BoneChat call #11 - Patrick Jamnik - startup with a partial joint replacement for OA gap patients

Welcome, Bone Chatters. I'm live with Patrick Jamnik, and he is going to walk us all through kind of a new treatment modality for a lost group of patients. So I'm going to turn it over to Patrick. He's got great slides. He's upping the game on bone chat.

Thanks, Tiger. Well, first of all, hopefully that this conversation that we all have today is not sort of just, you know, me talking at everyone. So please, anybody, feel free to kind of interrupt along the way or ask clarifying questions or anything that might be needed. Hopefully what I can kind of impress upon the group today is not just share a little bit more about the company, but also really kind of leave this kind of notion with everyone that in orthopedics, certainly as pertains to surgery of the knee, we kind of have a problem that it really is not the fault of anyone, but we kind of have a problem with middle-aged patients that there's just not a lot of good treatments out there for sort of people between about the ages of 40 and 60. And I'll get into some of the— kind of information around that. But, you know, if everybody could take one thing away, at least outside of company-specific stuff, it's just this sort of notion that middle-aged patients have sort of been kind of left behind historically within orthopedics. So everybody can see the slides, right? Yes. All right, great. So EpiSurf Medical, we are a Swedish-based company. We're headquartered in Stockholm. We were founded by an orthopedic surgeon. And I think it'll come through in a couple different points throughout this presentation how being founded by a surgeon really left a sort of strong mark on a lot of areas of the business. And a lot of the way we do things really comes back to that clinician founding. But that's Professor Leif Ryd that you see on the right-hand side there. Leif was a lifelong orthopedic surgeon or was a practicing orthopedic surgeon. His last spot was at the prestigious Karolinska Institute in Stockholm. And Leif basically started to develop a problem with his own knee in his late 50s, and that really led to the founding of the, the company. I'll get into a little bit more on that in just a second. We've got a global footprint. We've got patients treated to date in over 20 countries around the world. I mentioned we're headquartered in Stockholm. We are publicly traded on the Swedish Nasdaq exchange. Almost all of our funding to date has come from within Sweden. One notable Exception I might add though is a gentleman by the name of Niles Noblitt, who along with Dane Miller was one of Biomet's original 4 founders. Niles was Biomet's board chairman all the way up to their sales to private equity in 2006 or 2007. So he was Biomet's board chairman for 25 years or so. And Niles is one of our, at least on an individual level, one of our leading investors. Middle-aged patients, like I said before, this is a group of people that have gotten kind of the short end of the stick. There's a lot of historical reasons for that. A lot of it comes down to just kind of the way that orthopedic surgeons in the US have kind of chosen to self-segment and self-categorize themselves. But there really is no one who caters just to middle-aged, middle-aged patients. It's a tough group to treat. And historically, a lot of options have been tried where they're just trying to make the best do of kind of more sports medicine type products or joint replacements too early than they ever were really intended for. And this is where EpiSurf sort of thinks of ourselves as fitting in as a company, at least. We're all familiar with these types of charts, these left-to-right continuum of care charts. On the left-hand side, as your knee is sort of like, you know, in your 25s, say, for example, your knee's not that bad. There's lots of good surgical options for 25-year-olds for whatever sort of knee problem that they might have available. On the other end of the spectrum, for let's call it a 75-year-old, there's not a vast array of surgical procedures. There is one procedure, a knee replacement, which even though it has some shortcomings, it's obviously a highly effective treatment for the right people. But we should always remember that knee replacements were intended to be sort of an end-stage treatment. I've been in orthopedics for about 20 years now. When I started, when people would get their knee replaced, it was sort of nobody under the age of 70 would sort of almost allow to get their knee replaced. And before you know it, 65 became the new 70, 60 became the new 65, 55 became the new 60. And it sort of just has gotten this gradual kind of sort of age creep. And the middle has been sort of left, you know, gotten— the middle has been left a little bit sort of unrepresented by the product offerings that are out there. So this is sort of the market that we intend to to see. I will admit our customers every year may pull us sort of a half step to the right and a half step sort of up in terms of like damage to patients, to patients' needs. But again, we make, we make products that fit all of this sort of group in the middle, 40 to 60, give or take maybe 5 years on either end of that. I won't spend too much time in this presentation on sort of what is or isn't approved. Within the US because we are a worldwide company. We're a company that started in Europe. That's almost a little bit jarring sometimes when I talk to different distributors out there and they want to know, well, what day is this product going to be available or that product going to be available? And, and, you know, there's different answers to that. Every country obviously has their own regulatory landscape. The one last— the last thing I, you know, that might impress upon everyone with this slide is just that even though you may be hearing about hearing about EpiSurf for the first time, or US surgeons may be hearing about the company for the first time. We're sort of many years past the two guys in a garage phase of the company. I think a lot of that will come to show here. Everything that we do, we'll keep it centered around the knee for now. Everything that we do, we make customized implants for middle-aged patients, and everything is predicated off of MRIs. Our team takes an MRI scan in, And then what we make back within a couple of days are what we call these damage marking reports. These damage marking reports, what our engineering team is doing is taking images in, recreating, resegmenting the entire femur, and then showing back to the surgeon exactly where a patient has damage to their specific knee. Where is the cartilage partially damaged? Where is it all the way damaged? Importantly, what's going on, on the right-hand pictures here and the lower picture here, what's going on on the subchondral level. There's a lot of talk always about, you know, cartilage injuries, cartilage injuries. It's really important to remember cartilage has no nerve endings. When someone has the quote unquote cartilage injury, they're getting pain signals from their bone that's sort of getting them symptomatic, getting them into the office. So if you leave the bone and you sort of ignore the bone, you're missing a lot of the overall, a lot of the overall picture. But these damage marking reports come in a variety of sort of shapes and sizes. Some of them are really small, like the upper left-hand picture. A lot of them look like this, this sort of very, very classic kind of, um, mid, you know, KL3, early KL4, sort of mild or mid OA types of things. Even this wear pattern, medial and anterior, is very sort of characteristic. But again, you see all these blue, um, pictures on the, on the bottom, or these blue sections on the bottom, that's all where there's underlying bone marrow or bony edema, underlying bone marrow lesions. That's what's really causing a lot of the pain on these patients. We also get plenty of scans in that come like this. And this is where I think we earn as a company, we earn a lot of credibility as a company because if a scan like this on the bottom right comes in, we'll give the surgeon back these reports sometimes and say, you know, here's what this knee looks like. But frankly, we have nothing to offer you. This patient actually does need a total knee. So thanks for, considering us, please send us the next scan, but, but, but we don't have anything for you. And we gain a lot of credibility that with, with that, because these damage marking reports, what, what they're really proving in the marketplace, first in Europe and now in the US, is that they're proving as a real powerful patient selection tool for surgeons. Patient selection is something, if you go to any medical meeting, it's something that doctors talk amongst themselves about all the time. Patient selection is not spoken about as frequently sort of within the halls of medical device companies. The objective is really like, let's make a product and let's go sell as many as we can to whomever we can under any circumstance we— as we can, as fast as we can. What we're finding, though, is when you can help surgeons pick the right surgery and sort of pair the right surgery with the right patient, there's a huge kind of like goodwill that comes from that. And we've had a number of surgeons at prominent institutions tell us they think this offering, these damage marking reports, this could be its own sort of like standalone product or its own sort of, you know, kind of, you know, business. There's an unclear sort of business model to fill in.

Patrick, is there, is there a charge for that? Is it included in the implant price? What, how do you do it?

It's included in the, it's included in the implant price. Obviously, if we were going to offer it as sort of a standalone product, we'd have to figure out, you know, a sort of a pricing scheme. So it's a standalone product right now. Doctors, generally speaking, you know, they don't get overused too much. They know that, okay, EpiSurf can help me out, they can help with patient selection, but they're not— they also know what we make, sort of what our end sort of sales come from, the end products that we, that we make. So they're not too, they're not too eager to overuse it or deliberately overuse it. If there's sort of these in-between patients where they're leaning one way or, you know, they're on the fence one way or the other, we're happy to do it for them. But Nobody's sending— doctors aren't sending us like a horribly 100% arthritic knee that is an 80-year-old that they know needs to— you know, those types of things.

And what are the mechanics? So a patient has pain, and they get sent— they get prescribed an MRI. Then what happens after that?

Yeah, so the MRI scan is a sort of company-specific or a customized sort of protocol. We give the MRI facility. Sometimes that's in the doctor's office. Sometimes that's at a hospital. Sometimes that's at a standalone. Imaging center, they plug in our protocol. It's very, very similar to a normal diagnostic MRI. We don't get too much kind of friction, friction in terms of like plugging in our protocol. But patient goes, gets an MRI with the EpiSurf protocol. Those images are uploaded electronically, um, to us. It's all a web-based system. We've got usernames and passwords for whoever needs them. It's a, it's a electronic upload. And then within a couple of days our team is spitting back this. This is just page 1 of these damage marking reports, but they're usually about 12 pages long that gives sort of a full kind of diagnostic, you know, sort of a workup. So we'll make comments on the condition of the meniscus, the condition of the ACL, the condition of the collaterals, those types of things. It's not just sort of cartilage mapping. It's a— we're painting a whole picture of the knee.

Cool.

So where we got our start as a company really was making what I'll call, for simplicity's sake, these sort of femoral-only implants, inlay style, customized. So we're customizing the thickness of— from us, let me back up— from a set diameter or a handful of different set diameters, we then are customizing the implant's thickness and I think really importantly customizing the implant's surface curvature to match the native anatomy. So once, once they go in, the, the sort of trick in the OR that we love to tell doctors is to close their eyes and kind of run their finger along the surface of the joint, and they shouldn't really be able to tell, am I touching native bone and soft tissue or, or an implant surface, because the geometry should fit perfectly. But where we got our start was this, these sort of single implant femoral only, a variety of different sorts of like, you know, ages and levels of, of damage. Over time though, what we've started to see more and more of, and as doctors— this is in Europe— as surgeons have gotten more comfortable with our technology, they started to sort of push it back to that continuum of care picture. They started to push it as sort of a half step to the, to the right, because basically that's where the patients are kind of more frequently symptomatic. So we'll get a lot more of these types of examples. You see this kind of a circular picture here where there's 2 implants, one in the trochlea and one on the medial femoral condyle. It's almost like spot welding of the knee where we're able to show them exactly and only where the specific damage is, and they're able to go in and resurface just the particular points of the knee. We've got many examples of 3 implants going in in the same knee. And to get into the OR, these people will have had clean or clean enough, let's call it clean enough, tibias. If the tibia was too damaged, it would trigger a contraindication and we wouldn't do the case anyway. So we're very confident that this type of things works because again, we're matching to our sort of stated list of indications and contraindications. And frankly, there's a level of off-label usage when you're making customized devices that have specific indications and contraindications. There's a level of off-label usage that we just can't be complicit with in terms of like, it's not like, well, and the doctor, you know, hey doctor, anything you wanna do in the OR, that's sort of up to you. If we see something on imaging that triggers a contraindication, we can't just say, well, screw it, we're just going to make an implant no matter what anyways. It all needs to be sort of consistent with the actual label. And as I'll get to a little bit later, staying consistent with the labeled indications has really kept our clinical results sky high and built us, I believe, a ton of credibility with our customers. So Patrick, again, yeah, just more sort of examples of different things that we've done over the over the years. Where we're sort of headed though, this single implant, one femoral only, so leaving the tibia or leaving the patella untouched, this is a big hurdle with FDA. Anything where the other side is, or one of the two sides of the knee is left untreated, that's a Class III device in FDA's eyes. So we started years ago, we started an IDE to get this through, but anyone who's ever been involved with IDEs know That takes forever, and it's obviously very expensive. And in the meantime, I think the plan was to sort of start the trial first. It'd be the first thing to start and the last thing to finish. And in the meantime, we can fill in all of these different holes where there's a much cleaner, easier, cheaper regulatory pathway. And that's where we're sort of getting started in the US. It's with a patellofemoral product. So damage to just the trochlea and the patella, so isolated— isolated osteoarthritis of the anterior compartment of the knee, about 18% of people presenting with knee OA have it actually isolated in the anterior compartment. Numerically speaking, it's a drastically undertreated part of the joint. Or I should maybe rephrase. Anterior compartment OA is a drastically overtreated part of the joint because most of these people end up just getting total knees. That's not where they actually have just their problem. There's a litany of sort of problems with other historical patellofemoral devices. Many of those sort of design shortcomings, I think, really stem from the fact that they were trying to just take the anterior third of a total knee replacement and just sort of like drop it on there rather than think of the actual sort of patient-specific geometry and patient-specific sort of pathology. So nonetheless, the, our patellofemoral product, it's been cleared for about a year now. We started doing surgeries last year and we're sort of live, I guess you could say, live and, and commercial.

Taking a look at this back. Yeah, it's hard to see the PFG damage, PFJ damage with plain X-rays unless you do a sunrise view. And most people don't, you know, prescribe the sunrise view. You gotta do an MRI to see it. So, yeah, I think that's why it's forgotten.

Yeah, exactly, exactly. It, but it, the problem is, is out there. If you look at this is a, this is a meta-analysis, 3,500 patients, about a dozen papers, all of them pooled and collected. Where do people have OA? Asking just a basic simple question amongst people who have arthritis, where do they have arthritis? We gotta remember when someone gets a total knee replacement, let's not forget the word total in there. It's taking off a centimeter of bone all the way around the femur, off the top of the tibia, off the backside of the patella. It's removing both of the meniscus. It's removing the ACL. It's sometimes removing the PCL. It's changing the kinematics of the knee oftentimes. Where do people actually have arthritis, though? Half the time, it's just in one of the three compartments or one of the three sections of the knee. Only 17% of patients have osteoarthritis in all three compartments. So in many respects, it's a bit of a sort of overtreatment. There's a lot of historical reasons that we can have its own conversation of like sort of how do so many people get total knees when maybe not all of them need them. It's a complicated, you know, complicated discussion. But nonetheless, we feel that there's a place for us because of data that like this exists. So many of these people that get total knees, they're getting them younger and younger and younger. But the facts are they're just not doing as well. It's an end-stage procedure that was always designed to be end-stage. These charts here show— these are from— this is from the British Joint Replacement Registry. So 1.4 million-plus patient study. This is not, you know, one paper with a guy who did 10 cases. And what they did is they bracketed patients in 5-year age brackets at the time of their index knee replacement surgery. And these charts show just cumulative revision rate by age bracket. And every single age bracket that you get younger and younger and younger, the patients do worse and worse and worse, basically from day 1. So, you know, I understand 15 years on the 80-plus-year-olds, those patients have passed away and they're sort of out of follow-up. But from, look at, you know, 2 years out, 3 years out, 5 years out, there's no reason that 50-year-old, you know, 50-year-olds are doing worse than 60-year-olds who are doing worse than 70-year-olds who are doing worse than 80-year-olds. So this idea, I think, that like everybody can just get a total knee younger and younger and younger, it's not proving that that's like an effective, you know, an effective sort of surgery for people who are in this kind of middle-aged group. They're too active. They've got a history, you know, a longer history of problems. And it's charts like these that I think give us a lot of enthusiasm that there's a place for a company like us to fit. We've also got this sort of— we've got a foot and ankle business that is sort of in addition to our knee business. This resulted really from demand. Some of the things that we were doing in the knee caught the attention of some really prominent European foot and ankle surgeons, most notably a surgeon named Nick van Dijk, who's probably one of the most one of the most prolific foot and ankle surgeons in the world, operated on Cristiano Ronaldo. So I mean, that's a pretty pressure-packed kind of environment. So in Europe, we do make an implant for like Taylor-Dome lesions, completely customized. It's off of a CT scan in the ankle. But these are really, really challenging patients. And a lot of these people receive total ankles or end up fused. And again, these are total ankles. Fusions in the ankle, fusions in the toe, which I'll get into in a second, total knees. All of these are end-stage procedures. And if there's sort of a, you know, like a, what's the point of EpiSurf beyond the individual products that we sell? It's to help middle-aged patients and kind of repark some of these end-stage procedures back at the, back where they were originally intended. Not that they're not good surgeries, they're just not good surgeries for people in their middle ages. They're good surgeries for 75-year-olds, but just not for 45-year-olds. We've got a sort of R&D project. It's not even a project now. It's a submission into the FDA right now. We're kind of back and forth in the submission process, in the 510 process to create a customized implant for hallux rigidus or osteoarthritis of the first MTP joint. This is another huge problem where the gold standard surgery is still fusion. So, you know, no high heels again ever if you're a woman. You know, this is a— we're not the first ones to try to tackle this problem. The video you're seeing here is from Cartiva. Plenty of people who've been around orthopedics will know the sort of whole Cartiva story. Really good idea. Got a lot of commercial traction when they sort of post PMA approval. They were up to $35 or $40 million in revenue within a couple of years. What that signals to me at least is that surgeons are looking and will move en masse to non-fusion solutions in the big toe if they see a solution out there. For a variety of reasons, Cartiva didn't work clinically. We're not copying anything really about Cartiva's implant, but the marketplace is there. And so there is a proven or a semi-proven history now that surgeons are looking for non-fusion options. In forehallux rigidus, or arthritis of the big toe. Again, this is a product we've submitted now to the FDA. We're in the kind of back and forth submission process, developed it in close cooperation with the former ACFAS president. And this is something that we're hopefully going to have on the market and commercial at some point during this calendar year. I mentioned imaging, and if there's sort of one kind of like sort of secret sauce to everything that we do, our manufacturing sort of methods are not sort of revolutionary in terms of what we're doing on the actual machines or anything. But if there is sort of a secret sauce to what goes on at EpiSurf, it is this sort of imaging process. We've got a whole team of engineers that have really been perfecting this sort of whole step-by-step-by-step receipt of images, resegmentation of the joints. And this is something that we've really been perfecting for really a decade now. There's proprietary software that we use. It uses AI-based sort of image segmentation. So the AI kind of does the first pass at everything, and our engineers are sort of, you know, refining everything from there. But it's fast, it's reliable, it's scalable, and I think most importantly, it's accurate because The stuff that we, we make, the guides, the way that they fit on, we get constant great feedback on how well everything fits. What you're seeing here are some surgical videos. On the left-hand side is the knee. The right-hand side is, is, is in the ankle. But we're making these, these guides custom off of the damage. We know exactly where the damage is on any specific bone. So these, these guides are designed to fit right over the damaged area and only the damaged area, lock into lock into place with simple, you know, sort of OR tools that everybody has and then sort of just drill or core out only the damaged spot, much in a way that a dentist sort of would see that someone has sort of like a cavity in their tooth and just sort of go at the specific area of damage. I had a surgeon tell me recently, as I made this dental analogy, and he came back right away and he joked and he said, we were out and he said, I said, yeah, if you went into your dentist and they said, you know, well, you have a cavity in your tooth, you know, we can fix just this cavity or I can do dentures. And they would, you would look at your dentist like, you know, they're out of their mind if they suggested dentures. And if you said, well, why would you do dentures? Well, you know, the decay in your tooth could spread to another tooth or it could spread to another tooth. And you would look at your dentist like they were completely out of their mind. And it's not exactly the same in knee surgery. I fully understand that. But hopefully you get the point that, you know, This idea of like, let's treat what's damaged and let's sort of get this person back to the status that they had before and get them on their way. It's well proven in a lot of different areas. I know this slide will make Tiger happy, as I've seen him write about this sort of concept before. Central to our kind of like business model, I guess you could say, is that we're a completely inventory-less company. So there is no warehouse, there is no EpiSurf warehouse anywhere around the world. There is no EpiSurf instrument tray sitting anywhere in, in any hospital collecting dust on a, on a shelf in sterile, in sterile processing. Everything that we make is patient-matched. We, um, design, make, and ship in sort of all the hospital needs is a mallet and power equipment, and we will send in everything else, and we'll send it in sterile. Everything— the implants go in, of course. The instruments get used once and then discarded. So you can imagine the distributors, they love us. Everything, you know, there's no, no dropping off the day before, no picking up the day after. It's a, it's a super sort of clean— it's about a dictionary-sized box that—

do you have to have a rep?

Everything arrives in What's that?

You have to have a rep in the case. What's your— what's kind of been the experience, uh, in Europe?

We see— I mean, you know, they go when they want to go for a variety of business reasons. Have to, I would say no. I mean, you want to maybe the first couple of cases just to ensure everything, but you know, there's, there's really no reason that a rep needs to be, needs to be there on the, on the 20th, or you know, that, that type of, um, that, that, that, that type of, of thing. Because again, it's, it's all right, it's all right there. It's 4 instruments. You can literally hold them in in one hand. Back to this sort of idea of precision, what you're seeing on the top here, they're a little bit kind of brown or gray colored in this picture. Those are individual different sockets. Those different sockets, they fit into that guide that is the most, the lower right-hand most instrument there. What those sockets do, there's different sort of dials on there and those sockets allow the surgeon to change the depth of the implant because these types of, for these types of implants where they're inlay and they're kind of working in harmony with the rest of the native knee structures. Depth control is super, super important. And these, those dials allow the surgeon to drop the implant in or change the depth of the implant in 0.2 of 1 millimeter increments or 200 micron increments. And that allows the surgeon to sort of like, you know, drill, trial, check their depth, go a little bit deeper if they need to. And everything becomes sort of really, really sort of precise at the end of the day. We're surgeon-founded, as I mentioned. And as a result of that, clinical results have been sort of at the forefront of the company's DNA. Because we had a surgeon with a life, a career's worth of reputation on the line, Leif wasn't going to let the company kind of get itself too exposed in the earliest of days and just sort of put the product in the wrong people's hands for the wrong uses. And, and central to the way that the company has been built and developed has been this really strong clinical foundation. And foundation is the word that I use a lot when I tell people why I joined the company, because I was so impressed myself with the foundation in a way that the house of a— the foundation of anyone's house, it needs to be laid perfectly. It's kind of boring, it doesn't sort of like sell the house, but everything builds on top of that foundation and. It doesn't matter how nice the bathroom tiles are in your house if it's sitting on a rickety foundation. EpiServ has an incredibly strong foundation. All of the, you know, some of the things that are a little bit less sexy sometimes, getting the long-term clinical result, getting the clinical program going right away. So by the time you really want it to be commercial, you've got real sort of data. The RA stuff, the QA stuff, the IP, all of that, all of those kinds of foundational elements are really, really strong here. And that was one of the types of, One of the things that really impressed me as, as really someone who's like a, you know, tile and bathroom fixtures guy in the whole kind of like eco system to have the foundation as strong as it is. It, it, it, it makes it really easy sometimes to do a lot of those other, to do a lot of those other, other things. Yeah, again, just more examples of, you know, clinical programs for, for a company of our sort of relative youth. It's very rare to see these types of longer-term or mid-term, I suppose, clinical studies, multi-center, multi-location types of things. And we're really, really proud of not only the work that's been done, but the, of course, like the results and the actual, the actual output and how well the patients are, are doing. It's very common to hear that we hear from surgeons, well, you know, everybody who's, everybody who's rotator cuff I repair they live within 20 miles of my office or 30 kilometers of my office. But everyone who gets these products, they come from 100 kilometers away. And that's through no sort of external marketing. That's just word of mouth and whatever channels the patients are using to talk to each other. Surgeons are using or are seeing our devices work as a way for them to sort of expand their own individual catchment area. And that's something that I think is a trend that bodes really well for us long-term. What you're seeing here on the left-hand side, this is actually our first patient ever. He's at 10-plus years now. He's won cross-country skiing, age-bracketed, but cross-country skiing championships. And, you know, on the right here, this is like a professional soccer player who got one of our products in his ankle. So we're talking about, you know, these patients are able to return back to really high levels of function. Last slide, I guess the last slide I could maybe leave everyone with is that, you know, it's always so sexy to talk about like we've got something new, revolutionary, brand new, you know, all of these, these kind of these buzzwords that, that become overly sort of clichéd. The idea behind what we're doing at Episerver is frankly not a brand new idea. It's not even an idea that we came up with like out of of nowhere or purely invented. It's something though that when it originally came around, the available sort of imaging and manufacturing technologies just didn't exist. The sort of like the backbone of the idea didn't match the sort of like top of mind idea, if that makes sense. And what we think we're able to do, and you see this all the time in orthopedics where these good ideas come and they sort of like fizz out right away and all of a sudden 10 years later they're back, but they're back because like the idea has been refined and the technology has gotten better, the manufacturing processes have gotten better, the materials have gotten better, whatever the case may be. And that's how we see ourselves fitting in, is that this idea around just treating, you know, only the damaged area of patients' joints, it's a really sound one. And it's one that we think we've been able to sort of take, harness, understand what some of the previous shortcomings were, improve upon them, and then improve, you know, sort of the end output. Because ultimately, If it's not us, it's going to be someone else. There's just not a world where people are going to get their knees replaced at age 40 or 45 or something like that. A lot of these biological things, they lose a ton of efficacy as patients start to enter that kind of middle-age bracket. So the industry, we think we're at the forefront of this, but there are other companies as well doing similar. You'll see this kind of like continuum of care slide in many other companies' presentations, this idea around getting after the middle-aged patients is, I think, a really sound one and probably one that I think everyone will kind of hear more and more about as time goes on. So that's the end of everything that I have. I'll stop sharing my screen and we can, you know, I'm happy obviously to discuss anything that the group wants to.

Well, here, here's a question from chat. Kyle had to leave early. So is the tibia damage as a contradiction from the MRI and damage report means that having a total knee system around as a bailout isn't necessary anymore?

It's the right question to ask. So yes, it would be the answer because remember, we're making everything customized. So if there's, if there's tibial damage, and again, we're talking about this, let's call it in Germany. This would be like for, for Europe right now, for example. If there's too much tibia damage, we're just not doing the case. If there's no tibial, if it's a clean tibia, if the tibia looks good, we're going to know that from imaging. And therefore, they don't need to bring, you know, what about this backup upon this backup upon this backup? We've seen from the MRI, we've seen all of the pertinent information from there. And occasionally, I'll get that question from a surgeon. Well, How do you know that the information on your MRIs is, is correct? And I understand why they're asking that. It's not a crazy question. And what I sell, what I go back to telling them is that this line I used earlier, we are way past as a company, we're way past two guys in a garage. And if, if our damage marking reports were saying something and showing something and then surgeons were opening the knee up and seeing something different, we would have been out of business with the doors locked many years ago. There's just not that's just not hap— like, that's just not, um, happening. That would be like the end of the— that would be the end of the company. So I suppose there's some sort of leap of faith on the, on the first one, but, but it's not something that we see where doctors are like, you know, backup upon backup upon backup upon backup, because who knows what's going to happen when you just get in there. We've got— we're taking some of those stressful questions and some of that planning, you know, taking it out of the OR setting and, you know, bringing it forward 6 weeks ahead of time to be able to make much more sound decisions in a much less stressful environment.

Thanks.

There's got to be a question.

Oh, question. Hey, Patrick, is the, is the backside of the implant, is it threaded like a screw or is it a post?

Good question. So it's a post, one piece implant, no tapers, no junctions, no, you know, sort of like points of mechanical weakness. If you ever hold one of our implants, you will see some very small threads at the very kind of bottom. That's purely for manufacturing reasons because we plasma spray them with titanium around the sides. We don't have like a good way to do that if the implant doesn't thread in on the machines, it doesn't like thread in. To something where we can kind of spray around it. The threads that you see on the actual implant, though, are not like meant to be, you know, the implant does not get screwed in, it gets hammered, it gets hammered in post, one-piece construction. And we don't have any reported instance anywhere around the world, thousands of cases now of like an implant breakage, an implant loosening. Of course, something could happen and we just don't know about it. But we think we have a pretty good handle on not just like published revisions, but any revisions because it's a customized implant. So doctors will probably reach out to us just even wanting to know dimensions. How thick is this? How wide is this? I need to take it out, et cetera, et cetera. And we don't have any, a single one of those. All, any failures we've ever seen has all been kind of general progressive OA, you know, different part of the knee ended up fading or deteriorating over time.

Yeah, go ahead, Corey.

So I think it'd be interesting to the group if you describe your ideal surgeon customer. Who are you targeting with this?

This?

Yeah, sure. That's a really relevant question, and honestly, it's a tougher question in the US than it is in Europe. The way that a lot of European surgeons get trained, you're much more likely in Europe to be sort of a knee surgeon, like a cradle-to-grave knee surgeon, where you, you do, you know, you don't do things in the hip, you don't do things in the shoulder, but you handle maybe not kids, but, but all adult knee conditions. In the US, we know it's a bit of a different the way that surgeons organize themselves are a little bit differently. So there's no clean answer, honestly, of like who an EpiSurf surgeon is. It could be a sports surgeon and it could be a joint replacement surgeon. What I tell people, like when I tell our distributors on like who they're targeting, I tell them to start though about thinking of people who both scope and replace knees. Regardless of what a surgeon's educational background is, if they scope and replace knees, they're going to be— that means almost by definition, by any definition, they're going to see these middle-aged patients ahead of time. When it comes to the larger sort of mega groups that are all like hyper, hyper, hyper segmented, that comes down to local knowledge, frankly, sometimes, where they— people just need to know where these middle-aged people— because there's no like set, like AAOS sort of kind of consensus statement on where these middle-aged patients go, and it differs from group to group on like who handles who, who gets the 50-year-olds. Some people, the 50-year-olds end up with the sports surgeon. Some, sometimes the 50-year-olds end up with the arthroplasty surgeon. It really does just sort of depend. But I tell people in their, in their targeting efforts to start by thinking of surgeons who both scope and replace, and replace knees.

Hey, Patrick, it's Ted.

Oh boy.

Good to see you.

You too.

Hey, I think for this community it'd be great, I just want to ask the question because you've got, you know, a wide variety of experience and orthopedic, you know, industry knowledge, you know, for you as the person responsible for standing up EpiSurf, you know, in the US and growing it, what are your biggest challenges, you know, over the next 1 to 3 years?

I mean, there's a couple. Putting aside the general challenges for that would always come with a company of size. So like we all, you know, of course we would like to have more money. Okay, fine. But that's like, I think that's kind of an automatic, you know, that's, that's an automatic type of thing. Of course we would like to have more awareness. That's an, you know, that's an automatic type of thing. I think there's a, there's a couple. One, finding quality distribution is and always will be a challenge for a company of our, of our profile. You know, I have my own network. There are different recruiters. That can help. We do a lot of things. We're probably, you know, more kind of socially active, social media active than your average company. And some of that is just free, you know, that, that, that brings in, that sort of turns on the, the, the, the distributor faucet a little bit. That's always going to be a challenge because no matter what, at the end of the day, we're still selling. Nobody can be just like exclusively just an EpiSurf distributor. We're always fitting in with a handful of other products that somebody is selling. So So finding not just any distributor, but finding the right distributors that will give us the appropriate amount of time, I think is one sort of challenge. We have regulatory challenges just like, you know, just like everybody does. We'd love to have more products available in the US, but, you know, we have one, there's one FDA. So I don't know that that's the kind of thing that we're going to be able to change ourselves. The surgeon, The surgeon profile thing, back to Corey's question, I think that's a challenge for us still figuring out. Kind of, we're right on that fence in terms of like the, like in Dallas we would be more of a, like a sports medicine company and in Houston we would be more of a joint replacement company and like there's no, and I'm just picking two random cities, that's not like an actual thing, but we don't have a clear like, these like people who scope and replace knees, that's tons of surgeons. Like that's just like lots of surgeons for like, you know, numerically speaking. But what it's not is like at your sort of like tip of the prestige pyramid paper publishing class. None of those people, those people are all hyper, hyper segmented. So if they want to, any of them can all look at us and say like, well, that's not for me because of reasons X, Y, and Z. Now, As we broaden the product portfolio out and as we get further and further, certainly into the US market, I think some of those things will start to take care of themselves, but they're gonna take probably some deliberate actions on the company's part. And, you know, to be honest, I think we, some of it is product specific, but we kind of started as the last sports medicine company on the continuum of care. I think long-term we need to land for just market size reasons. We need to land as the first joint replacement company. But it'll take a couple of deliberate actions to get there.

Are you focused more on— are you finding yourself focused more on the ASC market these days versus the hospital with that?

Yeah, mostly. I mean, we talk to surgeons first, and they do the procedure where they can. But we are definitely— we can absolutely be done in an ASC. More than half of our procedures, like, you know, US procedures that have been done to date are in— they're in surgery, they're in surgery centers. And honestly, that's a saving grace for us because one other sort of challenge baked in for any company of our size is just the whole kind of value analysis committee process and, you know, getting in at institutions. But it's, you know, that's almost like an ante at the poker game that everyone's going to have those types of challenges. But we're not We're not immune from that. And the surgery center aspect of this obviously makes it easier than it would have been even 5 years ago.

And reimbursement and coding is defined and positive.

Yeah, domestically we're playing in sort of established markets in terms of like, you know, established reimbursement, you know, the coding's out there, the pricing is good enough that we can, you know, we can hit gross margin targets and all those types of things that it's not really— that occupies very, very little time and attention right now. It could long term. There's an IDE study, and as that got further along, that's a different sort of reimbursement challenge. But everything that we're doing and will be doing in the US for the foreseeable future, that all is sort of— the products look different and they feel different because of this sort of targeted approach. But the intended use coding infrastructure that gets used and stuff, that's all sort of settled and taken care of already.

Thanks, great presentation.

Oh, you bet.

I got to give credit to the, the team in Stockholm who, um, they, they put most of the slides together, certainly do a lot of the, uh, the, the really fancy aesthetics. Um, I, I, I would— it will take about 20 years for me to get a presentation with those kinds of videos going simultaneously, uh, going.

Well, I've been drawn to the EpiSurf story for a few reasons. One is I used to work on that donut hole patient from 40 to 60 when I was at Active Implants. I, that's the first time I discovered there's this whole group of patients that they get braces, they get HA injections, they get painkillers, they get, you know, steroid injections, and they just, all they're trying to do is buy time until they're 60. And they're, these patients are totally miserable. They don't have any, any options. So I understand that. And then I really love the, the clinical discipline that EpiSurf has done, you know, 10 years in Europe before coming to the US. That's really impressive. You usually don't see that. And then really impressive with the patient selection tool. Uh, most startups are just trying to get any surgery they can. They don't even care, but EpiSurf wants to get the right patient and that, Yeah, you just got to love that. Here, I got a— yeah, go ahead, Patrick.

Because everything is patient-matched and patient-made, you know, granted, I'm sure our gross margins on a per-case basis are not as good as if they were, you know, baked, you know, pre-made inventory. But because we— there's not, you know, of course we want to grow as much as we can. I don't want to be, you know, create false impressions with that. But I think because, you know, the psychology of it like that, nobody ever had to like make some sort of difficult and expensive inventory decision with EpiSurf. Nobody ever had to like sign off on some purchase order to some, you know, contractor to just make a bunch of sets and then all of a sudden feel the pressure, the week by week and month by month pressure to turn those sets. It's allowed the company to, to use this house analogy again, get the foundation right and make sure the foundation is right before you start putting the walls up, putting the roof on, putting the tiles in, putting the bathroom fixtures in, all those types of things.

Yeah, this— companies, especially startups, put way too much capital into inventory and it can really kill them. I mean, Colleen can talk about that all day long. It's, it's hard. Speaking of Colleen, she's got a chat question here. Patrick, would your IFU for foot and ankle products in the pipeline be a appropriate for patients over 70?

I don't believe— I'd have to double-check the anything published. I don't believe there's an upper age bracket. When we talk about the GAP patient, we say 40 to 60 because that encompasses most of the people, but it's really, you know, the condition of the average 40 to 60-year-old. So they could be 30, they could be 70. I don't think that there's anything that has an upper age as a purely just an age limit on it. It's obviously condition of the joint-based, much more so than a numerical age.

So there's no labeling that says you got to be under a certain age?

No, no. Okay.

No, I think some of that question almost gets answered a little bit by the doctors themselves. As the patients get older and older, they're just more apt to, you know, put in an end-stage procedure, you know, in the knee for sure. People who would have, you know, an epi surf knee in a 50-year-old is probably just treated differently than epi surf knee in an 80-year-old just because the doctors have different thresholds. The patients have different sort of demand expectations on their own joints. There are different activity levels. These middle-aged people are very difficult to treat because they're really active still and they tolerate, you know, basically zero zero worsening of their activity levels.

I had another question, Tiger. Patrick, so I think it's really slick. I love the single-use instruments that— are you familiar with Arthrosurface? They're acquired by—

Yeah, I mean, we used— I saw Corey's question as well. We used Arthrosurface's devices for the majority of our predicates. So, and I didn't want to sort of name them in the presentation, but when I'm on the last slide, when I talked about sort of this was a good idea a long time ago, and we think it was a good idea a long time ago, we just don't think at the time of that original idea, manufacturing techniques and imaging processes and all these types of things weren't available to Arthurs. When they started, it was like, let's make an instrument set and let's sort of get in there and hope that the doctors can just can just sort of, you know, with their eyes do their, do their thing.

Yeah.

Yeah.

Fix the potholes.

Yeah.

Mm-hmm. Yeah. Yeah.

So who do you think, if, if you think there is anybody that you can identify, who do you think is your competitor in this space?

So ArthroSurface would be, would be one. It's really because we, again, we sit at this sort of like mid continuum of care. We're sort of surrounded from different directions by different competitors that there's not like a clear, this isn't like a— this gap patient, this is not an established sort of marketplace. This isn't like Zimmer and Stryker sort of like trying to out-attribute each other in everybody's— in their own total knees. So like, you know, we lose some patients to the left of us because doctors are sort of trying to get away with a goopy, jelly, pasty sports medicine type of solution longer than they maybe should. We lose patients to the right of us because doctors are just sort of doing a— a total knee or a fusion, you know, of some sort in the foot and ankle. So I mean, numerically, if you consider every total knee patient as like a theoretical competitor, that's the biggest sort of like number. But I don't think it's realistic to like, or very sort of accurate to like, you know, properly sort of place that. So there's no clear answer to like, who is your competitor? Because the market is a bit, I hate to use the blue ocean cliché, but you probably know what I'm getting at, that the, there is not a clear sort of like middle-aged patient. Like, it's a, it's an undefined marketplace still. And as a result, we get competitors that come from all around us or in both directions of us in the continuum of care, right?

Yeah, I mean, it's, it's really, uh, kind of a bridge technology to a total, right?

I mean, for people that can put it off, you know, I mean, if you can do a cap and, you know, and that's central in all of our designs, you know, and it's obviously a question we get all the time from surgeons. What if I have to take this? What if I have to take this out?

Out?

And the answer is easy. Take it out. Once you take our implant out and you make your normal, like in a knee, you make your normal cuts around the, the, the, the femur, you'll see where our peg hole was, but it's 3 millimeters. And besides seeing where our peg hole was, it's like we were never there in the first place after they do their sort of normal total knee cuts all the way around.

Right, right.

Burn, burning no bridges and potentially gaining 10 or 15 years, you know?

Yeah. And, and that's another question we get is like, well, how long do these last? And it's like, well, I don't know. The first patients are out 10 years. The first ones are out 10 years now. So there, we have no, we have no good, you know, knowledge yet of like the total like upper end of the spectrum. If you look at some of the Arthrosurface data, a lot of those patients followed kind of like two clinical like sort of tracks. They either failed within 18 months or they're doing great at 10 years. And our perspective on some of that is that a lot of those patients who failed right away or failed within 18 months, that was probably the wrong procedure for them in the first place. The doctor didn't know it, patient demanded it, whatever the case was, it was the wrong procedure for them ahead of time. They should have probably because the tibia was too damaged. Frankly, that's usually what the case may be. There's a, you know, an ICRS grade 3 or grade 4 tibial lesion that was underneath the level, you know, the doctor couldn't see it that well. And there was no advanced imaging done or anything like that. And those patients failed, right? Failed pretty, pretty quickly. But if you, if you can get rid of those patients through modern imaging and manufacturing techniques, getting the implant placed exactly at the level of the, of the bone, understanding the whole sort of condition both at the chondral level and at the subchondral level of the bone ahead of time, you can remove those early, those early those are those, those early failures. There's a, a cohort of patients from Arthrosurface that they're doing great at like, well, you know, 10 plus, 10 plus years now.

Some 20.

Yeah, exactly. Yeah. I mean, long-term, not, not, not just, yeah, long, long, long-term.

So the, and, and Arthrosurface came in a variety of set sizes. So you, they tried to make it fit a lot of times and they did. It's hard to fit the contour of a femoral condyle because there's no, radius on a femoral condyle, especially the trochlea.

Yeah, yeah. Right.

Wow. And our, in our patellofemoral system, we're doing all of the same stuff we've been talking about for the femur. We're doing that on the patella as well. We're customizing the polyethyl, the, the, the polyethylene implant. So the, the curvature of that, that's a weird bone. Everyone who's been in a, in a knee operation knows that, you know, the, the patella, patellas are, are, you know, we all have kind of similar femoral condyles. We all have very different patellas from each other. And we're customizing the curvature of that as well. And that's something that I've been very kind of pleasantly surprised by as we've been selling the patellofemoral device is how much doctors have wanted to talk about the patella itself. I kind of came myself, my own background, like certainly for the first half of my career was working for Zimmer. And I've been in thousands of total knee operations. We all know that like the patella sort of gets done in the last 5 minutes. They're opening boxes, they're opening cement up. It's just like, other stuff going on in the room while the doctor's cutting the patella. The way that the patella is done in a total knee is like basically the way that John Insall did it in 1975. It's like more or less unchanged from that. They're eyeballing it sometimes. There's, you know, they don't know if their cut's being done perfectly level. It can be done on sort of a, you know, the wrong, the wrong plane sometimes. And to be able to have a guide that we make that sits right on top of the patella, matches the curvature of the anatomy no matter how thick or thin or where the kind of like the apex of it is, and then to drill down in there and replace it with an implant that matches the curvature spot on. That's something that doctors have wanted to talk about more than I ever envisioned before we started selling the product. But it's a, it's a comfortable sort of space that we've sort of walked that I'm glad we've been able to walk into.

Chat question from Corey. What did you use for predicate device? And I assume he's asking about the PFJ.

Yeah, I saw that coming. Yeah, we use the Arthur Surface device as the— well, amongst a couple of different predicates, you know, there's a— we use that, but there's a couple that you can use for different sort of design attributes, but Arthur Surface was the primary one.

Cool. Any other questions?

Have you ever thought about using the damage report We talked about this a while back, but as a separate business, like a service business, we, we have, yeah, the, it's, and we've gotten that, that question from, we got that question from, we get that question from doctors. The business model is a little bit, I would call it undefined. If we're going to interject, there's no, you know, there's no unique coding for something like that. So if we're going to sort of as EpiServ interject ourselves in the whole billing process, like, you know, where— if we're getting paid something, like, at whose expense is that coming from? Obviously gets a little bit easier when the—

when—

if the MRI— if the clinic's own— if the doctor's clinic owns the MRI machine, it's a bit of a different— you know, that, that's obviously much, much easier than if it's a third-party independent or a hospital, um, facility. So it is something we would like to do ahead of time because I've had numerous doctors tell me, like, you know, we should just get these on everybody when they come in and then get them 5 years later and then get them 5 years later. We, you know, we have— there's all— in other therapeutic areas, there's numerous screening you know, surgeries that people receive, colonoscopies and stuff, and, and, or there's different imaging studies that people receive, things like mammograms and stuff. Yet when it comes to like the condition or the deterioration of your knee, you wait until it hurts and you get into the doctor and they give you an injection and they say, well, come back when it hurts so much that you can't sleep and then we'll replace your knee. And like, that's a, that's a weird sort of like paradigm that, you know, if, if people would just take a little bit more or had a little bit knowledge, a little bit more knowledge of like the condition of their their joints, they may be apt to make different— I don't know whether it's lifestyle decisions or activity decisions or treat things a little bit differently rather than just sort of waiting until things get so bad that you need to go in and see a surgeon because you're in so much pain that you can't sleep.

Yep. Question from Mark. He came in late. Are you targeting HTO docs?

And a lot of those sports doctors that are doing, that are doing HTOs are the same ones that are doing different, different types of procedures. So it always takes a conversation, but there's a lot of customer overlap there.

Yeah.

Yeah. I mean, I've, from my travels in Europe, I, I mean, they, like you said exactly, there's knee surgeons, they treat anything in the, in from a 10-year-old to an 80-year-old in knee and they, they do a lot more HTOs in Europe than they do in the US.

Yeah, that's for sure. They do. Yeah. All, all types of osteotomies are, are done more frequently in Europe than the US.

Interesting. Anything else? Don't be shy. Jamie's barely alive. He's barely awake and he's driving.

I'm not driving.

Thank God I have a driver.

Excellent. Excellent. You fooled me there.

No, I got, I got, look at that.

Best driver. Oh, you got a best driver in the world.

Okay.

She's probably got a good question.

Do you have any questions on, uh, curvature? No, we're good.

John, I saw, I saw your question. Um, they can do surgery 6 to 7 weeks after they approve an order. So couple of— once we receive the images, we have a damage marking report back to them within a couple of days. Um, and then if they— once the surgeon approves it, 6 to 7 weeks they can do the surgery. We, we quote time frames usually from the time of the approval because sometimes the biggest bottleneck is chasing the surgeon down and getting them to approve something. So, but after they approve it, obviously we don't need them for anything. So 6 to 7 weeks after they approve the plan.

Yeah, I had a question, Patrick. What's the interface for the surgeon? Is it an email that damage report, does it show up as an email or how?

We've got our own like an online management system. We've got usernames and passwords for surgeons, for imaging personnel, for sales personnel. Different surgeons use it to varying degrees. Some use it for like everything, some use it for, you know, for virtually nothing. So the damage reports, they're produced as like a PDF. So like, you know, the doctor will get a notification email that this— the plan is sitting there for them to approve. Some doctors will take that email right away and approve it. Some doctors need to be sort of chased or hassled by their reps. But, but it's a PDF that can be, you know, a text message can be sent, it can be emailed. It's not as if the only thing that It's not as if the only way for a surgeon to approve a case is like getting them into their office to sit in front of a desktop to open it up. There's numerous ways that they can approve a case beyond, you know, beyond that. It's a, you know, it's pretty approval-friendly. We try to make it as— keep the wheels greased as much as possible to make approvals as easy as possible.

Got it.

Mark, why don't you ask your question in person?

Good.

Let me unmute myself. Good. There's a Canadian company in Montreal called Imovi that has a very interesting biomechanical diagnostic technique that they've been working on for 12 years. They're really, really good at identifying early knee pain and early loss of function before total knee. And I just think that that would be a good company as an ally because they are very much into the same thing, uh, trying to push that total knee replacement off as far as possible. And if you're interested in, in that, I can introduce you to them.

That'd be great.

Thank you. Okay, cool.

Yeah, I had a question on your sales and distribution, Patrick. Are you, are you just basically signing up 1099s and where your surgeons are, or do you have regionals? What are you doing?

No regionals yet. I mean, I think that will, will come, right? I don't know if— no, if that's the right term even. So right now it's, it's, um, it's, uh, it's just me. Um, we've got about 25 different distributors under contract. Obviously that number will, will continue to, to grow. There's probably people in here who've done this exact business before. It's, it's, you know, it's over 100 probably at the end of the day. But it's, it's not regionally based. I live in Dallas. One of the reasons I live in Dallas is because it's in the center of the country. The airport infrastructure is really, really good. I can get to anywhere in 3 hours that I need to. So we haven't, we haven't set out to sort of like color in the map from east to west or north to south or anything like that. Most of our distributor acquisition in 2023 honestly was from outreach to us as we as a company started. I mean, I kind of work my own network. And then between that and us doing things like on social media, LinkedIn has been a fantastic place to pick up distributors. I think we all spend time on LinkedIn because we think the surgeons are there and they are, but they're talking to each other and that's great for us to sort of listen in and kind of participate in those conversations. But the distributors are there for sure, and they're there because they know small companies are are there because it's a sort of democratizer of kind of information. And smaller companies can be a little bit more, they can show more personality, they can be more fun, they can just, you know, be more active than anything at Stryker or Zimmer or J&J, which is going to go through 20 levels of lawyers before a post makes it out there. So there's been a really good and positively surprising number of kind of of just outreaches to us, whether it's my inbox or my LinkedIn direct messages or the company's kind of like, you know, info@episurf.com types of outreach. And then, you know, once you have a handful of distributors on board, you treat them well, you train them, you go into the territory, you work with them, and then, you know, they can help refer you to the next group. And you have to sort of adopt additional tactics over time to keep the, to keep the upside-down pyramid kind of growing. But we're not all the way, you know, we're not at the top yet. So I think there's a really good chance that we add headcount during this year. In what exact capacity, I think it's totally kind of undefined yet. But for the first year, you know, we're trying to do as much as we can with me. And again, the fact that we don't have inventory in the field makes it a lot easier. We don't have to—

Yeah.

Move sets around. We don't have to sort of play the logistical game of, of, of getting the sets around and, you know, worrying about that sort of asset and figuring out how many sets and where we're going to park things or, or anything like that. We can just concentrate on sort of spreading the message, talking to the customers, and, and, and ginning up interest.

And, and these distributors are drawn to you because you serve a niche in these— that donut hole patient, or you're approachable as a small company, or you have no inventory?

I mean, what Yeah, I mean, I don't think anyone contacts us because of the gap patient message. When they learn it and then they start using it in the field, they're like, wow, that's a much more sort of powerful message and interesting thing to talk about with customers that I didn't really think of. A lot of these distributors sometimes are so focused on like, which guys in my territory are doing which procedure and which, like, can I just get an implant that like sort of can feature and benefit, you know, my way, my way in. Distributors contact us initially because one, they see the product as like something different. Like, oh, this is unique. I can get some, I can get an audience with this. I can get some attention with this. I can get some because of the damage marking reports. I can get some conversation going around this. Ultimately, I'm sure they're thinking this can help me with access with some of my, you know, higher volume products that are, that are in the bag. But they approach us initially because they think, wow, this looks interesting. This looks this looks different. They like the inventoryless model. You know, we don't require a ton of their time. You know, an EpiServ case is one trip to the hospital, not 3 trips, not a trip before, the day before, the trip the day of, and the trip today, the day after. It's, you know, we're—

so they like that efficiency.

Yeah, exactly. Like Corey's just said there, they don't have— there's no such thing. Like, no sterile processing department knows that EpiServ even exists. They have no idea unless there's a company, because We don't go there. We're not in the sterile processing department business. We don't drop things off. We don't pick things up. So that's a feature that they like after they learn about.

They're like, oh, wow.

I think that sort of reels them in further once they learn about that. The initial inquiries usually come from, this looks interesting. This looks different. Or like in the patellofemoral example, this doctor does 150 total knees with me a year, but I lose 8 cases a year to Zimmer, or that type of thing. And they're trying to get the other guy, get the— get, get some other people out of the room. And then once we get into talking with them about the overall product portfolio and where we're going, the conversations obviously get easier and easier. And they say like, well, this is great. I'd like to be, you know, you know, I'd like to carry this and I want to, I want to stay close with you guys as, as time goes on.

Great stuff.

Thanks.

Thanks, Patrick. I, we've gone over the hour, so I would call it a wrap. And yeah, thanks for your time. We're going to have to explore the how do you build a sales force for a startup one of these days, because that's everybody's number one pain. It is so hard to build an effective sales force with 1099s or partnerships.

I always say you can go fast and bad or slow and good, and then picking your sort of spot in the middle is like the— is, you know, as much of the art as anything.

I love that. All right, well, thanks. It's a wrap, Bone Chatters. We'll see you next week. Ted's going to talk next week, I think, about crowdfunding. Yeah.

So thank you, Patrick.

Thanks, everyone.

You bet. Yeah.