We report the case of a man with a transhumeral amputation in a rural area of Sierra Leone. The patient had fractured his humerus during a football match. Due to lack of transportation and medical centres nearby, the patient was seen by a traditional healer. Although the traditional healer expected the fractured bone to heal within 3 days, the open fracture became infected. This finally resulted in a transhumeral amputation. The patient began to have a lack of self-confidence and felt excluded from society. He could not afford a conventionally fabricated prosthesis. Fourteen years later, the patient received a lightweight three-dimensional-printed arm prosthesis developed at the Masanga Hospital. The patient was very satisfied because the prosthesis met his criteria of aesthetics and functionality. His story highlights the socioeconomic hardship of being a person with an amputation in Sierra Leone and the need for affordable technological solutions.
- rehabilitation medicine
- healthcare improvement and patient safety
Statistics from Altmetric.com
If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.
Sierra Leone ranks 181 out of 189 countries on the United Nations Development Index, with 58% of the population living in multidimensional poverty.1 Poor results on health indicators are indicative of limited access to healthcare. For example, 19% of the Multidimensional Poverty Index can be attributed to deprivations in healthcare, and there are only three physicians per 100 000 people in Sierra Leone.1
A long civil war from 1991 to 2002 ravaged the West African country. Machete amputations performed during the civil war have the effect of humiliating and disabling people. After the war, the healthcare system was disrupted. The effects can be noted until this day.2 Due to limited access to medical care, complex wounds and fractures often result in amputations.3 The majority of patients seen in hospitals have previously consulted a traditional healer. Where this does not lead to a cure, the patient seeks medical care at a hospital.4 Insufficient treatment of wounds and delayed patient presentation at the hospital are therefore common problems.
For people with amputations, upper and lower extremity prosthetics facilitate function and mobility and are important for access to income, food and education. However, the number of amputated patients receiving prosthetic devices is alarmingly low in Sierra Leone. Patients cannot afford the high costs of the conventionally fabricated heavy prostheses and transport to rehabilitation centres.5
Three-dimensional (3D) printing is considered to be a promising, affordable and accessible technology. In several developing countries, 3D printing was successfully deployed to print low-cost prostheses.6–13 Various projects focused on the development of functional prostheses with moving components. However, most functional 3D-printed prostheses have a robotic appearance that negatively affects aesthetics.12 13 This may result in reduced compliance of patients wearing their prosthesis.14 We believe that aesthetics is as important as functionality in the development of prostheses.
In this case study, we present an individual with a transhumeral amputation in a rural area of Sierra Leone with a 3D-printed aesthetic arm prosthesis made at the Masanga Hospital.
Shortly after the civil war (1991–2002), a 24-year-old man broke his arm during a football match in a rural village in Tonkolili District, Sierra Leone. At that time, there were hardly any medical centres in the area. The village was far from a town with a major hospital and there was no transportation to get there. The patient was advised to go to a traditional healer who was known for curing fractured bones. The patient’s family had to pay around US$30 and they were asked to bring a chicken. The traditional healer repositioned the bone, tied herbs soaked in chicken blood around the patient’s arm and instructed him not to untie the arm for 3 days. He assured the patient that the fractured bone would be healed after 3 days. However, the condition of the arm deteriorated after 2 days. According to the patient, swelling, pain and an offensive smell of his lower arm prompted consultation at Magburaka Hospital, Sierra Leone. A contaminated and infected humerus fracture (open and displaced) was diagnosed. A transhumeral amputation was performed (figure 1). The patient stayed in the hospital for 1 month and there were no complications.
At the time of the accident and the amputation, the patient was in high school and he had no income. He was the second child of a family of eight. Before the accident, only his father, who was employed as a teacher, had some income. Since his father died shortly after the accident, the patient and his family lost their only source of income. He and his family could not afford a conventionally fabricated prosthesis.
After the amputation, the patient lacked self-confidence and felt excluded from society. It took him several years to recover and to rebuild his life. He did not go to school for over 10 years, so he had fallen far behind. He went out for sports and social activities only occasionally. He could not resume his football career and became partially dependent on other people’s assistance.
Fourteen years later, we started a project in Masanga Hospital, Sierra Leone, to develop affordable, lightweight 3D-printed arm prostheses.14 As part of this study, we made a prosthesis for this particular patient. He confided in us he would like to become a teacher without being laughed at. Furthermore, the patient wanted the prosthesis to bend at the elbow joint so that he will be able to put his arm on the table while writing (figure 2). Therefore, both aesthetics and some degree of functionality were important for this specific patient. Aesthetics appears to play a major role in Sierra Leone.14 Although the function is limited, prostheses can be of added value in restoring confidence.14
The overall aim of this project is to make it sustainable. This means that the design and manufacturing process of the prostheses must be made as simple and standardised as possible to ensure that the local staff can run the project themselves. Furthermore, the prostheses must be affordable and within reach for Sierra Leonean people with amputations. As most people in Sierra Leone cannot even afford transportation costs to visit the hospital, it is important that our 3D-printed prostheses require little maintenance.15 We believe that a simple aesthetic prosthesis with few maintenance-dependent parts and types of material can be within the reach of Sierra Leonean people with amputations. As regained confidence can be the result, people can be encouraged to participate more in the community again.14
The design and manufacturing process consisted of three stages. Dutch and Sierra Leonean prosthetists were involved in both processes. First, our local physiotherapist, who is trained in the use of 3D systems, scanned the residual limb and the contralateral arm using a 3D scanner (Einscanner Pro; SHINING 3D Technology, Hangzhou, China). This process took approximately 15 min, including preparation of the scanner and clinical inspection of the residual limb. Second, we made a design using Meshmixer (Autodesk Meshmixer V.3.5; Autodesk, San Rafael, California, USA) based on the mirrored version of the contralateral limb and the residual limb. The design consisted of three components: the upper arm with custom-made socket, the elbow joint and the lower arm (figures 3 and 4). Third, we printed the plastic components using a 3D printer (Ultimaker 2+; Ultimaker, Geldermalsen, The Netherlands) and attached the components to each other with bolts and nuts. We used polylactic acid (PLA) (Black Tough PLA; Ultimaker) to make the prosthesis. It weighed around 600 g (US$28 in material costs excluding VAT). Tough PLA was selected because of its low cost, ease of printing and high strength. We even demonstrated that tough PLA can be used to create strong transtibial prostheses.16–18 Positive follow-up results for both arm and leg prostheses are reported.14 16–18
The printing process lasted approximately 12 hours. Additional adjustments were made according to need, together with the local physiotherapist. Foam was used to prevent pressure spots. To protect the prosthesis from ultraviolet light and moisture, the prosthesis was coated with epoxy (XTC-3D; Smooth-on, Macungie, Pennsylvania, USA) and ultraviolet light-resistant colour pigment (UVO; Smooth-on).19 20 The prosthesis was attached to the upper body through an adjustable fabric bandage made by the local tailor (figure 3). The whole process took less than 24 hours.
After receiving the 3D-printed prosthesis, the patient was very satisfied. He explained that it made him feel like he belonged to the community and gave him the impression of being ‘normal’ again. Six months after receiving the prosthesis, he filled in our follow-up questionnaire. He explained that he uses his prosthesis when he goes to school. Furthermore, he mentioned that the socket is comfortable as there is a soft lining between the device and the residual limb. He did not have any skin-related side effects.
Global health problem list
In Sierra Leone, traumatic injuries account for a significant morbidity rate.
Poor hygiene and a delay in surgical care often lead to severe life-threatening infections.
Traditional healing is a contributing factor for delayed patient presentation at the hospital.
People with amputations in Sierra Leone experience negative attitudes toward visible physical disabilities and feel excluded from society.
There is a lack of support for people with amputations from the government and international organisations.
There is limited access to prosthetic and rehabilitation services for people with amputations in rural areas.
Global health problem analysis
Traumatic injuries and poor hygiene
In Sierra Leone, non-fatal injury prevalence per year is 12.4% and fatal injury prevalence is 5.6%.3 The overall most common cause of injuries are falls (40%), followed by lacerations, burns and traffic-related injuries. The lower and upper extremities are affected in 34% and 21% of all cases, respectively.3 Such injuries often cause severe wounds. Wounds cover 19% of reported conditions in need of surgery.21 Sixty percent of these wounds are caused by injuries. However, only 29% of those with conditions requiring surgery actually receive surgical care.22 People living in rural areas are relatively more likely to need surgical care. Common reasons for not receiving care are lack of money and lack of skilled personnel or equipment.21 In the whole country, there is only one tertiary referral centre, situated in the capital Freetown. Emergency and trauma capacity are limited. Therefore, there is often a delay in surgical debridement and other surgeries.23 Given that poor hygiene contributes significantly to the health problems in Sierra Leone, severe life-threatening wound infections are common.24 When the skin, fascia, muscles and bone are infected, amputation is often the only solution.
Delayed patient presentation and traditional healing
A reason for the delay in surgical care is delayed patient presentation. There is approximately one traditional healer per 500 inhabitants and one medical doctor per 40 000 inhabitants in Africa.4 Due to traditional beliefs and the inadequate transport infrastructure, people are often seen initially by the traditional healer rather than a medical doctor.4 Furthermore, visiting a traditional healer is less expensive than admission to the hospital. In the case of a bone fracture, the family of the patient currently has to pay around US$15–30 for a visit to a traditional healer and they could be asked to bring a chicken. Hospital admission including treatment and medication for 1 month costs around US$75 (at the Masanga Hospital). In Sierra Leone, 42.1% of elderly individuals seek healthcare from a traditional healer for surgical diseases.25 Traditional beliefs that disability comes from evil, is caused by witchcraft or is the will of God are causes for not seeking help from a medical professional in addition to financial barriers.15
Negative attitudes towards disability and lack of support for people with amputations
In Sierra Leone, people with amputations experience many obstacles in society. They are stigmatised and discriminated against. Families neglect disabled children. Traditional beliefs are viewed as a cause of discrimination.26 Furthermore, people with amputations in Sierra Leone face challenges with the availability,15 affordability26 27 and quality28 of assistive devices.
In 2007, the Government of Sierra Leone signed the United Nations Convention on the Right of Persons with Disabilities to include this marginalised population.29 However, people with amputations continue to face discrimination, especially in rural areas.30 31 Education on the cause of disabilities could increase acceptance. Families need knowledge about disabilities and they need support to take care of their disabled family members. More than 50% of Sierra Leonean people with amputations have no access to education at all.32 Skills training should reduce poverty and increase access to rehabilitation services for Sierra Leonean people with amputations.33 Examples were given of patients using assistive devices who were able to contribute productively to society again. As a result, they managed to gain respect of the community.15
Low access to prosthetic and rehabilitation services
Sierra Leone is one of the world’s poorest countries with an average income of US$490 per capita per year.34 People with disabilities in Sierra Leone tend to be extremely poor.35 Their socioeconomic circumstances are often worse than those of non-disabled people. They are more likely to be unemployed, live in rural areas and have less access to proper healthcare services. Sixty-nine percent of people with disabilities have no income at all.35 Prosthetic services should be accessible to people struggling with poverty or living in a rural area. Potential patients living in rural areas are often unaware of existing rehabilitation services. Information campaigns have increased the number of patients seeking help at rehabilitation centres. However, it is difficult to reach patients living in rural areas. Besides, patients cannot afford transportation costs.15 Until now, prosthetists in Sierra Leone are reluctant to make a prosthesis for someone who lives in a rural area because they might not come back for a delivery appointment. Therefore, follow-up programmes and outreach services are suggested for rural patients.33 People doubt the government’s ability to sustain rehabilitation services. The government’s low prioritisation of prosthetic services is seen as a barrier. There are few prosthetists, and appropriate materials are expensive.33 According to the Community-Based Rehabilitation Guidelines Health component, only 5%–15% of people in low-income countries who require assistive devices have access to them.36–39 In Sierra Leone, the total cost for a patient to receive a conventionally fabricated prosthetic limb is approximately US$150. Considering their average income of US$490 per capita per year, buying a prosthesis is beyond reach for the vast majority of Sierra Leoneans with amputations.34 Local prosthetists expressed that non-governmental organisations are needed for financial support, for staff with the right skills and for appropriate materials. They express a desire for continued training as they feel unable to deliver prosthetic services of high quality.33
The 3D printing project in the Masanga Hospital may increase access to affordable aesthetic 3D-printed prostheses for people with amputations in rural Sierra Leone. Local staff will be trained to run the project themselves to make the project sustainable and to build local technical skills capacity. To achieve this, the process of making prostheses must be made as standardised and simple as possible. Currently, digital designs are made by Dutch students as this process is still too complex for the local staff. We are working on a programme to automate the digital design process by which the local staff can eventually carry out this design step independently.
Of course, there are some technical challenges and limitations of the 3D printing technology in a rural setting; power outages are common and 3D printers, 3D scanners and 3D printing materials still need to be imported. To prevent failure of 3D prints due to power outages, a solar system combined with batteries was used. For this project, our 3D systems were donated by Dutch companies. As developments in the field of 3D technology are moving very quickly and prices are steadily declining, we believe that these technologies will soon be available to developing countries.
To assure quality control, voluntarily involved Dutch 3D specialists, who are affiliated with the Radboud University Medical Center in Nijmegen, are always available for online consultation. To date, only the local physiotherapist has been trained to administer follow-up questionnaires and to decide whether maintenance of the prostheses is required. These efforts are made to ensure that the local staff will be able to run the project themselves and to make the project sustainable.
I was that athletic-type child, very active and strong, but fate has reduced me into a partially dependent person for the rest of my life. In my village, I was part of the soccer team, and in most of the games we played, if I was not on the team, both the fans and teammates protested.
Losing one of my body parts brought untold suffering and a total setback to all my dreams and aspirations of a future career that would have brought me money, satisfaction, independence and better achievement. Sometimes I don’t even want to think about it because the thought of it would bring fresh and renewed tears in my eyes. It took me several years to recover from shock and trauma.
The community and especially the youth were seriously impacted by this incident as well because it led our team to disintegrate for fear of repetition of the same incident that occurred to me. We also learnt a lesson that whenever somebody has an injury of that sort, we have to rush him to the hospital right away because we now believe that in the hospital there are trained and qualified medical practitioners who can administer treatment without hate.
The artificial limb you provided me is useful and sometimes gives me the impression that nothing is wrong with me. I am really grateful to you and the team for providing it to me.
Public awareness of disability due to amputation is needed in Sierra Leonean society.
Support from the government and international organisations is needed to decrease barriers for people with amputations in Sierra Leone.
Access to affordable prosthetic devices of high quality that meet their criteria of functionality and aesthetics is very important for people with amputations, giving them a sense of dignity.
Three-dimensional-printed aesthetic arm prostheses are an affordable alternative to expensive conventionally fabricated prostheses for people with amputations in the rural area of Sierra Leone.
We would like to express our gratitude to Throy A.R. Koroma, the local physiotherapist, for his contribution to the project.
Contributors MDvG, MvdS, JHVN and LB were involved in conception and design of the study. MDvG was involved in acquisition of data. MDvG was involved in analysis and/or interpretation of data. MDvG was involved in drafting the manuscript. MDvG, MvdS, JHVN and LB were involved in revising the manuscript critically for important intellectual content. MDvG, MvdS, JHVN and LB were involved in approval of the version of the manuscript to be published.
Funding This study was funded by Delft University of Technology, Dutch Albert Schweitzer Fund (NASF) (2019-2-18), Ultimaker (Ultimaker BV, Geldermalsen) and Makerpoint (Makerpoint BV, Arnhem).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.