Watch a Total Shoulder Arthroplasty with a Nonspherical Humeral Implant and an Inlay Glenoid with Dr. Anthony Miniaci and Dr. John Zvijac with Baptist Health Orthopedic Care in south Florida as they performed and moderated the live surgery at the OSET Orthopaedic Summit 2022 in Boston, MA in September 2022.
No. So today uh my job as moderator is to talk to you a little bit about something that you haven't heard too much of which I think might be a paradigm shift in treating these an atomic total shoulder arthropod city problems that you see and getting rhythm where we're gonna treat it with a non spherical human head and an inlay glen oid. And the reason for this combo is that the human head shape reduces the stresses on the glen oid side. It has been applied and there are outcome studies showing that even in these severe Glenroy deformities it works and it reduces the stresses on the glenn oid side, especially with an internet component by at least 10 times. So I think we'll go uh without further ado to dr john Jack who's the sacrificial surgeon today. He's in Miami, my new and current partner and my old partner uh from the Cleveland clinic dr South Random or who has developed significant interest and now has converted to his uh total shoulder arthropod city practice with this? So john, I don't know if you can hear me but you're on screen. Hey Tony. Hey, how you doing man? Doing great. You guys came in at the perfect time. Welcome to Miami. Technically coral Gables florida. Can we see the palm trees? Oh it's beautiful out here today. It's about 100 and two and 97% humidity perfect day, awesome. So we're a little late. So maybe you can just fill us in in terms of, this is one of the ones we've been doing today. Uh This where you guys actually came in at a perfect time. So this is this is a 65 year old gentleman. Uh Can you guys see his X ray up there? He's got severe D. J. D. And a glint of humor both sides. A lot of lot of huge asked if it's already chopped that one off for you. I know Tony you don't like to take those but I usually do that helps me pick my sides better. Even though I've done a little preoperative planning we got rid of the loose pieces and such. So we're actually right at the top point of uh putting the uh use the cloth first. What type of annoyed is it? We didn't see you there. So it's a it's a probably a B. One B. One it's got a slope but it doesn't have a secondary group is a little bit of post relaxation. We'll try to put that X ray up for you, tell us what you're doing then. So I'm gonna use today I'm gonna use the oath or oval motion as opposed to the straight ovo. Um Kind of a tight guy as you can imagine how to do a little bit of release to get his head out. But it it came out came out relatively easy. So I was just gonna show I don't usually use this thing. Some people do, this is a claw. I don't know if you guys can see it. Yeah yeah Yeah. Yeah. And it goes in like this and people use this to size and to use uh for putting their pin uh I'm old school. So I what I do is and for a couple of reasons I use the remembers uh and I size them up. This one happens to be a 50 so that means it'll be a 50 50 forehead. I that's what I had sized. Uh I was just playing with these while I was waiting for you guys and it seems like a 50 54 is the right size as you as you well know it's uh you no longer a tapi than medial collateral. So that's what we're dealing with here. So john this is sal when you're in between sizes when you're doing that. Um Do you lean towards going a little bit smaller And and and and what what are you really looking at? The superior, inferior or medial lateral when you're when you're you know, getting your measurement. So the main thing is I uh I always lean smaller. I always I've learned that lesson uh early on that you go one size down as opposed to one size up. And one of the beauties of this is, you know, as we all know, inclination version angle are all different in different people. And even in the same show and the same person in different shoulders. So I put many a different size in one size than the other. Uh so this this is basically makes it allowable to use their head as the guide to reconstitute the new human head. This one's got a little bit of hibernation. We'll talk in a minute. We're gonna leave it a little bit proud. But allows me to look, I can feel the neck, I can see the size and I can look at my version, my neck version and there's a little bit of a nasty fight down and I'm trying to take off here too. So go ahead. Just put that pin in. I'm gonna put the pin in and keep the thing moving here. Yeah, that's uh I actually like to use that claw guide because I could take that superior part of the code and kind of kind of mallet it in right to that a couple of millimeters away from the supra. And that's a nice uh it's a nice way to do that also. But this is uh I haven't seen it done this way. So that's interesting. So the beauty of this is it allows me to look at, you know, if I'm not happy with the version, the inclination, I can change it and I can see through it. That's why I like it. Um so I like the angle. I like the inclination. I like the version. I think we're in great shape. And so now we're gonna put the screw in next. Let's give this a little bit of a push this way. So this is a central core which is a little bit proud. So you saw some Yeah, I'm gonna leave that up. Just a hair. These guys a little you can see on his X rays and you don't need an extra or staring right at it. I mean it's definitely flat. So I usually don't leave it proud. I'd rather air on the side of under stuffing over stuffing this joint so that if you do this, don't leave it four or five proud. Just agreed. Yeah, I usually leave it up just when there is flat. I usually put it up here. Alright, so let me have a lap here. Let's just reposition these retractors for we don't have any issues. Here we go. Here we go. Alright, go for it. First thing we're gonna do is remove off the Osteo fights. And so this is our 50 reamer, he mentioned he's already got his height version and various valve is angular offset by the face of the human head, those thin curved and this has gotta stop on it. So, a little more to go. Obviously these 65 year old active but sclerotic shoulders, you know, they got hard as bone. You can't say I'm sorry, I forgot you're in boston it's ours. Right. Yeah, yeah, yeah, good. All right, so we're done. All right. Let me have the curved and so we just get rid of. These are the flights here, somebody grab a ranger. So while you're doing that at this at this point, are you um in terms of an atomic shoulder replacements, what is the kind of are you doing this for everybody or is there a certain patient that you will not do this type of replacement for? So um so I've been using this for about 11 years and my indications have definitely gone too. This is my primary shoulder for most people. Um Obviously if there's issues that you know cuff issues that require reverse or you know, significant people, I'm sure Tony probably has more to tell you about the glen noise. But if there be too as I have no problems but I think there's a big bony defect then. But I gotta tell you I'm on uh I'm pushing 500 of these now. And yeah there's a cyst right there. He's got a little cyst on his X ray too. But it's back there. Um So I tend I tend to use this, this is my went from athletes to young people to Even 70, 70 and 80 year old people that may have the Rangers. And are you fixing rotator cuffs with these or is a is a is a rotator cuff tear uh contra indication for you. So we've put a few uh we've put a few uh heads on top. Almost like a C. T. A. Type you're talking about for a massive massive tear. Yeah. Are you saying that small tear? That's reparable. Oh for sure. Yeah. No that's that's for sure. I've done that many times. Yeah. Yeah. Yeah I've done that many times. I think it's an easier way to do it in all honesty. Then if you're using you know the stem stem or even the short stemmed prosthesis, you know you just don't take so much bone. I do a lot of straight ovo. So today we're gonna do the oval motion. So this is taking a little bit more bone. But let me just have and this this doesn't compromise the fixation at all because you'll see it still leaves a big rim on the periphery. So that and actually in the evolution of the university Rogers had been studies showing that this amount of peripheral fixation uh when you compare it to other stimulus implants as well as stem and short stemmed implants actually is very similar to stemmed and short stemmed implants. So that that's periphery of bone that you're going to see that he leaves behind here actually gives you significant fixation which makes it comparable to a stem type implant. This was done to help people with exposure of the sometimes these tight shoulders. So john uh you've got some you're gonna take that the central portion out. You take it out. Yeah. Usually when you're screwed up sometimes you know there's this little extra piece of bone here. I don't know if you can see it right here with this technique, the oval motion technique, but often it just comes out right with the screw. If not, I just take an acetone and finish it. Let's just take this out, take the pin out. So what if this bone is not as hard as you anticipate it's going to be um like typically those hard time getting it through. But what have you ever have you have you used that extra bone to kind of fill fill in the that central hole to give your screw some more purchase or anything? Yeah, I've done that. Um I've used tactile set at times. I've used cement depending on the size of the hole. I was a little concerned looking at this guy because he did have some cysts. But I when I did my measurements beforehand, I was pretty sure I was gonna miss it, which I did. But alright, let's gonna go to the Glenwood. So we're gonna take this out now. You've done all your soft tissue releases, I assume. Yeah. That's how I when I was waiting for you guys, that's what I was doing. Yeah. Uh let me have the posterior retractor. So do you do a biceps with these patients? Uh My fellows do. And then you know, every I think we're the only people down here Tony that we you know, john and I still save the biceps, but I think we're we're we're a lone breed. I mean people, it was normal, but then then I cannot be taught me a lesson because I had a patient who had a perfect result except anterior shoulder pain. So I sent him to a naughty for a second opinion. And then I saw me in the hole. He goes, why don't you just cut the freaking biceps every time? And I go, why? It was normal? He goes, because then they wouldn't have to come to me for a second opinion. Yeah. So I've had to go back on a couple of scope. Let me have uh together, I've had to go back on a couple of them and cut the biceps. I have done that, but I guess I I get it. You know, I, you know, I still I'm still a sports medicine doctor, so I'm not I'm not I'm not officially a shoulder doctor like you guys. So we have a baby, it looks like you're in a shoulder. So yeah, I'm not either. When I decided to do a uh sports fellowship dr Kennedy told me that I was not a shoulder surgeon either. So yeah. So do you do a complete capsule ectomy? Do you ever save the labrum? You know, what are your indications for? Uh you know, there are times that I used to not do any of that Tony, but now I do all of that. I I often save the labrum. This one, this guy was pretty tight. So I'm gonna free this thing up, You know, his motion when he was asleep wasn't, wasn't great. I don't know if you guys, can you see the glen oid in there? Can you guys get in there and see that the perfect. Let me just get to the point with. Yeah, so he's got a very exactly, very sclerotic annoyed. He's got a little lost a fight up here. You know those, sometimes I leave, but if you have to at least pay attention to when you're putting your glen oid in and so here's the bottom of the glen oid right here back. I think we got a pretty decent look at this. I'm gonna probably put this right about there. Um I think this is a good example of why this, why this system is, is very nice because a lot of the patients that you see are these really muscular, tight shoulders and having this um, you know, uh off center um you know, guide that you could use. It really makes it easier to, to, you know, you don't have to externally rotate and pull that criminal head down so much makes it makes this part of it the part that you worry about the most, you know part, you don't have to worry about as much the other little check. Sometimes I usually put like a small dara dara retractor down and just push down the head a little bit. I don't know if you guys can see this, but I'm kind of sizing this, I think this is most of the time I just put singles in. So I know you guys john did uh do you really care where the position of this is? You know, when, when I first designed this was meant to be in that inferior circle of the glen oid, but the data doesn't show that it makes any difference. So do you care where it goes other than sort of somewhere in the middle of the, you know, I maybe it's, I don't know if I see a lot of differences because I see a lot of them around, but I still wanna, if there's like a B to glenn and I still want to take care of that, you know, I still want to make sure you wanna make sure you have bone around there, you know, it's important. So what do you do in that case? Um If you do have a B. Two, um are you uh do you just wait for reaming or do you take it down? Do you take the ridge? If it's, if it's a true rim, I'll take it down, I'll take a little burned burned down. But most of the time I just rim over the top of it, so I don't always take it down. I, I used to do the same, but then I just let them do it. The key is that because there is a little bit of a shelf there, you have to make sure that the poster edge of that guide sits on the poster part of the Glen Oid. So that because you don't want any of the implant to be sitting proud. Sorry, we were chatting. It's like having a chat at dinnertime. So this is um you know the double lines for the for the Snowman and a single line for the single one, and I think a single one is gonna be very nice here. I guess you guys can talk well, I'm you know, when I'm reading this stuff, you guys can talk about. You know, one of the things we always talk about, it's entering to the head, right? I'm sure I was listening to some lectures while you guys were I was working and you guys were talking 15. Yeah, won't let me talk now. And and one of the things is that it, wait a second. You know, I always used to believe that it was the glen oid right, that it was in terms of centering of the head. But uh one of my partners who doesn't put the glen droids in and I used to tease him because he couldn't get to the glen oid. But the reality of it is is he puts these heads in and that the centers Yeah, so maybe there's something about the a spherical humorous side that I'm not bright enough to catch on to Ready. Perfect. So this also has a stop on it. But what he's doing is uh it's at an angle. It's hard to appreciate the angle but it's coming in at an angle so that dream eccentrically. But you end up with historical basis and you'll see that the implant has a spherical base. Yeah so there is a stop. I use it. But more importantly I usually use the four suction. The four the four rings in the back. And I usually start, I actually opened up a 15 and then go to a 20. That's what I usually do so that they make twice as much money. Yeah I feel bad for these guys. Let me just have a grand jury grasp or something. Something up here. So what was the biggest difference when you started using this type of implant versus a traditional um an atomic shoulder with an on way. Um did you see anything different with range of motion or what kind of drew you to using this? Uh more consistently so several things. One is the range of motion I found better too is they didn't get that. You know some sometimes people get that uh that human pain from knocking down the stem. I'm just sizing this up here that looks maybe another micro uh let me just have 20 back one more time. But most importantly but most importantly to two things, you know we've been we actually just got our ten-year data coming out and we have 17% of people have had the other shoulder done in the same year, which is unheard of, you know, statistics say about 6% of people do that. I just want to get another millimeter of this. I like that, that looks good. And so that was, you know, people as soon as they got the one they got the other pretty quick and they rehab much quicker. You know, obviously, I can't tell you the last time somebody ever stayed in the hospital for this all outpatient surgery center right now doing this alright, alright, I'm gonna take this pin out. Yeah, I think sometimes initially, you know, get the range of motion. I don't, I think that it's um you know, especially in those very active individuals they could get uh they could get that range of motion a little bit quicker I think um without lateral izing the joint um Really, you know, the the idea of over stuffing is, is almost taken away from at least from a joint medial ization lateralization standpoint, I'm sorry. And um I also think that because we're doing these in younger people that um you know if they do happen to um to have a rotator cuff that fails in the future, you get rid of that rocking horse phenomenon and they could, it's almost like having a um it's almost like having a a hemi which is what we used to do before reverses got really good. So I think that the other thing is um let me have the all the other thing that you mentioned is is we have the mallet. The the glen oil loss. You know we we've been obviously that's you know I've given a lot of talks on this and people are keen to mention this whole inlay which I think is a brilliant idea but you know obviously people have the reservations about all I'm doing is making the centering hole a little bit more uh john I think we have about 15 minutes here looks like on the clock starting to email the security. Okay escort me from the facility when he put it in so he can see you can see the trial. Alright so we got the we got the trial glenn Oid in. I don't know if you can see that or not? Okay in there a little bit so you can see you've got a dental freer. Give us the other angle again. The other glenn Oid angle there you go. Over one shoulder I guess. Yeah there you go. Yeah so you can see we're spot on in terms of the uh joint. This is the so we got a nice uh coverage. We've got definitely we're you know it's a load sharing device. The reason we had them put the string on here is because so many times we got in there I couldn't get it out. So he got the string so I can pop it back out. And then do you drill holes for your cement? Yeah. I usually just take somebody start mixing cement once you start mixing, reminded him you know what I usually do is use um the all I just punch holes with all give me the bag so while you're missing that I could Tony and I could ask you with this having with maintaining so much of that that bone on the human side and you do you fix your how you typically would in like an open subs cap repair or do you do you do anything different? I mean that's another thing I really like about is I could with with a double row repair like I would if I was doing an open subs cap repair, I don't take any bone I think you know, cut the tendon and that's exactly what I do. Oh the other point I wanted to make was you know, an older people, I don't know but you guys but we have a lot of people that fall down here and it's when they get these prosthetic fractures, they tend to be able to be to be treated non surgically. I mean you can, you know, they'll fracture but you can let the proximal humerus fracture heal and have a good result. We got a whole bunch of those that were getting ready to publish as opposed to you know having to wire them and all that other stuff you gotta do? So when when you were talking about the inlay glen oid you've had a lot of experience with this Tony has, how many times have you seen one of these pop out or dislodge or have any issues with that? Because initially when you're when I was starting to do these, one of my big concerns was how you know with a little amount of cement that we're actually getting in there, how do you know how this thing wouldn't pop out? Um assuming that you're not putting it proud because I know that's one of the risk factors for um have you seen any any issues with this or how many times does something like that happen? So I have not seen any loosening or displacements. I've seen I've seen a couple um I have seen a couple where uh I think to where the patient had some uh you know piak knees and he got loose and we popped them out. But we haven't we haven't seen loosening and in fact we're doing a study. In fact we're just sending it out right now where we've been we've been paying close attention yet. So we've been doing uh we've put in different quadrants and putting some cement mantle uh measurements. You know we've uh in there and we take serial X rays over time and ct scans. And so we haven't seen any cement changes over time. So there hasn't been any loosen see over time. What it is is when when it starts. Alright. Somebody gave me the pusher. Have you got the pusher push her and the dental frere? Simple free. And the push your hip? All right smell it little tips here. So I guess Tony while they're eating while they're busy getting this. And uh have you have you had to revise any of these two reverses? And if you have is that a difficult? Um Is that a difficult issue because that's always a concern with any an atomic shoulders. How they could be so converted. So you know they're series plus a few other independent series including uh Nicholson, a lot of rush and our series in each of those there's been no reported loosening. Uh In my own personal experience I've had three cases all for P acne that we had to revise. Uh We had to revise uh two of them, one of them actually after a scope and a washout. Uh he became asymptomatic and didn't want anything further done. The other 21 was loose and the other one Glenwood was solid and uh the one that was loose and we treated with antibiotics and spacers and all that kind of stuff, revision to reverse is fairly simple and that's what she has in place at this point. So there's a lot of different ways of doing the cement. I'm kind of anal about it. I have this little silicone finger so that I can touch the uh cement, which I start putting in when it's very liquid if you've seen it, you know, when we were going through this, trying to design something which would pressurize the cement. The engineers kinda got piste off and you're saying, what's the best thing that you've seen? I got my finger and they said, well what's the problem? I go, when I put my finger in there and this cement is too liquid, it sticks to your glove and they go, what if we gave you like a piece of silicone, which doesn't stick to it? So actually there's a little silicone finger. So the nurses are always saying, when do you want us to give you the finger? So that so I use a little finger and I pressurize this about five times. He's using the cement a little more solid and pressurizing it with the stick so you can do whatever you want. But I like to do it and gives you a nice cloud behind the implant when you're done. Yeah, yeah, yeah. So any, any questions from the audience john, I'm just gonna open it up, see if everybody's drinking heavily and yeah, I'm just, I don't hear any snoring just hanging out until the cement dries now, now we can tell jokes or whatever, you know, Normally I have a question, so we don't just discourage or take concentration off the session know everybody understands. Yeah, very. Yeah. So uh usually usually when you pop it out, some of the stuff that comes with it, but usually with its inner digit ated, I just try and create as much of it as I can out of there. Uh it usually defines itself if it's all loose and grimy, I just take all of that stuff out of there with it, but if it's solid, I don't go making holes. Um but I try and get as much of it as possible. There you go. There you go. Any questions, is there any questions rob? I think my question oh there you go. So let's talk about the a spherical head because you know, you've noticed that patients have less pain, they seem to get their flexibility back. Why do you think that is just because it's more an atomic or what is it about? It centers ahead. And so there's actually, you know, everybody says, oh I've never heard of this, but if you actually go through our literature, there's a lot of proof that our human heads are not a spherical. I think we all know when we dislocate the human head, it's not spherical. So that I think the anatomy hasn't enjoyed. And he has the best actually paper out there. Looking at this where he compared to spherical to a non spherical head and showed that there was better range of motion. There was better stability and the center of rotation actually moves like a normal human head. Whereas when we have a sphere, you know, just imagine this fear is like a soccer ball and the the non circle has like a football. So if you roll a soccer ball across the floor, that center rotation stays in the same spot in the football, it moves like this and that's what our shoulders do. That center rotation moves back and forth especially as we go through forward elevation extension and rotation. So you get that obligate translation that Madison talked about. And I think that when we have a spherical head in order for us to try and get range of motion, it has to almost force its way to move that center of rotation. I think that that's some of the differences of it. So I think that the mechanics is all much better and then that reduces the stresses on it. So, you know, this is a little bit of Heresy, but I think that you know, the study would wait to be done, but I think that even if you just did a hemi in this case without doing the Glenroy, I think that they would do a lot better. Um And with if matt wants to do is Raymond Run technique, I think this would be the better head to choose the spherical one. Yeah, I I agree with you Tony that's one of the things that we've talked about that a lot right, that you know, we've you know, Madison did those great studies and but maybe he had the wrong prosthesis. Great idea. Wrong wrong side of the and the right side but the wrong prosthesis. But definitely the motion gets dramatically. But we're almost we're almost ready to pop the head. We've got five minutes left. I'm just giving the five minutes. I don't want any flags from. I think it's also the total volume that you have in the joint is more is more similar to their native. I think it's less tension on the rotator cuff. And I think and decrease pain has to do with that Dr. Wyatt has a question it's a great video. So that to me looks like a huge expanse implant. Looking like it resurfaced only about 25% of my hands. I'd be putting the biggest extra large sizing and whether there's concern for many years. I've been I can't say bitching. We can't say ask but I have not been happy. No, but we can cut that out. So uh but when you look at the data, these guys have 10 year data and they've only used the circle one for every patient and when you look at my data where I've used so in the big weightlifters I put the biggest implant I can in there. But when you compare the data of the ones that I use the big one. There is no difference in the data which is very interesting. So now I can't argue with the data. So I just do the circle most of the time. But I still in some of those big guys where that glenn is huge. I still put the double one in just because it makes it look nicer on the pictures. Yeah, I agree. You know the bottom line is it seems that the usually the problems in the bottom right? But the biggest, I think the biggest thing is is the fact that it's no matter what it is, it's it's not gonna loosen. I mean that's really the key to me. Yeah, that's that's we know that now as well. So he's got the human head dislocated again, you're putting the central guide pin down so you can now 54 50 54 50. And we're gonna put this down. And the nice thing about this oval motion is Tony will tell you I do a lot more over and over emotions. But the nice thing about this is that it fits flat. You know, you got a great fit here. The mechanics of this. The fixation is actually fairly solid and most of it is on the periphery as opposed to in that screw post. So that uh that peripheral cortical uh surface there is really important in this operation Tony when you're looking at this, you talk a lot about the times like this stays more centered than Suboxone back. You sort of talk about whether or not you think that's coming from the humerus or the fact that you're not changing the joint line more? Yeah. So you know, I wish I knew the answer. I think you you asked that question because you know, I don't know the answer. So I think that there's all these things contribute to it. You know, the soft releases the shape of the head. But you know Madison and his Riemann runs they re center so that there's something about not doing something to the glen oid leaving it in its version. Because I think that most of the time what we do and I thought about this a lot that we get that actually review. It's a static picture. We don't see what's happening dynamically. These things may be sort of like rolling in and out and we just don't know it. Uh And then with an only problem is that's a that's a fixed device and it's semi constraint so that as you rotate, if you have any instability which won't happen with this. This one just slides back and forth where it's been used to doing that for a while. So I don't know the answer to that question, but there's no question that they re center and they stay there. He published that in Js es a few years ago. All right. Did we lose picture? No. Okay. You ready? You got a couple of minutes here to put that head on. So everybody we're mucking around here? Yeah with a minute 30. Um can you go into what you use for your fixation? What angle you have the R. Mat and you know do you do you do you fix it an external or do you fix it neutral? I fixed it usually at 30:30 or 60, 60. Yeah. Usually these people it's usually not an issue. I mean once they get the uh just put it right in there. Yeah that's what I mean. That's what I've seen when I could fix it. Like I would do an open subs cap and use those are the rotator cuffs. You don't have to worry about when they're you know when he's putting the screw post and you can see there's a little shoulder on the screwdriver at the top which tells you that the dist you need to put the post in because that's all measured to the heights of bone. So you don't want to over tighten this because as you over to tighten the screw post in too far you reduce the amount of engagement screw post which then could potentially disengage your implants. I just this is an F. Y. I. So he's got a screw post in there. Everything looks great. So I'm just putting the top hand to make sure to screw. I'm happy with the screw setting the trial and you mark the head. All right salutation little irrigation after this and then uh we'll grab the head and don't drop it please? We're doing good so far. Don't make it. Don't make it. Uh Oh, there you go, john looks great. Yeah, I'm very happy. Looks good. As you, as you all know, having done these before. They're sometimes can be a little bit harry. But uh, we've got got the uh, I got my top top staff here and I've got dr vargas in the building is our fellow here, top notch anesthesia. We got our top team and nurse Katrina and john, yep. So what I do is marked and I should have showed it to you, but you put me under pressure for time. But on the bottom of it, it's mark 54 I took a I take a marker and mark it with a line. I don't know if you can see it or not. So I know where it goes and I just rotate it. So just posted the biceps superior up and we got ourselves check it, make sure it's on there. It's a nice Morris fit. Take these out. We're gonna try real quick. So we're gonna, we're gonna do right now. So here we go. I don't know if you can see this if you can back away, but It's excellent motion here gets 90 of rotation. I think there's no sub scat. Yeah, that's true. But you got good, good rock. Very good. Good, good beat easy to dance. So I'm giving it an 85. There you go. Well, listen, these are so hard. Everybody in this audience who's ever done one knows it and you were the sacrificial guy today, but you have done a tremendous job, John, thank you very much. We appreciate it, enjoy the rest of your day. I wish I was up there. Have a great day. You guys have a great day.
