Episode Transcript
[00:00:02] Speaker A: Welcome to your Cases on Hold, the JVGS podcast, hosted by Andrew Schoenfeld and Aisha Adkeen.
[00:00:08] Speaker B: Here we discuss the best of what each issue of JBJS has to offer with the usual dose of entertainment and pop culture.
[00:00:16] Speaker A: Take us with you in the gym, on the commute, and as ever, whenever your case is on hold.
Welcome back everyone, to your Cases on hold, episode 101.
It's March 3rd, if you're listening, on the day we drop for the March 4 issue.
We are excited to present everything that JBGS has to offer in this month. Some really exciting articles. Interesting articles. I think this is we're definitely going to have a lot to talk about on this episode. Some things may go on hold. Some things maybe not. We'll see if you are tuning in for the first time or obviously if you've tuned in before you've heard this. But the lawyers say that we have to let everyone know that the opinions that you are hearing are those of the co hosts of the podcast and not those of the Editor in chief, the editors of the other constituent journals in the JBGS family of publications, nor of the Board of Trustees or other members of the editorial team.
I am Andrew Schoenfeld. I'm a professor of Orthopedic Surgery at Harvard Medical School and I have with
[00:01:32] Speaker B: me I'm Aisha Abdeen. I am the Chief of the Division of Hip and Knee Arthroplasty at Boston Medical center and an Associate professor at Boston University.
[00:01:41] Speaker A: This episode is brought to you by the Miller Review course we're getting into that time of year. Testing is right around the corner for all sorts of different tests in the lifecycle of orthopedic education.
One of the best ways to get caught up Let JBGS do the work for you. Attend the Miller Review course. Sign up now if you haven't already. You will not regret it. That is a case that will not be put on hold.
Let's get into it at this point. Top of the pile. We have preoperative gait speed as a predictor of patient reported outcomes after total hip arthroplasty. Insights from patient acceptable symptom state and K means clustering analyses by Michael and colleagues. There is a comment visual summary and permanently free. Then we have fluoroscopy guided lateral tibial plateau fracture fixation with and without needle arthroscopy, a biomechanical and reduction quality comparison by Mizaheim with a comment and infographic.
This is followed by Diagnosis and management of osteoporotic Vertebral Compression Fractures by Daher. That is a highlight. I'm also an author on that instructional course lecture, so check it out if you can. The Post Hoc Ergo Propter Hoc Fallacy by Sahu. And that is a fallacy. So definitely you should look into that.
Next we have I bring you what scans can't see. I that's Intriguing by Upal and that is permanently free. Scrub Nurse in the Glow. That better be a painting or some kind of artsy photograph like a Woody Allen 1979 Manhattan Black and White kind of thing. At least I hope it is. It's by Lou and it's permanently free. Then we have Strengthening Residency Training Challenges and solutions from the 2025 AOA Resident Leadership Forum by Bansu.
And that that's what we got in the top of the pile. We're now going to go into the headlines.
We had mentioned that in this new year, in the new rendition of both JB JS and your cases on hold, we would occasionally be covering non scientific articles. I think that I did that already in January. But in looking at the articles that were on offer and reading this one, I just said I have to talk about this one. I just, I really want to to speak about this to the audience. It's something that I'm very passionate about and I think it's very intriguing to discuss these kinds of things. So I'm very interested in what, you know, I'm springing on this. You knew I was doing it, but I'm springing on you that, that I'd love to hear your insights as well after I give my two cents, if you will. This is on Rethinking Residency Selection Beyond Test Scores and Prestige by Wu and Edward.
And it is a highlight of this issue.
So for those who are avid JB JS listeners, you will remember that we did an episode, a special episode where we had several program directors sort of convened and we discussed various aspects of and best practices for the the residency interview process and the match.
Obviously, as this is in March, we're going to have the match later this month. I'm sure there are budding orthopedic surgeons who just cannot wait to that day. And some, you know, with nervous anticipation are thinking about it. So this is definitely timely. And Doctors Wu and Erard, you know, are putting forth a missive here in terms of wanting to rethink residency selection.
They are from Duke University. Normally we don't really say, well one is from Duke, Dr. Wu is from Duke and the other is from Mount Sinai. Normally, we don't say where authors are from, but I think it's relevant here because I feel like if you've seen how one program does its residency selection, you probably have seen how one program does its residency selection.
And I have been involved in a number of different residencies over my career, and I spent a lot of time talking to people about strategies and how they do residency selection. And I'm not saying I have the inside scoop on any particular program or the real nitty gritty on any particular program, but I do think I have a fairly good handle, and I really don't want.
What I really want to avoid is interested readers picking this up and saying, oh, this is how it's done at every single program. I mean, they make very broad stroke statements here.
So they say that residency selection has long been guided by two key metrics, standardized test scores and the prestige of medical schools. And, I mean, right off the bat, I have to put that on hold. I don't agree with that.
I think that in certain programs that may be true, maybe, and it might not even. I mean, I don't want to cast aspersions, but I would have to assume that that might be the case at the programs where they are. They do mention later that Duke, anyway, is trying to do some things to combat that, you know, bias.
But I don't believe that this is the way it's done at every residency program, and it certainly isn't done at the residency programs that I've been affiliated with in the past, and particularly as it pertains to the prestige of medical schools. I think that they say fundamentally they want to rethink the approach to evaluating candidates, prioritizing attributes such as resilience, cultural competence, collaboration and communication.
And they say that despite the clear importance of those attributes that they're advocating, that the current residency selection process fails to assess them. Well, how do you know that?
How do you make such a statement regarding that the current residency selection process fails to assess them for all the programs across the country? On what objective grounds is that really measured?
I mean, if, you know, they're making a rhetorical argument, you have to create kind of a straw person to take down.
So, you know, the first thing that I want to say is that I do really believe that, number one, how each program handles, you know, making that initial cut for all the applicants and then what they're going to value in terms of interviews and things like that is probably different between every single program. I don't think there are broad brush similarities that you can say all these programs do X, Y or Z.
And something that I share with the mentees that I have here or people who are in med school that I speak to here in whatever venue is that I really do think that programs care about kind of the narrative, and not just the individual person's narrative, but the narrative that they understand as bringing you to their program.
And the programs want individuals who are going to make good orthopedic surgeons, who are trainable, who will work within the culture of their particular program, and who they intuitively understand as potentially wanting to be at that program. If you're going through the college application process with your kids recently or in the near future, like you'll hear this idea about selective colleges or universities wanting to see demonstrated interest. And, and that's what I think a lot of residency programs are interested in. Whether it means you do an away rotation there or they can intuitively understand why you want to come to their program.
Now, large market, big name programs, and by name I just mean name recognition, they may not have to rely on that as much as, and I think that maybe these authors are speaking to those large market programs that have some degree of name recognition for whatever reason.
But the programs want to understand why you want to be there. They want to know that you're going to value being there and that the applicant is going to be successful over the course of their five years in the program, both going from intern year to graduation or with, you know, not having difficulties, academic difficulties, social difficulties, interpersonal difficulties. And certainly the. Probably what I think is the worst thing for the programs is individuals leaving the program.
I mean, that is, that's catastrophic for a program because one, it looks bad for the program for future recruitment and two, they're losing a person. Like a person, you know, if you, if you have a class of three and you lose one, that's a big deal, right?
[00:10:56] Speaker B: Like, absolutely.
[00:10:58] Speaker A: Like that's call issues, that's rotational issues, coverage issues. You know, a lot of those can't, can't be made up.
So I think that different programs are going to look at individuals differently. And I don't think it's prestige of medical schools. I think that residency programs get comfortable with a certain phenotype of applicant. Whether it's we, it's our home, our home medical school, or you know, we have this pipeline. You'll hear about pipelines because like they, it's comfortable. And also what's comfortable is letters of recommendation from people that, you know. And I think that that's going to trump medical school prestige or a particular board score any day of the week. They want to know that they're getting somebody. That someone that they know who they trust says, I vouch for this person. They're going to make a really good resident in your program.
[00:11:57] Speaker B: Yeah, I mean, I think I read this slightly differently. I kind of read this as an announcement to the residents that are the medical students that are applying your residency to say, hey, we are really not just focused on the board scores and your medical school prestige alone. We want the whole person. We're addressing the fact that we need medical students that are equipped with the requisite emotional intelligence, the soft skills, and the grit that it takes to be a successful orthopedic resident. And that's not going to come alone with high board scores and the procedure of your medical school. I think more than 20 years ago, when I was applying, people talked about being able, affable, and available. So you have to have the technical skills and the intellect to be able to do it. And you have to be a good person. You know, inherently someone that gets along with people and that can work in teams, and then available, someone who's willing to work hard and has that diligence. And I think that's what sort of they're showing. That's a changing of the guard where we're really trying to take that into it into account.
But the question I have with this paper is the how. Right? Like, how are we really going to make sure we get the candidates that do have that emotional intelligence and are able to work with people? And, you know, is it the reference letters? Because the reference letters might not be accurate. Right. We think of the students that often go to an institution and they want the person with the most notoriety to write their letter, and that person might not actually know them that well. And we sort of see these catchphrases in the letters that say so. And so was the top 1% of medical students I worked with this year. But that same person might have written that same line for all the students they worked with. Right. So how do we get authentic letters? And what I'm seeing more of, you know, I've been on the end here at Boston University, and I was at your stomping grounds at the Harvard Combined Program years ago. And it does boil it down to, you know, looking at these reference letters and seeing genuine letters. I'm seeing more of it now where a junior partner who actually worked with the medical student in question is writing it paired with the More senior colleague who has the notoriety and is sort of that. That sort of figurehead at that institution. So they kind of get both aspects. And I think that's a little bit more telling in terms of the person's aptitude, how well they worked, and getting some vignettes of how they interacted with patients. I think that's more meaningful.
And I think when you talked about demonstrated interest, demonstrated interest in orthopedics is obviously critical, but then to make sure we get the right students in the right programs, demonstrated interest in coming to that program. And I think this whole signaling process has improved that a little bit to some degree. So at least the programs know who's interested and who's really intending to potentially come. If we. If we rank them highly.
[00:14:37] Speaker A: Yeah, I mean, I think everything you said makes absolute sense. But when they say things like letters of recommendation are often treated as secondary, I don't agree with that.
[00:14:48] Speaker B: I'm with you on that.
[00:14:49] Speaker A: Yeah.
All right. So for those who are, you know, reading this and are in the throes of or getting to the stage where you're going to be going through residency selection, it certainly is an opinion. It's their opinion and their experience, and I fully respect and honor that. But I would say don't take this as being emblematic of every program you're going to interact with across the country.
[00:15:15] Speaker B: Yeah, I would agree with that.
[00:15:18] Speaker A: Okay, so let's get into your headline. Results of a Novel Osteotome System for Femoral Stem Extraction in Revision. Total Hip Arthroplasty Technique Limitations and associated Complications by Noor and colleagues. And this is with a comment.
[00:15:36] Speaker B: Yeah. So this paper by Noor and colleagues is a retrospective observational study of a cohort of patients from an institutional arthroplasty database.
As most listeners probably know, removal of a well fixed femoral stem is one of the nemesis of the arthroplasty surgeon. Conventional methods involve using osteotomes, flexible osteotomes, slap hammer extractors, drills, high speed burs. Then we still often have to perform an extended trochanteric osteotomy to get the stem out can take a lot of operative time, which increases surgical risk and cost.
And the conventional methods of removing these stems is associated with bone loss, fracture risk and ETO is also not benign and can increase morbidity.
Also, stem removal can be tedious and exhausting for the surgeon. I don't know, Andrew, if you've watched the Mandalorian, but I'm a big fan and little grogu also known as Baby Yoda. He could use the Jedi force incredible ways against his enormous evil creatures. But then after he expended all his energy to defeat his adversary, he would fall asleep.
[00:16:34] Speaker A: He just passes out. He just crumples.
Very good.
[00:16:39] Speaker B: Yes, I like it totally how I feel after I take out one of these stems. So I have to say I'm super excited about these novel systems that are better designed designed for efficient stem removal, and there are a couple of them on the market.
They're contoured to be able to remove well fixed stems, and they're designed to correspond to femoral geometry and to protect the anatomic structures such as the trochanter and the calcar.
The system that they used in this paper was the Exodus system, which is a Zimmer biomet product and has three osteotomes, a concave lateral blade to protect the trochanter, and then a medial blade with a cutout for the trunnion that's contoured to hug the most stem shapes at the calcar and then a straight osteotome to disrupt the interface anteriorly and posteriorly. It's a one size fits all stem system rather, and there are others on the market that do have a spectrum of sizes and shapes, but the authors sought to determine how successful the use of the Exodus was in revision. Total eparchoplasty cases they identified 92 cases of well fixed press fit stems that were revised from 2017 to 2024 in which the Exodus was used for stem removal. Their exclusion criteria were loose stems as determined radiographically or intraoperatively. Cemented stems because the system's not designed to be used for cemented stems or fully coated HA stems. Hydroxyapatite stems where the osteotome system is not designed to extract the outcome. Measures were a successful extraction defined as absence of intraoperative fracture or need for extended trochanteric osteotomy.
Preoperative radiographic details of bone quality by the door classification and presence of trochanteric overhang in space between the implant and bone of more or less than 1 millimeter as a dichotomous outcome were collected to determine if these played a role in intraoperative fractures.
The cases were performed either by a posterior or an extensile direct anterior approach. A pencil tip bur was used in all cases to develop the space at the proximal bone implant interface to subsequently insert the osteotomes, after which the stem was removed either with a through an extractor or a stem agnostic sort of loop extractor.
They used descriptive statistics. Out of the 92 stems revised, 65% were a single taper wedge, 16% were fit and fill design and 9% were fully coated hydroxyapatite.
The most common reason for revision was infection in 49% and gross trunnion failure in 18% of the cases.
In only 10% of the cases, the system failed in removing the stem and required an extended trochanteric osteotomy. In one case the case was actually aborted due to hemodynamic instability of the patient.
The need for an ETO was associated with stem type. None of the single wedge taper stems required an ETO and while ETO was required to move 27% of the fit and fill design stems and 50% of the fully coated stems.
Intraoperative fracture occurred in 17 cases, which is 18%, and the majority of these 12 or 71% occurred during extraction.
Most of the fractures occurred at the calcar or the greater trochanter and only one extended into the subtrochanteric region.
Interestingly, out of the 12 fractures to occur with implant extraction, 75% or nine cases were during a direct anterior approach and three were during a posterior approach. The authors didn't directly point this out, but it is included in the table.
So intraoperative fractures occurred in 8% of the single wedge tapers, in 27% of the fit and fill stem and 13% of fully ha coated stems.
There was no difference in intraoperative fracture rate on the basis of trochanteric overhang or the presence of a more than 1 millimeter potential stem space between the component and the cortex. Radiographically, there were actually no fractures in the dorsi femora, but this accounted for only 2% of their cases.
Although they weren't able to measure bone loss associated with the use of the system, the authors noted that in many of the stems were revised to a metathysele engaging fit and fill stem. So in other words, they were able to use primary designed stems in the revision setting because they had preserved so much bone, which is a good thing after extraction rather than having to use a distal fixation revision style stamp.
The authors discuss their findings relative to existing literature, which also shows a 19% incidence of intraoperative fractures during revision. Total arthroplasty of uncemented stems, more than 2/3 of these typically occur during extraction.
They conclude that this particular system is most effective in a single wedge taper design, but there is a higher risk of fracture and or need for an osteotomy with the fit and fel designs.
Furthermore, based on the preoperative radiographic features, it can be difficult to predict the potential success of the system.
Reduced operative time is another potential benefit of these systems which can result in reduced morbidity, less blood loss and less cost. However, these issues were not examined in this particular paper. I also think they could have described other systems that are similar in this and the studies with these results in their discussion. But there are very limited studies about the other systems because they're all very new and novel.
I think the take home message from this is that the Exodus system can be successful for removal of well fixed single wedge taper stems and that the system is less reliable in fit and fill designs. And with distal fixation stems. One major benefit is that there may be less bone loss which allows revision with metaphysele engaging stems rather than distal fit stems. While there are many systems emerging on the market, many of these are expensive. The osteotomes are disposable. There are nuanced differences between the systems. For instance, this system is a one size fits all osteotome set where there are other new systems that have a spectrum of sizes and shapes to match the implant geometry. And there are also contemporary extraction devices with longer osteotomes that are not contoured. So we kind of need to see more studies evaluating which systems are best in the clinical scenarios pertaining to bone morphology and stem design. But overall, I think this is a good observational study with a large series with some very important findings.
[00:22:31] Speaker A: Yes, I was just curious.
Obviously this has been. The patients that they're reporting on have been collected from 2017 to 2024. So that's, you know, over the course of, we'll say six years, they're doing about 15 cases with this instrumentation. That doesn't mean, you know, there might be other revisions where they're not electing to use it. Would you say that, you know, 15 per year is reasonable volume for a procedure like this to give you a good representation of the spectrum of these types of conditions? Presentations over, you know, the full gamut of phenotypes, if you will, of revision hips?
[00:23:12] Speaker B: Yeah, I would agree that it's a modest amount, but it is meaningful because the system is so new. To have 92 cases of these is actually a substantial number. So I do think kudos to the authors on that in terms of the numbers, because think about it, they're revising so many other stems that are loose stems and they had to Exclude all of the loose stems because there's no real need to be using these systems in a loose stem, cemented stems, revising a lot more older cemented stems and it's not applicable there. So I think they probably are a pretty robust revision arthroplasty group and this is a small segment of those cases that were in particular using this system.
[00:23:54] Speaker A: Yeah, I think even still, the numbers being what they are, it would have been helpful, I think, to give a better idea of, you know, they're presenting their clinical, their rote clinical retrospective, as they say, describing our experience with the novel system in a large series of revision total hips for the purposes of translational capacity. If they gave a 95% confidence interval around their point estimates, that would give you a better idea. It's not going to be 10% out of 1,000, for example. It's going to be 10% across the country.
And then the other thing that I really didn't, I don't understand how they reconcile level three evidence. This is a pure clinical retrospective. I don't think they have a good comparison cohort, really. I think there's, you know, selection, indication, expertise bias, all those things not, you know, not taking away from the report. It's just contextualizing it. But I think this is level 4 evidence.
[00:24:54] Speaker B: I agree there.
[00:24:56] Speaker A: Okay, so we're now moving into the your cases on hold featurette.
Long term trajectories of patient reported outcomes following total knee arthroplasty. This is like tailor made for you.
[00:25:12] Speaker B: Bring it on.
[00:25:13] Speaker A: A longitudinal study of 1264 patients by Choi and colleagues. This is the lead article for this issue. There is a comment, there's an infographic and it's permanently free. That's the perfecta right there. We hit the perfecta, we have a winner.
But is it perfecta enough that it's not going to go on hold? I don't know. We'll see.
So this is obviously a very interesting. I thought it was a really good study. Patients who underwent primary total knee for arthritis between 2005 and 2013 and then were followed for about a decade postoperatively. Their primary objective, they stated, was to investigate sequential changes in disease specific and generic PROM scores following primary total knee and to identify associated factors in a large cohort with greater than at a minimum 10 years follow up. But they do have more than that. They have a 10 to 15 year range. So they hypothesized that both disease specific and generic PROM scores would decline.
I didn't love the hypothesis.
Sometimes people feel Compelled to put in a hypothesis and it is preferable to have a hypothesis. But when you're doing kind of this, you know, long duration natural history study, like the hypothesis just seems kind of like, oh, you thought that the disease and their prom scores would decline as they age 10 or 15 years. Like that doesn't really seem like that's somewhat intuitive. Right. And I'm not going to come back to that as well. But they were able to include 12, 164 patients, which is incredible. And you know, only in certain places and unique situations are you able to have this many patients that you're following so many years. So it really is useful and it's high quality information and I think this is testable material just to throw that out there. But you know, minor critique, but still all the, all the surgeries are performed by just one or one of three surgeons. So huge potential for expertise bias in that context.
And obviously they were evaluated at baseline and then at 6 months, 1 year, 2 years, 5 years, 10 years and 15 years. For those that made it that far, they use generalized linear models and linear mixed effects models, which is good because these are non parametric outcomes. So gold star a plus on that front.
Now they found that the physical and mental component scores of the SF36 domains declined by more than the minimally clinically important difference after five years. Social functioning scores showed continued improvement, although not all changes were significant.
They have the Womack pain and stiffness scores, the Knee Society knee score, the Knee Society function score, and then as I mentioned the SF36 domains, octogenarians demonstrated lower physical functioning scores but higher social functioning scores in the long term. And female patients demonstrated inferior functional and vitality scores compared to male patients. At the end of the day, what do they conclude? They say disease specific and generic PROM scores after total knee improved significantly and remain superior to baseline scores over a 15 year period. Which is really dramatic, I have to say. Wow. I would not expect, I would not have expected that to start with. And then physical function scores tended to decline in the long term that I did expect.
So I think that one of the fundamental questions that I would love to pose to you, the indication for doing a total knee replacement is advanced arthritis of the knee that's causing pain and dysfunction.
And what is the. I wouldn't think that we're trying to tell patients, well, we're going to give you a perfect knee that's going to basically outlast you. The knee is perfect for the rest of you. Like you are going to be so Wonderfully functional after the knee replacement, it's never going to change. Like you're never going to age anymore. We found the fountain of you. I mean, that's like, like the individual in whom you're putting in the total knee replacement. Like they are getting older, they are going to continue to have functional decline as is expected with aging. So like, the fundamental premise of this, that one, you know, on the one hand, it's like we want to look at how patients are doing 10 and 15 years out, but how they're doing 10 or 15 years out, I don't think really has very much to do with the knee replacement.
[00:29:56] Speaker B: Yeah, exactly. Right. I mean, this was an impressive body of work. Right. To follow more than 1,000 patients out to 15 years and beyond with patient reported outcomes in such a huge, huge battery of them. Right. Like we can barely get whose junior score is at one year. Right.
It's really hard to get this data long term.
But no, we're not telling patients that this knee is going to be the bionic knee that's going to outlast them. We really try to temper patient expectations. I mean, we always have that number thrown around that 20% of patients are dissatisfied after a total knee replacement. We need to temper it with that data as well. So it really is eye opening that the function was so good pertaining to the knee this far out. I thought another really interesting tidbit from this article was that we have something to look forward to.
[00:30:40] Speaker A: Right.
[00:30:41] Speaker B: If our social lives are not good now, when we're octogenarians, our social function is actually going to be better than it is now, provided we undergo a total knee replacement at some point.
[00:30:49] Speaker A: Social life, not where you want it to be. Get your knee replaced.
[00:30:54] Speaker B: And therein lies the question which I don't want to. You know, we can't really criticize this because it's such a great body of work, but we don't have the other side of the, you know, we don't have controls and that would be difficult to get, obviously. But I am curious how, how would this compare to a group of patients either that are controls with no arthritis or the arthritic patient that didn't get a total knee replacement. Right. That would be hard data to get, but it'd be interesting to see.
[00:31:18] Speaker A: And I just thinking about some of this, I have to think that some of it is cultural and specific to the context. Particularly again, to come back to the octogenarians, they had higher social functioning scores compared to what? Not compared to peers that didn't have their knees replaced. But as compared to younger patients who had the knees replaced. Right, exactly.
[00:31:38] Speaker B: Yeah. Which is interesting.
[00:31:40] Speaker A: Yeah. And just to have so many octogenarians in that you're following, you know, if somebody was 80 when they had the knee replaced, they're 90 at the time. 90 to 95.
So there are good longevity genes just at baseline at play and probably social supports.
[00:31:59] Speaker B: Right. I mean, we can't ignore that this was performed in Asia, it was in Korea, where people respect their elders and they have a big community in general. You know, in terms of societal translation from an Asian society to the U.S. or North America may not translate in terms of the social functioning aspect of the auctionenarians, but I mean, I think
[00:32:20] Speaker A: at the end of the day it is very like just the large cohort, the battery of scores, the duration of follow up. Just nothing. Nothing to put on hold here for sure.
[00:32:32] Speaker B: Yeah, agree. Not on hold.
[00:32:35] Speaker A: All right, so then we have in the honorable mentions category, the impact of cervical multifidus sarcopenia on outcomes after laminoplasty for cervical ossification of the posterior longitudinal ligament by Zhao and colleagues. And this is permanently free.
This study is looking at associations between the cervical multifidus sarcopenia and outcomes after laminoplasty for cervical ossification of the posterior longitudinal ligament. A lot of intersections there.
They specifically are looking at cervical sagittal alignment and patient reported outcomes. They evaluated the sarcopenia on T2 weighted MRI sequences at C5.6 graded according to the Gutelier classification. They had 134 patients with cervical opll included.
And in this cohort they found, perhaps not surprisingly, that sarcopenia of the multifidus had a negative impact both on sagittal alignment and patient reported outcomes.
That's about all the time we have for this episode.
We'll try and do better next time if you like what you heard. Definitely like subscribe Hit the notification bell. Share the podcast. Share it with some people who are trying to match into orthopedics or thinking about it. Share it with all your third year medical students who are getting ready to start entering the pathway if you didn't like what you heard. Thanks for listening this long and tune in next time for episode 102 where Dr. Abdeen will be be leading it and probably do a better job than I even possibly could.
With that said, you know, hopefully where you are, your cases are all ready to go, but whenever you're with us here, even if we actually like the work, your case is still on hold.
