The changing landscape in total hip arthroplasty: part two

Listen to Andrew Duckworth, Dominic Meek, Ed Davies, George Haidukewych and Thane Munting discuss the changing landscape in total hip arthroplasty.

This episode is kindly sponsored by Smith & Nephew.

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Transcript

[00:00:00] Welcome everyone to the second part of the final episode of our Smith & Nephew sponsored special edition podcast series. I'm Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As you may know, this special edition series is focusing on hip replacement surgery, including what the current issues are, what emerging technologies may help with these issues, and what the future may hold.

In this episode, we'll be building on our previous episodes in the series to explore the dynamic shifts happening in total hip arthroplasty, highlighting some of the cutting-edge innovations and how the orthopaedic community is adapting all of this to our ever-evolving healthcare systems. We'll further discuss the rise of personalised surgery, the economic implications of these innovations, and improving the success rates of hip replacement and bringing together, really bringing in together our previous episodes on how implant designs are driving precision,

hopefully reducing risk and improving the efficiency of total hip arthroplasty for us and our patients. So for today's podcast, I have the pleasure of being joined by three guest surgeons and a colleague here from the BJJ. First thing, I'd like to welcome [00:01:00] back Dr George Haidukewych, who is an orthopaedic surgeon based at Orlando Health.

George, great to have you back with us. Hello. Secondly, I would like to also welcome back Professor Ed Davis from the Royal National Orthopedic Hospital in Birmingham. Ed, thanks very much for joining us again. Thanks for having me. Thirdly we have the pleasure of welcome Dr Thane Munting, who is an orthopaedic surgeon based in Cape Town, Thane,

thank you so much for taking the time to join us today. Pleasure, Andrew. Thanks for having me. And finally, I'd like to welcome back my editorial board colleague here at the Journal, our hip specialty editor, Professor Dominic Meek. Dominic. Great to have you back with us. Thanks very much. Great to be here.

So team I thought we'd sort of kick off and I'll maybe start with yourself. Ed and George, you know, you've taken part in the series already and just to summarise and highlight some of the key points we've discussed so far regarding how the role of personalised total hip replacement surgery is evolving and how this is potentially improving outcomes and reducing complications.

So maybe Ed, if I can maybe start with yourself and then I'll come to you, George. Thank you very much. So starting to learn now how, how do we do the perfect hip replacement? And if we're gonna do a perfect hip [00:02:00] replacement, then we've got a few choices to make. The, the first thing is how do we personalise the component orientation for that particular individual?

And I think technology certainly helps us with that. We then, of course, need to execute that plan. And so we need the precision of execution with technology. I, I think we also need to realise that actually implant selection is a huge part of this, and, and I think particularly over probably the last five years, we've learned much more about design of stems, whether we should be cementing, uncemented and bearing choices.

So that's, that's hugely important, which I hope we can talk about a little bit later. And then of course when we're executing the hip replacement, we've gotta be cognisant of the soft tissues and trying to do the least damage as possible. So I think we're, we're building all those things together. We discussed before,

I think we don't wanna get caught up with technology about I think the trap of technology, helping us plan the perfect position and technology helping us to [00:03:00] execute that plan. There, there's absolutely no point in being precisely wrong when you are executing a plan. So, so as we start to move forward in, in realising where these technologies fit, I, I think we've got to,

we've really got to tease out those two aspects that, where do we want to put it? And technology's hugely beneficial on that. We've got planning softwares now that can really personalise component orientation, but then we need a slick system that within the operating room we can execute that plan and deliver that component orientation.

That's a really nice overview, and I totally agree. I think it's, like you said, there's no. No point in putting it in perfectly inaccurately or perfectly wrongly. So George, anything you'd add to that? Yeah, I think Ed hit the high points that you need to define a target and how do you do that? You know, there are programmes that can help you run simulations to determine an impingement-free arc of motion.

I think these are very helpful in [00:04:00] patients that have the outlier spine and pelvic relationships, fuse spines, stuck sitting, stuck standing positions where your typical 40 to 15 will not be adequate. So. Recognising which patients need that further workup and that more advanced planning. I think that's a growing body of knowledge.

We don't know how many patients need a 3D plan. Are you okay with 2D? That's a growing body of knowledge, but I think the outliers with significant lumbopelvic deformity will benefit from more sophisticated imaging and preoperative impingement analysis. And I agree with that. The the tools we use to hit the target, so to speak, won't be giant robotic arms.

I think they're going to basically distil down to handheld robotics. They're simple navigation tools that are basically transparent to your workflow. They'll hand you a robotic reamer instead of a standard reamer. It'll look very similar, but it'll still help you as a robot would help you, but the technology will be in your hands.

I think that'll be the way we evolve in the future. That's really, really interesting, George. I, I totally [00:05:00] agree. And I think like you've, you've highlighted some of the, the, the previous episodes where we did talk about these patients who are maybe the outliers, the more complex patients, and where this particularly can really come into its own to really help you in those situations.

Thane if I could come to you yourself next, you know, just maybe expand on those comments and what your own thoughts are on the current technologies that are helping with personalised surgery. Yeah. For me, the, I think the overall purpose of these technologies is, is to, to make us as orthopaedic surgeons, better orthopaedic surgeons, which will have knock on benefits in the long term, obviously.

I just want to also second what the our previous two speakers have said. You know, the, the planning before has always been very generic, and now we have techniques that we can plan appropriately for our patients as opposed to just the generic way of doing things. But more to that. It facilitates actually bringing into play what Ed mentioned earlier in terms of implant design.

So if you know the exact design parameters of your implant you're using, it also helps you choose the [00:06:00] correct implant for your patient when you start putting the dynamics together between cup orientation, vis-a-vis the spinal pelvic movement and the positioning of your stem in terms of the anteversion of the femoral neck, for example.

And when you can test this all on a computer before you do surgery looking for impingement range, it adds to, it adds to the, to the bespoke planning of, of each case that you do. Which then if effected precisely afterwards with proper surgery using the robotic or computer-assisted techniques can only benefit in respect of outcomes

in my view, it's, it's fairly common sensical, and I can tell you that for you, after using this for the last two and a half years. I really don't have outliers on my X-rays post-op. I have no leg length issues. And and thus far, touch wood, no instability issues. So. So it's also taught me a few things.

The processes have taught that taught me that I don't need to use lip liners for posterior approach. For example, I don't need fluoroscopy for my direct [00:07:00] anterior approaches. So there are numerous benefits this kind of technology can provide which we'll allude to as we'll discuss later. Cost benefits, I think for the most part, over and above the benefits for our patients.

There's a last aspect, which I think is very important. We all know that outcomes are really dependent on volume. So large volume centres and surgeons do better. Now for me, this kind of technology really can benefit the lower volume surgeon. Bring down their, their, their complication rates and all the benefits associated with that in the long run.

Yeah. So ultimately a no brainer. That's, that's really interesting Thane I think, I think you've again, highlighted some of the points we've discussed already in terms of, you know, reducing those outliers in terms of your, your, you know, what you're seeing in, in your postoperative x-rays. And certainly my colleagues would say the same things in terms of the reproducibility you get with it is

is quite marked. And I think also, like you say, trying to reduce those complications and something that's been discussed before is actually that, you know, a hip replacement is a very successful operation. The complications are thankfully rare, but they are when they do occur, we know they are [00:08:00] big and actually are very, very impactful to the patient and the healthcare system.

And I think that's something that you're, you're really highlighting nicely there. And so, Dominic, that maybe brings me to you in terms of, you know. Anything you would first of all add, add to what, what we've heard already there and, and you're, where are we at sort of with the data for this at the moment?

'cause it's relatively, relatively new in the grand scheme of things. Sure. So, I mean, I think everyone's really covered well, this sort of idea of imaging, digital planning, custom implants, and then surgical technologies, et cetera. And we're aiming for this safer, faster recovery and natural fit function.

But I think from the journal point of view, there've been some interesting articles really on prediction from the spinopelvic point of view. Last year there was one from Tang et al. Mm-hmm. And it was a really a preliminary validation study, but looking at evaluating patient-specific algorithms from the sagittal pelvic tilt idea.

They came up with a, a nice classification that had good reliability and validity in [00:09:00] predicting what the pelvic tilt would be before and after a total hip arthoplasty. And I think. Th that sort of research is where we're gonna make the, the big leap forward. It means that we are able to preoperatively assess from the sagittal anatomy, like what the functional orientation is, and a lot of these algorithmic programmes will then help us understand where we want to put it.

Those sort of studies, some of them are retrospective obviously by nature. So I think as things get more perspective and the data from a lot of the robotic work that we're doing can be used, then that will be very useful. Yeah, and I think there's a really nice summary were done last year by Fontalis et al, which was really about the that again about the spinopelvic movements, which I think really that mechanics is where we really need to understand and how we're gonna have to

future proof of the, the hip replacements. So understanding them, what imaging, what postoperative changes we're going to induce. Things like whether we do the hip or the spine first. And some of these, some patients gonna get complex spinal surgery. Do we do that first before [00:10:00] doing the hip? Because that's obviously gonna change the whole mechanics.

I think algorithms that will help with that will be very useful. As you say, there's implant-specific considerations, head sizes, dual mobility, use of strategic use of constraint, but it's really the enhanced technology and how we interpret that spinopelvic, and I think that's where the role of AI will certainly come in.

And we've seen that in a lot of papers being submitted using that big data. And when we know what we want to get from it, we, we can use AI, but we have to realise that rubbish in rubbish out. So AI will only be as good as what information we give it. We'll need to have solid validation externally of these algorithms.

But, but I, I think to conclude there's, there's really is an increasing understanding of the spinopelvic mechanics and that's, that's where I see a lot of the future research going. That's, yeah, that's great Dominic and a really nice overview, like you say, of some of the studies that have been in the journal and actually sort of again, highlighting one of the our previous, previous episodes in the, in the [00:11:00] series about the importance of the spinopelvic area and actually how we, this may, may really may be a game changer there.

And that's sort of, I think that leads us quite nicely. I'll come back to yourself, Ed, you know, you know, talking about data and sort of big data is obviously the role of the registry data. And, and how do you feel this can be used to influence implant choice and determine outcome as the data evolves in this area?

I think it's hugely important. I mean, you said earlier one, one of our problems in hip replacement, which is a nice problem to have, is that we are so successful and therefore designing conventional studies, RCT or prospective studies to look at, look at complications or outcomes is incredibly difficult because we are so good with hip replacements.

Mm-hmm. And, and as you said, the complications are rare. So how, how do you solve that? Well, you look at big data and, and you look at large numbers, and that's exactly what the registry does for us. I think. There's always, there's always some [00:12:00] caution with that, and I, and I think certainly over the last few years we've realised that actually when we're looking at joint registries, revision for us now is not the only critical endpoint.

We, we need to accept that periprosthetic fractures are a major operation for patients and we need to be collecting them. And obviously the registry's starting to do that, but in the legacy data that is regularly quoted and has led to, to essentially telling us what to do the foundations of that have really been shaken.

So. Like everything, it, it's great as long as you are looking at the right things. And, and particularly over what, since we've had highly crosslinked polyethylene really, which was the big game changer, the indications for revision have changed. Mm-hmm. And now if you choose a good bearing periprosthetic fracture it is, is, is probably the most common reason why you are gonna need a major reoperation.[00:13:00] 

And if you're just looking at revision, you are excluding all those poor patients who had an ORIF. And you may be making the wrong assumptions. And, and I think that's particularly worrying when it comes to the sort of legacy information that actually is still used here in the UK to say that if you draw a line at 70 and you say if you're older than 70, you should have a cemented stem.

And, and I think we, we are really showing that that probably wasn't true and what that was based on. Actually, we've missed a whole group of patients that need an an ORIF. And also implants have changed to address that. And if you choose a good uncemented stem, then, then actually you could be getting lower overall reoperation rates than if you did use cement.

So I think caution. But I think they're hugely valuable and I'm really pleased that, that we're starting to tease out some of those concerns to make it more robust so that we can trust it more. That's a really nice overview, like you say, of the registry data and what it can and can't and can't do.

And I think we'll [00:14:00] come onto that in a, in a bit more detail actually, when I speak to Dominic. But maybe before I do that, I come to yourself, George, and then yourself, Thane you know, from your own perspectives and you know, your respective nations really, you know, what's your feeling about the use of, you know, maybe not registry data, but big data in this way.

Oh, you know, we have the AJRR, which is quite huge. And there's imperfections in the data collection as far as even surgical approach isn't often entered. So I'm a little dubious about putting too much weight on the conclusion unless there's a very strong signal from a registry, especially early in the learning curve, for example, as far as this preoperative, more sophisticated impingement modeling.

I don't think we're capturing that right now as to what methodology the surgeon used to template or plan the hip that he or she implanted. We don't know that. It would be fascinating to know that. I don't think we're capturing how many levels of spine surgery or whether it was a stiff pelvis stuck in 50 degrees of extension with a 2 cm leg-length discrepancy.

So the [00:15:00] complexity of the preoperative hip, I do not believe, correct me if I'm wrong, is captured right now in any registry. It's simply the methodology, the approach, and the outcomes and the diagnosis, age. That's about it. So I think we're gonna need to get much more granular 'cause as you said, hip hip replacement's so successful.

The number of patients needed to show any meaningful difference is massive. But I do think if we get more granular and define a super high risk patient for instability or component malposition, I'll, I think we'll see a signal earlier with some of these new technologies. That's really interesting George, and I think you make some really good points, like you say, and I think we'll talk, we've since in this at the Journal is you, you know, the registry data is very useful, but it has its limitations and, and you can only

tease certain questions out of it. You know, you, if you push it too far, you'll, you, you'll, you'll get, maybe get a signal that's not real or no signal at all, like you say. And I think that's, that's a really interesting point. But actually, as you know, as not only does the technologies in hip replacement, all technology evolves, is our ability to capture that more granular data, I think is definitely there.

Thane what [00:16:00] we, what your own thoughts on that, you know, based where you are. Well, we certainly enjoy the British Joint Registry. It's used a reference regularly and as Ed said, extremely important. And I just want to second what both he and George said in that, there, there are some parameters in the registry which are perhaps necessary.

I'll give my thoughts on that process. So in South Africa we have actually quite a, a young patient group and a high percentage of our, of my joint replacements are fairly young, and these are cases which I think need to be looked at even in even more detail, given that we want extra longevity out of our joint replacements for this cohort. Now

the other thing about looking specifically at sort of generic patient parameters and then looking at design parameters. The problem we have, of course is that it's both the strength and the downfall of the registry is that it gives an overview for all sorts of surgeons. However, I would like to see if we could perhaps divide out those surgeons who perhaps have a more a more,

a bigger love [00:17:00] for the, for the business of doing hip replacements, if you wanna put it that way. And it might be reflected by some, a simple tick box as to whether or not robotic or computer-assisted surgery has been used in a case or not. And have that reflect on the registries so that one can, can tease out whether or not these systems that we are using actually have benefit in the long run

with regards the big data that we can get out of a registry. Mm-hmm. And then I wanna second what George said. As far as I'm aware, in in, in the orthopaedic literature, we still do not have a simple classification system for what is a simple primary versus a difficult primary. And it's in my country

it speaks a lot because we have pay for service pro processes with our medical aid funders, but they charge the, they give us the same amount of money, whether it's a complex primary, post fracture, severe DDH, whatever the case may be, versus a simple osteoarthritic hip joint. I think this is actually quite much, this is sort of needed and, and if [00:18:00] anybody's interested, I'd love to collaborate with this.

We worked out, we, we are sort of working on a simple system, much like anaesthetic ASA grade, but something similar for hips where you can d differentiate between what's a difficult primary and what's not, and then, interpret your results accordingly. That sort of thing is needed, I think for bigger registries.

No, I, I think I totally agree with that. It's, it really interesting you say about, you know, knowing about, you know, robotic versus not non-robotic or, or however you want to phrase it. And I think actually we do need that information, don't we? Because we need these answers relatively, relatively fast. Well, as soon as we can, because actually we need to know if these are actually, these in interventions or innovations should we say are actually having a difference.

And that maybe, we'll, and that's what will link us probably to our next section on, on, on the health economics of it. But before we do Dominic, it's interesting listening to all three of our guests. You highlight a lot of the issues that, you know, I certainly, and I know you'd hear at the editorial board when we discuss registry data and the pros and cons of it.

How would you sort of sum that all up? [00:19:00] Yeah, no, absolutely. I mean, I think there've been lots of good examples of the pros and cons there, but I mean, things like the population level versus individual level. These are large populations and not patient-specific variables being included, like the bone morphologies we've just talked about, the shape of the femur, previous osteotomies, et cetera.

So something that performs well on average may not be the best choice for that individual. Selection bias. Some implants are used in the younger healthier implants. The Journal published a few years ago that ceramic-ceramic has lower infection rates, but they go into younger fitter patients. So there's always a possibility of association rather than causality.

So. We have to be in mind that patient selection may be the issue rather than implant superiority. And there's, as we've discussed heterogeneous today in the surgical techniques and various surgeons using various types and high volume, low volume, you may be reflecting learning curves rather than implant designs. Incomplete data.

If we don't hit a high 90% entry. How [00:20:00] valid is that data? So, you know, it also won't re record activity level, often function. We've had difficulty getting our PROMs into our NGR data, so we, we just really are looking at, tend to look at revision-free survival, which is a very crude outcome. Really, we don't know about pain relief.

Gate restoration, return to sports and work, et cetera. There's also a lag in reporting. These registries take a while, it may well be an argument more for implant retrieval and analysis because otherwise we may not pick up that we're putting in a bad implant for many years and several hundred thousand can go in.

Mm-hmm. And again, I think there is a danger of taking registry data from one country and translating it to another. There's lots of things that we, you know, some are cementers, some cementless, different antibiotic profiles. So I don't think you can take the Swedish or Australian registry and necessarily apply all that to the UK population base.

But in summary, it's really valuable benchmark. It guides where you should be doing the research and I think it's it is [00:21:00] useful from that point of view. Yeah, no, absolutely. And really nice summary that I've actually overview of our, the registry data, certainly here in. Here in the UK. I, I, I totally agree, but I think, like you say, those, those finer things, you know, you're talking about PROMs and actually you, you know, Thane, was talking about he has younger patient population with these, and as you, as you all do now, how are they doing?

What are their main, key outcomes? You, you high highlight that very nicely. So, yeah. So I think that sort of brings us on nicely to my sort of final question, which I'm, I would appreciate comments from you all because you know. Ultimately the outcomes for the patient are obviously very, very important.

But in a lot of the systems we work in, certainly ours, money is tight. And so, you know the health economics of all of our innovations and interventions is very much scrutinised. And so of the innovations, you know, the innovation we've discussed here today and throughout this series. You know, what are your individual thoughts on our ability to show that they can drive cost saving savings in the healthcare systems?

I think improving outcomes I think probably, might, [00:22:00] might be a little bit easier, but maybe not. But in terms of what are your thoughts on how, how we're gonna do that? And if, and if you think it is gonna be possible. Ed, maybe I'll start with yourself. I think the first thing to say it, very difficult going back to what we said earlier because, because hip replacements are so successful.

So, so we're chasing after we're chasing after a very small amount. However, as we know in arthroplasty, if you get an infected arthroplasty, that costs a fortune. You know, if you need a revision, if you've got you know, you, if you've got multiple instabilities and you've needed multiple revisions for instability, that's hugely expensive.

Not to mention the effect on the individual. So I think these things are difficult. I do have, I mean, when it comes to implants, I think that's probably slightly easier to look at cost of implants because of the revision rate and periprosthetic fracture. I've got an anxiety with technology though is, is how quickly make our mind up about technology and that we don't stifle innovation.

Mm-hmm. The, the way the world is moving, we're, we're moving [00:23:00] towards technology and I, I think one of the big things about technology is reproducibility. Mm. And I suppose I've got a concern that we are gonna struggle to show the economic benefits of technology in the early phases because of what we've mentioned earlier that we're, we're, we're, we're working out those that interplay between where we want to go and the execution.

I, I, I suppose that I'll throw in that I think possibly the revision area with technology may be, may be vastly more cost effective than the primaries. But I, I think we need to be a bit more savvy, which is we need to, as I think George says, we, we need to work out who's the ones that are at risk and maybe invest more money in those at risk patients.

And, and that would be hugely beneficial to the whole health economic plan. Mm-hmm. But let's, I think, let's be cautious as we're developing technologies and learning that we don't, we don't throw things out too early and then regret that in [00:24:00] years to come. I think that's a really good point, Ed, and like you say, it's, it's interesting your point as well about the revision surgery and whether that is actually an area where you can show benefit and then it will just take, develop with time.

George, what are your thoughts, and particularly from your own practice in and, and in the States? Yeah, obviously minimising complications, your biggest bang for the buck. But that aside, because that'll take a long time to prove that. Right. But short term there is a very, easy to prove benefit of this technology is you're faster in the operating room.

Mm-hmm. You can get more cases done per day, get more patients taken care of, because you know, you have a 56 cup and a size five high offset stem with a 36 0 ball, you know, your neck cut, you know that's impingement free. You don't have to trial five or six times, so you are more efficient in the OR, and more importantly, you have to bring less cases to open between cases.

You may only open two or three pans instead of six or seven. You don't need all the trials, you don't need all the implants. So that saves a lot of time in a surgical suite and also saves a lot of autoclaving costs in the US. We still autoclave and wrap all [00:25:00] our trays. I know it's a little different in the UK, but all of that time and personnel costs associated with turning instruments over is a significant cost that's very measurable right now.

And the other one is fluoroscopy time. You know, if you, I'm a DA surgeon, I, I use probably 30%, maybe 20% as much fluoro as I used to. That's quicker, that's better for the patient. It's cheaper. So there's definitely a short-term benefit that's easily measurable. Mm-hmm. The long-term benefit will probably take a decade to prove, given how successful total hip arthroplasty is.

That's great point. Like you say, I think you talk about, you know, in terms of efficiency, I think that's a big problem in lots of places and actually trying to improve that, like you say. And actually if you can get even just one more case in, in that day, that has huge implications, doesn't it? Over, over time.

And also also, like you say, in terms of sustainability, you're not opening multiple impacts and everything like that. You actually, and we've talked about that in our previous episodes, about how it can be such a, a, a tangible benefit. And that's a really interesting point about how we will see that quicker.

Thane what are your thoughts on that? Yeah, I've got a few things to, to, [00:26:00] to highlight, I think. So, so robotic assist assisted surgery is, is expensive from a capital outlay for a con for continued maintenance. And then there's the, there's, then there's the usables. And, and this is what many systems baulk at.

You know, if you think about the UK and, and NHS buying in a robot, you know, they just don't want to put that kind of money down without definite evidence. So it's intrigues me that some papers actually looked at the difference, be looked specifically at computer-assisted models, which will give us the precision, arguably, that we get out of a robotic system.

Di a, a huge, bulky robotic system, but bang for buck in the sense that there's far less cost outlay as far as that case is, those cases are concerned. With as much benefit. And then the one which, which everyone's forgetting of course, is the preoperative planning, which we all like and talk about all the time in terms of doing the right planning before the time, which doesn't really cost that much.

It's essentially software. So, so big benefit is, is. To my mind, it's, it's sort of a no brainer. And there's some good papers from the States which have actually shown that, that [00:27:00] the cost per event with large volume centres is cheaper for the computer-assisted and in some cases the robotic-assisted procedures that are done.

But there's one aspect which everyone doesn't really look at maybe seriously, and that's litigation costs. So, you know, if you think about the simple aspect of leg-length discrepancy. It's a big, it's a big draw card for lawyers. And to get that simple parameter correct every time is just gonna take that kind of cost out of the economic system completely outta the equation.

So that's, that's, that's something that not many of us think about necessarily. It might also drive down our medico you know, our, our, our insurance costs. So there are other aspects to this which need to be kept in mind. That's really interesting Thane, actually, those latter points, like you said, people don't really consider that, but actually huge implications for healthcare system and society as a, as a whole in terms of costs.

Dominic, just f final thoughts on that. We can learn a bit from our knee colleagues. Looking through the literature there was a randomised trial on cost effectiveness of, of [00:28:00] surgical reconstruction for the ACL versus conservative management.

And that actually showed reconstruction as a management was effective. It was more expensive, but 18 months, the better function meant that the patient was less using up resources. So it was cost effective. And interestingly you mentioned about the revision scenario. There is articles showing the cost-effective dual mobility in revision and that because it reduces dislocation, that was a couple of years ago in The Bone & Joint Journal.

I of note it was actually recommended for the younger patients, which is counterintuitive, but the older patients don't live as long and therefore they maybe don't get the cost effective balance so. There's lots of interesting subgroup analysis you can do with that. But again, going back to our knee surgeons, just this year, the my colleagues in Glasgow published in the robotic-assisted medial compartment uni knee.

Now that actually took 10 years to show the cost effectiveness because they showed that they had no revisions at the 10 year results compared to an 87% survival at 10 years. So [00:29:00] I agree we are gonna have to wait a long time to say maybe show some of these cost effectiveness, but it doesn't mean that technology

isn't going to be useful. And even if they are to put money out front, if you're getting a longer survival of that implant, it will pay in the longer term. Yeah, no, agreed Dominic. And I think that's a really nice, nice point to finish on in terms of, actually we may have to invest a bit, but in the longer term, it, and actually, as George has highlighted, maybe in the shorter term, there's actually notable financial benefits that can be seen.

Well I'm afraid, that's all we have time for, but thank you to you all for, for taking the time to join us and great insights and discussion. Really bringing together a lot of the topics that we've covered in this series, it was really great to have you all with us. And to our listeners we hope you've enjoyed our special edition podcast today, and a big thank you to Smith and Nephew for sponsoring this series.

Feel free to be in touch with us about anything we've discussed here today. Thanks again for joining us and take care everyone.