my color and has a shoulder extension, which I think was what the other one was missing. When I put it on, I am completely straight and it has improved my posture and my back pain a lot. When I take it off, I realize my brain misses that filler,” says Caroline.

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Caroline is part of a group of 24 patients at the institute, 13 children and 11 adults, who received models made on site with 3D printers. Another 15 patients have already been evaluated and are awaiting the fabrication of their prostheses. The project started in 2017 with the aim of offering prostheses to children who are born without a part of the hand due to a congenital malformation. Sandra Helena Moura, occupational therapist at the institute, explains that there was no prosthesis option for these patients.

Then, its use was expanded to children and adolescents with amputees. Pediatrician Germana Bahr, director-general of Into, explains that this is a difficult group to prosthetize with the conventional accessory, given that the growth of children requires constant changes of the device.

The minimum period required to exchange a conventional prosthesis is two years. However, to accompany the child’s growth, this would need to be done every six months, for example. Despite this challenge, Into offers conventional child prostheses, but this is not common.

— There are a lot of places that don’t make prostheses for children because they grow very fast and the replacement of prosthesis takes place many times and this has a high cost — adds Moura.

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The value of a prosthesis varies according to its type. But a conventional upper limb prosthesis for children costs, on average, 13 thousand reais. For adults, around 18,000. While the 3D version costs about 30 dollars, which is equivalent to approximately 165 reais.

In addition to the cost, the process of buying and making the conventional prosthesis is more time consuming than the 3D. Often, when the release occurs, the child has already grown and some steps need to be retraced. In 3D, there is no such problem because everything is done in the institute. The waiting time will only be necessary for patient evaluation, measurement and product manufacturing. According to Moura, the production process takes about seven days, depending on the complexity of the prosthesis.

— Partial hand is faster than a full arm, for example — points out the occupational therapist.

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She is also more malleable. For example, since all production is done on the printer, if one part is damaged, it is possible to replace only that component. In mechanics, the only option is to change the entire prosthesis. Other advantages of the 3D version include being lighter, more customizable and being able to be used in the water.

It may seem insignificant, but the simple fact that it can be used in water makes a difference. For a child, this means being able to do more activities in the pool, take a shower and use the fingers of the prosthesis to paint with a washable paint, for example. For an adult, it allows you to shower, cook and wash dishes.

Another point celebrated by patients, especially children, is that the material can be customized, such as a drawing of superheroes and butterflies, for example. There is also the option of colors close to skin tones, which was Caroline’s choice. After all, although the priority is the functional part, aesthetics are also important.

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The 3D prosthesis also allows for more motor and functional experiences than the conventional one. With 3D, for example, it is possible to perform the movement of bending the fingers. This is also possible with bionics, but not with conventional – which is also called mechanics. This model only allows a “C” shaped opening, in which the thumb moves along with the other fingers. And that simple act of moving your finger makes a difference for patients.

—These are simple activities, but they add functionality to the patient’s daily life and that’s what we care about — evaluates the occupational therapist.

On the other hand, the 3D option is more fragile than a conventional prosthesis. The mechanics also feel more like a real arm. Therefore, conventional prostheses continue to be offered. In the end, the choice is up to the patient, says Moura.

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Rehabilitation

Into is a national reference for treatment in traumatology, orthopedics and rehabilitation of amputees, aimed exclusively at serving patients in the Unified Health System (SUS). This year, the Institute’s Child and Adolescent Orthopedic Center was ranked as one of the best orthopedic hospitals in the world in the ranking of the American magazine Newsweek, made in partnership with the research company Statista. All patients at the institute who receive a prosthesis, either with conventional technology or the 3D version, are included in the rehabilitation program.

— Our intention is not simply to give prostheses. The prosthesis is part of the rehabilitation project, but it is not the most important point. Giving the prosthesis without rehabilitating the patient makes it a simple object or even a toy. The patient needs to see the function of that and understand how it can help him in his daily life — says Moura.

Therefore, even before receiving the prosthesis, the patient undergoes treatment with occupational therapy and a psychologist. This tracking continues after the device is delivered. Rehabilitation aims to enable the individual, especially the child, to be able to perform their activities normally. Whether playing, writing, drinking water or performing household activities. Therefore, the fundamental part is to make the use of the prosthesis natural. May it become part of the individual and his daily life.

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Moura says that many people consider it useless to have a prosthesis for children because they “turn around”. Which, in fact, is true, but a finger, hand or arm prosthesis can bring invaluable gains for child development. A functional prosthesis, such as the 3D, minimizes injuries and functional losses, in addition to favoring the stimulation and reorganization of neuroplasticity.

This is clear in the case of little Maria Heloá. At just four years old, she was the youngest child to receive a 3D prosthesis at Into. Diagnosed in her mother’s womb with a congenital malformation, Maria Heloá was born without her left forearm. The girl dreamed of riding a bicycle. That’s why her mother went to the institute. Today, in addition to her bicycle, Heloá can jump rope, comb the dolls’ hair and play with the ball.

— The child’s brain plasticity develops from motor and cognitive experiences. The prosthesis is important for the child’s neuromotor development. This improves the quality of this development, as it increases the possibilities of activity that she can perform – explains the occupational therapist.

For this age group, the 3D prosthesis is even better than the conventional one, as its characteristics allow for a greater number of motor and functional experiences. The child can play ball, ride a bicycle, play on the jungle gym, paint with the fingers of the prosthesis and hold the adult’s hand.

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3D printing

The 3D prosthesis is something very recent not only in Into, but in the world. 3D printing, for example, became a topic in Brazil just over two decades ago. The technology came from the industrial and automotive sectors and more recently, it showed that it could have a real impact on people’s lives. Creating prostheses is just one of its uses in medicine. This type of technology already helps doctors in the planning of complex surgeries and allows the creation of personalized orthotics and implants.

To produce the three-dimensional pieces, the occupational therapy team works directly with the IT technicians. A special computer program gathers information from patient measurements and modeling made with other materials to configure the instruments. From there, PLA parts, a thermoplastic used in 3D printing, are developed.

The focus of the project, which started in 2017 with the name “Pelas Mãos”, is still offering 3D prostheses to improve the rehabilitation of children and adolescents. But in 2021, adults are also included. For now, the focus is on making upper limbs.

According to Bahr, who is directly developed in the project since the printing of the first hand prosthesis, the objective is to expand to the lower limbs. In addition, 3D printers are already used for other purposes at INTO

— They range from simple things like artifacts to improve mobility, to prostheses, guides and models for planning complex surgeries, such as those for the spine — explains the director-general.

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