Advancing Human Mobility through Technology with Jeff Denune

In this episode of the Prosthetics and Orthotics Podcast, hosts Brent and Joris engage with guest Jeff Denune to explore his extensive background and developments in the prosthetics and orthotics field. Denune shares his journey from his initial involvement in the field, influenced by post-WWII prosthetics professionals, to his adoption of cutting-edge technologies like CAD for socket design. The discussion covers the progression from traditional methods to advanced digital fabrication techniques, emphasizing the impact of 3D printing and CAD in creating more effective and personalized prosthetic devices.

The conversation transitions to the nuances of patient care within the field, highlighting the importance of customizing treatment plans and prosthetics to individual needs. Denune discusses various socket designs, including ischial containment and sub-ischial techniques, illustrating the critical role of personalization in enhancing patient comfort and mobility. The hosts and guest also delve into the evolving landscape of prosthetics, discussing potential advancements and the integration of new technologies like powered exoskeletons and myoelectric devices.

Lastly, the podcast touches on the future of prosthetics and orthotics, contemplating the balance between large-scale manufacturing and boutique-style patient care. Denune advocates for a patient-centered approach, stressing that successful outcomes hinge on understanding and addressing each patient's unique situation. The episode concludes with reflections on the importance of innovation and adaptability in the field, encouraging professionals to embrace new technologies while maintaining a strong focus on individualized patient care.

Brought to you by Advanced 3D.

Transcript

Brent: 0:00

Welcome to Season 8 of the Prosthetics and Orthotics Podcast. This is where we chat with experts in the field, patients who use these devices, physical therapists and the vendors who make it all happen. Our goal To share stories, tips and insights that ultimately help our patients get the best possible outcomes. Tune in and join the conversation. We are thrilled you are here and hope it is the highlight of your day.

Joris: 0:32

Hey everyone, my name is Yoris Peebles and this is another episode of the Orthotics and Prosthetics Podcast with Brent Wright. How you doing, Brent?

Brent: 0:40

Hey, yoris, I'm doing well. I'll have to apologize to everybody. Last week I had strep throat. I had no voice. So you and I, we're quite a pair, right? You got hobbling along and no voice. I mean, what in the world?

Joris: 0:57

Exactly.

Brent: 0:58

Minor things.

Joris: 0:58

This is minor things, I'm all right, with the little small challenges. We have a sponsor right for this show and that's Advanced 3D, I believe, and they're a contract manufacturer design service for prosthetics orthotics. Do you know anything more about them? Brent?

Brent: 1:16

Well funny, you should ask, Yoris. You know Advanced 3D. I'm a part of it along with Tyler and Paul. We are a contract manufacturer, but I would say our wheelhouse is helping bring some of the products to market or say something that's technical or technically challenging for a patient. That's something where we can definitely use our expertise and design something digitally and then 3D print it for you. And then the other thing that we can do is come alongside you and wherever you are on your digital journey. We talk about scanning, design and fabrication, and we can help you with that as well.

Joris: 2:00

Okay, super cool.

Brent: 2:13

So if you want to give a shout out to Advanced Review or check them out, do so. So, brent, what do we have on the podcast today? And one of the things that I think you'll find interesting is he is part of a. I don't know if it would necessarily be considered a startup, but we'll just say it's in a startup.

Brent: 2:32

They are called New Tech Institute, and one of the things that they do is they are kind of the eyes and ears for companies that are looking to get into the US market for prosthetics and orthotics, so it may be somebody. They have a kind of a portfolio of services that they offer, and they offer that to their patients as well. So not only will you get like your product in front of patients or on patients, but you'll actually get feedback as well, and so I think it's a really neat for opportunity for companies that don't have a massive R&D budget or whatever to really piggyback on another company, and so Jeff and I have also talked a little bit offline about socket design, different types of prosthetic R&D projects, and he was also an early adopter to 3D printing. So we've got a lot of ways to go on this show, so it should be a good one.

Joris: 3:47

Yeah cool.

Jeff Denune: 3:47

Welcome to the show, jeff. I appreciate. Thank you guys for having me. Yeah, it could be a part two episode. Uh, there's definitely a lot of a lot to cover over 37 years.

Joris: 3:54

Yes, sir all right, all right. So how'd you get into omp first off then?

Jeff Denune: 3:59

well, I always share the story that was either uh, omp or prison, but you probably don't want that for your podcast.

Joris: 4:07

No, no, this would be really exciting if it's true.

Jeff Denune: 4:09

The truth is, I was very fortunate that two old Germans came over after World War II, started an OMP facility. One of them actually learned prosthetics in the United States Army and took a liking to me. My father and grandfather were both in the Marine Corps, so I was raised maybe in a little different environment, which is why I think I aligned so well with them. You asked me to do something. I did that, no more, no less. We worked really well together. It started as a part-time job Truthfully, it was a summer job, part-time job. I was fortunate enough to have a mentor that took a liking to me and saw opportunity for me and talent and pushed me to go to school, pushed me to go to college, and that's truly how I got into this.

Joris: 4:57

Okay, that's an interesting story. And then, and how did you kind of train or and get get started? Uh, you know the end of practice outside yeah.

Jeff Denune: 5:06

So, as I shared originally, um, they took a liking to me and pushed me to go back to school and I worked. Ironically, I worked 40 hours a week and still went to school at night just to get a degree. And um, one thing led to another while I was in a private care facility and I guess my life's kind of gone in weird phases. But while at that facility in 1996, I started in January of 1986. My career started. But in 1996, I was in an office that was very innovative and we went completely paperless and went full CAD. So I started using CAD for socket design in 1996.

Joris: 5:55

But that was amazing. Everything worked so well back then.

Jeff Denune: 5:58

It did. It actually did. Okay, I can sit down with younger clinicians and if you followed this protocol that we created, you would have a well-fitting socket. Is it perfect? No, I'm not going to say it would be perfect, but we had created a protocol at that time that we would at least have a well-fitting socket and you would have a successful initial diagnostic socket fitting.

Joris: 6:24

Okay, okay, okay, that's a nice approach. It seems like a really sensible approach, given limitations. But hey, so tell us, given the fact that you've been working in CAD for so long it's quite unique in the field what's been the biggest kind of changes in CAD for prosthetics, orthotics, do you think, over the time you've been working on it?

Jeff Denune: 6:41

Yeah, I would guess it's getting easier to use, as strange as that may sound. So the original CAD program that I started with was more engineering driven, more engineering based, so it was a little more, I would tell you, advanced, where I think today it's become much more user friendly. But the biggest evolution in CAD that I've seen is the shape capture technology. So in early 2004, I took a position as a clinical director for an international manufacturer of prosthetic components and I drove their DOD VA research and their clinical care at that time and we continued to develop and design advancements in CAD at that time. But again during that time, shape capture right Shape capture was expensive.

Jeff Denune: 7:33

So if you got into some of the handheld shape capture devices at that time, it was a heavy lift man. It was a very expensive venture for an OOP facility that at that time again saw zero reimbursement for paying $17,000, $18,000, $20,000 for a handheld shape capture device at that time. So now, with iPhones and having that shape capture device in your hand, that's a huge advancement. I'm hoping more and more people adopt it now.

Joris: 8:01

Okay, and do you think, if we're looking at the future and also CAD, you know we're looking at digitization. It's an interesting subject to us. Now, learning CAD, you know it's quite an investment right, and it's made even worse because you're kind of learning like one package kind of more so than just all CAD. You know it'd take you you know I always call it like using around 2,000 hours to do it it. But we're seeing all these kind of like automated, one click kind of packages come out, you know. So what would your advice be to somebody kind of new to the field? Maybe would you be like no, no, absolutely use cat, that'll give you edge. Or would you be like, no, kick back. This is like a solved equation yeah, I guess it's.

Jeff Denune: 8:37

You know it's an unfair question for me because I was fortunate enough to good or bad um I had. I still have that hands-on experience right because I came up in in plaster and casting and, um I guess, palpating the residual lemon, better understanding the underlying anatomy and soft tissue and limb length and all those variables that play into um making a well-fitting prosthetic socket. So I I agree with you, yours. I've actually just recently seen some software that was pretty impressive. It's AI driven and good or bad.

Jeff Denune: 9:13

I don't know yet, but that's definitely the direction it's going, that you could complete that shape capture, push it through the pipe, basically, and hopefully have a well-fitting socket on the other side. I don't know if that's good or bad yet, so I guess I feel fortunate enough that I have a pretty good understanding of anatomy and and tissue type. That I think gives me an edge when I go into modify and manipulate my cad files, because I still do modify all my own cad files. But your question is yeah, I tend to use probably four or five, six different techniques in modifying, so it isn't like a hundred different techniques where I could see, you know, a clicker two or clicker three or that could produce a well-fitting socket for sure.

Joris: 9:56

One thing I just thought of. It's kind of really random, but if you're taking a plaster cast right it's a very tactile experience right. Especially people like with tactile kind of learning styles and stuff like that that might actually help you understand anatomy and things like that better. Is that also why you still recommend, like, like doing more doing plaster and keeping that tactile thing, or do you think you could we can really kind of start to go fully digital and not have that kind of casting step?

Jeff Denune: 10:19

Yeah, and that's where I was leaning is, I think, that that hands-on approach where you're understanding the patient's underlying anatomy or the density of the tissue, right? So is it a really firm residual limb or is it a more mature soft residual limb with redundant tissue? And those are different modification techniques, right? I won't get into weeds on this, but this is a whole nother topic to get into. But I've always questioned our shape capture technique. I still, to this day, after 37 years, capture our current shape capture technique. I think we're missing the boat, I think I shouldn't say I think I believe that possibly lack of contact or non-contact of the residual limb for shape capture is potentially not serving the patient in its fullest capacity. And I'll expand on it just a little bit because I don't want to go down this path with you guys.

Joris: 11:16

I'm super interested in this. I don't think this was the antenna of the discussion.

Jeff Denune: 11:23

I've questioned this 37 years. I've had this question. We ask our patients to sit. Usually, if we talk about trans-tibials at the time, they're in a seated position and we capture the residual limb. Let's just talk about plaster because it's a conversation we were having, or even I guess we could have a scanner non-contact with a scanner and we scan that patient's residual limb in a seated position, right, non-weight bearing.

Jeff Denune: 11:51

We do modifications to the best of our ability. Some have better skills, some have less skills and I think that comes over time. It just does. It's not something you just learn in school and all of a sudden you have this skill. I think with any trade, no matter what you do, any skill you have, you get better over time. We modify that to the best of our ability. We generate this initial diagnostic socket, whether it be static or dynamic, and then we ask the patient to stand on it and then walk and I can't be the only one on the planet that finds that to be odd. We get shape captured in a non-weight-bearing environment and then we expect that patient to stand and ambulate in a weight-bearing environment. I've never understood that my entire career. So I'm really looking aggressively to the future and see if we can disrupt that a little bit. It's really a passion of mine right now. I think we're missing the boat by shape capturing in a non-weight-bearing environment.

Joris: 12:46

Yeah, I think that's a wonderful point. I think you know also an additional scan of the weight-bearing kind of movement as well, and also just the general movement of the person's leg and stuff like that right, and the funny thing about that is we have tools for those right.

Jeff Denune: 13:09

And saying those tools like the video and all these other tools, those are used for orthotics but not really for like a lower limb prosthetic, right Right. So I just finished a department of fence research project last August where we looked at comparing non-contact definitive sockets to weight bearing definitive sockets and and where, why I'm leaning this way. I can tell you I've got tons of photos and videos of the patients during ambulation but the residual limb shape is completely different in a weight-bearing socket than it is a non-weight-bearing socket. But for me, the huge benefit to my patients is the overall limb health. Benefit to my patients is the overall limb health. We're seeing improvements in residual limb health by not squeezing and choking the heck out of that residual limb, adding socks, adding socks, adding socks and reducing and restricting that blood flow. It's extremely detrimental to the patient. I know it is.

Brent: 13:58

I think that's pretty interesting and you know you look through some of the historical documents and such and see even before, like plaster and stuff, there's a lot of people doing this kind of weight bearing type of either captures or jigs or what have you. I think one of the things that sticks out to me the most and it changed the trajectory of my career and I still talk to people to this day that have been involved in the course and it's still around is the. It was the RCR course but then it became the StableFlex course. So very much, hey, when do you want your prosthesis to be the best-fitting prosthesis? Because, as you mentioned, your leg changes throughout its motion or cycle.

Brent: 14:43

So you want the prosthesis to be most comfortable and best fitting when they're putting all their weight on it, when they have their biggest weight moment on it, and what as always gets me is, uh, so many people cast in flexion and it's like, well, that's not really where you get your shapes right if you're trying to get somebody comfortable at mid-stance. So it's just, it's just kind of funny to me to have this, this discussion, because it is so important and I think that's where you've got this non-contact scanning. But then what kind of rigs, jigs, uh, now we're starting to see some fabrics that come along that help this idea of um weight bearing. And I mean for you guys you guys do a lot of definitive sockets through some of the companies that you work with, right, that are very hands-on, but I mean you're actually making the socket to the limb real time.

Jeff Denune: 15:59

Yeah, exactly, I want to back up for one minute, just real quick. So I was very fortunate to have met Carl Casper's in 1999. And if anybody doesn't know Carl, do your homework on him. He was an awesome person, he and Craig McKenzie. I became really close friends with both of them, especially when Carl started coming out with all the vacuum pumps and stuff big red, if you remember all that, oh yeah.

Jeff Denune: 16:22

And I remember being in a bar one time with Carl because I'm against. And again I'm going to create. I'm going to go ahead and continue to throw fireballs here, and I've proven this. So please, somebody else, do it. Prove me wrong. I'm OK with that. I love being proven wrong because I learn Right. Go ahead and measure your patient's ML inflection. Measure your patient's ML full extension. Tell me which one's bigger. I extension, tell me which one's bigger. I could tell you which one's bigger.

Jeff Denune: 16:48

So why are we, why are we shape capturing the um inflection? I think it's wrong. I think you want to shape capture them a full extension because the ml's larger yep, it just is right. So all these years this company had been going around telling you to to do a three-part cast and non-weight bearing inflection. Man, I just, if that works for you, that's great. I I've always said this um, even when I work for this, this international manufacturer, if you're having success and you're happy with the performance of the product and your patient's happy and the skin tones are doing good and you're meeting the warranty, don't change. Don't change Because I think there's what did I say? 138 different ways to skin a cat. But if you're not having success. I think we need to step back and step out of the box a little bit and say why? So, yeah, so back to your point. There we are. We are working with a lot of companies right now no-transcript. So Mark's vision of New Tech Synergies and then my vision of New Tech Institute, because for the last 17 years my primary driver has been research and outcomes, functional outcomes, outcomes While I was at this manufacturer.

Jeff Denune: 18:30

Then I relocated to Indianapolis, indiana, in January of 18 and opened up a third-party, independent research company where we could really dissect the patient's functional outcomes and the performance of this technology that's coming to the market as an unbiased professional right. Because at the end of the day, I've got to be honest with my colleagues, my friends like yourself, right, brent? If you come to me and have respect for me and say, hey, jeff, what do you think about this widget, and I potentially give you half the company line and half my clinical line, then that's not fair to you and that's not fair to you and that's not fair to your patient. I want you to be successful. One of the things I always stuck with when I would travel or visit other clinicians was I want to make you the rock star. I want to make you the rock star in front of your patient's eyes and I want you to be successful. And if you're successful, I think that comes full circle Right. We all help each other.

Jeff Denune: 19:29

It's kind of a karma thing, so, and that's where kind of the New Tech Institute evolved from, where we can work with young upcoming companies who have some great ideas and great great designs really smart, talented engineers, ideas, some great designs, really smart, talented engineers. And then when we engage them and they want to come to the US market with some technology, it's ironic to me how few have actually put their technology on an amputee. For example, we're talking prosthetics at this moment. Well, we should probably put that on a couple of amputees before we bring it to market, because I want you to be successful and I want the patients to be successful. So that's really the vision that came from NewTek Synergies. But NewTek Synergies at the time needed a facility such as the NewTek Institute to perform and handle all those functional outcomes and patient care, and they needed patients at the time to test that technology.

Joris: 20:25

Yeah, okay, okay. And what do you guys do exactly then? Because the thing is okay, it's nice that you want to be honest, but if I'm the one paying you, then how does it work?

Jeff Denune: 20:36

I will be honest. I'm too old to not be honest anymore. That's why I ended up leaving and opening my own company in January of 18. If we do the research for you, obviously it's a funded research project right, and that's why I love doing DOD and VA research. The outcomes are the outcomes. You don't have to like them, but if it's a reality and we can make that product better, maybe sometimes we need to suck up our egos and say you know what I think we can do a little bit better. Did we try doing this or did we try doing that?

Jeff Denune: 21:07

So, at the end of the day, if it's an industry sponsored project, right, and let's say you're the industry, those outcomes and that data is all yours. That's your data to do with what you want. Now you have options with that data. You can allow me to go to move forward and do presentations on a national level. You can allow me to take that outcome and maybe present it to a DOD or VA funded style research. You can take that data and grow. On your fair question, what you're asking, um, you can do with it what you want. You can. You can shelve it if you want. It's your call, you paid for it. That's not my goal. My goal is that we work together and, if we find an error or a deviation in some of the research, that we work together and make it better to help more patients okay, that sounds sensible.

Joris: 22:04

So so the idea is like like, essentially, I'm like a Swiss startup and I have some do hickey and you would then test out the do hickey. How would you do that, would you? How does that? What does the next step go to?

Jeff Denune: 22:15

Yeah, so. So Mark drives a lot of those relationships right. So I I I am a partner in a new tech Institute is a patient care facility, so I see patients all day long your normal patient care facility, and I tell everybody that I usually take a step back and the reason that's important for us is that we need amputee subjects to test some of the technology. Right, and it's very difficult. What I've learned over the years in research everybody wants to do research. It's super exciting, it's so fun to do until you actually have to do it. I have never approached a facility that hasn't been interested in research and then get super excited and jump on board 100%. Everybody gets excited about a brand new foot, a brand new microprocessor and brand new 3D printed socket design. We all get excited over new technology because I think, at the end of the day, as orthodosprositists, we're here because we want to help our patients.

Jeff Denune: 23:13

It's a lot of work, so we have to create a protocol, we have to create outcomes, we have to create that workflow. What is that workflow? What are we going to do? How many patients do you want to fit? You want to do a small pilot study of maybe five to 10? Or do you think you have enough information and data that we can take this to a larger study? The normal protocol, yours, is that you'll present some technology, we'll do a small pilot study of maybe five to 10, five to eight subjects. We'll collect that data, we'll look at the outcomes and then we'll circle the wagons, basically and say, okay, where are we at with this? Do we have enough outcomes and data that we can move this forward to a larger study, or do we need to regroup and say, hey, we need to make a few changes, design changes on this?

Jeff Denune: 23:59

So that's one of the reasons that NewTek has teamed up with some functional outcome study, some functional outcome manufacturers such as Tracer and Adapt Tech, who owns Modio. So all of my patients, 100 percent of my patients, whether you're in a study or not, when you present at my facility, you're going to go through a Tracer outcome and it's an assessment tool for physical therapists and I can see how you're doing today. It's an assessment tool for physical therapists and I can see how you're doing. Today. Every patient gets a socket comfort score when they present. Then they'll go through about a 10 to 12 minute assessment program. It's a virtual reality assessment program with Tracer and, depending on where we're at in that fitting, they potentially may go home with a Modio unit for the next 30 days and then they come back. I start putting the pieces together, start putting the patient profile together to see where they're at today.

Joris: 24:51

If that helps at all a little bit, okay, that's really cool. And then, but then of course working with the bleeding edge technology all the time could also be like kind of frustrating. It can be really difficult for patients, also for your staff and then people, right, yeah because not everything works right.

Jeff Denune: 25:06

I mean, you know, I'm very, very fortunate that I have some amazing. I guess I would tell you that I probably have eight or 10 patients that are kind of my go-tos, that I know that they've lived it with me over the years so they understand that things fail or they understand that maybe things don't go um cause. We all want success, right, nobody wants failure, although we, we do our most growth um in the Valley, right, we do our most growth at times of failure, not times of success. So I'm fortunate enough to have a handful of patients that I can go to as my you know, my pilot patients, that we can put it on and if it fails they have an understanding. I have another group of patients that are just patient care patients that they're really not candidates for until we get a little more advanced, a little more down the road and see if it's truly going to be a functional project.

Joris: 25:48

Okay, that sounds really cool. And then, and do you have any kind of best practices for people who want to do research as a researcher as like a firm? What are some things I could I need to know in advance or maybe do that would lead me to have like more, a better chance of success?

Jeff Denune: 26:02

Yeah, so there's a lot of technology. I mean, that's such a hot buzzword right now, right, functional outcomes. We started doing functional outcomes in 2008, 2009, when I worked for this manufacturer, and it's really exciting. Talking about exciting time, we kind of took a little bit of a turn here in the conversation, but it's an exciting time because I'm seeing more and more major players, big manufacturers, supporting functional outcomes, so it's an exciting time.

Jeff Denune: 26:34

So I guess what I would say to you there is currently technology available that you can use every day in your practice. It really doesn't take that much time and that much space and you have to start somewhere. I tell everybody that when the patient presents we don't have any data on them let's say, an initial evaluation presentation I don't have any data on them. I've got no baseline data and I don't have anything. So I got to get baseline data. Then I get 30 day data, 60 day data, 90 day data. Before we know it, I have a year and a half worth of data on this subject and I can go back to see where were they today, where are they basically a year later, and show them their progression and how well they're doing or how well they're not doing and what changes we need to make. So I guess my advice in that would be there's currently technology available from all these major players, major manufacturers. Don't shy away from it. Accept it and start.

Joris: 27:26

You gotta take a first step and if we look at like uh, prosthetics research generally, I get the opinion well, I don't know much about it, but it just seems like it's, it's kind of underfunded when compared to a lot of other medical areas. I'm saying, or it seems like that to me, yeah, uh, it's getting, it's getting better, right?

Jeff Denune: 27:43

I mean, um, I see a lot of research that's being funded but unfortunately some of it doesn't produce product right, and I guess one of my drivers. I want to be in a situation where we collect functional outcomes and research from my patients and it leads to a product, to a deliverable that can benefit thousands and tens of thousands, as opposed to a research project that happens in the lab, I guess, to be fair, a research project that happens in the lab or the gait lab and never produces anything to help patients. Interactivity as a daily living. So so, yeah, so that's, it's a fair question.

Brent: 28:28

Yeah, with all these outcome stuff and like the tools that you're talking about and things like that, what are some of your biggest hurdles for adoption to this and like to make it more mainstream.

Jeff Denune: 28:42

I think it's like anything in OMP. I think this is how our conversation started. So thanks, brian, kind of took a full circle. There's no ROI, right? I mean potentially there's no ROI but there could be If I can prove that this patient the hot thing right now is and I'm so excited about this because our geriatric population, in my opinion, has been ignored but a lot of times I don't get paid for that extra.

Jeff Denune: 29:09

Let's just say 30 minutes of time I take collecting functional outcomes on my patient. But that's a comment I hear all the time. It goes back to the hand scanner that we talked about earlier to spend $17,000 on a handheld non-contact scanner for CAD, but I don't make any money on it. Handheld non-contact scanner for CAD, but I don't make any money on it. But that's so short-sighted If you look at it in the big picture. You do, because if I can take 30 minutes of my time or 20 minutes of my time, it's a great opportunity for a resident or an intern or an assistant to do this. It doesn't mean that a prosthetist who's seeing six, eight, 10 patients a day has to do all the functional outcomes. Take an opportunity to, to educate somebody and be a mentor to somebody who's interested in the field. But yeah, it's, it's the ROI, right? It's the same story I've thrown in my face all the time.

Jeff Denune: 29:57

I don't make any money on that. I don't get any money but you do, because if you can collect that functional data and you can show that that patient's progressed from a K2 to a K3, or, as I was just leaning into a little bit, the super exciting thing happening right now is potentially the ability to provide MPKs to our geriatric population not our K2s to hopefully reduce falls and with stumble recoveries. It's an exciting time for that. So, having that data, having that outcome, to be able to lean back on it to say, to go back to a payer and say, no, this patient is a candidate for this. Look at this data, look at these outcomes, look what I have, as opposed to just being we lived in such an anecdotal field almost my entire career Looks like he walks pretty good in that. What's that mean, you know? So, yeah, it is definitely an exciting time and using that data will be of great value to you in the future. You're going to need it Okay.

Joris: 30:56

and what about like something like, for example, 3d printing In all this new stuff you see? Is 3D printing just another thing for you, or is it fundamentally a little bit more important?

Jeff Denune: 31:08

I started 3D printing in 2008. We did a TATRC project for the Army and we were printing SLS sockets 2008, 2009, and 2010. I actually have two. Actually, that's how Brent and I met. I have two sockets currently in my office from 2009,. 2010 that patients wore home for a period of six months and they were the most durable bulletproof sockets I've ever fit in my entire career. I have one gentleman that would break everything, so we put him on one and he came back months later and has a big chip in the side of it. Um, and I asked him what happened here, what's going on here? And he said, oh, I was hunting and fell on a concrete drain and, man, if I wouldn't have that socket on, he said it chipped it pretty good but didn't break it. So yeah, 2008, early 2009, we picked up a TATRIC project from the Department of Defense and we were 3D printing SLS sockets. So it was CAD modified 3D printed sockets and I'm a huge proponent. There's no plaster in my lab, let's put it that way.

Joris: 32:11

And how about all this like robotics and myoelectric stuff? Do you see that that's always been like a pricey kind of stuff? Do you see that get cheaper? Because to me that would be something that could really change everything if that got significantly cheaper.

Jeff Denune: 32:33

Yeah, I think there's pros and cons with bionics, right?

Jeff Denune: 32:37

So we just finished another DOD project. We finished in August as well. We were looking at the Empower foot, comparing it to the Proprio foot Obviously I know they're apples and oranges and comparing it to their standard of care, their SOC, which was an energy storage, dynamic response foot, a carbon foot or a J-spring style foot, and what we were looking at was in socket pressure. And we were also looking at limb health. But we were also looking at joint angles and velocity and understanding how these feet play a role or play a part in ambulation. I guess one thing I've learned over the years I don't think there is any one device for everybody. Every single patient is unique, has unique needs, and I've had some of my patients that loved the Empower, the powered ankle response, and I had some of them that did not like it. They preferred the Proprio Again, apples and oranges two completely different technologies. Rio, Again the apples and oranges two completely different technologies. Some of them love the empower for long distances and extreme ambulation.

Jeff Denune: 33:32

Right, I had a gentleman who worked in a warehouse and he couldn't believe he wasn't tired toward the end of the day. So, man, I really liked his foot and I had others who didn't like dragging that amount of weight around. So I think technology is continuing to advance. Obviously it's getting lighter, it's getting better, it's getting faster. Battery life is still a thorn in everybody's side, Even with some of the more advanced MPKs. You know we don't want I don't want my patients being inconvenienced, having to stop and charge their knee. It's kind of the Tesla thing that's going around right now. Right, Some of the adoption to the EVs, as it becomes less and less restraining or restrictive to our patients, I think it'll be more and more adopted. So I think that goes to weight, I think it goes to performance and I think it'll also go to availability and price.

Joris: 34:24

Okay. Well, what are some other developments you see happening or don't see happening, like what would you think are really cool?

Jeff Denune: 34:29

Huge push right now in a powered exoskeletons right Um. We've been dabbling in that field for four years right now.

Jeff Denune: 34:36

Um with the new codes, uh for powered exoskeletons. I think that's an exciting time. I just shared this recently in a presentation. So my entire career it's always been, I've always.

Jeff Denune: 34:47

I hope this doesn't come out wrong because I don't wish for it to. I've always felt sorry for orthodists because a lot of times a prosthetic facility will have an orthotic angle to it to pull through and you have to be a full service facility right. If you just do prosthetics, sometimes that can limit your patient population and patient pool. And it's a lot of times, you know, in my career you see these orthodists getting stuck with inserts or inlays or custom molded shoes or you know plastic AFOs and things like that and the pull through really isn't that great. It's a super exciting time to be an orthodist. I just want to make sure I get to that point If you're an orthodist. What an exciting time with the power upper and lower extremity exoskeletons. I think in my lifetime we will see the reimbursement of the powered exoskeleton be on par with some of the powered bionic upper extremity and lower extremity prosthetic devices. It's an exciting time, really exciting.

Joris: 35:47

Yeah, but also and that could change a lot of things because that same exoskeleton could be used for the military, could be used for all the Amazon workers or whatever. So the economies of scale and that could be much, much larger than whatever prosthetic stuff it competes with.

Jeff Denune: 36:02

Yeah, I agree. I think you know I live in this bubble, right, this prosthetic bubble, because that's what I know. But you just nailed it If we really step back out of our bubble for a minute and look at you mentioned the Amazon thing to be able to help workers and protect workers, to lift objects throughout the day or turn, twist and turn and protect them, and they'll be able to perform at a higher level and a safer level. That's a massive market. I agree, and we're already there, right, we're seeing more and more of that. I think we're going to continue to see more and more of that.

Joris: 36:36

And then if we're looking at these kind of future development kind of things, no-transcript say like oh no, they're just going to become a. You know, we're going to get like a kind of like a warehouse kind of solution, one-stop shop, or do you think? Hey, you know, just because it's always better to have an independent component manufacturer, because they really do what they understand yeah it.

Jeff Denune: 37:27

It's such a fine line right now. Right, the industry's changing rapidly in the last I'll just say 24 months. I've been very fortunate to have traveled all over Europe over the last 20 years and fit patients all around the world. So I saw this integration especially if we talk about the UK at the time, for example, with Latchford, with Indolite at the time. So it was just a matter of time before it started to come to America. How honest do I get right? How honest do I get here? I think it's an exciting time for independence.

Jeff Denune: 38:00

I'll share with you my own opinion, which is not gospel, it's just Jeff DeNoon's opinion on this topic. There are patients who will benefit greatly from being seen and worked with, treated at a facility who's potentially owned by a manufacturer or a larger conglomerate. I also know for a fact that there are patients who don't like that. They don't like being treated as a number. These are human beings who want to be treated as human beings and they don't want to be seen in three weeks or two weeks. I see my patients seven days a week. That's a fact. If my patient calls and they have a problem, I had a gentleman call me on a Friday afternoon who was having some discomfort in his prosthesis and I said man, when can you get in? He said, well, man, I'll come in on Monday, he said if you got time. And I said well, you just told me your prosthesis, your socket's hurting you. Yeah, yeah, I'll just take it off, man, I'll get through the weekend. No, you won't. I'll see you saturday and we'll make adjustments and we'll work on it. I don't, I mean, I take that personally right. So I don't want somebody to to take a prosthetic device off um for the weekend and see me on a monday. So I have an open door policy.

Jeff Denune: 39:12

A lot of my patients I'll say there's a lot of a lot of my patients have my personal cell phone. That can be good and bad, so please know that. But also our direct line when it calls into the office. If nobody there picks it up, it'll come directly to my cell phone and I'll return your call. Not all facilities have the ability to do that. So as we continue to scale and get larger and larger, I've heard patients tell me multiple times yeah, they see me every two weeks, or they couldn't get me in for two weeks, or they work with me for one hour and they'll schedule me back in two weeks. It's not uncommon. I schedule my patients you might be my entire morning.

Jeff Denune: 39:50

Our facility is very unique the way we're set up. I treat my patients like family and I try to create a very, very welcome environment for my patients and a very relaxed environment, and it could be a four hour appointment. It could be an hour appointment and they're gone and I've got three hours to catch up and do other things. But I never want to rush my patients. I was there till midnight a couple Fridays ago before we went to academy.

Jeff Denune: 40:15

I was working with some patients that actually obviously our patients have jobs, right, so they work till 5 pm and they have families, and she couldn't get in until six o'clock till 6 pm. I said, well, I'll see you at 6 pm. She's like really, yeah, I didn't get out till midnight. It's just what we do, man. So I think with these larger, larger scale facilities, I don't see that level of patient care taking place. Maybe I'm wrong, I'm okay with that, but what I've been experiencing is patients like being treated like they're number one and each one of my patients are number one and I think, as you, you treat people like that, that pays off tenfold. Um goes back to that whole karma thing that I shared earlier, and I think that's a huge advantage for smaller independents over some of these larger facilities that are starting to take over the markets.

Joris: 41:07

Okay, but then of course, like the patient kind of pays, but also the insurer kind of pays, so maybe you should still just give the insurer a better job or expanded opening hours. They could be open like with swing shifts or something like later on, without doing maybe the level of personal care, but, you know, maybe the opening hours could be expanded, or do you see that?

Jeff Denune: 41:24

that kind of like you know, you, you think that boutique kind of approach will still resonate yeah, so so I I'm fully aware that there are facilities that have been extended their hours and open earlier, open later, one night a week, same as our veterinarians, right? I had a veterinarian that's open on Thursday nights till 7 pm. Why do they do that? They do that because they understand that people work and they can't always get there at noon or one o'clock or something. So, yeah, I definitely see that as an opportunity and I'm not big on putting everybody, stereotyping and putting everybody into one bucket, so hopefully it doesn't come across that way.

Jeff Denune: 42:01

I'm just sharing with you my experience, what I'm seeing and the engagement that I'm hearing from our current patients, that they love being treated like human beings and not numbers, and they love being seen when they need to be seen and they prefer to work with somebody. That's another thing. When you come in to work with me, you're going to see me. That can be good, that can be bad, depending on what side of the fence you are on that Some of the patients who have come to me said yeah, I see a different prosthetist every time I go in for the last six months. I'm tired of that. I have to regurgitate my situation and why, why this doesn't work or what does work, so they're seeing somebody different all the time. So, yeah, I'm a huge fan of the boutique thing, but maybe it's because it's the environment I live in. There are downsides to a boutique. If you want me to go down that road, I don't plan on, they're definitely downsides, oh, I think I think you know brent's probably always just like, like, like.

Joris: 42:52

He's always like that. For a younger generation of people, maybe this work ethic or the it was not going to be something that's compatible with that, with their life, so that he's kind of a little bit worried that now it's good but the next the people entering the field now would be a little bit more reticent to to be on call like 24 7 yeah, I agree.

Jeff Denune: 43:13

If you're an employee, maybe, but what if you're an owner? Okay, okay, so you think there's always a place. If you're an employee, maybe, but what if you're an?

Joris: 43:16

owner, Okay, Okay. So you think there's always a place if you're, if your heart's in that place, you're skilled and you make people feel that and maybe even, yeah, if you own the business or in part own the business or you get a profit share or something like that, then maybe that that ownership and thing will mean that there's a real future for for an operator elsewhere.

Jeff Denune: 43:43

I think so. Again, that's been my take and I'm not saying I'm right. I think there's an attractive opportunity for young talent to be entrepreneurs and to own their own facilities and have a future. And that's not for everybody, Please know that. That is not for everybody, but there is opportunities for those young individuals today to own their own facilities. And again, there's big drawbacks. Again, it goes into some big drawbacks as well, but some people strive to do that, some people strive to do that, some people strive to to um, to have that opportunity for growth in a future, and others, and there's no, there's no, there's no wrong answer here. I want to make sure I clarify that.

Jeff Denune: 44:26

And there are others who just like going and doing a 40, man. I go in on Monday at eight o'clock, do my 40. I'm out of there at five and I'm playing softball with my buddies and drinking beer at 7 pm. There's nothing wrong with that. Or, you know, I want to go home with my family. My kid's got soccer practice tonight at six, so I want to be out of there at five. There's nothing wrong with that. It's just what works best for you. And that's what's so cool about humans, right. We're all different and we're all unique. We have different unique needs and drives. For some, being an entrepreneur and working seven days a week or being there at midnight on a Friday night is attractive. For others, no way, man. I'd rather be at home with my kids or my family, and that's something you, as a human being, need to decide what is important to you.

Brent: 45:07

I want to take down a little bit of a curve road here. We talked a little bit about some of the lower extremity prostheses, specifically the trans-tibial stuff, and I agree with you there's many ways to skin a cat. I'd love to hear your perspective talking about the transfemoral prostheses. Now I've been in my career while it's not been 37 years, kind of all over the map, right Sub-issue issue, containment, ramel, containment, moss, no moss, all the sockets, ucla, northwestern, sablitch, all the things, and I think this is one time that I'd love to get into the weeds just a little bit and just hear your journey. And then where have you landed now? So yeah, that's how we.

Jeff Denune: 46:06

So, brent and I, I do a pretty good job. At least I should say, I believe I do a pretty good job of laying low on social media.

Jeff Denune: 46:14

I struggle with keyboard warriors. I do not think everybody's right, I do not think everybody's wrong. I think everybody deserves an opinion, right, I think we should respect everybody's opinion. Unfortunately, we live in a society today, with social media, that somebody can have an opinion good or bad, whether you agree or disagree, and they get attacked. So I tend to lay low on social media. This one time I happened to throw something out there and Brent messaged me privately and that's kind of how this whole thing started today. So I'll do my best to keep it short. So this is a conversation Brent and I had offline which led to this podcast today. He was talking about issue containment, issue containment sockets and CAD and 3D printing, and he and I talked a little bit offline and and so when I worked for this international manufacturer, I, I taught their educational classes. So this would have been early 2004, late 2003 to probably 2005 or 6, something around in there.

Jeff Denune: 47:13

Um, I would teach a transfer moral class, and I don't mean this to be disrespectful, I truly don't. I would have colleagues come in that are very skilled, prosthetist, orthotist, couldn't measure residual limb length. I'm not being funny, I'm not trying to be snarky. You know, sometimes we have to step back and look at ourselves very honestly in the mirror. I had a huge advantage because these patients that were in the class were my patients. I already knew the residual limb length. I worked with them every day. These were research and test patients, et cetera, et cetera. And I would see measurements, residual limb measurements, all over the board for this one patient just for example. And the problem with that is the realization that came to me is now that patient's going to suffer, and let me elaborate a little bit. If the socket's too short, now we got to cut it, split the diagnostic socket and maybe get it right and lengthen it. If the socket's too long, then we're putting a bunch of padding and stuff in the bottom and again, I'm talking diagnostic here, please know that. So they're all over the board. But you just blew a diagnostic socket and you blew that patient's time, maybe two or three hours of that patient's time and your time modifying, et cetera, et cetera.

Jeff Denune: 48:25

So I came to the realization that a lot of prosthetists struggle, palpating, locating ischial tuberosity and getting a good residual limb length on transformoral patients. Some can agree, some can agree, some can disagree. In this podcast it's all good, I've seen it, I've lived it. So what I started doing was I started measuring this would have been again around 04 to 06, measuring from the perineum to distal. Why did I do that? Because I could teach that. I could teach you to take a link gauge, push it into the perineum and get a good residual limb length. Is that ischium to distal? No, understand, we're using CAD at this time, right, so we're using brem templates at this time. So, but it had an ischial tuberosity landmark. I had to know that to get my limb length. So what I would do is I would teach my students to measure perineum to distal and add three quarters of an inch. You're pretty damn close. That was kind of how it all started, um with with again CAD, rem templates and things like that.

Jeff Denune: 49:25

At the time I was working with an individual um who was working on a surgical technique. At that time they were patella grass. We had about seven or eight patients at that time that had patella grafts. So if these were elective surgeries or traumatic surgeries where the patella was still intact, they could do the amputation. Leave a long transformoral amputation, take the patella, suture it there so they could fully inbear. I hate to use this word, but this is the easiest way to explain it. It's kind of like the transformoral hurdle. I hate to use this word, but this is the easiest way to explain it. It's kind of like the transform oral hurdle, just for layman's terms. Well, these patients could inbear. They didn't need ischial containment, they didn't need that socket shoved up in bad areas. So we started experimenting with lower trim lines About that same time.

Jeff Denune: 50:14

This would have been 05, 06, 07, the Limb Logic came out at that time. So 05, 06, we're prototyping and fitting things. My next big project after the release of that would have been 07, 08, would have been the Transformoro version, which is a side mount pump in the sub-SQL designs at that time, mount pump and the sub-ish skill designs at that time, um, I got 10 kinds of hell from a lot of very close, respectful clinicians or friends of mine. I had a friend of mine fly in because he actually telephoned me and said hey, you can't do that. I hear you're cutting brims off the sockets. I'm like whoa, whoa, whoa. A little more to it than that. I'm not just cutting brims off the sockets, I'm like whoa, whoa, whoa, whoa, whoa. There's a little more to it than that I'm not just cutting brims off the sockets. I have a CAD program. Here's what I'm doing. It's volume controlled, it works with vacuum, blah, blah, blah, blah, blah. And he ends up coming in spending two or three days with me and couldn't believe what we were doing. It's just like anything, right, I said it earlier in the program Nothing is for everybody.

Jeff Denune: 51:20

So at that time we were developing the Transformer LendLogic system, side mount pump and we started experimenting with lowered trim lines. At that time I was actually starting to teach it in some of the classes and somebody actually trademarked it. Another prosthetist who I know ran with it and he trademarked the brimless socket. I hate that term. They're not brimless, they do have a brim. So that's when I think a smaller group of professionals got together and said this could be dangerous, kind of like the socketless socket, right, well, how can you charge for a socketless socket when you don't have a socket and kind of the you know the who's on first outcome. So I think a smaller group of us got together and agreed that sub-issual they're really sub-issual style sockets and I really think that's where the birth of the sub-issual socket design came, and that would have been again early 08, probably to 2009-ish, probably 10 maybe, and that's kind of where the sub-issual design and style came from, with vacuum style sockets at that time. Does that help at all? A little bit.

Brent: 52:31

I think that's an interesting perspective and I think one of the things that I took away from our conversation after we talked was it all depends on the patient right. And you know, one of the things that I think and I and it's a measurement that I still take to this day, and I learned this from Dale Perkins from Coyote Design is he goes Brent. It just kind of like what you said you add three quarters of an inch to the perineum length and you're in the ballpark. He said what I do every single time I take a measurement, trocanner to trocanner, I divide it in half and subtract a half inch. Your socket cannot go past that, or you're into the other side of the patient's leg and that's stuck with me for a long time and that has also been another turning point for my. You know practice as well, as like when you're modifying this or even doing the digital modifications and you're throwing brims and such on that ML, you cannot go across midline. That's just. That's just. That's just the way it is and I love that.

Jeff Denune: 53:40

Yeah, and I and I think again, there's a lot of different techniques and systems at work I fit some people in some issues that hated them. So, please, you know I do not and I will not notice. You know me and my close friends, um, I'm very honest, honest to a fault. I get in trouble a lot of times for my honesty and that's okay. You know, I grew up, uh, as I said, in marine corps family and I remember something my dad always said. He said, um, you may be mad at me today because I told you the truth, but you'll never be mad at me in two weeks because I lied to you. But if we can work in that environment, then we're good. It doesn't make me right, it just makes you know I have an opinion, just like you have an opinion. So there is no one system for everybody. I have fit people in sub-issue style sockets that hated them. Right, it's the truth. Um, it's not for everybody. I fit people in sub-issue sockets that have loved them. They'll never go back to an issue containment socket. So, um, I just think we need to be honest with ourselves and honest with our patients and try some things.

Jeff Denune: 54:37

I have a gentleman right now who I'm getting ready to start fitting. Awesome guy, short transfer moral amputee. He has very, very high proximal tremolines right now and it is eating him alive and he hates it. He's asked me if I would try to lower the trim lines and do some things with him. So I'm going to try. Right, I'm going to at least try. All we can do is try to give it our best. As I explained to him, let's try, and if it works, that's awesome. If it doesn't, then it's a shorter transfer more. We may need to go back to the little higher trim lines.

Brent: 55:17

And again, maybe I had the luxury of doing that.

Jeff Denune: 55:18

It goes back to what you said earlier. Maybe being this, this boutique style facility, I can experiment maybe a little more, um, because I I have a little bit more bandwidth as opposed to maybe a higher end or higher volume style facility. Um, but I'm going to try. Right, I couldn't live with myself if I don't try.

Brent: 55:42

And I think that's a great mantra and I think that's what moving stuff forward. And then I think it really applies to the additive manufacturing side too. The additive manufacturing side too, you know the this idea of, hey, can we do clinically relevant things using a technology that is growing, a kind of a moving target, uh, materials coming out that are new and different, and how do, how do we do that in an effective way to not also just mimic the traditional fabrication. I think it's so important, and sometimes you fall on your face and sometimes you're surprised.

Jeff Denune: 56:28

That's what I said earlier. Right, I've done my most growth in the Valley. I've done my most growth at times of failure. If we continue to have success and success and success, is that really the best you can do? So you know, it can become discouraging, right, you can become an island sometimes where you feel like you're failing, but at the end of the day you might be surprised what you learn from your failures. It pushes you a little bit harder to go a little bit farther, to really try something, and maybe that's good, maybe that's bad. It goes back to we're each individual human beings and we digest information differently, and I seem to strive on my failures and that's what pushes me to be better. It definitely has some, definitely have some tough days, right, where you get frustrated. You go home and think, wow, could I have done better? Could I really help that person do better? You know they relied on me. But then there are other days where you you push something, push a boundary and really take somebody to the next level. I'm getting ready to do a project and really take somebody to the next level. I'm getting ready to do a project.

Jeff Denune: 57:41

I just did a very, very small, single subject project which is getting into weeds a little bit here. I keep going into part two to this, maybe. We just did a study with a trans-tibial amputee. We tried three different shoes on this amputee and then we recorded data using this tracer assessment software and I am shocked by the difference his deviation, his acceleration, deceleration, his lateral movement with three different pair of shoes. All we did was same prostheses, same prosthetic sockets, everything the same same day. And we tried three different pair of shoes. All we did was same prostheses, same prosthetic sockets, everything the same same day. And we tried three different pair of shoes on him and we collected assessment on this patient and we actually found a shoe that no question performed better. You can see the data. It's not not anecdotal, right? You can see the data that he definitely performed better in this one style of shoe I share.

Jeff Denune: 58:33

Why do I share that with you? Why do I find that exciting? Well, what about feet? What about prosthetic feet? What about prosthetic knees? What about prosthetic socket designs? Is there one foot that performs better for this patient over that patient? I think potentially could be right. So if we can do that with shoes, what can we do as prosthetists? Orthotists, can we get into orthotics, we're getting into the realm of orthotics and can we put an orthotic on somebody that really performs better, um, a certain style orthotic. So I'm super excited about that project. It's. It's getting ready to kick off, maybe next month or two, um, but yeah, I I've definitely done enough failing. That pushed me a little bit saying yeah, maybe we've got to look, maybe we got to look, maybe we got to look outside our bubble a little bit, totally, totally.

Joris: 59:15

And, jeff, I think we could do a second, a third or fourth episode here. We're having so much fun talking to you, uh, so, but, but thank you so much for being on our show today I appreciate you guys having me.

Jeff Denune: 59:27

Like I said I, I was talking to brent a little bit offline. I tend to. I tend to lay low a little bit in social media realm, um, but we were talking offline and Brent's doing some great work, excited about him pushing 3D printing. I'm very passionate about 3D printing. As I said, there's no plaster currently in my facility. I have 3D printers and scanners and technology there, so excited about where you guys can take the future and continue to push the boundaries.

Joris: 59:56

All right, yeah, thanks a lot for you two again, Brent.

Brent: 1:00:00

Oh, this was great and yeah, I loved hopping into the weeds, kind of hearing some of the historical perspective and, and I think probably the most significant thing out of all this is, you know, not only the discussion about the, the boutique versus some of the large companies, how that works, how to take care of patients, I mean that's all stuff that's very important. But the other thing to remember, just like Jeff said beforehand, is there are a lot of people that have come before us in the technology I mean, jeff's talking about 3D printing stuff in the early 2000s and there was even some before that and you know we've talked to remember and kind of step back that we are standing on the shoulders of giants that have gone before us when this stuff was like really, really hard, very analog, and and I think you know that really comes through with what Jeff has said over the years. You know it's definitely gotten easier and it's going to be easier for the next generation, but it's this progression that's been built on history and I think that's important.

Joris: 1:01:24

Totally, totally, totally, and yeah, it's a good, good, good point, good points all around. So we should probably do this again, guys and uh, but thanks a lot for you guys for listening to another episode of the prosthetics and Orthotics podcast. Have a great day.