Welcome to the curve beam AI cast, bringing you the future of Orthopedics and bone health. Hi, curve beam AI cast listeners. It's Lou shown again. Here, with Francois Linsst, one of the key innovators in Combeam CT, And, we're gonna talk about some of the advances, cutting edge advances, I should say, in the technology. That, I think are, you know, mind altering and game changing. French, why did you tell us what you're up to, what you've been up to. Where where where where's where's the cutting edge in in in your life right now with, combi. So, picking up from, from Talas, which was the three d biometric system, we started thinking like, where could we apply the same principles and found that basically we could apply them in the whole foot and ankle and probably, all the body. And then we also realized we needed to standardize this. So I have to say there's there's there's three cutting edges the first would be to explore the rest of the foot and ankle system. The other one would be to apply these principles to the rest of the lower limb. And, the other would be the work that we're doing with the standards committee which we now call the scanner's endeavor, and, work on a universal reference system. So you can just think of it as as, what do we compare the foot bone positions to, you know, and and sort of, have an international consensus on that so that we don't all start working in different directions. So I would say those are the three areas that we are investigating now. So let's talk about some conventional thoughts that the practitioner would have. He's looking at combine images, and he's saying, okay, this ankle joint looks a little wide. It looks a little narrow. We're talking about the cartilage space. We're talking about maybe fluid between cartilage spaces. We're talking about the, the bone, maybe the bone density above that cartilage space. We're talking about looking at these, these dimensions that are very much not just about the bone itself. It's about the bone cartilage and even soft tissues at the same time. So how do how is this how how does Joe Orthopedic surgeon now look at a joint that has some widening, some narrowing, is this ligament, is this arthritis, is this is this a, is this normal range? It's not normal range. So I would say there's already a tool that's out there that's called distance mapping or joint space width or three d joint space width. It's been coined differently in the literature but the idea is that instead of just looking at the AP of your ankle where you have this joint narrowing and depending on the you know, is it less or more than fifty percent? It's grade two zero three and then it's completed. It's grade four if you've got change in it. So that usual way of, segmenting things that we have into different categories than the first part, of these high end tools that we have is a visualization tool called distance mapping, where you have a three d color coded map where if it's like bright red, that means there's no coverage and there's a contact point. And if it's bright blue then, you know, you've got some space there. And there's a normal range that's based on, you know, it's just literature, you know, what's being published, what's out there. And, after if you have more than a certain width, then you've got some distraction back joints. So you've got probably instability and you have ligament failure. I don't think we're quite there yet in terms of, making the link with the soft tissues. For that, we still use finite analysis, which is based on assumptions on the quality of these tissues. But I think that the answers are coded within, the, the white brain CT dataset. So I like, you know, to talk about dimensions, and I really think that the bone density is the fourth dimension. And that we have clearly been overseeing this in the past research, which is not, I know I'm not being judgmental there because we first had to work out the third dimension and that's not even we've barely scratched the surface. So, there's still a lot of work to do. And and we've we've got to look at each pathology, you know, in a, in a very precise way and describe the norms. That's also a big field of research, you know, what is normal. So, and then that kind of closes the loop with, you know, the reference because you're talking about the reference in terms of reference frame in which the foot is placed, but also what is the frame of normality? Then that's part of the job. That's part of our job. We have to do. So creating the visualization tool with the, the, the, the, the normal range, for Joe, is, is part of our job as researchers and then there's gonna be another stage is helping him with diagnosis and, we're still gonna figure out how to do that. And there's also an issue about, you know, patient, data protection. You know, getting funding for the research and and and everything. But I would say that that's the first step, distance mapping. And then you have to looking at things is not enough. You have to quantify it. So in order to quantify, then you still have to segment things. And so, but instead of segmenting the stages of, loss of, joint height, what we're looking at is segmenting the joints into quadrants, to show us where the narrowing is happening because that doesn't have the same meaning in terms of pathology. For example, in PCFT, your tilting forward. So you have the loss of joint height is more on the posterior side of the, of the stylus, and you have an increase in enjoying space at the anterior side. And of course in the carnal plane, you know, various arthritis is obviously the opposite of valence arthritis. So we have to describe the norms inside each of those quadrants. So choosing where the quadrants are is also another, another question. And I guess my personal quest, but it's very much, it's very close to a philosophical quest. Is there out there like, you know, a universal law of physics that encompasses quantum physics and general relativity, is there a unique theory of measurements in the fungal, in the whole skeleton, and that's what I'm after personally. I think it exists, but I think it's gonna, you know, we might discover it, but in a number of years and after we've gone through all these stages of of segmenting the space and segmenting the pathologies and and and the joint distances. Yeah. So I think most orthopedic surgeons are, looking at joint space. And, And that's why I focused on the joint space question, and they'd say, well, is that narrowing of the car cartilage or is that laxity of the ligaments? And and I think we could we could give that answer in the future probably pretty easily based on the densities of the tissues. Exactly. Soft tissue, cartilage, bone, all have different densities. So the, so we can you think do you think we can get that answer to people? Like, is this lax? Or is this early arthritis? I think that we can give answers and pretty sooner than we think, than we would imagine because it's a question of, referential, of this frame of reference. Your, your joint is drafting relative to some point that you have to describe, or it's compressing relative to some other points. So it's all a question of, of perspective, where you're looking from. And, but it's difficult to do this. You know, it really requires some, some, some, some thinking because It's in four dimensions. You said it yourself. We have to take into account the density of the bones, and their positions in space. So there's a lot of maths involved, a lot of physics, a lot of, computer science, and even some coding and some tricks and mathematical bricks and that that's that's the stuff we we're working on. So, but I think that, to to put it in a nutshell, the bone is like the reflection in a mirror of the tensions in the soft tissue because it's like in old physics, maybe not in all the physics, but what I know of it, the it's it's always a zero sum game. Like there's your body weight is always the same. You know, the gravity is the same anyway for the foreseeable future. So it's got to remain framing this way where if you have the bone this way, it means the soft tissue has to be that way. And sometimes, you know, we're working on things like, automatic segmentation, and I think I'm really waiting. I think it's coming next year, but the definitive in your online usable version of Autometrics, which is the automatic segmentation tool, and we really looking forward to that because it's gonna make things much easier for us. Like this first step is done. We can very quickly then go into the the the the hardwood science. We don't have to divide the bones between them itself. But sometimes looking at these pictures, I'm thinking, okay, so we're leaving all the soft tissue out. But the forces are also going through the soft tissue, so so and they also have a density. So why do we, you know, why do we leave the belt? So we're gonna have to answer all these, all these questions. But I think you're absolutely right to say, the answers are there in the data sets. The, let's go to a very specific area that that has been played with by radiologists for years. The bone density issues, like when you look at an x-ray, you you'll see sclerosis, you see cysts, you see leucency, And there's a lot of reasons behind that, of course. Metabolic conditions, weight bearing conditions, surgery, trauma, etcetera, etcetera. You are you are tackling this bone density issue. You're you're you're tackling the pixels or, I'm not sure what the right terminology is. And what is your venture like in that domain? So, we have been looking at this intuitively for a number of years. And then, we put together a methodology and, a study and we were, blessed to have this, study published, after peer review in the journal of bone and joint surgery, and so what we looked is how the bone distribution looks like in the coronal plane relative to a hind foot alignment. And so it looks like the alignment is funneling the bone to build up where the alignment is, and there's feedback. So the the bone is then also creating the alignment. So I'm thinking as far as, you know, things that may sound stupid, but I think are not, like, when you put a screw in a bone, even if the outer shape doesn't change, it changes the alignment because it changes the way the forces are flowing through through the bone. So that's kind of our venture. And, and, we've also been blessed by being invited to, to work in the Duke, in the Caesar's research lab. For a year starting next year, and I'm very much looking forward to that because, obviously, we'll have a lot of means at our our disposition to, to work on this project. I think it's, Caesar likes to say, it's my baby. So I'd say that's my that's my baby, the the Houseford units, and and looking at the Vauxhall, which is the the unit of volume as, as, being a four dimensional object with three coordinates of space and one coordinate of, of density. It's important to state though that density we're not really looking at density of calcium and phosphates in those voxels. It's a proxy. We're actually looking at photon absorption and those are some, you know, of the things we had to answer to in publishing our paper. So, so yeah, that's that's kind of the venture. How does bone influence alignment and how does alignment influence bone? And and and at some point how do our procedures and how does our hardware and implants influence this whole, sort of complex system. Yeah, it's really, fascinating. It's, it's, typically, I think most of the time we've been looking at the voxels or the Houndsfield units as, a, statement as to health, of the patient or health of the local bone. But it's it it is actually that's just a very small part of it. It does tell us a lot about the health, of course, but the amount of information that we can get from that is is maybe exponentially more. And looking at the information that we get with realignment, osteotomies, realignment along another plane of that of of the bone, or of a bone next to that bone, or we're putting in implants such as screws or artificial joints. And what does that do to those bones? And how does that then affect the the the function of the musculoskeletal system is is really way more vast than anything that we could have gotten from just understanding that this is osteopenia or osteoporosis? I think it's not at all unreasonable to say that we will be able to answer questions like I did this procedure in this patient and he's doing perfectly fine. I did exactly the same procedure in a very, very similar patient. And he's doing awfully. So why is that? All this probably things within the bone that are written there that are coded in in in in those data sets that can give gives answers relative to that. There's probably thresholds in terms of bone density where you can put a screw there in that position. But if you're like past this threshold in terms of, bone density topography or something, you have to change slightly the direction of your screw in order not to cause some pain. So at some point, we'll be able to elate the pain with the bone density and with the alignment. Very interesting. And I'm a, also assuming that you're not gonna be just looking at can't sell this phone that you're looking at cortical bone as well, in your endeavor. Correct? Well, it's, when you look actually inside the, inside the datasets, There's the cortical bone that we know of, like the outer shell of the tibia, for example, which looks like a cylinder But if you go more distant on those bones, there are, tracts of cortical bone inside the canceled bone that we have no idea existed and that are infinitely variable, depending on patients. And so we're looking at how, you know, how come those tracks are there? What do they represent? And, and, I think that's, that's really fascinating. It's kind of artistic and beautiful as well. When you when you look at them, yeah, you sort of feel humble, in front of what nature is able to to create and also humbled in terms of what humans are able to create in terms of machines just like Kombi City to enable us to see this. I think it's, it's, kind of, otherworldly, or it's very humbling. So I really enjoy you know, this part of the research? Well, this should be a great opportunity for everybody in the, in the fields. Specifically for you and Cesar to get together with the other brilliant members of of the society and also the faculty at Duke to innovate in this domain. I think it's, another, tipping point, so to speak. And, we're looking forward to your visit. And, we expect so much from this, endeavor. So thank you. Oh, thank you. For venturing out there, and, it's it's very exciting. Well, I would definitely visit you in Baltimore if, if I may during that year. Yeah, no, we, we welcome you and we won't make you clean or anything. Okay. Thank you. I would. It's no problem. Well, thank you again for this, most enlightening, Pod. Cast experience. We look forward to more in the future from you and from us as a whole. Thank you listeners, and, have a great day.
