CAD/CAM: Time to Join the Digital Age

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By Chris Handford

Why has CAD/CAM become so important? Fabian Santschi, Giglio Orthopédie, Carouge, Switzerland, shares his view: "CAD/CAM technology enables us to delight physicians and patients: We can visit a hospital in the morning to scan a patient, then deliver a superior-quality custom brace that afternoon. The boosts in efficiency and service level are allowing us to profitably grow our business." If profitable growth doesn't sound like a significant achievement for the practice, bear in mind that it has been over 16 years since Swiss O&P reimbursement rates last changed.

Indeed, clinics across the world are reaping the benefits of CAD/CAM technology, enabling practices to grow and help more patients.

A Digital Plaster Room Full of New Tools

In O&P, a complete CAD/CAM solution includes a scanner to capture patient measurements and render them as a 3D model, software for making clinical modifications to that model, and a carver that automatically machines a corresponding mold out of lightweight foam. However, some early adopters are using 3D printers along with scanners and design software as a CAD/CAM solution to create devices directly from computer models, removing the need for mold carving and manual plastic forming.

Integrating CAD/CAM into clinical practice can be achieved in different ways: A facility can adopt a full scan-design-carve solution in-house or instantly transmit scan or design files by e-mail to a central fabrication partner. The latter option is favored by smaller practices because, as Thomas J. (TJ) Daley, CO, Great Lakes Orthopedic Labs, Buffalo, New York, explains, "A carver is a big investment for a clinic of our size, so we decided to engage Spinal Technology [West Yarmouth, Massachusetts] as a central fabrication partner to do the carving for us. The new business model lets us deliver better care to more patients with the same staff."

Millions of Measurements, Precise Modifications, and New Capabilities

practitioner with hand-held 3D scanner

The Vorum 3D scanner captures over a million measurements in less than a minute. Photograph courtesy of Karl Hager Limb & Brace.

When a high-precision O&P 3D scanner is used to take a patient's measurements, it can capture over a million measurement points in under a minute using noncontact imaging technology. Scanner software then renders a 3D model of the patient's limb, head, or torso-a model that includes the slightest bumps or contour changes. This highly accurate representation is the first step to creating a device that fits and performs better than a device made from plaster casting.

The data from the scan is then imported into a CAD software program, which has point-and-click tools for applying clinical corrections to the model and creating the desired mold shape. Clinicians can quickly apply the exact modifications they want without the time-consuming, messy process often associated with plaster models. Martin Kauffman, founder of OrthoPets, Denver, says he considers the process superior to using plaster. "Computer-based design tools enable us to make shape modifications that are more anatomically correct. We can rotate, align, and twist in ways that we just cannot do in plaster."

young patient with new brace

A young patient receives a new brace that was made using CAD/CAM tools. Photograph courtesy of Cascade Dafo.

Working in the digital realm, practitioners can benefit from new capabilities, such as being able to overlay their 3D scan models with images and x-rays to serve as visual design guides, resulting in better-fitting devices and greater patient compliance. "We can get a truer picture of what the patient is going to look like in the brace and how the brace may affect their curvature," says Don Virostek, CPO/L, director, orthotics department, Texas Scottish Rite Hospital for Children, Dallas. CAD systems that are built specifically for O&P and include customizable, individual modification and/or full shape design templates are most beneficial for use in O&P practices. Practitioners can import a patient's 3D shape scan data and then apply a set of common modifications to yield a clinically viable starting point for further interactive design, thereby saving time and improving consistency, especially for less experienced practitioners. If appropriate, established device designs can be scaled to match measurements extracted from the 3D scan.

Better Results in Less Time

Digital technology often enables significant increases in efficiency: According to case studies from a number of Vorum users, the majority of clinics using its CAD/CAM tools find that properly trained practitioners can realize a 400-600 percent gain in productivity. That means clinicians are capturing a patient's shape and creating a mold for fabrication in one-quarter to one-sixth of the time that it takes using plaster. Nolan Hayday, business manager, Karl Hager Limb & Brace, Edmonton, Canada, describes the gains the practice has experienced. "Using the old plaster-based process, it took 90 minutes to cast a patient, create a plaster positive mold, and modify the mold for brace fabrication. Now, we optically scan the patient's leg, modify the shape on the computer, and automatically carve the positive mold in foam, all in under 20 minutes of hands-on staff time." Other practitioners have had similar experiences. Jeffrey Bruce, CPO, director, orthotics and prosthetics, Shriners Hospitals for Children - Twin Cities, Minneapolis, says, "what used to take me approximately two hours, I can now do in approximately 20 minutes."

technician with 3-axis carver

A technician works with the Vorum 3-axis carver. Photograph courtesy of Spinal Technology.

Productivity gains can help maintain profitability in the face of frozen or declining reimbursement rates. They are also essential to offset the short supply of qualified O&P practitioners, exacerbated by the many practitioners over the age of 50, who will presumably be considering retirement within the next ten to 15 years, according to The O&P EDGE 2015 Salary Survey (October 2015).

Advances in efficiency lead to a wide range of additional benefits. Practitioners can see more patients, spend more time with each individual, improve device turnaround times, and build better relationships with referring physicians. In many cases, increased efficiency can also help them enjoy a better work-life balance.

The impact of CAD/CAM extends beyond productivity. Digital tools can enable clinicians to work with greater insight and precision, crafting devices that fit better and yield better treatment outcomes. Many practitioners have also found that using such tools helps them provide a better patient experience than they could in the past.

Noncontact Scanning: A Better Starting Point

The CAD/CAM starting point is the noncontact measurement process. Some patients find the casting process uncomfortable; infants, patients with skin sensitivities, and trauma patients may find it unbearable. Daley highlights the benefits of noncontact scanning with pediatric O&P patients. "I don't know who found it more stressful, the child being wrapped up in plaster or the parents," he says. "The process with the 3D scanner is easier and far less stressful. Patient movements don't matter and, as in the case of infant cranial scans, parents can hold and reassure their kids as they're being scanned."

3D scanners also capture a more accurate representation of a patient's shape, providing a better foundation for the application of clinical modifications. Not only does the hair-width resolution of a high-precision scanner accurately capture every body surface feature, scanning can be done with the patient in specific positions, so body alignment and muscle contraction reflect the patient's true shape in daily life. "We can scan the patient in the standing position, with their muscles engaged and contracted," Hayday explains. "When we used plaster casts, patients had to sit or lie down, meaning their muscles were relaxed and did not represent the true shape of their legs when walking or running. But with the scanner, we can get an accurate picture of a patient's knee shape in active use. That lets us build better-fitting braces. We can reduce excess joint movement, avoid pressure points, and eliminate gaps within a brace that might cause a decrease in support to the affected limb. That makes for happy patients."

The portability of 3D scanners enables practitioners to provide home, hospital, and satellite office visits. "Business has changed since the introduction of CAD/CAM," says Leif Nilsson, market and product manager, TeamOlmed, Stockholm, Sweden. He recalls a girl who could not be discharged from the hospital without a custom cranial helmet. Using CAD/CAM tools, Nilsson fit the girl's new helmet in less than six hours.

"I can make more aggressive and more precise modifications than when working with plaster," Daley says. "Complex, asymmetrical [modifications], such as those in Cheneau-style TLSO scoliosis braces, are now much easier. Armed with this higher level of design precision, we're making better-fitting, more effective devices and seeing better patient outcomes."

Another benefit of CAD/CAM is the weight of the foam material used to carve molds, which is lighter than plaster molds. "It is not only patients who benefit from the CAD/CAM system," Nilsson says. "Plaster casts for a typical spinal jacket can weigh between 30-40kg (60-80 lb.). Now employees are working with digital files and foam molds which weigh approximately 2kg (5 lb.). Therefore, potential injuries due to lifting heavy plaster casts are effectively eliminated."

Digital Shape Collections, New Possibilities

With patient scan and design files stored electronically, new ways of working are made possible. Unlike a cast that is destroyed in the plaster mold-making process, the patient's original 3D scan file is always available for future reference. By comparing multiple scans over time, a patient's shape changes can be tracked and treatment progress assessed. The computer-based visual models and related measurement data also help educate patients and improve communications with physicians and payers.

technician with 3-axis carver

Image overlays and device preview in Vorum's computer-aided O&P design software assists practitioners in designing a scoliosis orthosis. Photograph courtesy of Vorum.

Digital files can also help communication between clinics and central fabricators. "Digital technology allows us to collaborate with practitioners and quickly troubleshoot issues," says Loretta Sheldon, director of business development and education, Cascade Dafo, Ferndale, Washington. "I recall a case when refabrication of a brace was required. The CAD solution allowed us to look through the layers of modification to unravel the root of the problem. Thanks to this history, a conversation with the practitioner, and a video of the patient, we were able to quickly come up with a good solution, using information we could rely on."

Replacing plaster molds with digital files also saves a lot of space. Bandagist Jan Nielsen, Copenhagen, Denmark, that country's leading O&P provider, ran out of space in its clinic because it was storing hundreds of plaster casts. When the company switched to CAD/CAM, it was able to scan the casts to create a digital library. Now a scan of a cast can easily be found by searching the digital library.

Even outside of the consultation room, digital recordkeeping can revolutionize the way patient treatment programs are constructed. With large amounts of data at their fingertips, practitioners can incorporate analysis of children's growth rates into their treatment plans, pinpoint indicators that a patient requires a new device, or create design guidelines for certain patient conditions.

CAD/CAM can have a positive impact on clinics and their patients. "CAD/CAM has transformed our practice by enabling us to practice O&P at a higher level," says Daley. "It increases efficiency, and the technology really lets us deliver better results for our patients. I wish we'd made the switch earlier."

Also, no one should underestimate the draw of modern technology for patients, referring physicians, and employees. Some patients expect such technology because they see it used in video games and routine dental work, among other places. Kazunori Sasaki, Sasaki P&O Services, Sendai, Japan, agrees, "By advertising our use of CAD/CAM technology, we gain new customers." Modern tools also play a key role in attracting top O&P practitioners and the brightest young talent entering the profession.

Finally, the CAD/CAM imperative may be best summed up by Hayday. "An architect could not compete today without using computer-aided design tools, and the same will soon be true for custom orthotic and prosthetic providers. It's time for our industry to join the digital age."

Chris Handford leads the customer service and consulting team at Vorum, Vancouver, Canada, a global provider of O&P CAD/CAM solutions. He has 14 years of O&P industry experience in North America and Europe.