BoneChat #50 - Learn about the secret sauce at VIsie to "Make Robots Great Again!" with the CEO

Foreign.

Welcome to Bone chat discussion number 50. Today we have Doug Fairbanks. I'm a. I was a big fan of Doug actually, before he took the helm at Vizzy. And then once I learned about Vizzy and what they're doing, I fell in love with Vizzy. So they're creating a technology that I think every robot and navigation system in the world needs, but they haven't figured it out yet. So. Doug, welcome aboard. The mic is yours.

Yeah. Thank you for, for correction. I think we figured it out now. Can everybody else figure it out? Is the. Is the answer. But I'm, I'm very pleased to be here. Like Tiger mentioned, you know, Tiger and I really had a growing relationship in the time before I came to Vizzy and then became CEO. And, and actually Tiger helped me hire one of the best employees in the organization and that continues to bear fruit for, for us as a company. So we're excited to be here. As a, as a point, I'm, I'm very open to discussion. So if you have a question about anything that you see or something point in time, I'm happy to answer it and to stop me anytime and go ahead. I'm going to give a presentation that's eerily similar to what happened at mnbc. So some of you were familiar faces there, but I will go ahead and switch over and, and present my screen. You let me know when you see the right thing. Here is my. Does everybody see the.

There you go.

Good. Okay. So. So Vizzy is a deep tech spatial computing company. And that's a lot of word salad a little bit. Right? Really what we are, is, is, is a technology that's operating kind of on the edge of what is scientifically possible. And we're really giving, you know, spatial awareness to these technology systems that are becoming more and more a part of our day to day. And I'll tell you, I start every conversation and end every conversation with a talk about surgeons. Surgeons are our customers. We're very deeply interested in what surgeons want and what they need. And I think that's a winning strategy for us as a company to say, hey, are we solving a problem? I will also tell you that we pay unique attention to experience and I'll talk a lot about experience in this. Not the experience of the team, although that's valuable, but when someone interacts with our device, what is the interaction doing for them and how is it making their lives better? So that's a little more lead in than I usually start with. But here's, here's a Bain and co study from 2022 that said 89% of surgeons were interested and orthosurgeons were interested in using robotics, while 51% had adopted. Now there's a huge gap between adoption and interest and there's any number of reasons why that gap might exist either through the cost of the systems, the learning curves, any number of things. But what it does speak to is that there's a growing interest in surgeons making decisions about their procedures based on the technology to do them. It used to be that we'd pay very close attention to the curvature of an implant or the features of it, or even the surgical approach, anterior or lateral approach. Then we seem to be in this era where part of the decision making, if not a very large part of it, is based on the technology used to put it in. When we think about that technology, we get this, this experience of putting pins and arrays into tissue so that the technologies can see where the tissue is there, the bone is right. And then that requires that we do a registration process. And many of you are familiar with this, but you take points on the anatomy and in this conversation we primarily focused in total joint replacement, but there is some spine material and that communicates back to a system. Now when I think about this process, I actually think about my father. My dad went to get his partial knee done several years ago and he said, Doug, what kind of surgeon did you send me to? You know, he operated on my thigh and my ankle. What's wrong? He couldn't find my knee. And, and we chuckle about that and say, well, you actually went to one of the most famous orthopedic surgeons in the world, Dr. Headley in Phoenix and his past and has since passed, but phenomenal surgeon and did a really great job for him. But you think about that experience and that's a bad experience for the patient. It's also a bad experience for the surgeon. The surgeon doesn't want to do a bunch of extra procedures and doing a bunch of extra registration. And the challenges associated with it go beyond the anecdotal that that there's tons of literature that point out that, that the use of these technologies, you know, result in pin site fractures, infections. The learning curves are very high. And the FDA actually issued a warning that says that these tracking technologies can result in patient death, life threatening injuries, failed, aborted or prolonged procedures. And that's pretty impactful. Now when we think about what this is, you and I see a bone with a couple percutaneous pins and arrays, but we have to think about what the computer sees, what the computer sees is this. A couple of dots in space. And when we think about the power of data and information and how often we talk about the use of data, we realize that there's a very, very low quality image data associated with these procedures that, that essentially a couple glowing spots in, in space tell us where the tissue is or where the bone is. And at Vizzy, what we're at, what we're asking you to do is to see the problem that everybody ignores. And in fact what we're saying is it's time to see the patient. Here's a single scan out of a scanner that we invented. A million data points in a fraction of a second. Size, scale, color, accurate, right. The computer can now see the tissue in the same way that the surgeon does. And we're excited about this. We invented this new way of three dimensional scanning and so we can change the embodiments and size and form factor. Here's a number of ones that we've looked at and continue to play around with as we work through in the company and, and we've gone to solve some bigger problems. Here's a scan that, that is in, that is done in infrared. The knee, right? A single scan of a knee in infrared that gives us data that doesn't disrupt the room or wireless, not disrupted by turning the lights on or off or the glow that happens in the room. Here is an anterior hip, a scan done quite frankly with the device not developed for an anterior procedure. And here we caught this very small female with an anterior approach, caught the bottom of the acetabulum and had enough data to superimpose a preoperative image. It was this image that won us the anterior hip foundation. Shark tank and 150 surgeons stood up and applauded us for, for solving this problem of putting pins and arrays in the patient to be able to know where the tissue is. Here's a glenoid the size of a half dollar. We can grab 12 to 14,000 data points easily enough, easily enough data to create a superposition to the preoperative image to allow your tissue to be able to understand what your computer to see what happens in the procedure. Here's a pig, 6 to 8 inches of adipose tissue in the office. We take a single scan, catch the side of the lamina and boom. Bring in the preoperative image. So being able to see where things are without radiation, without, without delay to the case and you know, when it's fine, we think about moving down the segments as, as you move down the segments or touch another segment, you introduce motion. And in fact, that's the goal. And so how do we know where those pieces are and make a meaningful connection to the tissue? And when we go further than that, we think about the ideas and concepts around registration. Right now, registration requires trace, where you take, you know, on a FEMUR of maybe 40, 100 or 350 data points, and that could be done in a minute or a couple minutes, again in a fraction of a second. 376,000 data points, orders of magnitude more precise than trace. Right. And is and is objective, not subjective, to where the surgeon decided to choose the. The point. And so last year at Academy, we did this. At Aukus, we did this. We mounted a scanner, robotic arm, we said, register the patient, then drive to a cut plane. And it did. I'll take you back through it. You see it very quickly here, but it's going to go to the anterior cut plane. It'll go to the distal cup plane on the femur, and it'll do automatically. Now, we're not moving towards an automated answer, but we're saying, hey, look, the tissue without pins and arrays can be seen and can be registered and made. We can make sense of it. We developed our own IP here and we filed it around the world. We are this week loading and sending through another tranche of ip. We can continue to develop and file ip. And we've done that globally and in really strategic markets. We're really excited about it. Our FDA pathway is through 510 and it's really as a component level which requires that we meet the 1345 and the 60601 testing go to market plan is through partnerships to gain market access to sell software and hardware and disposables. We're really excited about surgeons. And when we talk to surgeons, the response is very strong. I was at MNBC and I had a line of nine to 12 people. And that's honestly typical of our presentations. People line up to see how do they be more involved or how they understand the company or how do they participate more actively. But when we talk to surgeons, they say things like simplifying image registration would be huge. We need robotic systems that save time and tissue. Pinless robotics would be the holy grail. Pinless robotics would be the holy grail. So I'm excited to come here and to continue to share the special things that we've done as an organization. And when I talk to the engineers, they describe something that they call technical feasibility. And when I Have the marketing people say what we've done. They say, well, proof of concept. But when I talk about it, what I think we've done is seismic. It's huge, a big change. And that is continuous anatomic auto tracking. The ability to not only see the tissue in a snapshot, but to continuously see anatomy and use that to track where the procedure is going. Here's an image of it. Here's Dr. Andrew Fisher, PhD, biomechanical engineer, have in the office. We have a scanner mounted to the end of a Kuka robot. We're not a robotics company, but we happen to learn a skill to program a robot. What's happening here is really special. Looks simple. It is not. Dozens of times a second, this scanner that's covered by a blue dot here is looking at a knee. It's saying, I know that's a knee. It knows how big it is, knows how far away it is, it knows what its makeup is. And it's saying, I'm going to follow that. And on top of it, to make the problem harder, we've mounted it to a robotic arm that's moving. I use the analogy, you know, taking a picture of a car as it speeds by is pretty easy. Taking a picture of a car as you are driving with your head out of the car, holding a camera and steering the wheel and driving next to another car is much harder. And that's essentially what the team has done here, is essentially drive a robot while scanning the tissue and using it to get to a position. And so we asked, what's the impact of that? And the impact is, sorry, the video is getting caught up here is pinless robotic assisted surgery. The ability to not do those little surgeries outside of the patient, to be able to operate on them, to let the computer that you rely on for data to see the tissue the same way that you do. And we think that's impactful. So we, you know, we're really excited about the team. I actually am not a huge fan of this team because it tends to focus on leadership. And really the people who are making this happen are the, are the engineers who show up every day and push the very edge of what scientifically impossible, scientifically possible. And, and we're really excited about the things that we've achieved. We have a number of surgeons that work on, on a consulting board with us. We won a bunch of awards. It's exciting to reap the benefits of the awards and to be seen. We're in the Nvidia inception program. These are great, but the team is really focused on the big reward, which is treating our first patient, and we're barreling headlong at that. So at Vizi, I'll leave you with busy. There's more to see. I encourage you to all go to vizvision.com or to engage with us as meaningfully as you can to help us make our, our dream a reality. That's my presentation. I'll maybe show one more video because I just probably have one right off the press here. And I'll stop sharing while I do that and I'll open it for questions and then I probably have a couple questions that I want to send to all the experts here on the call. Sorry. There you go, tiger. Any thoughts?

No. This is fascinating. I mean, I think everybody's wheels are turning, like, trying to figure out, so how many, how many times a second do you automatically register now and what's the goal in the future?

Yeah, so we are. Well, I'm not going to give a direct answer there because. Because it's, first of all, it's influx. We gain speed every day. That's the big thing is that getting to a speed that's tangible for the robotic system that would be integrated into that being said, we're at dozens. I think that you watched a video just now at 25. It just so happens that the human eye perception is about 24 times a second. So if you go much faster, you're actually going faster than you need to go for people's perceptions. You know, there's like video gamers that can see faster than that, but they're trained for it. But, yeah, we are. We are, I think, above human perception standards and moving into places that, that are even faster for robotic systems.

25 hertz. And I remember the old television interlacing used to be, I think, 30 hertz or something like that. So.

Yeah, yeah. And we have 30 on the radar. We're not, we're not quite there yet, but we see a pathway to 30.

All right, Asher's got the first comment or question.

Yeah. Quick question and I apologize if I missed this. Why you guys start with knees instead of spine? Just out of curiosity.

We've worked in spine. We actually had done more work in spine before knee. It's an optical scanner, so it has to see the tissue to be able to execute on it. So open procedures are more compelling to us. So knee is very, very good for us. Shoulder and hip are interesting. Spine is a little bit deeper down. And we're working the formats that we believe will be more Compelling there, but it just so happens that the market in knees for this technology is, is much, much larger. Is that fair?

Yeah, yeah, that makes sense. I was thinking more at it from the perspective of open scoliosis surgery, which is really where the majority of surgeons who have adopted robotics in spine go.

You're right.

In terms of the percutaneous market, it really isn't, doesn't seem like a good fit, but that's good thought.

Thanks. And, and, and Ashley, that was a good comment because there are some players that are working on optical registration only now. We're not, we're registration and you're seeing tracking now. And the other players that are in the space tend to all be in, in spine. You see Path Keeper, Approprio and some others. Yeah, exactly what I was asking. Yep. 70.

Cool. Could. Great comments, Mauricio. And then Ted.

Great, great product. Great idea. Almost kicking myself, I didn't think of scanning the surgical field in 3D. I play with 3D scanners. I have one at home. So it's just. Yeah, I feel like I, I should have thought of it. But anyway, we, I, I'll give you a quick story, a quick pitch. We have a 3D platform for like surgical planning. So we've created a whole cloud based thing where you upload your ct, we auto segment it and it gets visible for the planning process. And I have a ton of CMF indications where maybe not for robotics, so it could be an easier pathway, but for surgical guide positioning. I think this would be an incredible tool. So I would love to discuss this further.

Mauricio, first of all, we happy to talk, happy to talk about segmentation. It is a need that we have. We are very clearly trying to stay in our lane. So people asked about segmentation, they asked us about all these things, we said no, we're, we're there and I'll even go a little bit further that we're not just a robotic solution. What the company does is it solves the very hard problem of connecting the technology to the bone or the tissue and that's agnostic. So that can be embodied into AR VR glasses, into navigation systems, into robotics. It just so that saw that you, there was an arm with a robot on it, but that that arm is not actually part of what we, what we bring as value to the company. So I, I'll touch on those pieces. The other piece is yeah, we absolutely do think about 3D and we're interested in there and so we will, I'm happy to connect at some other time to See if there's any synergy.

Yeah, that, that's awesome. Thank you.

Good stuff, Ted.

Yeah, Doug, great. I'm glad I was able to catch this presentation this afternoon because I was not able to see it in Memphis. But you know, Asher really covered the question I had about the spine side of it. And that makes sense because you know, minimally invasive percutaneous procedures, you know, if you have to, if you have to be able to capture a minimum amount of bone, it's, it's not going to be the right fit, at least for that side of spine, you know, the ASC type procedures or where it's going with endoscopic spine surgery. So, so is there a possibility or a technology that could take your technology onto a chip on a stick tip type thing if you get a minimal amount of, through a, through a cannula to be able to do the same thing? I have a follow on, I'm, as.

An investor, I'm marking my default answer when I don't want to answer. Is this mercy? So, so first of all, the company holds a lot of IP about a new way of 3D scanning. So that, that actually goes back to Mauricio's comments. Mauricio, we, we saw 3D scanning and we actually had to get to very accurate and very fast, which is a, which is not an easy problem. So, so that's where we spend all of our energy. Secondly, Ted, I'll tell you that that we do have thoughts or ambitions in spine and in mis. Appropriate procedures. We do think that there is a scalability to the product. Is that, is that going right now? They're still kind of early days there. I will tell you. I was actually on the call early with Tiger and I said, you know, someone had a quote about saying no to a thousand things so you could say yes to the one thing that matters. You know, one of the hard things in my role is all the really brilliant ideas that come here that I could go that I have to respond to is, hey, that is awesome. I see it, I want to do it. We cannot do it. And it, and it breaks people's hearts because they're like, I have a great idea and I agree they're great ideas. So we have, we have an mis place in, in the business. We have a place where we are thinking about it, but it probably won't get to fruition until we achieve some of our near term goals, if that's fair.

I completely support that philosophy.

Yeah.

Particularly with a startup. Focus, focus, focus.

So there's only so Much gas in the tank, right?

Absolutely. So an investor question. You know, where are you at from a, from a capital raise. Capital. Capital in capital raise. And, and you know where you're going to go in the next three to five years.

Yeah, I appreciate that. So last year, 2023, we went out and put an A round together. 8.2 oversubscribed around $8.2 million. That gets us cash into late 2025. We are pretty capital efficient. We don't, we don't spend a ton of money that gives us a fair amount of Runway. I particularly don't want to get into a bind. We were in a rough spot and going to raise money and everybody knows right now cash is tough. It is a tough game out there. So we are glad to not be raising right now. And we had that done last year. In the next three to six months, we will pick up the torch in terms of what is the, what happens at the end of 25 for Runway. And so I'm happy to continue to be transparent on the efforts that we're going to make there. It likely for us looks like not a B round, probably at the far end in A two, but more likely something like a note or something that rides with the company. So I hope that answers your question. I'm happy to continue to communicate and we can sign you up if you want to get information about the company. We will go to raise start talking about it more publicly if that's fair.

Ted, that, that's fair. And did I miss it? 510k approved yet or sorry, commercial.

Not, not yet.

Okay.

510. Not yet. We, we, we believe our best pathway is through essentially the sub component classification, which essentially means we have to meet the engineering standards, but then will be filed with the larger component. And I was going to let the questions clear out, but, but we'll hold on to that piece because I would like to just take the feedback of all the experts on the call on a, on an element there. But, but Tiger, there are other questions that are lingering.

Nobody's asked the business model question yet. So you guys, you have a unique way you could create your own devices or you could license what, which direction you think you're going.

Yeah, and, and, and I think that this is, you know, Tiger asked me to prepare some questions that I, that I could bring to some experts. And, and I appreciate that. So I will do that. Now my, my question is, and we, we think about this a lot, but really, we have solved this really challenging problem. We don't want to be a robotics company. And we, and I don't necessarily think that the value is standing up a standalone robotics platform. I think a lot of these companies have a robot to be able to put a moat around their business and secure the implant business as their real revenue driver and in, in a market. And I give a good presentation, I think on YouTube is a pretty fun one that talks about the mid-1970s, mid-1980s where there's, there was hundreds of computer companies and only two had something really different. Apple with Lisa and Microsoft with Windows where they thought about the user using a mouse to click on things rather than a command line to type in. And it made the computers way more usable and they were rewarded for this. So, so I positioned the company as having something that, that really dramatically improves the patient and surgeon experience and is a tool to make your robotic system better for your customers. And I really want to zero in on that. So as a model, I'll explain that our business model is to integrate into other platforms to make this, this a reality in surgery. So that begs the question. It shortcuts the, the ability or f or the effort that you have to do to launch a commercial organization. But it requires that there's real intensive work right now from OBD element on our business to make sure we secure partnerships. And that can be complicated because in, in any startup and a startup like this, an exit is critical. So when you think about strategies as it approaches, you know, a company that has to be embedded, how do you, how do you follow through with partnerships in a way that facilitates a maximum exit? And that would be the question I have for the, the folks.

Great question. So how would you guys, a lot of smart people, how would you position this to it to license agnostically?

Yeah, I can, I, can I jump in? So Doug, my thought is, you know, to be universal at least at the first stage of that process. You think about another sort of robotics company, say Essential Robotics for example, you know, in Spine at least they, they've gone and kind of partnered with half a dozen and probably there's more in Q companies to apply their, their technology to their, you know, mostly mid size or smaller companies to compete with the Mazores and the, and the Excelsior with Globus and, and on their, on their contracting basis. But I, I think it, my thought is it'd be important for you to just demonstrate efficacy and, and, and how the system works successfully and collect all that data by, by doing a few of those partnerships. Just don't give any exclusives away. And then you build that sort of momentum and that buzz until Stryker finally comes to their senses and gives you the right number, or J and J does, you know, for the, for the early investors. And so that would be my recommendation, is just, you know, draw up a list, you know, in this column we got these six that we want to start working with, and those are going to be the best or easiest to work with. And we do a really good job within the company and perhaps with them as partners and collecting data and being able to continue to get the word out, you know, up above the radar screen about how great this is and differentiated it is. But at the same time, keep your eye on the mission of, you know, a legendary exit, you know, in the space, because you're not going to try and become a robotics company either. So kind of just build the momentum that way.

TED I really like that answer. And again, the smirking is because I, I believe that is close to my exact answer. But, but I think that there's another hand up there. I like it. Thank you. Thank you, TED it's good validation. I think we are somewhat on that route, and I'm going to tweak that for you a little bit after we get some of these questions out of the way, because there's something another interesting piece of this. Sorry.

Interesting.

ASHER so I don't know if there's a CPT code for surgeons who do navigate a knee surgery. I know there is for spine, but if you're able to get a database of surgeons that use robotics in knee surgery at this time, then kind of working backwards to figure out what systems they're working with and then targeting those companies, maybe a sort of roundabout way to kind of get your customer, bar, your, your end customer buy in for the actual OEMs to understand the value proposition of this. If you're struggling with a strategic partner side directly, you know, if you, to me, if I was a surgeon and you showed me this, I'd be all over this because it seems like just an objectively better product than what's currently out there. And so Even if the OEMs don't really understand the value, kind of working backwards or indirectly may be, you know, a way to kind of get them interested and kind of, you know, force your way into that opportunity.

ASHER I think it's a great idea. In fact, there was a tool that got acquired and called Care Voyance that I used to do a lot of data mining out of. They're now owned by H1. So I don't know if the tool still exists, but they basically let you search all the CPT codes. So you could even go into your city and say, oh, I'm in Austin, Texas. And you could see what surgeon was performing what and data mine that way. So I do like that approach. We happen to have a pretty strong surgeon investment pool that, that is very strong. Advocates of us and high volume pretty well recognized folks. But, but I do think that when we show surgeons they get on the board pretty, they get on board pretty quickly and I like that as an approach. We plan to do some of that next week at Aukus. We have an off site event to continue to drive it. You bring up something really interesting, Asher CPT codes. There are a CPT code for navigation which also has been applied to robotics in, in Ortho. There is also something very interesting for us called oct called Optical Coherence Tomography. It's not accepted for, for bony procedures, but there is an OCT code for eye surgery. We have a very close correlation to October. And so one of my efforts in the back of my mind, and I'm open to anybody having a thought on this is to see what is the, what is the work that needs to be done to make an OCD code applicable to a spine or ortho procedure. Because essentially improving reimbursement would be a value add. That. That is significant.

Yeah, that's great comment. I, I mean obviously I'm a little biased. I would avoid getting into the space of trying to create your own CBT codes. I know there's a lot of companies that are doing that. It is a slugfest of work and it takes millions of dollars and years of collecting clinical data. And then if you think about it, you're basically taking away reimbursement dollars from other categories to be able to allocate to your novel code.

It's.

If you're able to make it work without it. Personally I would highly recommend that. But I know a lot of companies are pursuing novel codes just for scalability.

Yeah, I'm surprised that I saw somebody get one the other day and it surprised me because I know that it's a rigorous route. Thank you for the feedback.

You're going to let your partners do that part? What do you need to do the first surgeries next year other than FDA clearance?

Yeah, we think that there's also a possible route to get a lower classification as a Class 1 device. It's a camera, so not real risky to patients. A sterile drape actually is more risky. But, but we Think that we could even get, jump through a hoop and get a Class 1 device pretty easily and take this and start scanning patients and start building a database of optical scans to be fed into AI tools, which is a, which is a route and a business opportunity in the, in, in the company. We don't play that hand very heavily because I feel like everybody has to talk about AI. We have an AI play, we don't, we don't work it too hard. But the, the securing of a partnership, and I'll take Ted's lead here, is critical to our business. I think going downstream to a lower tier player and dictating the terms of the relationship is probably the, the best or bailout route alternative to not securing one of the biggest companies at the table.

Good cope.

Hey, Doug, more a question of back to in the operating room workflow associated with this. What's it look like?

We're, we're hoping much better. You know, we, we think about all the steps that take place to get to a surgery. So we showed that knee. But you walk in as a surgeon, okay, I'm going to put the, I'm going to put the pins in the patient. I either going to extend my arthrotomy to put the pins inside the wound or I'm going to do some stab incisions above or below put the pins in. So I got to put pins in the patient. I then have to close those little sites, right? I got to hope or pray that I don't have a pin site fracture. I got a guy in Los Angeles, he said, Doug, I do 500 needs a year. I have, I know two patients names, you know, I know these two patients names. I got a periprostate fractures the pins on two patients. And I'll never forget what a nightmare that was, right? And so look, not extra incisions, not extra pins in the patient. Also not the time to go and register this point, this point, this point, this point, this point, and then all the instruments and disposables that are associated with that. We still have a disposable component and that's critical to us in our business. But we're not going to have those pins and arrays and potentially less tray, one less tray for instruments to be able to do those parts of procedure. So the experience we think is enter the procedure, do the arthrotomy, point the camera at the patient. The camera knows how big the tissue is, knows where it's at. You say go and go. And I in fact think we have an opportunity in the next Couple months to even do a small clinical study that says we can go from our end of arthrotomy to first cut plane faster than, than mechanical instruments and certainly faster than any robot on the market.

Thanks. We, I sold apparently the only 7D in the state of Pennsylvania, and we were just using it this morning for spine. Obviously, it's a really cool system and workflow is pretty easy for the surgeon, but we see more Excelsius robots and stealth system sitting in corners because of the business model where the reps don't want to do it, the company won't send anybody in, and it's painful to set up and take down. And I, I don't know that, I don't know that I have much of a, a comment other than caution on the setup before the surgeon walks into the room, because it'll end up, if it's a lot, it will end up being back on your team no matter what anybody else tells you. And there's costs and expenses and investor money associated with that. That is astronomical.

Yeah. Yeah.

Not to mention sort of interesting because they, and 7D experienced it. Because they're experiencing it still, even though they were acquired by C Spine because they're, they were agnostic originally and they couldn't get any orthopedic or spine rep to want to learn how to do it, try to get business for surgeons. I, I really don't understand why that's a whole different discussion. But it is like a cautionary tale to be actively.

I get, I get it. Yeah. And I think it's a good one, Mark. And, and you know, making sure that, that these systems are supported is a key element of the equation. Now, I'll tell you that we've actually done some things to reduce the burden of the setup. Right. And so you think, like, when someone does a robotic procedure, that somebody's got to come in and tell the robot where it is in space and program it. You know, we've, we've taken considerable steps to reduce that burden so that it, that it is easier to. But, but I think some of these business model things actually correlate back to company supporting him. And by the way, I, I, I did the, the orthopedic business turnaround for brain lab years ago. But, but when we think about it, when you walk past a system in a hospital and it's not getting used, there is no worse feeling for the hospital administrator who really had to work hard to buy that system. Now they got to walk by it, and every time they curse, they curse the person who got. So the business is not just not, not good to be using your implant. Everybody walks by and curses you as they do it. So I'm with you, Mark. Good, good thought and I think important to us. And by the way, I think that's part of where we are different from other folks. You know, everybody at a lot of these meetings, everybody's talking about new and innovative ways to treat different things. What we're saying is there's better ways to do the things that you're already doing and surgeons experience matter. If it's easy for them to use, they're more likely to use it. So that might tie back.

Yeah, let me, I'll speak For David K. Dr. David K. Is not on the call today, but he's preaching over and over that you have to reduce labor in the operating room and you have to at all cost. Anything new has to reduce labor. And so I would quantify it as much as you can, Doug. You know, is it five minutes, is it 10 minutes, is it, is it a, you know, one more circulating person that's not there, whatever.

Yeah, yeah. I think that that's part of the value analysis that we're doing right now is to say, you know, how do we improve what you currently have. But I think, I think that, and by the way, I don't want any of these to come off as claims. We're still pre market, we're still pre fda. I'm assuming everybody on this call gets it. But these things, you know, we are, we are seeing that an improvement is certainly attainable through the technology.

So Mark Maloney is driving and he sent a text. He's got a, he's got multiple startup companies. Mark's incredible. He said he's got, one of his companies has software that can search a surgeon list and identify who is paying them as consultants. So if you, if you want access to that, Mark Maloney can, can point you that to that.

I appreciate that, Mark.

Yeah, so that's interesting Mark. Better than the government reported sunshines. So there's a small, small, a lot of small companies out there that probably aren't reporting. Maybe your guys, your software is picking up on that.

What, what quarter, Doug, do you think you're going to do your first cases? I.

Right now it's, it's tough to know. We, we are very eager to get going inside of the first couple months on some bigger projects, first couple months of next year on some clinical applications. We likely, we have a big kind of event at Aukus to show the technology to Some strategics, but our effort is to start turning the key on the go to market product in early next year. And so I, I can't say if it's gonna, if the process is a big one or a small one. From, from this, from this outlook, we tend to move very quickly. We set very aggressive milestones and honestly, to the team's credit, they accomplish milestones often ahead of, ahead of time. And so it's really great to work in an organization that shows up with the output and, and I'll tell you, in the last couple weeks where I've been talking about this technology, the reaction that I'm getting more often than not is, hey, you said you were going to do this and then you did it. And I'm surprised that rattles people, but that's what we're into. We want to set the goal and we want to hit it and people are taking notes. So it's good for us.

It actually indirectly drives evaluation. Your company, when you do what you say you're going to do, that is really impressive. So, so keep up the good work. Eric, you got any comments or. John, Andrea, you guys are kind of quiet. Anybody?

One thing I thought about when you were talking about, you know, partnerships and. As you're at the forefront of this incredible technology of the context of what I was doing and. Time and even though they're saying that you're not going to get into this for a while and you know, as someone mentioned, fine, this is for general offices early on, no one else is like, you know, you see, it's a small group of people.

But if you're.

Not giving it, someone else will.

Yeah, I think, I think there's two kind of takeaways there. And on my side, it was a little bit muffled there, so I apologize. But, but kind of two pieces that I'll take away is a be careful about the partnerships and how those contracts work. Yeah, we are very meticulous about those and, and it, and we agree it's a critical step for the organization to be able to make sure that they have the flexibility in contracts. It's funny that everybody wants to ask for exclusivity and, and sometimes we were offended. Oh, they're asking for exclusivity. No, that's good. It's. Of course they're going to ask for everything and some of these people are known to ask for everything. But, but that's one piece of this. We did take a pretty big turn on IP about three months ago. We hired the former lead of IP at NuVasive during their kind of acceleration time and in the I think early 2000s. And he took a portfolio that, that was in a lot of places and really kind of folded it down to very clinical, clinically applicable and applicable to the business. And so he's doing a really great job of kind of reining that in so it makes the right impact. And I agree we share some things in trust. I'll try to have everything protected before I mention it, but we continue to push on those elements and we believe in the uniqueness of our device and the ability to connect that protection through the things that we already have. I think we in a lot of cases have over filed and so that's a different type of problem to have because there's residual costs associated with that. But the upside is that you have some coverage in places that you were going to push for anyways. Yeah, thank you for that.

It's hard. We're not hearing you real good, Andrea. I don't know if your audio or your bandwidth is off, but, but that was good. Eric or John.

So I'm, I'm, I'm good. I think all of us fine guys had the same question all at once. So, so that got taken care of. Great presentation. Appreciate it.

Yeah, yeah.

I'm kind of a fracture, you know, trauma nerd. I'm just amazed at the technology. It, it continues to blow my mind as you super smart people figure out how to do things in spine and, and totals. It just amazes me. I wish I had some great contribution, but I'm, I'm happy to be here and be amazed. Very cool.

Yeah, thank you. I wish I, John, I wish I had a better place to go in fracture work. The fracture work, you got to get the segments unless they're open, it's hard for us. I did see and I don't know who had it, but I had a pretty good presentation on a reduction robot and in fracture work which I thought was neat in mnbc. But we did a lot of attempts at fractures at brain lab with navigation in the arrays were just very hard to work with positioning as you move the in three dimensional. So I wish I had a better solution for that. I don't see us backing that place soon, but I wish we could find a way.

Well, I remember at brain lab watching and just thinking, how's this going to work? How's it going to happen? And, and to your point, I think it was, you know, it, it didn't quite work out the way that we thought. So the US Trauma Guys will just sit in the background and, and I guess be like carpenters or whatever the heck we are. Anyway, very cool, very cool technology.

Yeah. Thank you. I appreciate that. Mark, I think you had your hand up.

Yeah. I just had another question. Outside of your surgeon advisors, who will end up probably doing your first cases and all of that, who's, who's going to be. And this might be a question for your marketing team. Who's, who are your first customers? Are they 35 year old right out of fellowship? Are they. Who do you, who do you think's going to grab onto this early as a, as a general group? Just curious.

Yeah, I happen to have the head of marketing on the call, so I don't know if we'll have some fun and maybe make. Actually try to answer that. I, I certainly have a very strong feeling about it. Ashley, do you have any comments?

I do. I suppose this is not something we're not commercialized yet. Still not FDA cleared. But certainly when we talk with surgeons, there are different groups that are interested. At this point we're talking primarily with hip and knee surgeons based on our first venture into robotic knee surgery. And so of course we're, we have some surgeons who are at the cutting edge thinking about how they are advancing robotic knee surgery, total knee surgery, to continue to improve outcomes for patients. So some of the surgeons on our design team are certainly at that cutting edge and highly, highly experienced robotic surgery users. But of course, as we think about the potential to simplify robotic surgery and our aim of removing steps and saving time in the procedure, we certainly hope that, and intend to show that we can improve the learning curve for new surgeons and, and certainly also remove some of the barriers. Doug told the story of his dad who had robotic knee surgery and told about the experience. My stepfather just had his second knee replacement and knowing what I do, asked his surgeon, did you use a robot? And they said no, we didn't want to put pins in your legs. And so we are hopeful of course that we can enable pinless robotic surgery and remove some of those barriers to adoption. But given our, our go to market strategy, it's very much likely a conversation that we will be having with the partner that we integrate with and who makes sense. I would imagine limited market release starting with those adopter, early adopters.

Yeah. Ashley, thank you for that, Mark. I'll, I'll answer that. Kind of the same vein but more brief is that we don't care who gets it first and we hope that it makes an impact for somebody who's been a long time user. What we really hope we capture is the person who, like Ashley's father, surgeon, who did not want to do a procedure with a robot because of the pins and now Will because there's a better way. So that's a person we like and we'd hope our partners like. But, but outside of that, we're indifferent.

Seems like the, the high volume surgeons and like teaching hospitals would be all over this. Mark, does, Does Charlie the cook use a robot when he does 16 knees a day?

Negative.

Okay. That would have been a good one.

He, and he, he tends to be a bit dismissive of robots. I'll just put it that way.

Interesting.

Yeah. I'm friends with Charlie and, and we have some good conversations. He and I have known each other for a while, but yeah, doing a crazy amount of volume. We think that, we think that actually this improves volume for those who want to use a robot and, and helps them save some time.

I mean, yeah, it's got to be, I mean how, how many minutes does it take to put place pens or even markers that you know and, and register the thing?

It's not, it's not majorly significant in the folks that do it frequently, but you know, they, the, the folks that are really streamlined. It's a couple of minutes. We had a company tell them, tell us the first time their surgeon does it. The Registration alone was 25 minutes. Right. So you know, once you get good, it's like anything else. But, but you know, registering 25 minutes is untenable for us. We do it, we do it 25 times in a second.

Yeah, I mean it's faster than you can blink. That's incredible. Interesting. What about foot, ankle? It's, I mean there's not a lot of open procedures there, but there's not open procedures.

We haven't pushed and foot and ankle just yet. We're, we're looking at all avenues. We've done a lot of work in cranny craniotomies. We actually were born as a company that tracked brain shifts. So if you do craniotomy and the brain floats move, we can tell you where the brain moves. So for deep brain stimulation or brain computer interface, we, we feel very bullish about the application there. And to be able to be very precise in brain surgery, we're looking at hundreds of microns of accuracy. You know, I tell the team 2 millimeters is what the FDA kind of defaults to. The. No, like 2 mil. 2 millimeters. That's, that's miles off. You Know, so we're really excited about the accuracy that comes out of the system.

Yeah.

You remember you telling me the, the inception of the company was basically, I think there was a professor of optics that was trying to scan his firstborn child and there's a guy trying to horse breeder scanning his horses for sale. And then they ran into a brain surgeon and he said, hey, when I'm working on the brain, it's jello. This is exactly what I need. And then it became let's turn this into a company and try to make it work.

Yeah, it's a pretty good memory. And we kind of cobbled this all together long before I came. And I was excited to be able to join the business about two and a half years ago and then become the CEO about two years ago and, and really work to kind of bring some professionals. Ashley comes from a long time, 25 years in the business and the head of market, head of engineering, which you helped me hire a long time, maybe 30 years in, in engineering. And we're really excited to bring some veterans to make this go.

Yeah, this is Tiger there. There's a question in from Ann Guzman in the Q and A. Open up. Q and A. Yeah.

Let me.

Are you getting real time images? Real time during after resection with your technology, would you need to. To make a longer incision in order to expose and track the movement of the femur and tibia post resection? Some of those parts. I can't answer those. Some, some I can't answer. We don't anticipate a longer incision. The nice thing about knee is you get a pretty good incision. One of the things that we're really proud of is you get a very high density of data through the scanner. So you know, we saw that, that lamina, very limited exposure on that lamina and able to create a superposition to the ct. So small incisions are not super, are not terrible. Depends on how this is functioning. We, we don't anticipate a larger incision and also validating when things are cut. That's a very interesting place for us. You also think about what happens in. Imagine a total knee that's infected and you'd like to use a robotic system, but you need a CT scan. Well, you don't know how much bone you'll lose when you pull the femur off. And so whatever cement or biologic press fit you've gotten, you can't quantify that. Now you can take the scanner into a procedure and say, okay, I've Removed the femur. I now know how much bone stock I have and can now use these systems in a revision scenario where you can identify what the bone loss is. And I think you go a little bit further there. So hopefully that kind of winks at your question without me having to directly answer or give away our secrets.

Yeah. Revision procedures are really open and yeah, you could get great visibility and they're also very unpredictable when you, when you remove the, the original components, you have no idea what you're going to be end up with. You know, if you're ice cream cone or a lot of bone.

Yeah.

And if you're robotic and if you're using a robotic system that requires imaging, then you got all that scatter associated with retained hardware. And so that creates another level of challenge.

And you think about it. So this works with metal components and because it's generally.

Yeah, yeah. Optically looks at all the tissue that.

Can be seen and you haven't even talked about this, but there's no radiation either. You're getting perfect visibility radiation either.

Yeah. So it's, it's, you know, you saw it. It's in white light or in infrared. Infrared is not penetrable by the or light. So it's better that way.

Wow. Any before we wrap up, any, any ask Doug, any additional ask of the group?

No. I really enjoyed this discussion. My ask is that you follow us or if you have thoughts, please feel free to reach out. I, I think it's always nice to connect with a group of peers who are thinking about these problems and challenges. It was nice to hear that a lot of the thoughts were things that I had considered and had a very strong feeling for and in a lot of cases were supported by you all. So I want to thank you for having me. I think this is a really good group. It was good to see some of you at mnvc. You know, we're pushing like crazy and, and we hope that we showed you something special today.

Excellent. Thanks. Great, great stuff, Doug. Yeah. Keep. Keep up the strong work. Good luck at akus and I'm. We're going to see this all over the place next year. It's. It's going to be fun.

All right. Thank you, tiger. Have a great day.

Go visit.

Thanks everyone.

Thanks, Ash.