BoneChat #75 - How BoneBridge is bringing elegant simplicity into traditional trauma and winning.

Okay, this is BoneChat Discussion 75 with Jesse Dionne, who leads up the US business for Bonebridge. Jesse's a relatively new member of BoneChat, and he's going to be sharing his business and technology. Turning the mic over to Jesse.

Thanks.

Thank you. Uh, thank you very much, Tiger and Bonechat, for the opportunity. Uh, I will say I've— this, this is from a few months ago. So Tiger, one of his posts out there was just based on where— how simplicity is where the, the market should go. And I was reading, I was like, finally somebody that gets it. Uh, so that's how me and Tiger connected. I reached out, I was like, thank you, thank you for putting this out there. Um, so we've, we've communicated since, and I'm, I'm very happy for the opportunity. So Gonna do a little share in here. And I'm gonna do a quick overview of who we are and so on and so forth. So you guys have a little bit of baseline. All right, is that coming through? Yes. Okay, so, so Bonebridge. So just big quick overview, down and dirty of what our company is. So we're a Swiss company founded in 2018. First implant developed was our first iteration of our distal radius, and that was in 2019. We're currently 18 employees in Switzerland, 4 US, 4 Australia, 32 suppliers in Switzerland and Germany. Everything is made in Switzerland or, and/or Germany for the most part. Our trays are actually made in the US. We have 40 hospitals that are regularly served in Switzerland, subsidiaries in Australia, New Zealand, and of course the US subsidiary that I run was established in 2022. We just got our first 510 at the end of '22, and we did our first US surgery in January of '23. So very young company with respect to the US. We're currently active doing daily business in 15 US states as of today. And this is our mission. Our mission is broad strokes, just improving patient outcomes by applying and promoting the power of simplicity in fracture care, which is something that's been kind of lost, but I think is really making a comeback. And here's our concept. So reducing complexity, as a concept with respect to a company. So this is a chapter written by Professor Christian Gerber, who's one of the most respected, if not the most respected shoulder surgeon in the world at this point. I mean, he won't— he might give me crap for saying that, but phenomenal human being. He wrote this chapter for Rockwood and Mass in the Shoulder. He's the head of our board. And this is with respect to innovation. So innovation as a cost curve with respect to health and how much value you provide. So something like this B section would be, a product like polio vaccine, very inexpensive to make but saved millions of lives. Whereas C would be like something like the first-generation total shoulders. They were expensive because they were new. The poly didn't work out that great, and these things were actually a detriment to those patients' health because they needed revision. So ideally, you want to stay in this range. You want to stay where that inflection point of the cost curve is, where you're maximizing the health of the patient and the health system, but not adding incremental costs that don't need to be there. And we do it from everything that we do, from every layer that we provide. We always— is this making it easier? Is it making it less complex? Everything from design and development. I mean, we challenge our design surgeons to limit the variance. I mean, applying to the patient, which I'll show you shortly. I mean, our logistics are as streamlined as possible, logistics. And then our interaction with our clinicians is direct. I mean, is there KOL and interaction with our clinicians go almost directly to our R&D? There's as few middlemen as possible. And you saw, I mean, we're relatively small team, but very, very efficient team. And like I said, we've— this is starting to become very apparent. I mean, the cost of complexities are hard to see until they're gone. So you realize when you cut them out and then you realize how much you actually paying for this. And this is going across not only healthcare, but several industries as well. So when I say about application to the patient, this is one example of it. So our systems are designed with one drill bit, one screwdriver, one depth gauge does everything, one tray. So this 3.5 tray here in the left will do everything you see around it. A proximal humerus, a distal humerus, midshaft forearm, tibial plateau, peel-on ankle. I mean, so, and it's all with one tray. I mean, I was just at a facility today doing, we did about, we did 3 surgeries. We used the exact same tray every time and they're all different parts of the anatomy. 2.5, same concept. One drill bit, one screwdriver, one depth gauge. Tried to be very smooth and efficient, compact and versatile. All our plates are sterile packaged. Everything's stainless steel because we're Swiss and stainless steel, the way to heal with steel. I like to do this little story 'cause this is a perfect example. So clavicle fractures, probably one of the most boring fractures out there next to ankles. Relatively simple plating patterns. Most systems out there have 20+ different plates because they have all these different iterations. So we came up with this idea how to limit the complexity and have one plate that could do multiple parts of the clavicle. This launched in 2020 in Switzerland, mid-COVID, no sales force, and pretty, pretty much just launched this just with, hey, here's an email, this is a new product we have. Realizing that we're going against players that had, and point out like we only have total of 8 plates. There's 4 for the right, 4 for the left, whereas most companies have 20 plus 30 different plates in their tray. So we thought it'd be an uphill battle. Currently we are at 24% market share in Switzerland. So this place went off like crazy and it's all because it's very effective and it's simple. So the, the simplicity is what sold this product, not the product itself, even though it's a very good product too. I'm not gonna negative on that one. And then so what I'm gonna, I'm sorry, I'm too quick. I'm gonna tell you what got us here. So this is a little story of like, tell like, 'cause most people are either in spine or arthroplasty. They don't really, trauma's kind of like the rounding error. So there is a story behind trauma and why we are the way we are. So why Switzerland? Why does everything come from Switzerland when it comes to trauma? And it all comes down to the AO. So the Arbeitsgemeinschaft für Osteosynthesefragen. Everyone from Synthes had something to learn how to say that. I think it was part of the training. But there was a group of surgeons back in the 1950s that started this, and it was— they globalized fracture fixation with plates and screws. And they— and it was all through several layers. It was— obviously through research. It was heavily leveraged on education and documentation, but they were great creating all these great ideas of how to fix these fractures with plates and screws. So they had to find a way to develop it. So they had a development arm that created the instruments and implants, and that became the multi-billion-dollar company everybody knows, knew as Synthes. Uh, Maurice Mueller was one of the founding members, and this is a quote that kind of refer— that he is attributed to that life is motion, motion is life. It's all about getting patients moving. So when I talked about, I said before about clavicle fractures and like the evolution, this, I think ankles is probably the best way to explain the evolution of fracture fixation because we have orthopedic trauma is, like I said, there is a timeline and a progression to this. So the patient on the left here has a Weber B fracture treated with very simple plates and screws, very, inexpensive systems, the 1/3 tubular. And then patient on the right, pretty much the same fracture. It's a Weber B equivalent, but similar fracture pattern, a little more expensive, posterior lateral pre-contoured plates, locking, so on and so forth. I know the one on the right did very well because that's my ankle. That is a glorious mullet that I was rocking back in that day. But there was a progression. So I mean, it started off with simple plates and screws, and then they came out with compression plates, and then limited contact plates, and then a locking plating system, then anatomic pre-contoured plates, and then non-anatomic variable angle locking plates. And with each iteration, all these instruments had to be rehashed, new implants brought in, and every time the cost kind of went up. So this kind of built the track record. And I'm not saying that the progression was— is a negative. I mean, I think some of these were actually— these— most of these systems are basically very good for the, the, the patients and the surgeons, but The problem is, is that this was like crack. Hospital or medical device realized like, hey, I develop a product 5, 6 years, I come out with a little bit better product. That's, and then I charge a little bit more, get rid of the old one and just keep doing it. And it's been going on since the, the '70s, the '60s. So I mean, the patient on the left, I mean, this is a very cheap instance. It's, it's, well, cheap. It's about $200 probably. Ballpark how much it costs. But you needed some skill to do it. It was, there was some skill aspects to it. Whereas on the right, this about, I know because I paid the bill on this one, it was probably about $1,500, but everybody made a lot of money and everybody was very happy. So we're, but then we digress to where we are now. So I mean, this is the healthcare system. This is, I mean, I could have put a million news releases on this that we just had a major health system go under about a month ago here in the Philadelphia market. But I mean, we have hospitals are closing, services are being lost routinely, staff shortages everywhere. Surgeons are getting paid less, which they all, everybody knows about that. And I mean, the question is like, is there enough money in the system? Probably. And this is another debate is like, is there enough money in healthcare? I would debate there probably is. There's probably just people that, and entities that are better at extracting that money. Whether, whether it's health insurances or so on and so forth. But it's, we're, we're at a point now where the foundations are starting to crumble. And then we get to where we have with respect to medical device. I mean, we already know how we make money. We just keep making new product every 5, 6 years, charge a little bit more, obsolete the old generation. So, and we rationalize these with being innovative or some innovation or some new product to new addition to it. So, I mean, it's, we're all doing it. I mean, pick, pick a company. There's, these are all new product place in the trauma world that brand new systems that launched in the last few years. I mean, are these clinically relevant? I mean, we'll see. I mean, that's the market's gonna decide, but I'll be very blunt in the fact that I don't think Bonebridge would exist if people started questioning whether or not they were relevant or not. And then we, and then this, I, I stole this line from, from Tiger Buford with feature creep. I think it's a phenomenal word because it's pretty much where we are. So just add an extra little feature to your system, a little bit more just so you can say that you're, has something that nobody else has, and you can get on that, that health system contract that everyone's fighting to get. And it's really not about, is it providing a clinical benefit? It's like, ah, mine's different. I should be able to get on this contract too. So then where does innovation really matter? I mean, so where does, where does innovation and the complex clinical problems actually come in and have synergy to it? So we'll give a good perfect example here is proximal humerus. Broschini risk to this very strong debate right now of whether you should even be fixing these. They should be non-opt, replace with reverse for everybody or fix them. I mean, this, this, the failure rates of these are depending which journal article you read are up to 30%. And whether it's the 2 Broschinis that fail or goes into the Varus collapse or AVN, these, it's still a relatively unsolved problem. So we'll try to find maybe coming at it from a different perspective and trying to find a way to innovate into a problem like this is where we should be going. So we have two ways of doing it. We have one— this is Christian Spross, this is an article in JBJS, uh, so we do it through the— for education. And this is a phenomenal JBJS article with respect to a good algorithm, how to treat the right ones. So, uh, that's the clinical side. We, like I said, we like to share and educate as much as possible, so I like to share this one as well. But also, are the implants right? And this is where— this is where the innovation comes with are we making an implant that's actually going to help us with it? So I mean, everything we make is from— when we start with a clinical problem, it's from first principle. It's not like, what does Stryker make? What does J&J make? What does Smith Nephew make? What does Zimmer make? And then try to make an iteration that's— that can sell. It's, what is the clinical problem and how can we solve it? So we just went over, I mean, what, what the current problems are with respect to— maybe the tuberosities aren't feeling— aren't healing because the current products, the only way you can fix them is with suture and you're trying to tie suture to bone and trying to get suture to heal bone. Maybe that's not the best way of doing it, or maybe you're pushing the head in the varus and maybe you should try to find a way not to do that. So we came up with the Tamina TF. So that's a product that's actually using metal to fix and compress the tuberosities, which is unique. It's patented and it's a unique solution on the market that we think is gonna help to give hopefully better than 30% failure rate outcomes. That currently being reported. And just for example, terrible fracture right here. This is done, this was a 44-year-old construction worker and he was lucky enough to fall into the hands of a master surgeon, Dr. Bayat Mohr, who treated him with this. And you can see in this, this X-ray here in the middle, you're not gonna see that with anybody else, that type of fixation and terrible fracture, excellent outcome. Patient's doing great. So that's where we are. That's how we're— what we're doing. Um, I can talk a million things about the, uh, trauma, but I don't want to get too much in the weeds. I'd rather hear what you guys have to say and any questions.

Well, I mean, that we talked about this, uh, early on with David Kay. I mean, the problem now is complexity for hospitals. They can't— they can't absorb all of the implants, the robots, the new training, the systems, and they, they, they're hit the wall with labor. And like David Kaye says, I'm not even gonna look at a product unless it reduces steps, reduces costs, reduces complexity, reduces labor. And then you get his attention. So, I wish David Kaye was on because he would say we're at a tipping point where hospitals just can't do it anymore. And so it's unique. So how— tell everybody where you are in the US roughly. And, you know, you've only been in the US a few years.

Yeah, US a few years. I mean, we're— the one thing I will say that I love working about a Swiss company is that everything is very systematic. So it's a very controlled— you don't come to the market, especially the US. I mean, it's just too broad and you'll die by a thousand cuts if you try to to, to hit the US in one big shot. So we go after, so we're in, in, in our, in current markets, I mean, we're very strong in Texas, the Southeast. I was, I'm in the Pennsylvania area, so we're actually doing several cases today that I was at this morning. That's why I was telling Tiger I was strapped for time, but it all worked out. Midwest, Mayo Clinic, in California, we just started out there. So we're, we're kind of like Spread out, but still we, we kind of focus on hot pockets. Um, and we were kind of talking about it before, is it was, we talk about entering the US market and being as flexible as possible. When I first presented this to a lot of my friends in the trauma world, they're like, oh, this is perfect for like the rural hospitals that they don't have a rep and they can just have a simple proceed implant proceed system that they can get away with and do all things with one trade. Like, yeah, that's probably right. So we started kind of going that way. That's not our strongest market. Our strongest markets are the major huge trauma centers that where you have a well-trained, yeah, level 1 trauma centers.

Yeah.

Level 1. I mean, our, our, the busiest trauma center in the US is Memorial Hermann in Houston. It's our, one of our stronger markets. Uh, Grady, Mayo Clinic. I mean, these, it's what this actually is really calling to is actually the experienced traumatologists and they're the ones that are pushing back, be like, I don't need another iteration of a proximal tibia plate. I just need one that works and I need it simple and I need to have so that my scrub tech is not gonna have to ask 50 questions of which drill bit to use. It's like, that's why I tell people, he's like, you can take a drill bit and put in a drill, you can use our system. That's as hard as it is. That's the hardest part of the whole procedure. And that's not the case with most systems that are out there.

Jesse, have you counted steps?, with your system versus, you know, a big trauma company, or have you counted time?

Uh, we've, we haven't counted. Well, we, we have counted time, and this was a lot of our data is mostly on the Swiss side. So, because that's where we were, we started at and we're strong. So we actually do have some like a white paper type research on the clinical system. And that's when I said about the perfect example of a something simple that you would— you wouldn't think would be the market driver. I mean, clavicles are— but most, like I said, most people are used to having a system that has 5 different contours so they can choose the one that fits perfect and they want to sit. And so you look at our system, you're like, wait a minute, you only have one contour plate. Like, how am I going to use that for every clavicle? I'm like, trust me, it works. I mean, the— and it does. And the market's proven that you go from with no sales force in 3, 4 years to 20% market share. That's not an accident.

So there's never a rep in the case, mostly?

Well, I mean, are you a rep? I mean, the system's easy enough to use. I mean, then you could have this whole argument about distribution. I mean, in Europe, no, they don't need, they don't have sales force. I mean, there's not people covering cases and the system's designed to be that way. In the US, I mean, you, you need distributors. I mean, as much as, or someone in the room, it's not, it's not that someone needs to be in the room to actually tell people what to do. Uh, it's that last mile logistics, that last mile logistics at a major trauma center. If you don't have someone that is doing the work to make sure that stuff is in the OR and actually getting billed for properly, it's, you're gonna have your, I don't even know how you, you recover logistically from that.

Yeah.

And that's, I mean, that's, it's when we talked about, because we launched in the US right when COVID was hitting too. And I thought that was actually gonna be the, the bellwether was like, nobody wants reps in the OR, nobody wants people in and out to manage stuff. So maybe a simplified system would work. No, no, they, they, they, they, I, it's at the point now, I mean, where I'm, my many hats I've worn in my career. I mean, I was a distributor for a time towards the end of it. I would get calls from the OR that asking where I was and be like, oh, I'm on my way. Be like, well, we're not bringing the patient back until you're here. I'm like, everything's there. I'm just the rep. Like, the doctor's there. Like, oh no, no, no, we're not, we're not opening a tray until you're, you're present in the building.

Like, you're the insurance policy.

Yeah.

And unfortunately, that's the state of where a lot of, a lot of hospitals are at. I mean, it's not perfect, but it's, it, it, we, we are part of the team and sales is an important aspect to it of just making sure that the patient's taken care of. So we, we can abide by it.

Elizabeth?

Yeah, hey Jesse, have you all considered, um, the trauma center, Level 1 trauma center here in New Orleans? Because we have— it's the only one between Galveston, Texas and Tampa. And, uh, have you, have you tried to come in here?

Yeah, we've actually done— I think we've done at least— I know approximately here works. We've done I know a case at Tulane or the University Hospital, so we've been there before.

I mean, do you have regular point of contact?

And yeah, I mean, we're, we're actually, I think we're in the process of actually getting a new distributor for that area, but it's, it's, it's in the works.

That's okay. Okay. All right.

Good. Yeah. I mean, we're at the stage now and me and Tiger were talking about where, where we are at different levels. I mean, we're at the, we're at the scaling part. I mean, we have, we've, we've have a proof of concept. We have a market. We've proven that we have a market in the US. Now it's just building out the tentacles and the sales force to drive it to that next level. And we're, we're getting the right distributor partners is the hard part.

I can imagine. Well, if I can be of any help, I would love to be.

You can break your humerus.

I'm not breaking nothing.

All right, John Allman.

Hey, uh, thanks. Sorry, uh, I am on a blank screen. I'm sitting in a parking lot, um, so instead of having you guys look up my nose, uh, Jesse, I missed the beginning and I apologize for that. If you, uh, cool idea. I'm wondering, cool, obviously a cool company. I'm wondering, I'm a former Synthies guy as well, and as I think about what you guys are doing, would you say that, uh, and if I missed it, I apologize, but would you say that the real value in what, uh, Bonebridge is doing is delivering simplicity. I'm sure cost plays into simplicity. Are those the two main things, uh, that you're— the values that you're driving into the system, uh, obviously hopefully to get, uh, adoption and value and things like that? And again, if I missed that in the early stages, I'm sorry.

Yeah, no, no, that's fine. Yeah, I mean, simplicity actually, like, it's the core of everything we do. So it's not only just the the logistical part, the interaction with the hospital, we try to keep that as streamlined as possible too, which everybody would hope that they have that interaction. But like I said, the simplicity side is pretty much from everything from the developing the product to, I mean, interactions with KOLs, like stuff like that. Like you normally think that's not really part of the, the sales process, but for us it's like, it's, it's a mantra. Like we, our CEO, Kristof, I mean, he's, it's not uncommon to, after we have a meeting of like a new proposal of something that we're doing, it's like, all right, let's make it easier. Is there Are we, are we making, are we taking a step out that's normally in the system? Because that's always gonna, at the, at the forefront of everybody's mind. And it's, our, our OKR system. I mean, that's an OKR for everybody. He's trying to find a way to take a step out. Can we take a step out that doesn't need to be there? So everyone is always thinking about it.

Yeah, I, I think that's really good as a, as a former trauma person that used to live in the OR when things got futsy or acute, it was usually a very bad, very bad day. So I commend you guys on not making the next cute thing and focusing on the patient and getting the procedure done correctly. So I think that's a lot of value there. So anyway, thank you.

Thanks, John. Al, from your car?

Yeah, thank you. Jess, you and I have talked and I definitely can appreciate the journey you're on and you talk about the importance of finding good distribution. My question's a little different. Having dealt with outside U.S. company leadership and ownership, how has your experience been on the business side of leading the U.S. market and getting, I guess, for them to understand just how messy and how, you know, nuanced the American market is relative to like product adoption expansion, understanding FAC committees, all that stuff that you as the head of the agency for, for the US or head of the, the business development for the US. How's that, how's that process been in, in working with your international kind of leadership that owns, owns the organization?

I'll be very honest. I have probably the best infrastructure with the executives you could possibly have with this company. I mean, they're phenomenal. Uh, and they take a lot of, they understand that the US is a different market. We have people that understand the US market. You tell us how it is. And I, and I will be honest, like the first time I, when I first joined the company, I had, I went to Switzerland. I met with our CEO and our CFO and I told them like how the VAC process works, how distribution works. And they were looking at me like, no way. It can't be that dysfunctional. It can't be. And then you're in the market for about 6 months, be like, oh, what is wrong with the US? Like, no wonder you guys are terrible at delivering healthcare.

It's like, it's—

I'm sorry. I take it back. We're not terrible. We're just expensive. Why is the US so expensive? Like, it's— there's a reason for it. I mean, the cost, the amount of red tape that you have to be able to weave through just to get through the process of getting any traction is, I mean, it's from the outside looking in, I can understand it's just, it's ridiculous, but it is, it is what it is. Unfortunately, you have to, you, you can't change the world one day with and come in and just beat your head. And I mean, what's, what's the, the, the saying? You can be, you can be, you, you can be right longer than you can stay solvent or something like that. I mean, Sure.

Yeah, they think they get, you know, sometimes it's like, you know, well, you got FDA approval and it's like, okay, you know, go, you know, go capture even a, a 10th of a percent or half a percent of the market. It's like, yeah, it doesn't, doesn't necessarily work that way. Oh yeah, FDA approval does not mean that we're going to have the, the skids greased to go wherever we want, right?

Oh no, no, especially, I mean, a small, a small company like us too. I mean, you're going, we're, we're in a different perspective in that. I mean, we go in knowing that we're— our competition is the big companies. I mean, we're, we're one of the few general orthopedic trauma companies. There's a lot of extremity companies that focus on the hand or focus on the upper extremity or focus on lower extremity. Uh, we're going right after the meat and potatoes trauma business, which is only J&J, Stryker, uh, Zimmer Biomet, Smith Nephew, I mean, that's— we're going after the big guy, so we realize that it's going to be a slog. And we've, we've thrown a lot of elbows to get to where we are, and we'll keep throwing elbows. I'm okay with that. That's the beauty of sales.

Uh, Mark, you got a comment or question?

Oh, Jesse, it's nice to meet you and hear your story. Uh, I learned a couple of things right off. One of the companies that I've long admired was a former East German company called Bauerfeind. They make a really great high-quality German brace. And as you know, in Germany, you know, there's a physio on every corner that, you know, treats everyday aches and pains. And their motto was motion is life. And I always thought that was a great motto. And I didn't actually realize that either they stole it from Dr. Mueller or he stole it from them. They, they've been around since like 1890 something. So he might have stole it from them. I don't know.

There might be some shared synergy.

I mean, yeah. Yeah. And I, I've always been a big admirer of the AO, even though it kind of always stood for always operate, but It's always a great story. And I used to love to hear Hansjörg say that he had no marketing department and brag about it when basically he educated every orthopedic resident in the United States to use Synthes. It was always a great story. Another thing too is, you know, one of my mantras has always been easy always sells. And You know, sounds like you guys are making it a lot easier and simpler, and that's brilliant.

Yeah, it's, it's, you, you would think, I mean, I going in, you would think of several challenges, 'cause I mean, you're dealing with, I mean, pre orthopedic surgeons, especially in the trauma world, they're used to having the Bellagio buffet spread out above them and I can pick from here and pick from here. And, and there's, and there's a lot of surgeons, I'll be honest, that we, we present our portfolio and they're like, no, I, I want the buffet. Like I need the buffet. But then, but so we just say, thank you, thank you for your time, but you're not our customer. And that's, I probably, that's one of the hardest things from a lot of startups to say is like, they're not everybody's your customer. You, you have to be able to walk away too. But you find the right people that are passionate about what you feel and we've been lucky enough to find those. And there's plenty of people out there. There's a lot of orthopedic trauma surgeons out there that are like, thank God, I'm tired of being sold another plate that has a 5-degree bend this way and a 5-degree bend this way. And then I have 14 plates sites and I have a scrub tech that can't find 'em because there's, they're spread out all over the field and one's wrapped here and one's wrapped there. It's, I mean, the logistical aspects have just become such a headache. And we talk about like where hospitals are, are, are hemorrhaging at the seams with the amount of stuff that's part of this problem. Like they're just getting hemorrhaged with new product, new product, new product. Oh, I need this, I need this, I need this, I need this. But it's like there's now there's actually rational people out there like, Do I really need this?

Yeah, it's a great story. I mean, I love trauma. As Tiger knows, I was one of the founders of a company called eDrama. Oh, nice. So, and I was the first Orthofix dealer here in the Southeast. So it's a, it's a beautiful business. I mean, it's, it's kind of a young person's business, but it's a beautiful business. And so I love to hear the Grady story. I see Al's raised his hand, so I don't wanna take up all the time, but I live, I'm in Atlanta. I would love to hear the Grady story.

Yeah, I'll, uh, well, we'll ask that. We'll let Al go and I'll come back to the Grady one.

Sure.

Yeah, no, I, I always enjoy listening to— I've only got to hear Mark talk, uh, a couple times now, but I always enjoy his perspective because it usually is aligned and, uh, we get some good information. Um, Jess, on, on the, on the user's first experience, uh, let's take a, let's take a specific product because that's your You know, that's like your, your chance, right? So when you go to distributors and you do get somebody to buy into the concept and the, the benefits of the efficiency of the system and everything, and when you say like, hey, everybody's got like 14 plates and different bends and this and that, you come in with a product like this, and I'm just staying on Clavicle because it's the easiest one to, to align with this question, but how just, I'm curious on user's first experience when they do finally get a chance to use a product like that. Like what's, what's been the, you know, feedback has been positive? Has it been like, wow, okay, that makes sense.

You know, I mean, yes. I mean, the, in the US there's a big trend right now to going to like mini fragment plating and dual plating. So we're, we're not, we don't have a full portfolio to, to accommodate that thing. So there's a lot of people in that world that just, aren't our customers yet. Yeah. But then our current plating where it's opted for superior clavicle, it's biomechanically favorable. There's a lot of reasons for it. We talked about first usage. I had a very experienced traumatologist today use it for the very first time. I think our surgical time was maybe 18, 19 minutes. I mean, it was I mean, he's, he's a high, incredibly skilled surgeon too, so that helps. But yeah, I mean, it was, he got the reduction, laid the plate on, laid the, just perfect. Couple screws, couple of clamps, put a couple more screws in, close. I mean, it's the simp, the, the, the simplicity side of it with, or not simplicity side, but the smaller portfolio, there is almost, there is a little bit of a leap of faith that they have to trust that, all right, this is going to work. And there are some people in the bell curve of where they, where adoptions are, they're just not gonna be an early adopter. But I think now with, with the track record we have, especially with the having a, as much of an opportunity we have in Switzerland to prove that, hey, we've done hundreds of these, it works. We've done, I mean, and the contouring fits great. We do have the ability to bend the plate if you need to, but that's hasn't been an issue yet. So it's, there's, They're something like the clavicle, like I said, there's almost a, a little bit of a leap of faith 'cause they're so used to like, well, every other company tells me I need 25 plates. You're telling me I need 8. Like that's, someone's lying to me. We're not lying to you, but we're telling you that we, you can do it.

Well, yeah, thanks. I guess the stainless product knowledge is real quick on this. I'm sorry. Again, just from an education perspective. So you're going in stainless, right? So clavicle, I haven't sold a lot of trauma. So as you know, you know my background. So is that a question of thickness of plates or anything? And again, it's very product specific, so you don't have to dive too deep, but just curious as a, you know, somebody with limited trauma experience but has heard that comment before about plate thickness and clavicle obviously doesn't have a lot of soft tissue around it. So, curious.

Yeah, I mean, with respect to the material, I mean, stainless is still the predominant trauma market product that's being used. I mean, there's always the, the titanium wave comes and goes and comes and goes. There's, I always tell, I tell every, because everybody comes out of, I mean, every orthopedic resident comes out of training, not everyone, but a lot of them come out of training saying that I have to use titanium. It has the best modulus of elasticity compared to bone. It's biocompatibility is the greatest product ever. I'm like, you say that now, take one titanium plate out and then you tell me. And then they take that first titanium plate out and all the screws are stripped and they're, they're chiseling it out because the bone grew around the plate. And then they're like, yeah, I'm never using this again. So there's, there's a give and take with titanium, not— but I mean, it still is a phenomenal product. The thicknesses, I mean, we are a thinner, lower profile 3.5 version when we talk about clavicle with respect to what the, our competitors are when it comes to 3-5, uh, which is there's two issues with— I mean, I don't want to get too deep in the weeds with the limited time, but I mean, with Cloud Gold, there's the thickness of the plate is one thing, but having a poorly contoured plate is actually more of a problem than the thickness of the plate. And that's— there's, there's a lot of literature out there that there's a lot of systems that are heavily used that just the contouring isn't very good, and that's actually the problem. Cool.

I think titanium, the, the wave is people want colors.

Yeah, I like pink screws. Yeah.

Oh, it's crazy.

Jesse, while you were first talking, I was texting via WhatsApp with a couple of friends of mine in Switzerland. Mm-hmm. And they wanted me to ask if your company was going to be at Ortho Sports Day on the 16th of May in Switzerland.

I'll, I can find out for you.

Ortho Sports Day. I think it did a, It's going to be in, uh, Genollier, which is spelled G-E-N-O-L-I-E-R.

Oh, we can connect.

I would have not phonetically said that name like that based on the spelling.

Yeah, Genollier is not, not how it— I would, you know, I wouldn't spell it like that. Heck, my French pronunciation.

Yeah, for sure.

Yeah, I mean, I'll have to reach out to the Swiss team. Oh, okay. I don't, I, I don't have that level of details, but I can, that's an easy question to ask.

I told him that you guys have been 40 hospitals in Switzerland. I think I read that on your website or something.

And they, yeah, we're over 40. That impressed him. That's amazing. Yeah, we're, it's, they're, they're doing phenomenal in Switzerland. Like they just keep taking market share every day and it's the, the, the simplicity side is a big seller to them.

I was at a trauma meeting once in Munich, and, uh, one of the German doctors I was talking to, a woman, leaned over and said conspiratorially, you know, the Swiss are very bright, just ask them. I mean, the German talking about the Swiss.

That's—

I, I, I will give them credit. They, they, they're— we've, like I said, I mean, we're relatively decent size company with respect to footprint and how we do logistically. And I mean, we're less overall worldwide, less than 30 people.

That's so, so the Grady story, did it start with one doctor and who was it? And tell me how that happened.

Yeah, it started with one doctor.

So one of, for those of you who don't know it, Grady's a giant big, it's kind of like Charity in New Orleans, you know, it's a big public hospital here. It services the inner city and You know, a lot of people who go in with gunshot wounds are called Sammy or Willie.

And yeah, it's great.

They have a great nursing school and they really train great trauma orthopedic surgeons.

I mean, the, and especially now, now that AMC is closed, I mean, that's, I, I know this is a big, big argument between the Memorial Hermann Houston and the Grady people about who's the busiest trauma center now.

Yeah.

I mean, I think, I mean, don't, don't quote me on it to the Hermann folks, but Grady could pass them here because they're just, they're just getting overwhelmed with volume. Like I, I, so when you mentioned names, so, uh, Dr. Mara Shankar, she's one of our advisors. Um, she's a phenomenal human being. Uh, and she's been a great, great person to collaborate with, but she's, uh, yeah, she's, I've been to a few of their fracture conferences and just the volume and it's, I mean, it's unfortunately it's Atlanta. I mean, it's a lot of ballistics, a lot of crazy trauma. And they just, every day it's like, oh, this here, 15 came in last night, 20 came in next night. It's crazy.

So was she the, the leading proponent for your—

Yeah.

I presume.

Yeah.

Yeah.

She was the leading proponent to help, to help us integrate. I mean, we, we work with other surgeons there as well now. But she, like I said, we are, when we, when we want to, the surgeon we want to work with, we want to work with obviously very bright, up-and-coming. We, we joke about it. We want people like in their, their mid-career because they're the ones still actually doing the work.

Well, they're ambitious sometimes.

Well, ambitious. Yeah. There's, yeah, ambitious.

And that's, if you're looking for, if you're looking for early adopters, early adopters are somewhere going to be in that mid to early third. And what they really, they crave recognition and they're visionaries and they, they, they're, they'll take a risk. And, uh, throughout my entire career, those are the guys that I hunt and they make a company.

Oh, I, I, I would agree. Cause I mean, a lot of the people that we're currently with are probably in that, that age bracket.

That's great.

Uh, but I mean, I will say like the, the whole simplicity actually really calls like the older generation too, because the guys that trained with just a simple non-locking small fragment system, and now they have iterate and all these iterations of systems in front of them. They're like, we come around, it's like, hey, look, we have this system that's very simple, and we're like, oh my, where were you 20 years ago? I could just use this my whole career. Um, so it's, yeah, there, there is a little bit of nostalgia with us as well that sells.

So you were at AMC too, the old—

no, no, we, that's, that, that closure happened before we even were Oh, okay.

That was a great hospital. They had a great service market. And some of the people that worked there that lost their jobs, some, most of them walked to work. They had no, when that closed, they had nowhere to go. That was terrible.

That's, and unfortunately, I mean, that's, that just happened here in Philadelphia. I mean, Crozier just closed about a month ago. Hanman closed a few years before that.

I mean, it's.

It's, it's a tumultuous time. I'm hoping that these waves settle a little bit.

So in my other company, I deal a lot with rural hospitals, and so I go to rural hospital conferences, and the stories that I hear will break your heart. And one of them I went to last fall, and, um, the founder of the conference said You know, 10 years ago I would ask the average administrator in this room how much cash on hand. They would say 6 months. 5 years ago it was 3 months. Today it's 1 day. Now he may have been slightly exaggerating, but that would— you get the point.

They just— but the trend is not the right direction.

They're getting killed. Yeah. It's not sustainable. Anyway, nothing about that.

And I think it goes back to labor because, well, I mean, what Jesse's talking about is simplicity in the operating room, but there's simplicity in training, simplicity in the number of trays, simplicity in how many things are handed back and forth. I mean, some— there's just simplicity everywhere, and it, it's making their life easier to do the case. It's not just the OR. I think that's what— another thing I was thinking about when Jesse was talking is that no incumbent trauma company could ever do this. You know, you, you talked about the four giants. It had to be a new company that started with a blank sheet of paper and they said, what, you know, what would it look like if this was simple? And from, from first principles. And I, I mean, that's, I applaud you guys. That's awesome.

I, I've, I mean, I, when I discuss like with perspective of the competitors, I'll be honest. Like I think where we are right now is where everybody needs to be in 5 to 10 years. It's that they just got these huge battleships that they're just— well, some of them are going to try to turn that way. Some of them are like, we're just making too much money the way we're doing it. We're just going to keep status quo. So that's, that's their business. That's not mine. I think we have a good track record in how we're approaching the market, and I think we're going to keep going pretty good.

Yeah. Well, another thing is you're so small that you can get a tiny market piece of market share and, and double sales, you know, every year. Which is, which is beautiful.

Yeah, we're— I mean, just, we're, we're at— going right now about doubling, and we matched last year's sales already in the first quarter.

So, wow, that's, that's brilliant. What are you doing? What are you doing with distribution? Are you, are you hiring distributors? They're, they're using whatever—

whatever distributor's got access to the Level 1 Trauma Center is Yeah, I mean, and this is, this is the, and especially with Al, he can feel free to comment on this one as well. I mean, with, with distributors, it's trying to— there, there's different flavors of distributors. There are some people that have broad swaths and they just want to have a large distribution network and have their sub reps and handle like their, their, their relationships. And then there's some that are just more independent salespeople that have direct relationships. Uh, I mean, we try to, and it's been very apparent that this is probably the only way to do it, is you've got to do it almost by referral basis. There's, there's distributors have, there's, there's always like the, the rub between distributors and, and, and, uh, OEMs about who needs who. I mean, I think distributor, I carry the bag many years. I think distributors are essential to this, but, uh, they need to be focused. And finding a distributor that wants to partner with you is key. And there's a lot that will tell you they want to partner with you and then they're just kind of like, ah, we'll, we'll, we'll keep you on the back burner and maybe we'll sell it if opportunity comes around. Or if you get it for us in there, maybe we'll use it. We'll, we'll sell it for you. But then we have other distributors that are phenomenal, be like, hey, this is what we're doing. Like, hey, and they just take the bag and run with it and they're doing, doing great. So, they're, they come in all flavors. There's no one size fits all. But we, that's, we've, we've realized very early that you have to have a distribution network to handle last mile logistics.

And how do you test a new distributor? Is it contractually or you just watch their sales?

Yeah, it's contractually. There's, I mean, we're, our contracts are very generic. But we do maintain the ability to, if we have to, if the relationship's not going the way either one of us want, that we can back out relatively quickly. Uh, we don't want to sign any long-term deals because you just get people trying to hold hostage your paper hostage, and that, that's, that, that's going to kill a small company.

Yeah. Yeah. Mark famously says, uh, feed the winners and starve the losers. So he moves, he moves inventory back and forth very quickly. Uh, I— you, Mark, you can explain it better than me, but, um, I love that strategy.

Yeah. I, yeah, I mean, I'd love to hear it. That's a phenomenal approach.

That's pretty simple, really. I mean, I used to have constant arguments with like the CEO of a couple of startups in which I would, at budget time, give 80% of my resources to the top 20%, and I would tell the bottom 80%, you want more, we're, you know, sell more.

Yeah.

And it actually always worked pretty well because it's like when you, when you're building a like a Grady or any territory, you really only need a couple of super high producers to make it. Everybody else eventually follows. It's like the early adopter guy, you know, that's like 5%, but the other 95% eventually follow them. So I used to use the analogy of called, you know, everybody's seen the Nature Channel, you know, in the Serengeti Plains when those, you know, all of the grass eaters go against, and they eventually come to the river, you know, all these gazelles and antelopes. Well, you know, the first few people, I mean, the first few, they do, they just get right across the river. Nope. You know, the gators and the crocs don't even hardly see them. Those are the early adopters. And then the next few, not so good. Yeah. Oh boy.

So anyway, have you done the top-down approach where you find that mid-career surgeon and you say, who do you want to rep the product? You pick.

That's, yeah, I said when I say about referrals, that's, that's the referral pattern. That's, I mean, every market's different. I mean, I have new markets where we have someone that's a surgeon who's very passionate about working with us or wanting to use our, like, products that we, because we have stuff that nobody else does. So we will— I'll ask that surgeon, like, who do you want to work with? Because they're going to tell you who's a good rep and who's going to be the right person in that market. So that's, that's usually my first, first question or first approach. Referrals from other distributors that have been successful. That's another one. I mean, my business development vice presidents are phenomenal and they have relationships of distributors from the past that have done well for them and, and worked well together. So we've tapped those markets. So it's— there's It, there's no cookie cutter way of doing it. It's you, you, every, every market, every, I mean, that's the US. Every state is completely different. Every city's completely different and you just gotta be very flexible in how you approach them.

So yeah, it's a local business. What about logistics? How are you simplifying logistics? Because, you know, it's a lot of inventory going back and forth.

It is. I mean, we try to consign as much as possible. I mean, the beauty of our, like I said, the beauty of our set, it's one tray. So, I mean, you, you have two of our trays on the shelf, you can do any procedure essentially for that we can provide. So everything from a tibial plateau to an ankle to a proximal humerus, it's the same tray no matter what. So logistically it's actually very easy because you're not shipping around all these different trays for all these specialized procedures. And the fact that we have sterile, sterile plates, our last mile delivery is actually very efficient. I mean, we have a good logistics provider. I'll give a shout out to Global Medical Logistics in Atlanta. They've been a good partner with us. So there you go, Hunter. You're welcome.

Do you know those guys, Mark?

Yeah.

Isn't that Gordon Ford's group?

Yeah, that name sounds familiar. I know Hunter. I don't know all the whole crew there, but yes. They've been a great—

yeah, that's Gordon, and he's the biggest Stryker dealer in the whole world.

Yeah, that's him.

Several hundred million. Yeah, he's an Eagle Scout too, by the way. For real, I don't mean that like some kind of, you know, being cynical. He's a good guy.

We had Ortho-X on, uh, a few months ago. They, they do logistics out of— I think, I think it's Vegas. And they, they do. It's, it's great for startups because they can just scale. Everything's super organized and they can scale with your business. Sounds like it's a similar, similar business.

Yeah, similar business. I think this was done, the Global Medical Logistics was done before I started, but they've been a good partner with us. And I mean, there, we had some stipulations because a lot of our financial and our logi— our logistics from Switzerland had to mate with the US system that they were using. So there was kind of some high guardrails of who we could work with, though they were able to accommodate.

You are— the Swiss use ERP systems that have to talk with—

yeah. How long have you, how long have you been with the company, Jesse?

22.

So I, I started the summer of '22. We got our 510 about 3 or 4 months later, and I've been with them since. So what was your point number 1?

Where's your biggest pain right now, Jesse? If you had to— if you had a magic wand, you could fix something.

Oh, it's— oh, I mean, it's, it's the same with everybody. It's just finding the right distribution partner is probably the hardest thing, finding someone that's going to focus and partner with you. Um, we're, we're— it's a constant battle, but it's like I said, we have to be— we're trying to be as flexible as possible. We've been lucky in the 15 states that we're in to find those people. Uh, but it's not from lack of trying.

Yeah. How many, I mean, the good thing about Level 1 trauma centers is you can just, there's a list, you know exactly where they are.

Yeah. Yeah. But the hard part is, and there's a bias with trauma. Everybody thinks trauma is like, oh, I'm going to be working at 2 AM. And it's not that anymore. I mean, it's, I'll be honest. I've, cause I've, I've sold a lot. I've sold arthroplasty. I thought arthroplasty was the worst job ever 'cause the reimbursements were terrible and you still are on call for hemiarthroplasty. So you're still doing a hip fracture at, on a Saturday afternoon and you're getting paid half as much. Like it's, it's crazy. The trauma, trauma's more of a 9-to-5er because now most big trauma centers have a designated trauma room and anything that comes in after 8 o'clock at night, put it in the trauma room the next day.

Plus, it depends on how you run your territory, because my early career was in trauma, and there was— I had a partner in town, and he was being called in at 2 AM. And one day he said, how come you're not being called in at 2 AM? I said, because I bring pizzas to the 311 crew every week. I pay them to not call me. Uh, and you know, I'm try— I trained them.

Yeah. Who tells?

That's, that's hilarious. I used to go, my first startup was a trauma startup. We, I used to go to the, the med in Memphis, Elvis Presley Med Center, whatever it's called, level 1 trauma center. And it was, they would just Monday morning at 6, they would just flash through all 30 cases. You know, it was all gunshots, car wrecks, falls. That was the big 3, I think. And, and they would, you know, they'd, they'd save the patient's life first and then they would schedule them for surgery. Yeah, usually 2 or 3 days later. So I learned it was more elective than I thought.

Yeah.

I mean, when I first started my career, it was, there was a lot of overnighters. I mean, that wasn't, that was, but I mean, we're talking like the early 2000s. I, I'm, I've aged well, but there's, it's changed a lot now that they realize even an open fracture, you give them antibiotics. Train them in the morning with the, with the fresh staff and they do better. So it's become a lot easier on just logistics and, and the, uh, sales force.

And why is that? Is it the surgeons? Is it just, uh, lifestyle? The surgeons want to work during the day, or—

I mean, Pat, no, it's, it, well, I mean, that helps too. No, there's actually like literature on this that patients do better because you get, you're not working when at the wee hours of the morning with Yeah, yeah, whoever was on call that night who doesn't know orthopedic trauma. But if you have a designated orthopedic trauma room that's ready for you to book cases in, I mean, patients, yeah, you got staff that knows what they're doing. You got everybody got a good night's sleep. The patient's gonna get the best care. And a lot of stuff like, I mean, that were thought were emergencies, like these open fractures that you had to debride immediately when I, for my career first started, that's, no, that's probably not the case. They, they do just as well if you give them their antibiotics. I think, I think there was, I mean, I don't, I'm not good at remembering when these literatures came out, but I remember there was an article that came out that it was actually the time to antibiotics was the most determining, the most important determining factor for these open fractures. And that kind of changed the perspective a little bit.

I also think the surgeons on call get better information in the middle of the night because our first digital startup in the late '90s, was putting the X-ray of the fractured hip or the trauma online so they could see it from home. And they can tell from looking whether it's displaced, non-displaced. I can do it in the morning, whether I have to come in right away. As far as I suspect that that has had an impact too.

Oh yeah.

Yeah.

I mean, the ability to—

No more.

Yeah. You don't have to come in and look at the X-rays in the OR, in the ER. And like I said, there are emergent fractures that need to be treated immediately, but The list is not what it used to be. It's a very short list now.

And then the other thing I learned is it, it's the residents and the fellows that do the first work on the patients. You know, they stabilize 'em, you know, they triage, you know, and they don't know what they're doing half the time.

Yeah.

Yeah. I got another call. Thanks a lot.

Enjoyed your talk. Yeah, this has been great. Yeah, this is, uh, I think this is a trend. I think you're ahead of the curve simplifying the entire system for the system. I, I love it. So hopefully other companies follow your footsteps. And thanks.

Not too many, not too many. Let us set traction and they can come.

Maybe in joints or spine or something else.

Yeah, yeah.

All right.

I appreciate it.

Thanks a lot.

Good.

Thank you, Tiger. Thank you so much.