Why Global Thinking Matters in Orthotics and Prosthetics with Hugh Sheridan

We explore how pricing, policy, and 3D printing are reshaping orthotics and prosthetics from the UK to the Gulf and across Africa. Hugh Sheridan shares hard truths about aid that bypasses clinics and a road map for sustainable, locally led care.

• roots in shoe materials evolving into O&P supply chains
• UK reimbursement pressures and the pivot to prefabs and 3D printing
• UAE as a hub versus Saudi growth and privatisation
• pediatric disability needs and cultural barriers to access
• why direct aid can starve local clinics of patients and revenue
• franchise-style partnerships as a sustainable aid model
• China and Turkey’s rising role in components and materials
• open materials, SLS/MJF economics, and avoiding lock-in
• central fabrication versus in-clinic making and clinician psychology
• direct scanning, hybrid workflows, and protecting clinical value

Special thanks to Advanced 3D for sponsoring this episode.

Transcript

Warm Welcome And Holiday Banter

SPEAKER_00 0:01

16 and 13 of the prosthetics and tests. This is where we connect with experts in the field, patients who use these devices, physical therapists, and defenders who help bring it all together. Our mission remains the same. To share stories, tips, and insights to help improve patient outcomes. Tune in and join the conversation. We're glad you're here and hope it's the highlight of your day.

SPEAKER_03 0:26

Hi everyone, my name is Yoris Fields, and this is another episode of the Aesthetics and Methodics Podcast with Brent Wright. How are you doing, Brent?

SPEAKER_01 0:33

Hey Yoris, I'm doing well. Happy New Year to you. Happy New Year to you as well, man. Happy New Year.

SPEAKER_03 0:39

So next time with family and stuff like that?

SPEAKER_01 0:41

It was, it was. We were in Orlando, and I got you a Christmas present. I'm trying to figure out how I'm gonna get them to you. But uh I I saw that you saw them uh on LinkedIn. What'd you think?

SPEAKER_03 0:54

I don't know, yeah. Um so they're like they're stocks with like Brendan Ly's face on it saying the stocks are the expanding line of swag uh for a fucking very very exclusive exclusive.

SPEAKER_01 1:08

Yeah, well I figured you know that they're gonna be perfect for uh New York, you know, when you're here in New York and they wear that with the suit and tie, you're ready to rock and roll. I never thought my face should be on a pair of small phone so it's a very good stuff. Well, and here's the thing that I I the reason why I thought this was cool is and and just like you had said before, like, hey, I love that two guys are making custom stocks and making a go. They've been doing this for 10 years. Um and um they literally sell stocks around the world. They're they're they are world famous, two guys. They have a uh a small shop in a very high traffic area in Orlando, and they have just a great collection. And so I just thought like how how appropriate too, because we're talking about orthoses and prostheses that are very custom for a specific uh niche. Uh I thought it would be kind of appropriate uh also.

SPEAKER_03 2:05

Thanks, man.

SPEAKER_01 2:07

Okay, um uh oh hey, we we've got a guest uh today, right? We do, we do. Um so I wanted to introduce you to Hugh Sheridan. He is, and I don't think we've ever had anybody on the show that's actually living in United Arab Emirates. I think we had one person that was on the stopover through United Arab Emirates, but he's doing a lot of really neat things in the Middle East, and um he's he actually has quite a few followers on LinkedIn, almost 25,000 followers. And um, you know, one of the things that's interesting uh when I talk to other vendors and such is they just talk about how the Middle East is really coming into its own, especially in orthotics and prosthetics. There's a lot of uh a lot of 3D printing that's happening. Uh, and I know like 3D systems is there, HP has a presence there. Um and so I'm really curious to kind of hear what's what's going on in his world. We've actually sat um on a couple podcast webinars. Um, I think one of them was for Ispo uh recently, and so I thought it would just be really cool to hear what he has going on in that part of the world. Awesome, awesome.

SPEAKER_03 3:27

So welcome to the show, Hugh.

SPEAKER_01 3:29

Thanks a lot for inviting me.

SPEAKER_02 3:30

Happy New Year.

unknown 3:32

Happy New Year.

SPEAKER_03 3:33

Yeah, happy new year to do. And and so how tell us how you got involved with uh OMP.

From Shoe Materials To O&P Supply Chains

SPEAKER_02 3:38

I've been involved in the OP industry since I was 10 years old. My father bought a company, they bought a company, a shoe repair wholesaler in Liverpool, um in the United Kingdom in about 1989. And a shoe repair wholesaler has everything that you'd imagine for um shoe repair, but also orthopedic shoes. So there were some orthopedic shoe customers. Um, one of them originally was the technician who worked with Hugho and Thomas. Now, in the orthotics world, everybody should have been taught about the Thomas splint in the First World War, and then the history of Hugho and Thomas travelling around teaching bone setting in the 1800s and 1900s. Well, that was all based in Liverpool. Um, so that business kind of um merged over a 20-year period into the UK's largest material foot health um company selling capital equipment materials to the like of all the service providers, the likes of Blatchford, Steper, um, Otka, all through Europe. And then over over a period of time, I we we we opened businesses in Australia. We had Taiwanese procurement offices, Indian business, a UAE office. Um, we had an office in California for a time. Um, but it was all it was all very very much focused on materials. I'm kind of a material geek, and that's where I get. So I'm not an authorist process, I'm very much a commercial beast. Um, and I've been involved in different businesses. And with a family business, you're always very lucky because you get to experience parts of the industry perhaps a clinician wouldn't do. You know, you get to visit factories and you get to understand commercials and the manufacturing um side of things. And then also the the the flip side, which is kind of the reimbursement and what you know, how do we make money out of all of this?

SPEAKER_03 5:33

I think it's interesting. Uh I think it's interesting, by the way, because in the 1980s, well, 70s and 80s, this the shoe industry, generally in Europe, also especially that Liverpool area and the UK, was very strong still. Um, and this is like a very risky time to buy a shoe wholesaling business, just as this European manufacturing thing started to really collapse, right? And we used to make like a uh not like a cigar sizable, even in as late in the 90s, I think, we made a sizeable proportion of the world's shoes, and this has just you know gone to almost nothing now. Uh, so that must have been a really risky bet, or or did it did it just seem like a risky bet to buy a business like that?

SPEAKER_02 6:11

I don't he didn't buy it for the he did he bought it to do something else with it, and then and then it just so happened that it it gave it gave the family revenue in that in that part of the business, and there was a there was this niche in orthopedics, and this niche where orthopedic shoe and especially photopotics was just starting. So uh originally it was this kind of um we we were the people who brought in the first true prefabricated insole that's that saved the NHS, which is the UK health system, huge amounts of money. And in the end, we were probably by 2000, I left the business in 2016. By that time, we're probably selling a mil over a million pairs of prefabricated insoles, it just didn't really have customer service. So it was very in that 20-year period, it went from almost no foot orthophotics being kind of procured. And if if they were procured, they would they were um generally custom made from a foot foot foam fresh and box or a plaster pasta paris hoard in um to a very slick system of in in podiatry. Also the uh the actual orthotics prospet the orthotics industry kind of ballooned as well. So there was there was for for a while there was kind of good money good money in the UK. We did we did supply all the shoe manufacturers left. So you've got all the gent all the high-end gentlemen's shoes, which you've got and got Joe Lobb, um John Lobb owned by Prada now, church shoes. So we supplied with tow puffs too.

SPEAKER_03 7:37

I have a pair of those, by the way, they're amazing. Yeah. I have a pair of churches, they're amazing. Crockett and Jones have as well a pair of church shoes that are.

SPEAKER_02 7:43

So my favorite, my last are Barker shoes, but that that's the problem, they last forever. Um and they're very, very expensive, and they're kind of they're a luxury item, and the volumes compared to what um they used to be in nothing, but it was always a very good um as still a number of different businesses in the UK just focused on custom you custom orthopaedic shoes. Um much of much of the install business now because of the very low reimbursement rates, has kind of gone to 3D printing in the UK.

SPEAKER_03 8:16

Okay, and and and just talk to us a little bit about like if you're talking about a gentleman shoe like that, like a brogue or something like that, what the part that you guys supply is it, the cork or the the the the the rubber portion? What is it that you make?

SPEAKER_02 8:28

So one of the weirdly, the one of the first deals my dad did was actually fly to Portugal and go and got cork. So we were cork merchants. Um and that's that's where we that was one of the key products originally in the late 80s. Um before polypropylene and polyethylene, you could start to get into different products, but no cork. Also, we would have supplied to like to church and John Lobb all the toepuffs heel counters, um, which were made of resin, fermoplastic resin. Um and then they were cut, depending on the last, they were cut at different periods. But they would do they do batch manufacturing, so you get an order for 500 to a thousand pairs at a time. Um, and it was hard, it was hard business really. I would stole that part of the business in the end. Because sadly, even at though, even at the luxury prices, we couldn't we couldn't make it work.

UK Reimbursement, 3D Printing, And Cost Pressures

SPEAKER_03 9:14

Oh, okay. And then and then in uh you mentioned that the the the a lot of the uh orthodox businesses went to 3D printing. Is it is it in the UK now, is it the lowest cost option for these kind of like orthotic kind of custom made insults? Yes.

SPEAKER_02 9:30

I mean you the one of the the issue with well, there's lots of issues in the UK. I I lived in the UAE 15 years ago, then I went back to the UK. Um and that what one of the and then I came back into UAE, so I've been away from the UK business, but I kind of keep up with what's happening. But there's but just the different price points that the the service provider, all service providers are on contracts, you don't generally have a reimbursement system like an Elko system. Um Germany, perhaps Holland get paid three or four times what they do for the UK. So let's say for for a an AFO, you'd probably get paid£150 sterling, which is about$180,£190. Even then that, and you'd struggle, and that would probably be a unilateral. You'd struggle on some contracts to get a bilateral IE a pair of AFOs. Um in terms of insoles, you again you're not you're not getting much. It's gonna be about$70,$80 if that included including the time and the service and the patient care and everything else. So the UK is uh we we we have a very fair socialized medical system, but that doesn't mean much for for the kind of uh the the system of OMP put it that way. So you have to you have to design your business around costs first all the time.

SPEAKER_03 10:54

And then and how about like uh like if you if you look at uh do you think 3D printing will the the Marshall 3D printing will continue in that in through the lot of the prosthetic stuff, or you're what are you thinking about and that's uh and that's a if it makes sense because it was far this is the personal opinion, I don't think there's enough pressure from the commissioners who can who write those large volume contracts asking the right questions about outcomes.

SPEAKER_02 11:18

So I I think it's it's almost too weighted towards cost, and therefore they'll will always be charging themselves to get the cost down, which is difficult because even$150 for an AFO and generally the state of the industry is that technicians there's a small population of orphatists, let's say a thousand orphatist rosters, there's probably the same population of technicians, and the technicians sadly are apprentices, they leave the industry at 20 between 25 to 30, and they're all they're all on a a minimum wage. They generally generally start working for these for the contract providers about 17, 18, and they train them up. But the fact is they it's still cheaper to use technicians over um 3D printing. You can probably see a slight there'll be a slight kind of hump when that kind of um stops working, but it at the moment I can still see it like that.

UAE Vs Saudi: Markets, Policy, And Privatisation

SPEAKER_03 12:16

Okay, okay. And then and and how about the UAE? Because we know absolutely nothing about that market. What is that like? Because there is like there's strong, kind of like there's a strong entrepreneurial culture, if you will, but there's a lot of government involvement, a lot of things where they want to make you know lead the world and stuff. It's kind of very, very government directed. So, what's it like to work in that that area?

SPEAKER_02 12:34

Um, I move to the UAE because I believe India, Middle East, Africa is kind of the next hundred years, 200 years, so it's a good place to kind of base my children. That's why that's one reason we we we have in theory, it should be safe. Um the UAE actually isn't a great market. The UAE is a has a population of 10 million people, only a million are local Emiratis, the rest, but nine million are actually expats. That means there's potentially eight million, eight and a half million of Indian, Pakistani, Bangladeshi. The rest would be English, um, Chinese, Russian. So there's only government reimbursement in the UAE for um those one million, and they have very, very five star very, very good five-star, seven-star hospital system. Um the actual contracts used to be very, very best, much better 15 years ago than they are today. Um, but they are f but the reimbursement is similar, if not slightly better, than Germany, Netherlands, and USA. Definitely better than USA, I think. On a par with um the bet the mo the reason the much better market where we're seeing a big change is Saudi Arabia, where there are real incentives to build orthotic prosthetic businesses for the government. Um as they because they're privatising most of their there's about 50 workshops, and these are large-scale orthotic prosthetic workshops in Saudi Arabia. And over the five to ten years I'll be privatizing all of them. So what happens with that is a huge volume. Um the population of Saudi is about 40 million, and the expats are only four million. So there's much more government is controlling a much, much bigger pot with real invert with real reimbursement. So it's going to become a very um that's quite one of the reasons I joined was because I spend at least one week, two weeks a month in Saudi. Um multiple different opportunities in manufacturing and also status provision. So UAE is a great place to kind of as a hub, um, but the local cloud p market's quite small.

SPEAKER_03 14:39

Um also, and if you look at if you look if you look at something like this, like is it true still? Because it used to be that the UAE was a place you lived and you did business all over it. But if you're doing business with government entities and stuff like that, local language, if the big market is Saudi, would it be kind of you know, does it still make sense to be in the UAE? Uh or or would it be make more sense even be in those countries where you're trying to sell to where the big market is, even though living there would be a little less convenient?

SPEAKER_02 15:05

So for what I do at the moment, um, it's easier for me to be in the UE. However, two years ago, the Crown Prince, because Crown Prince came to power in 2017, he changed everything overnight. And the entire country is completely different to what I I knew 15, 20 years ago. But basically, the Crown Prince said, right, if you if you as a company, let's say you're HP or Microsoft or any other kind of corporate guys, if you're regional director, your CEO of the Middle East or whoever, if you don't relocate to Riyadh or to Saudi Arabia, you're just not going to win any government contract. So if there was the need it was kind of a huge everyone, every everyone had to pick up pick up their sticks and move to Riyadh. But wives weren't too happy because Riyadh still is going for its transition, so it's still not really a Western life. UAE is very much Western, kind of it 50% western. Saudi is kind of more difficult to live. Again, that might change the next five years, but it's um so currently with what I do, I don't have there's all certain things that are trying to trap you. Tax issues are trying to trap you onto if you have a different types of business in Saudi. But the moment I'm okay in the UAE. It's an it's a very different place to live, but it's a nice, it's a great place to bring up children.

Conflict Zones, NGOs, And Sustainable Care

SPEAKER_01 16:25

So one of the things that I see that you do post on uh frequently, and I just know from some of the past, like you do care a lot about access to orthotic and prosthetic care for kids, but then a lot of the stuff that's going on in the Middle East, you've got the Gaza stuff, Syria stuff, that sort of thing. Are you able to give us just a little bit of insight into what's what's actually going on? And then how can people truly help, right? Uh for those areas. And you know, I know in your newsletters uh you've also written some, I believe, uh it's I I think I saw one, at least the title of it, about like how how do you actually uh make uh longstanding help rather than either some NGO or um you know group come in, parachute in and try to help like 50 kids all at the same time, yet you're leaving hundreds of thousands of people without services. Uh I'd love for you to share a little bit about that.

Rethinking Aid: Franchise-Like Local Models

SPEAKER_02 17:34

Um there's a f I think there's a few different points there. So if you I always say I'm in, so I started this newsletter in and it's called inmayascpo.com. It's now become a website. We have it, we kind of it goes out every Tuesday. UmmayScpo.com. I started two years ago to kind of highlight some of the first of all, the entire region of India, Middle East, Africa didn't really have any kind of news channel celebrating or connecting processes offices. Any any marketing you saw was always a whiteface from either Otto Bok or North American vendor, or also you know, they're always happy white faces. And although I'm a happy whiteface English friend, I was I was kind of always frustrated with that concept. And I have because I've travelled I've been lucky to travel across most of the region for the last 20 years. So that's one of the reasons I started we don't make any money out of it, but it's a great kind of connector and it pull it pulls together different stories. There's a there's quite a lot people don't perhaps understand about the different parts of the region. So Indian Middle East Africa is broken down to India, Middle East, and then Africa, they're all completely different. Um, even the Gulf countries within Middle East are completely different to the rest of the Middle East. But to understand kind of historically, because all of these countries are pretty new. The UAE only actually came into existence in 1971. Yeah, 71. Um, Saudi only came into existence really in 1946, Israel was 1948. These countries are are younger than my parents, um, and they've they're going through this almost teenage transition stage, um, trying to grow up, um, whereas our countries have been around for a couple of hundred years at least. Within Arabia, so let's forget the book the borders, because many of the borders were written by um or drawn by British people with with rulers, so none of the borders really exist. You have a you have a mark, different markets where the different cities are connected in originally by camels, and in many cases it's still the same, so they have different markets of Riyadh Jeddah Dubai, but they're all on the same mid-continent of Arabia. Because, and this is still true today in 2025, because of the intermarriage within within um the Arabian families, especially across the Arabian Peninsula, um congenital deformities at birth are eight times higher than the USA, which is so there is this not just in Saudi Arabia or the UA or Catar Kuwait, but across the entirety of the you there's always been this pediatric disability issue. So we have many, many um pediatric PT rehabilitation centers. Sadly, the culture of the of the region is still to kind of high disability. You know, I do I always say I'd never see a child in a wheelchair in a shopping mall. And that's on, and I've lived here and I've been around for 20 years um traveling back with that. I find that really, really sad. I see a lot of them because I visit these pediatric rehabilitation centers. Um, generally they're run by very kind of wealthy um philanthropic groups. So there isn't a money problem at all. These are very wealthy economies. Um, the money problem that comes for places like Egypt or Palestine, uh West Bank, Gaza, Syria, Georgia, Iraq, where again they're very new. Iraq, you could argue, is a country which is still at it's less than 20 years old. Um, Syria is literally just brand new because um Assad has just left, so that's only a year, two years old. So how do you how do you help? Um in Palestine it's difficult, but that's a whole political conversation which perhaps shouldn't get into, but it's gonna at the moment no one can go into Gaza. It's very it's virtually impossible. I know a few people who've who've been, but at the moment it's it's still locked off. You can't actually see a kid, and there's 6,000 um pediatric amputees, child amputees in Gaza right now, and we can't see them. We can we can't help anyone to go and see either, which is frustrating. They're gradually coming over the Egyptian border into Cairo. So the Cairo private market is doing it for cash, but there's no real um at the moment, there's no real government or United Nations helping that system. What the the perhaps the another point which I kind of I do make I try and make quite strongly is the Because if you look at the WHO and the ICRC and all the different United Nations development groups, and then also people who collect prosthetic components in order to reuse prosthetic components and sometimes even donate the sockets and then maybe thermo mold or just force fix a prosthetic solution. The issue I've got is that although most of the industry, but we don't talk about it enough because we're all kind of a slightly bit scared, um is but it's it's going straight to the patient. You're writing off the entire lithotic prosthetic industry, stroke community. The ICRC um is giving away the the actual solution for free, which doesn't allow any now let's say um in Sudan or even in Egypt or Libya, um the funding of that of those components is going from the ICRC straight to the patient. If there were there may be um 20 or 30 private authors processors who can't get involved in that project, and they should be getting involved with that project. There should be almost a secondary market helping and assisting and building a long-term reimbursement model so they can actually market themselves to referral groups, they can lobby the government for true, for true financing, for true reimbursement. You know, and it's but by gifting componentry with service away on in all these countries, it's kind of not allowing any of these markets and industries to kind of flourish. Because then they can't, they don't they can't make profit, they can't make margin, they can't then improve their service, they can't improve the devices, they can't then go buy 3D printer because there's no money to buy it, and there's no there's no volume to buy to serve it, and it's uh it's a real frustration. And a lot of people come to me privately and agree with some of these articles right um or written, saying you've you've said we need to kind of keep pushing. And it's it's uh it's to me it's ISPO who should be ringing the bell for this, but my opinion of ISPO isn't there as high.

China, Turkey, And The New Component Economy

SPEAKER_03 24:10

And is it also like, and would you what would you argue for then? Let's say you were in charge or you you would be able to change it. Would you argue for that because one thing you could be doing is stimulating much more the local market, right? Or giving them money, setting up workshop. What kind of approach would you think would be uh an effective approach?

SPEAKER_02 24:25

It's it's to make it's to kind of almost have a it's a bit like a hanger, isn't it? It's a bit like an or not a hanger, but it's a um it's almost like a franchise relationship. So for instance, the ICRC devices are made by a Swiss company. Um I probably don't know my name of a Swiss company. Anyway, they're attempting to they're attempting to start to privately make the certain ICRC product catalogue distributed through the different CPOs in all these countries. The problem is that it's it's so well subsidized by the ICRC that you a sash for is$40. But a guy in a guy in Tanzania in Dar Salam can buy the minimum quantity, can buy a sash for$6 from China. So I suppose how how do you do it? How would you do it? It's almost like how do you protect those patients so those patients can can can fill the pipeline of um but the private orthotic prosthetic market. So you need so in my in my eyes, it's almost like a franchise system of you, you know, you'll be our preferred or preferred partner in this region of this country, and then we'll make sure that all the patients go for you, and and we'll we'll and if you do it on a contract, we'll pay you for this much money. But it's up to you what you use. You can't, you know, you don't have to use the$40 SASF. You can use the$6 as foot and make an uh make$35. It's kind of there needs to be a rethink. I mean break if the problem is it breaks all the rules of the ICRC and some of the thinking about United Nations, but unless we're always gonna be the poor the poor man across the region unless we start thinking differently.

SPEAKER_03 26:11

And how and how about like the the commercial market there? Like like do you you know, do you try to get business a lot in a place like Tanzania and Kenya, a place like that? Is there an emerging commercial market for vendors there as well?

Government Tenders And Local Manufacturing Push

SPEAKER_02 26:22

Yes, very much so. Um and then I have a business called Kadir, which we set up primarily to do um originally it was to do government tenders as well as capped equipment, and that's why we've been doing more 3D printing deals. Um you can't the Chinese are getting very, very powerful around both but the countries really who control the market for materials and componentry are the Chinese and the um the Turkish. The Turkish have done very well for North and North Africa and also Middle East. The India has a very kind of well-protected market for materials components, but China's really big. China's kind of changing the ball where let's say if we go back to 20, I was at ISPO in Stockholm, and this changes how to meet it changes different opportunities for 3D printing as well. You you know, if you wanted, let's say, just again, let's say stick on sash feet, you'd have to really do left and right, and you'd have to have a minimum order of let's say 100 to 500 units, and therefore you'd have to take a an option to kind of buy, let's say, 500 units or 250 left and rights. Um they'd normally all come beige, but you're selling into a place like Tanzania. But I think there were five or six Chinese manufacturers, and most of them didn't have any minimum order quantity. They could do any colour, PU colour you wanted, and they could send it to you in 10 days. Now you could now as a UK European company, you can't compete. You can't literally you cannot compete with that with that customer service, shipping out of China. Um, now you can only buy so much, but and the price is slightly elevated, but they're still but you can still build a very good business out of them. So I so I focus on the some of the government tenders, which again across Africa, you know, there were some very basic, let's say, BK sets we were seeing 10-15 years ago. We're now seeing much more advanced thinking around manufacturing. You know, they they want to get into 3D printing, they have no idea where to start, um, which I suppose is the opportunity, but they kind of want to be handheld and work out okay, so we don't, as a government, we don't believe we haven't got the right skills, but we could centralize using digital workflow somehow and digital manufacturing to make sure the margin stays in the country, um, which is which is a big trend, that's a big trend across the region. There's an awful lot of incentives to make sure manufacturing stays in the country and that and it reduces the balance of payment.

SPEAKER_03 28:56

I think it also makes sense, it's sensible, and also you could imagine them saying, oh, wait, there's some manual labor custom stuff. Hey, that's something I can do, you know. Maybe we can't make cars, but this is something we could make. I mean, I think it's also, you know, it could, it could, it would feel like their sense of pride would be like, come on, handcrafted stuff, we could do this. We got this, you know.

Why 3D Printing Adoption Stalls: Cost And Culture

SPEAKER_02 29:13

And also, and but the big again, the big challenge is the is how how you know the skills perhaps aren't there, um, although certainly not there compared to Western Europe or North America. Um, but even even the a class one ISPO um CPO there's still you know, even in the UAE, I know Pakistanis are only getting paid maybe$400 a month,$500 a month as a class one CPO. So it's a guy, so all of when you're when you're a private service provider and you normally you're not getting paid for service, you're getting paid for on a manufacturing products. If you're only paying that actually for your service and your product, and the guy can make it as well, it's it's always more tricky to kind of try and uh build return investment models for capital equipment and technology, and that's holding people back. Um because it became it then becomes well, we'll buy a 3D printer just purely because it's a 3D printer and we can sell, we could perhaps sell it, sell the outcome at a higher price. And and again, I see that constantly. It's not it's again it's reason.

SPEAKER_01 30:26

So I mean, I know you've been around the the business side a while. And um, you know, what do you with your experience and then you knowing the business side well, uh what are some of the things that are kind of holding back the adoption of say 3D printing in the orthotic and prosthetic realm? And then I mean I know that there's been some concerns about not only uh reimbursement, uh not only in the US, but uh around the world for device, getting the value for what we do, but then also the recognition. So I know I know that there's a lot there in what I just said, but I'd be kind of curious just to hear from your perspective. You know, what you know, I've been doing this uh you know since I was a teenager, so sometimes I get my blinders on as a uh clinician, and uh yours helps me uh shed them every now and then. But um, you know, I think that's the biggest thing is having somebody look from the outside in and be like, hey, this is what you're what you are getting right and what you're not getting right to to really make a uh a big difference. And I loved you're you're saying, hey, for the next hundred, two hundred years, because that's that is a way that we should be thinking.

Open Materials, SLS/MJF, And Vendor Lock-In

SPEAKER_02 31:58

Um I'll speak I'll speak for um just this region, I suppose. Well, I well uh my feedback from if you like our customers it all comes down to cost. And sometimes I get lost because if if you're in the if you're in South Asia, everything is priced. The whole the entire culture is based on price. Um how you when you have a one and a half billion like India for instance, where you've got one and a half billion people, what the the the greatest value is the volume you can do, so you can so they immediately come back to almost kind of trading as a commodity trader, pricing, and it and that happens in orthotics prosthetics, and that because India-Pakistan are such big powerful forces in orthotics prosthetics, and most of I mean 80% of the prostitutes in the UAE are Pakistani, um, the rest probably Indian or South African, the Brits. Um, that kind of cultural mentality, and it's until unless you really live out here and work out here and go to it's kind of most of the Western world miss out, but everything's you can't get around that, so it's kind of priced. So people immediately look, okay. Well, listen, I've got a guy, I'm in Bangalore, I've got a tech, I've got a CPO, class what class one, class two. He's also a technician, he can make an AFOs are perhaps more interesting than insults, but like you can make an insult an AFO for um twenty dollars, and then and that'd be probably quite a good quality AFO. He's got he's got locally sourced ankle joint, he's got locally sourced polypropylene, do it for$20. Um, the price in India is only$50. But he's generally only gonna get$50 for his AFO. Maybe that's unilateral. Um, again, those these prices could be could be wild and different things, but that's basically how that Indian market works for AFOs. How so the his so him when the owner of that business in Bangalore is gonna say, well, how do I get to$20? And I think if you look at on a global level, you look at um how do we get to$20 for an AFO? Well, I we we actually got so my but before I came to the UAU, unfortunately COVID and all the lockdown kind of messed up a different few different projects. But one of the one of the things I was involved in was a country called Andy Armour, and that was an eight-year, in a sense, it was originally a research project. Um it partnered with EOS on SLS, um, a design an AI design platform before AI design platform was probably one of the first ones. Um we just kind of had a really tough time in COVID, so we stopped it. But what we started to understand, because we worked with SLS with VOS, and then we worked with HP, and then we started working with the chat some of the Chinese, um, Chinese guys, and it was just purely on cost. And one of the reasons we we're raising venture capital money, so we had to we wanted to get as low cost AFO um as possible in order to develop some kind of outcome measure within the AFO. Um, because we believed that that you could then tag and you could actually get a bit more added value on a an L code. Um it was a long project, but it's kind of we we sourced it. But in the end, we worked out on one of the printers which had a big chamber from China, we could squeeze down one print um if we had the volume to about$40. So it's and that and that's when we're using open, it was all open source, it was open source material. There's another thing because I'm a I'm a traditional manufacturer, no one's gonna tell me what to use kind of thing. Um, so I think when you look yeah, the the challenge I keep coming back to is the cost because that's what everybody looks at first. It's the cost of the capital equipment, but the cost of capital equipment can be financed, that's not a problem, it's the out, it's the output, which is the original thing. You have a thing that people come back and they people are scared of where to start. Uh, they have a they have a natural fear, um not perhaps the the younger CPOs, and this this region is interesting because I think it's there's 6,000 CPOs in India, which is still a tiny amount compared to the country, but there's like 50% of those are under 25, uh the age of 25. Saudi is the same, I think it's 35% is under 25. So all the younger of that generation are going to be very good and digital, but the problem is the managers are not of that generation, the managers of the departments are all kind of over 50 and are in place for the next 10 years, and they're all very, very fearful of how where do we start with software, where do we start with scanning, where do we start, you know, and that's that so there's two things there's cost, and actually this is the digital skill or the digital culture of maybe not the guy with that generation, but definitely that level, um that level of management.

SPEAKER_01 36:54

Um so I mean I want to do dive into the the aspect um because I mean you were kind of before before the time, right, with the SLS and then multi-jetfusion kind of came to to be, and I and I think there's there's something to your statement about uh materials open source and not being beholden to a an ecosystem. Can you expand on that a little bit?

Central Fab Vs Desktop: Shipping And Psychology

Direct Scanning, Hybrid Workflows, And Regulation

SPEAKER_02 37:21

Um so again, all my life I've been in materials. So um my first printed insole was 2000, I think it was 2012. My we had we had a problem in our business where we had let's say two, three million dollars of inventory of just sheet EVA or CAD or CAD blocks or polypropylene or polyethylene or or PU not support on PPT, you know, everything you can imagine in a in a orthotic prosthetic plate. And I could see this juggernaut in 2012 coming on, and whether it be powder, whether it be filament, I didn't know. But I felt we had to have at least some kind of offering in 2012. It hasn't happened as fast as you'd think. Um so the first I think the first um I went to Spain and I went and I met a guy in a garage who was making filament in his garage with his dad and his sister, and that was Philoflex. And it just started, and we had this TPU filament, and we could and the TPU was genius. Um the printer was hopeless. The extruder kept heating over and I could only print PDF. It kind of gets it kind of the model of the model of our material business was always it was open source. You could, you know, we weren't gonna tell you what material, and that could that's very important for the psychology of a CPO. You can't dictate um any manufacturer how he's gonna manufacture because all the all the competitive nature of your the product you're making is all in your skill, but it's also in the material. Um and our material generally gives it kind of a commercial value. So so we spent a lot of time with HP, um, who are genius salespeople and genius marketing people, um, and obviously do a huge amount to um push the use of digital in an orthotic prosthetic environment, however, and there's there's so many different solutions who aren't going to touch orthotics prosthetics from a marketing point of view. I mean, HP of a 50, 60 billion dollar company, they have a marketing budget, which can so they can touch a very, very small industry like OMP. But the there's other solutions which we're kind of finding. Um I mean the there's a there's a literally we just found just in the last few weeks, actually. We were we we found a Chinese printer which is an SLS printer. I can't remember the brand name of it. And it's a it's basically$8,000 for an SLS printer. I think it's common on the iPhone. The chamber size is quite small, but you can print about a batch of 12 pairs of installs. Um that only works if you've got um the commercials only work if you've got kind of open source and you can't and if you track back all the the material buying in orthotics and prosthetics, it it kind of it all goes back to China, Taiwan, or the raw all the raw materials. Now the wet the most of the um product that comes out of you know the huge volumes and the best prices for PA12 and P11 right now have kind of come out of China. And why so why aren't why would you choose any other way? So I think there will be certain distributors globally who's gonna pick up on this. Um because it's just gonna make sense. If you actually the economics completely start to change once and we've done we've all done the return investment for HP printers, but but there's just no other big brand who's come up because they probably never will, because why would they? The industries are far too big. Um what the other thing which I kind of find interesting is in our what in my world, in my in this Gulf region here, the biggest industries are oil and gas, right? So the but so the largest um printing operations are digital warehousing, you know, Emirates and also AdNok, and as well as Ramco, and now they've almost scanned their entire inventory of spare parts, and all the spare parts are getting metal being metal, um between the metal components. But the price list I see from China, Taiwan, um on metal powder, you kind of you maybe we're not there to support it and the and to build that kind of stream, but you know, just in time on demand metal components, I think is and that but that has to that can't be um a closed loop, closed circuit. There has to be um a complete open source material.

SPEAKER_03 41:51

And do you think do you think if you if you look at this world, like on the one hand, we've got the industrial 3D printers and we've got desktop and we've got services from China, and you just have that regular manufacturing from uh China just making molds and just regular manufacturing from you know just to establish larger players. What does that competitive landscape look like to you in a couple of years from now? Is it gonna be dominated by printing or cheap printing or cheap services? What do you think are the things that are gonna win out?

SPEAKER_02 42:17

It's an interesting well it kind of um it comes down to shipping cost. I mean, that's got as far as I'm concerned, these central fabs are gonna exist in places like China. And then it's all about the shipping cost. What I mean, even what Trump's done this weekend about a swelling has been anything wrong on it, but that's perhaps potentially in the next five years, we're gonna see lower shipping globally for both air freight and sea freight. So if you can get a if you can get a component or a finished good out of anywhere, to me, it doesn't make to me, over the next 10 years, 20 years, it doesn't make any sense to me to go to have central fabrication in these high-wage locations because digital takes it all out. The one thing where desktop comes in, I think, is again it comes back to the psychology of a CPO and the fact that he wants he's been taught to make stuff. Um and if and the educate and the whole education system has to be kind of will develop, hopefully. But while he's being consistently, while every single university doing um or fossil processing has a plaster room, for instance, he's being taught some to rectify, which is important by the way, but he's being taught to make stuff. So the culture of CPOs to make stuff, generally makes stuff for himself, because he believes if he makes stuff for himself, he can make a bigger margin on the stuff that he makes. And that's where I feel like there needs to be almost this kind of hybrid stroke model where he's maybe doing some central fab from other players, but actually he can still make more, especially when we've got such cheap wage rates across Africa, Middle East in. Europe I kind of see the same thing, but they're but you guys have you guys use C Fab a lot lot more than any of the rest of the world. Um maybe it's because you're also taught I don't know, it's just a different culture. But here they like to make their own things from scratch. Now that that I don't think that matters whether it's digital or whether it's um from sheet plastic or whatever, but I think that's that kind of it's the psychology of how they think about it.

Commoditized Insoles And The Value Of CPOs

SPEAKER_01 44:30

What are your thoughts about some of the I mean we looked at some of the direct scanning and I um and such, and then you've got uh Johan Weigel uh with the air fit, which I'm a big fan of, um, that sort of thing. So I think that there, in my opinion, there's a there is a hybrid way to get great outcomes. So hands, uh skip plaster, and uh and the actual manufacturing move to 3D, and then um the the fitting side of things, almost like the dental model. And I and I actually take your point very well on hey, if there's somebody that's good at fabrication, why not outsource at the same time where someone else that might not be their jam, but they're really good at evaluations and fittings. Um, I think that's a pretty interesting point as well. But where do you see the the world going as far as is it all going direct scan or is it going to be a hybrid, or what would be a preference just from what you've seen where our industry is?

SPEAKER_02 45:36

Um with Andy Armour, we actually we invented something called the hoogie, which was a polyaster cast. Because again, the skill is again, it goes back to me, it's the psychology of a CPO. You have to understand why they chose that professional it's actually a it's you're engineers, but you're actually um very tactile. So you're you have a great skill in your hands, you know, you're almost like a a pot a true creative engineer. Um and if you can't put a correction on a child's um thought for the cast is that psychology is that psychology robbed by doing on a screen, or is it s is it robbed by doing on a very, very simple prescription, which is then turned into a into whatever you want. Um we actually because again imagine it was five, six years ago, maybe the world's moving on, but we actually invented this thing called the hoogie, which was a polyester cast. You you slipped it over the the ankle, and then the correction could be built in. And therefore, each time the the authors felt like they were involved in the scan. And they were they were involved because then the scan being made, there'd be certain kind of um trimline points and whatever wherever could be drawn on the actual cast, but and it would like would like to think that you'd get a better fit and a better outcome on the device if it was hybrid. But I don't but I don't I haven't seen any real studies on that or anything else. I think direct scanning is all is it kind of depending depending on what you do. I mean we d I do cranial with Starban for instance, so they have a smart sock for moving heads when you that's out of scanning, but actually the smart sock SAT is actually a very, very clever technology. Um I was given us I was given a demo the other day. I would say it has a baseline but yeah, sure they'll do it for they'll do a direct scan for foot of footing, but actually they've got a version which where you can just send it to the patient and not even the patient, it's just retail. And then that retail scan can then come back into a central fab to be good for purpose. And that and that's kind of scares me. So I think you can't direct scan is almost too easy. We need to have some it's it needs to have depending on what you're trying to achieve, I think it there still needs to be some kind of regulation around it. Right.

SPEAKER_01 48:03

Yeah, no, I think that's interesting, and and and definitely on the foot orthoses, it's definitely becoming more of a commodity. And one of the interesting things, uh, and I'd have to find go back and find the the uh a couple articles, but you know, uh, and I think where you're when you guys did all the off-the-shelf foot orthoses and such, the reality on foot orthoses, there are those cases where you have to be super careful, diabetic feet, that sort of thing, offloading. But just getting a little bit of padding and a little bit of arch support uh does wonders for I I want to say it was like over 90% of people that put in uh some sort of foot orthosis. So I think that there's a lot of wiggle room, and and that's why it's become such a commodity. But I'm with you as far as the direct-to-consumer stuff is pretty interesting because I think it's gonna be a big jump to say, oh well, uh I can scan my foot and put a foot orthosis in too, I can scan my whole leg and then I can do my own AFO or I can do my own prosthesis. I think it's uh there's a lot going on there, but that's that's the media for you too, because they will make that jump immediately. Well, hey, they're doing their own foot orthosis, so now we're gonna do a full-on, you know, myelectric arm in alignment with all the set, you know, all that uh direct to consumer. I just don't think it's gonna work that way.

Closing Thoughts And Future Trends

SPEAKER_02 49:34

Well, it could I mean the thing is it can't make everything starts to collapse. I mean, it's it goes back to fails, reimbursement will just start to collapse. And that where's the value of the actual this profession? That's what it does to scary piece. There's it needs to be always more value built into what we're actually doing rather than just oh, it's really simple. You could even you even the use of a um iPhone actually kind of devalues the work of CPO if he's doing um because it's almost too simple, it's almost too. I know there's lots of different scanners, but it's kind of okay. Well, once you've got this. And you're right about insoles. In the dangerous part is many people, even in Walmart, you can I think still that you can buy um custom insoles. What's the word custom? So there's a lot no but no one's policing it. I don't think anyone, maybe no one ever will police it. It's just purists like a food.

SPEAKER_03 50:26

Exciting stuff, Hugh. I think I think we can talk lots, lots more with you. Maybe we should uh revisit uh this conversation another time. But uh really, really enjoyed uh this so far. Thanks so much for your time today, Hugh. No problem, enjoyed it. And uh yeah, Brent, uh thanks for for your time as well today.

SPEAKER_01 50:41

Oh, this was great, and it's always uh interesting to hear uh the perspective from another part of the world and uh you know what is potentially coming uh this way or even some trends that need to come this way. I think that was good. So thank you, Hugh.

SPEAKER_03 50:58

Thank you, and thank you for listening to another another episode of the Procetics and Orthodox Podcast. Have a great day.