Interview with Brett Carey: 3D Printed Orthoses

Dr. Brett Carey is the CEO of Kalo Multispeciality Group based in Kona, Hawaii. His clinic exclusively uses 3D-printed hand orthoses for all post-operative patients. Kalo has also performed clinical trials with Spentys Orthopedics, trialing Ankle-foot-orthoses within adult patient populations. Additionally, Brett is an Adjunct Professor at Hawaii Pacific University which became the first University to offer additive manufacturing education to Doctor of Physical Therapy students. He serves as a Key Opinion Leader in Orthopedics for Desktop Health and believes that additive manufacturing will help meet overarching healthcare system goals of decreasing cost while bettering patient outcomes. Brett will be joining us for the upcoming 3D Printing for Orthopedics Virtual Event.

When was the first encounter you had with 3D printing?

Brett: The first time I encountered 3D printing was through dentistry. I was Board Chairman for a community health center network at the time. Our health centers struggled with being able to provide cheap dental care to uninsured adults. Senator Bernie Sanders once referred to the lack of adult dental care through Medicaid as one of America’s worst healthcare crises. 

I had read articles of college students making their own aligners. Through Facebook, I met Dr. Eric Muraoka from Oahu. Dr. Muraoka had years of experience in printing full dentures for patients. Dr. Muraoka was kind enough to teach me about DLP / SLA printing and that laid the foundation for me to start self producing hand orthoses. 

Seeing dentures being printed in as little as twelve minutes was absolutely incredible. Solid dentures being produced from liquid resin felt like watching a magic trick unfold. I started to dream of how such technology could help low income patients and those in developing nations to have access to care that would otherwise be out of reach. 

Yes! These are actually dentures. Dr. Muraoka made these for a community health center patient. The patient received the dentures the same day they came in to be scanned. Dr. Muraoka’s team characterized the dentures to look realistic including the slight discoloration around the teeth and gum line. 

Shortly there after, the COVID pandemic hit. My wife was pregnant at the time and also was the manager of the Intensive Care Unit at our regional hospital. Hawaii always has a difficult time sourcing common medical supplies due to shipping being so expensive and slow to the islands. Our entire community knew that the pandemic would put us in a horrible position with obtaining PPE. 

I knew that printing as many face shields and Montana masks as possible would be the best option to ensure the health of my wife and unborn baby. Myself and an extremely talented team of volunteers ended up with fifty Prusa printers and produced thousands of face shields and masks for everyone from hospital employees to post office workers. 

Luckily our son was born completely healthy in 2021 and my wife never contracted COVID despite working with COVID patients daily while pregnant.

Home made Montana masks with blue paper towels as filter media. Back in 2020, research suggested that blue paper towels had a similar filtration rate when compared to surgical masks.

What inspired you to start your journey?

Brett: In my home town of Kailua Kona, we always have shortages of all type healthcare providers. Throughout my career, I have tried to meet emerging needs. One day a new local hand surgeon (Dr. Tirre) called me and said that he needed our practice to take on his post-operative patients. My clinic was the only clinic willing to see patients with various Medicaid insurance plans. Medicaid patients had nowhere else to turn but to my practice.  

I agreed to start seeing hand speciality cases even though none of our providers had experience with hand forming speciality orthoses. I needed a mechanism to ensure that every hand orthoses we produced was done correctly and quickly. Typically patients need to be fitted for a correct orthoses within 36 hours after surgery.

Using 3D scanning, CAD design and 3D printing allowed us to make sure that every single patient in need could be fitted quickly – even if they didn’t have an appointment scheduled. Digital processes have allowed us to serve many more patients than we ever could have served with traditional hand made thermoforming. We also are able to make custom orthoses for patients living on other islands without access to care. We simply have their family members use one of the free iPhone scanning apps and then we create and mail the orthosis.

After successfully fitting patients for a consecutive year, I started to consider expanding into other applications for patient specific devices. I quickly started producing adaptive tools for patients who were unable to grip utensils when eating. I also began to produce ankle-foot orthoses for patient’s with foot drop and issues related to calf contractures.

Left: Heat smoothing an FDM print to blend layer lines and make the texture as skin friendly as possible for the patient. 

Middle picture: A patient with a PLA resin orthoses. One entire month of wear and no skin breakdown. 

Right: An adult with bilateral AFOs. This individual has no sensation to light touch or pressure and was extremely at risk for skin breakdown. 3D scanning ensured the best fit possible and after sixteen weeks the patient still has not experienced any skin breakdowns.

Who inspired you the most along this journey in 3D printing?

Brett: My biggest source of inspiration has been Dr. Tarek Loubani (of the Glia Project) and all of the healthcare providers in the Gaza Strip utilizing basic hobby level printers to produce incredibly well made general medical equipment as well as patient specific assistive devices. The blockade of the Gaza Strip has made it incredibly difficult to gain access to all medical supplies. Engineers and physicians there are using plastic bottle trash that floats in from the Mediterranean Sea to melt and then turn into printable PETG filament. This filament is then used to create anything from transparent facial orthoses (used for burn victims in air strikes) to stethoscopes. 

The United Nations stated that by year 2020, the Gaza Strip would be uninhabitable. Two million people still live there and everyday are discovering innovative ways to serve the healthcare needs of the population.

Left: Made by Prosthetist Rabee Naeem. Prosthetic arms like these are made on cheap printers costing $200 USD for Palestinian refugees in Jordan. 

Middle: The Glia Project’s open sourced stethoscope. Acoustic trials suggest that this stethoscope functions as well as the Littmann three stethoscope.

Right: Concept design by engineer Jakub Kaminski. This work flow is to allow healthcare providers in conflict zones access to offline solutions for making customized medical devices. 

What motivates you the most for your work? 

Brett: My biggest source of motivation comes from Irish history and culture. Although I live far away in Hawaii, I am very engaged with mentoring and socioeconomic issues back in Belfast, Northern Ireland. To say the least, the Irish community has suffered many traumas in recent history; especially in the North of Ireland. 

Our duty as the Irish diaspora is to help those suffering from the same traumas that we have lived through. Whether it’s new immigrants to America without access to healthcare resources or assisting victims in places like Ukraine and Gaza, the Irish community takes personal responsibility to discover new ways to solve human rights issues.

The first question I always ask myself when helping to develop new technologies is: how does this help those who are most vulnerable and most in need? Everything has to be viewed and  developed through this lens.

Left: one of 109 barriers that currently separate British and Irish communities in Belfast, Northern Ireland. These barriers were designed to prevent further conflict between East and West Belfast communities. 

Middle: Myself pictured with Frank Liddy (left) Chairman of Mindfulness Belfast and Máirtín Ó Muilleoir (right) former mayor of Belfast.

Right: The Irish Hunger Memorial in Manhattan, New York commemorates the millions of Irish that either died or were displaced from Colonial occupation and famine within Ireland.  

What is/are the biggest obstacle(s) in your line of work? If you have conquered them, what were your solutions? 

Brett: Initially, 3D printing meant climbing multiple steep learning curves simultaneously. From obstacles with 3D scanning being difficult with certain skin types to issues with post processing, I had so many challenges that I only solved by creating relationships with engineers.  

Until recently, it seemed very rare for clinicians to have ongoing professional relationships with engineers. Perhaps one of the greatest side-benefits of additive is bringing the engineering and clinical communities together. I believe that the stage is now set for tremendous innovation. Bringing the lab and clinic closer to one another will radically accelerate the pace of prototyping, performing iterations and clinical trials.

What do you think is (are) the biggest challenge(s) in 3D Printing/bio-printing? What do you think the potential solution(s) is (are)?

Brett: In the Orthosis space: I have seen several start ups in the orthosis space struggle to appreciate day-to-day  clinical workflow. These companies have had great products but producing and fitting these products needs to sync into existing personnel roles and workflow within clinics. The right product fit needs to include both provider and patient considerations. Many of these same start ups don’t have clinical cofounders or even clinician board members. In short, new start ups steeped in engineering talent also need healthcare providers as founding members. Doing so will prevent capital waste and will increase adoption rates among users.

In bio-printing: I still remember the first patient that came in for rehabilitation following stem cell injections to both of their knees. When I asked the physician that performed the injection what the rehabilitation protocols should be he responded with “just take it easy”. 

My concern with bio-printing is that the rehabilitation protocols might not be well researched or clearly defined. If we have patients showing up to physical therapy clinics with bio-plotted menisci but no specific post-procedure protocols, we could be setting patients up for tissue failure. 

The solution will be for kinesiology researchers to make sure they are advocating to be included within the entire spectrum of research from early human trials to outcome studies and to inform physical therapists regarding any relevant precautions. 

If you are granted three wishes by a higher being, what would they be? 

Brett: Replace armed conflicts with intellectual challenges that would have rival nations compete with each other to cure devastating diseases such as Amyotrophic lateral sclerosis, cancer, and other poorly understood diseases. Winning these challenges would be a much better source of national pride than participating in an armed conflict.

Access to high level education for everyone regardless of: Country of origin, Race, Religion,                      Gender. We would solve a lot more global problems if all of the world’s 7.8 billion people could contribute. 

For every nation to have the ethnic and racial diversity of Hawaii. Here in the islands, there     is no ethnic majority. As such, everyone gets along and we don’t have racial divides that plague so many other regions of the world.

What advice would you give to a smart driven college student in the “real world”? What bad advice you heard should they ignore? 

Some bad advice I received was to focus on my academic courses and not engage in side work while in college. The advice I would give is: gain as much real world working experience as possible while in college. Form as many connections as possible within the career field you are seeking to enter. So many college students graduate without any strategy as to how to convert their degree into a progressive career. Also side work will help to hopefully not accumulate too much debt while in school.

I co-founded my first start up shortly after graduating with a doctoral degree. I worked through all eight years of college and didn’t have any student loan debt. Not having debt allowed me to take the financial risk of co-founding a start up. If I had student loans,  I’m not sure that I ever would have become an entrepreneur. 

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