Beyond Robotics, What's Shaping the Future in Orthopedics? | LSI USA '25

Kim High  0:00  
Kim, good morning, everybody. And first of all, thank you to the LSI team for inviting us to talk about a topic that I think this group are all fairly excited to discuss. So we'll kick off with a short round of introductions. I'm Kim High. I'm British, as you can probably tell, I am a venture partner for NLC health ventures. So we build new companies around promising technologies, and I lead our ortho spine portfolio. I'll hand over to Adam.

Adam Wollowick  0:34  
Thanks, Kim. Good morning. Everyone. Pleasure to be here. Adam Wollowick, I lead mergers and acquisitions business development for Stryker's trauma and extremities business. I've been with Stryker for 10 and a half years. Spent a lot of that time in our spine and enabling technologies business before pivoting over to to the trauma extremity space. Thanks, buddy. It's

Christopher Campbell  0:57  
Christopher Campbell lead our platform strategy and digital surgery for J and J on the ortho side, I'm an engineer by training. I've had my own business. I've worked for mid cap companies and then with J and J so it's great to be here. Thanks for all the innovators and entrepreneurs here, excited for all the innovation you guys are driving.

Tomir Kosowski  1:14  
Hi. My name is Tomir Kosowski. I'm a co founder and CEO of Altach biomedical based in Dublin, Ireland, and we're developing a truly biomimetic scaffold for the repair of osteochondral defects. The company was founded two years ago, and I'm very grateful to be here today.

Brian Hess  1:31  
Thanks. My name is Brian, Hess. I'm the CEO and founder of Rev bio I've been in the orthopedic industry for over 20 years. I've worked at Stryker, and then I founded my own company. We're developing a novel bone adhesive. It's regenerative for many different indications. We're in the clinic, and I'm really appreciative to be on this panel representing the startups in this orthopedic space.

Kim High  1:53  
All right, so let's kick it off. The title, as you have noticed, was probably a little bit tongue in cheek, because, quite frankly, you can't really talk about innovation in orthopedics and just completely ignore robotics, given the constant discussion about clinical versus commercial focus and the growth of enabling tech. That said, the landscape keeps on shifting. Kris. And as an expert in this particular space, I see we have Stuart in the audience here, and we're seeing a bit of a shift there, with platforms moving from closed to open. So I'm going to throw you a slight tough question to kick us off and loosen things up a little bit. If we were to see an acquisition of a company like think, what do you think that impact would be on the broader landscape? 

Christopher Campbell  2:41  
I think Stuart would be very happy. But no, I think companies like think and others you know, are leading the way in changing how we think about transactions in the digital space in orthopedics, you know, robotics, you know, as the evolution of Mako and other technologies have really changed how we think about delivering precision and orthopedics. I think some of the other waves that are coming is, you know, reduction in size of how we deliver it, but also the transaction so things like open platform, changing the dialog on how we have this conversation with hospitals and surgeons. I think we're going to continue to innovate not just open versus closed, but how we think about software, how we monetize those, and how we deliver those to customers. I think it's exciting times. 

Kim High  3:24  
And so, you know, as we see the clinical data come out to support the use of robotics, which has been a big question previously, but is starting to improve now, you talk there about innovation, not just in open versus closed, but what do you see the future of robotics in orthopedics looking like

Christopher Campbell  3:41  
it's a good question. So I'll be wrong about the future, but, but my my thoughts on the future, I think we're gonna continue to see the the the effort to bring the size of robotic formats down, so the desire for surgeons to have the precision of robotics and a smaller form factor, I think it's just going to persist, and how that looks is going to look different ways. But they increasingly don't want the size of a robotic arm. They want a different form factor. Then that's one area. I think advanced tracking technologies. Optical tracking, has done a great job. It's served us well. I think some of the innovation of AI is some of the advanced vision systems that we're seeing, they will open the doors for different ways and more minimally invasive ways to approach and then I think the curation of big data sets will enable us to bring real time planning right into the operating theater so surgeons can make personalized decisions for the patient. And so I think over the next decade continue be evolution, but I'm at the gen two of a robotics platform. Okay? And

Kim High  4:42  
Okay? And so you talk about data sets there and the perioperative space, but thinking just about digital more broadly. And then I'll, I'll switch gear a little bit, and what, how do we, how do we get away from the hype and think about something that's really going to make a step change in orthopedics specifically? 

Christopher Campbell  4:58  
Yeah, that's a good question. I. I think I think about that a lot too, right? There's a lot of great technology. Many of you are innovating around those, but how do you make that impact? I think a couple things. I think one is you keeping the problem center in view, like, there's lots of problems to solve, but those one or two big problems you're trying to solve can be super focused. You have to do good science. The technology has to be sound. It has to be robust. And then I think having that beach head indication, you know, all digital technology, by and large, are platformable, but you can very easily get distracted by going everywhere, so you go nowhere. And so having that hyper focus of the first application where, where that really make a big impact. And then having an evergreen technology. The great thing about digital is you can quickly iterate on it pretty quickly. So I think that's how you avoid the hype. Keep the keep the keep the focus on the problem. Focus on the science. Keep that beach head. And then develop evergreen approaches to keep it, keep it real.

Kim High  5:57  
Interesting. And then one point that you mentioned just in the last question that I want to pick up on with you, Adam, if you don't mind, is you mentioned personalization, and I think that is a nice link with smart implants, particularly in orthopedics. Again, there's a lot of noise about smart implants, sensors within implants, but we have seen some companies come to market and build partnerships and then struggle with actually shifting market share as a result of that. So what do you think, first of all, is there merit in smart implants? Number one and number two from that, what do we need to see for them to really, again, shift gears?

Adam Wollowick  6:35  
Yeah, no, I think it's a great, great question. You know, I think we're kind of at the tip of the iceberg right in terms of smart implants, right? I think we can collect a lot of data. We don't always know what that data means. You know, I think canary is doing a really nice job in their partnership with Zimmer on starting to bring this out to the masses, if you will. But at the same time, again, I don't think we fully know what it all means, right? Again, they collecting tons and tons of, literally millions of data points on almost a daily basis on the patient. But how does that change the care paradigm? Right? How do you actually take that data and translate it into something actionable that that can change the care continuum for that patient, can lead to earlier interventions or different interventions, and we, frankly, don't know. So I think there's a lot of effort to collect the data, but it will take time to amalgamate it and figure out what it what it means. And I think until we have clinical outcomes that result from all this data, it I don't know that you're going to see massive market adoption, right? You're taking it on faith right now that it matters?

Christopher Campbell  7:46  
Yeah, I think if I could add one thing, I do, think patients are the kind of a wild card in ortho like and rightly so. We focus on surgeons and we focus on on hospital system, then we should. But patients help change the market, like we look at robotics, it's increasing. Patients demand. They want that precision, even they don't fully understand how it works. And I think that some of the wild card even with like data and sensors, I think patients are going to start to demand new things, of us as the industry, but also clinicians, of how we deliver that care, even even natural or biologics. I think patients are waking up to the fact that they want their own body to help in that healing process, in the biomechanics. So anyway, I do think, when I think about changing market dynamics and even sensor that patients are wild cards, and they they make huge impact to the market.

Tomir Kosowski  8:35  
Yeah, I think that's a good point on patients, and something that maybe is overlooked by early stage companies, the patients, or even potentially your investors. We had great success with with a crowdfunding campaign, which was based in Ireland, primarily on a on a group of non specialty investors, but if you have a message, or if you're solving a problem that sort of resonates with people, without even delving deep into the science, they're willing to put their own money into a problem they believe needs to be solved, the one they can identify with. So in our case, you know knee osteoarthritis, everyone knows what a joint replacement is. Everyone knows the consequences. And they were willing to invest money at a very early stage in the company. So I think moving forwards, you know, patients not only are a potential future angle, but they can also even be involved in your in your fundraising strategy very early on. Awesome.

Speaker 1  9:23  
Yeah, it's fascinating to think about that. Until now, we've really considered the surgeon, and not so much the patient, in the impact of that innovation. So just before we step into what the patient's really looking for. Adam, your background as a surgeon, I think is helpful here. Can you help us understand how orthopedic surgeons think and how, until now, that has shaped the industry in the way that we innovate?

Adam Wollowick  9:49  
Yeah? No, thanks. A great, great question. So yeah, I'm a former orthopedic surgeon practice for seven years after all my my training, I was focused on on spine. I think we're. Orthopedic surgeons are interesting kind of creatures, right? And, you know, I guess I can say that as since I am one. But I think, on the one hand, orthopedic surgeons like to believe that they're innovative, right? They want to portray themselves as innovative, and I think many of them are. They're certainly early adopters across all sub specialty areas. But at the same time, I think we've also seen that they're relatively slow adopters in general, right? So you look at things like navigation and spine surgery, you look at the current state of of robotics, where it's certainly increasing. You're you're seeing critical mass, and yet, the majority of cases are not being done with robotics or navigation. It's taken 15 to 20 years to get spine navigation where it is. So I think it comes down to having persuasive clinical data being cost effective. Because I think even though orthopedists like their toys and their tools, they are seeing and feeling the need to be cost conscious and to bring bring value. But at this at the same time, they want to be efficient. They want to be fast. They have high volume, and so you can't slow them down with the innovation, right? If you're going to add an hour to a case, then that's a problem. So I think it has to be slick and smooth, but also have the right, the right data.

Speaker 1  11:19  
So if we like I say, then think about the patient and what the patient's looking for. And also we kind of recognize that there's solutions that are missing. Still, orthopedics are particular creatures, so that said, particularly in large joints, they're widely known to be one of the most successful operations that are undertaken. And so Tamir, I'm going to throw this one to you. I like the phrase that the biggest room is the room for improvement. What do you see as the room for improvement in orthopedic implants? 

Tomir Kosowski  11:55  
I think you know, focusing specifically on the area we deal with so, neocthritis. I think, as you said, joint replacements, obviously are very successful surgery, but they do impact your quality of life. And I think going back to you know, what patients want, a 56 year old patient today is a very different patient towards 20 years ago, and they have very different expectations for quality of life and what they can do. And I think technologies that allow patients to have that quality of life which are minimally invasive, which utilize, you know, the body's own ability to heal. So various form of biologics and things that sort of slot into that continuum of care. So when you, you know, beginning to to have knee osteoarthritis, to have solutions that can sort of delay that onset as we progress, of course, ultimately, many will will end up with the joint replacements. But if you can push that down the line for 20 years, I think that's a successful result, and that's what patients want. So that's the areas we're working on, I think, and that's where, where the progress is going is in novel biomaterials and harnessing the body's ability to heal and everything in a minimally invasive fashion that will allow you to spend less time in surgery, which also benefits surgeons, you know, quicker procedures. And that's that's where I think things are heading currently.

Speaker 1  13:09  
Love that point about harnessing the body's power. And you know, if you think about orthopedics, traditionally, it's a hammer and chisel specialty, broadly speaking, and thinking about how we really bring orthopedics out of the dark ages and stop thinking about the musculoskeletal system as just a frame Brian. What are your thoughts to add to that?

Brian Hess  13:30  
Yeah, I mean, picking up on your point in personalized medicine, patients do on more natural implants. They want to maintain their mobility. They want products that will get them back to their jobs, back out, playing sports, whatever. And so trying to get out of the dark ages, we're thinking about biomimetic implants, right? Implants that have properties that mimic the tissues that they're being replaced, so bone or soft tissue. When you're thinking about all the great companies out there, they're really thinking more sophisticated about the design of the implants being patient specific, perhaps harnessing technologies like 3d printing using patient specific scans to develop implants that have the right form factor, whether it's minimally invasive procedures or implants that come to The operating room that essentially plug and play into the patient, and it restores their natural anatomy. I mean, this is how we're going to move out of the dark ages and actually advance PAC patient care, and then we can do these clinical studies that you talk about where we can show the effect, if we show the effect, that'll lead through the whole chain with regulatory approvals, but ultimately reimbursement and adoption. So I think of a really exciting future that's happening now with companies here and in the future, as we think about regenerative technologies to help rebuild the patient's body to be where it really is supposed to be

Speaker 1  14:59  
okay. So. Yeah, we're shifting into regenerative technologies, and we have an aging population and a declining birth rate. We have patients that are 50 and 60, that look different than they did 20 years ago, and that want different things, and we need to find solutions for them. And then if we look at biologics and regenerative technologies. They're tough markets. They are tough development cycles. And ultimately, the two of you know very well it's so well and good to want to build something exciting, but you have to build for the market. So Brian, thinking about the work that you're doing and your point there on clinical data, how do you navigate the current need for clinical data? Because strategics are looking for commercial traction, and to get to that point as an awful lot harder than it was once and then again, once you throw in biologics or regenerative medicine to the mix,

Brian Hess  15:56  
well, it's necessary. I mean, so you have to embrace it so early on, you know, we, we talked to a lot of clinicians. Obviously, we have, we have a platform technology we can apply our material throughout the body to help regenerate different types or regions of bone, but, but that means we're going to have to generate the clinical data, right? And so thinking about clinical outcomes and designing these studies, not just for regulatory approval, but obviously long term for adoption. And so I think it's really important to embrace it and then turn it into a marketing strategy, right? So, yeah, we have to. We have to set up sites all around the country, in the world, depending on the markets that you're going after. And it's really important to do that, because now you've got clinicians using your product during the studies. This will then lead to hopefully publishable data that these clinicians will go around and talk about. They'll go to different conferences. They'll share it with their peers. It'll bring awareness, awareness to such materials like this. So I think all the clinical data is going to be helping companies differentiate their products and put it on the radar, especially for potential acquirers down the road. And so I think you have to embrace it. And it's it's just a necessary part of not only regulatory but it really is your marketing strategy, and then your go to market strategy is really set up because you have installed base. You have an installed base of users that have been using your product already,

Speaker 1  17:26  
and then, Tomir, kind of following on from that, as you're building out your regulatory and your reimbursement strategy and the complexity that Brian just talked about, how do You build that into your funding strategy? Because it's it's not just timely, but it's expensive too, right?

Tomir Kosowski  17:45  
That's true. And ultimately, your regulatory strategy really defines your, your the way you you fundraise and build your build the company, because these milestones, these trials, these these endpoints, which you agree with the FDA, or anything are ultimately what will build value for the company as you move forward. But it's a it's risky in the sense it's a one way street. You usually only get one shot at these sort of things, and this is what makes it difficult for a very early stage company as ourselves, when you're raising capital, is you're looking at an extremely long runway and a risky one, which, which does pose its challenges from from a point of raising funds where you're very early and sometimes you're outside of that window that people are looking for, for returns. And so that's when, when you look alternative options, such as as crowdfunding or angel syndicates, and also the regulatory I think it's it has a big impact on your strategy. And these things can change. So coming from Europe, with the MDR changes in recent years, it used to be a given thing for our type of products that you know you do your CE mark first, build clinical data, raise some money and go to the US now, as a as a company, at any stage when you're looking at the maths now and the data required to do the the MDR, the problems with the notified bodies, where you're stuck waiting two years for an audit, a lot of companies are shifting gears and saying, Okay, if we're going to do this once and we do it properly, let's focus on the US. And we're seeing that more and more where companies are are making the choice to go us instead of EU, which I think you know, is an unintended consequence of the of the MDR. But these things do impact your strategy, and you have to make the decision set

Speaker 1  19:35  
so on that Kris and Adam, I'm going to kind of switch to you and Kris. First of all, I What do you see as the external factors that are going to shift again to influence some of that? Because Tamir just mentioned MDR and speaking as a Brit, and it's eternally frustrating that we are having to pursue FDA and. And we're going to be slowed down with market access right the way across Europe. But what are some of the external factors that you see, not just in the regulatory landscape, but also in the in the cost of some of these regenerative materials? You know, you think about stem cell production right now, it's hugely expensive, but offers massive opportunity. Can you see some things that might happen, some things that are nearer, some things that are further, that will help with bringing some of these technologies to market. And then, then the second bit to that is bringing them to market across the globe, and not just in the US.

Christopher Campbell  20:35  
Yeah, good question. I mean, I think that the opportunity of biologic implants, bringing a patient's body along the healing journey with the implant. Super important and super exciting. I do think the pricing of the challenge right there is, whether you're in the US or us there, there isn't a huge amount of increased money coming from governments or insurance. And so I think the challenge has to navigate. I think some things that are that could change. I think, you know, robotics or digital surgery is helping, right? It makes surgery less invasive. It adds precision to the procedure, that opens the door to some of the precision requirements or techniques that are used for the biological implant. So I think that's a big factor. I do think that either going to be through the data that's collected in the evidence change in reimbursement. So you're gonna have to more reimbursement from the government. Could they see the patient impact? You don't have to do surgery, say, for another 20 years. That's a benefit. Or, I think also at the same time, supply costs have to come down. And that's a combination, not just in pure manufacturing, but release testing, all the regulatory requirements we want product safe and effective. We also probably need to be a bit more efficient on more efficient on the regulatory side of what it takes to get those, get those products, and

Brian Hess  21:47  
I would just say real quickly. I mean, if you want to generate the evidence thinking about those outcomes, just to, you know, reduce hospital stays, you know, try to, you know, avoid complications. These are all benefits that'll help your cost structure and show value in your product, right? So, yeah, these materials may cost more, but on the other hand, maybe you have an opportunity to really show a difference in the patient care, and then that'll sort of work its way through in the market dynamics. 

Adam Wollowick  22:15  
I think it's important, because you have to actually be collecting that economic data, right, really, right from the get go, and it's about showing value, not just improved outcomes to justify that cost. Because, as you said throughout the entire episode of care, you'll you'll see perhaps the returns on that early investment, right? And so, but it's critical that founders and young companies are thinking about that like right from the get go, not just getting more clinical data and enrolling more patients in the trial?

Christopher Campbell  22:41  
Yes, absolutely, that's your point of O us. I do think for the differentiated technologies are leading the way government supports super important, right? If you look at the growth of robotics, say, in China as an example, a lot of that's because the government's really leaning in to help grow that in the Chinese market. And so I think as we go, oh, us and to different markets around the world. You know, having that partnership with regulatory bodies and the insurance agency super important to see these new technologies, you know, take root in the market. 

Speaker 1  23:09  
That's a really good point. Adam and Adam, Adam and Kris. I'll ask the two of you to kind of close up with that on on your mind for the innovators in the room thinking as a strategic acquirer. What some of the advice that you would give people navigating some of these, these longer term trends, but the ones that are really promising for the future? What's the advice you would give to them? Adam, first off.

Adam Wollowick  23:33  
I mean, great, great question. Look, I think orthopedics is ripe for innovation. There's been tremendous strides made over the last pick, your number, 5, 10, 15, 20, years, but there's so much more that that we can do, and I think young companies, founders and entrepreneurs need to be pushing those boundaries, right? I think that a lot of the focus, even with the strides that we've made, is on doing the same procedures better. We need better procedures, right? We need to do things differently than how we've been doing them, in some sense, right? Where we're still fusing spines, which is a very interesting sort of paradigm, right, to if you really take a step back and think about it. On the other hand, we know that collecting the amount of data, doing clinical trials is expensive, and these types of innovative products, enabling technologies, advanced biomaterials, are expensive and don't always have great margins. So from the acquirer's perspective, we look to see that not only is the technology sound and and frequently already gone through the approval process. But then is also further de risk, so for early commercial traction, and so that creates sort of an Innovator's Dilemma, right? How do I get in and talk to a striker or a J and J, when stryker? That's good.

You know, when it. Such a long and expensive road, and to me, I think the best advice is, stick with it, right? It takes fortitude. It takes persistence. And I think if you're solving true clinical problems and meeting unmet clinical needs and delivering value, as we've been talking about, the investors will be interested. They are going to fund good technologies that meet those sort of criterias and then the strategics also at the at the back end of it, are going to be interested in acquiring those so we could bring great technologies to more patients throughout the globe. So I again, I think Stick, stick with it. 

Christopher Campbell  25:37  
Yeah. I think my perspective first is just, you're all working extremely hard. The Innovators in this room, from my perspective, is strategic. You got their heroes driving innovation, leading the way. It's hard, and having have my own company, it's difficult. It's difficult to get through those days, funding the challenge, capture the challenge. So I echo Adam's comment of not only stick with it, but you're driving the future of med. Tech is in all the startups that are here as strategic. I think one of the role we play is to scale and integrate and bring it to broader mass, but a lot of the core innovations you're driving, you know, when I think about, you know, advice, I would say having that, that clear story of focusing, what are that one or two problems, and how best can you solve it? You know, it's really difficult challenges, but the story is the same and consistent. Storytelling is really important as a strategic wants to hear what's that clear story that we can understand and we can see the vision, how to bring it forward. When I think about the future, I do think understanding, how can you generate data and intelligence and orthopedics, this would be a big theme moving forward. And then how can you integrate into the digital ecosystem of technology? And then, like we're talking before, about open system and think and other technologies that are changing transaction discussions, you can be a part of that as well. We're reshaping how we go to market in the orthopedic space. And a lot of that comes from the technologies introducing new ideas and new ways to transact. Go,

Brian Hess  27:05  
jump in. I was just going to say it's also exciting, because last week, at double A O S evamed sponsored a meeting, and it was the orthopedics working group, and it was a CEO Round Table led by, you know, executives from Stryker and Smith and Nephew and and Zimmer, J and J and and then also startups that were in the space, and they said, What's one common theme we can all work on? And the idea was, let's, let's bring awareness to musculoskeletal disease, right? Like we think about orthopedic orthopedics, it's fractionated, right? You got arms, you got arms, you got legs, you got the head right, all over the place, the spine. But like other diseases, they've put campaigns around it, right? Like, let's bring awareness to musculoskeletal health in and maybe that will drive awareness to investors. So I think that was like, a great message coming out of that meeting, and is very encouraging, especially as a startup, as we're trying to think about, like the challenges of fundraising.

Kim High  28:07  
So I guess we'll finish up on that point, which is ultimately a call to action. There's a bunch of innovators in the room, hopefully some investors and strategics too. And ultimately, we have a big opportunity in orthopedics to shift the way that we do things and think about delivery of care in a completely different way than we have for a long time. And so the call to action is for for those three groups to really come together much more and much earlier, so that we can drive some real change. Thank you all very much. Thank you.