Episode Transcript
[00:00:03] Speaker A: Welcome to your Cases on Hold, a JBJS podcast hosted by Antonia Chen and Andrew Stonefield.
[00:00:10] Speaker B: Here we discuss the science of each issue of JBJS with an additional dose of entertainment and pop culture.
[00:00:17] Speaker A: Take us with you in the gym, on the commute, or most certainly whenever your case is on.
Welcome back everyone to your Cases on hold. This is episode 89 as we close in on the road to 100 to be starting next episode, we count down to our 100th episode, which will be in February of 26. But today it's September 2nd for our September 3rd issue of JB JS.
I am Andrew Schoenfeld, Deputy editor for Methods, and I have with me I'm.
[00:00:58] Speaker B: Antonio Chen, executive editor of JB js.
[00:01:01] Speaker A: Okay, so we are presenting, as always, our opinions, our impressions.
What you're hearing here is not the opinions of the editor in chief, the editors of the other journals editorial board, or the board of trustees for the Drone Bone and joint surgery. Today's issue is brought to you by jbgs cme.
You can go to jbgs.org you can access all types of different CME.
Get credit for what you're listening here. Get credit for what you're reading in the journal. Get credit for what you're discussing in your journal club. And then beyond that, there's clinical classroom, there's self assessment exams, there's Miller Review course, there's overseas review courses. So check it out.
It's really one stop shopping for all that you need in terms of CME for board prep, self assessment exams, maintenance of certification, you name it, they have it. At JBGs CME, we're not only advertisers, we're also subscribers, right?
[00:02:14] Speaker B: Exactly.
[00:02:15] Speaker A: Let's get into it here. We got a fair amount of things to discuss. So top of the pile.
What's new in Osteoporosis and Fragility Fractures by Rogmark. Permanently free. And we have Value Based Care and Orthopedic Surgery Outcomes Costing and policy updates by Kleinsmith.
Beyond the Incision, the Power of Patient Narratives in Surgery by Kumar. And that is permanently free.
Then we have orthopedic slang.
Time for revision.
An interesting opinion piece. I'll tell you, a lot of their premises I think are kind of sort of, you're looking for a problem where there probably isn't one. But that's by Zhao and colleagues, so you can check that out, see if you agree with me or you agree with them.
I think it's very hard to change slang except over a concerted amount of time and it's usually not effective from a top down approach. I mean barring things that are offensive and stuff like that. That's not really what by and large it's not always what they're talking about. A unifying radiographic description of leg Calv Perthes disease at skeletal maturity. The head acetabulum trochanter classification by Herring and colleagues. Then we have migration of cemented and uncemented implants in total knee arthroplasty with an asymmetrical tibial component. A randomized controlled trial with a two year model based radio stereometric analysis follow up. That's actually at the top of the pile because it's incredibly interesting study that we're also going to present in that your cases on hold feature at.
That's about where everything is at this point. We're going to go into the headlines. What's new and exciting in orthopedics this week and that's going to be 10 year outcomes of hip arthroscopy for the treatment of FAI and labral tears in patients with a workers compensation claim by Dom and colleagues with an infographic and it is 30 days free.
So there are many like orthopedic memes and jokes if you will, about patients with workers compensation status. Most of them tend to have a negative connotation but of course these are individuals who are injured at work and many of them are absolutely earnestly trying to get back to work depending on the nature of the occupation and the nature of the injury. There are individuals with workers compensation status who have some really severe and potentially devastating function threatening, limb threatening, life threatening injuries in some respects.
This study of course is focused on hip arthroscopy for the treatment of femoral acetabular impingement and labral tears. It is work that they basically prospectively collected data on patients with workers compensation claim who underwent hip arthroscopy at the American hip Institute between February 2008 and December 2013.
So of course just based on that date range we're talking about, there's concern for secular trends, especially over the 10 year time window. You know, I don't know how patients operate on in 2025 in terms of the technology, techniques, facility, familiarity, evolution of surgical procedures, certainly spine surgery in 2025. And you know, I don't really feel I'm speaking out of turn to say hip and knee Replacement in 2025 is not what it was in 2008.
[00:05:43] Speaker B: Thank goodness.
[00:05:46] Speaker A: And that potentially is the case for these types of Procedures as well now, you know, as we're really starting to see now, and we discussed this in the last episode too, we're seeing a lot of propensity score matching techniques now. Like that's like what used to be, like you would see regression in every study. Now it feels almost like every study has propensity score matching, which the new drug of choice.
Well, it's just because it makes it seem like you're doing something that's like more advanced. Like you're not just doing a regression analysis, you're doing propensity score matching. But I mean, at the end of the day, and as many have heard us say, it's really in like what is the substrate? What is the rationale for using the causal inference technique? And then does it really apply? And I have a lot of questions about the approach that they used here. So they match patients in a one to three ratio on age at the time of surgery, body mass index, sex, acetabular outer bridge grade and capsular treatment release or repair. These are not things that drive a workers compensation claim.
So I feel like you could have done a regression approach and not have to go through this like one to three match and then, you know, find matches for. You could have just used everybody and done a regression analysis. And you probably be getting at the same thing. Like the, the use of the propensity score technique in this setting. To me, it, it doesn't really apply very well and it isn't, they don't certainly rationalize it. Then they say that the matching was performed with a caliber of 0.3, which is like super permissive.
Normally like it's like.02, but 0.3 is like, you know, when we talk about is it Picasso to Picasso, Picasso to Renoir, Picasso to Van Gogh, Picasso to Michelangelo, Picasso to my kids, you know.
[00:07:40] Speaker B: Crayola to me, because I am not an artist.
[00:07:44] Speaker A: Yeah. So I mean, what are like, what are we talking about here in a mat? Like, are you really matching comparable patients or is it just sort of like that's how you get things where it's like the 50 year old male patient with heart disease and diabetes is matched with like an 18 year old male patient with no medical comorbidities and they're like, oh yeah, perfect match. Like, is it really, Is that really a perfect match? I'm not saying that's exactly what happened here because a lot of that is sort of, you know, behind the scenes and there's a little bit of a black box to it. But you basically have a score and the score is built up of like all those parameters and they're different contributing aspects to the score. And it can be mix and match. And, you know, in some respects you might have men matched with women, and others you might have an older person matched to a younger person. If the caliper is very narrow, then you don't usually see that kind of stuff.
When the caliper is very permissive, you get all sorts of stuff that it just sort of again, could have just done this with a regression analysis. In my estimation, it looks like graph in.
[00:08:51] Speaker B: Just kidding.
[00:08:52] Speaker A: Yeah. Then they go into a power calculation which is generally not supported in retrospective studies. And if you are doing a power calculation, it generally means that like you're assuming balance across the rest of that cohort, which with their propensity score, technique and approach, I don't think actually really makes that much sense.
But, you know, take it for what it's worth. They achieved more than the patients that they said they needed. I think that's all that they're really trying to show you there. So they had 70 patients successfully matched to a control group. They found matches for all 70 patients that met eligibility inclusion, which is another red flag. Like, if you can find matches for everybody, you're not working hard enough. Like, you might have matches. Not only matches, three matches for every person.
It's like, you probably need to make that more restrictive. Of course they only have 70 patients, so they, they don't really have incident cases to lose.
In which case you could go to a waiting technique. But again, you could have kept everybody if you just, you know, say it with me now. If you just did, like the chorus. If you just did regression analysis. Ultimately, at the end of the day, they found a good news story for workers comp claims, which was patients with workers comp was associated with favorable outcomes and a high return to work rate at a minimum of 10 years in this group of patients. Right. Caveat. This is patients who are presenting at this center who were selected and found indicated for surgery at the center. So there may be some cluster and expertise bias associated with that.
The workers comp group, incidentally, has significantly higher rate of revision hip arthroscopy. Take that for what it's worth. That wasn't like a main, really a main outcome. It's kind of a secondary finding. So at the end of the day, you know, other than somewhat presenting a counterfactual to the popular maybe misconception that workers compensation patients always don't do as well as your, you know, non Workers comp patient whatever their payer status or insurance may be.
I'm not sure there's a lot here that changes practice or influences care or that also isn't artifactually meaning that there are artifacts informing the conclusions based on selection, indication expertise and cluster bias, none of which are affected or impacted by their analytic approach.
[00:11:21] Speaker B: So are you a fan of proprenhes score matching?
[00:11:24] Speaker A: I am a fan of propensity score matching in the right hands and in the right context. I think it is being increasingly overused and deployed in inappropriate settings.
Ultimately, at the end of the day, any methodology is going to be based on the substrate and the clinical rationale. You can do any. You can do a randomized controlled trial with two patients. Doesn't mean that the results are useful. Doesn't matter that you did in rct. Like you just said it. Like I just wanted to say it.
I didn't really want to order it, I just wanted to say it.
[00:11:54] Speaker B: I do like the art analogy. I'm going to go back and look at my finger paintings and see how artistic they are and how beautiful they are.
All right, so talking about RCTs, I'm talking about bupivacaine Meloxicam extended release solution compared with a standard periarticular injection in primary total knee arthroplasty. A randomized clinical trial showing similar efficacy in post operative analgesia. Really, really long title to basically give you the final statement. It's by Salmons et al. It's free for 30 days. So many of us perform periarticular injections around the knee when doing total knee arthroplasty that contain different cocktails to reduce the likelihood of pain after total knee replacement. There have been all sorts of formulations there. Bupivacaine, ropivacaine, epinephrine, clonidine, ketorolac, steroids, antibiotics, everything. I personally use bupivacaine, epinephrine and clonidine plus or minus ketorolac based on the patient's kidney function.
The main limitation is most of these periarticular injections have their efficacy drop off after 12 to 24 hours after surgery. They did introduce a periarticular liposomal bupivacaine injection for extended release pain control. But RCT has demonstrated really no difference between this periarticular liposomal bupivacaine versus bupivacaine.
Now there's this new formulation on the market, the Bupivacaine Meloxicam extended release solution and was shown to have better analgesia up to 72 hours after total neartaroplasty compared with saline solutions and bupivacaine alone. But there were no studies that are conducted that compared bupivacaine with this extended release meloxicam to intraarticular standard of care which includes bupivacaine and another nsaid. So this study out of Mayo compared pain levels and opioid consumption 72 hours after primary unilateral total knee arthroplasty for osteoarthritis, comparing this bupivacaine and meloxicam extended release intraarticular injection to their combination of ropivacaine, ketorolac and epinephrine and an rct.
So the comparison was really all inter articular. So the control Group received 60ml of the standard weight based standard periarticular injection prior to the closure orthotomy. Remember it was rapivacane, ketorolac and epinephrine. An additional 60 milliliters of the standard the per articular injection was injected subcutaneously. In the experimental group they got 400 milligrams of papivacaine and 12 milligrams of the meloxicam extended release solution prior to closing the arthrotomy. But they also got an additional 60ml of the standard per articular injection subcutaneously following the closure of the arthrotomy. So the real difference was really just what was deep inside the arthrotomy, not anything on top of it.
The exclusion criteria were if the patient had a history of type 1 hypersensitivity to NSAIDs or bupivacaine or pivacaine. Severe renal disease patients that undergone a contralateral totaling arthroplasty less than two years prior to the index total knee, those with chronic pain syndromes or prolonged opioid use and those with bmi is greater than 45 or greater than equal to 45 were excluded. The randomization was stratified by variables with potential confounding effects in the outcomes of interest.
Specifically, patients were stratified by age group less than or greater than 70, sex and BMI categories less than or greater than 32 kilograms per meter squared, which I'm not quite sure where they got that number from.
Patients are blinded to their group allocation and there were four surgeons involved in the study. No patients were administered a concomitant peripheral nerve block and all patients received standard multimodal analgesic pathway. The minimally clinically important difference was considered to be 30%.
Power analysis determined a minimum of 44 patients were needed per group.
Now as part of before starting the study the statistician said you know it's a good idea to do is do a a priority Pilot study There was an initial group of eight patients from one surgeons that were randomized to each of the two study groups. The medications used, the procedures followed and the data collection were identical to those outlined for the full rct.
The data from this pilot study were collected for verification of the power calculation and were separately analyzed from the full RCT analysis and it confirmed that the original sample site estimate of 44 patients per group would provide greater than 90% power to detect the MCID of a 30% reduction in the NRS pain AUC at 72 hours.
So the primary outcome was the NRS pain auc up to 72 hours prior to surgery sorry 72 hours after surgery and the data were collected using patient reported pain diaries. Secondary endpoints included NRS auc up to 48 hours after surgery and any adverse events.
So there were a total of 209 patients with 209 knees after exclusion. The final cohort consisted of 101 patients.
More than half the cohort were removed because of exclusions. 63% were female, 53 patients in the treatment arm and 48 patients in the control arm. The mean age was 68 years. The mean BMI was 31. Study groups are similar with respect to age, sex and bmi. No surprise because that's how they're randomized. There was no loss to follow up in the 72 hours. Thank goodness.
What did the findings show? It showed that there were similar post operative analgesia observed between groups with an AUC for the adjusted NRS pain score. Remember, it was adjusted for pain consumption for up to 2072 hours of 331 versus 373 and they did not exceed the MCAD.
The same was found at 48 hours. Not surprisingly, opioid consumption was similar between the two groups at 72 hours. The mean consumed total morphine milligram equivalents were 85 in the bupivacaine meloxicam extended release group versus 77 in the standard injection group at 48 hours. They were very similar between groups a little higher than bupivacaine meloxicam er group at 67 versus 60.
The mean maximum NRS pain scores were similar and reflected good but not completely complete analgesia scores were 3 to 5 on a scale of 10 on the day of surgery, 4 to 6 on post operative day 1, 5 to 6 on post operative day 2 and 4 to 5 on postoperative day 3. With regards to early post operative complications, one patient in the experimental group had nausea during PT and one patient in the control group had postoperative nausea resulting in unplanned admission through the emergency room. And one control group patient had a post operative seizure in a previously known history of seizure. None of these adverse events were deemed to be related to the analgesic choice.
So in conclusion, this randomized controlled trial demonstrated similar analgesia with this bupivacaine Meloxicam extended release solution and a standard periarticular injection up to 72 hours after total knee arthroplasty.
I think it's interesting to see a randomized control trial especially looking at new drugs, especially as they hit the market. They are normally more costly and the real question is, does it make a difference in our patient outcomes? There's something really makes a huge difference in our patient outcomes. Tranexemic acid being a great example of that. Everyone's on the bandwagon. When you're looking at something that has a lot more cost and maybe not a lot of benefit to it, then you got to really ask yourself why before engaging in it. I thought, this is a thoughtful study. Again, more were excluded than were actually included in the study, but it did follow their sample size calculation.
[00:19:11] Speaker A: Yeah, I thought the name of the drug is Zinrelef or Zinn Relief maybe, but like Zyn is like those nicotine pouches that fraternity guys like to use a lot of people.
So I'm like, oh, I don't know that you want to be associated with Zinn or Zine. I don't even know how it's pronounced. But I don't like that they use the word similar when they actually mean no significant difference. It's not similar. Like 331 and 373 are not similar numbers. There's actually there quite a bit of, there's, there's quite a bit of gap between those numbers. 3 is not similar to 5. 3 is different from 5. 3 is similar to 3.
Sure, you could make a case that like 370 and 373 might be similar, but don't use similar as, you know, a homonym for not significant because it's not everywhere that says similar. Here they should actually be saying there was no statistically significant difference. And if you look at the P value for their primary outcome, and I'm not somebody who likes to, like, just rely on the P value. Anyone who listens to this podcast knows that. But when you start, you know, people talk about trends, and I don't like when people talk about trends either, because basically all they're trying to say is, like, the P value is between 0.1 and 0.05, but not less than 0.05. That's what they're using that as an inappropriate euphemism.
But, you know, essentially here, when you're seeing this comparison and you're seeing the P value is pretty low, and certainly in the range where it's edging toward 0.05, similar would be like 1. A P value of 1 is, like, identical. Right. There's no. There's no demonstrable difference when you have a much lower P value, especially when you have a relatively low sample that's actually showing that, you know, were you. If you had higher numbers, you might even be finding a significant difference there.
[00:21:15] Speaker B: And that's the hard part about this. I mean, they did choose a pretty big difference already for their sample size, but if they did have more patients, it might actually turn out that way. So definitely interesting to see.
Right.
[00:21:27] Speaker A: All right, let's move into the your cases on hold featurette. Migration of cemented and uncemented implants in total knee arthroplasty with an asymmetrical tibial component randomized controlled trial. A study so cool we mentioned it twice in this podcast. This is by Altun with a commentary, and it's 30 days free.
So when speaking of euphemisms and homonyms, when I initially read this, as you know, we're getting the articles to look at, what are we. When I read migration, I was thinking, like, things actually moving, like migration of an implant.
I feel like you should be saying is micro motion, because we're talking about things smaller than a millimeter, by and large.
[00:22:14] Speaker B: Like, I migrated from this end of the table to this end of the table.
[00:22:17] Speaker A: Yeah, it's more like I migrated. So small movement in my seat. You didn't even see it.
That's. That's so. I. I feel like that should really be, like, micro motion now. Maybe, you know, joint replacement specialists are allergic to micromotion. Like, that's not a term. Not like micro motion, but you don't like migration either. I'm sure if you don't like micro motion, you'll hate migration. Right?
[00:22:43] Speaker B: Like, exactly.
[00:22:45] Speaker A: So this study is kind of like it's leveraging an rct, but then it's also leveraging this radio, ISO, stereo radiostereometric analysis. Say that three times. RSA will abbreviate going forward to evaluate migration and segmental motion of cemented and uncemented femoral and asymmetrical tibial Persona components for total knee arthroplasty. This was a trial with 63 patients that's quite imbalanced when it comes to biologic sex.
22 males and 41 females. And they were randomized to total knee with cemented and uncertain. And then the primary outcome is the maximal total point motion after two years.
So they look at the femoral and the tibial component separately. Not surprisingly, you know, it takes up to like three months or longer for things to actually like completely fixate when you're talking about at this micro millimeter level.
But in both groups there's a certain degree of motion tends to be more.
Not surprisingly in the uncertaintied group after 24 months for the femur there was 0.51 millimeters in the cemented group and 0.83 in the uncemented group.
Those figures do not overlap.
That is a difference. Then there was a significant difference between the fixation types at 3 months, 6 months, 12 months and 24 months in the femur on the tibia side. After 24 months it was 0.72 for cemented and 0.78 for uncemented. And they do overlap. So conclusion Basically, Tony, arthroplasty with cemented and uncemented Persona components showed migration. Read for me micromotion values within acceptable ranges suggesting successful long term fixation.
But if you drill a little bit deeper, there's some points that I'm really interested in your take on and I'd like to pose them to you.
We start with the premise that implants will have some degree of continuous. Again, they're using this term migration, but for me it makes more sense that they're talking about motion at the interface to some degree and that the more or greater that is, the greater the rest for aseptic loosening and you know, subsequent need for revision. So they introduced the model based RSA as sort of this novel way to approach doing these measurements and it can be analyzed with computer aided design as opposed to previous ways of measuring this that were more problematic and less favorable. So they did the RCT patients 40 to 70 years of age undergoing primary tone. The arthroplasty they started overall with 66 patients.
They did the a priori sample size calculation of course and block randomization with 10 patients in each block and a one to one allocation with or without cement, all that is fine. And then they make their post measurements and we already went over the results.
Most of the components are stabilized within the first three months. That I think is interesting in and of itself, but maybe that's just me. And then they found differences in the femoral and not so much on, on the tibial side. Now here's the part where I'm like, hold up, I have some questions.
So first thing is that they say what they think is the acceptable rate of this kind of motion is 0.54 with anything over 1.6 unacceptable.
Then anything between 0.54 and 1.6 is reading there is considered to indicate components at risk.
The first thing they say is that previous studies found median motion of the femoral implant 0.87 and 0.89.
In their study they found 0.51 in the cemented group and 0.83 in the uncertaintic group for femoral components and then 0.66 in the cemented group for tibia and 0.8 in the uncertaintic group for tibia.
So basically like, except for the cemented femoral group, everybody else, all the others are at risk. They're in the at risk category according to these parameters that they are stating as kind of the established gold standard metrics.
Does that make sense to you?
[00:27:28] Speaker B: So the hard part about RSA is it's all numbers based on radiographic measurements, based on the distance from an implanted bead that was placed. And as this says, you can see it says potential aseptic loosening. Right? It didn't say that these were aseptically loose or none of these are revised. You know, like all these sorts of things make it a potential. So that's what I always worry about RSA is that you can retool far into it and you know, let's say I take these patients back. I'd probably have a really hard time getting these implants out. So, you know, so it moved a little bit, right? And especially for cementless implants, you know, which this is obviously looking at too, you probably expect some sort of micro motion, not macromotion, not migration.
And by doing so, you know, there's bone ingrowth into the, you know, surface and all that sort of stuff like that. So, you know, if you move, like we always say, if you move it 1 millimeter, are you going to go and revise the patient? No. You're not going to do that, right? It's not that the patient's septic aseptic loosened. If they have pain, maybe that's a reason for it. But typically what happens is these micro motions will happen and then will settle after a period of time. So no, I don't think it necessarily correlates to something bad.
[00:28:39] Speaker A: Yeah, well, I mean, because it's just to me it's like revisions are that common where it's like basically the average of all these studies. Everybody is in the at risk range.
It's sort of like when you go to, you know, someone who's a charlatan or and you know, basically no matter, no matter what you give them, they're going to tell you it's like bad. You know what I mean? Like, oh yeah, you definitely need, you know, this laser based treatment that I do like because your ankle hurts or your knee hurts or I made these, these measurements and any kind of measurement that I find is going to be bad. You know, the sky is blue so you need the laser treatment. Like, like it can't be that everybody is in the bad range. And if everybody is in the bad range, then it probably isn't actually a bad range.
That's what I'm saying.
[00:29:30] Speaker B: And then, and that's the problem. Everyone can't be bad. Right. If it's in that area.
[00:29:35] Speaker A: And just, you know, I'm hearkening back to some other studies, one of the ones that was in my web based longitudinal assessment this year. The number of like radiolucent lines that you see on, well fixed like implants or non problematic implants. I mean it just harkens back to this for me. Like I felt that there was definitely some synergy between those kinds of findings in this.
[00:29:58] Speaker B: That's a great way to put it. What does it actually mean? So, you know, radiolucent lines are probably even a little more telling, but differences in rsa, not as telling at all.
[00:30:09] Speaker A: All right, well, let's move into the honorable mentions. I think we might be running out of time here.
Is there a difference in postoperative outcomes between kyphoplasty and vertebroplasty in the management of vertebral compression fractures? No, that's not in the title. I'm just answering that. This is by Daher and colleagues and is a meta analysis of RCTs looking at the two classic cement augmentation procedures, vertebroplasty and kyphoplasty. They had a metasynthesis with 600 patients in the kyphoplasty group and 590 in the vertebroplasty group. Kyphoplasty patients had a lower risk of adjacent vertebral fractures, no differences in operative time or postoperative pain.
Then they had a lower postoperative kyphotic angle observed in the kyphoplasty group.
Their conclusion was that kyphoplasty was associated with a better post operative local kyphotic angle and a lower risk of AVFs. Again, just repeating the results with no difference in post operative pain or cement leakage.
I think most people are using kyphoplasty in reference to vertebroplasties, if only because of risks of cement injection leakage. But next we have tension band wiring versus pre contoured plate fixation for two part and multi fragmented olecranon fractures. A prospective randomized trial. This study, which was conducted by the Croft study group, recruited 200 patients 18 to 75 years of age with isolated displaced olecranon fractures and randomly allocated them to tension band wiring or plate fixation.
At the end of the day, after a focused assessment, tension band wiring was non inferior compared with plate fixation. The surgical procedure was quicker for tension band wiring, but the frequency of secondary surgical procedures was higher. The majority of the need for removal was symptomatic hardware. I know when I was in training and on the trauma service I vastly prefer doing the plates to the tension band wiring.
[00:32:28] Speaker B: They're kind of fun. The twisting, twisting, twisting, twisting.
Each their own.
[00:32:35] Speaker A: Yeah, not for me. Next is Psychological distress is common and associated with greater hip dysfunction in adolescents and young patients. This is by Wiley and colleagues with a comment and a visual summary.
The aim of this study were to report the prevalence and risk factors and determine relationships with patient reported pain and dysfunction among individuals 10 to 24 years of age who presented for hip pain at an initial clinic visit at which they were asked to complete The Patient Health Questionnaire 917 item Optimal screening for prediction of referral and outcome Yellow flag as opposed to black flag, red red flag or purple flag and the International Hip Outcome Tool 12 so among 500 patients who participated, 10, close to 11% had moderate or greater depression symptoms and about 27% had severe psychological distress.
They feel that this shows that psychological distress is common in adolescents and young adults with hip pain and is also associated with greater patient reported pain and dysfunction scores. So some some interesting information there. Certainly you don't need to take it from us.
Pull these articles yourself. Have a look.
That's about all we have. We are out of time. We'll try to do better next time. As always like subscribe hit the notification bell. Find us on Catstos, Stitcher, Apple, Spotify, Amazon or the jbjs.org website if you don't like what you heard from me, thanks for sticking this long.
Come back in two weeks and hear what Dr. Chen has to say as the Executive editor when she's leading the conversation as we begin the official march to 100 with our 90th that's 90 episode of your cases on hold. Hopefully by then in two weeks your cases will be ready to go. But if you're here with us, you know everything is always on hold.
Sa.
