New technologies in the O&P market - interview with Drew Buffat
The Adapttech team had the pleasure of interviewing Drew Buffat, Director of Prosthetics of one of our partner clinics in the US - De La Torre Orthotics & Prosthetics.
Drew worked, together with Cassandra Delgado (MSPO, CPO), on an investigation that evaluated the efficacy and cost-effectiveness of using the INSIGHT System versus traditional trial-and-error methodology regarding the fitting process of prosthetic sockets. You can read the study here.
Our INSIGHT System was installed at the De La Torre O&P clinic in July 2019. Almost two years later, we had the opportunity to interview Drew to find out more about his opinion on new technologies that help improve the socket fitting process.
What does the socket fitting workflow at Delatorre O&P look like? Which tools and technologies are you integrating into your practice?
We have been striving to streamline and modernize our fabrication process over the past several years. The reasons behind doing so are varied but the three main reasons were to make the fitting process more efficient, more accurate and more consistent.
We bought a CAD/CAM system several years ago and it is has made world of difference in our fabrication processes and we have accomplished the goals that we have set out to do and are now looking to fine tune the process even more but the process that we have developed thus far is as follows.
When we are making a TT prosthesis, we still take a casting of the residual limb by hand in order to capture the shape of the limb in a consistent manner. We have tried using hand held scanners to do this task but the results were very inconsistent and the results were very disappointing. The fact that we can manipulate the tissue when we hand cast is still the best method from our perspective until the scanning process can be improved or perfected.
Once we take the cast of the residual limb by hand we then “digitize” the inside of the cast with our contact digitizer from Provel in order to create an electronic model of the inside of the cast. Once the cast is digitized and checked for accuracy the scan is then loaded into a file in our Provel software that is proprietary to each practitioner. The clinician then uses the modifying software to electronically modify the model. Once the model is completed it is saved into the system in an .aop file format and from there it can be loaded on to the software for the single axis Provel carver where the model is then carved out to specs from a foam blank. Once the model has been carved out it is taken out of the carver cleaned up and it is then prepped to have thermoformed plastic pulled over the model to create a diagnostic socket. The plastic socket is then removed from the foam model, cleaned up and set up for the diagnostic fitting.
Once we fit the diagnostic socket and are satisfied with whatever changes have been made to it we then once again digitize the check socket with the digitizer in order to capture these changes that were made to improve the fit and increase the comfort for the patient.
Once the diagnostic socket has been digitized we once again check it for accuracy and them clean the model up on the software and once again carve out the new model so it can them be laminated over with a liquid resin to create the definitive socket which can then be fit onto the patient.
We use the same process with our TF sockets except we do not cast the patients directly over their residual limbs, we instead take a series of precise measurements and plug them into the modifying software where we can chose from a series of 8-10 different brim designs and shapes. Once we choose the proper brim/shape for the patient’s limb and determine a percentage of reduction based on the limb length, muscle tone and skin integrity we plug the measurements in to the program and the software modifies the model accordingly. The clinician can then continue to modify the model to their satisfaction if needed. Once the model is done being modified it is saved to their specific file and then sent over the carver for the foam mode to be created. The model is then removed from the carver and then prepped to be thermoformed for a clear plastic diagnostic socket.
This process has saved us time and materials and it has also allowed our clinicians to be more consistent and accurate in their fittings. If given the choice to go back to doing things the traditional way and spending a lot of time standing over a plaster model in order to modify it, all of our clinicians would prefer to stay with the system we now have in place.
We are also hoping to begin 3D printing some sockets in the next year or so once Provel’s O&P designed 3D printer is available to us. When this happens we should be able to begin to eliminate carving the model and go right from the modified 3D model to a 3D printed socket.
How do you see the relationship between the prosthetists and the new technologies?
I know there are many seasoned prosthetists that are very set in their specific traditional ways of fabricating and fitting their prosthetics for their patients. For these clinicians the relationship with the newer technologies seems to be one of anxiety, mainly of the unknown and fear of losing control over the fitting process to the detriment of their patient care.
Then of course there are those prosthetists who are newer to the field who are actively seeking to incorporate the newer technologies into their practices to enhance the fitting process, not only from a time savings perspective but from a clinical perspective as well. These clinicians can see the value that the newer technologies bring to the fitting process in terms of creating a process that is more accurate and consistent with better outcomes for their patients over traditional methods.
We had both of these types of prosthetists on our staff when we made the conversion over to the CAD/CAM system and I can tell you from experience that once those who were very skeptical and full of anxiety became familiar with the process and saw that it did indeed save them time and also improved the outcomes and quality of care for their patients they would not go back to the traditional ways of doing things if given the choice.
I had been wanting to incorporate CAD into our fabrication process for years and every time I would approach the ownership they would balk at the idea. They did so because they had heard from other owners who made the investment in the equipment and then it ended up sitting there collecting dust because no one in their company bought into it and took the initiative to really learn how to use it properly and gave up on it when they ran into any difficulties. One owner stated that they had to threaten termination if the clinicians did not start to utilize the system.
Our owners simply told me that they didn’t think our staff had the capacity to learn the system and make it work properly so they were not at all interested in going in that direction. It wasn’t until I had done enough research and provided them with enough information about the benefits of a CAD system that they began to come around to the idea. I also had to prove to them that our staff had the capacity to make the switch over and to make it work. In addition, I had reassure then that I would take ownership of the process and bring the other staff members along with me. Of course getting the proper equipment to meet our facilities needs and to make sure we had the proper training was also a key to our successful transition away from plaster and into the modern era.
What is your opinion on technologies focused on the analysis of the pressure distribution in the interface between the residual limb and the socket? How do they compare with traditional ways of analyzing pressure spots and skin breakdown, like direct observation?
Until I had been introduced to the INSIGHT System I was not aware of any other technologies that were able to analyze the pressure distribution between the residual limb and the socket in real time with visual and scalable feedback in such a dynamic way.
Our traditional methods rely on the practitioners training and experience to interpret visual cues from the skin and feedback from what the patient is feeling as they fully weight bear and ambulate on the prosthesis. Not every clinician has the same ability or skill set to interpret what they are seeing from the visual clues on the skin or to correctly interpret the feedback that they are getting from the patient. As an example, it is at times difficult to tell if a patient is getting too much contact on the distal end of their limb or not enough. The pain that the patient is feeling may be the same in either scenario and the skin may be red and irritated as well so it takes some expertise in determining what the best course of action would be to correct the problem at hand.
In some cases, the patient may be experiencing pain/discomfort in what they believe is one area of the socket when in fact after probing inside the socket the pain is emulating from a different area of the socket altogether due to the nerves and tissue being displaced during the amputation surgery and subsequent closing of the wound.
So, I am excited that there are technologies such as the INSIGHT that takes the guess work out of the equation when it comes to solving specific problem areas of pressure within a socket as well as simply being able to see if the goal of creating a total contact and equal weight bearing socket has been accomplished.
From your experience, what is INSIGHTS’s contribution to this pursuit of understanding the relationship between a patient’s residual limb and his/her socket? What does it bring to your practice?
INSIGHTs contribution to the fitting process has allowed us to see in real time the relationship between the patient’s residual limb and the socket in a way that we have not been able to see before. Up until we started using the INSIGHT System we had only been able to assume that there are different pressure areas on the residual limb within the socket as the patient goes through their normal gait cycle. We were aware that the pressure on the limb changes in location and duration from heel strike to mid stance (fully weight bearing) and toe off all the way through swing phase but we were never able to see these differences in such a visual way. The fact that we could see the changes in pressure within the socket as the patient was walking in our office was a real eye opener for us and it was also very educational for the patient.
The INSIGHT brings another dimension to the fitting process in that it takes the guesswork out of trying to pin point where there is too much pressure in the socket and it allows us see if the changes we made to the socket adequately resolved the problem that the patient was having. I also see the INSIGHT as being a tool that we can use to help us communicate with the patient as to the nuances of the fitting process and to help educate them about the relationship of socket design/fit and the effects it has on their residual limb.
Where do you think O&P field and all its major stakeholders are headed in their relationship with these up and coming technologies?
I think the relationship with all the major stakeholders in the O&P field and the up and coming technologies will continue to be a little bit strained like it is now. There is a struggle going on between the traditionalist who are satisfied with the way things have been and may be more skeptical of the benefit that these new technologies bring to the table and those who embrace these new technologies and see them a means to make the fitting process more efficient and at the same time provide better outcomes.
Unfortunately the expense side of things also comes into play when it comes down to many O&P companies decision to embrace the new technology or not. Many smaller companies simply do not have the ability to afford these new technologies, particularly given the squeeze on reimbursement from the payer sources across the board. The larger companies will be in a better financial position to adopt these new technologies but it will take some time in convincing the majority of companies to get on board. Those companies that do adapt will no doubt begin to realize the short term benefits to their efficiency and improved patient outcomes but will also begin to see the long term benefit to their companies bottom line and overall fiscal health.
