In their recent update, Wilsons Advisory predicts that BTM/MTX will be able to capture just 15% of the US trauma market within 10 years because of its deemed limitations in addressing multiple challenges seen in trauma wounds.
To support their view, the Wilsons' analysts rely on a treatment algorithm for open extremity wounds which is used by three orthopaedic surgeons from the Atrium Health Musculoskeletal Institute in Charlotte, North Carolina. To be clear, despite the way in which the algorithm diagram is presented by Wilsons in their update, neither BTM nor MTX are mentioned in the original algorithm diagram, nor the paper from which it is sourced. Commercial brands used at the Institute which are discussed - Integra, A-Cell and Primatrix- are supplied by Integra.
Wilsons doesn't mention that in the
same paper from which the original treatment algorithm diagram has been sourced, the orthopaedic surgeons cite two potential deterrents to their use of dermal matrix products – high cost per use and potential patient allergies to bovine, chondroitin, and silicone. For some reason the surgeons don’t mention the potential for patient allergies to the various A-Cell products they use at the Institute, which are all derived from pig bladder.
What Wilsons highlight instead is BTM/MTX’s “comparative lack of flexibility” as a hindrance to its use in “deep, irregular landscapes” and they also reason that the structure and ‘thickness’ of BTM/MTX makes these products less likely to be used for facial, finger and genitalia reconstruction. The orthopaedic surgeons at the Atrium Health Institute favour A-Cell particulate in wounds with irregular or uneven wound topography and the use of Integra Thin in some applications where less thickness is required.
My first observation is that BTM and MTX don’t come with the potential animal product allergy and high cost that the Integra-owned products do. If these features are deterrents to surgeon use, surely this points to a competitive advantage for the Novosorb products? If so, Wilsons hassn't picked up on this.
Secondly, I note that in its
Macquarie Conference presentation in May (Slide 6), PolyNovo has flagged that within the next 12-18 months it will introduce multiple thicknesses of both BTM and MTX (1mm, 4mm and 6mm in addition to the current 2mm) and also a particulate MTX product suitable for contouring of irregular or uneven wound topography. These products should address the thickness and wound topography concerns of Wilsons.
And with respect to facial, finger and genitalia reconstruction as areas where Wilsons also don’t expect BTM/MTX to be used?
First, I note that there are already several published case studies in which BTM has successfully been used in facial wound reconstruction, following burns and acid attack, for repair of an open nasofrontal encephalocele and following the removal of large cancers. In a
recently published case of BTM being used for facial unit reconstruction with adjuvant radiotherapy, surgeons reported achievement of a good skin colour match with minimal contour deformity.
Also, there are now multiple reports in the literature of BTM being successfully used in hand surgery, including on fingers. PolyNovo’s website even includes a
case report of the successful use of BTM in the treatment of a gunshot wound to the finger following a failed skin graft.
Successful use of BTM in scrotal reconstruction has already been reported both in
Australia and the UK. In addition, in
a recently published review of case logs from three US-based reconstructive surgeons, it was reported that BTM had been used in three cases to reconstruct radial forearm phalloplasty donor sites. The authors commented that, historically, Integra has been the preferred dermal template for addressing this specific defect. However, the excellent results achieved using BTM in this application were said to highlight its potential as a cost-effective alternative for such procedures. The radial artery forearm free flap (RFFF) is typically used for phallus reconstruction as it provides good cosmesis and potential sensory recovery. However, as the donor site is large, it increases the potential for donor site morbidity, such as nerve injury, delayed wound healing, and decreased hand strength.
Finally, also mentioned in the
last publication reference, reconstructive surgeons have reported that the low cost of BTM allows them to also use it simply as a temporary wound coverage, protecting vital structures and keeping the wound hydrated while awaiting definitive reconstruction. In one practice, almost a third of BTM use was in temporization rather than definitive reconstruction.
In their recent update, Wilsons Advisory concedes that NovoSorb BTM has pushed into trauma faster than they had anticipated. I predict that sometime in the future Wilsons will also be conceding that Novosorb BTM/MTX has pushed into the trauma market further than they had anticipated.
(20min delay)