the role of bone stimulation with Dr. Robert Anderson. Dr. Anderson is the founding orthopedic surgeon of the O.L. Miller Foot and Ankle Institute of OrthoCarolina in Charlotte, North Carolina. He practiced there for 29 years and then moved to Green Bay. He served as a team orthopedist to the Carolina Panthers from 2000 to 2017 and is now an associate team physician to the Green Bay Packers. Dr. Anderson serves as the co-chair of the NFL's Musculoskeletal Committee overseeing all orthopedic injuries and research in professional football. He is past president of the AOFAS. Before I turn the program over to Dr. Anderson, I'd like to just touch on a few housekeeping items. This evening's session is meant to be interactive. We will use the polling feature throughout, so please watch out for questions that will come up on your screen. We'll also take advantage of the chat feature, which can be found on the Zoom toolbar. Please feel free to submit questions throughout the talk. We will leave time for Q&A and Dr. Anderson will address those questions at the end of the presentation. Dr. Anderson, thank you for your insights tonight and I'll turn it over to you. Thank you, Christine, and good evening, everyone from Green Bay. I hope you're taking a break from the football game that's on and learn a little bit about the role of bone stimulation as it pertains to the foot and ankle fracture treatment and other issues we see in our more active population. So pertinent to this presentation, I'm a consultant for BioVentus, who makes the Exogen product that we have been quite familiar with. In fact, I've been utilizing this adjuvant therapy for over 20 years. These are the US indications for use of Exogen. As you know, it's basically a non-invasive treatment for established non-invasive patients, but also can be used in situations of acute fractures where external fixation may be present, but as the FDA will say, the Exogen will not penetrate metal and therefore should not be applied directly over the hardware. It can be used in the setting of infection, but it's not meant to treat the infection. And it can be used, again, in people with diminished bone quality, but is not meant to improve bone quality itself. So again, Exogen is very unique. It's been found to accelerate time to healing in fresh fractures, such as tibia distal radius. We'll get into that in a few minutes. And I think most importantly about Exogen, just to introduce this product to this talk, is that there are no contradications. Basically, there are no side effects, no downside to utilizing an Exogen when it's indicated for one of your patients and their particular bone issue at hand. So why do I use bone stimulation? Again, I've been doing this for over 20 years, utilizing bone stimulation to help particularly my more active individuals, particularly the athletes. And I think it is helpful in multiple scenarios. It's oftentimes difficult to heal fresh fractures, particularly in our aging population or smokers. It may be helpful in people with non-unions, whether it's fractures, non-unions after arthrodesis or fusions, and those with recalcitrant stress fractures. So again, you see that illustration on the right. That's a recalcitrant cuboid stress reaction in a very high-level athletic runner. And again, this is an indication that I found Exogen to be extremely helpful for. So again, multiple scenarios where you could consider the use of Exogen as an adjuvant to your treatment regimen. Again, fracture non-union, something we unfortunately see quite often. Accelerated healing for indicated fresh fractures. And when we talk about just using for fresh fractures, it can be very helpful in multiple scenarios. I find in my sports world, which is a business situation, unfortunately, that this use of bone stimulation can help tremendously. Getting people better quicker, getting these fresh fractures healed quicker, and getting them back to sport can be extremely helpful from a business standpoint. And then there's also economic situations. You talk about the workers' compensation patient. They're trying to get back to work. You're trying to get them back to work as quick as possible. By applying bone stimulation, you have the opportunity here to basically accelerate the healing for these fresh fractures, get them back to work quicker, and again, help that socioeconomic situation that's oftentimes at hand with these difficult, complicated patient scenarios. So I guess the first question then, Christine, is for the audience is, do you use bone stimulation in your practice? Very simple, yes or no. And those are your results, Dr. Anderson. All right, so people on this call are obviously well-seasoned when it comes to bone stimulation. All right, that's very helpful. At least you know where we're starting from then. Okay, so let's move on then. Trying to move my slide forward, Christy. I don't know if there's a little glitch. We may have a little lock here. Okay. Oh, there we go. All right, so stress fracture. Oftentimes, I see stress fracture that have been delayed in diagnosis for months. They basically become a non-union by that time. So a non-union of a stress fracture is probably my number one indication of using exogen, bone stimulation. So these non-unions, basically, these start out as a stress reaction. People have pain. They may have negative radiographs, but you may see inflammation, like you do here on the right side, on bone scans, spec CTs, or MRIs, indicating you have a stress reaction. We get a CT scan. If the CT scan shows nothing, we say, okay, you got a stress reaction. If the CT scan shows the propagation or the initiation of a fracture, now, of course, you're in a stress fracture. And so oftentimes, these people come in with a delayed diagnosis, four months, five months out. And by that time, you essentially do have a stress fracture non-union. These could be incomplete. They could be complete based on the CT scan. And you say, okay, now what do we do? We've got this situation here where this person's already had this stress fracture for months. They have an established non-union because they're delayed in recognition and diagnosis and referral to you. And what adjuvants do we have to assist with predictable healing in this scenario? And again, if you've seen a lot of these stress fractures in athletic individuals, you sort of get this wrenching-type feel that you go, well, golly, this is gonna be a difficult one to heal. What do I do? And again, these are the adjuvants that I see for non-unions of stress fractures. Immobilization, dietary, metabolic issues that you wanna address, whether it's through vitamin D supplementation. As you know, so many of our individuals now, whether even healthy individuals, have vitamin D deficiency. So you have to always think about that. Calcium depletion, adequate intake of the appropriate nutritions, and do they need additional calcium supplementation? Sometimes we prescribe Forteo, which as you know is a synthetic parathyroid hormone that can assist with osteoblastic response in the body system to help with fracture healing and with osteopenic, osteoporotic situations. You have your biologics. You have your PRP, your BMAC. And then you have bone stimulation. And then you have surgery. So all these are basically adjuvants to your stress fractures at whatever time in that spectrum that you may see them, whether they're fresh or whether they're established non-unions. And if you look at the history of bone stimulation, there are multiple types available on the market. There's implantable ones. I've had extensive experience with implantable bone stimulators. These use direct current electrical stimulation. And then there's multiple types of external bone stimulation. There's the capacitative coupling, inductive coupling. And then there's the two that all of us know most about, or at least we're most familiar with these two types. One's basically your electromagnetic field, your pulsed electromagnetic field. And the other is lipase, your low-intensity pulsed ultrasound modality, which is basically the oxygen. So again, these are the types of bone stimulation currently available in the marketplace. And of which these are probably the most highly known. Implantable, your electromagnetic field, your ultrasonic derivatives. And so our next question for you all that are joining us on this webinar is, what are the following types of bone stimulation have you used, do you use? All of the above, none of the above, and such. So we look forward to hearing your response to this question. And those are your results, Dr. Anderson. Okay, so we have a lot of lipase users here. Some don't use any of these, and I'd be very interested to know if you guys wanna get on the chat line, which other types of bone stimulation you may use. But lipase is certainly nice to see that so many of you are familiar with exogen and the low-intensity pulsed ultrasound modality that we're talking about this evening. And again, I think I need to gain control back, Christine. Yep, there's just a slight delay to give it a second and you should be good. Okay. So again, I've had patients that basically have used almost all of these. They've tried the electromagnetic field, the lipase, and then eventually had to have an implantable device placed for recalcitrant problems. So again, these are all very viable options currently in the United States. Okay, just waiting for our delay. You can go ahead and try again or click into your slide. Yeah, I'm trying there and there we go. All righty. So let's talk about exogen, lipase technology. This is low intensity pulse ultrasound, that's why we call it lipase. Actually, it's a form of sound. So if you look back in the history of where this came from, it's actually a form of sound. The first article about the use of lipase technology was in 1983. The FDA approved this technology for the use in fresh fractures in 1994. Some of the original studies done on low intensity pulse ultrasound was it increased chondrocyte population, which actually then increased that population of cells in soft callus and endochondral ossification. So again, the whole idea that you could utilize this technology to improve ossification of otherwise difficult to heal fractures. So in a nutshell, the mechanism of action is that the lipase sends ultrasound waves through the skin and soft tissues, goes to a certain depth, which then activates mechanical cell receptors on the surface called integrins. Then these integrins cluster, and then they create this intracellular cascade that stimulates a number of different molecules, regulates gene expressions, goes to the nucleus and so on and so forth, and eventually increases protein and growth factor expression at the area that you want that to happen, which basically is a fracture. The key though is all about the COX-2. So the COX-2 is, the expression of COX-2 is up relegated by the lipase treatment. And COX-2 is the key enzyme involved in the synthesis of postaglandin, which PGE2 is important for angiogenesis, as I'll mention in a second. So here's another way to look at it. This is the ultrasound mechanism of action. You have your stimulation, your activation, your upregulation of COX-2. And then COX-2 is vital to the production of PGE2, which is critical for bone repair because it brings in all those things you see on that bottom of the chart. The cell differentiation, basically converting stem cells to osteoblast. The VEGF, which stimulates the growth of new blood vessels, the angiogenesis, which is so important, particularly in the elderly and smokers. All the BMPs that are essentially creation of new bone are stimulated by this COX-2. And then as is mineralization, basically increasing your bone mineral density. So again, this is the mechanism of action that's been proven and thus the basis, the backbone of utilizing exogen for your fracture situations. So again, I think it's all about angiogenesis. When you look at lipase and all the things it does, the basis that I looked at is it increases angiogenesis. And this has been proven in diabetic rat models of fracture healing, where you see this neovascularization occur within a certain number of days post fracture. So again, this is a study that was well-received in 2011 and continues to be a resource helping to support the use of lipase when it comes to fracture healing, particularly fresh fractures. Then the question about external bone stimulation, whether it's lipase or other ones, number one, does it work and is it worth the cost? And if you look at the literature, there's much more support of literature for the use of lipase than PEMF when it comes to effectiveness. And cost efficiencies and such that external bone stimulation does work and literature has proven that particularly lipase is well-supported in that regard. So here's our levels of evidence that we look at. You got your level ones, twos, threes, fours, fives, five in expert opinion on one level, and then your high quality randomized control studies or metal analysis in the level one category. So you got a lot of different case cohorts and such in between there. But again, we look at levels of evidence and say, okay, this is what we can rely upon. And lipase, interesting, if you look at literature, it's been highly studied, but highly published. This is just article Sheldon Lin and his colleagues actually talked about the mode of mechanism of low intensity post ultrasound in fracture repair and very, very nice review. Highly recommend that you review this if you're interested more in the way that lipase works, how it works, and what some of the current studies will show in that regard. If you look at just acute fracture evidence in the literature, most of it is on lipase. These are all various articles. I'm gonna touch on some of them more specifically here in the next couple of slides, but Dr. Heckman's original study of 1994 and then Christensen's article of 1997, look at the distal radius. Those were the two main articles that basically alerted the orthopedic field to the advantages of adjuvant therapy in the, with the exogen unit itself. And then many other tibial studies since then. This is Dr. Heckman's original study in 1994. This is a level one study, very highly received. It basically was talked about the acceleration of tibial fracture healing by non-invasive low intensity pulse ultrasound, the exogen unit. And basically they did this for closed or grade one open tibial diaphyseal fractures and a very, very well done study. And basically found that in this study that they had a significant improvement in the exogen treated group. Better healing, quicker healing in that group as compared to the control group which did not receive the exogen unit itself. So this was the first and only technology that ever demonstrated that acute fracture repair could be accelerated clinically by the use of an adjuvant therapy like lipase. So again, this was highly received and basically was impetus behind utilizing exogen for a number of different reasons. And it also was the reason that exogen then was found to be beneficial to increase healing effect in those risk factors of elderly smoking and possibly increased fracture gap. So again, that was the first basically fresh fracture study available where exogen was found to be of significant importance and an advantage. Now, what about non-union? And there are a lot of non-union studies. So we're talking about different types of studies that help support the use of exogen in your patient population. So this is a summary of the non-union studies. This was a table taken directly from a review published by Dr. Romano in 2009. But again, showing the various number of cases, delayed union, non-union. But again, also highlighting that exogen was an advantage when treating patients with established non-unions. These were non-unions of fractures. This was another one by Dr. Azura and his colleagues, a treatment of chronic fracture non-union. Again, these are traumatic injuries, not arthrodesis. These are fractured non-unions. And they basically had a cohort of 767 patients treated with lipase. And again, they found tremendous advantages with the exogen unit as compared to the control group with these fracture non-unions, even those that have been delayed for a long period of time. This is Leighton's article. Again, bottom line, fractures treated with lipase, three to six months post-surgery have a greater chance of success compared to those treated greater than 12 months after surgery. I'll come back to this again, but the quicker you can get your exogen applied, whether it's a fresh fracture, a non-union of a fracture or arthrodesis, the better the results are. So again, if you can get lipase approved and applied for these indications within those first three to six months better outcomes than those that wait greater than one year. So again, try to get the exogen unit applied earlier rather than later for your non-union situations. This is another study, 2017, more recent. Lipase ultrasound for non-operative scaphoid non-unions, a meta-analysis. Again, going down, you'll see the average time of union was 4.2 months, overall heal rate was almost 80%. So again, this was where you utilized the exogen for non-operative treatment and they compared it to those with surgery and actually had a very comparable heal rate with this non-operative therapy. So again, something else to consider, particularly if you have a patient that's not an operative candidate. So going to our next question though, which of the following do you consider to be the most significant risk factor for bone healing? So again, we talked about how exogen can be used for fresh fractures, for non-unions, but what about those that have risk factors where you say, okay, I've got somebody who's got a smoking history or they're elderly or they got diabetes or they've got a fracture with a gap or they have a bad fracture location like a daffodil, a tibial fracture. Which of the following in that group do you consider the most significant risk factor for bone healing? So Christine, I'll hand it off to you to get the results. And there you go. Very good. Smoking and fracture type. I certainly don't disagree. All right. Well, let me tell you that they're all an issue. So smoking. Smoking is a known risk factor in fracture healing. As you all know, cigarette smoking, nicotine use diminishes the vascularity at the bone healing sites. So, yeah, obviously these are patients that are gonna be at higher risk for developing a non-union, whether it's a fracture or arthrodesis. Fortunately, lipase accelerates healing of fresh fractures in patients who smoke. And again, there's been a number of studies that have supported that. The one reference here is the Bishop article of 2012. Again, showing that that indeed is a side advantage, so to say, of lipase is that that could actually accelerate healing in those particular patients. But the same is true for elderly. I've found for years that age is associated with slower healing. And again, that's been well-proven in literature. But lipase has been shown both in vivo and clinically to reduce that effect. When you have an elderly person, they tend to have lower COX-2 production. But we know that lipase has been shown to up-regulate COX-2 production. So basically, lipase treatment can lessen the effect of age on healing. And it's possibly done through counteracting the reduced COX-2 expression. So again, high risk factor, elderly, smoking, but fracture type, fracture location, they all factor in. So basically, that last slide, all of the above are true. So we talked about the healing studies out there concerning fresh fractures, Dr. Hexman's study, the distal radius study. But there are other bone healing studies out there, not just pertaining to fracture, whether fresh or non-union. There are several out there concerning osteotomies, the healing of osteotomies, lower extremities, stress fractures at various locations, patients who undergo bone transport or distraction osteogenesis. And all of these situations, there's been literature out there that have shown that the use of lipase actually can improve or enhance your healing response and healing acceleration. So let's get into joint fusion now. What's the clinical evidence behind joint fusion and the use of exogen? And this was Dr. Coughlin's study, published back in 2008. And what they were looking at is subcutaneous orthodesis procedures in patients either receiving exogen or not. And what they found is the acceleration of healing in those who received exogen was substantially improved based on CT scan analysis at even 12 weeks post-operative. So again, there was a faster healing rate on both plain radiographs and CT scan in those patients who received exogen post-op as compared to those who did not. And this was one of the first studies that showed that not only was exogen a significant adjuvant to enhancing your orthodesis fusion rate, but it was also one of the first that showed us the value of CT scan in analyzing appropriately our fusions and the degree of fusion that's occurred at any given time. So basically, I've had great anecdotal results with this adjuvant. As you know, I have a large sports practice. A lot of my patients are career or elite athletes with easy access to this technology. So again, I'm very fortunate. But you don't use this in isolation. This is another, this is an adjuvant to appropriate care of your patients with fractures, whether they're stress fractures or fresh traumatic fractures, or those with non-unions or delayed unions, or those undergoing orthodesis or other types of bone procedures where you're trying to accelerate the healing. It does not take the place of surgical stabilization. So there are indications when you're dealing with an unstable fracture or fracture of diastasis, you still have to fix that fracture. There are patients with vitamin D deficiencies. In fact, we know that vitamin D deficiency is an epidemic across our country, particularly in the Northern states, and where I now reside, is that we have a tremendous number of patients who come in with vitamin D deficiency. So you still have to consider that. You still have to treat the vitamin D issue. You gotta consider the calcium replacement in addition to surgical stabilization, and then look at exogen as being another layer of opportunity to enhance your healing process. Again, this was just a, this is just a way to look at it as just another adjuvant that you can utilize. So let me just take this opportunity now to go through some cases, just very briefly, couple cases that will be a little interactive for you as well. So this is case study number one. This is a 37-year-old professional basketball player. He's had a six-month history of vague ankle pain, denied any injury, no prodromal symptoms, but he was consistently tender over the dorsal midfoot with anterior impingement signs. So he's got that anterior ankle pain, a little bit of anterior ankle pathology, and tender over the dorsal midfoot. X-rays and CT scan were done. You'll see just one representative sagittal cut there of a CT scan on your right. And you'll see that he's got some osteophytes over the tibial-tabular joint anteriorly, both on the distal tibia and tabular neck region. So he's got the diagnosis of anterior ankle impingement, and he's got a little ankle DJD. He gets an injection done to his ankle and feels a little bit better. So everybody's thinking, okay, this is just simple anterior impingement syndrome. He'll be fine. Let him continue to play. Well, unfortunately, he still had a lot of pain, limitation of activity due to the anterior ankle pain over the dorsal foot, dorsal area of the midfoot. So an MRI was done three months later. So this is a guy that's already had ankle pain for six months. Now, three months later, gets an MRI done. And you'll see on the MRI, on the left side, you'll see in that coronal image that there seems to be a disruption of the cortical surface on the dorsum and the navicular. And on your sagittal image on the right side, you see that the navicular is highly edematous. Certainly on that T2-weighted image, you'll see the difference in the navicular as compared to the corresponding talus or cuneiform. So obviously a situation we don't like to see, but this is obviously an evolving navicular stress fracture. Whenever we see these MRIs that are abnormal, we proceed directly to a CT scan. CT scan, which was previously normal several months before on the repeat imaging studies, now noted a type one disruption of the dorsal cortex of the navicular. So this is indeed now a stress fracture in the navicular, type one involving the dorsal cortex, but now this has probably been going on for months, six months, if not longer. In his workup, he had a bone scan, which then highlighted the active lesion, again, in the navicular itself, asymmetric, no similar activity in the contralateral. He also had a SPECT CT done, which is obviously some of the most highly sensitive imaging studies we have for problems like this. And you can see that it does show significant uptick over the dorsal third of the navicular on both the sagittal and axial views. So we now are faced with a situation where you've got a type one navicular fracture on a professional basketball player, and this has been going on for months. It's basically already a type one nonunion of a navicular stress fracture. So the question is, what would you do next? I know what I did, but we'd be interested to know what you would do next. So if you want to type your answer in the chat box, we'd love to hear from you. I think we have some shy audience members tonight, Dr. Anderson. That's okay. Well, very good. So I'll just go ahead and show you what I did. Actually, I just got one response, non-weight bearing and a bone stem. Well, very smart person. So that's exactly what was done here was that we did go non-weight bearing. We did initiate the exogen, and we repeated the MRI three months after initiating it, and he had minimal edema. So the edema tremendously improved, again, probably the combination of both a non-weight bearing, decreased impact loading on that part of the foot, but also, I believe, with the assistance of exogen as well. We actually performed a CT scan four months after initiating exogen treatment, and you'll see that his type one fracture is now completely healed. So again, an example of where we were able to successfully utilize the combination of immobilization non-weight bearing exogen to avoid a difficult surgical procedure on this aging elite athlete and avoiding a major surgical procedure. So again, highlighting the effectiveness of exogen in this particular situation. Now here's case two study. This is a 19-year-old cross-country runner, several months of ankle pain, worse with running activity. In this situation, they went ahead and they got a CT scan pretty early on, which noted a type two fracture of the navicular. And again, this has been going on for months. This has been going on for about five months. So by the time that he has the CT scan, he's already got an established non-union. He's had it for over three months. There's been no progression of healing. And by definition, now you have a delayed, if not non-union, of that navicular stress fracture. So the question here is, what do you do next? Again, 19-year-old high-class runner, five, six months out now with an established type two fracture. Again, type two means it's propagated further into the navicular, but not all the way through. A little more of a diastasis than you'd see with a type one. And again, obviously more concerning, because we've written papers showing that these tend to propagate and actually go to a type three and then have a poor prognosis. So the question here is, what would you do next? I'm not sure we have any takers or not, but we'll see. We just, a screw, non-weight-bearing, and a bone stem. All right. And I have now another four fixation. Four fixation? Yeah. Very good. Well, I'm glad I'm not going to embarrass myself then. So this is exactly what I would do with this person, 19-year-old cross-country runner. I do worry a lot, whereas the first case was a type one, this is a type two. I'm much more concerned when you start seeing type two, because we have seen these propagate to type threes, and again, the poor prognosis. So in somebody like this, I'm going to be a little bit more aggressive with my surgical recommendations. And so I would recommend screw fixation, a period of immobilization, non-weight-bearing initially, and then perhaps mood immobilization after that, and definitely exigent. So I'm always very nervous about stress fractures, particularly navicular stress fractures, medial malleolar stress fractures. They have a high risk of nonunion, regardless of how good the surgery is, how good the patient is. So I always want to provide everything I can to get them to heal. So I'm going to look at the vitamin D, the calcium, but I'm always going to use exigent. And so for these stress fractures that have a risk of nonunion, even with perfect surgery, like screw fixation or bone grafting, I'm going to want to add exigent. So this is exactly what we did for this particular person, screw fixation, and then we initiated exigent post-op. 11 weeks post-exigent, there's his x-rays. He had two screws placed from a lateral remedial, which is my typical technique in doing this, utilizing partially threaded canelated titanium screws that do not penetrate the medial side. And you'll see everything looks very good there. This is 16 weeks post-treatment and exigent, and you can see there that the CT scan that we typically do routinely, somewhere between 12 and 16 weeks, now shows complete union of that particular fracture. So again, just a nice case study showing the use of exigent as an adjuvant to your surgical intervention, which I believe is also very important with these particular situations. And here's the last case study I'd like to present. This is something much more typical in the general population, not necessarily an elite career athlete, but this is a 49-year-old woman who is healthy, she's a non-smoker, and she's a very, very dedicated ballroom dancer. This is what she does. She does it multiple times each week, she's in competitions, and unfortunately, one evening, she fell off her high heels. She had a twisted injury when she tripped on her partner's foot and basically twisted off her high heel and had immediate lateral foot pain with swelling and tenderness. You'll see that there on the X-ray there on the right side, showing that spiral distal from metaphyseal to aphyseal fracture of the fifth metatarsal, a significant amount of displacement. And as you all know, these are notorious for taking a long time to heal. And the question is always, do you operate or not operate? I usually give the patient the benefit of the doubt and say, this should heal with time and you should do okay, but we'll watch it closely. So this particular individual was treated non-weight-bearing for three weeks and then was in a boot for eight weeks. At 16 weeks, she was still painful, she was frustrated, she was unable to get back to any activity, let alone her ballroom dancing. And she showed at this point, this is now 16 weeks post-fracture, no progression of bone healing. So she is an established delayed non-union patient. So here you go. What would you do next? With this particular fracture in this individual, would you go in and fix that? Would you bone graft it? Would you try your non-operative adjuvant therapies? We'd be interested to know what you might consider doing for this particular delayed non-union of a diapso fracture to the fifth metatarsal. They're thinking hard. I don't need to think too hard. I have no helpers. All right. That's okay. I just did get one. We got plate screws, bone graft, non-weight-bearing, and lipis, all together. All right. Well, that's blue plate special. I don't disagree. This is a situation that we actually talked to this woman about what the options were. One of them was to go in there and bone graft it, plate it, screw fixation. She wasn't really interested in a big surgical procedure with those risks of surgical intervention. So I said, well, the other thing we can do is you've shown no progression of healing of this fracture over the last 16, 20 weeks. You could qualify for an exogen unit. Let's apply for it. It was approved by the insurance. That's exactly what we did here. We initiated exogen. Amazingly, this is her x-ray seven and a half weeks later, showing a huge amount of consolidation of the fracture. Yes, she has a malunion, but I tend to find those are usually well-accommodated for in the population. She had no pain with full weight-bearing, even at eight weeks post-exogen initiation, and she was able to eventually get back to ballroom dancing. Again, a very nice illustration of the bone production that occurred in this particular patient just by applying exogen and really doing nothing else but keeping her in her boot, which she was already doing before this. Again, interesting case study. Hopefully, this has been of interest. We've shown you different ways to use exogen, whether it's fresh fracture, non-union, non-unions of arthrodesis and such. People still say, well, golly, it's so expensive. That technology is so expensive. Yes, it is, but it's a tremendous advantage. When you look at the comparison for an exogen unit to that of non-union surgery, it's very, very interesting. Just as a last question for you all, what do you think the average cost of managing a non-union surgically is? What is that hospital cost? Is it $5,000, $10,000, $25,000, or is it over $50,000? So it'd be interesting to know if you all want to just take a shot at it. And there are your results. Well, that's a good stab at it, and I guess this is a little bit of semantics. But if you look at the average charge for non-union hospitalization, this is 2014, obviously probably higher now, but you're talking over $70,000. Now, the hospital may not get all that, but they're still going to get paid somewhere in that vicinity of about $30,000 for this. So you're talking about a tremendous amount of healthcare dollars that go to treating a non-union with hospitalization surgically. And obviously, that's tremendously higher than the use of an exogen unit. So again, I think we need to really look at what adjuvants we have out there that can improve our union rate, whether it's fresh fracture or arthrodesis, when it comes to these kind of numbers, that we can use an adjuvant, a non-invasive adjuvant with no side effects like exogen, improve our fusion and our healing rates, and avoid these kind of numbers, because again, we unfortunately use a tremendous number of healthcare dollars on non-union surgery hospitalizations as seen here. So again, a little plug for the use of exogen. So in summary, I really do believe, again, I've been utilizing this technology for over 20 years, as I mentioned, and it does work. I've seen tremendous results anecdotally, and I read the literature, and I have found support from the literature and a number of different indications for the use of exogen when it comes to foot and ankle. I think the studies out there demonstrate accelerated healing for the fresh fractures and the healing of non-unions. It's very safe. It's great in athletes, obviously, which is where I use it most commonly, but also your workers' population, where you're trying to get these people back quicker with complete healing. It's obviously very easy to use. It's very quick. The nice thing about exogen, the compliance is not an issue. You're talking about less than 30 minutes a day to apply this. It's not like you're trying to put it on overnight or for three, four hours at a time. The compliance is not an issue, because it is fairly easy to use and quick to apply. And again, compared to non-union hospital costs, as we said, the bone stimulation costs much less. I think, again, there are multiple indications. There's multiple studies out there to support the use of exogen. And I really think you should consider it whenever you have a high-risk situation, as well as what I see, the stress fractures. I think that's where, again, as I mentioned before, stress fractures, stress fracture non-unions. This has been extremely helpful in my own practice. But also something to consider, particularly if you're doing arthrodesis in the higher risk patient population. We did not get to have our AOFS meeting in person this year, but there was a multi-center study that was to be presented by Dr. Lau and Sheldon Lim talking about the advantages of utilizing exogen when it comes to not only primary arthrodesis, but those with non-unions and risk fractures. So something you'll see in print, again, that demonstrates and supports the use of exogen in those indications, as well. So again, happy to take any questions. We can open a chat line for that. If you need additional resources to learn more about exogen, you can visit the biovettesacademy.com. Docmatter.com slash exogen has a great open chat line and exchange of information on those who are considering exogen for different indications. Your local reps can be seen at exogen.com. And again, if you're looking for just more CME courses on bone healing, go to www.advancing orthobiologics.com. And again, that could be very helpful to you. So we do appreciate your participation tonight, and hopefully this has been of value to you. But again, I'm happy to take any questions that may have arisen. Christine? Yeah, thanks, Dr. Anderson. I'll join you again. We do already have a few questions in the queue here. The first one goes back to case number two, which is your runner. And the question there was, how do you determine the time frame for non-weight bearing? Are you using pain as a guide or something else? So if we're talking about post-surgical, I pretty much use a standard formula. So when I go ahead and I fix a stress fracture, whether it's medial malleus, navicular, we tend to go splint for two weeks. I oftentimes take them out of the splint into boots. They can do range of motion exercises and avoid some of the atrophy concerns that we might have, particularly the higher level athletes. But I will not let them weight bear for approximately six weeks. So I will keep people non-weight bearing six weeks. And that's irregardless of what their symptoms are, what their x-rays look like. It's just my knee-jerk response. Two weeks in a splint, non-weight bearing. Then an additional four weeks in a splint, where they can come in and out of the splint to do suspended pool work, perhaps, or some range of motion exercises. And then I'll let them weight bear in the boot at the six-week mark. I'll typically then utilize that boot for an additional six weeks. And then I will obtain a CT scan somewhere at that 12 to 14-week mark to ensure that there's union. If there's union, then I let them progress with the rehabilitation. If not, then we usually will protect them for a longer period of time. In regard to exogen, exogen I will start immediately post-op. Again, that's the advantage of not utilizing a cast at the two-week mark, but rather than a boot, so they can put the exogen directly on the area of concern and not have to worry about having a window and a cast, which certainly works fine. But it's a little bit more of a time crunch for the provider. But again, I'll use exogen starting definitely by the two-week mark. And I'll continue it always for a minimum of four months. So if they have complete healing by four months, then, of course, they may elect to not continue it. But I tell most of my patients, just keep using it as long as you want, as long as you can, that it's going to have nothing but advantages for you. So that's our usual post-surgical protocol. We talk about those stress fractures. And then, more specifically, how many times per day and minutes per use are you prescribing? So really, if you look at the technology for lipase, you only need to use it once a day. So literature shows once a day for the 20 to 30 minutes is adequate. However, I have a lot of patients that do utilize it twice a day. There's been no, there's, I don't believe, and Christina, correct me if I'm wrong, but there's been no studies that have shown that using it twice a day is an advantage to once a day. But there's also been no studies that have shown that it's a disadvantage. So there are a lot of people who say, listen, is there a disadvantage to using it twice a day? Absolutely not. So I do have a lot of patients that do use it twice a day, particularly the higher risk patients, the career athletes. And again, there's no downside at all to doing that. But I don't believe that there's any scientific proof that it adds a lot to it that the once a day is adequate. You're correct. Another question that's come in, has COVID changed your fracture treatment plans in any way? And has that impacted your use of exogen? Well, COVID has changed my practice, that's for sure. Because again, when I migrated here to Green Bay, I was pretty much doing nothing but sports foot and ankle. When COVID came around, there were no more sports, there was no more athletic injuries, no more stress fractures. So COVID has certainly changed my practice in that regard. As far as if I still have a patient with a concerning fracture, stress fracture, we've worked around COVID in that regard. And if they need surgery, I'll still do surgery and I'll still use the adjuvant of exogen. I have not gotten to the point that COVID has basically changed my algorithm to say, well, we can't go to the hospital, you have to use exogen, if that's what they're asking. We still will do surgery when surgical stabilization is necessary. But we still use exogen whenever appropriate in that regard. Okay. And those are all the questions that have come in. So we'll thank you, Dr. Anderson, for sharing your insights with us this evening. And we'll thank all of the folks who stayed on the line to listen and join us tonight. Very good. Thank you, Christine. Thanks, everyone. Be safe.

bone stimulation

Exogen product

healing time

non-unions

stress fractures

ultrasound waves

safe to use

accelerate bone healing