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So we're gonna talk about proximal ulnar fractures. Um And this is a bit of a spectrum. So it can go all the way through from a proximal a avulsion of the, of the electron through triceps, all the way through to something a lot more complex. Um And a lot of the time, it's about trying to convert something that looks on the right into something on the left. Same with this. If you've got something that's got a smashed, proximal ulnar, it's about trying to work out, particularly giving a CT scan, how you can make it look like a thing on the right. So you can then fix it in a much more straightforward way. We can start with the leg fractures. I'm pretty sure Pete's already gone through a lot of this with you. So it might be a bit of a revision. Um That's relevant to what we'll talk about later on 10% of the fractures around the elbow. Um They're relatively common. Uh The pattern of your fracture around the elbow is determined by the force and the posturate impact. So, if your um elbow is extended to less than 80 degrees of flexion, you're much more likely to get a combination of a coronoid and radial head fracture. So, a terrible tri type injury, um or uh posteromedial instability. If you're 80 to 100 and 10 degrees, then it's much more likely to be an electron fracture. And then if you're flexed to more than 100 and 10 degrees, it's more likely to be a distal femoral fracture. The Mayer classification is the most commonly used. Um It splits into type 12 and three. Type one is undisplaced. We do see these on occasion. They're quite obvious on the X ray cos the um class is intact, um not very displaced, more often stable, but it's, it is less common than the rest. Communist type two. And these are split into er noncommutative and cognitive displaced and then finally, type three, which is the unstable. The instability that's being referenced to here is the loss of congruence between the distal humerus and the anterior portion of the great sigmoid notch. We'll come to that again later on. So the type one, the this place, this is less than two millimeters. It's a stable configuration and these can be treated conservatively with sling mobilization but comfort predominantly for the 1st 7 to 10 days and an active range of movement exercises but avoid resistant extension for 6 to 8 weeks. And I do keep an eye on these. So I get another X ray of one week to make sure it's not misbehaving and then again at four weeks to make sure it's still in a reasonable position. The type two, they displaced the noncom say two a options for treatment include tension bo plate fixation and fragment excision. This depends on the kind of fracture that you've got the age of the patient and their expectations. The tension band is something we're all quite familiar with. Um, it's been used for a long time and on the whole, it works pretty well. There's different ways of thinking about the tension band concept. And for me, it's about a shift to the center of rotation. So if you imagine this picture on the right, this is a normal elbow that's all intact. The center of rotation is around the center of the capella. When you are biceps and triceps, five, the force is transmitted through the ulnar and you get rotation around that center of rotation, giving you flexion and extension. You then introduce a fracture through the electron on and that force ends up being a distracting force and it opens up your fracture rather than transmit the force of the forearm. But the tension band wire, what the dorsal wire does is it shifts your sensory rotation to the dorsal cortex of the ulnar. So then when you introduce the fracture, if you bring about the same rotational forces instead that results in compression around your fracture, which aids its stability and potential for healing. Um rather than distraction. So it's converting a distracting force into a uh compressive force. Um There has to be potential for stable reduction. Um ideally, there would be no comminution. And for me, these need to be proximal to or up to the center of the greatest stigma notch to confer that kind of stability. And reassure me that attention man fixation is uh in the best interest of that patient. It works pretty well. People been doing it for ages, but there's some of that. It's a particularly poor operation in particularly Burkhart's group a little while ago. In 2014, they published a paper describing the myth of technical simplicity and they went through all the things that can go wrong. Um They can be nonparallel KWS. So if you don't get your KWS straight with one another or parallel, um then it prevents compression across your practice. Like using the tension man wire, the Ky is coming too long. Uh Traditionally, it's described as being up to a centimeter prominent of the volar cortex of the metastasis that's been reduced a little bit more recently. And now the recommendation is less than or equal to two ky widths, the cortex, the K Ys can extend more radially. If they extend radially enough, then you can go into the PR UJ or even into the radius itself um and result in a restriction of pronation and cation and quite seem to complain there can be insufficient proximal fixation. So you can fail to grasp that proximal fragment as well as you need to, to give it stability. The wires can be intra medullary. And I know some colleagues of mine still deliberately put the wires in me to stop them coming out of the V cortex. But biomechanically it's a lot more stable for them to go through the vowel cortex. You can perforate the joint so you can put it into the actual er ulnar humor joint itself. A single wire knot biomechanic is inferior to a double wire knot. And those knots can be prominent and uncomfortable underneath the skin if they're not properly knocked down. Uh So they're flushed, you can do a loose figure of eight. So it ends up not giving you the compression that you need and you can get an incorrect reduction. So it can be not perfectly reduced and therefore unstable. I've got reservations about this cos you could potentially put any x-ray fixation up and then go all the way through all the ways that it's gone wrong for. I mean, you could put up a D HSX ray and say, well, this could go wrong, this could go this way, one of the solution sites just don't screw it up in the first place. Um But there's sufficient concern over the, the non simplicity of this for people to start thinking about different ways of doing it. And for me, the biggest issue with this is it, it's always common. Pretty much people hate having that 10 man wii underneath their skin and it is a subcutaneous bone that does cause irritation. So, Adam Watson and his group came up with the idea of an all suture, tension and suture technique. This is appropriate for simple uh transverse electron fractures of Chevron Osteotomies. If you look at that, the radiograph on the bottom left, the X ray on the left hand side, you can see that there's still congruence between the distal humerus and the greatest signaling notch. Um Although there is distraction at the fracture site, the dorsal cortex is remain in regional alignment. That's as opposed to the X ray that you can see on the right where there's loss of some of that con displacement of the dorsal cortex. Um and that will be less lean detection band fixation. In terms of the procedure, we look at the image on the right hand side, the first image of the top left. So image A that's reduction of your simple transverse fracture held with a spiked ma force. So um augmented with or without K wires, you then drill a hole of at least 2.5 millimeters width, although you can go bigger than that. So if you go all the way to four millimeters, it's much easier to pass your sutures backs and forwards. But you do need to leave at least a centimeter of dorsal cortex to stop it being unstable. And the hole has to be distal to your ulnar humor joint. Once you've done your hole and got your reduction, you pass your suture from the lateral side to the side of the radial head on it, from lateral to medial, bring it up to the medial side of your tri triceps, fascia, take a big chunk of the fascia, take it back on through the hole, back up through the lateral side of your triceps FSA and then tie it off on the lateral side. And that first suture. So the one in green in picture C that's equivalent to your K ones, you then take your second suture. So it's all four of five wire. Um You pass it from the lateral side through to the needle side, arch, it back over to the lateral side of the triceps, fasher take a decent bite, bring it back through the hole onto the back across onto the needle side and then tie it on the lateral side. And that's the equivalent to your um tension band wire. And it's exactly the same principle. You're trying to confer some level of um translational stability, but then shift the center of rotation to the doors or side. So it gives you compression when triceps and biceps start firing. And it does work pretty well, particularly for these proximal avulsion fractures where you're not sure you grasped it with a plate all that. Well, this is someone who did a little while ago. You get nice, pretty interupt x rays and they carry on looking pretty good postoperatively and you can get them moving. The main method is there's nothing to take out. So they did not, you can deliberately put them underneath the fascia. It didn't cause too much trouble. Um, same with this one more of an avulsion. Um, you can see the hole on this one for some reason, we went slightly bigger with this one probably because we were trying to pass the sutures. Um, but the, er, they're happy with the POSTOP, they get the air while moving. The biggest appeal to me was in the context of distal femoral fractures. Um So, um I'd look at this X ray now and I think at this stage, I'd be hopeful that we could fix this without doing a elect nosy at all. This is a little while ago now. So, for whatever reason, we went straight to the idea of elect nosy. When you do an electron osteotomy for these, you fix it as a humerus, then you fix your electron osteotomy. But if you use tension band wires or if you use a plate, there is an expectation, you're going to have to take that out further down the line. So then you're pretty much unzipping the elbow that you've um done a, just a humeral fixation on. And quite often you don't want to take out the distal humeral plate. So you're potentially exposing them to um a further search procedure with a with risk of infection or leaving hardware in place. So this one, we took down the electron on, we did our distal heal fixation and then fixed it with Te Ands and I've done this a few times and usually it works pretty well. In this case, it comes back for the X ray in clinic. Distal hum looks good, but there's something not quite right about the electron mastectomy. It's starting to drift. Initially, we were hopeful that this would look all right. But no such luck carried on, drifting off. And in the end, the patient went back to the room and had this uh taken out and wire put it instead and it remained stable following this. Um My worry is that when you're using this for an electro osteotomy rather than for a fracture, you don't get that fracture into digitation that you do when you've done a couple with a sore. So, although you can reduce it and you can press it. The potential for loss of translational um orientation is far greater because they can just slide against one and that's so much easier. Um I think my preference would be to do this would be a couple of stout k wires with additional uh fine wire over the top as a tension band wire valent. Um And then removing these is just a simple case of doing a little niche in the back of the elbow removing the K wire and then you can leave your humor place in place. So two B displaced communist fractures. So these are off if you tried for tension band wire this and I know some people still would. I think they, they put tension band wi with the wire. I think this would crush down. And although it might restore your extensor complex, as long as it healed, I'm not sure you'd get a congruence, congruence of your Sigal not and distal humans. Um So for me, in my hand places, the idea is that you restore the articular surface, um give it some compression need with KS or a clamp, a positional plate if you're locking electron plates um and get them going. Um The unstable ones, the things to look out for on the unstable is the loss of that congruence over the front of the humeral joint and also the depression of the intermediate electron fragment. Um And this suggests for transmission of falls directly down through the humerus into the electron. Um that causes the comminution for these that needs to be lifted back up again and then supported with the rectal screws beneath. Um so that you can give them some support. What I would say in this one is that, that proximal pregnancy is quite small. Um The plates that we use here is the option to use a plate with times. I don't like it very much because it limits your options for proximal fixation if there is any bone there. Um And Adam Watt's group actually say that the tension band suture construct that we discussed previously can be done in addition to one of these plates to give you some control over that proximal fragment, I've not done it, but it strikes me as a sensible option if you're worried about control and that um popping itself out. So then type three, another example of an unstable again, fix the screws with a reduction of the articular surface and then get them moving. This one actually had a sagittal split through the proximal fragment. So that needs to be fixed independently. Um So you turn it back into a proximal block and then that was used to compress down. So electoral fractures um when you look at them and you say is the only humoral joint stable. If you come to the conclusion that it's not, then just go on and do plate fixation. If you think that it is, then it's about the patient. If they're elderly, low demand with dementia, you can potentially leave them alone and run with it conservatively, even accepting a certain loss of um triceps function and elbow extension. If it's a transverse or stable, a bleak fracture, then you can consider tension van or suture. And then finally, if it's comminuted, go to a blade flexion, Peter already talked about this. And I think you've all drawn over Miss Fisher in your practical sessions as well. Um These are pictures, uh certainly one in the middle is from these paper in Abrook. Um And this is the way that I do pretty much all airways now. So Supine with the arm over a trough, um there's numerous benefits to it. You can access pretty much everything you want to access. It's easier positioning. So you don't have to flip the patient onto their side. The anus is far happier because you're not flipping the lateral. Um It reduces the deforming forces and this isn't just for elbow fractures. This is also for any kind of humeral fracture. If you've able to fix the humerus with them lateral over a bar, it doesn't matter where you put that bar and the whole thing tends to angle off over the, over the your, your bar and it effectively um causes further destruction fracture with this. All you do is lift it up a little bit in the trough and it reduces open for you and find it easier imaging. So if you've gotten over a bar, you try to pull it even further over to get a proper lateral of your elbow. With this, you just um uh extended the shoulder and bring the arm out onto the intraop imaging. Um And you can take a good x-ray. What I would caution you against if you're doing an elbow fixation is externally rotating the shoulder too much to get your permanent lateral because your elbow fixation will only tolerate so much. So, make sure you get the UM II machine to rotate rather than turning too much through the shoulder. So, approximal fracture dislocations, I think this is the meat of what um uh Mr Fisher and Charlie wanted me to talk about. Um and there's different configurations of this. They're all relatively complex. There is a posterior lateral. So this is more your terrible child. So this is where you have a posterior lateral force with fracture of your radial head, destruction of the coronoid and destruction of your your lateral collateral ligament. But part of your nasal cater ligament, there's the posterior medial. So the coronoid anterior facet injuries where the forearm has gone off um posterior immediately because of your coronoid fracture. And this is best appreciated on the coronal cuts of your CT scan going basically effective the axial cuts that quite often end up being corona. Um And you can see whether there's been disruption of your medial fusa. And then finally, um the bigger ones is the complete ulnar. So the transect trans ulnar and Monte Ovarian sending for the complete ulnar fractures is multiple classifications, initially described Monte fractures in the various angulations associated with them to have the subclassification of be two. And then there's the exhaustive AO classification, but it's so unwieldy, it's pretty much only used for research. There's also the descriptive terms as well which become relatively confusing themselves. A Monte variant equivalent and also the one versus transect and all of these distinguishing the terrible trial by complete destruction of the arm. So Lee Vans Institution in this paper a little while ago, er J CO in 2011 came up with a proximal and a radial fractionation comprehensive classification system. Um The difference with this, although it's still complicated, it does give you some indication of what the treatment recommendations should be. So you split them in two. It's an alpha numeric classification. Uh 12 and 31 is your electron fracture. So this is what we've already already just discussed. Stable versus unstable. Um And fixation will be the same two is the mon fractures. So uh various angulations with disruption of the PR UJ dislocation head radio capitellar joint three is the trans ulnar basal coronoid fracture and then four is a combination of one and 35 is a combination of 32 and six, is all three. What I would say is that the most challenging to manage in all of these is a type three. If you end up with a 45 or a six, then for me, it's about converting that 45 or six into a type three so that you can then go on and think properly about how you're gonna fix it. The subclassification. The A one and the A two, a one and A two is um is something in itself. So it's like a forearm dislocation. So, there isn't disruption of the PR UJ. So the annual ligament in T and there's the dislocation of that entire unit, either anti or or either or or do. Um in theory, once this is reduced, then it will look much more like an electron fracture. What usually recognizes is that this is a much higher energy injury with much more significant collateral ligament injury compared to standard electron fracture. The B is the variance of the uh type two or Monte with anterior lateral or posterior discussion of radial head. Type C uh relates to the type of radial head injury that's been sustained. Type D is the intraosseous destruction with D IU involvement. And then type E is again an entity in itself, it's a, it's a dislocation of the um of the ulnar humor joint with or without disruption of the radial components um but no actual fracture of the pro and that's a much higher energy injury. So, in terms of treatment, who believes this already, the type one is your electron fracture, treat it in the same way you would as we've discussed previously with the electron fractures, the ulnar shaft fracture. So um the type two, once this is reduced, if you get it anatomically reduced, the vast majority of the time that will result in reduction of your radial head um congruence of your ulnar heal joint. Um And as long as you can take the wards, a full extension under II on table that might be all that you need. The type threes is where it gets a bit more tasty. Um And as we mentioned, there's a continuum between the 345 and six where you're trying to get back and fours between each of them based on what your CT scan shows. Um This is described by others as the trans basal coronoid fracture. Um in terms of fixation of these, a classification that's slightly more useful to think about in the scheme of management was produced by Mayo more recently in 2023. And this is based on what's happening with the coronoid. So they call it a coronoid centric classification system. And they say, well, the coronoid is attached to the old metaphysis or whether it's attached to the electron or whether it's attached to neither. Um So the ones that are attached to the metaphysis are effectively the same as a type three mayo unstable electron fracture. Um or the type one from the Gianni Cola system of a mole already. Um Basically, this is a, this is a um unstable electron fracture that needs to be treated with plate fixation, the type two or sorry, the the electron. So where it's attached to the electron, excuse myself. Um This is the monte variant. Um So the coronoid fragment is still attached to your electron. Um and these are treated with a pre sort of atomic plate such as in this scenario where you, you could probably make out from the X ray that the coronary is still attached to the electron. Once this is reduced, and once you've reduced the radial head, then it's about um getting some compression across that with a clamp and um stabilizing it with your, the locking screw through your plate construct and then get them go. One of the most important thing is to recognize that the dorsal contour of the ulnar is not completely straight. So in these fractures, if you've got comminution and you can't get it completely reduced, what you mustn't do is fix it completely straight because that will continue to give you radio capar instability. This is a bigger risk when people were still self contouring recon plate to put it around the dorsal aspect of the ulnar or with the Precontoured anatomic plates, then it's a lot easier to manage this. And then finally neither. So the coronoid isn't a tax reason and this is about your plan for management and stabilization of the Coron. Um For these, you open them up dorsally and I tend to pass a stout k wire from the proximal electron fragment down into the shaft of the ulnar. Um You do this with the elbow, put into extension and then bring it back down into flexion. And it gives you a much better idea of extended combination length of the ulnar. And what kind of reduction you can get across the dorsal cortex. You don't have to think about, well, how am I gonna stay like that stab that further down the line? Where is my plate gonna sit? And what do I need to fix through my plate? Um Because then you take that, that's over the doors. It, because then you take that KW out and you visualize the base of your corno through what has affected your electron osteotomy. And ideally the win in this scenario to be able to fix that back onto your ulnar. Um because then effectively, what you've converted it into is uh a type three unstable electron that can be fixed with a plate. How you go about doing that is determined by the shape and size of the coronal. Um So if there's a small comin fragment, that might be Transosseous sutures, if it's a, a large fragment and that could be screw fixation, the screws could come from dorsal or bowler. It's described by literature going from bowler, I've never done before. It strikes me as a real fact, there's a lot of clockwork sitting over at the front of the arm in terms of reaching that, what's much easier is to use one of the anterior medial er dedicated coronoid plates because you can swing them in from a slightly more medial or posterior position. And then we use it to pull that coronoid fr down. So this is one of the ones that flu up earlier on. This would be a, a one of the ones that falls into the neither category. So the coronary is not attached either to the electron or the ulnar metaphysis will scroll through that ct scan on the right side. That's the back of the electron. As you go forward, you can see that there's a large anterior medial coronary fragment. And as you go into the ulnar metasis, there's an additional fragment over the var aspect of the or that doesn't reconstitute until much further down. Tricky bit about that is that if you don't have something to reduce your coronoid onto, then it's, it's, it's quite difficult to reducing onto the electron fragment is, is much more challenging for that to come all, all the way out. So in this one, you actually snuck down the medial side, reduce that, that metaphyseal fragment for the plate and then used um drill holes and trans sutures to bring the medial plastic back down again. Um We then fixed his radio head with a screw. It was quite a simple configuration and postoperatively looked like an elbow. I was quite pleased with that, but he was super stiff, really stiff even after seeing him at two weeks saying we need to get you moving. He was quite apprehensive and didn't move it much. And when he did get you moving, he got you moving much more into flexion than extension, which isn't ideal. Um And he actually did his, his dorsal wound a little bit and we had to treat him on a basis, he was infected. So, further down the line, we actually took all his metal working out. I performed a column procedure at the same time and he's now much happier. So he's running uh from about 20 degrees through to more than 100 and 10 degrees with six degrees of pronation, see nation. Um but it has taken about a year and a half, there's still some disagreement potential even with the Mayo classification. And that's for the combination between the Monte and the trans ulnar when you have a Monte where the coronoid is still attached to the electron, but there's pollination directly underneath it that doesn't extend into the articular surface. So in their paper where they looked at the interobserver reliability, this is the one that's still a bit tricky. And this case here is an example of that. So if you scroll through the CT scan, there's the electron going into coronoid attached to electron, but then combination directly beneath it. And even on actual imaging, there is still some inter observer disagreement as to which classification this would be um for this one. In the end, we fixed it with a dorsal plate that used a headless compression screw from lateral to medial to bring that on the comminution beneath the corona fragment back in place. And then once we've done that, we're able to bring the coronal fragment back down and fix it with screws through the plate and it went on to look like an elbow, which is what we're looking for. So, they're quite hairy procedures. So it's quite nice to be able to look at somebody else's experience and see how they're getting on, particularly see what their complication rates like. The ma group off the back of this coronoid centric classification system brought up their experience and they looked at the 17 years between 2002 and 2019 and they only have 32 patients. So that's less than two a year even for a um uh an environment as big as theirs. Um 20 available to follow up had 13 females, 15 males. The age range was quite big between 28 and 78. Yeah, 25 of them went on to Bony union but two Coronoid non unions and they had complications in 36% which makes me feel better. Deep infection for ulnar neuropathy to contraction to and non use to reoperations was 39%. The vast majority of this was hardware removal, which is consistent with my experience, but also ulnar transposition contracture release with hedge classification removal and a revision with bone graft. Um The main clinical and radiological follow up for the cohort was 37 and 29 months um respectively. And a final follow up, they had 16 of their ows had hetero and 20 of them had arthritis. Obviously, the arthritis would have had varying degrees of functional limitations, but it's fairly sobering to know that all 20 of them have issues with arthritis. Um So I think it is important in terms of patient um expectation management that this is an elbow changing injury and what you're aiming to do is get it to look like an elbow again so that they can have a functional hand beyond that. So it's all well and good saying. Right. Well, we're gonna look at the CT scan, we're gonna put this metal work there and that metal work there. I think one of the things that people find most um er apprehension driving about these is how to actually get down there in the first place because you want to be able to get in there, put your metal work in, in a way that allows you to close it up in a way that doesn't roger all of the neuromuscular suctions around it. Um So we're gonna have a bit of a chat about that. Um You can see the immediate mistake the AO group are making on the left hand side there. They've still got the patient the wrong way around and that's upside down for me. So for me, it's much more presented as in the right image. So that would be somebody's right elbow. I'm looking at it from the dorsal side with their head to the left and their feet to the bottom of the table. Um And we're gonna unzip it from the subcutaneous border of the ulnar. It's quite often not subcutaneous when you have these kind of injuries because it's all so swollen. But you make a best estimate of where that's gonna be. And then you skirt around the electron and go approximately to the mid humans. Once you've done that, you're gonna be presented with the investing fascia and the fascia over the triceps. It's much easier to find that layer and that triceps fascia more approximately to the level of the humeral metastasis. And once you've found that layer, then you raise all thickness skin fs on both sides. On the lateral side, you then make your incision through the fascia obliquely distally, leaving about a half centimeter of cuff cutting down onto the lateral radial border of the ulnar. Um and taking down a super running proximately. What that will expose is your annual ligament and the distal insertions of your lateral collateral, you take them down through sharp dissection off the bone and that will reveal the radial head beneath. So if you look at that image on the far right hand side, the blue dash line along the border of the ulnar going into the electron, that's your cap of fascia. But then when you look down beyond that, then you can fully expose the entire lateral side of the um electron coming proximately, turning our attention to the medial side, you're gonna have to feel around approximately. So you can feel the ulnar nerve and then track that down distally to the cubital tunnel. And then the fascia over see you more distally, we incise that carefully along the um radial border of the cubital tunnel, leaving a cuff of tissue to limit instability, postoperatively and then go down and release the two heads of the FCU U. You can then take that out of the equation by immobilizing it. And then you've got two choices. So for the X ray and the middle on the X ray on the right, you can either go down through the bed of FC onto the and then do sharp sub elevation to get round to the medial side and the anterior medial side of the, of the proximal ulnar or you can go full tailor and shower and take a whole FC U off. So you're hopefully going from the dorsal side of the ulnar working your way down to and that gives you full exposure of either side of your um proximal. Um So you've got those cuffs of fascia, as you can see on the left hand side and the greened out bits on the right, the two windows that you're gonna be working through. Don't forget of course, that the electron will quite often have that osteotomy in the middle portion of it. So that then also gives you access to the coroner. If you've got a radiohead fracture that's completely destroyed, you may, will be taking that out, that gives you even more exposure. So in summary, it's a spectrum of injury from avulsion through to prox prox uh complex fracture education. You've gotta think of it in terms as stable versus unstable for the electron. What you're aiming to do is to convert this complex multifragmentary injury into something a lot more simple, simple inverted problems which you never get that simple so that you can fix it. And it's about recognizing the severity of this initial injury and counseling patients appropriately. Some will be sat there thinking, what about the radial head? Well, what I'll say to that is that it's not a proximal ulnar fracture. So I'm not gonna have to talk about it. I think Emmett will be talking about it a little bit in a minute in the context of proximal fracture. For me, the radial head management is about what will give you adequate stability. So if you look at it and think, gosh, that's a bit common. If you're thinking about doing some kind of a little bouquet of headless compression screws that is then just gonna go and fail and impinge and get in the way and also not give you stability of your lateral column. Then that's um they're a loser for me. I'm just quite aggressive in terms of saying, oh, abandon that, put in a um radiohead replacement um and be more confident in terms of getting them going cos stiffness is always a problem. So any questions and there's some um references so I'm gonna stop sharing. I can and then she can you go back up? No, can't do that any questions for anybody. No. Fine. So I go and find um Emmett or be back in a minute. Thank you. I.