Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Listen. Um uh uh my understanding is that pretty much everybody on or probably most of the people on are uh pretty early in the quest for getting into orthopedics. Uh So welcome. Uh It's a, you know, orthopedics is obviously the greatest specialty there is. And within orthopedics, it's get this slide. There's, there's a lot of subspecialties. So we have depending on how you count them. Eight or nine or so. Uh trauma sports joints, hand, upper extremities, spine, pediatrics, foot and ankle and then oncology. Uh oncology is the smallest uh orthopedic subspecialty. Uh There are, I don't know, 25,000 or so orthopedic surgeons in America, maybe 100 and 50 or 200 maybe 2 50 orthopedic oncologists in the US. Turns out at UF, we have a very busy and strong orthopedic oncology program. It's really because the, the department was started by Doctor King was one of the kind of like fathers of orthopedic oncology. Uh And so there's been a really a big focus in orthopedic oncology here for forever since 1960. Uh we have uh one of the few orthopedic oncology fellowships in America. We have two fellows per year and there's about 20 or so fellows trained in the US per year. And historically, we've, we've educated or trained close to 20 to 25% of the practicing orthopedic oncologists in America. Uh So we have a very busy referral program. It's myself, uh Doctor Spiegel, uh Doctor Gibbs, little background about me. I've been on the faculty for uh 32 years, I think. Now I've had a bunch of different roles here at UF. I started out as, you know, just one of the orthopedic Oncology Faculty and then later took on some leadership roles, the first of which was as the program director. So the orthopedic residency program uh director and that, and that was nearly 20 years ago, maybe 17 years ago. I did that for five years and then I became the department chair, which I did for 12 years. And most recently, uh January of this year, uh Doctor Gibbs uh took over as a department um chair. And so, you know, I had my rena I'm happy to, to move on to just doing orthopedic oncology, which is really what I love to do. So this talk that I'm gonna uh give is really kind of an introduction to the kind of the orthopedic oncology, surgical procedures. Uh it's meant to be fairly quick. I'm not super in depth and give a feel for mostly the surgical component of orthopedic oncology, kind of what we do um as an orthopedic oncologist. There's a lot of other things I'm not gonna talk about, which is like a big portion of orthopedic oncology is really the diagnosis, making a diagnosis. Every patient I see is an unknown. Whereas in most of orthopedics, the making the decision of what to do is the main thing and how to do it is are the main fe foc uh areas of focus. But in Ortho orthopedic oncology, literally every patient we see in, in clinic is an unknown, we have to figure out what they have. And then once we figure out what they have and if they need surgery, we get into this, which is what this talk is all about. So I'm gonna run through reconstructive options. How do we make decisions? What do we do? And and then mostly just show you some cool cases about reconstructions. So how do we decide what to do surgically after removal of a tumor? So it depends a lot on the anatomic site uh also on the extent of the tumor resection. So how much, what did we have to take out? What's, what's left, how, how much of the soft tissue is still there? Did we take out bone and how much, how much and what parts? And then you kind of put all that together with patient matched reconstructions uh to really match what your choices for reconstruction are with the desired, desired level of function, kind of the goals and preferences of of the patient in the family and also kind of factor in their disease process and longevity and such. You know, first you have to think about it. Is the reconstruction, is it possible? Is it predictable? Is it practical? And if you look at uh historically, there's a lot of stuff that was done back in the, back in the day before we came in before we developed and other people developed lots of uh cool reconstructive technology and stuff. But back in the early days, they did things like crazy stuff like put in an upside down uh hip prosthesis in the knee joint. Fortunately, we have much better options than that today. And early on for reconstruction following re resection of tumor, there are a lot of custom implants. So you cut out a tumor, you kind of predict what needs to be taken out and you have, have a have it made in the shop and then you implant your kind of pre-made parts and that's what that's what it was done historically and that goes back to gosh, the seventies and eighties. But more recently, we do a lot of reconstructions with, with when we use metal with modular components. So kind of off the shelf um implants that are interchangeable kind of Tinker toys. Um Custom implants take a long time to make at least three or four weeks if not longer. Whereas these off the shelf components, you can basically literally pull them off the shelf and put them in. Um And they're also more cost-effective than custom made implants. Although they're still quite expensive. Here's just an example of one system that we actually still use a lot. This was developed actually in the eighties. And it's still one of the most widely used systems out there. And you can, in this diagram, you can see that you can replace basically a good portion of the tibia, the whole knee joint, uh any components of the femur, including the uh femoral head, um and also the shoulder. Uh and then kind of any, any portion of that, you might just do a knee, you might just do a shoulder, you might just do a, a hip and I'll show you a bunch of examples of how we might um kind of rule that out when we do prosthetics. There's lots of things that we have to keep in mind and, and a lot of that is how does the, what's the interaction between the host and the implant? So what's the fixation of the implant to the bone? How do you deal with soft tissues adjacent to and attached to the implant? Uh How do you restore the uh and stabilize the joint? How do you reestablish the length of the patient, the alignment, the anatomic rotation and then deal with soft tissue coverage. And just to, to be clear, another thing I'm not really talking about in this talk is more biologic reconstruction. So things like allografts, I touch on it a little bit but not much. Uh and some of the other reconstructions and a lot, another good portion of orthopedic oncology is soft tissue tumors alone, but they're not as cool to show you the reconstruction. So I'm showing you all these kind of bony reconstructions with and with the prosthetic reconstruction, we have a lot of things we have to deal with post-op. So how does the healing occur? Mostly between the, the implant and the soft tissue, but also the implant and the bone. And then remember the a lot of these patients get chemotherapy and radiation therapy. So that may influence um the function, the motion, the power, the stability and the longevity of the implant. Long term like any prosthesis implant, we worry about loosening infection where the components corrosion breakage, all those things that can go awry. Uh And then you also have to pay attention to the adjacent cartilage. If you retain cartilage like in the hip joint, you might have to deal with the acetabulum or the knee, maybe the patella. Uh we um often we use methylmethacrylate, polymethyl methacrylate, which is PM ma uh bone cement to fix the components. Uh Sometimes we'll do other cool implants like this one which is actually press fit with a spring loaded device where you put this thing in, you put these screws in it and then you, you torque it to 900 newtons of pressure. Um and it basically spring loads it. And then another issue is soft tissue attachment. So a lot of the components will have um portions of the design such that you can sew things to it. So here's a couple of examples. One of a proximal femur now are humerus where there's holes for sutures to pass through to try to get at least some degree of soft tissue attachment. And then we can also throw an allograft. So in addition to a prosthesis, we might actually put an allograft or a bone transplant from a cadaver to augment the metallic implant. So here's one on the left shoulder replacement, the upper half of this. Uh So there's a prosthesis which is the white thing and then there's uh the upper part has an allograft uh with the rotator cuff still attached to it. And then on the hip, same kind of idea uh uh hip arthroplasty with an allograft composite. So that's kind of the introduction. Now, I'm gonna go through kind of site specific reconstructions just to show you how do we, how do we deploy this? How do we uh do these reconstructions by kind of site? So the first and we're gonna, these are the different ones we're gonna talk about, we're gonna talk about shoulder, hip, knee, uh femur interco area, meaning segmental geographic, meaning just taking out a like a puzzle piece, rotation plasty, which is the coolest part and I'm not gonna talk about the pelvis. So in the shoulder, uh again, you have to kind of bring into play all the anatomy that's in, in the area of the reconstruction. So in the shoulder, the glenoid, the humerus, the rotator cuff, the deltoid, all those muscle and soft tissue attachments are important and it turns out rotation uh is much more important than an abduction or flexion of the shoulder. So if you think about it, uh rotating your arm and, and hand in space, trying to get your hand to where you need to get it to is way more important than lifting your arm up high to where you're trying to like paint the ceiling or something uh from a functional standpoint, um we often will do some degree of rotator cuff repair. So when you take out the proximal humerus, you have to cut through the rotator cuff. And if you can save some of it, you can reattach that to the, to the uh prosthesis. And then the goal is both stability and also motion. And I'll show you some kind of good and bad of how this can go. Um These are kind of our menu of options of what to do. So you can do resection arthroplasty, which means just take out the humerus and do nothing, just leave a gap. And that actually is uh works OK. It's not great. Sometimes that's a temporizing measure in somebody who's terminal, terminally ill. And they can still use their hand el bow wrist, they just can't move their arm around that. Well, osteoarticular allografts or bone transplants where you actually use the articular cartilage of the cadaveric bone to replace the, the piece of bone that you take out. So the proximal humerus should be taken out the proximal humerus and replacing it with the cadaveric proximal humerus and then reattaching the rotator cuff. But more commonly we do prosthetics. Occasionally we'll do allograft plus prosthesis or allograft prosthetic composite. And the new thing relatively new is the idea of reverse shoulder arthroplasty. And I'll, I'll give you an example to that. Uh And the shoulder prostheses are um used definitely more often than allograft prosthetic composites. The fixation um is pretty good. There's some uh problems with loosening. There's also problems with instability of the shoulder and then trying to get the soft tissue attached. The soft tissues to attach can sometimes be tricky. Usually the function is pretty good. Allograft prosthetic composites. Still fixation is a bit of an issue. Soft tissue attachment is better than with straight prosthetics. The allograft adds uh bone and soft tissue, but it's technically a little bit more difficult uh kind of the big technical problem in the shoulder is instability. So the shoulder joint, if you look at this example, there's, here's a tumor, it was removed, here's uh the defect after removal of the of the tumor. Um And just think about it the whole, this is rotator cuff and that's all gone. Uh, there's still some of the other end of the rotator cuff there. But this piece, this trailer hits this kind of round ball is kind of sitting in the shoulder joint and you can imagine it's kind, kind of flop around a little bit. There's some things we can do to keep it from flopping around and one is to use, uh, like a, uh mesh. This is actually dacron mesh or an aortic graft. You can do something to put a sleeve around it to kind of hold it in place. Uh And here's just some, some um pictures of using an allograft composite, allograft plus prosthesis composite where you use the allograft sew the rotator cuff of the allograft back to the rotator rotator cuff of the host and then you implant it and sew things back together. Here's an example of one this long story, but basically 24 year old, she had osteosarcoma. Most common pri primary bone cancer had it resected. I did like 20 years ago, had an allograft prosthesis reconstruction. Uh She had a nonunion meaning it didn't heal together, then she got infected and then she had a space replaced and then eventually she had a mega prosthesis or one of these big prosthetic placed with an aortic graft. I'll just run through some of her pictures really quickly. Here's the original tumor. She had a, a destructive lesion. You can see, soft tissue mass is kind of classic osteosarcoma first surgery resected. It put in a, a prosthesis with an allograft actually didn't heal. So she got a nonunion uh broke. This is actually after she got an infection and then she had a breakage of that. And eventually she had a um an a mega prosthesis. So, one of these modular prostheses put in with cement to hold it in place and it works good for elbow and uh and uh well elbow and hand motion, forearm motion. But the shoulder sub is a lot. And here's just an example of, of her, you can see it's kind of gross but her, her shoulder moves around a little bit floppy, her hand works great. Her elbow works great but her shoulder kind of pops in and out of the joint a little bit. She has really good um external rotation. Um But then passive motion is OK. But active motion meaning she can't lift her arm up that well on her own. Here's another one. This is kind of a cool case. This is a nine year old. So a young child also with osteosarcoma. Here's the images post chemotherapy. They had a previous pathologic fracture, big tumor proximal humerus. This was tricky right? Nine years old. I don't know if you have any nine year old brothers and sisters or look at nine year olds very often, but they're pretty small. This patient probably weighed, I don't know 80 lbs or something, proximal humerus tumor, really big tumor uh had to resect all of that. They get chemotherapy, we resect the tumor and have to reconstruct it. And at that age it's tricky because they're still growing. So what we did is we put in a um and, and they also have their whole life to live with this thing. So we put in a allograft plus a vascularized fibula. So the allograft is the bone here. The vascularized fibula was a fibula from her leg that we transplant into there. We put a metal cap on it like a prosthesis cap and then put a plate on it here, it is three years later, actually, everything healed. Uh The kid work um range of motion is, is really good. Shoulder motion is excellent cause we're able to save the rotator cuff um and attach it to, to the allograft. Uh The child's still alive as far as I know and uh has a shorter arm, but a very functional arm. Uh Here's another just example, this is a patient with a pathologic fracture, older patient with pathologic fracture of the proximal humerus due to lymphoma and radiation therapy. And this one, we actually did a mega prosthesis, what's with what's called a reverse shoulder prosthesis. So, rather than having the round part beyond the head, you stick it on the glenoid side and then it, it actually allows them to have more range of motion of the shoulder. Uh This is also a kind of a cool collar that fits on it uh to kinda anchor the hum the uh prosthesis to the humerus. This device was actually designed by myself, Gibbs and a guy from Ital Italy. Um at least the the tumor components of it. So we're switching gears down to the hip. So um in the hip joint, same kind of theme resection, arthroplasty, cut it out, just kind of leave it flail, not a great choice cause in the patient has the limp, use crutch, two crutches or a walker all the time. Osteoarticular allograft really doesn't work. So it's mostly prostheses. And historically, we did some allograft prosthetic composites. So we're gonna focus most of that prosthetic reconstruction. Uh These work really well, good function, lots of options for, for implants and you can customize intraoperatively. I'm actually doing one tomorrow. Um So we do these pretty regularly. Uh They can dislocate but not very often. Uh If you take out the whole proximal humerus, you're detaching the abductor. So the patient might have a Trendelenburg Git or a gluteus medius limp. Uh So they, they kind of lurch a little bit when they walk, but they can typically walk without any kind of re cru or crutch or cane or, or a walk or anything after, after they get used to it after they get over the surgery. So here's just an example, a patient with uh renal cell carcinoma metastasized to the proximal femur big tumor. They, they initially tried to fix it with the plate and screws and basically, the tumor continued to grow. Um We embolize the tumor cause you're super vascular and then you can do an implant and here's the prosthesis that's implanted. We can reattach all the soft tissue attachments to the hip joints. Over here, you kind of take everything apart, put it all back together, put all the abductors and the uh vas lateralis and the glutes and all those things back together again uh over the prosthesis. And here's what it, the prosthesis looks like and these patients are great. They really uh surgery takes about an hour to take out the tumor and a couple of hours to put it back together and they can be walking the next day. Uh allograft prosthetic composite, we used to do these back in the, you know, 30 years ago or so, but don't do so much. If you add an allograft, you can, you can at least theoretically have a little bit better soft tissue attachment kind of more historical than actual. Um Occasionally we'll need to do and what we can do tertiary reconstructions where you take out a tumor and you don't have to take the joint out. So you can actually just take a piece of the central portion of the bone. Usually the most commonly the femur, occasionally the tibia, sometimes humerus. Uh here's a 16 year old, uh who had osteosarcoma. So this tumor is interesting cause the the tumor is right here. You can see a little reaction on the surface of the bone. This is a high grade osteosarcoma, a super malignant tumor. But if you look on the mr the tumor stops well above the knee joint, not that far above the knee joint, but enough where we could reconstruct it, we do something kind of tricky to, to not have to take out the whole end of the femur cause if you can save the, the end of the femur, you save the articular cartilage and you can basically leave them with a essentially a normal knee. So in this case, this is when we resected. So you can see the tumor extent is where that arrow is about to there tumors up here. So this is post chemotherapy, good reaction to the chemo new bone formation, all that the margins are clear. So we resected the whole tumor. This is cut in the path lab. And you can see that we cut through the metastasis of the distal femur can save the lower uh couple inches or so. And then this is a diagram what we did. So you take out the tumor, you put an allograft in and then you take a vascularized fibula. So one of my partners will take the fibula out of the same leg uh with the, with the vascular supply um disconnected and you reconnect the vascular supply of the fibula to the femoral artery. Um And so you have a essentially a live fibula attached adjacent to a dead piece of allograft with the normal end of the femur and the normal proximal end of the femur, you put it all together with plates and screws and stuff and there it is and then basically leaves a normal knee joint. This patient's 25 years out, I think, doing great uh in the knee joint. Here's really kind of the choices. And this is the most common location for reconstruction that we do. Uh most tumors. Um Most orthopedic oncology, you know cases, the tumor occurs about the knee. Most common location is distal femur. Um And so this is an area that we focus on a whole lot. Again, historically, we did osteoarticular allograft. The last one I did was in 2001. So it's about 22 years ago. Uh But we also do a ton of prosthetics. I'll talk about expandable prostheses. So those prosthetics can grow that we can occasionally use on a young child allograft prosthetic composites, mostly proximal tibia and then the cool case rotation plasty, which has a super limited indication but is it's pretty amazing procedure. So, osteoarticular allografts, here's a an O A allograft. This is a dead person's bone. So fresh ca cadaveric harvested bone. So the patient dies, they, you know, the organ procurement teams go and harvest their lungs and their kidneys and their uh hearts and, and the last place on the list is the, is the musculoskeletal retrieval team will come in and take out femurs and tibia and stuff. And so you can actually take a fresh cadaveric bone, put it on ice and then later reimplant it. The advantage of an O A alla restores bone stock. You, there are some soft tissues, you can reattach it has an articular surface and if you need to, you can later convert it to a standard total knee arthroplasty. They're technically tricky size matching is super important, you know, trying to match your, your cadaveric um catalog of, of specimens or samples to the patient and it's never perfect. They have a pretty significant degree of instability in the knee and they have late arthritis that develops and then they, they obviously can't grow and there's about a 10% infection, about a 10% fracture rate, not really rejection. Uh Here's the literally the last case I did 22 years ago, 14 year old femur uh distal from Las sarcoma classic x-rays, bone forming lesions, distal femur. There's the extent of the disease resected it. That's the younger me cutting out the distal femur and there's the intraoperative um uh with the tumor in and now with the allograft reimplanted with a plate and screws and where you put a nail in also. And there's the reconstruction plate and screws in urary nail, nail graft. Here she is uh 19 months, uh really good range of motion and, and had a little bit of knee instability but, but not, not bad. And here she is walking. So she actually did really well. Uh from a reconstruction standpoint, bad news is she actually died of her disease, I think a year, about a year four or so. Here's another one, this is a lady who had an osteoarticular allograft, um, quite a while ago and she's still alive. And this is the last video I have of her and this was at 13 years. I've actually seen her more recently. She, I think she's like 25 27 years, something like that now. Um And she has an osteoarticular allograft. Uh She had a really good fit. She's um s thin lady. She didn't wear, you didn't overuse it too much and her knees continued to do. Well. The main stay of what we do is prosthetics in the knee. They have great function. Distal femur works a little bit better than the proximal tibia mostly cause of the extensor mechanism. Um There are lots of implant options. You can kind of do whatever you need to do with implants cause you can add sizes and shapes and lengths and stuff. Um The biggest issue is in the proximal tibia, dealing with the patellar tendon, but we have ways to scan that cat. Here's just an example of one of these. Uh this is post implant obviously. So distal femur resected for tumor, uh, shave off the proximal tibia and you put these kind of hinge knees. These are a little bit different than the total knees you'll see in the, for arthritis because they actually have a hinge. It's called a rotating hinge because it, it connects, but it's not a fixed hinge. You can actually spin a little bit because a fixed hie would get loose cause it be too, too tight. Um So mega prostheses are the most common. Sometimes we can do in the, in the proximal tibia. The issue is you're taking out the proximal tibia and you have to deal with the extensor mechanism. So the patellar, the quadriceps mechanism, it inserts onto the patellar tendon. That's really how you extend your knee. So if you take out the proximal tibia, you're disrupting the, the insertion of the, of the patellar tendon. And you can deal with that two ways. You can put an allograft in, this is an allograft plus a prosthesis and then you can keep the tendon and reconstruct it or you can put a mega prosthesis in and then deal with the soft tissues to try to augment that reconstruction. So the problem is the the attachment of the extensor mechanism of the proximal tibia again with no pa no patellar tendon comes to the prosthesis. So if you use a prosthesis alone, you basically connect all the other soft tissues and sometimes flip around the medial gastros muscle as a gastric flap to deal with that. Um Here's just one, the proximal tibia, one the make a prosthesis tumors out prosthesis is in and here's how we can flip the gas drop, take the medial gas drop, flip it around and then sew all the soft tissue attachments. Another way to do it is take an allograft. So here's an allograft getting prepared, kinda cut it to fit and you can keep the tendon, there's the tendon of the allograft with the prosthesis, skewering it and you can sew the host tendon of the quad patellar tendon to the allograft patellar tendon and as a reconstruction. And there's an example of that occasion, we'll do these kind of cool resections around the tibia uh for smaller tumors, its so called geographic resection. So this, this tumor is kind of surface based um right on the front of the surface of the tibia. So you can do these cool planning things and use cutting jigs and imageguided surgery to do a very precise cut and then take an allograft, cut it to fit exactly what you took out and put it back together. And that's an example of so called geographic resection reconstruction. We use a lot of image guided guided surgery to kinda figure out where we are. I'm gonna skip this one. I didn't really add much. And now the last topic is is how do you deal with the growing child? Really? Two options, expandable pros or three expandable prosthesis, cut the leg off or do rotation, plasty. Uh the growing child, you know, they have a lot of growth left. If you take out the knee, you took out the main focus, the main area of growth, the lower extremity, you have to deal with limb length, discrepancy, growing prostheses don't work well. I'm gonna skip through these, but basically, you can put a prosthesis in, there's lots of different ways to make them grow. Either you go in surgically extend it or you can put these electromagnetic coils on some of them and make them grow. They tend to wear out and fail a lot. I have never put one in. I've taken a bunch out complication rates really high. Probably is a role for them, but it's limited. The other thing you can do is a, is a van rotational plasty. Again, this is a super small subset of our patients. We do about one a year. Turns out we did 14 weeks ago. Uh It's an alternative to an amputation. It's a non amputation, amputation. No, Phon Len pain, they have great function and their leg keeps growing technically tricky. It's not, they're not that hard, but they're really tricky. You need a really good prost prosthetist afterwards. And there's an issue with patient acceptance and family acceptance. I'll show you why. So what we do with the rotation plasty is you take out the tumor flashing red, you shorten the leg, you rotate it 180 degrees and you make the ankle become the new knee joint, keeping the neurovascular bundle intact. Kind of weird concept. Again, you're keeping the neurovascular bundle intact, which you're taking out everything else and I'll show you what I mean by that in a minute and then they wear a prosthesis. But now they have a, their leg that feels like their leg and they have a functional knee above knee amputation, they have a prosthetic knee. So how do we do this? We do a ton of measurements to figure out what do you have to take out and to make sure the length is gonna be right. Um We measure and then ultimately, this is what you're gonna end up with. You wanna end up with the, the knee joint about the level of the or sorry, the ankle joint about the level of the knee joint pointing backwards. Once skeletal uh growth is finished so early on, they're gonna be too long. And then later the other leg grows to catch up to the rotation, plasty side, much of measurements. A lot of math. Um Here's an example, here's the tumor. We did the math. Here's the incisions we make uh we do a lot of alignment stuff. This kid had a previous fracture where that's why the legs crooked and then it's a big dissection. So this is takes about two hours to dissect out all the nerves and blood vessels and literally cut out the segment of the leg. With the exception of the nerves and blood vessels, there's what's taken out and here's what's left. You take the leg, you shorten it, you rotate 100 and 80 degrees externally and you, it OK, kind of freaky, but it works really well. So again, you shorten it, your se your rotator, 180 nerves and blood vessels are intact. So that's the artery in the vein and the, and the uh nerves and then you coil everything up and then you sew all the soft tissue. So that's what it looks like. Post-op. Again, this leg's gonna be longer now and later, this leg is gonna grow to catch up. Here's an x-ray post-op. Um Just another example with a, using a nail as a way to do it. And here's, here's an old case. This is a person just showing you how much range of motion they get and how the ankle joint becomes the, the new knee joint. And again, they wear a prosthesis, but they could walk really well. This is another patient with her venous rotational plasty. Hers was done about 15 years before this. You can see she puts on a prosthesis, she puts it on every day just like you would put on your shoe uh and then she walks around or runs around or does sports or whatever. And they also will walk around the house kind of limping pretty profoundly on the rotation plus your leg or they'll hop, they get really good at hopping too. Just they have to take a pee in the middle of the night or something. And here's a kid, this is shortly after we did his rotation plasty as a pretty significant limp. You can tell, obviously tell which leg. It is another guy at year five, post rotation plasty. And I uh you have to look really carefully to see which leg it is. This his left rotation plasty. And this is the same patient. We put those markers on him. Uh And, and we can do a reconstruction on the in the lab showing range of motion. And you, you can't really tell uh functionally once they're fully grown, they do all kinds of stuff. Here's some of the doctor Gibbs patients. This kid is a competitive rock climber's a kid that's water skis pretty well. A friend of mine, uh from Italy, this is one of his patients plays basketball and a kind of a, I don't know it was high school or minor league or something like that. And then this kid played a lot of, did a lot of, of uh wrestling actually with, without his prosthesis, right. So leg backwards, like freaked out the opponents. He also played college lacrosse and this guy's a nut job. He jumps out of airplanes and jumps off does bass jumping too. This guy, his, he didn't have cancer. He had, uh, trauma. Go figure, I can't imagine where he could have gotten traumatic injury. You do this kind of crazy stuff? Um, so that's kind of it. Um, and I'm gonna stop there and, oh.