BoneChat #55 - New sports medicine startup, Abanza brings a new era in soft tissue fixation.

All right, let's, let's kick this off. All right, welcome to Bone Chat number 55, and today we have John Rizzo with Abanza, uh, clever little startup in the sports medicine area that's got a— I call it a better tibial tunnel fixation, but that's just the beginning of what they're doing. And I'm gonna turn it over to John.

Mike, sure. Thank you very much, Mark. I mean, everyone. Either way. Thank you very much. Appreciate it. Hopefully you can see my screen now. Yes. So after I told Tiger, after I set up my slides, since watched Ted Byrd's talk on anatomy of a pitch and mastering the pitch deck. So forgive the errors, I'm going to improve it. But this is a little bit about the company and the product. So obviously a very busy slide, but it lets you know that we are a startup, but we actually have a lot of people involved. This company actually started in 2017 in Spain. Headquartered in Pamplona. We've got all of our R&D, quality, engineering, all that product development work is done in Spain. And then I started the US business earlier this year, and this is my team on the left. We're, we're based at least right now in Orlando, Florida. We just incorporated in Orlando. Or in Florida, and we're, we're excited to, to hit the ground running. So getting right into it, what Abanza is about is, in the soft tissue repair market, is resolving unresolved problems that have to do right now with ACL, but really throughout the soft tissue market. There are high rates of failure in ACL, meniscal root, rotator cuff, 70%+ ACL patients develop some type of osteoarthritis during a lifetime. A lot of argument is that it's due to some of that residual displacement and windshield washer effect of the, the graft. And there are lack of specific solutions for patients with poor bone quality. And there's an inability to adjust or retention of soft tissue repairs once fixed. So we resolve that because we use a unique biplanar soft tissue fixation, which is independent of bone quality. We allow for adjustable tensioning, which is super important. Another problem that, and it's related, is that the inherently weaker tibial bone lacks mechanically sound fixation. So many surgeons are so concerned with this that they're using two devices in the tibia. They're backing up or using supplementary fixation. So, uh, they're using a second anchor device, which adds OR time as well as cost to the procedure. WasherCap will eliminate this. So we talk about, um, you know, what's new and what's different. Well, you know, we're not just a little bit new. The, the current technology for soft tissue fixation is outdated. It's 40-year-old inline technology, uh, and really If you're using inline technology, um, with soft tissue pulling in the same direction, mechanically it doesn't make a lot of sense. So what we've done is created a device that uses both cortical fixation and cancellous fixation in a cross-planar or biplanar method, which eliminates that poor bone quality as far in the cancellous bone., so we have no dependence on that. So another busy slide. Now I'm gonna, I'm gonna make this, this one better, but most importantly, uh, or a first thing I'll point to is the upper right-hand corner. Would you see that a Bonza washer cap has over 800 or around 860 Newtons of pull-out strength? It far exceeds everything else on the market, but that's less important because much beyond 500 Newtons is kind of irrelevant. So to be honest with you, but it certainly shows nice. But on the bottom of the screen on the right, you'll see that our residual displacement is 0.6 millimeters, which is an order of magnitude, really it's 10x better than some of the other devices on the market. And so this is where we really are game-changing and it makes a big difference. So using the same testing protocols that these other company, companies have used, We've demonstrated this over and over again on the benchtop.

Dr. Hansen? Yes.

Just to back up on the last one, the residual displacement, which—

what is that?

So it's through cyclic loading between, say, up to 250 newtons and 500 cyclic loads. Placed on the, the implant with soft tissue, what happens is you get— with these other devices, you're getting residual displacement that far exceeds 2.5 millimeters, uh, in most cases. And that is kind of the line of demarcation in the literature that states that, uh, you're going to have a subclinical failure. You're going to end up with some windshield washer effect, tunnel widening, which leads to osteoarthritis and really which leads to enough laxity that they're failing a simple anterior drawer test or Lockman test. So what you set out to do to repair is the laxity in the knee. And if you have residual displacement, while it may be tight at time of or time zero, over the first year to 2 years, there's significant loosening that happens, especially when you've got an inline screw, which doesn't really provide a locking mechanism. Does that make sense?

Yeah, that was part of my question.

When the graft is healing, and losing strength initially, does that add to that laxity? No, I don't think that any of this really affects— I mean, if you harvest a graft at 2 weeks, it's actually weaker than at time 0 because it needs to— you need to recreate blood supply and get nutrients to that graft. You know, you really— the benefit is when the patient gets back to sport and normal activities of daily living, when they're really putting load on that graft.

Thank you. Yeah.

So we're really not just a product. It's not just Washercap, the ACL tibial fixation. That's just our first device that's FDA-cleared. This is a portfolio play, and it basically uses the same technology, the same concept. But what we can do now is we're really doing one half of one procedure in tibial fixation only on an ACL. A year from now, when all these other devices are approved, we will have 45 to 50 different procedures that we'll be able to address. So the growth opportunity is significant. And we already have our second product, the, the WasherCap Mini, which will— should be launched end of February, early March. We're— it's pending with the FDA now. So title of this talk was, you know, what we do, but it's, it's also simple but not easy, right? So I've done this before. I've been involved in a couple of startups, actually 4 startups, and one of them, uh, 2 of them we sold to Zimmer Biomet. Uh, 2013 we sold Knee Creations subchondroplasty procedure to Zimmer. I ran U.S. sales for that company. Uh, and then more recently last year we sold Embody to Zimmer for up to $275 million. Um, so that's if we hit all the milestones. But I'm looking to reproduce the successes. And I say it's simple but not easy because it is simple. I mean, you know, we know what to do. We know what the market is looking for. They're looking for a de-risked product. Strategics don't want to invest in R&D anymore. So what we need to do is demonstrate growth. We need to demonstrate adoption. And, um, and, and how do we do that? We, we build a focused distribution channel, uh, through independent distributors initially. Um, we'll incentivize distributors with higher commissions and opportunities for equity. Um, we will utilize KOLs, uh, for medical education, podium presentations, and papers. And eventually we'll build a hybrid sales team, um, of some direct reps along with independent distributors because there are certain markets that we simply can't penetrate. I, I— it's difficult to find, uh, good independent distributors in some markets, so direct reps are, uh, indicated in that, in, in that situation. However, it's very expensive. Uh, it generally takes 12 to 18 months, if not longer, for a direct rep to even break even. So, um, that's, that's kind of where we're at. This is, this This is the plan, but right now the challenge is identifying and gaining approvals with key IDNs and GPOs, local networks. We've got some of it going, and we'll have a lot more opportunity once we have our second product and significantly more visibility from some of these companies. So first 9 months of commercialization, we did our first case in March of this year. So far we've got 90, 1% of the cases are coming from repeat users. So we've got positive adoption. Also, 63% of those users have done 2 or more cases. The ASP target of $600 has been exceeded so far. So it's been stable. We're at $676 year to date. And the breakdown is that we're 64% from the ASC, 36% from the hospital outpatient, And that's important because the ASC generally has less flexibility when it comes to pricing. So that's a good scenario.

Now, John, why is the price— why is ASP so low? Have you tested 1,000 or something higher?

Yeah, well, we have, and we've sold some at list price, $975, and we're offering, over 50% commissions if they can sell for over list price. So we are pushing that, that envelope. Uh, but what we're comparing to is the, the interference screw, uh, even with a sheath, uh, you know, the most expensive interference screw is the, the J&J's product, the Interfix, and that's, that's about $600 ASP, but most of the others are $400 or less. So we are, we are getting a, a premium for this. The IDNs are still a challenge. Um, oh, I don't forget this. So far, only a little over a third of our independent distributors have participated in, um, in, in confirmed cases. So only 8 of the 22 distributors, uh, so far have done cases. So we've got a lot of upside. We've got some opportunity to help some people to, to grow their businesses. So my, my question for the group, or questions for the groups, are, you know, here on the bottom I've got multiple questions surrounding KOLs and how to, how to set them up for whether it's fee-for-service, equity, royalties, or, or some combination. I wanted to know about, you know, consultants versus full-time employees., and, and, uh, what the, the group's feelings are, which direction to go. Um, and, uh, Tiger and I talked about this briefly before the call is what's the most effective way to hire full-time employees, whether you use a recruiter or personal networking. Um, you know, and so let me, let me stop there and, and ask the group if they've got any thoughts about the presentation or my questions.

Why don't we just go down the questions one at a time?

All 6. Yeah.

How to manage KOLs. I'm not the— I'm sure there's other people that have strong opinions on this. Mark and Kyle are up in that order.

So I love this product. First time I saw it 2 years ago. At the academy because it reminded me of when I was a Boy Scout putting in tent pegs and having them not pull out in the wind by the design. And I saw another company design a product called IOFIX that utilized a very similar geometry and it was very successful. And then also at that time you had a, which you are gonna, I think in Q1, have a meniscal root repair device, which could be, If you're going in to talk to your sports medicine guy and they don't have a good solution for something, that's one really good starting point.

It's also the fastest growing sports medicine procedure, right now.

Wow. There you go. I mean, they're all doing ACLs that they say are, you know, are not, not a problem. They always, you know, nobody's killing people. Right. And they don't see their failures. They go somewhere else. But the pullout strength is critical. That's why we switched to FH a long time ago, because their pullout strength at the time was the best around. In fact, Arthrex copied it. So you're on the right track. In all of the other applications, it's just gonna be exploding. I think, you know, in 2 years, this is gonna be huge. We really feel lucky on the orthotecnic side of our business to be part of your team.

Yeah, we're glad to have you, Mark.

So Mark, the KOL question.

Well, KOLs are, I mean, doctors sell doctors. What was, you mean, how do you, how do you get them?

I mean, no, how do you incentivize them?

Yeah.

Yeah.

Fee for service, equity, royalties, some combination.

The best advice I ever got out of that was from Tony Russell. Uh, you know, back in the '90s on one of the startups I was in, he said, He said, if you can get one, if you can get one doctor on your advisory panel, get one. If you can get 100, get 100. He said, that's your real sales force. So that's kind of where I always came from there. But the second thing he told me was, he said, you know, you do this to the best of your ability. He said, don't pay anybody anything. He said, find young doctors that are ambitious, that want to be president of the academy. They want to be a player. They want to be recognized. You know, they want to be somebody. And I think the next guy that I recruited was Bill Ritchie. He was just a young guy out of Wash U, and he became president, and several of the other guys, you know, became president of AO North America. That was a great team. So again, that means you're going to go after the younger fellows as opposed to the older fellows, but you got to, you know, you got to have one to attract the other to a certain extent. It's kind of a, you know, it's poker.

I appreciate that, Mark.

Thank you, Kyle.

So it's been a couple years, but I think you want to be really, really careful with giving away any equity to surgeons because that can get you choked out of some reimbursement systems. I think Kaiser has a strict rule there.

They'll all take—

HTA is the worst, actually.

Yeah, they'll all take royalties if you offer it, but you might have a tough time with anything that's considered complete.

Design-wise, right?

But maybe you have people really excited about promoting your current product because they know they're gonna get a piece of a future product. So you can play that game for sure. And then onto your second bullet point, consultants versus FTEs. I'm, I'm fully biased because I work in an engineering consulting firm and we do this type of work for companies exactly like this where you're trying to get something developed and you don't wanna wash out the equity that you have. But there's pros and cons both ways. And then for sales management, I don't know the right answer for you, but I can tell you the first step would be to use this network here. There are so many people on this call and in this BoneChat network that know tons of sales leadership that can give you names out the wazoo, and we'll probably all do it for free.

That's great.

Thank you.

Good stuff. I'll add on to Kyle. Um, so the best way to hire is use your own network first. Uh, but we— John and I were talking, you know, you tend to just— you tend to hire or interview like-minded people. If you want to— if you want to get a sampling of people that think differently, you can certainly use a recruiter, and you can pay a recruiter nothing up front if it's a contingency search. So pay, you know, sign a contract with a good recruiter to see resumes that are people you've never heard of before that think differently, and you can compare them to your, your network. Um, that I would definitely do that.

That's good advice. Appreciate it.

Thank you.

Yeah. And who had a question?

Bill?

Yeah. Hey, just wanted to chime in. Um, good to, good to be with you all today. Thanks, Tiger, for the forum, and John, great presentation. Um, my only thing on the KOLs, um, I do think I agree with what what Mark said, it's a really important strategic group to have involved. And then with what Kyle said in terms of, you know, kind of having that mix, my only input there would be I agree on the equity and royalties. If you can avoid that as best as possible, I think it presents a lot of issues both with surgeon expectations as well as, you know, some unintended consequences. I've always, looked at equity and royalties as well as if they're bringing some IP, then that's really reserved for surgeons that are going to be getting equity and royalties. Sometimes that's hard to avoid. But sticking to fee-for-service, I think, is probably the safest. And if you can engage and bring surgeons in that are willing to, you know, kind of be a part of it without necessarily requiring that fee-for-service for everything they do, that's also a very safe position as well. So just real quick on the second bullet, consultants versus FTE, also really important. Point. And I think that it really depends strategically how you want to grow the company. The more you can pull in-house, I think, is going to be to your advantage. Those are going to be people that carry the business card and are going to really be representing your company to the fullest. So I think, in my experience being in a startup environment in orthopedics, that's been a, you know, it's been a kind of a slow way to grow. But for those strategically important roles that you're focusing on, which in this case appears to be marketing and, and sales kind of on the get-go.

So, yeah, perfect.

Thank you. Yeah, thank you.

Yeah, how to find and engage solid 1099s. We had a, we had a whole bone chat discussion on that. And I remember if you're everybody, anybody chime in, but I remember the theme was go from the top down. Once you find a customer you like, just ask the customer, who's your favorite rep, nurse, whatever, and sign the contract with them, you know. And, um, don't go find the 1099 first, right?

We've done some of that. That's good advice.

Yeah. Colleen, any— anything to add? You've built Small companies, geez.

Yeah, you know, I agree on the fee-for-service is the best way to manage KOLs. We did that pretty successfully. Now, obviously as a startup, that's an expensive ticket because they expect a nice hourly rate. But what I find is if you set the expectations in a contract of how many, you know, hours a quarter that you expect, You can set it to something you can afford. And then, you know, I find that, you know, the, you know, your KOLs actually feel like they're part of the team, right? They're engaged on a fairly frequent basis. I think everybody already made the point, the points about equity. And for consultants versus full-time employees, you know, I am a big believer in, you know, making sure you have in-house the key positions that you need, whether that be marketing or sales management. You know, if you are a little slower in the finance area, that's probably okay, but I think you'll find that over time, a really good finance professional that has knowledge in the medical device space can really add a lot of value to the team. And then, you know, I think using your network for recruiting is, is also always a good first step. But, you know, I would say that we used a lot of social media for marketing early on, and it also helped attract some KOLs because I think that the surgeons are a big user of certainly LinkedIn and then You know, solid 1099 partners, I think, as you said, Tiger, you know, find, you know, find the customers first. But, but I don't know, the PEOs versus employer of record, you know what, I think you can go with the professional employer organization as long as you have good communication and you pick one that's well organized. For instance, I work for an investment bank. And we use one, but they've customized a lot of stuff for us, so it doesn't feel like it's much of a sacrifice.

Yeah, good, good. And I— it's a real— it's real expense. It's very expensive for the employer of record, we're finding, which is where we started. But as we grow, it becomes exponentially more expensive. So I'm talking to ADP right now.

Yeah, there's, there's a lot of them out there, so I would talk to, you know, 2 or 3 to see what you like. Um, there's Insperity, there's TriNet, um, so there's, there's several that are well established.

Okay, thank you.

Good, great advice. I mean, I'll add 2 cents to the digital marketing question. So And I'm kind of biased because I do a lot of digital marketing, but small companies should always do digital marketing first instead of traditional marketing. Don't have a booth, you know, have a small presence at medical shows so you can walk around and get more done. I mean, the, the, the best poster tiles are Artelon and Osseo nowadays. I mean, Arvalon just killed it with, with digital media. We actually had Jansen Cole on Bone Chat, you know, a few months ago. Um, I mean, they were just, they were, you, they were putting out unique content on a daily basis. Uh, and it, it, it helped to build their brand. Not only did it inform people about their product, but helped to build their brand. And then Osseo, same thing. Osseo is the same playbook. They put out different looking content. Doesn't look like a medical company, you know. And I would, I would just go on LinkedIn, search for Osseo, and it's O-S-S-I-O. You probably know them. I do. Yeah. And Ardalan, probably a lot of the Ardalan stuff is scrubbed now because they got acquired. But, I mean, boy, did they put out great content. You may be able to call Jansen and bend his ear. But the key is for digital marketing is it's free. So when you're a small company, it doesn't cost anything other than time. And you— and the other thing, it's trial and error. So you're not going to— your marketing is not going to be perfect. You have to constantly put out something, see if it works, put out something, see if it works. Okay, let's do more of that. And you got to get somebody in your organization that's doing constant trial and error on a daily basis. And it's literally a secret weapon for startups because the big companies can't do it. It's the big companies can't pass their regulatory, their legal review, their compliance reviews, and they literally can't even post. So it's a way to get noticed for $0.

That's exactly where I was going to go. Go, go for marketing. Uh, that, that is such a volatile, uh, rapidly evolving, uh, subject, uh, with social media and digital marketing, and you get so much for your money, uh, but it requires almost like a, a samurai warrior of the digital world to really do it right. And I'm not going to say that older, older people can't do it, because they can, uh, but you need somebody that just is voracious in learning what's new today and tomorrow. If 24 hours is the, is, is the time in solar time, in digital time it's an hour. I mean, it moves so fast. And now that we have the rapid advent and adoption of AI, uh, it's even moving faster. Um, I just signed a contract today to introduce a, a B2B, B2C AI, uh, agency, uh, to the United States, to the healthcare market. Um, and I'm doing a symposium on January 21st, in which I'll have a panel of, I've got the chief of ortho from Kaiser Permanente, chief of cardiovascular from Cleveland Clinic, 2 or 3 other pretty well-known docs. And these are all just, you know, mostly orthos. And they're, you know, they're not like 30, you know, these guys are like usually in their 50s, but they're influencers. And they're already using AI. They don't even know how to really wield the weapon, but they know it's going to make a seminal change in everything they do. And that, that's, that, that'll be the case in marketing too. So, I just, you know, and I, I can tell you this, in the last few years with VenOps, my, my regulatory compliance company, I've, I've engaged heavily in LinkedIn marketing, email marketing, and so forth and so on. And the ability to get to really super busy surgeons that make almost more money than they can spend. You know, time is, time is their most precious resource. It's hard to reach them. But with that social media digital marketing campaign that roars like a forest fire over California, you'll never get to them.

Good, good stuff. Thank you, guys.

Yeah, and you gotta, everything's on the phone nowadays. So. Everybody gets their information through their phone. So don't worry about any, any marketing, any digital media has to look great on your phone, has to be real easy to digest in a small screen. The other, the other big question you have to ask, John, is are you going to do direct to surgeons or direct to patients? And it's completely different, completely different worlds.

Yeah. Direct to surgeon is, is where we're at at this point. I don't think we have a, a play for direct-to-patient yet.

I agree.

Yeah.

One of the things I learned from, who was it, Therese, was that direct-to-consumer only works when the patient can diagnose themselves. And they, but if, you know, if you're, if you tear your ACL, you don't, you have no idea how it's going to be fixed. You know, it's black magic. So you don't even know what to search for on the internet.

Right. Yep.

Good point.

Yeah. What other questions haven't we hit?

I think we touched on all of them.

And this, so tell, how is Bonza funded? And it, tell us the, the found, the foundation story from 2017 in Spain and the whole thing.

Sure.

Yeah.

Yeah. So the, it was, the company was kind of born outta necessity, which, a lot of great products and companies, often are. The founder, the CEO and founder was a soccer player, football player in Europe, in Spain, as was his brother, his cousin. He has an uncle that's an orthopedic surgeon and a father that's an engineer. And so sort of all these athletes tore ACLs and were all told the same thing, that your career is, is questionable going forward. And they didn't, they didn't like the answer. So as a group, they came together, started talking about solutions. So the founder's father, the engineer, really developed this technology. The orthopedic surgeon had some input, but it was a necessity. How do we make this better? Why, why are there so— why is the failure rate for ACL so high? What's, what's happening and how do we resolve it? And that's really where this technology came into play. Wow. Now, if, if we had started 5 years earlier, we would probably have a much bigger impact because a lot of the market has gone from hamstring soft tissue ACLs to bone tendon or to quad tendon. And the quad tendon is a shorter graft. So the quad tendon generally does not come all the way out through the tibial tunnel. So we can't use our original washer cap. But that's why we developed some of the, the upcoming products which will allow us to not only do meniscal root but also with the same device in a different size, all inside ACL with the quad tendon. And that'll get us about 60% of the market for ACLs opportunity-wise. Because 38% is still bone, tendon, bone. And that's kind of out of this product's purview. But that's kind of the story, long and short. And how is it funded? A lot of family office, a lot of individuals, a lot of the, uh, the founders, um, the employees, uh, I have, uh, have funded this, uh, this company so far. Um, interestingly, I started in January. Um, you know, we were struggling to find money, and as we started doing cases and posting on social media the, the procedures and and the doctors doing their first cases. Um, it was kind of amazing. It was proof of concept. And the money has been rolling in actually of late, um, to the point where I've doubled my budget for 2025. Um, because, uh, you know, I can, I can always use that lever to, to increase your— or, um, I could spend more to grow faster, um, or you can you know, delever and spend less, but you're going to grow slower.

Yeah, those, those, that sales growth you posted is astronomical. I mean, that's, you know, 2 or 3x a year. That's incredible.

Yeah, well, that's, that's the plan, right? So we're on the right track, you know, it's early days and it's always, and I'll be honest, it's anemic the first year. I mean, we're talking $100,000 in revenue the first year. And it's really 9, 10 months, uh, is what we're talking about. But it takes— but, but it's also the same trajectory as I've had with other companies, uh, in sports medicine. Knee Creations wasn't much different. Embody was the same. It, you know, you're doing, you know, you start with doing one in the first month, and then you do one a week, and then you do, uh, you know, start doing one a day, and, and then it's two or three a day, and before you know it you know, you're, you're doing a million dollars a month, but it's, it's still, it's slow to, to ramp up to that.

And is the surgeon adoption rate, is it based on seeing early clinic results so they, they do one and then watch, or—

Yeah, no, it's, that's, that's, that's something that we had to have in, in previous, uh, companies. I've seen a lot of that, do one and watch, but they feel it immediately. They feel the difference in You know, if I, I've got a quote here from Dr. Nirav Amin out of Southern California. You know, having used this device, and this was his first time, he immediately noticed the exceptional performance eliminating residual graft laxity from the very start. So, you know, you can feel the difference. And the ability to retention is, while it's less important in ACL fixation, For meniscal root, it's been identified as a tremendous advantage.

Excellent.

Wow.

So we're excited. We've got, we've got a lot of good stuff coming.

Wow.

So let me say something about that stability. So, when I first got, when I first got outta the Army and got in the orthopedic business in the '80s, I would go to 2 to 3 grand rounds and fracture conferences every week. Either at UAB or at Grady, Emory, or Erlanger. And so year after year, I would always hear that first week or two of the orthopedic residents, freshmen kind of lectures. And one of the things that stuck in my mind in the very beginning was year after year, I heard the same thing. It was stability, stability, stability, stupid. That was like the first lesson that, that I seemed to hear. And I don't know how many other orthopedic residents heard that through the years, but you know, that's one that stuck, at least in the South, that's what I heard over and over again. And when I went in 2009 to France to pick up the FH procedure in Toulouse, the thing that I remember about that trip was the patients' sense of proprioception postoperatively, day one, was so incredibly strong that they didn't need a brace, didn't ask for a brace, they could walk and climb stairs immediately. And another thing that that procedure gave the surgeon was the ability to retention. They at no point could they not stop, take everything out and start all over again if they didn't like it. And so when you— this procedure right here, which is an even better design, gives even a higher sense of stability. That's got to be something that, you know, a surgeon's hands are going to feel immediately. So that's a great quote from Dr. Amin. Yeah, that'll, that's gonna sell. That stability will sell because even those that are, even those doctors that are getting good results, you know, I use that phrase kind of cynically, you know, the, you know, nobody's, nobody's complaining there. They're going somewhere else.

Right.

But still the, they know that a higher sense of stability is gonna get 'em better results immediately.

Right.

Are you seeing that patients need less bracing afterwards?

We haven't measured that yet. We don't have that, that much data, but that's, that's something that we—

anecdotally, are you seeing it?

No, I, I haven't, haven't gotten that feedback. The feedback we've gotten is at time zero, the surgeons say this is a rock-solid repair. They can feel it when they do the anterior drawer and the Lockman, the pivot shift. They just, they feel that this is not budging. It's not going anywhere.

Can you, does that convey on video if you, if you were to zoom in to the surgery site when you lock the washer in, can, does that convey or is it just a, is it a torque feel?

It's not because if you see the, the alternative is an interference screw that's in the tunnel.

Yeah.

You know, the, the other thing that we haven't, you know, mentioned here is because we're only going into the tunnel like 6 millimeters, you've got a lot more circumferential, uh, fixation, um, or ingrowth into the graft, into the bone. So you're not, you know, the, the interference screw essentially forces two-thirds of the implant against the bone, and that's where you're going to get ingrowth. And unless you have a resorbable screw, you're, you're never going to get circumferential fixation, um, with that as it grows in. So we have an advantage there as well. But the, the, you can't see it, to answer your question, Tiger. Um, it really keeps you— it's a feel thing.

Got it.

You could— you can see the drawer test, I guess, on the operating table, right?

A little.

Yeah.

And there's ways to measure that, you know. So there's KT-1000 that you can use to measure drawer. And so we need to— we need— there's some studies that we need to start doing, and we need to fund that as well.

I know, I think you've talked to Sean Cogan, who's a BoneChat member that's got the digital measuring device for ACL tension. I was hoping there's a marriage there somehow.

There could be, you know, that's certainly at least in a study situation.

Yeah.

That's an opportunity that we could, you know, we could do something. I gotta get back in touch with him.

Yeah, because I mean, nobody's getting a hard number. It's a feel. This feels tight enough. So I'm going to lock it in.

Yep, that's right. And once they fix it, they usually fix it with the knee flexed at some, you know, 20 to 45 degrees and they're married to that fixation once they drive that screw up into that tunnel.

Yeah.

Not the case here. And you don't have to take everything out. All you gotta do is back out the set screw, you know, a turn and a half, and then you can, you should be able to readjust it.

Wow.

That's great.

Hey, Doc. Soft bone.

What?

Yeah.

You got soft bone.

It'd be a really good solution for, for, you know, lower bone quality.

Yep.

Yeah. 'Cause even bad bone's got good cortex.

Yeah.

Maybe thinner, but it's still cortex.

Correct.

Correct. Hey, Dr. Lucy, what, tell, tell us your experience. I mean, you putting these things in, you know, years ago.

Yeah, it's been a while. It's been a while. But, uh, yeah, you never really, you never really know what your, the endpoint is, you know, in its field. Feel. I've done, you know, bone tendon bone grafts. I've done the hamstrings. I even did synthetic grafts. Did extra-articular repairs. I can't You know, I just don't know which is the best. Late, you know, the last, the last segment of my career, I was doing hamstrings. I, I know that there's no perfect spot that you can put, put the graft. And there's no, it's really hard to Well, I just find finding that perfect spot up in the femoral condyle to put the graft is really, you know, a challenge.

Yeah.

I must say my folks did well, but one never knows how many go someplace else. Yeah, again, it's feel and it's being lucky to be right on the, on the endpoint in the condyle where you need to be.

Yeah, yeah, that's the other part of the procedure is the femoral side. And, you know, our assumption in this whole conversation is that you've drilled your femoral tunnel in the right place.

Yeah.

But I mean, you've got instrumentation, right? With some, you know, cannula that goes up there and guides.

Yeah.

Yeah. Yeah. And it's with fluoro, I assume.

No, it's not often done with fluoro, is it, Dr. Lucy?

No, I just look at it through the scope.

Yeah.

Oh, interesting.

Direct visualization through the scope.

Yep. But you have to find that, you know, I haven't done one 15, 20 years, but you know, that's, you have to be right off the, the articular, the, the condyle and the, and the cartilaginous surface of the bone. You know, you have to be just within 2 or 3 millimeters of that sweet spot.

Right.

It's hard to find it, I'll tell you.

Yeah. Did you have to do notchplasties very often when you had a tight notch?

I sort of started to do them more routinely at the end just because it, you know, why, you know, why not try to do the best you can and, You know, if you have a notch, you want to have the graft not being impinged at all. So that's right.

Right. And you don't want to have to try to do the notchplasty after you got your graft in place. I've seen surgeons do that. It makes me real nervous.

Yeah.

Shaver right next to that brand new graft they put in.

Yeah. You don't want to do that.

Yeah.

But, uh, you know, I'm, I'm not an expert at ACLs, I'll tell you, but, uh, I've done enough to, you know, get a feel of them. And it's been a long time. So, please take that under advisement.

Sure. Yeah.

So what's the, what's the biggest challenge with meniscal roots? What, what is, what problem are we solving there?

So, That's, like I said, it's the fastest-growing sports medicine procedure. Something on the order of 30% to 40% growth year over year over the past couple years. The data's a little sketchy because it's not complete and it's moving so quickly. But, you know, it's something that hadn't been done a lot in meniscal repairs. The meniscal root is something that is, they've been, they've discovered more as an issue that, that had not been addressed and it needs to be. Because, you know, you can do a great meniscal repair but if the root is loose, you're gonna, it's not gonna do anything. If the meniscus basically slides out of the way, it doesn't cushion the knee joint at all. So, you know, having a solid endpoint with the meniscal root is, uh, is super important. Um, and so what we're fix— what we're doing with this is we're not changing the procedure, um, but we're changing the fixation. So what they're doing now is they're coming out and with suture coming out through a tunnel and either tying over a button or using, um, uh, like a, um, one of the Arthrex, uh, anchors that they just tack in on the, um, on the cortical surface But once they implant these fixed, these devices, they're, they're fixed. They can't change the tension. And this is super important in what we're, the feedback we're getting from surgeons in meniscal root repair. It's very important to be able to adjust the tension if you need to. And most devices won't let you do that.

Yeah, it's a very, it's a very technically demanding procedure. And the, the meniscal hoop, kind of the curve of it, maintaining that anatomical correctness.

Right.

The hoop stress they call it.

Really, really critical to distribution of the stress around, you know, of basically, you know, the, the, the demand on the knee.

Right.

You don't, you don't do it right. It's obviously, it's not like doing it at all.

Exactly. Exactly. I've, I've seen, um, had a surgeon show me, you know, um, CT data or moving X-ray data really was just showing how it looks great until you put load on it and it slides out of the joint. Yep. And so it's, it's completely worthless. Yeah.

And it hurts.

Yeah. Cuz you're bone on bone.

Yeah, it's your shock absorber's gone. Yeah. Yeah. It, uh, we developed this at, uh, Active Implants. It was a, it was a total meniscus replacement. And you, the little white lines around the edge are Dyneema fibers. It's like the strongest material on earth in tension. Yeah. It was for that very, it's for that very reason that, uh, Mark said it's a hoop. It's the hoop stress.

Right. Dyneema is an ultra-high molecular weight polyethylene. It's in most high-strength sutures.

Yep. It's super strong stuff.

It's incredible. Stronger than steel.

Wow.

So are the, are the meniscal patients, are they, are they teenagers or are they like weekend warriors in their, you know, they're, they're, they're throughout, they're teenagers through weekend warriors into well into their into their 50s.

Now, they're, most surgeons won't repair a meniscus on someone over 50. I don't know if that's changed, but that, that was kind of the, that's kind of probably the higher end, 50, 55 is probably the high end. And it's going to depend on the patient. You know, are they a super active patient?

Do they just keep trimming and trimming until there's nothing but a little rim?

Yeah.

Right. If you're, if you're not active, I mean, you could certainly survive without it. I mean, in the, in the old days, Dr. Lussi might remember that They just removed the meniscus when it was torn, you know, not, not even just partial meniscectomy. They just took the whole thing out. And what they found was that the, the osteoarthritis was, you know, you know, 10, 15, 20 years down the road for sure, they're gonna need a total knee. And this was, you know, they did this when they were athletes and 20 years old. So, which is probably why, you know, the fastest growing group of total knee patients is, you know, between 40 and 55.

Interesting. Huh. Interesting.

Yeah, you're accelerating the osteoarthritis. The shock absorber's gone.

Right.

Yeah, when I was a resident, we did total meniscectomies all the time.

Yeah, that was the norm.

And that was probably an open procedure too.

Oh yeah. And, um, No, I remember when my chief, Dr. Goldner, said, you know, I have this friend of mine in Japan, Dr. Watanabe, who's got developed this scope. And we started, we started doing this, you know, putting the scope in people. Yeah., you know, some sort of thing you cover the scope up with. And we had young, young tigers in my class like Terry Whipple and Gary Paling. They were all residents with me, you know. So it's really, we were right there in the forefront of arthroscopic surgery.

And they thought it was crazy then. Right?

Oh yeah. What are you doing? Really? You know, just make a little incision, take the, take the meniscus out in about 5 minutes. Yeah. And you're done. Yeah. So I'll be your source on orthopedic history.

I love it. Love it. Yeah.

I remember walking into the Houston Clinic in 1981. Sure. With an arthroscope. Yeah. And hearing one doctor say, That's ridiculous. I've seen, I watched Dr. Andrews screw around for an hour and a half.

Yeah.

That damn thing. And he said, I can do an arthrotomy in 30 minutes and I'm out. I'm done. Right.

That guy Andrews has no future.

That's exactly what he was.

Well, you know, Jack Houston was a dookie too. And, uh, yeah. Dr. Goldner and Jack Houston used to go at it. Unbelievable.

Yeah.

I, I, I remember when the first shavers came out, or I heard the story that from Barry Bays at Concept, that the shavers were so bad that they would just explode in the joint. And every, every kit had a magnet on a stick and you'd stick the mag— you'd stick the magnet in there, fish all the fragments out.

Wow.

Every surgical tray had a magnet on a stick.

Oh my God. I remember, I remember telling that doctor at the Houston Clinic that although the arthroscopy was really fast, that 6 weeks in the cast for the patient afterwards was not so fast. And Dr. Andrews' patients were walking home.

Well, that's a big difference.

Well, my, you know, I remember my brother had a meniscectomy. I think he was in the hospital for 3 days.

Wow, incredible.

Well, this has been great, John.

Uh, thank you guys. Thanks for the opportunity, Tiger. I really appreciate it. Thanks everyone for your, your help and advice. Uh, it's, uh, it's, it's very important.

Yeah, and so hopefully we got your questions answered, and, uh, I think you've got lightning in a bottle here. I think, uh I think you got something. It's like you said, it's a platform, uh, soft tissue repair that is reversible and all over the place. It's, it's, it's incredible.

So best of luck.

Thank you.

Thank you, John.

Yes, thank you.

Thank you, William.

Great work, everybody.

Thanks a lot.

Bye-bye.

Bye.

Thank you.