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Podcast Transcript: Moving the Needle: Percutaneous Treatment of Tendon Injuries

with Dr. William Morrison

In this episode, Dr. Jacob Fleming interviews Dr. William Morrison, the medical director of Trace Orthopedics. Trace Orthopedics is developing a minimally invasive implantable device for tendon repairs. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) A Radiologist’s Journey in Musculoskeletal Interventions

(2) Evolution of a Minimally Invasive Device for Partial Tendon Tear Treatment

(3) Overcoming the Stigma & Promoting Innovation in Radiology

(4) Shifting Perspectives in Surgery

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[Dr. Jacob Fleming]
This is your host, Jacob Fleming. Today, I'm honored to welcome to the show Dr. William Morrison. He's a renowned musculoskeletal radiologist, and we're excited to have him on the show to talk about innovation in musculoskeletal interventions today. Dr. Morrison, thanks for your time and welcome to the show.

[Dr. William Morrison]
Thank you. It's an honor to be here.

[Dr. Jacob Fleming]
We've really been looking forward to having you on the show. Your perspective is so unique for a variety of reasons. Among your many titles, professor and medical director of the Musculoskeletal Imaging Institute at Thomas Jefferson, past president of the Society of Skeletal Radiology, and medical director of Trace Orthopedics, which will be a focus of discussion today. I'd just like to say that you have a very interesting background and a very interesting perspective. Let's hear a little bit about your background and how you got to your current practice, what that looks like today.

[Dr. William Morrison]
All right. The way, way back machine, I always liked comic books, graphic art. I love art history. That's what really stimulated my interest in radiology. When I was going through medical school and selecting a field, I went back to my roots in graphic art. I thought, I love looking at images and interpreting them. That had a lot to do with my decision. I had my residency at Jefferson. After training and MSK, I went in the Air Force. I was in the Air Force in San Antonio, Lackland Air Force Base for four years. I was head of musculoskeletal imaging there. Then I got hired back at Jefferson 1999, a long time ago, and I've been there ever since. That's my story, I guess.

[Dr. Jacob Fleming]
That's fantastic. I can actually relate to that a bit because when I started out, when the first seed of interest in radiology was planted, I was actually just a teenager and my thing was video games and art. I met a friend whose dad was a radiologist and I was like, "Hang on, he does what? He's a doctor and he gets to sit in front of computers and look at awesome images?" I can really relate to that path. You have really gone in a lot of different directions from there over your career and really interested to talk about those today. One of the things that you're well known for is being a great teacher and your use of humor in radiology education. Those who have attended AIRP courses or follow you on Twitter know that you use humor and just the weirdness of things that pops up in radiology images. I'd like to know, what is it that you enjoy about teaching? Do you ever stop seeing animals in MRI slices?

[Dr. William Morrison]
I love teaching. I love being next to residents and fellows and interacting with them. It's a two-way street. I learned from them as well, probably more than they learned from me, I have to say. When they talk to me about a case, they'll ask me questions about it. A lot of times those questions are from a really pure perspective that I didn't even have before. That allows me to think more in four dimensions and outside the box a bit. A lot of times I have to look things up and I'll tell the resident, let's look this up. We look things up.

I teach that to all my residents, fellows, and my kids. For me, it's like an itch. If you don't know something, you have to scratch it. You have to find out what that thing is that you don't know. It's a two-way street. I learn so much from the residents and fellows, not only about their perspective on things, but also pop-culture, technology, and things like that that keeps me on the cutting edge, I think. In terms of the periodolia, that arises from the visual stuff that I talked about, but also as babies. We have two granddaughters now, and they are just fixated on faces. That's where we start.

Our visual cortex develops that way. When you see two dots in a wall and a crack, and you say, "Oh, that looks like a face." That's a skill you can turn on and off. Anybody can. You look at clouds, and you can see a cloud, or you can see a squirrel or a bunny and you just draw your attention to that. I do like to do that. When the residents see me stalling, that means I've seen something. Then they'll ask me, "Okay, what do you see?" It's usually something too crazy to even talk about, but a lot of times, it's something pretty, like a face or something, or it might be Eddie Munster holding a hoagie.

It could be anything. The idea really goes back to my theory about having what we call a good eye in radiology. That's where you see something, you find something. The idea really is similar to when you walk in a room, and you might see the pictures are a little off. They might only be a millimeter off, but you notice it. That's very similar to the skill in radiology because you have a template of what's normal, what's level in your head, whether it be a chest x-ray or cardiac MR. You've developed that normal template in your head. When you look and you glance at it, and something is not quite right, then that's the good eye. Then you have to identify what that thing is.

Obviously, your experience and knowledge tells you what specifically it is. That's the thing I like to teach the residents. That's the thing that pareidolia, which is seeing faces and things really helps with is that you're tuned to look for those alterations in what's normal and abnormal.

[Dr. Jacob Fleming]
That's so interesting. It reminds me of-- there's a common saying about having a radiologist's eye. It took me a little while to understand this. That's not referring to actual visual acuity, 20-20 vision. It's really more about pattern recognition, which arises over just endless reps of seeing, like you said, the normal anatomy and seeing what the abnormal variations look like. To the point that when you first open a study and you can even just look sometimes on an MRI or a CT on the scout scan, and something will just jump out at you, and your brain just registers it almost subconsciously and says that something's not right there, draws your eye to that. That's something that just takes a lot of training and time. I think the pareidolia, that's a really interesting parallel in tandem to that.

[Dr. William Morrison]
Yes. The other thing it does is it makes it fun because I like to have fun in the reading room. With our residents and fellows, we play music. Like I said, we talk about pop culture and new things. It makes it fun when you see a happy face in the spinal canal. You're like, "Oh, look, there's a happy face," or "Look at that bunny in the shoulder." It takes some of the doldrums out of the routine nature of what we do.

(1) A Radiologist’s Journey in Musculoskeletal Interventions

[Dr. Jacob Fleming]
I agree with that, certainly. Shifting more toward the primary topic today, as well as renowned diagnostic radiologists, you perform a lot of musculoskeletal interventions.

At this point, you've invented several devices in this arena. Can you tell us a little bit about this interplay between diagnostic and interventional radiology and innovation? How do things flow between those ostensibly different disciplines?

[Dr. William Morrison]
In radiology, like I said, there's a lot of repetition and a lot of things that are "something we've always done." We've always done it that way. You learn dogma that may or may not be right. You go back and look at why you're doing it that way. It's not always clear. It derives from a frustration about things that don't seem efficient. You may have a PAC system that requires 20 clicks for you to open a case and you're like, "Why can't this be simpler?" We've all asked that question. Everybody has tons of ideas about making things better, making things more efficient. I think that stems from a low frustration level, which I definitely have, and some element of laziness, which I have, because if something takes a lot of clicks or takes a lot of steps, I want to try to reduce those steps because I'm relatively lazy. That low level of frustration and laziness has led me to try to figure out ways to make things faster or easier. When you're talking about products, bringing them to market, you have to-- like I said, we all have ideas. It might be for a birdhouse. It might be for something else. It has to be something you can do, and it has to be something in your wheelhouse.

You can come up with an idea like, "Oh, well, we have voice-to-text programs that we use, dictation systems. We have translation, so why not make a universal translator? We can stick a little earbud in, we can speak and listen to what we said in another language, and go to other countries. It sounds like a great idea. I think people are working on that, but I can't do it. It's not in my wheelhouse. I have no experience with that." It has to be something that you can actually do. In terms of medical devices, I've been doing intervention for a long time. When I was in the Air Force, I was doing a lot of spine intervention, a lot of nerve blocks, and discography, which was popular then.

L5-S1 was always the hard one to get into. We always said you make your money at L5-S1 because it's relatively low, and iliac crests overlie the disc, and so you have to curve the needle in. We used to take an 18-gauge needle and park it outside the disc, and then take a 21-gauge 6-inch needle and make a permanent curve over a hypodermic needle syringe, and then put that through, and it would curve into the disc when it came out of the 18-gauge needle. I thought, "This is a lot of steps. If it doesn't come out exactly right, patient has pain. Why not just make a steerable needle?"

I thought, "Well, let's take that solid stylet inside the needle that we've been using for 100 years and make it into two components. One component goes over a barrel with a lever, and you can deflect the tip." It worked pretty well, and we brought that to market after 15 years of development, but it didn't do that well. I figured out why because it costs about 10 times more than a straight needle, number one. Number two, people are used to using straight needles, so it involves a change of how people do things.

It didn't really catch on, but it's being used now for mostly celiac plexus blocks in patients with pancreatic cancer. That's a really nice thing. I'm really happy about that. In fact, just yesterday, I saw an interventional radiologist that was very proud that they were doing an anterior approach for celiac block through the liver. A typical way of doing a celiac plexus block is to go through the bowel, and patients can get peritonitis, which can be a big problem in patients with pancreatic cancer. The idea was with a steerable needle, you can go posteriorly and go around the spine and get to the celiac plexus.

This person was going through the liver, and it was like, "Well, that can cause complications too." It has to catch on. It has to be a need for it. That's the third thing. It has to be people asking for it. That brings me to trace orthopedics. After my experience with the steerable needle and how it didn't do that great, I took a hiatus in thinking, "Well, my ideas obviously aren't very good." I spent five years just things on the back burner. I was doing a biopsy of a humeral head one day near the rotator cuff and I was thinking-- at the time, I had partial-thickness rotator cuff tears, and the surgeons didn't really want to treat them because they said, "Well, to treat a partial thickness tear, what we do is we make it to a complete tear, and then we reattach it."

He said, "Why don't you just go through rehab?" I spent a year or two going through rehab. In the meantime, I couldn't do weightlifting. I couldn't golf. I couldn't do things with my shoulders. I was thinking, "This is really terrible. Why can't we just repair these partial-thickness tears?" I was reading that biopsy and thinking, "We can tack these tendons down percutaneously." I developed a device in my garage to do it and tried it out, and it worked really well. I made it out of Home Depot material and the spring in a pen and it worked really well.

Then I figured, "Well, this probably isn't going to work," so I sat on it for five years, and then just more and more cases came through. My mother had gluteus medius tears, and she got muscle atrophy, and now she has difficulty getting around, and I'm thinking, "I got to do something about this because there's a real need for it." There are also reimbursement codes, so it's not like it's going to be a problem in terms of the financial part of it and here's a real clinical need for it. It's in my wheelhouse. It's not much different than what we do now with dry needling, tenotomy, PRP, things like that.

At that point, I took it to our innovation office at Jefferson, and they liked it. We got a provisional patent for it. At that point, as the provisional patent was about to expire, we were going on to a full patent, and they were only going to cover it in the U.S., and we wanted international coverage. They said, "Okay, we'll release the IPTU." We formed a company, Trace Orthopedics, and went on from there.

[Dr. Jacob Fleming]
That's really interesting, and I think any of the radiologists or other musculoskeletal specialists can relate to this problem, the very common gray zone of tendon injuries in the shoulder and the hip. We see it all the time, and it's like, "Well, it's not really a surgical issue," but as you said, you follow these patients along, or if you are one of these patients or your family member is one of these patients, you realize doing nothing is not really a benign action as well. That's really interesting about what you talked about earlier with seeing the need for it and it being within your wheelhouse. All those things have to align, and that's really interesting. Tell us about what's the current state with the device.

(2) Evolution of a Minimally Invasive Device for Partial Tendon Tear Treatment

[Dr. William Morrison]
We're doing quite well. We went through engineering through a company in Florida called Nagelrider, and we developed the device, tested it, did a lot of performance testing, ergonomic testing, packaging, and all that stuff. We did animal testing, which worked really well. It's a sheep model out of the Colorado State University, and we did destructive testing on the sheep, and our implant withstood 674 pounds of force, which is much higher than a suture anchor, which was fantastic news for us. There's something about the configuration of the implant that I think gives some advantages over a suture anchor.

We've also gotten a lot of interest from orthopedic surgeons, and the reason why, I think, is because I've reframed this to them as an alternate form of a suture anchor. You think about it, when we were in the 70s, before arthroscopy and before, it was quite simple to repair a tendon. You do an incision, you reflect the tissue back, and you repair the tendon. Once arthroscopy got developed, it became very complicated to repair tendons because you had to repair them through these little tubes. Fantastic engineering developed suture anchors. A suture attached to an anchor took 20 steps, very complicated, to repair a tendon through a scope.

In fact, the older surgeons usually just repair them with an open procedure, and the newer surgeons that trained on it, because it's an art form, would repair them using arthroscopy. We saw that in the early days when I was practicing. The idea is it takes 20 steps to do this, whereas ours takes one step. Surgeons are very interested in using this to help shorten their procedures, because the OR is the most expensive real estate on the planet, except for maybe these space shuttles that are going up. It's about $10,000 an hour for OR time. If they can shorten that by 15 minutes, it's fantastic. We've gotten interest from surgeons that take care of athletes for things like core injuries, athletic pubalgia, adductor tears, which start off as tears that remain next to the footprint, the bone. If they can get this player back on the field to finish the season and get definitive surgery afterward, that'll be a huge advantage to them. One of our medical advisory board members is Bill Myers, who founded the Vincera Clinic in Philadelphia that takes care of most of the players that get core injuries. We also have on our board the team surgeon for the Jacksonville Jaguars. We're getting a lot of surgical interest. We're getting interest also from surgeons that do total joint replacements, especially hip surgeons, because there's an incidence of gluteus tears after surgery for total hip replacement. Their idea is to reinforce the tendons using this in a minute during the surgery to help prevent the complication of gluteus tears after surgery.

We've been quite successful in that regard, getting a lot of interest from radiologists, physical medicine rehabilitation people, pain management people, surgeons. We went through friends and family for seed funding. We raised about $400,000 with that. We went through Koretsu Forum, which is the largest angel network in the world, and they do a lot of medical funding. We did our diligence with them. We are finishing Series A funding round now, which is a $1.5 million raise. We have about $200,000 left of that. We're closing that out soon, and we're going to FDA in the next few months, hopefully, be on the market by next year.

[Dr. Jacob Fleming]
Fantastic. That is really exciting to hear about because I love the way you described is it's something that is applicable to a lot of different clinical scenarios. Going back to the steerable needle, the impetus for that was with discography, which has become a bit of a lost art form nowadays. It sounds like the use of it is still having maybe a little bit different than what you imagine, whereas the tendon anchor device is so applicable to a lot of different clinical scenarios. One of the things that I was thinking about as you were talking in getting the surgeons involved is a lot of times when you introduce a new minimally invasive device, the interventional radiologists may be using, sometimes the surgeons may balk at that, and looking at, "Why are you trying to come take my lunch?"

To me, from what you're describing, it seems like this is adding an additional step in the treatment paradigm that wouldn't really burn any bridges down the line in terms of getting definitive surgery. Sometimes if you can get away with doing something that is ultra minimally invasive like this, and the patient doesn't need anything extra, sometimes that is exactly what's needed for the patient and for the clinician. A lot of times the surgeons have a patient come in and it's just, yes, they're not a great candidate for full surgery, but you have something else to offer them.

It's rather than taking things away, I would say, and I would urge any of the surgeons listening to talking about your device and a lot of the new devices, that's not really what we're about. We want to focus on taking care of these patients who haven't really had a great option before and still involving the full realm of treatment there. It's really cool, and it sounds like we'll be able to hopefully get our hands on it before too long here.

[Dr. William Morrison]
Yes, hopefully by next year. We already have our clinical test sites all set up around the country and we'll hopefully do our first hundred patients within a month or so after we get FDA clearance. We'll get reimbursement data, and we're looking to exit to a big company that can provide better distribution once we get our clinical data back.

(3) Overcoming the Stigma & Promoting Innovation in Radiology

[Dr. Jacob Fleming]
Fantastic. That's really exciting to hear. I know these processes are really a marathon or maybe a triathlon even, especially from the time of idea inception to getting to where you are now. One of the things I wanted to bring up before we end is I saw you had a somewhat recent tweet maybe a few months ago. You said one of the challenges in pitching a minimally invasive procedure device like this is just to explain to the potential investors or whoever you're presenting to the concept as radiologists who perform procedures or who are involved clinically. Why is this such a problem for us and how do we solve it to promote more minimally invasive innovation?

[Dr. William Morrison]
One thing that was very apparent to me is that most of the public doesn't know that radiologists do procedures, that we do intervention. Investors certainly don't know that. Most of these angel groups, they'll have a doctor on their advisory board, but oftentimes they don't have any experience in what you're doing. If they do and they have an orthopedic surgeon, a lot of times they're either super sub-specialized or they're very general. They have difficulty envisioning the market perhaps for our device particular. I think a lot of this has to go back to our societies who collect our money for annual fees, but they don't do a whole lot of public relations in telling the public what we do.

I think that would go a long way toward bridging that gap, which really needs to happen, I think, fairly soon because we're getting to another inflection point in radiology, where we have challenges on all sides. I think showing our value is extremely important, not only to the public, but also to payers, legislators. They need to know that what we do can lead to a cost savings. That, for instance, an MRI can lead to a cost savings. It's not all expense. That if we apply radiology early on in the medical cascade, we can actually save a lot of money in the long run by directing people to the correct imaging and the correct diagnosis early on. I'd like to tell our societies all the way from RS&A to our subspecialty societies that we really need to do a lot more funding of public relations.

[Dr. Jacob Fleming]
I'd agree with that completely, [Dr. William Morrison]. My focus is more on the interventional side and the clinical side. This is a problem I think about all the time when a patient asks, what is my specialty or what do I do? Even after a few years now, I'm still struggling to have that 15-second pitch down. It's much easier to say, "Oh, I'm a hip surgeon." Everyone gets that, than saying, "Well, I'm a radiologist who performs procedures from head to toe using image guidance and imaging diagnosis." A lot of people eye's start to glaze over in that part. I think it is a challenge to do this. I agree with you.

I think that having the more public relations there. I don't see this in any way that we have to exert our dominance or pound our chests in any way compared with the other specialties. I think that we bring something unique to the table in terms of what we've been talking about this entire discussion about seeing things from the imaging aspect and then seeing problems from a certain perspective over and over again, you start to think about different ways of solving them. Whereas historically, there's the old t-shirt or the adage that says, "Interventional radiology, inventing procedures for other specialties since whenever." Which is a little bit of a shame. I think it's great that eventually, these devices and ideas can get to a point where they're benefiting a lot of patients.

I think the more that radiologists are clinical and involved, it really provides an additional benefit as well. I'll tell you in my fellowship, we're very clinically heavy. We have clinic pretty much every single day and seeing patients all the time. The frequency with which the patients are coming in with an adequate and correct understanding of their diagnosis is actually close to 0%. Part of that has to be with, most patients are not seen by a surgeon or a subspecialty surgeon, the definitive treatment person. They go through different specialties of different degrees of expertise. Most of them are not really looking at the imaging. They may be looking at the imaging reports.

Of course, as a diagnostic radiologist, we're a little bit hamstrung. We don't have the patient in front of us to know what may or may not matter. When a patient comes in and they've got lateral hip pain and you see on the MRI that they have IT band friction syndrome findings or things like this, you can pinpoint exactly what that is. Using that skill set of diagnosis, which is acquired from sitting in the dark reading room for a long time and extrapolating that to a clinical setting, is something pretty special, I think we bring that to the table. At this point, just preaching to the choir, but I agree with you completely.

(4) Shifting Perspectives in Surgery

[Dr. William Morrison]
Yes. I'll just bring up one more thing, a term you've probably not heard in many years, if at all, and that's exploratory surgery. When I was a kid, if you have abdominal pain, you go in for exploratory surgery to find out what's going on in there. Things like CAT scan and MRI have done away with that. They've done exploratory surgery in joints as well before MRI. The idea is for the public to know that this is something that has transformed medical care and made it so that you don't have to go under the knife for everything. It used to be the scary term "Going under the knife." That's what we're preventing. That's what we're taking out of the equation. We are imaging, finding out when something needs to be done. A lot of times we can accomplish that through a needle. That's the value, I think, part of the value.

[Dr. Jacob Fleming]
I agree completely. Nowadays, you talk to a joint surgeon, for example, and say, "Hey, how upset are you that you haven't done an open arthrotomy in maybe your entire life?" Most of them will say, "No, I have no desire to do that." Ask trauma surgeons, "Hey, do you miss the days of doing X laps multiple times a night on patients?" No, no one wants that in the future of medicine and surgery is minimally invasive and ultra minimally invasive. We were talking about Star Trek before we started the podcast. Of course, the surgeon of the future in the Star Trek is basically an interventional radiologist. All surgery and I think all procedure is going down that pathway of being more interventional and through a needle, like you said, or without a scalpel as one of the organizations uses its tagline.

[Dr. William Morrison]
Yes. Part of the reason we went with trace orthopedics as our finished indication where we're doing repair of the gluteus medius and minimus is because surgeons don't really like doing that surgery. Most of those patients are older patients, they have comorbidities, and it's almost ubiquitous. About 60% of people over age 70 have some gluteus pathology. If it goes on to muscle atrophy, they can get Trendelenburg gait and all kinds of gait disturbances and fall risk. It's a low-hanging fruit for us. When you come out with a device, you always want to get one killer indication, not only to get through FDA, but also, in terms of focus, not only for investors but also for your initial market. That was really the low-hanging fruit for us was repairing those gluteus or reinforcing those gluteus partial tears, trying to prevent the progression to atrophy and gait disturbance.

[Dr. Jacob Fleming]
Fantastic. I really look forward to hearing more as we get closer to market with this. Then over the next few years, hearing about the dissemination and the spark of using this device for different indications and figuring out how people are going to be using it. I think that's really exciting. Our listeners, where can they keep up to speed with developments with Trace Orthopedics? How's the best way for them to know about that?

[Dr. William Morrison]
Our website is undergoing redesign now. traceorthopedics.com. You can email me or follow my Twitter account. My Twitter is @MorrisonMSK. Feel free to email me, william.morrison@jefferson.edu. Happy to keep you updated. We can put you on our newsletter list if you're interested in following. Hopefully, you'll hear more about us next year.

[Dr. Jacob Fleming]
Excellent. Thank you so much, Dr. Morrison. Anything else you'd like to talk about before we end? Any final words?

[Dr. William Morrison]
No, it's just that it's an interesting future for radiology. We live in interesting times. Like I said, we're at an inflection point. I think that it will take all of us to get involved in public relations, innovation, product development, and we need to be on the forefront. We need to be on the forefront of research, product development, and we need to have a face with people. We need to be in front of them and show our value. That's hopefully what we're trying to do here.

[Dr. Jacob Fleming]
Agreed completely. I think it's exciting just to imagine where we'll be in the next two years when we hopefully see the launch of this product. Then the five to 10 years, I think it's unimaginable what we'll be seeing then. Thank you for all your innovation and enthusiasm to push the envelope forward. With that, I want to say thank you so much for your time. I really enjoyed our discussion. We're looking forward to our listeners to hearing about this, and hopefully before too long, getting their hands on the Trace Orthopedics tendon device.

[Dr. William Morrison]
Thank you. It's really been an honor to talk with you today. Really enjoyed it. Thank you.

[Dr. Jacob Fleming] Likewise. Thank you, Dr. Morrison. To our listeners, thanks for tuning in. We'll catch you next time.

Podcast Contributors

Dr. William Morrison

Dr. William Morrison is the director of the division of musculoskeletal imaging and intervention at Thomas Jefferson University Hospitals in Philadelphia, Pennsylvania.

Dr. Jacob Fleming

Dr. Jacob Fleming is a diagnostic radiology resident and future MSK interventional radiologist in Dallas, Texas.

Cite This Podcast

BackTable, LLC (Producer). (2023, October 4). Ep. 32 – Moving the Needle: Percutaneous Treatment of Tendon Injuries [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.