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Things I've learned over the years and I think you'll find in up in surgery, there is a lot of science, but there's also a little bit of opinion and dealing with patients is still the most important thing and they're individuals just the next slide. So 10 different thoughts. The first one that I've learned in years is that really not all distal by such ruptures need to be repaired. So I'm sure a lot of you have seen these patients in the clinic and uh sometimes it's difficult to know how the consultants make the decisions. But if the next slide comes up, I find that often the patients are telling me really what they would look like and I'm giving them advice that should be the case. So we're trying to present them with evidence of what we can offer them what they want to achieve. So if you think about it, the physics of how huge you on uh the elbow flexion and gravity is not that many nuts and to actually tear biceps tender, even a caver to make, you know, something like 1010 fold magnitude potentially to rupture that. And that guy there is lifting a 20 kg dumb as you know, Popeye sign is for proximal biceps. But I had to take a picture of this guy coming along with a distal biceps rupture and a Popeye t-shirt on uh next slide, please. And as you saw from the slide, the common customers for these injuries rarely are men. Uh usually with starting to have gray hair like me and trying to do things that they were able to do 20 years ago and still thinking they should be able to do it. Uh And uh more commonly in a dominant arm than the non dominant. OK. My next slide please. So the patients that I've over the years work on definitely to try and avoid operating on are really there's low demand patients like this lady in her Walker chair, you can see that she's not the typical distal biceps patient. Her skin is not great. Her collagen is probably not great. Overall patients with comorbidities. Generally, the older age group will tolerate the distal biceps rupture extremely well for low demand function, not dominant arm. That's an opinion. I certainly think twice about having my left distal biceps repaired, but right side, almost certainly I would still get repaired for work and racket sports and things like that. Um patients that sometimes refuse the offer of surgery, sometimes surprisingly, the self employed and you tell them about time off work and protection from lifting for up to three months potentially next slide, please. So what if you have to counsel the patient? What, what are the pros and cons, what are the disadvantages of non operative treatment? If you look at this paper by the flexion strength? Really, it it is there is flexion strength lost when you lose your biceps, but you've still got your brachialis. So 90 to 70% with a repair non operative treatment. So yes, there is a loss of flexion strength and usually there's fatigue. So loss of endurance. The main one, if you go to that next slide is really loss of supination strength and certainly supination fatigue is a definite problem. So you can go from nearly 90% with reparative, more like 60% or thereby, it's super emission strength with not approved treatment. And a lot of these 40 something year older men, they're not prepared to lose that degree of um stupid strength. Next slide, please. If you do repair them, there's a definite improvement in most of the upper and functional scores. And so you can give this evidence to patients about improved section, supination strength and functional scores with repair. Next slide, please. And I think this is quite a good summary because this is really what we do in the clinic. We're trying to present the evidence in an unbiased way, giving the patient with the information to make their own decision. And this guy says, I tried to ask an impartial health advisor. It's probably at least on a subconscious level, I do steer younger patients towards repairing older ones towards conservative treatment. But I think you take the patient on board with you try and give them the best information and let them help to make that decision to themselves. The next slide please. The other side of the argument is that what are the risks of having surgery? And overall, there's approximately 20% risk of some complication with distal biceps repair. And anyone that doesn't knows that that that's the case when you see them back in clinic. So about 20% have some sort of complication. This will be relatively minor, but up to 5% will have a major events such as fracture, major petros ossification, infection or nerve injury. Next slide please. In my experience, really, it's history is probably the most important factor in making the diagnosis. So classically as someone that's got eccentric force to their flexed elbow. So caly something like I was carrying the coffin when the guy on the other side accidentally slipped and let go. And I took the full weight of the coffin to try to stop the, the co from falling out of the coffin. And I felt something pop in the front of my elbow or in another case, I was trying to lift a car and felt a pop at the front of my elbow and then noticed the bruising. So it just go to the next five uh you describe a pop or a tearing sensation like someone tearing a elastic band or a tissue in the front of the elbow and they get this cap medial ecchymosis. When they lose that contour of the binding steps, it becomes flattening antecubital fossa. Next slide, please. Clinical test wise, I've heard of a hook test and it's always worth practicing on yourself. Blow, have to do that myself. Get my index finger from the contralateral side. I drag it from lateral to medial across the front of my flex and supernate elbow and you'll feel definite resistance. You can hook on your own biceps. If you can just fast forward, you can see that in slim people. The next slide, you can even literally hook it next slide. And when you're doing that, I as I drag my index finger across the front onto the anal fos onto the hook test. Then the next step is to pass my thumb again. You need to really tense, tense and flex your elbow against resistance almost and push your thumb from medial to lateral. And just before you get to where the biceps tendon is, you'll feel a really sharp edge which is the lacertus fibrosis. Uh So it just worth remembering how that feels in, in an intact person because uh if the laser um is ruptured, often, there will be more bruising and the tendon will attract more. So it is something that's worth examining for uh when you see these patients next slide, please. Uh texts that aren't in the book, I don't know if maybe someone else might have described the. But what I often do is if it's equivocal because sometimes you can see these patients late, there's a bit of scarring in the region of where the biceps tendon was and the foot test. I wonder if it's truly 100% sensitive and specific as the dry school says. But what you can do is get the patient to tend their biceps and then try and move it from side to side. So if you try on yourself as you tend to, it really won't move. But if it's not attached, it will sort of wobble from side to side. So there's a bit of laxity and I think that can be quite useful elevator sign again, made up. But if you go from pronation to super, you'll see the biceps move up and down and patients with a, you can actually feel it in yourself off, you see it moving up and down and if it doesn't move up and D and when they do that, there's a higher suspicion for a complete rupture. OK. Next slide, please. Uh I don't know if this video will play, but this is just to demonstrate making a pretty strong chap how much loss of super strength uh he has is that I don't suppose it will play. Will it Rachel? Oh, maybe it will Thank you. So you can see, I mean, he looks stronger than me and uh you can see I can easily turn him over. No bother at all. He's wearing a rugby shirt for goodness sake. And he's probably 20 years younger than me. So, um, really just to demonstrate the loss of supernational strength. Certainly in the early days people can get used to it and they'll get electric screwdrivers and things to get on some of the problemss. But it is the persistent loss that I think is felt. Next slide, please. We said that history and exam and admission is pretty much all that I think we need. For most cases you can use ultrasound this cobra position. So you're bringing the forearm into full prone emission. So the radial tuberosity is effective on the side and you can get a good image there on the right the radius is the circular structure and you can see that the the biceps coming in. So ultrasound is pretty sensitive in the right hands. Pretty good test. Next test. Next slide, please. My preferred investigation though is MRI if it's uncertain diagnosis and this is a particularly useful view, the so called fabs view flexion abduction and super of the forearm. And you get this beautiful longitudinal view of the biceps tendons, so very easy to interpret it and very helpful. Next slide, please. Partial ruptures definitely exist uh because I think it's all these questions or could it be a partial rupture or, or not. Uh Next slide, please, as you'll know that there are two parts to the biceps and at the top end, it's very obvious, shorten the long head. But when you get down into the radial tuberosity, they've merged in the vast majority of people and they do go through a slight twist and they occupy different portions of the tuberosity. So the long head is a little bit more proximal and more important for supination, short head, more distal, more anterior, more important for flexion. Next slide, please. And there have been case reports and I've actually have seen this where you may rupture one head and not the other and uh occasion have on, on occasion when I've seen this, we have um repaired the second head. Um uh Sometimes if you only got a little tiny scrap of tendon attached, you'll detach the whole thing and reattach it as a primary repair. Next side, please. So, out of a lot of patients in this series, about 8% were partial tears. Now that to me seemed a bit higher than I would expect, but just the reaffirm they, they do do exist next slide, please. Um Personal preference. Now for how you fix these, I don't know what you'll have seen in your different centers. I think probably most people using single incision technique. Correct me if I'm wrong. Anyone that's seen double incision techniques. Recently, anyone seen double incision in the in the region. Um Mr Patel who worked at no Norwich before did two incision when I was his registrar and did it very, very nicely and it worked well. Um If you just go on to the next slide, please, the tricky bit with double incision is you make one incision approximately defined from the tendon, which is pretty straightforward if you make a dorsal incision in the forearm uh to get to the radial tuberosity when it's in that uh fully pronated position. Uh the bit I don't like is the passing the tendon, but uh you have to have the elbow flex. So you've got a straight line from arm to forearm at the level of the tuberosity. And personally, I don't really like shoving things blindly through the forearm. Um and also um to go on to the next slide, please. And the next slide, please. Main reason that double incision and just click on the neck. Sorry, go back, go forward one, please wait on this single click. The main reason dual incision fell out of favor was this uh risk of he topic ossification? So, as you pass through between the radius and ulnar, if you get h you can potentially develop synostosis, which would be a major, major problem. But actually, for all other potential complications such as nerve injury, uh really opinion is divided and maybe there's on this study, slightly higher risk of nerve injury within an single incision approach. So all these things have to be borne in mind when you're deciding what to do. Really the advent of um anchors and then particularly end of buttons has made the anterior single incision approach that bit more popularized next slide. Yeah, I just sorry to keep going. I think it might just be reiterated that and the functional scores with single and dual incision really are identical. So from a function point of view, um in terms of um the scores, there's really no difference. Next slide, please. And again, this is saying the same thing really no difference. When you compare the two next slide, please. Key thing when you're doing a single incision and particularly approach, you've got to remember that the joint line is really quite proximal to the radial tuberosity. And it's actually the ante crease is proximal even to the joint as shown here. Next line please. And one we will want to make an incision that is potentially centered over the radial tuber. It's about five centimeters from the antecubital crease or two decent size finger breadths, um similar incision uh deep. This choice, you can use horizontal uh as a transverse incision like this one. You can use a longitudinal incision or a an oblique incision. I've tried all three. The longitude incision is probably the easiest more exposure and can be extended mostly easily, but it doesn't always scar as nicely. So I actually use an incision but you can, I've used all and you can, I think it's down to surgeon preference with as much as anything else next slide bleach, but I still need to center it over that five centimeters distal to the, the crease. My worst results with biceps repair uh have been with nerve injury and nerve injuries are particularly common in uh distal biceps repair because of the proximity of median nerve, last one to be cutaneous nerve and the post nerve particularly. And you really need to know your anatomy when you're doing this approach. It's it's in a deep dark hole. Often these patients are quite sar so you don't have as much space as you would like. And and it is one of those operations that I tend to do with without of Paquet. So you need to be uh have your wits about you and know the anatomy. Next, next slide, please. So about in studies, about 50% of patients will have some neurological dysfunction after this device for her potentially. And that's usually in the form of radial side or or numbness, which the textbooks you think is sort of radial nerve temperature. But actually, it's often this lateral cutaneous nerve which gets stretched when you're doing the approach. Um Next slide please, if you've ever wondered why some patients get extreme pain when you put the vent in the antecubital fossa. If you don't quite get it in the right place. That's because the lateral cutaneous, one of the bigger branches of that is closely seated underneath the C vein and you can hit it with the vent on or you can accidentally tie it off if you tie off any branch, big branch of the C. So you need to always look for this. Well, I always look for it when I'm doing the operation. The next slide please. And this is it, you can see the L and back on the right hand side of the uh picture is retracting the clic and just underneath usually about one, maybe two millimeters wide. Uh you'll see the later on tubercular cutaneous nerve. So always, always, always look for that when I'm doing the surgery. Next slide, please. No one patient I did have that had an anti cutaneous nerve traction injury and developed regional pain syndrome, which is not great because he get start to get, he was AAA bee keeper and he realized that when he was keeping his bees, he got stung and when he got stung, his pain got a bit better. And so he deliberately was uh putting his hand into the bee hive right above on to get stung dead. And his CRP s miraculously got better quite quickly. And so um the effects of aatox which is in be venom have been actually used for treating CRPS, not through our small case report, but it has been recognized that the aox can be helpful for desensitizing nerves with regional pain syndrome. Next slide, please. Postop nerve is the other nerve that we worry about. And definitely when you're doing uh an end of button technique, the the pain is at risk. So if we just forward to the next slide, please, um if you think about it, we're drilling often through the radius, you can use intramedullary ender buttons. Um I've never done that but they are, there are end buttons that are designed to be just catching on the proximal cortex. But most of them are designed to go through two cortices. So you're drilling through there with a drill and then you're putting an end of button on the far side somewhere which you can't see potentially. Next slide, please. And our low end of buttons probably do give the best load to failure. Next slide, please. And they, they don't, they don't recreate the anatomy as it was intended by nature because you can see on this side that the biceps tendon really is a ribbon like structure. It attaches very much onto the ulnar part of the radial duos. And there's not really any way you can easily recreate that the two incision technique where it wraps around and you drill through bone tunnels probably does give a slightly better angle of pull to give you more supination torque. But most of the anti techniques really go through the middle of the tuberosity. And although some of them were designed to use an interference screw to shift it ulnar. Most people I know don't use the interference screw to do that. I don't Rachel. Are you an end a button person with light screw? Oh, sorry. You probably can't talk my apologies. Uh The uh So uh if you were to try and recreate the anatomy perfectly, next slide, please, you'd be trying to attach the tendon back onto the ulnar most part of the radial tuberosity. And so you can imagine on this diagram, your drill angle would be at the insertion point demonstrated there which is very much oblique. Next slide, please. So that would be your ideal little drill point to get the most ulnar insertion of your biceps. Next slide, please. But the danger of that is you can see on this MRI scan where the sorry ct it is actually with contrast in a cadaver, you can see where the pin sits. If you were coming in from that ulnar angle, it's right in the trajectory of the postero nerve. So the compromise is next slide, please. Next slide, please. We try and mitigate them at risk in an anti approach by bringing a dri pretty much perpendicular to the fully super arm so that the pin is well out of the way. Next slide, please. And then try, please also trying to keep it appendicular to the the the long axis of the radius. Uh again, reduces that risk of catching the pin. Uh We have had one post intraosseous nerve captured by an end of button uh in Peterborough by one of my colleagues and he explored it uh dorsally and extracting the pin and repositioning the the end of button and it fully recovered. And then the patient came back two years later with the other side, distal biceps rupture, still wanting it repaired. Next side, please. Next side, please using the image intensifier. Uh is important. I think when you're doing distal B sets repair A for finding uh the tuberosity. Um because I have seen people approach the radial head, believe it or not. Um If you're too proximal next slide, please. Uh It just lets you know as well roughly where the middle of the radius is because you're often drilling a, a sort of seven or eight millimeter bone tunnel and fracture is the risk. So we're trying to get it centered and you can tell that clinically pretty well normally, but just nice to know next slide, please. And also checking that the end of the button is flushed so that you don't like to have any soft tissue or nerve trapped underneath it. So I do use the mi 10 quite a bit when I'm doing biceps repair, neck, slight lead. And lastly the fun bit, it, it can be quite a bloody operation as I don't use the tourniquet. But the reason for that is a, I don't want to squash the muscle of it, make it more difficult to bring it back into place and bi want to see vessels. I want to know where the radio arteries and I want to know where the leash is so I can actually deal with bleeding at the time rather than later. Next slide, please. This is quite a dramatic slide from the first distal B repair I saw as a trainee and I thought goodness gracious, what is this operation? But anyway, you can see there's quite a bit of bleeding up the front of my group nine blues. Next slide, please. But you really need to be able to hand tie it or use liga clips, some controlling vessels. So this is Henry's leash that comes off um brachial artery and you need to be able to control that really to get. I think most times I will deal with these vessels to make sure I've got a clear path for the tendon to come back onto the radial tuberosity. Some people will never do that. But II have to say I nearly routinely deal with these vessels at the time. Next slide, please. Um Next slide, please. I think you can, you can look at the anatomy of those a bit. Um Next slide, please. And this is just another s it shows then the lateral cutaneous nerve and the yellow sloop, the vein, the blue sloop, and then the uh Henry's recurrent vessels and the red sloops. And that's your interval. Once you've dealt with those, then you're straight down onto the bicycle tuberosity. Next slide, please. Delayed repairs can be difficult. So ideally, um II like to try and operate on these patients within 2 to 3 weeks. And uh after that, it starts to get a little bit more difficult finding the tract uh from where they've gone. There's a, you know, you have to do a bit more release from of the biceps from the brachialis. Uh It is possible to do delayed repair next slide, please. And but the complication rate is slightly higher or significantly higher in patients where there is a significant delay up to a month. So it's quite nice to have these patients coming through your upper and fracture clinic and then dealing with them in a timely manner. So we try and get them operated within 2 to 3 weeks if possible. Next slide, please. Um Yeah. So if you can't get them to the theater as quickly as you'd like because of the logistics or they just don't present early enough, what can you do if you presented with someone that is say four or six weeks down the line even longer? Potentially, there is a study from young Maurie in the States demonstrated that you could actually fix them with the elbow in about 60 degrees of flexion and they would stretch up and you regain a functional range of movement without too much difficulty. And a couple of weeks ago, I had to do one with a guy was, you know, basically 80 degrees of flexion within two weeks, he came back and had a about a 10 degree loss and a full extension. So it, it does, the muscle does creep, the tendon does creep a bit. As long as you've got a good strong fixation, you can um stretch the eye from a quite a degree of flexion at the time of, of fix. Next slide, please. Other options for delay are using usually either a graft, hamstring or allograft, potentially or tender achilles allograft. And I've done a few of these that I'm not going to satisfy because tendons quite hard body, they can feel it under the skin. Usually it does give some of the contour back, but it's certainly not beautiful cosmetically, but it does restore integrity of the muscle and tendon. Um So yeah, to be used sparingly, I would say next slide, please. And early mobilization is good. Like was saying we never put uh biceps repair cere into a cast of any sort. They just put them into a poly sling in my, in my practice and asked to mobilize nothing heavier than a cup for six weeks if you go on to the next one. So if you patients, if this patient hasn't had a block, then or has had a just a sensory block, then we get them. This is eating his custard creams in recovery and it's starting to get them moving his elbows straight away. Next slide, please. The reason for that is I'm sure Mr Van Rensburg has talked to him about this, but early mobilization is good at preventing heterotopic calcification, which is one of the complications of distal biceps repair. And it's good for tendon healing. We know and I'm certain that the strength of my repair with an end of button is easily up to that 20 to 40 newtons. Next slide, please. And the guy on the right as you see here um lifting his 20 kg dumbbell. This was him actually, I don't, I don't know if I think it's the next slide at the night play, but this is actually him doing that six week after his distal biceps repair uh completely against my instruction and doing a pull up. Uh He weighs a bit 19 or 20 stone. So the repair is pretty strong. What's an end the button? OK. That's distal biceps repair. Any, I'm sorry, I just talked and not ask you any questions. Um Any, any questions that you want to ask me because there is a bit on triceps if we have time, if there's no burning. Do you uh do you get ultrasound for any clinical suspicion of biceps tendon rupture or do you, you just basic, clinically, extremely rare? I mean, nearly no, as I say, 95% of the time I'll make the diagnosis from history and examination and on occasion, I have said to patients that II, I'm pretty certain, but I'm not going to wait for a scan and I have explored some, uh, being not 100% certain actually. Uh, but nearly always it's on the history and exam. Thanks. How are you doing for time? You finish your, no. Well, yes, but I've actually got a man who is on my list for tomorrow for distal biceps. I need to go see. Um, they're common, aren't they? I mean, we've got three waiting at the minute. Yeah. So they're common injuries and I think you have to individualize them is the message really to the patient. I think um I couldn't really talk because I couldn't stop my screen. Yeah, I know you. I don't use an interference screw. So I just use an ender button. I'd only ever seen a single incision technique whilst I was a trainee and I have adopted your kind of slightly oblique incision. And, but when I was in New Zealand, they did a two incision technique for everything and whilst it does recreate the anatomy much better. Um I'm not sure it's worth the kind of added risks and the fact of doing it, I haven't worked that out yet. I've only been doing this for six months. Um So it's completely up to you. How does everybody feel like obviously Mr White is a font of knowledge? So, well, no, I'm just talking, I'm very aware that you normally get asked questions and, but I have to just quickly. I mean, literally, the triceps is very quick if you want. That is everyone having a look at it. I mean, because the thing with triceps repair is, although you'll all see distal biceps repair, probably when you do an upper limb firm, you may do six months of upper limb or even a year and not see a single triceps rupture because they're much, much less common. Has anyone in the, in the room seen a distal triceps p and repair I have. But most of the trainees you might get, I don't know if you get asked in an exam about them, but they're a pretty rare thing to see on your regular trauma lists. For example, say we've got three distal biceps weight. I mean, that's pretty common. We've got one every couple of weeks I would say, but triceps repair, I've done one this year. Uh So just next slide, please. Teething with triceps. It's important actually to know the the anatomy of the triceps. Like you were, she was asking you questions earlier about radial nerve. People get asked quite a lot of anatomy. I think about the triceps in relationship to radial nerve. Um So worth knowing next slide, please. And the key thing not to get confused about the terminology because it doesn't really make sense. The tri steps terminology. But if you remember there's two superficial heads, one deep head, long, lateral medial is all very confusing. But yeah, the medial head is the deep head. OK. Next slide, please. When it attaches onto the tip of the electron, uh you basically have two halves of the triceps. In terms of its insertion, you have the medial half which is thick, there's a thick tenderness condensation which is really the strong bit. And then you have a lateral aponeurotic insertion which blends with the anus. Next slide, please. So you get this sort of aponeurotic bit on the on the lateral side. And the next slide, please, on the medial side, if you reflect that you'll see on the right side to side, there's this thick rolled, strong part to the medial portion of the superficial two heads of the triceps. And that's really the critical force dispenser in the triceps. Next slide please, that on the right is the sort of anatomy of the footprint and you basically have about a one centimeter area at the tip of the electron that doesn't really have any triceps attached to it. So you can knock that off. Uh If you need access when you're doing fractures without doing any harm to the triceps, and then you won't do any harm to the stability of the elbow by removing that bit of the einon neck side. Please. If you look at the insertional anatomy of the footprint, basically the two superficial heads attach it to the most dorsal part of the ulnar, the Arron that represented, I can't read it three on that. And then two is the sort of more muscular attachment of the deep head. Next slide, please. And then the capsule is really just at the tip, the more bare areas where the capsule attaches. If you look on an MRI scan, you actually see them what they're described. There is a lacunar a gap in between the superficial and deep heads. And in the anatomical specimen, you can see that you can separate on the medial side of the superficial part of the triceps. You can actually separate the deep and superficial portions. Next slide, please. This makes partial and complete terminology very difficult. It's pretty straightforward from the biceps. But in the triceps, I find it very difficult to know the difference between a sort of high grade full thickness tear of the medium thick tendon portion or with an intact auro portion on the lateral side because that rarely completely teared. Next. My please repair bit like doing any big tendon repair like quads or anything like that. You need some way of getting a good grasp on the tendinous portion and some way of opposing it to the footprint where it should be detached. And normally this is done through bone tunnels in some form like this, using a crack off top stitch to the tendon stump and then drip the holes through the electron which you can shuttle through and then tie next slide. Please. Alternatively, you can do knotless sort of double room type repairs. Um using bone anchors such as this technique, not something I've, I've done. I wouldn't, I don't really like techniques where I only rely on one single anchor for complete repair, but that's just my skepticism of anchor. Next slide. Please return to sports. These are nearly all similar demographic to the previous. They usually people in their men forties and fifties, often weightlifters, body builders by far and away, the most common. But I have, I looked, I have done triceps, a 65 year old lady. So they do occur in other demographics. But the vast majority of this and what they want to know is when they can get back to lifting weights. And generally speaking, I mean, the recommendation in most of the small series is about six months. Next slide please. The guy in the middle is a guy who ruptured his triceps a couple of years ago. He's the typical demographic, graying beard, incredibly strong, still wants to lift Atlas BS and things like that. He had his right triceps repair and about six months later, he was competing, but always a worry when you're operating on people like this because just waiting for something to snap. Next slide, please. And a lot of them have been on some form of supplements or steroids or whatever. And this is in uh pre op with classic uh physical sign of a dent just above the tip of the electron. You can put your finger into uh normally, you know, he could easily pick me up his arm. When you put it up above his head, it was just starting to lag and sag back onto his head and he certainly had very little active um triceps extension against resistance. Uh Next side, please, this is an MRI scan. So sorry that it's upside down, but it's in the position. If you were putting them in a DHS support, human is pointing vertically tip of the electron, then you can see the uh high signal and the stump of the tendon proximately, there was a gap of four or five centimeters and that's that medial tendon. And you can see in him uh where the tendon ended, there's a little sort of coffee bean shaped. Um uh and these are for like that's been pulled off by the tendon, which is very common in these weight lifters next line, please. So while I was desperately trying to send my uh talk to r earlier, this was the case I was actually doing. So this is the guy with his uh trps rupture. So this is him from lying on his back posterior approach. And you can see on the medial side where there's a um a cocker on the stump of the tendon. Uh You can see that that's completely avulsed from the electron on the right side, the aponeurotic portion on the lateral slide is, you know, not grossly disturbed. Next slide please. So we put some um that's just retracting to expose the tip of the electron. So you can see the ba and Leon where that medial rolled tendon should be attached. Next slide, please. And then what we've done is put some whip stitches with some fiber tape and fiber wire through the, the stump of the tendon and then pass them through drill holes on the milner oblique drill holes crossing and then a transverse de tension in there and tie them over to that next slide, please. And you can see how it's reduced it quite nicely. Next slide, please. And I then in these body build types, I also use an anchor into the, the sort of center of the footprint just to give effect to the double road type repair and I tie the sutures over an end of a button because I'm worried that they're going to pull through cause a fracture. So I just do that as a belt and place for these really heavy lifting type guys last slide. And this then is um it's not very clear on this f but the repair now it is back in place and the tidal sutures next slide, please. So that, which is what we did today and that's severity. So um I was quite keen to get, let you see that because you may not see that many in your, in your training. Ok. Well, thank you very much. Any comments, questions. It's getting dark, talked enough. Um, if there's no questions I, that was very thorough and.