BoneChat #63 - AI, startups, M&A, operational challenges, sustainability, 3D printing.

So this is an open— this is, uh, Bone Chat 63. It's open discussion time. Um, yeah, we had— and anybody can bring up anything they want to talk about. Um, I'll throw out a few topics. You know, Medtronic bought Nanovis. Um, Nano Titanium technology. That's kind of interesting. Then Mark Maloney did his AI webinar yesterday. I'd love to hear about that. I can talk about the Bone Factory. I've got a group of people where we're helping surgeons take ideas and turn them into products kind of fast and cheap. And it's kind of interesting. We've got 4 things going on right now. Um, I don't know, Jesse can talk, tell us about Bonebridge. Where does everybody want to go?

I'll tell you about the webinar when you're ready.

Go ahead. Yeah, let's just, let's kick off with that. Unfortunately, I got double booked and I missed it, but it looked like you had a great turnout.

We had a good turnout.

And kudos, Mark, great conversation. Oh, thanks. Sit in on some of his really impressive folks you have on there.

So I know I was pretty humbled. Some of my guests are pretty bright people. And so the panel was Ron Navarro from Kaiser Permanente. He's chief of the Central Region. He's a pretty practical guy, president of Hispanic American Orthopedic Surgeon Group. Pretty, you know, he's very active in the academy too. And always interested in new stuff, new technology. I think he's mostly sports. He probably does some total joints. Kishore Timpanini from Arizona, another orthopedic surgeon. It's kind of, it was orthocentric. He also is CEO of Tempita. Kishore wrote the software that we used to build eTrauma, the original digital imaging company we sold to Stryker. So he's been like a coder guy. He, in fact, he wanted to go to computer science school at UC Berkeley, but his father wouldn't let him because a good Indian goes to medical school. And he made him go to medical school. So Kishore did like a 6-year MD, you know, undergrad program. And he, but he kept on coding, and he's, doesn't, he's written a lot of apps through the years. And so his program Tempeeta is an AI-enabled templating system which literally increases revenue by 40% over the last 2 years. He didn't really get too much in. I told him to go light on that, you know, not brag too much. But that's how much time he saves. And then the, let's see, we had Roy Bujarno, who is the CEO of Scale Healthcare. He's a very bright guy, very extensive network, super connected, former investment banker. Uh, Roy's grandparents were one of the— signed the original document of independence of the State of Israel. So he's pretty, pretty interesting background in that regard. Uh, Nassim Aryanpour is a PhD in computer science, machine learning. She's out of Vancouver, Canada. So she was on there. Julia Komisarchek, whose specialty is also machine learning. And she does— her focus is de-identification of data. And she's all about building data lakes, data sharing, data access. You know, it's like Robin Young said at a dinner I hosted about 3 or 4 years ago. He said, if you want to make a lot of money in orthopedics, he said, make a lot of money in data. I mean, that's kind of what he's— you know, he was kind of exaggerating, but he was pretty much a— he was pretty prescient on that. Um, and then third doctor was kind of like Dr. Everyman, and that's why he was there. He's a regular good guy in here in Atlanta and very normal. He's trying to use AI, he's struggling with it, and he was on— he was there as sort of the representative of the people, so to speak. Um, and let's see, uh, and then we had Drew DeAngelis because he published his Orthopedics This Week And he's got a big network now. What came out of it was the, the biggest challenge that they, everybody agreed that they saw is data sharing, data access. Where do you get it? It's greatly limited. Most medical data just comes out of 2 or 3 big cities, big universities like Boston and New York. And it's, there's not as much there as you think there is. And there's not any more to be had unless people share data and they're There are varying degrees of pessimism and optimism on that. It was generally agreed that the easiest and most practical way for physicians to use AI in 2025 is to save time on documentation, you know, EMRs that they love to hate. Okay, they just spend so much time either during the day or at the end of the day on their, you know, EMR documentation, and AI can greatly relieve that. So that was generally agreed as the number 1. The number 2 was using AI for marketing and like, you know, everyday receptionist duties, things like that, and in your practice. And it's already out there. I took my wife on Tuesday to the urgent care. For a bad cold, sinus infection, and it was part of, uh, Emory University's Urgent Care Center where I live. I called up after— I called up to make the appointment, and to my great surprise, because I didn't realize it was this prevalent already, I wound up talking to an AI. She was very nice. She made the appointment. Um, you know, I felt like saying, so what'd you have for lunch? But yeah, yeah, so yeah, what are you doing after work? Uh, but anyway, and the week before I had had coffee with the VP, Senior Vice President of Supply and Logistics at Piedmont Healthcare, which is the biggest hospital system here in Georgia. And to my surprise, uh, they just signed a contract with an AI company to do, you know, receptionist, clerical you know, that kind of stuff. Because, you know, as we all know, in every company, personnel is your highest cost, and they're going to be reducing that, uh, considerably. I was surprised they didn't sign a long-term contract because they're not stupid, you know. They know there's, you know, they're not necessarily going to leave the dance with the one they— one, the one they took, okay. But, uh, you know, they're already dancing, and that, that actually surprised me. So anyway, I think my next topic for my next webinar, I'm kind of back— I'm going back and forth with— it's going to be about documentation, you know, just really, really drill down into that, probably. Or maybe some, you know, the marketing and the information sharing that they could do. So it was, you know, it was fun. You know, we didn't, we didn't achieve world peace or anything, but it was, it was a, it was, everybody enjoyed it and they got something out of it. Hopefully the people that chimed in enjoyed it too. Yeah. So anyway, that was, that's what, and I didn't, you know, I didn't make any money at it. I wouldn't say it's pro bono, but because I'm really interested in it, and I am introducing, uh, later this month a, um, a new company called Provencis P-R-O-V-E-N-C-I-S. It's a totally made-up Latin word, um, that's going to basically be an AI agent. And if you want to see an example of that, you can look on their website because the landing page is already up. Or you can also look at another one. There's a couple of guys at UC Berkeley that I studied up last year, real bright guys, raised a lot of money, Silicon Valley money, called Sully, S-U-L-L-Y, .ai. These guys are like way ahead of the game. So in fact, they were so far ahead when my team looked at their web page, they, they like got depressed. They go, oh my God, these guys are so far ahead. I said, no, relax. I said, this is, this is a good thing. I said, because business breeds business. I said, they're out there breaking down doors, doing customers, you know, paving the way. And, you know, everybody else will get a piece.

Yeah, well, when you look at the cost, it's really— it does— it sounds terrifying, the cost, as an employer, when you first look at AI. But when you look at how much it can save you, just, just in personnel costs, which are hard to find, you know, the right people now, it's— I mean, it's really worth it, what it can bring to you.

I mean, I can put a receptionist in your office at $500 a month.

It's crazy. And they're going to do a better job, unfortunately, in many— I mean, well, they were, they were really elevated now.

Yeah, they work 24/7. They don't take breaks.

Hey, one of the conversations, you guys, and I'm sorry to leave it yesterday, but you were talking about privacy. Um, I don't know if you've heard about privacy engineers, but it's probably one of the most up-and-coming professions kind of going, you know, rising in that AI pyramid. It might be worth investigating for you.

And a privacy engineer. Yeah.

So you can hire them fractionally or you can hire somebody in your company, but it's a privacy engineer, somebody who's going to protect your data within your company and make sure that, you know, even if they just pop in once a month and look at your system, because there's so many ways that your company and your employees can breach a firewall, just making sure that you're always protected, that your privacy, HIPAA, everything is protected within your four walls. I, I think it's, I mean, And I feel like if I was looking into the future with a crystal ball, we're gonna see privacy engineers in the medical device field space within the next couple years everywhere because it's just taking over really.

So that makes a lot of sense because cybersecurity has been a top issue for the last 3 years. And my cybersecurity insurance at Venops, you know, has literally tripled in the last 5 years.

Oh man, I am. So I'm an executive coach for an EVP of a reinsurance company. He specializes in cybersecurity. Yeah, I can't even tell you that, you know, we talk about private, like property and casualty with storms and global warming. Cyber is that next one. It's getting more and more risk involved and companies don't want to touch it. So I mean, my, my guess to your point about the insurance, you look at that privacy engineer what you, you know, that's got to be a, it's got to be one of those things that helps you.

You haven't seen yet where there's any way to ameliorate our rate by doing things like that, but that will hopefully come. Uh, they'll drag their feet probably, but there's not a, I, I don't know of a big orthopedic practice that I personally know that hasn't had a breach.

Really?

Wow.

And what do they take? Do they take financial data? They take patient data?

They just kind of go in and lock it up and ask for a ransom.

Oh, it's the— oh, it's the, it's the, uh, crypto ransom.

Yeah. And every time it happens, uh, the administrative CEO loses his job. Yeah, maybe not right away, but it's like a time, time bomb. Tick, tick, tick, tick. Within 1 or 2 years, they're gone.

Yeah, that's really common. It doesn't usually make the newspapers either. It's like my next-door neighbor was head of security for Citibank, and I'd play golf with him, and he would— there's like a DEF CON 1 to 5, you know, like 5 is, you know, World War III. And he goes, oh, DEF CON 4 today. And I go, what happened? He goes, oh, they shut down all the banks in Argentina. I've got to, I've got to— I mean, like every day. I mean, and it's all cyber, it's all cyber threats. It's incredible.

One of our panelists, you know, was Roy Bigiarno, and Roy is so well read. I think that's how I met him. We were both fellow English majors, and it would not just, you know, excluding business, we used to just chat on the phone about books we're reading or whatever. And so Roy started talking about how right now we're in this like bromance phase of AI. You know, it's like, gotta have it. You know, everybody wants it even though they don't know what it is. And he said, I mean, the people that are struggling and frustrated with trying to use it don't even use it, but don't even realize they use it every day already. All their revenue management programs, all the billing programs, they're all using AI already.

Yeah, book a flight. Yeah, I mean, it's everything. So I heard a great podcast the other day, and they said the first place it's going to go is anytime there's voice. So anytime two people are talking to each other, that's data. And there'll be a copilot sitting there listening to the data, and it'll make suggestions, it'll take notes, it'll do— it'll summarize the conversation, you know, it'll put something on your calendar automatically that was in the conversation. And that's kind of the first application I think that we're going to see. Every, every meeting is going to have some kind of agent.

Oh yeah, yeah.

Kyle, I don't know if— I know you have two different like presentations on this screen. Is one of those an AI note-taker? No, I, I, I use AI note-takers. They're amazing how they summarize it with to-do lists and follow-up. I mean, when you look at the operations of your company, just to do an AI meeting, use AI Notetaker, and then you have this immediate way to follow up with your team. It's unbelievable. And the accuracy, it's not what you would expect. Like 2 years ago, it would just be, you know, wrote exactly what was said when was said. The summarization of these things is really tremendous. Has anybody seen any medical device companies like AI-generated medical devices? I've seen a couple for the heart and instrumentation. Like, that will gauge in the heart, that type of stuff, but nothing else.

I don't know of anything. Chris, do you have a comment?

No, I was just gonna say, you just made— sorry, I'm, I'm not in a place where I can have camera on, but you made me double take to see if mine popped on. It popped onto a meeting on Monday and apparently was much more productive than I was, and I wasn't even on the call.

It was awesome.

Funny. Which one do you use, Colleen? I use otter.ai. It's, it's pretty good.

Yeah, I use Otter, but so I usually do my coaching sessions or when I'm talking to a client, I usually use Zoom. So I just use the one on Zoom and it's tremendous. I was shocked the first time because I, you know, I have my old school notebook next to me because I'm not a great typist. And all of a sudden I went to go type my own notes and this email comes, and I'm like, wow, this is better than, you know, Chris, to your point, better than I could ever, but you know, Mark, I'm right there with you.

And I, my, my note-taker is called Rewind.

Okay.

And it does, it does a transcript, a voice recording, and a summary. Kind of a, you know, notated thing. Have I ever played for you one of, one of the AI agents? That we are using. You wanna hear, you wanna hear, you wanna hear, you wanna hear one?

Far away. I think Colleen hasn't heard it. Go for it.

Yeah.

I mean, is, is, you know, have I done it before?

You, you did it only a few weeks ago, I think.

Oh, you did? Oh, okay. That's all right then. It's just, it's just a, just an AI taking an appointment, making an appointment. I, I made one up for, for, for an imaginary practice called Summit Orthopedics. And, you know, I'll just send you— I'll just, I'll just put the number in the thing. You can call it later and talk to her.

Cool.

That'd be awesome.

That's what I was gonna ask is, you know, all these AI tools with Mark's webinar and then the— what we're talking about conversations, there's got— what are the integrations that you have to integrate to make it really useful? You have to integrate it to your calendar, um, to I don't know, you know, to, to write emails automatically and things like that. Is anybody doing that with, with the integrations? Marcus? Summit Orthopedics.

All right, that's one. Yes, she's just— and she's a receptionist. She'll make you an appointment, you know, she'll ask you if you have any pain. Where do you hurt? So forth and so on. Then she'll bring you in to see Dr. Smith.

That's good. Well, that's funny.

That's funny.

It's funny. So I was, I was talking to an investor who, he was asking me like, what's out there in AI medical device that people would want to invest in? And, and I, it's kind of interesting. Well, if you hear, if you guys hear anybody, I mean, I certainly have a connection, I guess now, but I couldn't answer the question. I don't really— it seems like the possibilities are so broad, what, you know, what could happen with metal. Just, I think as an operator, how we could reduce on-hand inventories. I mean, that's a huge saving just by using AI and building it to suit, or, you know, I think there's so many opportunities out there, but I haven't heard of anybody in the startup phase with anything with AI and medical device at this point, minus the instruments. And that's, big company.

And you're talking about using AI to design products or—

Well, maybe not only to design, but kind of, you know, what is, what's innovation, like innovation with AI. If we, you know, I imagine in the orthopedic space being able to, I don't know, print a, you know, instead of repairing a bone, print a prosthetic bone, or I'm using the wrong term. Here's my medical device.

I think those tools are available.

Software type of stuff.

Yeah, personalized medicine, you know, I think those tools are available.

That'll go to a 3D printer in a hospital and things like that.

You have 3D printer in the hospitals got issues. I mean, the, uh, Lima tried that at HSS. They tried to print their own implants and it's just hospitals are not, they just don't have the right engineers, you know, quality people. And it's just, it sounds great to print it and use it the next day, but I, it's just too much operational, I think, challenges.

You know, Tiger, that one company I was talking to you about a couple months ago that I'm representing right now, I will, I will refrain from some of the information, but we did just implement our first printer in a facility in a hospital in North America that they will be able to print— can't say on demand because it still takes 24 hours to print it, but they'll be able to print at least the guides and the models, um, within 24 hours there in the hospital. And it— through the— since it's the company's tech, they can actually utilize it in surgery, whereas in like Mayo Clinic they have a printer but that's really frowned upon to use it because it's in-house made. Um, this is a good, a good test run, and it was, uh, we're using their engineers inside the hospital.

Interesting.

The hospital employees, they bought the machine, they got a clean room we set up. So this is the first of, we hope, 5 in 2025.

Super cool.

Wow, that is cool. And it's for like weird anatomy or trauma or something?

That's—

yeah, yeah. Ortho-oncology, orthotrauma, you know, pediatric defects, things like that that come their way that can be addressed within a 24-48-hour period.

That makes sense. Yeah, it's a big, it's a big difference going from guides, you know, or models. You get— surgeon wants to hold the bone defect in their hand. That's one thing. And then guides, cutting guides, it's kind of the next level, but implants, that's a, that's a big one.

Yeah. Especially for oncology, ortho-oncology. That's brilliant.

I hosted a dinner last night here in Atlanta. I had 3 companies there, Bonza, Acura Medical, and what was the other one? Easy Whip by Winters Innovation. And the reason I brought it up is that the flyer that we sent out and emailed had a phone number on it to call an AI agent.

Summit Orthopedics again.

And basically, yeah, and anything you wanted to know about those companies, she could tell you.

I just said, how did you, how did you build the, we, we, we'll all call Summit after this is over. How did you build that?

Well, for the, for the, for the AI agent for the dinner, I just, I went to all the companies that were coming and I just scraped their websites of everything, including their price list or whatever I could find and just fed that into a knowledge base and then uploaded that to the AI. So the AI knew that. Like I said, I did the same thing for an AI campaign I did in Chattanooga for Treece Medical. That was a, you know, I said, you wanna do a lab, dry lab, whatever. Doctor would call that number and then the AI would, you know, arrange for a demo or a rep to call or invite them to a lab.

Yes, so you have to have a unique phone number and you have to have a trained voice AI.

What—

and what tool are you using?

Also, the Prevencis thing that I'm rolling out, you know, you build an agent and you just—

you—

it gives you a unique phone number.

Got it.

Well, you can either do it by unique phone number, which I think is easiest, or you can, um, do it by Zoom. Interesting.

Yeah. And it's changing so fast. Yeah. And what, what Chris said was really important. You know, you don't grab a hold of any, don't sign a long-term deal with anything because it's, there's gonna be a better one a month later. You know, it's changing so fast.

Speaking of, did anybody register for the Medical Device Consortium in, that Mark, I think Mark, you brought it up last week, right?

At the academy?

Yeah.

Is anybody going or nobody? Everybody?

Nobody?

I'm going. Oh, good. Good.

Not me.

What, at AAOS? What is it?

It's at the academy, but they have on the 12th, they have a medical device consortium that's all Small medical devices.

Oh yeah, the Orthopedic, uh, Innovation. Yeah, I'm a part of that with my startup.

Yeah, that's pretty cool.

I was gonna say, Leah, Kuro, Abanza, we're all part of that, Mark.

Okay.

Yeah, no, it's a great group. We, um, it was what, we were at ASOM last year in Denver, and it was Leah, Molly maybe, had kind of like started thinking about it, and it was like, how great would it be to get these smaller companies that get lost in the convention floor, but more importantly, don't compete, but really kind of co, coexist and help each other. So, you know, if you think about it, EasyWhips there, right? And a Bonze is there that can be used very much together.

Two sports medicine.

Yeah.

Yeah. You know, our, our product, we hope will, you know, we'll start with tendons in the hand and foot and ankle, but then, you know, slowly move into quadricep tendon repair, slap repair where we could, you know, go with them and go, go with some other companies and pool our money together to do, you know, labs and to do dinners like you were probably part of last night, Mark. And that was a smart— Leah, Leah's a, Leah's a rising star in this industry.

She's sharp.

Yeah, I know. She's fantastic. I was on 2 days ago talking to her about something else, but she's just super sharp, super good.

What a great idea. Well, I look forward to meeting you there.

Yeah, no, it's gonna be, I, I highly encourage everybody, if you're gonna be at Devil's Ass to sign up for it. It'll be, it'll be good. Each company will have a wine barrel with their name on it and we'll have our product and you can come by and talk. And then we're also, I've invited, you know, obviously surgeons to show up as well.

What's the name? I'm sorry, what's the name of your company, Chris?

Tyber Health.

T-Y-B-E-R Health.

Okay.

Yeah, we're, we're, uh, a few days into our FDA submission.

So yeah, not, not to be confused with Tiber Medical.

That's right, I'm not Jeff Tiber.

That's right. Well, do you guys see the Medtronic acquisition of Nanovis? Um, yeah, so, you know, like AI is a buzzword now, you know, nanotechnology was a buzzword 2 or 3 years ago, I guess. And the problem is that nobody, there's so much bad information out there. Nobody knows. Surgeons are at the podiums saying wrong things, like, you know, bone's too big to grow into nanotechnologies and, you know,, and then everybody's putting nano on their product, which has no nano features. So it looks like Medtronic bought this to put coatings on things for better bone and growth. But, I don't know, we'll see what happens.

Is it clear, Tiger, what exactly the, what assets they acquired with this, or is it?

No, it's not very clear. It sounds like it's just assets, just like you said. Um, you know, me, I'll put the text, I'll put the website here in the chat. Yeah, it wasn't— the price wasn't disclosed either. Just could be, you know, could be. I don't know, was it— if was it exclusive licensing or is it purchase? It sounded like it was a purchase. But this is kind of what Dan Justin was doing down in Florida. You know, you could— the neat thing about nanotechnology is you could, you could put it on different— you can license it to different spaces in orthopedics. So you can just keep, you know, you can sell the sports medicine, you know, license and the joint license. Trauma. Um, you can sort of keep going. It's a neat business model. A little bit like Osteocentric. Are you guys familiar with Osteocentric? The, the— yeah, they have a better screw thread, and it sounds stupid, but it really works. It's totally mechanical. And you, it threads into bone easier than a normal screw and then it bites like grim death. It will not come out, but you can back it out. You, you can, it's, it, it's, the surgeons say it feels like you have bone ingrowth in like 2 seconds. It's called osteocentric. And they finally figured out their, they're down in Austin. They finally figured out their business model, which is a licensing model. Same thing as, as Like the nanotechnology companies.

Sorry.

No worries.

Yeah, so I was looking, I was looking into that when I first heard about them a year or two ago, and because a screw is a screw, right? But their design, they have a unique backside geometry of the, the, um, the back edge of the thread. So normally a thread pitch is just peak and valley. It's symmetric on either side of the top of the pitch. But theirs has—

it's like a—

it's not— it's just cut differently, and they must have a special grinding wheel that they use for it. But it just creates essentially a different ramp on the back of the screw thread and probably more surface area. And it's pretty neat, especially when you see something that— unless somebody showed it to you under a cross-section, you might pick up one versus the other and not notice the difference. Do they, Tiger, do they have a specific pullout strength or is it what sort is it, is there anything quantifiable that they push? Yeah, yeah.

Why it's, no, they do have, they have all the numbers. It's, you know, it's, it's the, it, it just bites like crazy. It goes in like butter and then it just bites and it works. And the hardest part is making it. They don't, they don't have any manufacturing in-house. They, they rely on suppliers and that's the biggest challenge. The engineers are at the suppliers all the time.

Oh, interesting. Osteocentric.

Osteocentric. Yeah.

Dot com.

Yeah. Okay. It works. There was another company called Diamond. They had something similar. There's another, and I, I, it, they were kind of struggling and I just showed up in the VB's portfolio. So obviously the VB's bought that thread. Diamond, Diamond Orthopedic, I think is what it was called. Yeah, it's another, it's a, yeah, I'll, I'll put all this stuff in. The chat. You know, I'm writing an article right now. There are so many startups. I mean, there, I'm, I think there's 1,000 startups in orthopedics in the United States. Founding. Yeah. I mean, it's amazing. And, and I talk to people, you know, I have, I see the startups a little more than most people because I, I just talk to so many people.. And, you know, I'll be talking to somebody and say, well, you are, do you know this company? You know, Osteocentric, you're in Austin, you've been working in orthopedics for 20 years and the startup's in your backyard. You'd never heard of them. It's like, and there's, there's hundreds and hundreds of these things and they're different phases. A lot of them are pre-revenue trying to figure things out, but a lot of them are commercializing. And it's just no one person has visibility of all the startups. And they come and go. They're either growing or dying, you know, and it's a really interesting— I'm going to try to write an article about— I think there's 1,000.

So are you able to make any educated guesses about how it breaks down? Spine, hip, knee?

Well, not joints would be the lowest because the entry, the entry price to get into joints is really high. Spine's probably the most because the entry price to get into spine and you got, you find your favorite doctor down the street, you design a new cage, you write a 510, you're, you're, you've got a business. I mean, you can get to, you can get to $5 million in sales in spine in a heartbeat. Now, the hard thing is it's really hard to grow, but you can get started really easy. The prices are high. Yeah, Mark. No, I thought you had a question.

Speaking of startups, Tiger, we'd love to hear about Bone Factory. I'd love to, personally, I'd love to hear how that's going.

Yeah, it's fascinating. So, I get calls from surgeons sometimes and they, they're frustrated. They gave their— they brought a, an idea to Zimmer or Stryker and just nothing happened. And they, they get stuck in meetings, you know, and then, and they call me and say, I need to get my idea back, but I can't. I gotta sue the company to get my idea back. And the big companies, the bottom line is the big companies are terrible at innovation. That's why they just They do acquisitions. They don't do R&D anymore. And so, but they, when the surgeon brings an idea, they don't care about the surgeon's idea. They want the surgeon's business. And so they lead the surgeon along, put them in their business development portfolio, and nothing ever happens. Anyway, that was, that's the need. And so I just wrote an article about this 3 months ago, I think, called a concept called the Bone Factory. Where surgeon can bring their idea in. We immediately put together a virtual team. We try to understand the idea, have the surgeon put a little bit of prototype money behind it, and get to a working prototype as fast and as cheap as possible. And, and if it looks like it's all green lights, you know, regulatory check, technology works, it's, you know, ASP, everything, then we'll spin out a company. We literally spin out a company and match some funding with it. If it's red lights, we just say, sorry, you know, this isn't going to work. And so we got 4 going on right now. We've got 3 out of 4 foot and ankle. And we told one of them, great idea. This, this business will never work. You'll never, you'll never be profitable. And we just said, your baby's ugly. Have a nice day. And the surgeon appreciated that. They were, it was just very refreshing. So anyway, that's the Bone Factory. And the website is thebonefactory.co. I'm scared to repost the article because I, you know, I don't want to get into 10 of these things. It's, It's a, you know, it's a Zoom call every week with a virtual team. The bonefactory.co. Yeah, that's— it's interesting.

How many companies have you had so far?

What's that?

How many companies do you have so far?

Well, they're not really companies yet, but it's 4 surgeon groups with 4 different ideas. And yeah, and it's— if, um, and another thing I did, I wrote, I wrote an article. I don't want to be the CEO of this thing. I don't want to have to go out and match funding and hire people. So I, I, I wrote another article saying I'm looking for the CEO of the Bone Factory, and there's no salary, there's no office, there's no guarantees, there's no, you know, if everything works out great, you might have equity and a little company in the future. And I got a CEO in 12 hours, and he's great. And he came from the venture capital world. He's great. So, um, congratulations. Well, it's just, it's fun. It's a lot of work. There's no— it's kind of like your webinars, Mark.

It's not not really doing much for me yet, but you're not raking in the cash.

Cash is zero and, you know, equity may appear in 5 or 10 years. So yeah, Jesse, tell us about Bonebridge.

Trying to hold out and not to give the sales pitch today, but okay.

Well, you know, just give an overview then.

Okay.

Yeah. So my name is Jesse Dionne. I'm the GM for Bonebridge. We're a relatively small orthopedic trauma company based out of Switzerland. We came to the US market with our first 510 at the end of '22, did our first surgeries the beginning of '23, and we've been slowly building beachheads in the US since. So relatively young. We're well established in Switzerland. It's mostly just OG AO people. So there's a lot of people, even today, I mean, especially now more than ever now that J&J is kind of thrown away the, the, the Synthes name and they've gone to J&J MedTech. There's a lot of, uh, hard feelings being felt in the clinical side of that. So a lot of this AO, uh, original contributors decided that they can probably do better and do it like the old Synthes. Um, so that's what we are. Uh, philosophy of the company's built is based off of reducing the complexities. So, and I don't think anybody can argue this point, most of the orthopedic trauma market that's been developed in the last 15 years is strictly marketing. Um, it's just trying to find new line items to compete on the contracting level and try to get their products above the next guy so that they can win the next, uh, GPO agreement. And it's gotten to the point where just a lot of these surgeons are just fed up with it. Like, like, I didn't need the last 3 tibial plateau plates, why are you showing me a new one? Um, and there's— I mean, like, we, we go over— there's companies— I mean, J&J has, I think, 5 or 6 plateaus on the plateau plates on the market. The Globus just launched a system that has 3 different iterations of it. When you talk to any surgeon, like, I can do that with a non-locking small fragment set. Why are you coming out with more and more stuff? So it's just adding burdens to the system that don't need to be there. So the pro— the philosophy of the company is to try to do it, all right, we can do it with state-of-the-art and providing a lot of instrumentation and implants that are getting rid of all the fluff. Small footprints in the hospital, but still providing strong clinical outcome for the patient. That's the gist.

You do an X-fix too, or just plates and screws?

Our portfolio is mostly just plates and screws at this point. So we're all pretty much done our 3.5 system. We'll have— we're starting our preclinical stuff for IM nails. That'll be our next launching. But the expectation is to be a full trauma company within the next 3 years. When I say full, I mean full trauma company, a company that could say that we can handle an 80% contract with a major health system.

All with internal capabilities, or you interested in acquisitions?

Uh, at this point we're still internal. Uh, we've, we've been in communication with some smaller companies, and, uh, but at this point we're— it's the beauty of the Swiss mentality. They, they have no expectations of the, the, how the US does it, where we just want to blow it up and try to get acquired at whatever multiple they have. It's all about maintaining cash flow profitability, and we, they're happy to slow grow it. Um, and we've been very successful with that.

Yeah, if you can do trauma with less SKUs, you can really, you can really win.

Yeah, I mean, like, perfect, like, the example of our pitch is we, we produce Our 3.5 system is one tray and it's one tray for all everything. So you can do a clavicle, proximal humerus, elbow, forearm, plateau, peel-on ankle, all without that single one tray. So you have a hospital, take our tray, put 3 of 'em on the shelf. You can do any 3 fractures that come in no matter what it is. And all the plates are sterile packaged. Whereas you look at the footprint of another company, I mean, we'll pick on J&J or Synthes. I mean, they're, they, you show up with a proximal humerus, that's 3 trays. You got a clavicle, that's another 3 different trays. And they have just rooms devoted to the hospital of just storing all these different levels of instrumentation that we can do with literally one bookshelf.

So your stuff is sterile?

Uh, the implants are sterile packaged, so— well, the plates are sterile packaged. The tray is a standard tray. We did, we did try the sterile screws and everybody hates it. It just adds 15-20 minutes to every case.

Okay. Cool.

So, OG, you like that?

Question. Jesse, are you guys at all focusing on sort of reducing surgical waste? I'm getting messages that that is an increasing priority.

Yeah, I mean, well, I mean, that's when you talk about like the— on the sports medicine side, that's huge on sports medicine because you can open 15 packages for one procedure. I mean, yeah, we do our procedure. The, like I said, it's all one tray that does everything. So you only gotta wrap one tray. That's your, your saving for the sterile processing and the logistics for the hospital. And then our plates, I mean, I don't have any in my office right now, but we, a plate is literally a box. It's this big. So I mean, footprint-wise, we're, we're, we're as small as they come.

That's fantastic. Yeah, that'd be a good selling point at, at some point.

Yeah, I mean, we've done plenty of like white papers with the Swiss people. We're working to get some going here in the U.S. right now to show that it is a major savings, not even respect to the pricing side, just respect to logistical savings.

Well, listen, I've been doing white papers for HealthTrust, so let me know if you want to connect about that.

Appreciate it.

Yeah, I probably will. You'll be seeing me.

What have you seen in the medical waste space, Elizabeth? I'm kind of curious because I was trying to do some work on single-use instrument kits and I just couldn't find a solution for recycling or donating or anything like that. I mean, came really, really close, but it's, it's moving large mindsets to make something happen.

Oh, sure. Oh, sure. And I mean, so what I'm, what I'm hearing that need, that needs to be done. Well, the stats are alarming. I, this is something that most people have never thought about, right? But apparently it's 5 Boeing 747s a day that is generated in the ORs in the US.

That's tremendous.

Yeah, it is. It's very disturbing. And the upshot of how—

I'm sorry.

The upshot of how to move things forward is, you know, you're not going to make a lot of progress unless you get doctor and administrator buy-in, you know, and you show them the bottom line and you just make them part of the process and the nurses as well, because, you know, they have their own stressors and, gee, do I open this now? How many of these do I open? That kind of thing. So it's a real systemic situation. And I don't know that many hospitals have gotten on it yet, so to speak. I don't know. Anybody else want to chime in?

Europe led the way, right? I remember in Europe, 10 years ago, that they— some hospitals would force the manufacturer to come get all the— take all the waste out of the surgery at the end of the day. So that's kind of an incentive to decrease your packaging.

Yeah, at least they didn't put it on the patient. Um, yeah, yeah, they— it's, uh, it's very interesting to, to look into all that, and, and I think it's going to be more and more, um, you know, it's very visible, right? If you can literally— like I said, the the Boeing 747s. And if, if administrators can be shown how they can save money and figure out some sort of reward system, all the better.

So you said it was 7 Boeing 747s a day?

I think it was 5. What did I say?

Anybody else?

Sorry. Yeah, where's our AI when we need it?

Yeah, of about roughly 5. Boeings, yeah, a day just out of the ORs in the US.

So I got some surgeon buy-in about a year ago and we were trying to get it done in California. It just, it just, we couldn't get all of the pieces together. We, the company I was with and working, trying to do this through was, wasn't creating enough waste to generate somebody to come in and pick it up. And, and it would have to be something bigger than that. But I talked to a company a couple months ago that felt that they were on the cutting edge of creating this system for all hospitals that would, um, kind of take titanium-based metals and, and create storage systems and bring that together and then be able to recycle that. So if anything comes of that, I'll share it with you. But right now, I, I don't know anybody or have seen anybody. So if you do come across— it's something that crosses my plate regularly. So if you do come across anything, I'd love to hear.

Yeah, sure. I will throw this in. The, um, so a couple of the different papers that I saw on this, um, kind of came to the same conclusion that to a large extent this is a cultural problem, you know, as far as what the nurses are used to doing, the techs, what the, you know, and how, how do you move the needle on changing people's behavior? All comes back to psychology, says the therapist.

Hey Kyle, Kyle, didn't, uh, didn't Crossroads have a recycling program as one of their products where they would come pick it up something after the case? I forgot. I remember Vernon did something like that.

I don't know for Crossroads. I know that Flower never really got off. They sure tried for years and years to do the single single sterile packed screws and plates and such, and they're still alive. But, um, hopefully that, Chris, you guys learned— or, uh, Jess, you guys learned that lesson faster and cheaper than they did. But somebody used to do something where there was a certain jig that you got a rebate if you kept it and didn't throw it away. They could pick it up and repurpose it, and it saved everybody some money. But I don't remember who did that.

Yeah, I looked at— I'm looking it up. So Crossroads had this thing called EchoSmart Instrument Service. Which, let's see, which provided customers with gamma sterilized reusable instruments, reducing waste. I don't, I don't exactly understand how this worked, but I remember, I remember seeing it as one of their offerings before they got acquired.

There's a French company called Science for Biomaterials that when they make a presentation to a hospital or a surgery center, they call it their green initiative. And it's about reusability. It's kind of that Euro sort of consciousness of that cultural issue you were talking about. And sometimes it's kind of met with derision by some of the, some of the anti-woke surgeons. Like, you know, it's kind of funny really how it quickly bridges into this cultural thing. I mean, what's wrong with sudden not wasting stuff? I don't know, but that's their thing.

Well, I mean, the single-use kits have been, I mean, one, it's a safety issue, right? There's— they're seeing that there's less infection with it, but it's also a time factor. Like, these surgeons can blast through a ton of surgeries during the day if they're using the single-use or not waiting for, for new equipment. But it goes like— the problem with single-use is you can't— there's no testing that's been done to say, hey, you can recycle this thing 3 times and re-keep packaging it. You have to— there's so many problems with it. It has to go to meltdown to be rebuilt. Unless companies decide that they're gonna take a single-use kit and see how many times that you can recycle it, but then how do you track it? And I won't bore you with all of that. But anyway, Elizabeth, if you hear anything, let me know, or anybody. It's something that crosses my desk all the time.

Interesting. And if David Kaye was here, he would say it's a labor problem too, cuz all the central sterilization has got, you know, they got hundreds of trays and if somebody calls in sick, they have to to literally cancel surgery at his hospital that he owns. Um, you don't see the— you don't see the, you know, the engine room down in the bottom that keeps supplying the ORs. Um, most people don't go down there.

That's been a big disaster since COVID That's one of the few places that hasn't recovered.

And how so, Jesse?

Staffing. I mean, it's, they got major staffing issues as soon as COVID hit. And I mean, I know especially Northeast down in this area in Pennsylvania, it's, it's the places that were beacons of efficiency, arthroplasty hospitals that would do, one surgeon could do 12, 13 arthroplasties in a day. Now they're struggling to do 6. I mean, it's, it's scary to see. You're, you're all nice if the implants are even sterile half the time.

Wow. The long pole in the tent is the, is the instrument labor. Wow.

You talking SBD?

Yeah. Sterile processing.

Yeah.

I mean, there's, we, we have a lot of hospitals that just never recovered having the right staff to, I mean, it's, it's a low-level entry job and unfortunately those people tend to get the, the brunt of the abuse because of, they're usually the delinquent part of having, uh, not having trays in time. So they don't, not many people stick around.

And, and I, I partly blame the manufacturers because, you know, over the decades, the trays have just gotten more and more complicated. There's more stuff and they're trying to fit, you know, things fall out, they're trying to rebuild the puzzle while they're down and, you know, and, and it's just more, more, more complexity and They just— it chokes them. It's Lucy in the Chocolate Factory, if you remember that skit.

You know, you're making my pitch for me, Tiger.

Thank you. That's true. Uh, let's see, what else, what else before we sign off? Tom's been quiet. He usually has some good philosophy. He's gonna stay mute. Kyle, tell us what you're working on, or what you can tell us.

I'm actually mostly involved in an operations transfer at the moment, which is not what my intent was to work with a particular client, was to focus more on manufacturing. But it turns out they were going to move some facilities and they learned that I'd done that a couple times before, so I get to be the guy. And just as you can imagine, that there's a lot of moving pieces with stuff like that. But I'll tell you, I've had the chance to— gosh, let's see— work at like 4 different companies as a full-time employee, and I've had a chance to consult a few more now. And, uh, man, it's fun to meet lots and lots of people from new places as part of the as part of moving around. And in the consulting realm, it's not as much of a commitment, right? So I'm not there forever, but it's also not— I don't have to— if I'm leaving, it's because it's just part of we finished a job. So it's, it's been, that's been an interesting adventure to get to know a wide range of people from new places.

Yeah, every company is different. I mean, they all— every— they have different technology, different people, different cultures, and they're— none of them are the same. It's really interesting. Yeah, they struggle with— they have different skill sets, they struggle with different problems. Yep.

And it's always fun to see where some of the influence of how they've grown or where they came from can impact day-to-day. So Place I work with now is an accumulation of what used to be a bunch of smaller startups, but now they're under a much bigger brand. So they're trying to behave like a startup, but they have this gigantic corporate umbrella that just holds them down. So it's, uh, it's to some degree the worst of all worlds, but they're trying real hard. And then I've seen it on the other side where you can be kind of a rogue skunk unit inside of a big company where you're hidden in the shadows and you can get away with everything.. And then I've seen the startup and acquisition space. Without what I have found to be universal, and Priority Medical, we're starting to make a focus on, on how we can help in this area. But what I found to be universal, when I've been part of the company being acquired or been around when the acquisition was made, seems like every time once the deal is made, all the work to integrate and figure it out post-acquisition is just dropped in the lap of people that have a full-time job already, and it is such a recipe for disaster. I've never seen it go well. The stats are way against it, but the, the acquiree isn't served properly because they get kind of closed out. The acquirer doesn't hit the milestones that they promised. Everybody gets overworked. It's, it's wild seeing that again and again.

And the acquirees are nervous and it's just become such a people issue, right? I mean, there's just so much anxiety on the people who have got, who are getting all this extra work.

It's, yeah, it is, it is a tragic misalignment of incentives in every direction.

Yeah. That's well said. Yeah. That's why the Zimmer Paragon 28 thing's just never gonna work. I mean, they will never, you know, get sales above where Paragon had it.

So I did hear something that surprised me recently. So Tournier was acquired by Stryker after having a just a great run in the shoulder space. And what Stryker appears to have done with that former Tournier team is largely leave them alone. Call them Stryker, leave them with their headquarters. Leave most of the people in place, expand on their brand and their product, but let them operate with influence from the Striker culture but without overtaking them. And they're doing extremely well. And that is— there are not a lot of examples of that.

That's a really good point.

That's—

when were they taken over by Striker? How long ago was that?

Maybe 2 and a half years ago.

Really?

Something like that, maybe. I guess it could be more.

I was right.

Wright bought Tournier first, right?

Right.

And then, yeah, and then, yeah, and then Stryker bought Wright. Yeah.

So it's been— the Tournier thing was 8 years ago.

It's a while back. Yeah.

Yeah. It's funny you say that, Kyle, because there's a couple of guys I know here in North Carolina that are, you know, Lifer distributor, Lifer distributor reps, and they were not the mold for Stryker. They've stuck on and I laugh and joke with them whenever I see them. I'm like, you're not wearing your Armani suit and you don't have a chiseled, you don't have a chiseled chin yet. And they, they're like, they leave us alone, you know? But that's what happens when you got a $4 million each, you know, client going on that you don't want to mess with. That was smart.

Yes. Similarly, we, I've had discussions the last 2 weeks with foreign companies that try to create a US subsidiary, a little bit what Jesse's doing here. And the ones that work are the ones where they hand them the keys. Here's the keys to the United States, you know, go, go make it happen. The ones where it doesn't work is where you have to call back to Germany, you know, every week, or Korea. I mean, there's so— there's a graveyard of bad companies. The, the stellar one is Osseo. OSIO came out of Israel, and they get 60, 70, probably 80 employees in Israel now. And they— I don't know how many they have in the US, uh, 30, you know, not including sales. And they handed them the keys. They said, here, Brian and Brennan, here, you guys know what to do. We don't know the market. Just tell us what products you need, and we'll keep designing them and manufacturing. And the engineers fly over from Israel to see the sports medicine guys in the US do whatever the US guys tell 'em to do and go back and make it happen. That's, that's been stellar.

You know what's interesting there too is like Brandon Murillo is not a traditional orthopedic guy, neither is Brock. So it was like, you know, they had the Medtronic big picture card. I think they're vascular guys, but here are a bunch of guys that are not your traditional orthopedic and they came in and they, they're taking what is, you know, seemingly a very, great, a great concept of natural, but, you know, very hard to do. Let a lot of skeletons in that pathway, gone before, but they're doing a great job. I, I, every time I, I applaud Brennan whenever I see him. He's done a great job.

They're, they're doubling sales every year. I mean, it's just insane, you know, and they have zero competition. 'Cause they're the kind of the only non-metal small bone fixation company.

Yeah.

Yeah. All right. Wanna end on that? Thanks guys. We have a speaker next week, TrackPatch, and then the speaker the next week is OREF. Gonna talk, tell us about their venture fund they have for startups.