Trauma and Orthopaedics Webinar



This teaching session will cover trauma and orthopedic surgery and provide insight on how to repair a tendon using the modified Kessler technique. Mr Sen, an associate specialist at Nobles Hospital in the Isle of Man, will lead the interactive webinar and provide an overview on training pathways, mechanisms of assessment, technique, and more. The session will also touch on areas such as knowledge, technique, judgment, and professionalism; and will also feature a few Q&A sessions to test knowledge and provide prizes for correct answers. Sign up now to enjoy a fun and rewarding experience, and take your surgical skills to the next level.
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Learning objectives

Learning Objectives: 1. Understand the modified Kessler technique for tendon repair 2. Identify criteria associated with satisfactory completion of competence 3. Learn the two approaches to orthopedic specialty training 4. Understand the four domains that must be assessed in order to become a surgeon 5. Recognize the treatment options for intra-articular distal radius fractures.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hi, guys. Thank you for joining us today. I'd like to welcome you all to another session of back to the suture this week. The teaching webinar session will be on trauma and orthopedic surgery given by Mr Sen. And the surgical technique that we'll be showing you today is how to perform a tendon repair. Um, as you're all aware back to the future is a 12 week teaching program. Um, that's been developed alongside asset for young budding Surgeons would like to thank asset for helping us develop this course along with them. Like to thank m d U for sponsoring us and a huge shoutout to medal for providing us with a platform to give you the necessary certificate and providing feedback forms as well. Um, so without further ado do I'll show you the video and how to perform a tendon repair. It's very interesting. Uh, let me just share my screen for you guys. One second. Okay. Can you see all of this? Everyone, I hope. Yeah. I just tender my head. Tendon repair is often encountered by plastic and trauma. Orthopedic surgeons, for example. Lacerations in the partner aspects of the hand, the standard technique that has been most commonly used is the modified Kessler technique, in which the tendons are brought together by grasping sutures that occur on either side. These grasping sutures will hold the tendon repaired together and is followed by EpiPen tennis sutures to close the edges all the way around. To add further strength and avoid exposure of the collagen fibers, which prevents the formation of adhesions. A monofilament suture is used to repair the tendon. When handling tendons, it's important to handle them delicately in order to prevent further damaged. If damaged, it can lead to scarring, impairing the smooth movement of the attendants. We want to divide our tendons into three parts vertically and two parts horizontally. A two strand modified Cazalot technique is used to perform to call Aniston officers for your first suture, enter through the cross section of one side and perform a straight longer TUNEL bite and exit at the anterior aspect of the tendon, approximately one centimeter away from the end, creating a suture loop. The second searcher is a trans bite, entering from one side of the tender to the other side, across the whole width of the tendon, through the middle. This creates a grasp and loop on the far side. Different. The third searcher is another straight, longer to general bite entering at the entire aspect of the tendon and exiting on the other side of the cross section of the tendon. This process is repeated on the opposing tendon and once complete tighten and not the Catholic or suture. Uh huh. The second part of the tender repair involves epic tenderness suges. These are simple running sutures around the cut tendon ends. This should eliminate any gapping when the tendon is placed under tension and that's further strength to the repair Start at an edge entering from the inside of the cut section. But rather than tying the suture, attach a hemostat to hold it in place. Take radicular brights with around two millimeter of spacing between each bites. Uh uh. Okay, okay. When you get to the other side of the edge past the hemostat underneath the tendon to flip the tendon over and reveal the bottom side the tendon carry on with continuous running searches until the whole circumference of the tendon has simplest running sutures come running through it. Uh uh. Let's see what? Okay, uh huh. Higher standard Reef. Not before performing a bite would belong in suture in order to bury the not inside the tendon repair. So yeah. Okay. Okay. Okay. So that is the modified Kessler technique that's used to, um, to repair a tendon. Um, I know it can be quite confusing to have a look at the video like that, but I think if you see a couple of times, you actually, it's actually a very a nice way to repair the tendon. And I'm sure Mr Sen will be able to talk to you a bit more about the tendon repair itself. Um, so without further ado, do I would like to introduce you to Mr Sen, who is an associate specialist at Nobles Hospital at the Isle of Man. So without the further do, it gives me great pleasure to introduce you to Mr Sen. I thank you, dear. She, um and, uh, I'm, uh, happy to be a part of your, uh, teaching program. Uh, it's a very nice, uh, platform. Um, so without any further delay, I would like to start the presentation. Um, this presentation is, um, partly interactive, so there would be a couple of slides Where, um, you guys would be able to take part and answer the question a clinical question on the slide. And there are, of course, uh, prizes for the, uh, correct answers. Although I'm not holding any promises up to the Shia and martyr to give you give away the prices. Know that's a joke. Actually, no prices there, but of course, uh, good answers and correct answers would be appreciated. All right, so I'm going to share my screen now. Can everyone see it? Yeah, we can see it. Yeah, OK, so go into slideshow malt. All right. Um, so, uh, topic is, of course, trauma and orthopedics. But my subspecialty is hand surgery. Uh, a fellowship trained hand surgeon currently working in the Isle of Man. Um, and, uh, surgical skills training is my passions. Uh, I've got a surgical skills training program here for the foundation trainees. Um, and I use simulation training. Now, there's a saying that medicine is, uh, signs of uncertainty and an art of probability. Um, it is probably difficult for you guys to understand what it means, but, um, it has taken me years to understand what exactly it does mean, um, hopefully with with in the coming years, Uh, as you go along your carrier part in medicine. Uh, this particular sentence will make more sense, but whereas for the time being, it is just a fun thing to say, maybe a party trick. So the training pathway for, uh, orthopedics, um, it's mainly delivered in, um, in a split technique. Um, it's, um there's an uncoupled training pathway, and there is a run through pathway. So after your second foundation year, you could get into around through Post, which runs from ST 12, s, t eight, uh, eight long years of hard work. Or you could go into a court specialty training of CT one and two and then, uh, get into the ST three post for orthopedics High specialty training. Of course, there are, uh, criteria for our satisfactory completion of all the competence. And your WB is being proper with a good portfolio as well. And there is, of course, competition for getting into these, uh, specialty training and core training posts. Uh, the culmination of all these after eight years, not after eight years. Usually, candidates do take the exam, the fellowship exam around year four, year five. The culmination is, of course, through the fellowship exam, Uh, which is arranged by joint committee of Surgical training. Jessie ST, uh, after the exam is done, people do take fellowship posts before they have life for consultant posts. Um uh, of course. Um, there are other ways of getting into the C C T status. That's called CSR or certificate of eligibly through specialist registrar. Uh, and, uh, like, I have done that. And, uh, it's a It's a post where you're not going through the training posts in the UK as such, but you can get to the same status and you are eligible for a consultant post. Um, there are four areas to access a surgeon, and it applies for both old critics as well as, uh, other, uh, surgical specialties. Um, we assess head hands and the heart. So there are four domains. Knowledge, technique, judgment, and professionalism. What does it take? It takes hard work. It takes tenacity and a desire to go beyond. Um, in 2013, Asset took a survey when European working Time directive came into play, and in that survey they had about 1200 responses, Uh, of which 71% felt that e W T d has negatively impacted on their training. And 72% attended training on off days. Now, you can see clearly that there is a huge amount of commitment and this commitment for some can strike fear and for others can be a cause of enjoyment. Now, I must say that attending training on days when you're actually off is not a great way. When you're young, you may find it. It's okay. But these days of extra work, um, negatively impact your work life balanced and men you may not find it that okay when you are bit older. But anyway, um, this is how and this is what it is now since, uh, last year's pandemic, uh, it has actually delayed the introduction of the new authority curriculum. It has been introduced this year, August, and this new curriculum is based on two main broad areas. One is the generic professional capabilities of G. P. See. The other one is capabilities In practice, G. P. C is a G M. C. Uh framework, which has got 220 descriptors and it calls to knowledge and skills, whereas, uh, the C I. P. It is basically assessment of your judgment and professionalism. And it, uh, access areas like managing an operation clinic, how you manage your operating list and similar things. Uh, of note. Uh, the fellowship. Example. FACS exam, uh, essentially access a candidate as they as they have been appointed as day One consultant, and thereby all these, uh, areas of professionalism. How you handle an outpatient clinic or how you handle your ward rounds or an unsolicited emergency Take these things do come into play when you take the exam. What? Um, now there are some jokes about Oughta pedic surgeons. And one common joke in orthopedic surgeons is that, uh, if you ask an orthopedic surgeon, what is hard? They would say that's the organ which pumps K proxim all around your body. And similarly, there's another joke that, uh, an orthopedic surgeon when they read an E c g. They would say Aces told is the most stable rhythm having all these jokes, uh, and and all the stereotypes, I must say the hand surgeons are different. Uh, we belong to a group of people with more fitness, and you'll see Why? So my case, uh, number one. Um, this case, uh, it's by the way, all these cases are my personal collection. Um, so the first case that I'm going to show you is a case where a cyclist, um, he was a middle aged cyclist, quite fit and healthy. And he presented after a fall from his push by, uh, with pain swelling deformity in his, uh, left wrist. And this was the initial radiograph from the emergency department as the x ray, the demonstrating fracture of the distal radius. Now, this is, uh, distal radius fracture in someone who is very active and, uh, in his dominant hand. Uh, sorry, nondominant hand, uh, this chap, uh, if I remember currently, um, also, uh, play quite a few sports. So when he presented with this injury, as you can see, the injury on the anthropological radiograph show that the fracture extends into the joint surface, which essentially makes this as an intra articular distal radius fracture. So he was, um, steel in the e. D medicine department. And after thorough examination, it was found the neurovascular function of his left hand are all intact. Um, and he was given uh, the choice of treatment now, treatment options for this radius fracture usually, um, varies from conservative to operative. Uh, if you're, uh, if you are well read about the literature on this radius fractures in the UK in the past 5 to 10, 5 to 7 years, there's been one study of, uh, most relevance and importance, and everyone talks about it. The study is called Draft Study, which has compared this radius accurate fracture fixation, um, against conservative treatment. And the study came out with the outcome that most of these fractures, if can be treated conservatively, should be treated conservatively because the long term outcome is not different from surgical treatment and and they have less complications when treated conservatively. Now, in this individual, this particular fracture if I go back to the previous slide, uh, is a difficult, complex fracture with intraarticular extension there by after total discussion about pros and cons of both types of treatment, he agreed to have this fixed surgically. So I, um, operated on him, and this was the fix session. The fracture was very distal, so I had to use what is called a bowler rim plate. This is a different type of plate different to a standard distal radius plate by that icon. Use for these kind of frax is now this bowler rim plate sits very distal on the unit bone, and usually it has got smooth pigs rather than screws, Uh, which can go very close to the joint surface without benefiting the articular cartilage. So the operation went very well, and, uh, it, uh, it didn't take too long. And it was performed on the tourniquet. Control, of course. And there were no anesthetic complications. There were no immediate POSTOP complications, either. However, that night, in fact, it was early morning. Next day. Um, this gentleman was complaining of severe pain in the forum. Relentless pain, not responding to energetics. And passive extension of his fingers was causing pain. 10 or 10. What's the diagnosis here? And you being the F two F three or CT one city to been called to the ward. What would you do? That's my first question in this interactive session. Um, if you would like to, uh, type a few things on the chat box, by all means. Go ahead and I'll pause for a minute. Is that OK? Yeah. So guys just put it on on the chat box. Now I can tell the answers to Mr Sent. I know. Mhm, um, someone's someone's mentioned compartment syndrome. Uh, someone else has mentioned a query. Extended tendon complication. Okay, um, another one said compartment syndrome. Excellent. So the consensus is towards compartment syndrome, and that is correct. So I'll go to the next slide forum compartments in Rome. It's a dreaded complication, but at the same time, it's a complication that all of us should be aware of should be able to identify before it completely sets in and should be able to prevent it from M bending compartment syndrome to a well set compartment syndrome. What happens, UM, trauma, surgical trauma or injury? It causes soft ish destruction, which causes bleeding and edema, increases interstitial pressure, which causes vascular occlusion, and it leads to my own neural ischemia, and this becomes a vicious cycle. As ischemia sets in, it causes further trauma. And as you can see, you can draw an arrow from ischemia towards local trauma and soft construction. The first part of the arrow and it continues as it goes on, um, it can be devastating for the limb. It can cause necrosis of the muscular neural tissues. And the limb can become completely useless if it is if compartments in room is not stopped in due time. Um, the Communist clinical findings to compartment syndrome It always starts with pain, pain and pain pain that does not respond to any measures of, um, energetics or anything else. The first thing you do or anybody would do if they come across a situation where the compartment syndrome is setting in or impending. They would first of all, release all sorts of constricting dressing materials from the limb. And that's what the junior doctor did. He took the plaster off because after the operation, the limb was supported by a plaster cast, not a full cast, by the way. It was a back slab, Um, that that slab was taken off, but the pain didn't settle. And then I got called in, and when I came around, I immediately took the patient to theater. Uh, it was early morning. So what did I do? I did What is called, uh, fasciotomy. Fasciotomy is a procedure where you open up the skin and then open the deep fascia to release all the pressure that has built up underneath. And this saved this man's four, um, and also did a carpal tunnel decompression along with the fasciotomy, which is a standard thing to do once the pressure was released. Um, due to excessive tension in the forum, the wound never gets closed primarily thereby it is customary to leave the wound open, but use what is called a shoelace, uh, pattern string to keep the edges somewhat approximated. Otherwise, the wound ages can actually go apart. And and that can cause further problems when you get back to this wound for secondary closure. So this was Day one after POSTOP after the operation, and I took him back to theater on the seven to close the wound, secondarily along with a skin graft. The skin graft was taken from his tie, and he went on the heal well, and he restored full function, and he had, of course, the skin graft. All those leaves, an area of discoloration, an area of different hair pattern on the forearm. But because it's the Buller aspect of the forum. Uh, the hair pattern was not, uh, such an issue there. Um, But eventually he rested all his function. Then he is okay at present. So this is a lesson where doing an operation landed me in trouble. But I dug myself out of the trouble. And the lesson is that, uh and it's been said by a famous hand surgeon, Jesse Jupiter, that there's nothing in this world that one cannot make worse by performing surgery. Um, having said that, um, to me, uh, to this day, if I come across a similar injury, I would always opt for surgical fixation. Unfortunately, in this gentleman that caused trouble. But that is not going to stop me from, um, from, uh, opting for surgical fixation of similar practice in the future. Anyway, moving onto case to, um, this is again a common fracture, but uncommon presentation. And this was if I remember correctly. Um, so this was a 12 year old who fell and while playing football and sustained his injury in his left elbow. Um, as you can see, this is a supracondylar fracture of the distal humerus commonest injury. In this age group, Communist presentation of superconductor fractures are, of course, a fracture in extension where the digital fragment of the humerus goes backwards rather than forwards. Now, this is an uncommon presentation. Um, and the reality of this presentation is only 2 to 3% of all supracondylar fractures in Children have this particular presentation called flexion tie fracture in the Isle of Man. I do see quite a few rare things, and this is one of them. So this child presented with a flexion type supracondylar fracture, and at the time of presentation, this child had tingling numbness in his little and ring finger. And there was also, um, very little movement in his intrinsic hand vessels. Um, anybody with the diagnosis? Any ideas, guys? Uh, full enough compression. Someone's mentioned. Good. Yes. Spot on al. A nerve injury, not compression, because compression is a condition which is usually a chronic presentation. But if you see someone with an injury, a fracture and presentation with Alan, our policy, then it is, uh, the nerve injury are than compression. Um, and in this case, that was the diagnosis. So this child, as you know, super candle fractures in the distal humerus in one of the automatic emergencies. And this child was taken to theater as soon as possible because of his, uh, associated neurological condition. It was more of an emergency to me. So Alan, have injury. Um, Alan Nerve goes very close to a bony production in the distal humerus is called the medial epicondyle. And it's just behind the medial epicondyle. And if all the nerve is injured, uh, then it can cause decreased grip strength. Because all the nerve supplies all the intrinsic muscles of the hand except the Tina muscles and the first to Limerick codes, and it supplies. It carries a sensation from the volar aspect of the little and half of the ring finger and the dorsal aspect of little ring and some part of the middle finger. So numbness, pain, tingling and muscle wasting clumsiness, clotting of the 4th and 5th fingers and permanent disability. These are the legacy of Alan of Injury. Um, this child was taken to the theater and I opened up the medial aspect of the digital humerus. And what you can see there is a picture of Elena being lacerated, being caught in between the two fragments of a fracture, which is an extremely rare finding because although Alan gets, uh, damaged gets stretched but being caught in between the two fragments is a rare rare finding, and this child had had this trouble. So I I retrieved Mulliner from that entrapped position and repair the nerve. As you can see, you can see the physicals of the nerve, which is again, another rare thing to see in an injury. You can see the physicals, the epineurium is gone and the physicals are exposed. So I repair the epineurium. So the and and one or two physicals were torn as well and and repaired it and fix the fracture with the help of what's called K wires. These are metal wires, single ended K wires, and you can see this fracture fragment has come back to position where it should be. One tip to see to make sure that you are looking at, uh, anatomically reduced position, the tip is in all views. Antropov, studio lateral views, radial head. This is the radial head, and this is the radial head always points to the capital. Um so radial head and capital remains in a straight line, always always in all views of the elbow. So that's a tip for making sure that the the fracture has been reduced anatomically. Six months later, the child, this is, uh, X ray. Six months later, fractures completely healed, and he regained full Elena function. So that was a good case to do. And, uh, an important lesson that these injuries common but sometimes uncommon presentation, like in this case. And if you see, if you don't do thorough neurological examination, then it's very easy to miss a neurological emergency. Case number three. Now, this is a showcase thing. Uh, this is a 17 year old girl who trapped are index finger and between two metal slabs while working in her stable. And she came with the chopped off fingertip packed in a bag of frozen peas. As you can see, the nutritional level there which indicates to the peas, not to the fingertip. And she had an exposed distal balance through the wound with this horrible looking injury. Now, this is a case which only hand surgeons or plastic surgeons would take. Um and I took her to theatre that they and what I did is called, uh, cross finger flap across finger flap. Is the flap to go to for these kind of injuries? Um, and this is, uh, fairly straight for procedure where you take a window of a full thickness skin from the adjacent digit and put it on the tip of the reconstructing digit. And then you cover the window by taking a full thickness skin graft from the Forum Medial forum. And this is how it looks when the window of that tissue is rotated and put on the Buller aspect of the fingertip. This tissue carries its own vascular pedicle when it's coming from the adolescent digit, and these two digits remain together for a period of 4 to 6 weeks. This is schematic diagram of how it is done. Um, and you can see this is the injury. You pick the window up with his vascular supply, this is the vascular supply. And then put the finger into that flap of tissue and take a full thickness craft from somewhere else to cover the defect on the harvest site. Three months postop. That's how the finger was, and she was extremely happy to have a fingertip with minimal loss of height and a fingernail which looked nearly normal and being a female, she appreciated the effort that went into it. Um, there was this harvest site, which took a little longer to heal but eventually healed. And I don't have any other photographs of more recent photographs, but, um, it looks completely normal. So hand surgery, um, can can have candidates from both trauma and orthopedics or from plastic surgery and usually trauma orthopedics at, uh, year 78, they can go into hand surgery specialty subspecialty fellowship, plastic surgery, SPS in year five and six usually go to hand surgery. Um, there is a big fellowship, or this is called an interface group fellowship. And this take fellowship is, uh, getting quite popular in the UK If you guys are interested in hand surgery, these the two common part, uh, whereby which you can get there. So that's, uh, that's my presentation. And I am happy to take any questions if you have any and thank you very much. Thank you, Mr Send. I was amazing presentation, actually, uh, learn a lot from that presentation myself. Guys, do you have any questions? Actually, so someone's message. Everyone's saying thank you very much. Dear Mr Sent. But any questions, guys, uh, think Mrs Sen pretty much went through thoroughly how to go through the orthopedics, Um, run through, like, how to go. Uh, you know, uh, you know, explain the pathway to us how to get into, uh, you know, surgery. And I'm just saying, if anyone, anyone has any other questions, actually, mhm. So do you have any tips for getting an elective in TNO? Um, do you mean elective placement in TNO as a foundation training or, uh, what level are we talking about? Is error. So she's a medical student. Medical student? Yeah. All right. Okay. Um, which university are you from? Aaron. Uh, so she's from Glasgow. All right. OK, like in the Isle of Man. I'm also the undergrad education lead, and we welcome medical students to come over here. Um, if you are interested, uh, you can apply here as well. But anyway, the way to get into an elective placement would be, uh, speak to your university and find out which hospital your university is associated with. And then contact the hospitals. Undergrad coordinator, Usually all hospitals, uh, in their education department will have undergrad coordinator and And as soon as you get in touch with them, they will be able to let you know whether they have any placements on offer and you can get through. And you can always express your interest that this is the subspecialty, or this is a specialty where I would like to have my placement. Usually these are some placement, as as they're called, and usually they are between 4 to 8 weeks of duration. Another person has asked, What's the difference between run through A T E N O versus core Training ST pathway in TNO? Uh, the difference is like, uh, in run through TNO. Once you are in the run through program, then you are only appearing in a competitive interview process once. But in the city pathway you are. You are in the first two years of core training where you can make up your mind. If you're not sure which way to go and after the first two years, then you are in a competitive, uh, interview system for a specialty. So in the city 12 years, if you're not sure whether you want to do general surgery or speak surgery or vascular surgeon or whatever you you are thinking about and those three years are kind of your foundation years in higher surgical training and gives you an opportunity to, you know, introspect. Think and see whether you are fitting into that, you know, uh, in the in the specialty on or whether specialty suits your needs. And that's main difference. Someone's asked that. Do hand surgeons work together with plastic surgeons? And where is the bridge between plastics And, uh, you know, surgery and hand surgery, as I mentioned before that, you know, and all speak surgeons have got a bad name about, you know, being a bull in a china shop. Uh, so the Hansa Hansa is like a bridge where it brings a bull and asked the bull to behave. Uh, in all seriousness, hand surgery and, uh, is done by plastic surgeons in many centers in the UK But hand surgery is also done by orthopedic surgeons. In some centers in the UK If you go to the continental Euro, um, then you'll find that hand surgery has got specialty. Um uh, as a specialty, separate specialty, uh, status in some countries. But other countries share the system. As in the UK in the UK, we have a British hand society which works hand in an, uh, unintended with the European Hand Society. And, uh, we have a diploma exam as well in hand surgery. So, at present, maybe, uh, specialty. The sub specialty of hand surgery is shared by both plastics and automatics, and in many centers, the workload is also shared by plastics and hand surgeons. But like a deviated where I'm walking, I don't have a plastic surgeon to help me, So everything comes towards me. Um, and then there are many mediators. Maybe where there are no automatic hand surgeons and the plastic surgeon perhaps gets all the cases. Um, what do you enjoy most about hand surgery? What do I enjoy most of the hand surgery? Um, I believe reconstructive work for, uh, trauma in the hand. That's probably, uh, the most enjoyable work for me. I do a lot of deep uterine surgery in depew Trine surgery. Uh, patient's come to me with horrendous flexion deformity of fingers and correcting them, giving them their functional, um, hand back is an in tremendous, uh, satisfaction. I enjoyed very much my other area of interest. Clinical interest is a distal radius fracture. Uh, and I enjoy fixing them. So, um and, uh, just a question for me. Did you have to do lower limb surgery during your training as well? Of course. I'm a I'm a general orthopedic surgeon first and have a surgeon second. So in my workload, um, I do pretty much everything. I'm good at doing joint replacement hips and knees as well. And I I still do them. Uh, that's, uh, kind of a disadvantage of working in a d g h s where I do pretty much everything, but also an advantage. Because I do pretty much everything I can handle pretty much everything. So when I'm on call, if whatever comes in, I'm not worried about it. I can't handle no. Okay. And, uh, any other questions, guys? Uh, someone just okay. Oh, some someone's asked. So not sure. This was answered already, but wanted to know how Mr Sends route was into hand surgery. And if this was something he was always interested in? Um, a No. I was not interested primarily in hand surgery. I was interested primarily in knee surgery. Um, but my interest piqued when I started. Um uh, my network with writing to the hospital and got to know a few hand surgeons I found them extremely friendly compared to other subspecialties, so I don't know. Maybe it's a personality. And maybe I like the Finnish side of the work more. And I I thought I I found myself liking it more and more as I got in touch with them. And then, uh, I did a fellowship with them and that set me up in hand surgery. Uh, there's another question. Why did you choose both critics? Um, again, I would say serendipity because originally, I wanted to become a general surgeon back in India. I did my general surgery rotation, and, um and then I completely disliked the idea of, uh, working with the, uh, bowel surgery group. You know, the shit and smell Put me off completely. Um, and, uh, then, uh, I started liking the engineering side of orthopedics and got into it, so I think someone last met met. Last question. Mr. Said what? What is the ratio for TNL surgery? What do you mean by the ratio? I think they meant competition ratio. Oh, the competition ratio. Uh, it's a tricky question. Uh, if you are looking for the current statistics, I'm not sure Not sure because the job. I mean, the higher surgical training in the last 12 months, Uh, the situation is very, very tricky. Because of the pandemic. It has stopped training for many trainees, and there is a huge amount of backlog dissatisfaction in the entire training network at present. Um, I'm not sure what's the ratio right now? Um, but it is an unfortunate situation for all of us, not only for the trainees, because most unfortunate are the patient's. They are the They're the worst one to suffer from the pandemic. Uh, there's a huge backlog of orthopedic cases all across the country. I'm not talking about one specific hospital, and it has put the entire specialty on the nights hedge. And, uh, I don't know what will happen in the next 12 months. There is a tsunami of waiting list. Patient's, um I think any other questions, Guys, Uh, I a brilliant presentation, Mr Sen. Very much enjoyed it. And the interactive session was great as well. And so I'd like to say thank you, Mr. Sent for taking your time out today to present today. And thank you for everybody to join for joining us. Uh, and we'll hopefully see you next week as well. All right, Mr Sen. Thank you so much to all of you standing up. Thank you. OK. Okay, guys. Thank you.