Orthoses manufacture

The other thing to think about is this. All well and fine when we can get them done at $120 a pop wholesale. History shows (fuel, asian imports etc), that for various reasons, costs can increase.


What, if in 4 years time, a decent pair of devices cost us $240 or more?


Apart from the arguments I put forth earlier in this thread, this is one more. The ability to make a pair of device can insulate the practitioner from issues beyond his/her control.

 

Inflationary pressures would cause the same $ result for Lab or self made. Cost of manufacturing your own orthotics is directly related to the time it takes. And Professional time is billed accordingly.

Unless you can make a pair of orthoses in 10 min, how could you 'contain' costs?

 

Does everything run at CPI Paul?



And another thing, there is no way that a lab will return you a device that is 100% what you wanted; particularly when the prescription is quite complex. Which leads to the question, what do you do, when a device returns without the treatment effect that we initially aimed for?

I would think it is easier for those that self-make to go back to the positive cast, make additions or subtractions and replace the pair.


For those that don't make their own, what is their "plan b". I doubt it would be to pay double wholesale, because this would not fit into their business model or cost targets.

 

I have the reputation (my wife is the first to say it – she’s also a Podiatrist) that I’m too exigent regarding to orthoses.

Till today all the orthoses I ever “prescribed” to a patient where done by me. Of course the outcome will be what I really want and other advantage is the possibility I have to change any aspect of the orthoses much quicker.

They give me a lot of work and I agree that financially maybe it’s not the best option (I wish we had the same prices in Portugal – they are much cheaper ).

I sometimes ask myself (when I see some orthoses made by someone else) if the components (materials) where chosen because the manufacturing process was easier that way…

Best regards,

 

The simple fact of the matter is if you are a Practitioner prescribing orthoses, you need the skills to do whatever is required to prescribe, modify, consult and achieve successful outcomes for the patient.

 

This is all very interesting to read, especially the the difference in time to produce an orthotic, some taking 100% more time than others, l guess this is representative of time in the lab and experiences.

Something to consider, if a young Pod starting their own practice is able to produce their own orthosis it would account for the not so busy times in their young practice and adding to their business been viable.

If you make orthotics early in your career does this not give you a better insight to the actual finished product of what you should expect and allow you the opportunity to try other options/opinions (as so often found on this forum) in your orthotics at a lower cost?

Just a thought

 

Can't agree more!

 

Definitely...

and you'll also learn the 'finished product' is not what you issue to the patient...

Cheers,

Paul Dowie

 

Bullseye. Win-win.

 

I would guess that the posters arguing the case of the value of making your own orthoses are the practitioners that have done or still do.
Certainly I know that Phil and Atlas have spent more than a few hours covered in plaster and EVA dust.
I know that I feel I have a much greater appreciation of how orthoses have an effect because I have always made them myself- I simply don't think that I could have gained this any other way.
If you have never done this, then you really can't appreciate its value...
So do you have to make your own devices? No- but I can't over state the value of doing so.
So this...

is spot on.

 

Hi All

I find this thread very interesting as I have used both orthoses made from a lab and also making them in house and although there are pros and cons for both i believe there is nothing better than making them yourself. I have used 3-4 different labs both in the UK and Canada. What i found to be the main problems were that a third of all the orthoses supplied by the company where incorrect and either did not fit the patients foot or did not have the prescription on them that i would ask for. Therefore ending up with a patient who was not happy and a extremely frustrated practioner. As for the costs the reason i used a lab in canada was they were more cost effective and a better product than thoses supplied in the UK. However, i now make my own as 3-6 weeks to turn around a orthoses is too long and i can do them within a week. This suits the patient better and i know that the device being made is what i require.

 

I agree with Chris in that this is a fascinating thread. I believe that all of us operate to provide the best possible care for all our patients. In our offices, that means using a variety of different sources. With four podiatrists and one pedorthist covering five locations, we find it would be foolhardy to attempt making all our devices in house. Since we can get lab made inserts within a standard two-four weeks, we send the majority of our functional orthotics to a choice of up to three labs. The most difficult cases are reserved for in-house crafting in order to achieve more directed attention. All of our accommodative inserts are made in house; we have yet to encounter a lab device that met with our full approval.

On a side note regarding materials, I do believe there is far greater versatility in selection of available padding and structural sheets when manufacture occurs in-house. Seeing the innovations in composites and visco elastics are just as important at industry shows, as any other topic.

 

I consider that learning how to fabricate custom foot orthoses should be a basic skill taught to all podiatrists. I was fortunate to be a student at the California College of Podiatric Medicine from 1979-1983 where we not only had outstanding biomechanics faculty (Drs. John Weed, Ron Valmassy, Chris Smith, Jack Morris, Lester Jones, John Marzalec and Bill Sanner) but also had the MO (mechanical orthopedics) lab. I spent many hours as a 2nd, 3rd and 4th year podiatry student, and during my Biomechanics Fellowship, "hanging out" in the MO lab, making plaster positive casts, modifying them, pressing orthoses, grinding them, making and grinding rearfoot posts, etc. In addition, Dr. Richard Blake, during his Biomechanics Fellowship and during my podiatry student years, was just starting to experiment with his "Blake Inverted Orthosis" and I was one of the handful of students he would let make his orthoses for him. It is because of my fabrication and clinical experience with Rich Blake's new inverted orthosis design that I was able to have the experience to design the medial heel skive positive cast modification technique.

For me, there is no replacement for the technical and clinical experience I received at CCPM making and modifying orthoses around others who were more knowledgeable than I was. Simply put, I wouldn't be where I am without that experience. Unfortunately, the MO lab is gone, orthoses are made at an outside lab at CSPM, and the Biomechanics Fellowship no longer exists, so podiatry students in California now receive a much different education than I did. The result is many more students that know 15 different ways to do a bunionectomy, and very few that know how to grind an orthosis correctly. Such is the state of podiatry education not only in California, but across the United States....surgery over biomechanics......since real doctors do surgery.....not orthotics.:bang:

 

Dear all

As an orthoses manufacturer it may seem strange but I definitely advocate everyone being trained in orthoses manufacture and having the ability to make there own/ adjust them.
At our lab we have hundreds of customers all using very different approaches. The majority 'make sense' but sometimes the 'concepts' we are asked to produce are stretching what can physically be manufactured.

However the vast majority of the concepts orthoses end up coming back for adjustments or re-makes. We are then blamed for not fulfilling the RX.
A example of this the type of request is for an intrinsic rearfoot post (Flat base) with a Medial skive and a large heel raise.

If practitioners had a better understanding of the whole process then I believe the service that labs offer would be significantly better than some have experienced.

Cheers


Phil

 

Hi Phil

My question to you would be is about the person operating the system. Is the technican trained in manufacturing orthoses and understanding what they are trying to achieve? For me in mpo is that the labs i have used and met with that the technican has either none or little understanding of the product being produced and the person with the wealth of knoweldge ie the podiatrist has little or no input on the shop floor. Therefore i find there is a flaw in the system and the device comes back incorrect. Surely there should be some form of product quality control that is performed by a podiatrist who understands what the practitioner is asking for. For me this rarely happens and therefore a faulty orthoses is produced with increased regularity.


thanks

chris

 

Chris

You are totally right. The skill mix and Quality Control is imperative to ensure that mistakes are minimised. I am lucky that my company is part of a much larger organisation with policy and suppprt to put these things in place.
Also we are 99.99% CAD/CAM so I have 3 staff manufacturing over 800 pairs of ffo's a month - this doesn't include the finishing staff - with a skill mix of graphic designer and ex plaster technicians.
However I feel that as the only podiatrist in the company, I should see as many of the RX's as possible. Also my staff are very strictly trained to only complete the Rx and not to improvise in any way. I don't get it right every time and will accept some responsibility for getting it wrong.
The question I will ask you - and any others - is what would you do in my positition when a Rx comes in for an orthoses with a 20 deg rearfoot posts, a 6mm Medial skive and a 10 degree medial pour to fit a men's dress shoe - would you manufacture the orthoses?

Cheers

Phil

 

Hi Phil

good reply! Like i said there are pros and cons of both ways of making them and i used cad cams for several years and on the whole i liked them very much and so did the patients. I fully understand where you are coming from but my concerns are especially with cad cam that many of the orthoses to my understanding are mirrored. My worry is how many feet are exactly the same not many so how can the manufacturer of the orthoses mirror the casts. Overall result will be the orthoses will not fit the foot. I am sure production time plays an influence when producing 100s of orthoses and i am unsure in your company if this occurs, but this is what i have experienced and after questioning several companies this is actually what happens. So if a majority of orthoses are mirrored how is the patient and clincian suppose to achieve the right prescription if it is flawed on the production line.

With regards to question i would query the practitioners prescription and contact them but i am sure you have lots of these coming through everyday and would spend all day on the phone. At the end of the day would you produce an orthoses and take the money of which you thought is incorrect ? I would say as a businessman yes but as a podiatrist no but easy for me to say when i dont run a company.

cheers

chris

 

Chris

Some CAD system do mirror the feet - not sure why as the CAD system is so fast it should treat each foot as individual.
However certain aspects of the insoles must be mirrored to ensure that they fit the shoes as patients usually have matching footwear. We try and match the outer boundary of the FFO to help with shoe fitting but the individual profiles of the feet are kept.
The question I would ask is how accurate can our cast or foams impression be and can we be sure that the differences in arch height etc are true or down to the variances of the cast. I big part of what we do is to try and assess this nad respond based on our knowledge of the practitioner, quality of the cast etc.

Cheers

Phil

 

I agree with your observations, however I would not attribute this to CADCAM only. I have seen plenty of devices from traditional labs where it appears that they do exactly the same thing.
I find it disconcerting that so many lab manufactured devices end up looking quite generic- meaning that you cannot see that the device was made for that individuals foot.
I think it is this that gives people like Ed Glaser ammunition to criticise traditional orthoses.
NB- this does not mean the orthoses don't work however...