BoneChat #135 - Surgical Robot Failures, FDA Hurdles & Ortho's Future

That's pretty funny. So we have open discussion today, Mark and Colleen. So anything you wanna talk about, I don't have anything particular. I would, I do wanna talk about vicarious surgical a little bit cuz that is, that's not in orthopedics, but that is fascinating to me. I wrote an article about Vicarious. It's been a 10-year train wreck.

Geez.

What area are they in?

They're in, they're in the da Vinci space. The general surgery had all these little robot pincer things that, you know, would go in and do general surgery. And they, they spent, they raised $300 million. And they never, never even launched a product, never sold a single dollar, and they went public and the stock went down to zero. And then yesterday the board said, we're done, we're shutting the company down. It's an incredible story of lack of hubris, I think, is probably the, the biggest take-home message. A lot of big egos. But Vicarious Surgical is, you, you know, they, you get caught up in the hype and everybody believes it and, and then they, you don't execute and people keep throwing more money at you. It's incredible how that, how that happened. Yeah, I just wrote about it. Um, the ticker symbol, let's see, uh, say, find it here. Well, maybe I didn't publish it yet. Oh, I didn't publish it yet.

Huh.

I'm always working on articles in the background. But Colleen's got the doubles going on here. I'm gonna get rid of one Colleen.

Well, that was Okay.

Try again, Colleen.

So my comment was going to be, you know, we've seen this over and over again. A space gets hot, you know, whether it's, you know, some subspecialty or whatever. And if they can get a big player in, you know, everybody just crowds to be part of, you know, FOMO, right? They don't want to miss out. But I would say, you know, going public without having launched a product. I don't know who the underwriters were, but that's just kind of crazy.

I think that's, I think that's irresponsible. I mean, Monogram got away with it. Monogram Orthopedics. They spun a great story, went public. They got very little raise when they went public. And then they, they sold their story to Zimmer and they got away with it, but that's rare.

Well, you know, Monogram actually raised over $45 million from crowdsourcing.

Yeah.

You know, so I, you know, I don't know if it was the right thing to do or not, but it clearly worked out for them and their shareholders. I was on the board of Monogram and for full disclosure, but, you know, I think that, you know, it's rare, as you said, that that works.

Yeah, I did a little early recruiting for Ben Saxon and I, I just didn't feel, I didn't feel right. I just couldn't take anybody to that company. I stepped away.

Well, you know, it was interesting. They offered me a position there. In hindsight, I probably should have taken it. But, uh, but you know, I, uh, I just was doing other things, right? You know, you get, you know, involved in what you're doing and selling Consensus at the time is what I was doing.

Yeah, yep, that was, that was a heavy lift. Yeah, so Vicarious, I haven't— I didn't, I didn't publish the article yet. Interesting. But Vicarious, um, I mean, that's, that's, that's just— it's almost like Surgiline. It's just big ego and bad decisions, and then it just torches all the investors. Um, that one, I, I will talk about that maybe after everybody looks at it. Todd, anything? It's open discussion today. Raymond? Mark?

No, let's— nothing top of mind.

Raymond, how did it go at the conference you attended here in the Bay Area?

Can you hear me okay?

Yes.

I'm driving on the turnpike in Florida, so hopefully the connection will be okay. So Colleen asked about this venture capital meeting in San Jose about a month ago. I can share that experience and two others if you really want.

Yeah, please.

So educational, in some respects interesting. Zero value. And what's really interesting is how BC people— and I'm sorry if I'm offending anybody— will even say, you don't want our money, we're the worst possible money you could possibly ever get, and we're not giving it to you, and we don't have any in the first place. But thanks for coming to our conference. Do you think I'm getting a little cynical? But, you know, I do appreciate the people that were running the conference. It was very well attended. It was interesting because it was a whole smattering of technologies.

There's—

I mean, if you're into really futuristic stuff all over the map, these are kind of interesting to go to. It was located right in the heart of Silicon Valley at the Personal Computer Museum. And so the venue itself was kind of interesting. I told my one joke. You ready for a joke?

Bring it on.

You know, you can't trust electrons. They make up everything.

That's pretty good.

It's a great dad joke.

Yeah.

Um, but I figured that was the right place to tell that joke in Silicon Valley.

Yeah, geek joke.

So, um, that was that meeting. I mean, amazingly, one of my board members came down from the city, San Francisco, and spent the afternoon with me. I figured— I mean, I'm talking about Sig Bourbon. I figured he would have been in clinic or in surgery. He must have somehow— something broke open. So it was a great visit with him and he was very supportive. I did my pitch. It was okay. And it's always good to pitch. I then went from there to Newport Beach, and this is a different group. That, um, it's different clientele, mostly people trying to get their hand in your wallet as opposed to the other way around. And so educational, I did my little booth and, you know, I kind of stand out amongst all these different health companies and other sorts of people. I figure You know, if you go to the conventional stuff with all the other orthopedic people, you're not going to make much headway. But this is really much, very much out of left field. And what I got were people who are like, wow, this is cool. Uh, what's a spine fusion? Um, you know, they don't know anything about orthopedics or anything, but they're pretty impressed. And What came out of that is one entity that I'm in discussions with that may be good. Um, they're wanting to invest $5 million, and that's a reasonable term, but it's the devil's in the detail, and that's about where I'm at right now. Um, and they also are, you know, they have 3 tranches of 5 additional million in 3 tranches that, you know, as debt. And so that may be interesting. We'll see. But it— so that wouldn't have happened had it not— had I not gone to it. On top of that, and again, I'm probably saying way too much, but there's a PE group that's now somewhat interested in what I'm doing. So that may be Wow. Interesting. And their number is 20 million. So that's encouraging. But we'll, again, it's way too early to, to say it ain't over until it's over. It's, so then I went from there. So this was a road show to Las Vegas, even more bizarre. And again, very disappointing, but interesting. Um, maybe some opportunities with people that are trying to get me in front of other people. Of course, everything costs, and it's interesting how many times people charge $7,500. I don't know what it is about $7,500, but that's the ticket price, it seems, going great. So I got a group of, I don't know, 10 or so options with other activities going on in the background. So that's my story. It's not a happy story, but it, it may turn out to be something. Did that answer your question, Colleen?

I was just curious, but yeah, so it sounds like mixed, really mixed results. But yeah, I totally get it. Conferences are expensive, although there's a few that are really good that aren't.

Yeah, and I'd like your advice on which you would advise You know, the Akuretsu Group is hitting me up, but again, I'm not sure they're the right group for me, partly because even their own data, the Angel Network, says they typically invest in companies with valuations less than $10 million, and they're all about multiples as opposed to ROI. And so I don't know. But lots of people looking for handouts, I'll tell you that. What would you recommend, Colleen?

Well, you know, I mean, you may already know of this conference because it's very much focused in orthopedics, which is MNVC. It's a really good deal for what you're able, you know, the number of investors that can hear your pitch if they accept you as a presenter.

Yep, yep.

Um, October, right?

Yeah, I think it's late October this year.

Yeah, usually November, maybe first week in November, right in there.

Where is that? Where is that one?

Memphis.

Okay, that's what I thought, with the M.

That's Gary Stevenson, if I'm remembering right.

Yeah, HealthPoint Capital. He used to manage private money, now he's with HealthPoint Capital.

Yeah, that— thank you, that's a good idea. Okay, um, I have a totally unrelated question if you want a topic. Um, so I guess the news broke that Depew Synthase purchased Ron Satcher's company Expanding Innovations. Um, are you aware of that? No. Just do a Google search. I'm thinking it came out today.

Mm-hmm.

And so, 7 hours ago, reading it. Yeah.

Do you know Ron Satcher and that company?

No.

I know Expanding Innovations, but I don't know Ron.

So they, he's, well, I don't know him well. I just met him a few times, but He had interacted with Depew Synthase for years as a partner company doing distribution, and he was spitting bullets mad a couple years ago, is what I recall, because they were doing nothing with it. Well, all I know is they ended up buying his company today, so, uh, congratulations to him, assuming it's a good deal. Um, I don't see any data on valuation. So my question is, does anybody know what he got?

I, I just looked it up. I couldn't find it either. It's, it's undisclosed, but it'll leak out eventually.

Yeah. One thing I did learn, and this may be helpful to the group. So Integrity Orthopedics, which is the shoulder rotator cuff product.

Yeah, Smith Nephew bought them.

Yeah. So I learned their multiple was even higher than 45. I don't know if you guys—

they had really low sales, so the multiple doesn't really make sense because I think they were just— they didn't have an early— they didn't really have a lot of history with sales.

Right.

They got like a 50x because they had huge trajectory. Really differentiated from an absolute gigantic market that there's a lot of room to grow.

Well, you call it gigantic, still, still way overvalued. Yeah, my interpretation is their market is only about $850 million in the US, unless you're understanding it different. What do you know? Growing it at about 8%, so it's not much different than the market I'm in.

Sports is more wide open.

Sports is in the billions.

Well, no, no, no, just rotator cuff. Rotator cuff is what I'm talking about.

Yeah, but that's the— well, rotator cuff has got to be approaching a billion, maybe 850 is close enough, but the same technology that used for the rotator cuff always finds its way into the hip and into the ankle and into other— it's good, it's got room to go.

Okay, I see. Okay, that makes sense.

Yes. Yeah, soft tendon ligament repair can, you know, you can change the device and use it in other areas pretty quickly.

Sometimes, sometimes you don't even have to change it. You just gotta submit a different set of data or indications for it and you gotta have a different sales force setup, which is why some companies don't do it. But I watched essentially a, a shoulder suture go into, go into a foot 2 days ago. Like it, It's just the same. It's the same. So, but yeah, in any case, Raymond, I think they got a, they got a really sweet deal.

They did.

They did. That surprised everybody, I think.

Yeah, we need more of those kind of deals. There's a drought.

There's more divestitures going on than acquisitions right now. Dr. Jacobs—

that one, that one happened towards the Dr.

Jacobs raised his hand, and I'm not sure he can hear us. All right, keep going, Kyle.

Well, Colleen, what else are you seeing out there? Anything?

Well, you know, I mean, it's more the same, I guess I would say. Early stage in medical device is difficult to get funded. And, you know, you've got the regulatory risk on top of the market risk and execution risk. And so I think money's going into other types of investments, whether it's, you know, AI or hard assets. You know, I think that we're just in that space right now.

Yeah, so I have a hypothetical question for you guys. Um, Raymond, if you wanted more on that, I don't, I don't have any more to offer, but sorry to swoop in there.

No, that's— I'm done.

Okay, so I've been thinking about this a lot lately, and I find the fact that the way our industry behaves from a regulatory perspective to be absurd in a couple of different ways, but in one way in particular, it stands out as We are required to demonstrate to the government that a product's packaging is going to last 5 years before we've gotten any sort of indication from the government that they believe that our product is mechanically safe and equivalent to something in the past. And I find that to be absurd that those two things are so intertwined. So for example, if we had— let's say we had an elbow device today. If we wanted to design that, build prototypes, proof of concept, file IP, put it through a QMS, run mechanical testing with the predicate, finalize the design, build all the design control up to the point of submitting a 510, except for everything process related. No packaging validation, no sterilization validation. Set biocompatibility aside too, because it's freaking titanium. We shouldn't be doing biocompatibility on any of that. The total cost of everything— all parts, all people, all labs, paying for some surgeons, all of that— you might get away with doing that for under $600 grand. Have a product ready to go, design locked in, we could submit this to the FDA. The cost of the rest of the stuff that is required for that submission— what's your packaging look like? Does it survive transit? Hasn't been in, you know, environmental conditioning? What is your sterilization validation? Have you done 2 times? And are there residuals? What's your shelf life and your labeling? And that stuff may cost another million dollars on top of it. It. And you're doing that spend not knowing if the first story that you have of the design equivalence is going to fly. So I've had this, this deep gnawing feeling like somebody has to figure out a way to put together a consortium to propose a pilot study to the FDA to do design approvals as a precursor to commercialization clearance and turn it into a two-stage process so that when it comes to companies, you can take in less money before you take your first step to de-risk. For even for sterilization companies, companies that do this testing, they would take on less risk because they wouldn't be working on parts until after it's already gotten call it, you know, Part A approval. Be better for investors. It'd be like everything would move smoother if you could break that down into two distinct steps where you got to a yes before you took the next step of having to get to the sometimes more expensive, sometimes more complicated yes. Will it just never happen?

No, it's not going to happen. I mean, if anything, it's going to get worse.

Well, let me offer this at least. Do you know who Dawn Lizzi is?

I do not recognize that name.

She was the founder of Empirical Testing in Colorado Springs. She sold that maybe 2 or 3 years ago, and now it's called ETC, and I can't remember who bought it, but But Dawn was not only— first off, she started her career at Acromed. She then established ETC to do testing of orthopedic devices. Very excellent engineer/businesswoman, super friendly, super supportive, and was very involved with the FDA in how to do things smarter. And she— I haven't talked to her lately about this, but I know she's had this passion for making improvements at the FDA and was very well connected there. So she would be somebody to ask if you're wanting to see— run it up the flagpole, see if she could give you a read on whether there's hope or And who, if so, who to, what pathway is the way to make it happen? That's my opinion.

I put, I put her LinkedIn in the chat. She would be a great person to have on phone chat.

I agree. She's very, uh, just a super positive person. Um, a very industry knowledgeable and, um, supportive. Um, So yeah, I, you know, she's actually one of my board members.

Oh, cool.

So ask her if you don't mind, since you ask her, sure, sort of give us, uh, the lay of the land with the FDA and regulatory changes from device, her device perspective.

Um, sure, I, I can ask her. I, again, I'm not sure how, if she's still involved as she was before, but I'll find out.

He's more involved than us.

Yeah, Kyle, that's an interesting idea. It kind of seems like it falls into the every good deed gets punished. Yep, I think that's right, you know. I've got something, uh, to run across you guys. So, um, we are, um, we were entertaining the idea of building a new platform called Forever in Motion dedicated to joint preservation, primarily the knee, through a series of acquisitions, all of which play into systemically prolonging the need for a total joint replacement. We have an established company with an international commercial base, and we have some target companies to acquire, and, um, we were getting ready to raise some money to do a reverse takeover on the Canadian exchange to make it happen. What is your, uh, knowledge or, um, kind of reference point or perspective on the idea of a company dedicated to keeping a patient from getting a total joint replacement?

How are you gonna monetize it?

Well, the way to prolong a total joint replacement means things like biologics, surgical intervention, meniscal repair, cartilage repair, basically everything up to and including, you know, the total joint replacement.

Replacement.

So there's a lot you can do. I mean, motion analysis, gait analysis, insteps, you know, use of AI to coordinate everything. Braces.

Tremendous.

There's a huge ecosystem, I think, waiting to be built. But I'm curious if anybody has seen this play anywhere else in the world. Colleen's thinking, I can tell.

Well, you know, there's a company and they're not doing everything. Have a specific focus to delay or, you know, maybe eliminate the need for a joint replacement. And, you know, so I think having not one specific focus can sometimes be a detriment if you want to raise funds from third parties, right? They just, you know, having to think about too many things being successful to generate revenue is a downside.

I agree. And that's why, uh, the platform is about joint preservation. It's about fighting the battle against time, a losing battle for the most part, but still. Um, I just interviewed a rep earlier today. He's 26 years old. He played football in college at offensive lineman, 325 pounds. He weighs about 225 now. He's got the knees of a 50-year-old. And I asked him, I said, when you're 18, did anybody really sit down and coach you what's probably gonna happen to you? You know, to get this scholarship? No, no, I never knew. Now I'm in the orthopedic industry and now I know. I wish somebody had kind of told me that. And I said, well, and then I told him about this idea, but just kind of talking, you know, I was just curious if, if anybody had heard of this play done internationally.

I, not internationally. I mean, I wrote this article a couple years ago called The Joint Conservation Consortium or something like that.

Yeah.

And it got people, it got people talking about it a little bit on BoneShout and stuff. But I think the hard, to me, the two things that are hard are the aligning everybody's incentives. So you have lots, you have, you know, 5, 8 companies and you've got to align, you've got to deal with all equity's got to work and the incentives have got to work and You know, and that's the first thing. And the second thing is sales and distribution. So how do you— you know, every sales channel is a different channel. And so, you know, biologics, sutures, bracing, stem cells, they're all different sales channels for the most part. That I don't— I can't wrap my head around how that would work.

I think it starts with a, uh, I think it starts with a new, uh, kind of physician. I've heard, just coincidentally, not related to this, uh, consumers, a couple of my friends and sisters use the word functional medicine when they've been to see their doctor in the last month, just out of nowhere. I said, what does that mean? Well, I ask him questions about, you know, uh, the complete systemic, you know, realm of that. What does this, this, this whole concept of treating the whole body, uh, is kind of catching fire. At least it seemed to, just coincidentally. So I think it— I think an idea like that has to revolve around a doctor or, you know, wanting to treat a patient and delay that as long as possible. Like we've seen physiatry and pain medicine in the last 10 years just blow up.

Yeah.

Anyway.

My wife's got OA under her patella and we were in Austin and we, I actually looked up a, who are the joint preservation guys in Austin? I found this guy.

Yeah.

60-year-old guy. He's done thousands of total knees and he just said, I, I'm not, I hate doing that now. I'm not doing it anymore. He goes, I, I think it's not the best thing for everybody's not a bone on bone and needs a total knee. And so he's doing all these alternative treatments. And, but you're, and I think you're right, it starts with a doctor. It, you gotta find practices like that. Yeah.

Yeah.

Just, I like, I like the, and why I was asking that question is I, I could be patient number one. So I've been, I was a pretty decent athlete. It was a big time trail runner. Then I converted into mountain biking when I started having knee problems. And so I have a, a right medial unicompartment currently. I've been 10 years, I haven't been running, I've been biking only just because of knee pain. So I'm that patient that, and you know, I designed a hip implant for Smith Nephew. So I know you get an implant when you're 40, Bo Jackson knows this, you're gonna get another one. And so I've intentionally been working my tail off to not get an implant. And I think the surgeon thing is, I've seen several surgeons here in Colorado. My favorite one, I know him, he's a sports trauma guy. I used to call on him when I did trauma with Smith Nephew. He's not a guy that's gonna do a total because that's, he doesn't do those, right? So his whole goal is preservation and not getting to a total yet. So I thought that was great. So I even saw him a week ago, and, uh, we're limping along. I'm trying to— I'm 58, trying to put it off until maybe 60-something if I can. And, and, and, and the one thing I found out, and it's funny because I just saw him, and, uh, he said, you've been wearing the brace that I got you. He said, I got a brace. It's one of those offloading braces. There's also an implant that they actually put in on the medial side, the to offload the medial side. It's crazy.

Yeah. That's crazy.

Yeah, I forgot the, yeah, crazy. I forgot the name, but, uh, but the, the brace works like a champ. It's a pain in the butt because it's just, they gotta put it on. There's 8 straps. It takes time. You know, the wife's getting outta the car and she wants to take the dogs right away. She doesn't wanna wait for me, but it really works. And it's so, you know, keep that in your mix cuz I, it's one thing.

I'm gonna keep your name on that list and Tiger, I'd love to get the name of that doctor in Austin. I like to call him.

Oh, oh yeah.

And Dr., Dr. Pat McNair here in Colorado is, is the guy that I really like that has been like helping me limp along, so to speak, and not get my, an implant yet.

And Mark, you, you introduced me to Alop, Alop Shah in Atlanta. He, yeah, yeah, definitely. He's gotta be on your list.

He's a good guy.

He's a good guy.

My oldest son, when he was 39, developed severe bilateral hip pain. I took him to see Dr. John Keating, who was at the time the team physician for the World Kickboxing Team. And obviously they get a lot of hip injuries. So John sat down with Stephen and he said, "You ever do any steroids?" He says, "Yeah, in college, yeah." "Do you drink?" A lot. I went to a military college. He said, you have AVN.

Oh no.

He says idiopathic. But he always asks those first two questions and just sort of anecdotally, it's, they're almost always get a yes. And so Stephen now is walking around with two Birmingham's.

Wow.

In his forties. He's doing great, by the way. He, he listened to my advice. I said, when this happened, I said, never run again.

No impact.

Stay on the bike.

Yeah.

The doctor that did it said, oh, I have guys that run. And I, I told Stephen, I said, don't listen to that.

No impact. Yeah. Is he concerned with metal on metal? You know, does he do metallosis testing everything?

So far, so far so good, Tiger. You know, I worry about that.

Got it.

Didn't Smith and Matthews, sir, Smith and Matthews had good results with their metal on metal, right? It was the, it was the a pew, they kind of just—

Everybody had good results. No, it was this one site in the UK that put all their cups in vertical because they were doing MIS surgery on big head metal metal resurfacing, and it was a disaster and ruined the whole industry. Metal metal works when you put it in right.

It is more difficult to put in than the— the operation is harder though, right? It's And the patient selection is another thing people botch sometimes.

I mean, you can make the same argument about ceramic. You could make the same argument about when you're dealing with smaller heads. It's the same, it's the same back and forth.

Got it.

Yeah.

I am not, well, I was, I don't know if you remember Tiger, so Tony Swartzkopf and I were working on all the Conserve Plus stuff. At Ray Medical when the DePuy ASR was launched. And we knew that thing was gonna fail, but it wasn't gonna fail because anything was wrong with metal-metal. They put the insertion feature for that cup on the inside of the design to get around the Ray Medical IP that grabbed around the outside that was really firmly established. So, and that's what happened, but it got combined with minimally invasive hip techniques, so the cups went in vertical. That's the worst thing that can happen for big head metal-metal. And then the cover-up is worse than the crime. Depew buried it, sat on it, you know, hid emails. Let's not talk about that for a couple of years. And then, man, it just— once the lawyers got a hold of it, it was gnarly.

Billion-dollar class action thing.

$4.5 billion.

Wow.

Well, I appreciate the feedback. I, I, I heard a couple of things which I will not forget. Number one, do not let the presentation devolve into a myriad of different companies or products or targets or or any of that sort of thing. That's the road to hell. It's gotta be really pinpoint, arrow-sharp, one thing, joint preservation, and don't let the potential investor think about anything else. And I think everybody agreed it has to be led by doctors, which has led me to think I'm actually gonna talk to Dennis about taking this idea to MD Envoy. So MD Envoy, as you guys may know, is a new Michael Sook startup with the sports agent that inspired Jerry Maguire, The Money, you know, that, that movie. And they are becoming agents for top doctors to negotiate, help them with their career path. And those kind— I think the kind of doctor that will gravitate to that will be a leader. And be interested in new things. We'll see.

Interesting.

So, Mark, there's a—

for physicians, that's fascinating.

So, Mark, I think one of the things that you're trying to fix here, whether consciously or unconsciously, is there's a lot of companies that operate in this early treatment, early intervention space, but they all have their own technology and they all stay standalone and No one's created a treatment algorithm or like a continuum of care. And if you can do something for that that creates kind of repeat business and one-stop shopping, that's, that's interesting because it goes— stuff even goes all the way back to laser treatments that have nothing to do with anything underneath the skin, all the way up to various through injections and interposition arthroplasty and into, you know, defect class defect filling things. So there's— that's an intriguing way of approaching it.

I think that's where AI comes in, because AI is part of the presentation that I put together, and that you need some sort of a, uh, hand of God guide towards the best, uh, solution at that particular time. You can't be tied to one particular nail because all you have is a hammer. You know, you've all heard that expression.

Well, right, and, and you're not putting it in the same piece of drywall. Sometimes it's going in brick, and sometimes it's going into, you know, foam. So the hand of God would be not just considering what the x-rays look like, it'd be considering what the patient health is, what their required outcomes are, and because that is probably a factor too.

The Hand of God reference came out because of the World Cup conversation going on these days.

And, and Mark, I think it's interesting. So, and I'm kind of going down this journey right now. So I actually just went to see him. I'm getting ready to do an MRI because it's, uh, I, I haven't had one. Um, we know there's, we've done bilateral X-rays, which are just, they're so limited, right? Because it's, he, he uses the analogy, especially for the knee, that you're, You're driving over a hill and before you reach the top of the hill, on the other side, there's a pothole, but you can't see it. You know, that's, that's X-rays. You just don't ever know. So the MRI is more, unfortunately, there's an expense thing, but I also like the thought of like a decision tree of what's next. You know, I know enough to be dangerous. I actually really like the uni, even though you only get maybe 10 years if you get a good uni. I like it. For the fact that the revision is pretty simple. The revision is a primary, right? So I'm definitely a very big fan because I know a lot about the Uni, but then even then, it's surgeon selection— who does it and who does it well. And then do you do robotic, right? And so I had a long discussion with them is, you know, oh, well, I'll back up one is the whole biologics, right? Like there's companies out here, Regen Revolution and QC Kinetics, these VR, uh, BMP companies, right, where they take your blood, spin it down, and put it back in. They're, they're expensive, like $4,000 for the injection. Um, you know, that component, this guy is very— he's like, it's just not proven. He said you can do it, it might be a placebo, you might be spending money. So he's kind of holding me back from doing that. Um, and then I kind of like the decision tree, like, do you go primary, do you go uni? You know, that kind of stuff. Patients. We are, we all need a lot of help in that. And I, you know, I spent 30 years in orthopedics, so I know a lot, but I'm still having decision tree anxiety.

Yeah, I've always thought that.

I'm kind of in the same spot. I recently developed some arthritis under my patella and it's not that limiting, but, you know, I'm not anxious to have an implant of any sort. And, uh, You know, I'm trying, I'm the physician that I'm seeing is trying to sell me on a, on a Uni. But I'm just like not.

Here, Colleen, go. We had, we had Icarus Medical on Bone Chat a few weeks ago. Call Icarus. They have a patella offloading brace and just wear that. You will bolt up out of your chair without any pain. It'll, it's amazing. And they're, they're all custom designed. It'll cost you $3,000, $4,000, $5,000, but it'll— and Todd's been dealing with brace. I don't know where you got your brace.

Yeah, my brace is cheap. It's a, it's a DonJoy product, right? One of those that you have to dial and it just pushes you over. So it's not a patella brace at all. It's just an offloading of one compartment or the other, medial or lateral. Tiger, can you put that chat? I missed that. That talk that you have. Can you put that— I'm sorry, my emails, I'm so far behind. If you can throw that in, because I wanted to see that. I was— when I, when I— because of my situation, I missed it.

Yeah, yeah, yeah, yeah. I'm a big fan of that company because they're, they're, they're, they're, you know, people call it the Tesla of braces. There you scan your knee with your cell phone and they'll build you a custom. It's just The whole process is fast and simple. I will put that in the chat here.

Can I weigh in on a couple of things that relate to this for Mark's benefit?

Absolutely.

So what kept the word that kept coming back to my mind multiple times while you were kind of describing your vision is the word that I've been seeing a lot lately, and that's longevity. Oh yeah, that's a key word in terms of health and wellness. In fact, somebody just said something interesting to me. He said it is possible that the first 1,000-year-old person is alive today.

Yep, I heard that too.

Yeah, it's kind of weird to think about that, but I don't know if I agree with that. But nevertheless, or what anybody would want to live more than 120 years, but, but that's, that's a whole nother story. But that's the first thing. The second thing, Mark, and I know you aren't interested in, you know, and I agree with all of your focus, you know, the focus and to investors and whatnot, but Are you— do you know who Dan Justin is down in Orlando?

Oh yeah, I know Dan really well.

Yeah.

Um, well, so he, um, is super innovative. He's very— a serial entrepreneur. He's got all kinds of cool technologies. One of the technologies is a chute that is shaped in a way that you'll and offloading in the knee. And there's studies that came out of, I think, England, and there's all kinds of studies and they track your gait and whatnot. And it actually works.

I don't know if you're familiar with, um, breaking up, Raymond, but I agree with the idea.

Well, there's various And so that actually is— I just learned, but I actually think they had a pretty good reimbursement story.

I don't know what happened to the company, but Dan would be the one to talk to if you're looking to, uh, to You were losing Raymond, but yeah, yeah, that, that you should definitely add that shoe into your armamentarium because it's, it's, it, you only wear it like, it's incredible. You wear it just 15, 30 minutes a day and it retrains your, your legs to realign themselves and it offloads whatever you need to offload.

It's a really good idea. The Europeans I think are a little ahead of this on us. We're looking at a target Austrian company that does, that does this. And there's a Belgian company that is also in this field. We're a little behind on the whole preventative medicine longevity thing. We'd rather, you know, we'd rather, we'd rather, we'd rather operate. You know what AO stands for, right?

Always operating. Always operating.

Dan is part of a group. It's basically a venture studio for orthopedic companies called Exodus. And so they've got some interesting things going on down there. They've got several companies under their umbrella. But yeah, they're really pretty innovative.

I agree. And— hear me now? Hello?

Um, still a little cutting out.

You're kind of in and out.

Okay, well, yeah, I just had lunch with Dan today, so if you need his contact, let me know.

That's great.

He's— we've— I've known Dan for 35 years. Great, great, great serial entrepreneur. Great guy. So I want to— let me whet your, uh, your appetite, Mark. So On July 30th, we're gonna have Kinematic on BoneChat. And my favorite, just my favorite orthopedic company because, and you can borrow or steal some of their business model. That's the reason you should definitely be there on July 30th. So what Kinematic does is they are a knee and hip company, but they are a concierge service. So they go to physicians and they say, how would you like to upsell your patients and take part of the profit? And they go, okay, I'm, I'm interested. And they said, rather than just the patient walks in, you look at the x-ray, you're gonna do the same hip you've done every time. We're gonna give you 20, 30 hip stems and you're gonna pre— you're gonna preoperatively plan find which, which of the 20 or 30 hip stems fits best. And you're gonna use AR goggles in the operating room and you're gonna charge the patient out of pocket thousands of dollars for this. And these guys are killing it. They have no implants, no instruments, no regulatory issues, no, no codes. They have, they have, their business is so streamlined. It's just the concierge service. And the guys that started it came from the intraocular lens world, where I guess when you get a lens, you, your insurance pays for the basic level, but everybody ups, pays more out of pocket to get more features with their IOC. I don't know anything about eyes, but it's really common in eyes, and they basically brought that business model to hips and knees.

It's so American.

I'm sorry.

You know, in, in general, there's a big movement. Sometimes it's under the umbrella of, quote, wellness or concierge services, but we are actually seeing more and more companies being formed that are going after those that can afford those types of services.

Yep. It's not for everybody, but there's a lot, there's so much wealth in the US. And, you know, if you ask somebody, would you, uh, would you be willing to pay $5,000 for a better outcome? I mean, 25% of the population would say yes, probably.

If they believe you.

If they believe you. Yeah. And the surgeon's, you know, he's, surgeon's got his white lab coat on and he's gonna sell the patient on this. Uh, that's, that's your sales force. Interesting. I love Kinematic. I love their business model.

I'll be there.

Yeah.

When I was 20 years old, uh, I had a little accident in Vietnam and lost a couple of teeth, so half of my mouth is capped. And the dentist that did the work, I kind of wish he had told me then the price of that. It's just kind of like doing a total joint for your, for your tooth. You know, basically, you know, you take off most of the tooth and you cap it, and they don't last 50 years, that's for sure. Uh, and that's why I've always kind of liked the Uni, you know, or the HTO. These things prolong that joint. The challenge, of course, that was up until relatively recently, you know, with the use of, AI and MRI and custom, implants, they were, those procedures were very hard to do well because it's such a complicated knee, you know, the knee's complicated. But if you do 'em right, it's a great way to achieve that longevity. I'm, and I copied that word down too.

Yeah.

Thanks everybody.

Yeah, I mean, Todd and Kyle and I and probably Colleen, we used to go to those total joint conferences and they were always talking about total versus uni every time, total versus uni. And it was, unis would go in and out of favor every 10 years or so. Yeah. And then they would, they, you know, too many people would do 'em and then they would have bad results and then people would start doing totals and it's just, you know, but yeah, if you find the right surgeon, You know, Dick Scott, I remember the guys that used to just do a ton of them. If you find the right surgeon, it's, heck, I wanna keep my PCL and my ACL, you know, and I want, I want my natural kinematics, you know.

I mean, I can't tell you how many years I would listen to the first lecture of the year at some orthopedic residency program, and I always heard the same two things over and over again. Number one, stability, stability, stability, stupid. And the other one was bone is your friend. You know, if, if you don't need to, don't cut it away. I heard that every year, every year. And it really always made sense. Yeah.

Yeah.

What is, so Todd, what did this, what did your surgeon say? How long is your uni gonna last? Did he say 20 years or, and, You have one side.

This, this guy doesn't do— he, he doesn't do joints. That's why I actually like him, because he's not pushing me, um, to do a joint tomorrow, right? The, the, the question's— the answer is money. What was the question? Uh, he, he definitely thinks like the, the uni put in— he has a couple partners that do them, you know— is 10 to 15 years. Is— and I, family member, my dad had two unis. I and they lasted 10 years. But, you know, that's definitely a— it was his size. He's a lot bigger than I am that probably contributed to it only lasting 10 years. Yeah, so it's— and I think, and it's interesting too, I kept peppering him on the MAKOplasty. Like, do you, you know, because you see that those guys do a great job of marketing, right? And, and I have— there's a surgeon that's in, in his group that does MAKO. But he even is like, look, they're, it's 50/50, right? They don't know if you're getting, and I don't know if you guys have answers to that as well. Do we, do you know, have you heard that like MakoPlasty users are, have better longevity?

Oh, no, no, no.

Okay.

That's kind of what I, he was saying as well. He's like, it's, it's still, it's a marketing tool.

I need, I need you to think about robots in orthopedics like self-driving. In automotive and Tesla. If there was an accident anywhere on planet Earth where a self-driving Tesla harmed a child, you would know about it because it would be the loudest thing projected in the history of the world. Same thing is true for robotics and orthopedics. If there was proof that robotics made your knees better, that would be— that'd be screamed down. They would be projecting it into the heavens. You would not be able to get away from it. So the fact that doesn't exist means that the, the that the data is sketchy at best.

Interesting.

I have a father-in-law who has one knee from a robot and one knee from no robot, and they're both bad.

So yeah, yeah.

I think the, I think the robots help the younger surgeons do unis because, you know, unless you do a few hundred, you can't get good at them, right? You can do 5 a year if you're, if you use a robot. I think that's the main benefit.

Yep.

I'm sure there are case studies. Like, I think in the shoulder, central pin placement for the glenoid is probably better with the robot. That's hard. There's a lot actually going on there. I'm sure there's just going to be— but proof that it's going to give you a better outcome is totally absent. And realistically, if you're making a decision for a sample size of 1, which patients are doing, which we would be doing. I don't care about what you do. What is my outcome going to be like? There's no definitive proof that says that robot does it better. What is definitive is if you go to the guy that does 700 knees in a year, he's probably going to fix it great.

And then there's the time problem. So by the time you find out what works, that you can't get that implant anymore. It was designed in 1990.

Yeah.

You know, and the robot will be different. I mean, think of what robots are going to look like in 10 years. They're, they're going to be tiny little things. They're not going to be— speaking of that, I just saw that Think Surgical's just running out of money. They're dying right now.

Didn't they just bring in $50 million, $65 million?

Yeah, they're just— they have— they're, they're bleeding, they're bleeding money badly.

I thought they had a big deal with ZB.

It fell through, I think, what I saw. I could be wrong. And then the other one, Shoulder Innovations. My God, how, how much money can they— those guys spend? They did $40 million in sales last year and they spent $80 million.

That kind of sounds like Conformis.

It does. I mean, they're doing the Conformis thing, you know, they're public.

I don't know how Conformis did it, but I think Shoulder Innovations is doing it the way a lot of other companies have, where they're trying to force a growth rate of revenue by finding a way to pay every doctor they can, by signing them all up for development teams, by signing them all up for education, by making them all consultants. And that creates a very, very expensive way to sell an implant, is if everybody has to make money from it.

The short-term drug, it's not a long-term sales strategy.

Yeah, yeah, I think that would be really detrimental if you get into discussions with the potential acquirer as well, that you've bought all of your revenue.

Yeah, I just— I don't—

I just have—

I, I also have a couple of particular things about their design that I have things to say about that are best left for totally private conversation.

I don't get that one's another, you know, I just— smoke and mirrors. I just don't get it. Don't get it at all.

I put a book in the chat that everybody ought to have on their library called The Diffusion of Innovation, and it's basically— it's, uh, published in 2003. Essentially, it says that a successful market making largely depends on the social order that it's using. And a perfect example is Apple. Every movie made in the '80s and '70s had an Apple computer logo. It became the cool kid. You know, so that when the iPhone came out, it was a fait accompli, you know, like Coke, like product placement with Coke. And which is why, which is why I'm thinking about MD Envoy.

Hmm. Anyway, yeah, I can't wait to talk about MD Envoy some more. So this guy is, he's the sports agent for orthopedists.

He teamed up with, uh, Dr. Michael Suk, whom I met as a fellow at HSS. He's an MD, law JD, and just a really mover and shaker. And, um, they just, they built this.

Wow.

I think it's cool.

I think it's really cool.

Yeah. All right, thanks, Tiger.

Yeah, thanks. Been a good hour.