Dr. Mohammad Diab presents "Hip Asymmetry – When to Consider Spine Deformity vs. Limb Length Difference?" at the UCSF Pediatric Musculoskeletal and Sports Medicine Conference 2023 in Berkeley, CA.
So our next speaker is Doctor Mohammad Diab. Um Doctor Diab is a pediatric orthopedic surgeon. Um He did his residency training at University of Washington and pediatric Fellowship at Harvard. Uh He serves as a vice chair of pediatric orthopedics at U CS F. Uh He is world renowned in the field and specializes in pediatric hip and spine conditions and is one of the innovators in spine tethering. Welcome, Doctor Diab. Um do um Doctor Dolittle was lauding um some of the earlier speakers because they were um so intellectually dense. My goal is to be um intellectually light um or thin whatever the antonym is for dents. Um um one of the people who trained me years ago said read original papers and then write the point of the paper on the top of the first page and that's all you need. So my goal is to try to be simple. These topics are too big for 30 minutes. Um Also, I've sort of given up power points. I mean, like when I talk to the residents, I just don't come with Power Point, I just show up and I make them talk to me. Um and ask me questions. So if this is boring to you, just stop me and I'm happy just to have a conversation about these two topics. Um, so I have to say I don't have any disclosures. Um, scoliosis for the most part doesn't matter unless it gets bad. Ok. It's not cancer. You don't have to find two degrees of scoliosis. Ok. One cancer cell is theoretically bad but scoliosis most of the time just doesn't matter. So, uh try to defuse it um when you approach it and try to defuse it, when you talk to your patients, the problem is the, you know, image on the right there and that's what sensitizes us all. Um And that's from a book by a guy called Blount from the forties from Milwaukee. He actually started the scoliosis brace. He's known for a disease that has nothing to do with scoliosis, but he was the originator of the brace and that child um died from her scoliosis because obviously nothing works in that kind of a chest. Um But for the most just remember that most of the patients who come to see us for scoliosis never need anything. And you all could probably manage a lot of the patients and have and you, I mean, you're so smart. I mean, the primary care doctors have to know everything. Um uh and I think that you could probably do it with confidence and not worry about it. Um And then if it gets bad, send it to us. Um It's been around forever and I put the, the image on the left there to remind you that people have been trying to manipulate scoliosis from the beginning of time. Um And manipulative practices don't have decent evidence. I'm not opposed to them in the same way that I'm not opposed to chiropractic care. I think all these things have roles, especially since a lot of times we can't help a patient. So why not send them to a chiropractor for back pain? Um But the evidence isn't there. So if you do it, just do it with caution, um There are two parts of the conversation in my clinic when it comes to scoliosis. So again, in the spirit of trying to be simple, it's growth and magnitude and I'm talking to primary care doctors and you guys know more about growth than we do. But all of the action or most of the action um in scoliosis for our patients is in the six months just before puberty. Ok. You, the fastest growth is when you're first born, but we don't see them then for the most part. Um But it's the, oh I'm, you know, oh, he just started to grow many inches or oh, she looks like she might start to mature. Um That's when scoliosis um can get worse based on the principle that growth amplifies deformity. That's a general principle in the skeleton. So nose whatever it, whatever it is and scoliosis, no exception, it's very difficult um to figure out um growth and maturation if you guys all followed me on Twitter. Um You would see that I said I have their variability betrays uncertainty when there are many um different measures when there are many different treatments. When there are many different religions. When there are many different political parties, it just shows you that there is no one right answer. Um And the same thing comes um for growth and trying to figure out does the patient have a lot of growth remaining. Um I listed some of the things there that we use, starting with the grow and Pile Atlas that was developed here down the road at Stanford by two anatomists. Then there's the Oxford Scale and there's so many um the reality is it's a bit of a guess game. And if I, when I talk about limb discrepancy, it's the same thing. It's a bit of a guess game. Um But we do our best and I still use Tenner. Now I'm not a primary care doctor, so I don't examine my patients for Tanner. I give them a, I give them a chart and I see which one of these um are you. Um And you know, we also use the sign because it comes free when you get an x-ray of the spine, you often can see the top of the Iliac crest. The problem with the riser sign is all the growth acceleration. Therefore, the progression. Therefore, the risk of the Scolio is getting worse occurs before um the riser sign appears. So it's the sort of thing that it's like a test that is useful when it's present, but not useful when it's absent. So if the patient has a risk sign, so if she's begun or he has begun to ossify the iliac apophis. So the ilium is a bone, it has a rim of cartilage on it. We call that an hypothesis and it starts to ossify a certain amount of maturation. Um And there is a grading system. Once you start to see that rim of bone, then the patient is probably out of the high risk time. But before that, you just don't know. Um And I have a picture of my son and his friend um who's about two or three months older than him at some piano contest. And so you can see how, you know, some kids who are 10 are just completely different than other kids who is 10. Um So we just do our best. Um But we still don't always get it right. Um I want to pause and acknowledge the fact that um the appearance of scoliosis matters. I don't think it's vanity. It's as old as Western culture and probably other cultures. Um The top right there is the statue of Hippocrates um in front of U CS F on paralysis. But even the Hippocratic Corpus. There's a whole, you know, discourse on that and that's from, you know, Shakespeare and I, I try with the patients to, to show them that I appreciate the fact that they don't like their rib hump. They don't like their breast asymmetry. They want me to operate on them when it's not indicated. Not because they're worried about the future, but because they loathe their appearance and that's OK. Um Our group was the group that defined the MC ID um for scoliosis in adolescence and of all the domains that we, um that we evaluate when we see patients with scoliosis, the appearance domain is by far the most sensitive to treatment. I mean, it just dwarfs everything else because the patients come in very healthy. I mean, how much better can you make a 14 year old? Right? Except in appearance. Um And I think that's ok and I think it's something that you all can talk to them about. Um if, if anything, you can just at least acknowledge it so that they're not disappointed that we don't want to operate on them. Um because we do appreciate that they don't like the way they look the same thing for s patients who are hunch back, they just loath it. Um They put up, you know, I have patients who will insist on wearing a backpack all the time at school because they don't want people to see their, you know, you know, hunchback. Um, and the, you know, the, the opposite is, is also true when I fix them, they just love it even though I've just fused their spine, which is just so awful. Um, because that is the most sensitive domain. The, the one thing to note is, um, that we talk about spine curvature, but it is spine twist. So you guys understand that, that's why the ribs stick out and that's why if it's a thin teenager, one ilium sticks out, I can turn this way and give myself 50 degrees of scoliosis, but I can't give myself a rib hump. Um, because I can't do that simultaneous move of twist. And if I did it wouldn't work, I would just rotate. I wouldn't suddenly have, um, ribs protruding. And we see that on an x-ray too. You can, if you imagine that every vertebra is a face and the spinous process is a nose. Um, there's a nose and there are two eyes, but here and here I see one eye and I sort of see the nose but I see the other. So that's the representation of, um, the rotation. And that's a problem for us because when we correct patients for scoliosis, the thing that we have the hardest thing doing is derotating them. But that's the reason they sign up for it. Um, because they're teenagers, they're not looking that far ahead for the future, but they are disappointed sometimes when their ribs still stick out and we do our best and every now and then I have a patient whose ribs stick out so much that I'll actually cut their ribs as well, um, to try to flatten them. Ok. Come on, here we go. Um, these are the sort of, this is a simple classification of scoliosis. I'll, I'll talk, I mean, I'm trying to focus on idiopathic. No postural is. And you, people in the audience may have had this, you wake up in the morning and you suddenly pulled your back and you're like over to the side, that's sort of postural. Um We don't worry about that so much. Um And then there are different ways to classify it. Um You know, neuromuscular is the C P population syndrome makers, Osteen imperfecta neopharm, those kinds of things. And ID just means cause unknown, you know, IDS just means alone. It's sort of the origin of the word idiot, a person who seems to be sequester from the crowd on their own, maybe talking to themselves, that kind of thing. And then pathos is disease. Um This is the simple way to look at idiopathic. So cause unknown scoliosis. I think the best way is by age. Um and they're quite different, the three different categories. The most common is adolescent and that's the one that you'll likely see, but you might see them younger, very early in life. You can have a one year old who has a scoliosis but they, all the vertebra look like they're formed. So they're not congenital. Don't mistake that congenital means that the vertebra is abnormal itself. Whether or not it gives a deformity. The idiopathic scoliosis in the first three years of life roughly is infantile. It's a bit different than congenital, may seem like they were born with it, but the vertebrae are all rectangular. Um, that's its own weird thing and I'm not gonna talk about, it's so rare. Um, juvenile and adolescents are basically different doses of scoliosis. If it's before 10, we worry about those patients because that's just a lot of scoliosis to have really early in life and you've got a lot of growth remaining and you're likely to have surgery after 10. There's a lot of equipoise of whether or not you should have surgery and whether or not you should treat and all that. And that's what I'm gonna focus on. Um, please remember that it's 10 degrees to be called scoliosis. So, if you see a six degree curve, don't send it off, just watch it. Get an x-ray in six months. Don't worry about it. A lot of the patients have a little bit of scoliosis. It doesn't matter, even 10 degrees, doesn't matter once it gets to be in the twenties, then it matters. So, for those of you who might want to manage your patients, um, if you see a patient with under 10 degrees, ignore or bring him back for an X ray that's optional. If you see a patient with 15 degrees, don't worry about it. Just bring him back in six months for an x-ray. And if it doesn't get worse doesn't need anything, doesn't need to see, you know, it's, it's not that, you know, we don't want to see him. It's just that when they come to us then they just load up, they're on the web, we have to talk them down, they don't believe it. They're completely worried. Um And there's a cost to that um, for the patients. Um We talk about progression, we worry about, you know, we're always worried about, is this going to get worse or not in five degrees? Is the number we use, we wrote a paper years ago that sort of modified that to 10 degrees. So if you see like notes from someone like me and I say, oh, it's about 30 degrees. The patients want to know, is it 32 or 30 or 29? That doesn't matter. The measurement error is too great. So it's around 30 for me or high thirties or mid forties, that kind of thing. Um Remember that girl, girls and boys get s schools about the same rate. It's just that girls progress, that's why it seems like we're operating on girls so much more than boys. Um But the sort of the prevalence is about the same. Um And then overall in the, in the, in in, in the population is 1% which is why I ask you don't worry about it so much. There is no way that we're seeing 1% of, of, of America's kids in our clinic and we're certainly not operating or treating on 1% of the kids. Um, this is the physical exam. Um, I think it's familiar to you all. Um, I have on the bottom left there, somebody who has a shift so a little bit out of balance. Um I think that matters. Most idiopathic patients should be able to compensate for their deformity no matter how bad it is. Um But if the head is not balanced on the pelvis, that's an alert that that scoliosis is decompensating. OK? So if you could add that to your physical exam, most people are familiar with the rib hump and the scoliometer, which essentially is a spirit level, right? You can bring the your spirit level from home, ok? That you used to hang up, hang things on your wall and you could use that. It's the same just because it's called scoliometer and it costs a lot more. It's, it's the same. Um um But what we say is about seven degrees of um tilt, we call it the angle of trunk rotation. The tilt about seven degrees of tilt is equivalent to about 20 degrees of Scolio or an X ray. OK. So I get that question a lot. How much is too much rotation. Um And the top right there is the way we measure these, we take complementary angles, we draw lines along what's the, the, the edges of the vertebrae. And then we take 90 degree angles to that. And then we figure out what the angle is and that's Cobb's method. Um On the top left, I um put in some warning signs if I would ask um the audience, the scoliosis hurt. What would you say to that or? Yes. OK. So let's just, let's just dispel that because again, I think it's a, it's a cause for alarm. I was taught, um, that scoliosis doesn't hurt. And I was taught that by Howard King of the King classification for scoliosis. Um, and I just don't agree with that and we studied it and guess what it hurts. We did a large population study, um, and 70% of the patients in the, in the cohort complained of back pain. So if you, if the scoliosis hurts, stay calm, it's ok. Um The reason I'm standing is because my postural muscles are working. I'm not saying to my quads activate, they just do it automatically. So I don't buckle my knees. I'm also not saying to my paraspinous muscles activate. So I don't flop down in a heap. Ok? But if your spine is bending, you're fighting that every second of every day because your body can tell I'm not straight, don't care. Your body is trying to balance um, and that hurts, that's muscle fatigue and that hurts. So, um, pain is ok in scoliosis. But I try to give you three things that I would worry about. Um, on the top left there. So, um, examine your patients, I don't have to tell primary care doctors because you guys actually examine um, your patients. We just, we just look at the x-ray. Um, but examine your patients, if there's something weird about the exam, then maybe the pain is something. OK? So if you've got a neural deficit, but remember most scoliosis is going to be a central deficit, central, we're not talking disc disease where you might lose the patella reflex. It's myelopathy, it's unsteadiness, it's that it's the child whose head is off to the side, why they should be able to balance, but they don't that kind of thing. So remember it's central and the most common thing is a K A um malformation. So examine the patients and if there's something you don't like, OK, then the pain may be significant if the exam is pretty straightforward, don't worry about the pain. And then I know that the um previously we talked about night pain for us, I ask the patients to wake you up. I mean, leg aches are night pain, the child's playing sports all day and not complaining. And then when they get into bed, they start crying and then they call their mother and father and everyone's awake and everyone's exhausted and everyone's crying by the end of the whole thing. So that's not what we're talking about. We're talking about, I went to sleep and it pulled me out of my sleep. Ok. Um, and then the other that's, you know, similarly constant pain, you know, back pain come and go. I'm able to play my sports. I'm not, you know, but then when I think about it, it hurts. I don't worry about that. Um But if it's just pain in just like, never, you know, never stopping pain, then I worry about that. Um And I think for the skeleton, those are good guides. If you, if you don't have that, I wouldn't worry about the pain. Um in scoliosis, the treatment is based on um growth and magnitude, the whole, the whole assessment is based on that. Um And this is a simple sort of algorithm under 10 degrees Mercer Rang. Um who's very wise um from Toronto called it Scoliosis. It's one of the reasons why um school screening has been abandoned in most States in the United States and now finally in California, um because too many patients are being referred with a slight asymmetry that doesn't really matter. OK. So it's got to be 10 degrees and between 10 and 30 we observe um because it's not a problem, right? And around 30 um we put the patients in a brace. OK. And up there, I have an old slide of a of a Boston brace. This also fits the um the sort of concept that variability betrays uncertainty. Everybody's got a brace to sell you. And if there are that many bras out there, then probably they all work about the same, more important than what type of brace is that you wear it. Ok. But there's one brace that has New England Journal of Medicine evidence behind it. And that's the Boston brace. So that's why I use the Boston brace. Um, but there are many, including in our area, there is the W C R. I don't know if you're familiar with that W is woods and he has, you know, he's come up to our place, you know, you know, to talk to me and, um, it's called the Aligning Clinic and it's very complex and they do this very, very nice analysis of the patient. Um And then they fashion the brace. Um, and it has its own sort of rationale, but it doesn't have decent evidence behind it more than any other brace, but the Boston brace does. So I use the Boston brace. It's, it's, it's the most cumbersome brace, so it's not user friendly. Um, so I would, I would, um, make my patients happier if I would use a thinner brace. In fact, I'd make my patients happy if I wouldn't use a brace at all. Um And that's what sort of, and there was a brace from Montreal that was just straps that go on to 60 minutes and then became sort of the, the rage for a while. So I think if you put them in a brace, that's good. Um, try to keep it, try to keep the brace on for a long time in a day. There's no right number. There's no right number. What I tell the patients is you don't have to wear it at school because it's a balance between many hours in the day and compliance. So, if I can. So I just say when you go to school you can keep it off the minute you get home, you put it on and you sleep with it. Ok? And then when you get in the car in the morning to go to school you can take it off and if I get 16 hours, 18 hours out of that, that's great. Um, after about 50 degrees we operate on it. Do you guys know why we operate at 50? Any thoughts? Yeah. So, no, it's not because of disease of any kind of cardio pulmonary? Anything? Any other thoughts on why? Pardon me? Yeah. Yeah. So it's, I think it's an important thing to, I try to articulate that to the patients and to their parents because I'm having a conversation about a big operation and one of the risks is paralysis. I mean, talk about, I can't make them any better. I can make them so much worse. Right. And I still take that. Seriously. I'm more than 20 years in and every one of every one of my patients, I mean, I look at them and I feel sad. Ok. Um, I'm just not, I'm just not tough enough just to bang out scoliosis cases. All right. Um, and I really feel like I need to explain to a teenage girl why she's gonna go through this nightmare when she's just minding her own business. So she has a little bit of back pain, big deal. And ok, so she has a little bit of chest asymmetry, you know what you can. That's ok. Right. Um, but it's because we have long term studies that show that around 50 degrees, the spine decompensates. It's, and the way I liken it to patients is, you know, the day, the old days of logging, um, and the tree starts to creak and then it creaks and it leans and it creaks and it leans and then finally timber 50 degrees is that moment for the spine? They don't have cardio pulmonary problems. Ok. It's just that they might develop them when it gets to be 100 degrees when they're their mother's age. So that's why we intervene at 50. And I think it's good to tell, explain that to them so they can help them with the decision. And I put to the bottom there, the bottom left, this sort of tether world you might hear about. It's a non fusion option. It's a good thing for patients who are really young because when we fuse patients a well, let me ask you if you have a spine fusion, how much you use? How much motion do you have at the part that's fused? Who who says zero know, be brave? Everybody should raise their hand. Zero. You don't even get one degree. You are not moving. And again, if you follow me on Twitter, my first, my first ever Tweet, my first ever tweet was vertebra. The only bone in the body that is named for its movement. It's sort of ironic, right? It's the only one that's named for its movement. And it's the one that we fuse all day, right? It makes no sense. All right. Um So that's one. So that's one reason to start coming up with a fusion less option, the bottom left this whole tethering world. And then the other is when you fuse the spine, does it grow? It does not. So you are restricted. Now, the flip side to that is you're still growing from your legs. So people think, oh my God, he's gonna end up being only four ft 10. No, that's not true. Only that part doesn't grow everything else grows. But still, if you're really young, you are gonna constrain the organs that are in whichever cavity you operate on. So just keep that in mind as well. So we're trying, we're not, we're not universally successful. There's, there's a pretty high fail rate. But when it does work, um, a fusion, this option at least maintains growth, in fact, harnesses growth because if you're like this and I tether you on this side and you grow on this side, you might actually spontaneously correct. All right. Which is fantastic when it happens, it's a home run. They grow out of their scoliosis. All right. Um But the other is they're also mobile. Um So which is a benefit? Ok. So I'm gonna talk about limb length, discrepancy. Um Just a little bit about the terminology. Um We're really talking about lower limb that discrepancy, upper limb length, discrepancy just doesn't matter. Ok? It just doesn't matter. Somebody, somebody said to me years ago, it's a tailor's problem. Very, very rarely do we have to act for upper limb length discrepancy. So lower limb length. Um And it's not leg, it's the whole limb, it's both tibia and femur. The fibula rarely is part of that equation. Um This is a big topic and I can go, I can go in many directions. So I'm just gonna try to focus it. Um When the kids are young, you all would worry about the difference in the length of the lower limbs because the hip might be dislocated. And that's what we're trying to show on the right there. You know, hemihypertrophy from Wilms Tumor and all that stuff is so rare. But hip, this hip, this location, I just got an email right now while I'm waiting to give it, give this talk from some, you know, fancy, you know, concierge patient who suddenly at two has a dislocated hip. And the, and the way it was figured out is because of this perception that one leg was longer than the other. Ok. Um So that's the key and I tried to, this is, this is an old slide kind of clunky, but you can see how if the, if the ball falls out of the socket, it falls into the butt and takes the entire thigh with it. So that's how to examine that. Please don't examine limb length discrepancy by taking a measuring tape and going from the A SI S to the medium. That's sort of faux accuracy. You think you're being so precise? But there's a lot of this that goes on in a squirming child, don't do that. Um If you're worried about the lower limbs in a baby, just flex their hips to 90 that pins their pelvis and then just check the knee lengths, knee heights. Ok, please don't do that because we get a lot of errors that way. And again, the patients come freaking out that they've got to let you know the child is so young and, and their legs are different size and stuff like that. All right. So I think that's the, that's the simplest way. And then the other thing is, please don't pay attention to cutaneous crease asymmetry. OK. It's only if there's a long standing problem and you would know that for other reasons, but cutaneous as symmetry and has been looked at and is normal. Um This is the way to measure limbs in a standing patient, just stand them and feel their iliac crest, pick a point on the ilium that you like and stick to it. OK? Um What we do in orthopedics is we try if we think there's a difference if we ask the patient to stand and we're like kind of eyeballing. So first of all, it's like scoliosis, go ahead and eyeball it because it doesn't matter if it's a few millimeters, it doesn't matter if it's a few degrees of scoliosis, you can eyeball it so you can, you know, people can make fun of orthopedics, there they go eyeballing things. But that's ok because it only, we only get interested when it gets to be a lot. So you kind of eyeball it. And if you think that one lower limb is longer than the other, we in orthopedics put a block under the shorter limb and we keep varying the blocks until we balance the pelvis. The reason we do that is we're trying to take away the instinctive desire to bend your knee to balance your pelvis. So your spine is comfortable, which is what people, what you know, humans will do. Um But if you are gonna do it without a block under the foot, that's fine. Just pay attention to the knees and make sure the knees are straight and then just eyeball it and if it's not too bad, don't worry about it. Don't, if you think there's a difference then get a Pelvis x-ray something as simple as a Pelvis x-ray, you can get that ok, locally and just measure it on the X ray in today's world. Practically, every x-ray um program has a measurement tool. OK? So if you wanted to, that's the way to do it or you can of course, send it to us. But at least please examine the standing patients in that way. OK. Um For us, when it comes to treatment, it's all about slowing down growth plates unless the difference is huge. And then we start doing exotic surgery which you don't need to know about. But the most, most of what we do is just slow down the longer lower limb so that the shorter lower limb can catch up. That's the majority of the treatment for limb discrepancy. OK? And this is the so called arithmetic method going saying that the distal femur gives 10 millimeters per annum and the proximal tibia gives. And that's where we do all the work, right? Um This is the algorithm the in the US, we say that an inch is a critical difference. So one centimeter we don't, we ignore. And I would ask this audience don't put shoe lifts into shoes just don't. Ok. It's just one more thing for a child to do in a day and it's messaging that there's some problem. Don't, it doesn't matter if it's a small, the most you can put in a, in a, in a regular shoe is about 3/8 of an inch. So, do the arithmetic. It's not much centimeter. Ok. A centimeter doesn't matter. So why complicate, you know, people's lives that are already complicated. All right. Um I would just leave the kids alone. Um but if it gets to be around an inch, then send them to us. Um because then we get interested, the problem is the one inch um recommendation is based on a 19 thirties paper by an author who said an inch is a is a lot. That's the evidence. Ok. It's problematic because we're operating on these kids, right? Um And the reason it's so, for example, I went and I had a shoe repaired. Ok. There is a, a cobbler in my neighborhood and I actually went to the guy and I said, can you fix this heel? And I took my shoe off and I gave it to the cobbler and immediately I was like, whoa, that feels uncomfortable. We're not talking about adults, ok, who have a hip replacement and they wake up and one leg is longer than the other and they sue the surgeon. The number one reason for a lawsuit against an arthroplasty surgeon, a hip replacement surgeon. Is if you get my legs the wrong length. All right. It's, I mean, it's, I mean, really you're gonna sue for that because adults can't stand it, but kids don't care. Ok. Um, and if, if you, any of you here had a lower discrepancy from youth that was even an inch, you probably wouldn't be caring about it right now. You know how I know because one of my colleagues has more than an inch difference in the lower limbs, ok? And he doesn't care, you know, how else I know my son has about an inch plus difference in his lower limbs and he was a college basketball player. So obviously he didn't care, right. Um So we don't really care until about an inch, but even that you should think about, you know, why we're doing it, we're doing it based on kind of flimsy evidence, but this is where we are at around an inch. We do what's called a which is just slow down the longer leg, starting at two inches, we're lengthening the bones. So that's the approach to lower the length for us. In today's America, people are asking for lengthening even at one inch, people are demanding. Um But it's just that lengthening bones is complication filled. Um So we try to dissuade patients from that. Um And then finally to link these two together, lower limb discrepancy does not give you scoliosis, just get that out of any, any anyone everyone's thinking unless you're guarding Buckingham Palace, ok? And you stand erect with your knees straight and you better be guarding it 24 hours a day, ok? Because you're just not on your two ft long enough. You can have a big difference in length of your legs and you can have a scoliosis because you're trying to bring your head back over your pelvis, ok? But you don't do it long enough to develop a contracture that will give you scoliosis, ok? In case that ever comes up. Ok, I'm gonna stop here. I don't, I don't know if I'm I am I am I at time in a good few minutes and I know there's a question and answer session. So what I'll do is I'm just gonna do a shameless advertising here. But the main thing I'm gonna do here is um I I know that some, some docs you know, connect with me more than others. I'm very open to physicians calling me. That's my cell phone. Don't give it to patients. It's the third version of my cell phone. Ok? So please don't give it to patients. Ok? Um but I welcome you um calling me. Ok, I love talking, you guys are saving us because you're on the front lines. So a phone call for you is, is welcome. If you've just got a question in clinic, just call me and go. What do I do with this? You need to see this ok. A lot of times we can get so much done just with a conversation. I know it's the age of text and everything. Um, but it's just a phone call is easy. And then the number below that the 353 number is, um, my assistant if you need to get to me directly because I might be in the O R and stuff. Um, and I always will call a physician back. Ok. And I'll call you the same day. I just have to finish whatever I'm doing ok. And it's helpful for me if you leave a cell because a lot of times I'm in the O R and I'm in the O R late, just the nature of my cases. But I'll call you if you leave a cell, I'll call you at the, um, by the end of the day. All right. Thanks.