Orthopedic Exceptionalism

Why Ortho is Unique Among Medical Devices and Why Outsiders Struggle to Grasp it.

Despite the reality that surgeons are losing their autonomy and decision-making power in hospitals, there are fundamentals in orthopedics that make it unique among medical devices. One might say “Orthopedics are Exceptional.” Sadly, too many boards of directors don’t fully appreciate this when making their executive selection only to find that the start up struggles or worse, fails.  All too often, leaders from different surgical specialties underestimate the gaps between other devices and orthopedics. They default to their own experience and successes and believe that by introducing these to an orthopedic company, they will enlighten these “knuckle-draggers,” bringing them into a more refined and efficient system or process. There is a fatal flaw in their reasoning which is the purpose of this post.


Breaking it down to is simplest form, it can be adequately explained by this one statement, “In general, the Orthopedic Patient rarely dies as a complication of surgery.” Apart from the extreme trauma cases, the vast majority of surgeries are elective and conducted on healthy people. Their reason for surgery is typically motivated by pain or immobility. Neither of these are what we might consider “life-threatening” diseases. Even if you live with terrible pain and immobility, you are much more likely to die from something else. If you are new to orthopedics, this small distinction carries significant nuances and if you are not careful, profound consequences.


Because of this fundamental difference, surgeons are not terribly concerned about “what they do at Cleveland Clinic” for example. Because the orthopedic patient is not sick and is very likely to emerge from surgery without any further health risks, orthopedic surgeons have tremendous latitude in their selection of which implant systems to use. A simple comparison to cardiovascular surgery reveals that those surgical patients have a relatively high risk of mortality, especially if there is a complication. Because of this, these surgeons are very careful to operate within the strict parameters of what the leading teaching institutions have shown to be safe and efficacious. The orthopedic patient merely started out with pain and restricted mobility. They are very likely to have less pain and improved mobility as a result of surgery, even when things don’t go perfectly.


This flexibility enables orthopedic surgeons to experiment with different treatments and implant systems without increasing their patient’s risk or their own legal liability. This is why there are over 250 small orthopedic implant companies and comparatively few start ups selling devices in most of the other surgical specialties. Unlike many other surgical specialties, the adoption of orthopedic devices continues to be driven on the local level and not reserved to the “safe haven” of the “Key Opinion Leaders” in the world renowned clinics.


This “exception” in orthopedics largely places the ability to drive product sales in the hands of the local representatives. While there is little doubt that more purchasing control will continue to be centralized, there will always be predominantly local forces that drive adoption of new products as well as utilization of legacy systems within orthopedics. Many intelligent executive leaders from outside orthopedics struggle to grasp this nuance. Whether it is hubris or stubbornness no one really knows. They often bring many preconceived notions and or a “chip on their shoulder” that hinders their ability to be openminded to the uniqueness of orthopedics. Sadly, too many of these venture backed companies ended in an asset sale. Certainly there are examples of executives who have successfully crossed over, but my contention is that the risk of failure, or at a minimum, dramatically slowing growth are considerably higher when going outside orthopedics to find leadership. Because of the exceptional nature of orthopedics, it is clear to me that the best way to mitigate the risk in an orthopedic start up is to hire talent that possesses a deep understanding of the orthopedic market and its drivers.


– Drue De Angelis

Originally Published 06/17/2014