BoneChat #97 - Startup that has "democratized" surgical navigation for hip, knee, shoulder, spine.

So today on Bone Chat number 97, we have Armen Bakertzian, I think, co-founder and CEO at Intellijoint Surgical. And these are my words, not his, but I believe that Intellijoint is democratizing surgical navigation. Their technology is simple for customers, no contracts, pay as you go, use any implant you want, and, and it just works. So let's dive in. I'm going to hand the mic over to Armen.

Thanks, Tiger. Thanks for having me today, and thanks everybody for joining. Um, I think the structure we're going to go through today is I've got some slides, so I'll probably try and spend 10 minutes or so just introducing folks to the company and the technology and what we do, and probably leave the balance of the time to go through a discussion and Q&A and have a back and forth on anything I think the group is interested in. I have some questions myself. So with that, maybe I'll put up the slides and I'll ask the classic question. If you can see my slides? Yes. Yes? Okay, great. So yeah, thanks again, Tiger, for having me. I'm super excited to talk about Intellijoint, you know, This company has been our passion for a few years now. We started the company in 2010, so we've been at it full-time for 15 years now. And really what we want to do is put surgeons in control of the surgery. So we've created a technology that helps orthopedic surgeons improve the outcomes for hip and knee replacements. And of course, we empower the surgeons to keep the workflow that they've got, and it's our job to integrate our products into the workflow of the existing surgery and not the other way around. We don't want to distort or disrupt how orthopedic surgeons are doing cases. So that's kind of just at a surgeon-level view, but if we look and kind of zoom out and we look at kind of the overall markets, there are new realities for orthopedic surgeons that, you know, you know, things have changed. My dad is an orthopedic surgeon, so I've been exposed to orthopedics for many, many decades, and I've seen how things have changed in the field of orthopedics, you know, from private practice to employed, you know, reimbursements obviously going down. That's a major trend in orthopedics. I think, you know, as a result to a few of these trends, you know, there's been a push in the growth of ASCs as well. So, you know, we've seen obviously similar outcomes in the ASC setting. We've seen, you know, more efficient use of dollars in an ASC setting. So a lot of patients obviously have gone to ASCs and surgeons want to capitalize on that trend as well and participate on the ownership side of the ASC, which I think exacerbates or puts a greater importance on not only the clinical, part of hips and knees, but the economics behind hips and knees as well. Surgeons are now the purchasers and the payers of certain products and services. So a lot of these things kind of matter more to them than they have in the past. So, you know, I think, you know, a lot of different trends are happening. I've kind of just highlighted a couple of them here. And the expectation of patients is not going down. If anything, it's going up. Everybody wants, you know, the latest and greatest implants and the latest and greatest techniques. And ultimately, you know, they're driving— patients are driving for this so they can have the best possible outcome. And ultimately, you know, as a technology company and somebody who's been in this field for a long time, we believe that technology has a positive role to play in the influence of outcomes for patients. You know, when I watched my first hip replacement with my dad many, many years ago, you know, we really learned about some of the adoption hurdles that were associated with existing technologies. You know, they were expensive, they added time to surgery, they forced surgeons to change their workflow, they forced surgeons, you know, to change their implants. And that was a major reason why orthopedic surgeons weren't adopting technology at the time. So that led us, I'm an engineer by training, I was trained in mechatronics or robotics engineering in undergrad and did a master's in biomedical engineering. So when we set off to kind of embark on this project, which was a school project at the time, believe it or not, you know, I was very inquisitive to my dad, you know, why doesn't he use these technologies that are on the market? And, and, you know, he shared the things I just mentioned. And that led us to, to create a list of requirements, not only technical requirements, but, you know, things like you see on the screen. You know, the system needs to be controlled by the surgeon. It needs to be simple. It needs to be cost-effective. It has to have a small OR footprint. It can't be specific or tied to a particular implant. It shouldn't have a capital expenditure. It shouldn't add time to surgery. It shouldn't be complicated to learn. So all of that led us to create a new core technology because we didn't see kind of the incumbents in the space go that way. You know, when we started our business, traditional navigation was kind of the flavor of the day, but really the market kind of went more towards exacerbating adoption hurdles in our view, not the other way. So, you know, if you compare a robot to a traditional nav system, they're more expensive upfront, they add more time to surgery, they still force surgeons to change their workflow change the implants that they use. They still require, some of them, preoperative imaging. You know, there's a lot of the challenges were not solved. And that's where we kind of took a different approach as a company. Of course, we wanted to focus on giving surgeons accurate real-time information, but we wanted to do it in a package that was elegant, that was simple, that surgeons were excited to use, not reluctant. To use. So we've kind of never pivoted as a business in our 15 years. We've been focused on the same problem from day one. My dad was the one who highlighted that problem, and 12 other orthopedic surgeons validated that problem to us. So, you know, this was the start of our journey. This was in May of 2010. We won a little bit of money through a pitch competition, and that put us on the start of our technology journey because we had to develop our core technology before building clinical applications. So So this was the first kind of prototype that we had, and it evolved. For those that remember the Nintendo Wii, these are some Nintendo Wii remotes that we made some modifications on. And then we went to this type of system, which was an optical active tracking system. Then we went to optical passive tracking. And ultimately, you know, we kind of landed with where we are today. But just to give you a perspective, this is the incumbent camera that almost every traditional nav or robot uses. And you can see the magnitude of scale that's different between an IntelliJoint camera and the standard kind of camera that a lot of companies or products use. And really it was the requirements of looking at ease of use, simplicity, cost, all those types of things drove us to create a new core technology which enables simplicity, it enables workflow integration, it enables open platform. So all those types of things led us to the creation of our camera, which ultimately we've put into multiple clinical applications. So, you know, this is the camera in the hip application. This is in a lateral position. So you can see the camera is directly in the sterile field. It's mounted to a quick-connect mount that is attached to the patient. It's surgeon-controlled, so the surgeon can operate the software themselves. They don't need a non-sterile rep to, you know, touch buttons and a touchscreen. So they're completely in control. And they're also completely in control of the workflow that they use. They're in control of the implants that they use. They're in control just across the board. And that's an important kind of philosophy to our business is we want to empower surgeons to be in control. And that's true for technology. It's true for, a bunch of things that they do, and we want to enable that. So this is just a photo of my dad and I after we did our first live surgery after many, many years of development. So he's in upstate New York, and this was the first case that we did together. So a super proud moment for both of us. So, you know, we started with core technology development, and ultimately it led us to create products in different categories. So of course, we've got a product that helps in hip replacement, so we control We helped the surgeon control the position of the implants and the sizing of the implants. And the same is true on the knee side. And these were our first two kind of entrants into the marketplace. And surgeons, you know, kept telling us, and it's something that we do a lot of is take a lot of surgeon feedback, you know, our navigation systems are telling surgeons where they are. It doesn't tell them where they should be going. So that led us to create IntelliJoint View, which is a preoperative planning solution, again, using the same philosophies of access and putting surgeons in control. So, IntelliJoint View is a cloud-based X-ray-only preoperative planning solution that's able to provide surgeons with really elegant and sometimes complicated analyses of different anatomies. So, on the hip side, with two-dimensional X-rays, we can provide you a patient-specific cup target that accounts for the mobility between the hip and the spine. So that's super novel. Everybody else that does this requires a CT scan. Scan, you have to take multiple images and in different positions, but IntelliJoint is able to do that in a really simple, elegant way. And that's kind of our philosophy as a company. So, you know, we've gone through a lot of milestones over the last, you know, 15 years or so. So it took us the first 6 years to develop our core tech and get it out into the field. It took us, you know, several years to get our first, you know, multiple thousands of cases under our belt. So in 2019, we announced our 10,000th case., and we also received our FDA clearance for our knee product in 2022. Really focused on the business of, for Intellijoint and ensuring that, you know, we can have a good healthy business that will survive in the long term as we scale. And now, you know, in 2025, we want to be able to sustain our aggressive growth. So we've done over 75,000 surgeries and we're on pace to have the best year ever as a business, not only in the US but internationally as well. So it just speaks to the value proposition and how that is relevant for a lot of orthopedic surgeons. So I know I've talked about this kind of throughout, but it's really simplicity, reliability, efficiency, and overall elegance. You know, our system has one cart, it has one tray, and it has one pack of consumables. Super simple. So people like this, of course, in the hospital setting and in an ASC setting. And, you know, when we have surgeons that use other types of competitive products and then we come along, you know, there's lots of genuine smiles in the room that, oh, that's it? That's all I have to do? So setup is easy, no calibration required. It's a very simple system. And because, you know, we've been around long enough, we know the system is super reliable. It has a long lifespan. Our preoperative planning integrates really effectively and elegantly into our system. And efficiency is the name of the game. We understand orthopedic surgeons have a lot of work to do. They have a lot of patients to serve, and we're never going to slow them down, and we'd love to speed them up. Just the last kind of idea here is our core technology, because we developed it from scratch, Intelligent owns it outright. We don't buy this from somebody else. This is Intelligent's core technology. And of course, because it has value and merit in hips and knees, we believe it has merit in other clinical applications as well, and the market agrees. So we've been able to establish relationships with other medical device companies who use our core technology as part of their own native clinical applications. They can buy cameras from us and integrate it themselves, or they can hire us to do the integrations for them. So, This is a new part of our business and one that we're quite excited about because the camera is super unique. There's nothing else like it on the market. So I'll just jump ahead here and show you a surgical video. So this is Dr. Wren Schwartzkopf at NYU Langone Orthopedic Hospital. And this is his workflow of using IntelliJoint in a lateral positioned hip. Of course, we tested it before, right, Tiger? And sure enough, it doesn't work. All right, we're going to go over here.

Here we go.

Let's do an animation video. Intelligent hip provides surgeons with real-time intraoperative measurements for cut position, leg length, offset. So maybe I'll do the annotation. So this is our core technology like we talked about. We'll see the setup in the operating room. Um, here just very quickly. So we'll see the patient, um, on, um, the OR table in a second. Here we go. So you can see a single cart system here. This is our camera in the sterile field, and then this is the single tray of instruments. So of course for a hip, we use a hip tray. For a knee, we use a knee tray. But for both surgeries, the workstation and the camera are the same. So you can use the same capital equipment essentially to do different types of surgeries. Because we mount our camera directly to the patient, we need to put some bone screws in the iliac crest for the patient. So these are disposable self-drilling, self-tapping screws. So surgeons are quite comfortable at placing these screws along the iliac crest. Here comes our magnetic, uh, quick connect that accepts our camera. So whenever surgeons want to take measurements, they mount the camera. Whenever they don't want it, they take it off and it's out of their way. And the important thing here is that the surgeon interacts with our system through manipulating the buttons on the camera itself. So they can drive, go forward, they can capture, they can do whatever they need to do. There's also some controls on the workstation itself if there's a non-serial person available. However, it's not necessary. The surgeon can drive the software themselves. And because we don't like to be in the way if we don't have to be, The camera is removable, so surgeons can take it off and put it on whenever.

Where does the cable go? Is it plugged? Is it attached to laptop or—

You got it.

Yeah.

Yeah.

Yeah. So there's a cable that is connected to the workstation, and that is how the camera communicates with the workstation. So that's the primary mode of connection there. And surgeons like the wire 'cause they can actually tether it to the patient as well. So that prevents them from potentially dropping the camera and things like that. And these are all kind of design iterations that we've gone through over the years. And we've never made design decisions on our own. It's always orthopedic surgeons that guide our decision-making. So you can see it in the product that it's really designed by surgeons for surgeons. And that's led us to have the most accessible, easy-to-use, most easiest product technology to adopt for orthopedic surgeons.

This is the longest I've seen people go without asking a question. So you're doing a really good job. But anybody—

A really good job or a terrible job?

May I ask a question? I didn't know. I wasn't sure we were allowed to ask questions, so I was sort of saving them up. I've been out of the navigation business for a minute, so Where are you relative to calibration? Are you going to talk about calibration of the device, or— I don't want to jump ahead, but I'd like to know if some of the old issues with calibration and, you know, bumping the camera, or, you know, what happens if the pins move if the camera is bumped, etc.?

Yeah, good question, Laura Lynn. So short answer is we don't have to calibrate anything. So Most, if not all, navigation systems that have a double camera, stereoscopic camera, you have to calibrate those cameras because the system needs to know how far the cameras are away from each other. And that's how it's used to localize a single point. Since IntelliJoin's camera is monocular, we have a single camera, you never have to calibrate the camera. So there's nothing to calibrate. In that sense. You have to do a registration just like you would with any other navigation system, and that's where IntelliJoint shines, is in the process of, of registration. So a lot of navigation systems or robotics requires preoperative imaging, so you need to take a CT scan, you need to fight with your insurance company sometimes for them to approve the CT scan, and then you need to do CT-based registration, which can improve your accuracy but really slows you down. So a lot of times those systems require surgeons to touch 60 points inside of the wound to then map the preoperative image to the registration that the navigation system is using. And that adds a lot of time to surgery. So the way we do registration is— perfect timing, actually. That's where we are in the video. So what we do here is we benefit from the proper positioning of the patient on the OR table. So just like any surgery, the orthopedic surgeon and the support staff want to properly position the patient. They want to make sure that the ASIS points are stacked on top of each other. They want to make sure the patient's not rolled in any direction. So basically with the patient in that position, before we make any skin cuts or anything like that, our system is able to register the horizontal plane or the sagittal plane of the body. So that's the step that's happening right now. And the surgeon does that with a simple click of the button. So they hit the green button on the camera and the system registers the sagittal plane. Then the next thing they're going to do is they're going to take our alignment rod, which is surgeon-controlled, and they're aligning this with the supine coronal plane of the body. And this is a visual assessment.. And what we found is that orthopedic surgeons are actually quite good at doing that step. And we've been able to show a high level of accuracy. We've done a lot of studies to look at, you know, where are the implants after we've done CT studies and all that. And we're able to have the same accuracy as everybody else. So everybody in navigation is a ±3 degrees on orientation and ±3 millimeters on displacement.. And IntelliJoint is well within those bounds, but we've been able to do it in a package that's faster, that's easier to use, that's more intuitive, and surgeons are actually quite good at doing. So then once you do this registration, then we'll proceed with the rest of the surgery. And if the patient moves, it doesn't matter because our camera's attached to the pelvis. If somebody hits the camera, that's okay because there's a magnetic quick connect. So, It'll just decouple from the platform that it's on. So we've actually solved a lot of these kind of annoyances with other navigation platforms. There's obviously never any line of sight issue because the camera is directly in the sterile field. So you can have 30 people huddled around the OR table and it doesn't matter. Like, these are some of the benefits that you get by miniaturizing the camera and introducing it directly into the sterile field. So what we're doing here is after we've done our registration, the patient— I mean, the surgeon, excuse me— exposes the hip. Obviously, they wouldn't do an incision this big. We put a platform on the femur. So this is with the native hip in. The surgeon picks up the femur, puts it in a neutral position. We take our baseline leg length, our baseline offset, and then the surgeon will take their baseline hip center. So again, they're doing this type of testing anyways. So we're capturing data as they're going through their normal workflow. So then once we have that data, then of course the surgeons can proceed. They can resect the head of the, the, the neck, the femur, and then depending what they want to do, we can follow them. So if they want to do cup first, that's fine. If they want to do stem first, that's fine as well. Here we're showing a video of cup first. So our camera's on, our tracker sits against any impactor handle. So again, open platform, so any vendor will do just fine. And of course, what you see here is the real-time numbers of cup position that are being displayed to the surgeon up here. So I'll just walk you through these 3 sets of numbers. This is the real-time number. So as the surgeon manipulates their hand, these numbers are modified. This is the preoperative plan that we've done with IntelliJoint View. So with our preoperative planning X-ray-based software. Okay, there it goes. I'll find it. So that's what that second row of numbers is. Sorry. So that's the second row right there. So we've done preoperative planning and what View has told us is for this particular patient, patient based on the mobility between their pelvis and their femur, we should target— sorry, the relationship between their spine and their pelvis, we should target 45 degrees of inclination and 20 degrees of anteversion. So there's an elegant way that you can pass that information to navigation and it shows up at the right time in surgery on the screen. This last number here is what we call an acetabular reference frame. So with a probe, a surgeon can essentially get the cup position of anything. So as long as they touch 3 points along the same kind of plane, whether it's the native acetabulum, whether it's a cup that's already in there, whether it's a liner inside of the implants, we can display a cup position number. So this, in this case, maybe it was a, it was a revision. This was the implant that's in there, and obviously you've got way too much inclination. So that's the reason for dislocation. You gotta, you gotta bring the cup more horizontal. And the cool thing here is that the motion of the pelvis is irrelevant to us. So if the pelvis moves around on the table, because our camera is mounted directly to the pelvis and we have intelligent sensors in there that know their own orientation, we're able to kind of filter that out. So whether the patient's rolled forward, rolled back, whatever it is, the numbers on the screen are accurate. And that's what we're showing with this animation. Okay. So then once the cup's in— okay, just switched to it. Got a mind of its own. Anyways, I'll just— I know we're at time here, Tiger, so maybe I'll just explain the last part during trialing of the femur. That femur platform that we put in, the tracker sits on top of the platform. And based on whatever trial you have in there, our system's able to tell you, you've increased or decreased leg length, you've increased or decreased offset. This is how you've changed hip center, and this is how you've changed the anterior posterior position of the femur. Similar type idea for knees. But maybe I'll stop there and, and field any questions or enter the discussion.

Thank you.

Yeah, it's good stuff. Andrea is up first.

Yeah, it's nice, nice to see the presentation. I do patent research and I come across your IP portfolio all the time and have to evaluate those claims. So I'm wondering why you decided to license the camera in spine and shoulder instead of taking it yourself into those areas?

Sure. Yeah, it's a great question. And, you know, maybe the naive versions of ourselves 10 years ago would have said, yeah, we can commercialize spine, we can commercialize shoulder, we can do all of those things. But we've learned over the years that maybe one of the hardest parts is the actual commercialization part. And there are companies obviously that have strength in that arena. They've got sales forces, they got marketing machines. So it doesn't make sense for us to recreate the wheel across all of the different disciplines. Like, we invested in a direct sales force in the US to be able to capitalize on the open platform nature of our hip and knee product. But, you know, to do that in shoulder, to do it in spine, it's a very, it's a very expensive initiative, and there are people that can do it already. So we decided, hey, let's, let's focus internally on the hips and knees and commercialize this solution ourselves. And let's try and leverage the commercialization engines that exist in the market today by creating a product for others to sell in different areas, different arenas than what we're currently in. Good.

Yeah, good question. Yeah, why don't you talk about your business model? Either it's a subscription, there's just disposables, and there's licensing.

Sure. Yeah. So in the, in the US, we primarily sell our products through a fee-per-use model. So again, going back to kind of the problem statements, you know, at the time, navigation was $250,000 upfront, plus, you know, some amount for disposables. And my dad was in a community hospital. And he would do maybe 60 or 70 joints a year, and his hospital would never spend $250,000 to get him something. So we thought, okay, well, if accessibility is important to us and putting the control in the hands of the surgeon is important to us, then we must have a system that can be placed at the hospital at no charge. So that's, you know, was one of the constraints. So we place capital equipment at hospitals at no charge in the US. And then we charge them per use, and that per use fee includes the disposables and includes whatever they need for that particular case. And of course, we'll train them, we'll do all that type of stuff ahead of time and provide any support. However, once people are trained in the operating room, our reps get out. So they leave and they move on to kind of the next one. And what we do is because we can work with any implant provider, we actually train the implant rep to rep Intellijoint in those surgeries. So we'll give that rep training. We've got a training program that supports them, and then we actually will commission them to support those cases after the fact. So then our sellers move on, you know, obviously they'll come back and check in and make sure everybody's happy and whatnot, but the main responsibility for service has moved to the implant reps. So that's our primary model in the US. Outside the US, we do sell to distributors in the kind of more classic sense, and we're flexible with our distributors. They can buy capital equipment or they can lease the capital equipment from us.

How does that work with competitors like Globus, for example, who also has both navigation and implants? And if the surgeon uses their implants and you're training their reps, Yep. Yeah, how does that work?

It happens. I mean, it happens. I think it's the— I think it speaks to the merit of our technology. Not only do the reps work with us, distributors of major implant companies also work with us, and sometimes they have competitive products. So I think it speaks to the merit of our technology and the demand for our technology from surgeons that people are willing to work with us because ultimately I think all of our jobs is to give surgeons the tools they need to deliver the best outcome for their patient. So it's, it's worked out just fine. I mean, you know, and I would argue that navigation does not actually compete with robotics. They're different categories. Not everybody wants a robot. Not everybody wants navigation. And most of the incumbents in hips and knees kind of skipped navigation and they went full bore into robotics and they don't have a navigation solution. So they kind of have gaps in their portfolio. And most of the time the robots only do knees. They don't do hips. Mako is probably one of the only ones that does both hips and knees. You know, Zimmer, Smith Nephew, J&J, their robots only do knees. So I think it just leaves gaps in big company portfolios and we're happy to fill those gaps.

Mark.

Sorry, I had to step away for a minute. Do you do HTOs?

We can. So my short answer is it's off-label, I suspect. However, what we've done with our system is that our mainline workflow you could use for like 80% of your cases. And then we have a toolbox for more advanced features that surgeons can use in different ways to help them achieve their goals. So, you know, to give you kind of different angles of the knee is, is doable. If you want to measure the, the cup in a revision, that's doable. These are all extra features that would be in our toolbox. But to guide a cut, we could do that.

Thanks.

Of course.

Yeah, good question. So your sales force is pretty lean because all you're doing is onboarding kind of other device reps. That's a brilliant strategy because most companies drown in sales expenses.

Correct. Good callout, Tiger. And, you know, we're a Canadian company. We want to remain Canadian as a company, which means we have to be super mindful of how we raise and spend money. So our commercial strategy and our financing strategy have been commensurate with each other. And not only do we have a lean sales force because we've been able to get ourselves out of the OR, We also have a lean sales force because we've been selective in the markets that we have targeted. So we launched in 2016. Again, we're— maybe this is the engineering side coming out, but, you know, we're thoughtful and we're inquisitive and we test. So in 2016, you know, we launched two markets only in the US. We launched New York City and we launched Chicago, and we partnered in Chicago with a distributor and we went direct. In New York. And, you know, we stayed there for a year, we learned a lot, and ultimately we landed on the direct model, but we bookended our sales cycle or our sales process with distributors. So, you know, I mentioned on the back end, you know, we train them and they support our customers, but we also incent them on the front end to bring us leads. So that's how we kind of modeled our selling. And really still to this point, we just started expanding this year. In 9 years, we kept ourselves, we expanded only to 6 cities across the US, and we really focused on getting deep adoption. It's not anything profound in our opinion to get 2 or 3% adoption. People have done that before, but nobody has gotten deep adoption in the use of technology. And we wanted to prove that to ourselves and to our current and next stage investors that Hey, we can get more adoption than anybody else. So if you look at, you know, the markets that we're in and you bucket all of the enabling technologies in the same bucket, Intelligent gets a third of that business. So it, it just speaks to the merit, to the value of our products and our technology and how much surgeons like to use us. So now that we've got a profitable model in the US, we've got deep adoption, that's really the kind of green light for us to take off our self-imposed handcuffs and start to expand across the US.

Yeah, that's— congratulations. That's a lot of discipline.

Patrick.

Armin, I've got a cultural question for you. So at least as it pertains to the US, how does being a Canadian company— like, what are the pros, cons, or maybe there's no effect at all, to it, but like what, what are some of those pros and/or, or cons in your opinion?

Yeah. Yeah. Great question. I mean, I'm, I'm, I probably straddle the Canadian American thing probably more than most because I lived in the US for a long time.

Yeah. You mentioned Western New York, that's why I was confused, but yeah.

And so I lived in the US basically all through the '90s and early 2000s. And my parents are still in the US, so we obviously spend a lot of time there. But, you know, I went to school in Canada. We— I started this business with my two co-founders from university, and we're still in the same community where we went to school. So it was important to us to invest in this ecosystem, in this community. Because it was really underserved. And we've had a fantastic experience as founders, and we want others to follow suit. So we try and influence the environments that we're in, that it leads to the success not only for IntelliJoint, but for all the other companies that are around. And, you know, when we started the business, we were the only kids on the block. And now I'm sitting in a 45,000-square-foot facility with 6 resident companies that are all spin-offs from the university that, you know, were started here, they're growing here. So that's kind of an important piece of us. But to answer your question specifically, I think Canada offers a lot of opportunity and there are advantages for companies. You know, R&D is super good. There's a lot of technical people. I'm in Waterloo, Kitchener-Waterloo, Ontario. We graduate some of the best engineers in the world. And I'm not saying that because I graduated from there. But, you know, access to talent is fantastic. There's lots of public supports, you know, grants and that type of thing. And proximity to the US is easy. And that was part of the reason why we chose New York and Chicago, because I could go there and come back in the same day. So, you know, I think if you're selective, you could do it, you could definitely do it from Canada.. But I would say the major shortcoming of being in Canada is access to local customers is extremely, extremely difficult. And it's something that we've fought tooth and nail to try and change that environment. We're making headway, but, you know, the worst, the worst time I had was trying to get my first sale in the US and then, hey, where are you from? Well, I'm from Canada. Oh, who's using this in Canada? Terrible answer because it's very difficult to get our products adopted by a public healthcare system. So that's, that was an unnecessary hurdle that we had to go through. But you kind of get through that as you get your first customers in the US and they become your reference customers. But yeah, I mean, there's definitely things that would be easier if we were in the US, like fundraising and, and, and that. But we're, we're, we're happy where we are.

Yeah.

Okay. Fundraising is hard everywhere. And Maloney's up again.

Yeah. So good presentation. I mean, I actually sit on the board of a Canadian company out of Montreal and the cultural differences are sometimes interesting. That's fair.

Yeah.

Is it a Canadian thing or a French thing? I was born in Montreal, so I can make—

You can see the hockey puck behind you.

Yeah. You know, I just, I think it's, yes, I think it's a hockey thing to be honest. I don't know. I don't, I don't, I don't judge. I love them. What can I say? Uh, so two other things actually. I was an, I was one of the first Esculap surgical navigation dealers in Atlanta and lost a lot of money on it actually. Sick. Um, they just, you know, they, they didn't, they didn't hang, so to speak. But there are some surgeons here that really liked navigation, especially on things like the HTO or some revisions. That are not being served. So that would be an interesting conversation to have at a different time. Uh, secondly, um, I know, I know, I have a contract with a, with a company out of Vancouver, okay, uh, for their AI, uh, model which we're using for marketing. We're just building it up and everything. But the reason I bring that up is that through them I met a, a marketing a specialist who, uh, is in Vancouver, Canadian guy. He's probably one of the best marketing lead gen contact call center guys. Cool. His command of the tech and the language, and I know he's looking for a job. All right, so I'm going to introduce you.

Please. Yeah, please do.

Okay.

I think he'd—

I think he'd be really a great find, to be honest with you.

Thank you.

Thanks, Mark. Yeah, his— by the way, his name is, uh, Conrad. Conrad Cosgrove. Okay. Conrad was the maiden last name of his mother, so she gave it to him as a first name. So it's a good Irish name.

Yeah, I like it. I like it. Thanks, Mark.

And Laura Lynn's Irish, I'm sure, and she's got a question.

I have another question. Well, I actually want to congratulate you because I saw your camera tech fairly early on and you've come a long way. Thank you. You've come a long way. They were a lot larger to start with. The camera was a lot larger to start with and it looks amazing. So congratulations on a job, a job very well done. What's the biggest obstacle you see? What's the objection? What's the self-objection that you hear? Great question. By and large, is it navigation robotics as a whole or is it, is there something specific to IntelliJoint that's that you deal with day in and day out?

Yeah, great question. So I'll answer that on a timescale or on a timeline. So previously the major hurdle or, you know, objection we would get is, I don't need this. You know, I've got optical navigation, I've got that before. And, you know, it was, you know, these are the stats, but not in my hands. Like, I don't have these issues kind of thing. I think that's— that tone has changed in the markets. I think people, especially in the way that we provide the technology, it's we're not in your way and will prevent you from making outliers or having, you know, patients come back. And nobody wants to be surprised with their post-op X-ray. So for little cost and little disruption, you've got a— you've got a bit of a a safety belt on. So I think that is helpful because a lot of the previous technologies and even some of the ones today, they're very complex. They're kind of geared toward those really complicated cases, not for your everyday kind of run-of-the-mill. So I think there was a mindset of surgeons that, oh, I only use technology for, you know, a small sliver of my practice. Whereas we took the approach of it should be so easy that you'll want to use it on all of your cases. So I think that kind of objection has gone away. Really, right now I would say it's kind of the economics of the whole thing. That's the major objective. And, you know, from my experience so far, like, the value analysis committee has gotten more sophisticated. They've become more negative. They've— they're saying no more often. So that's probably what's bubbled up to be our biggest challenge is how do we successfully navigate through VAC, because we're an expense line and I know it, right? We, we make surgery more expensive, but we improve the outcome. We prevent outliers, we prevent revisions, we help surgeons and patients have the best outcome. They'll market it to their friends, their friends will go to that hospital, but there is no, like, direct savings to the hospital. So that would be our biggest challenge.

And their view is short-term, right? Their view is very short-term. They don't care so much about the revision. They don't care because someone, someone else will do the revision.

Someone else will pay for that.

Yeah. Someone else will pay for that later.

Yeah.

Yeah, exactly. Thank you. Yeah, of course.

Good question. Kyle, did you have a comment?

Yeah. I just had to comment. I think, Armin, you're, you're onto the recipe that's been proven in the orthopedic industry of if you hone in on a need that is hard to object to, that you can get a hook in and then it can expand from there. I mean, and that's existed for trabecular metal, the SRAM hip, ankle fracture nails, on and on and on where there's like, there's this hard problem to solve and you go, well, I got a solution for it. And if it's a really good solution, it's inevitable that people will go, well, why would I not do this on everybody? So I love it. I think that's a good trap.

Yeah. Thank you. I appreciate that. Thanks, Kyle.

Yeah, I would love to hear, I mean, you've been doing this 15 years and I mean, this is almost a poster child for a successful startup. Raised money, raised just enough money to get things done, but you didn't go crazy. Started in 2 hospitals, the team lean, and I'm sure, and what I want to hear about is how you iterated. So, the successful startups are the ones that just keep, they're never satisfied, they keep iterating the product. So, can you give, can you just walk us through what's Yeah, where, you know, how did you get to here?

Sure, yeah. And I would say, Tiger, it's like evolution of the product and evolution of the business model because we want to remain in control of our business. Like, I guess control is maybe the theme of this whole session and, you know, putting surgeons in control. But at the same time, we want to be in control of our destiny as founders and as you know, owners and investors in this business ourselves. So, you know, we, we, we had the luxury and the opportunity to learn about how financing, um, can do you right and it can do you wrong, and how your commercial strategy, if done the kind of typical way, will force your financing strategy, which will ultimately force your hands for the business. And, you know, to tie this into the whole Canadian theme, if exit through acquisition is the only pathway, then Intelligent won't remain Canadian for very long. And most companies, and I think because the investment community conditions them to think this way, it's, you know, exit through acquisition is the only pathway that you've got. So, You know, it's the classic VC model where you raise a bunch of money, you go get adoption wherever you can get it, no matter how much it costs, you're constantly losing money. And then at some point you're going to have to sell your business and you better hope that there is an appetite from the market to buy your business. So you're, you're like shooting for a grand slam and you're not making base hits. And our approach was let's make base hits. So, you know, keep control of our destiny, raise as much as we need, and raise from a category who is patient. So now, you know, we've raised quite a bit of money, not more than we need, and it's all been funded by private high net worths and family offices. So we're in complete control of our destiny. There's no VC telling us, well, I got to exit to my investors next year, so you better sell this thing and all that sort of stuff. So we're just not in that, which gives us, I think, the luxury of pursuing the right business. And that's how we've evolved, right? Because we want to keep control of our business. We know we can't constantly lose money. And if we want to grow in the US and we're selling, you know, technology, quote unquote, only, we don't have an implant. Then we can't afford to have our reps in the room because there's no way you can make money with your reps in the room. So we had to figure out, well, how do we get our reps out of the room? Like, there's an expectation in orthopedics that you deliver service to your customers in, in the room. How do we break that and how do we get our reps out of the room? So I'll give you one example of like a product incremental improvement and how that also played into our business model. You know, I mentioned we have one tray of instruments, and in that tray of instruments, previously we would have non-sterile bone screws. So, hey, the thing is getting sterilized anyways, might as well put some bone screws in there, have them sterilize it. So when it comes back up to the OR, you've got sterile screws in there to use. But what we realized was, well, somebody's got to put those non-sterile screws in the tray. Before it goes up to SPD. And guess what? Guess whose responsibility that is? That's Intelligents' responsibility. So we were for— our reps were forced, even after the case was done, our reps were forced just to stand there with the screw in the room waiting for the patient to be closed so they could put it in the tray and then move on. So that was kind of one example of, I think, something that was anchoring them in the room. So we basically took all of our consumables and we turned it into a sterile procedure pack. So now there's no more non-sterile screws. So we're now pre-selling our sterile procedure packs to the hospital. We don't have to chase for POs on the back end after surgery is complete, and our reps don't have to hang out in the room anymore. So these are like an, uh, just an example of how we think about not only the clinical aspect but also the business aspect and how can we do things to, to, to be a proper business. Like, businesses generate profits, and we believe we should behave like a proper business and generate profit.

Excellent. Maloney.

So one of the questions I always ask everybody is, if you're looking at your sales force, what's your percentage of farmers to hunters? And basically, you don't really have any farmers.

We have a lot of hunters.

You have a lot of hunters. And that's the way it should be, you know, and that's where it's probably going in the United States market in general.

Sure.

As soon as they figure it out.

Thanks. Yeah. Yeah. And, and I mean, again, the engineering side may be coming out, but we looked at, you know, we did a whole exercise of a day in the life of a rep for one surgery. Like, what does a rep have to do in a whole circle for one surgery to happen?? And how do we take away all of those kind of individual, individual things from them? And then we also looked at how much revenue is each rep generating on a monthly basis, and that was the metric of success that we looked at. It's been 3 years now, so we've, we've more than doubled our revenue per head, per seller head, um, per month. But what about—

who tells the bad jokes and controls the music though? How do you overcome that obstacle?

Hey, there's an implant rep there that can be there.

That's a good point. Yeah, there you go.

I forgot about that.

Yeah.

You just have the technology tell you a joke.

There you go.

That's funny.

Kyle?

Yes.

Go ahead, Kyle.

Armin, just for you to have a data point, when I was with J&J last, they did a, they were sharing results of a big analysis of their sales force and their activities. And for on average, the sales rep was spending 85% doing non-sales related activities. So you're on it.

It makes sense. Yeah, it makes sense. And maybe that's okay. Yeah. If you're earning a few grand, you know, for standing there, but we're not earning that, so we can't stand around.

Walk into any operating room today and ask that rep who's breaking open the package, did you make the orig— did you make the sale to this doctor?

Yeah.

And the answer 9 outta 10 times is no.

No, I get it.

Yeah, Laura, Laura, Laura.

Sorry, it's, I like to, it's hard for me to raise my hand because I like to just talk. So one question though about incentivizing the sales reps of device companies. Has there been any pushback from the device companies themselves relative to you utilizing their reps to service their doctors on their devices?

Short answer is no. Like that's a general statement. Certain company, um, is difficult. Um, but not only do we work with their reps on the ground in the US, they also distribute our products internationally. So there are some companies that we work with their reps— these are like major implant companies— we work with their reps in the US and on kind of an individual basis, and they also distribute, like formally distribute, our products internationally. So thankfully we haven't had any run-ins I don't expect that to be true forever. Who knows when it happens, but, you know, it's working right now.

Yeah, that's awesome. That's it. I think that's interesting out-of-the-box thinking too. It's a good way to, you know, a good way to— because the reps won't do it if you don't incentivize them. And so as long as you're not getting blowback from the, you know, the strategic. So anyway, awesome.

Thank you. Have you done like a head-to-head study measuring your time for hip or knee case versus the big robot?

Yep. So that, that would be done, like, there was a meta-analysis done. I think it was published by NYU. There's Australian Joint Registry data that looks at all that. And yeah, we've got a lot of evidence to show the difference in time. Of course, the studies that we've done ourselves were all about the— we look at our own time add or we look at the learning curve of the surgeon. So in short, basically after 3 to 5 cases, a surgeon's time add with IntelliJoint stabilizes to less than 3 minutes. So the learning curve is really short. A lot of times, you know, we'll train them on sawbones or sometimes in theater. And then after a few cases, they get proficient with it and they basically— their time add is neutral.

Got it. And the value analysis committees need that anyway.

They do.

Yeah.

Although it doesn't seem to block purchases of systems that exacerbate surgical time. But hey, that's for another conversation.

Yeah.

Our, our VAC whisperer is not on today, but he would love to ask you a question. You have a question? You have a question for us, Armin? We have, yeah, collectively got hundreds of years of start-up experience here.

Yeah, I mean, maybe double-click on the kind of objection that we have still with VAC. So maybe this is for your VAC whisperer, but yeah, like, what are people doing in response to some differences in the behaviors of VACs over the last, you know, few years? And, you know, maybe are there any tips of success, or what's worked, what hasn't worked? Like, That's just my general question because that's our main objective at the moment.

Yeah. And how, how, how many months does it take you to get through that VAT committee right now?

It depends. I would say we're probably at a hospital, not an ASC, at a hospital, we're probably like 9 months, 9 to 12 months overall from, you know, if we have to do an evaluation or a trial, we go through the process overall. I would say it probably takes us around that much.

Got it. Okay, we're coming up on the hour. So Maloney and Kyle, go quick.

Last thing. So we had a senior VP of supply and logistics from probably the largest hospital system in the Southeast on a few weeks ago. He's a friend of mine. And when asked about the value analysis process, he said, I got bad news for you. It's— it is bad. But it's gonna get worse. So it's gonna probably go to a year. Thanks. Yeah. Well, it's not encouraging for me either.

Thanks. Thank you.

I'll help us end on something more positive. If you decide to start going into the total shoulder space, let me know. I've got a team with decades of experience in it, or we can give you references to surgeons and all kinds of stuff. We've got, we've got our fingerprints all over the total shoulder arthroplasty world.

Okay. Yeah, yeah, I'll definitely take you up on that, Kyle.

Who, um, can you share who you're licensing spine and shoulder to right now?

Um, I can share the spine, uh, it's with ATEC. Mhm. Shoulder I can't, it's confidential. Got it.

And good. Any other questions before we wrap? This has been terrific. This is, like I said, a poster child of how to do it how to do a startup. No implants, very few reps, raise the amount of money you need, focus on one or two hospitals, you know, founder, founder-led businesses. I mean, just, you just check every box.

Yeah. Thank you.

That's— your cell phone ends with 8160?

Yes, it does.

Got it.

Okay.

All right.

Thanks.

This has been great. Yeah.

Thanks, Tiger. Thanks for organizing. Thanks, everybody. Thank you.

See ya.