Robotic trials in arthroplasty surgery

Listen to Andrew Duckworth, Andrew Metcalfe, Peter Wall, Edward T. Davis and Fares Haddad discuss the paper 'Robotic trials in arthroplasty surgery' published in the February 2024 issue of The Bone & Joint Journal.

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Transcript

[00:00:00] Welcome everyone to our BJJ podcast for the month of February. I am Andrew Duckworth and a warm welcome back to you all from your team here at The Bone & Joint Journal. As usual, we'd like to thank you all for your continued support for our series, as well as a big gratitude to our many authors and colleagues who take part in these podcasts that highlight just some of the great work published by our authors each month.

So today for our monthly podcast, I have the pleasure of being joined by four authors from an annotation published in this month's edition of the BJJ entitled 'Robotic trials in arthroplasty surgery: design of the RACER studies and implications for the future'. So firstly, I'm very pleased to be joined by Professor Andy Metcalfe, who is professor of orthopaedics and the consultant trauma orthopaedic surgeon in Warwick.

Thanks for taking the time to join us, Andrew. It's great to have you with us. Thank you very much. Delighted to be here. Thank you for inviting us. Pleasure. So secondly, we have the pleasure of also being joined by one of Andy's consultant colleagues in Warwick and Coventry, Mr. Pete Wall. Pete, thanks for taking the time to join us today.

Thank you. Good evening, everyone. Thirdly, we are also delighted to have joining us Professor Ed Davis. He's a consultant arthroplasty surgeon and clinical service lead for arthroplasty in Birmingham. Again, Ed, thank you for taking the time to join us today. It's a pleasure. Looking forward to it. And rounding off our [00:01:00] lineup, lastly, but certainly not least, we are delighted to welcome back our Editor-in-Chief here at the BJJ, Professor Fares Haddad.

Prof, great to have you with us. Thanks, Dux. Thanks for doing this, and it's great to be in such company. Absolutely. So guys, I thought I'd maybe start off with maybe an overview of the current state and use of robotic joint replacement surgery. I thought, Prof, I'd maybe start with yourself. I thought you'd maybe give us a brief overview of your own experience with robotic hip and knee replacement and how you feel the literature has maybe evolved over the past few years from your position as Editor-in-Chief.

Yeah, thanks. I think this is a fascinating area and this is a really timely annotation to get us up to date with a high quality study in this field. In reality, robotics, it's not a new topic. You know, I grew up as a trainee and young consultant with the first generation orthopaedic robots out there and the data from those wasn't that great for a number of reasons. We didn't know the target. We didn't respect the soft tissues. There are all sorts of variables with ROBODOC and Casper and so on that [00:02:00] still bedevil the literature now. I think it's relevant for the reader in this day and age to understand that because some of the systematic reviews and big studies out there actually are referencing old generation robots that are no longer in use and don't really bear relevance to what we have today.

I personally didn't use those, but I was involved in the initial Acrobot studies 20 or so years ago that Justin Cobb led on and then went on to use navigation for a long time. It was really only in the last decade when I think we really got a little bit tired of implant evolving studies and started really looking at how surgeons can do things better themselves with the existing implants, how to remove the outliers.

Also trying to define our targets in the hip and the knee better that I really got interested. And since then, we've seen a burgeoning interest in this, and I think the literature is moving very rapidly from innovation towards a reasonable evidence base. I think the one challenge we've got is that [00:03:00] we've got a whole load of different devices.

There's one that's been studied in the RACER study that I'm sure everybody's going to come back to, which, if you like, has led the way for the second generation. But there are a load of other devices out there, and they too will need their evidence base. And that in itself is going to be tricky and expensive.

We can't translate from one to the others. But for me, it's been a surprisingly exciting journey for the last few years. I think that for the first time, we've probably known the target we've been aiming for a little bit better and hence being able to use enhanced technology in a more refined way than it's been used before.

Absolutely Prof. That's a very nice overview and actually a topic that we'll come back to about these technologies. But Ed, if I can maybe come to yourself next, for those of us who don't do lower limb arthroplasty, and I suppose one of the most common, maybe uninformed questions is why robotics? Surely conventional hip and knee replacement works so well, it's probably one of the best operations we have in orthopaedics. So, how can we ever make them better? 

Yeah, thank you. I mean, I [00:04:00] think the first thing to say is we're very privileged to work in, do hip and knee replacements, because as you say, they're a phenomenally successful operation, and I think we don't want to forget about that. However I think it's a little bit depressing when we say that we should just stop and we should stop moving forward.

I think that's a key point in everything we do in life. Yeah. And it's a challenge that we regularly get when we come up with new interventions, is we want to improve. We're striving to improve. But when we do try to make improvements, clearly that's change and change is often difficult to accept for everybody, but we need to make sure we're making those changes for the right reason.

And what we're here to talk about as well is evidence in those changes. Yeah. I think that those of us who do knee replacements, that's, I think, technology and improvements are fairly easy sell to your average knee replacement surgeon because they see a good number of patients in clinic who really aren't that happy and we know that from the literature.

And that makes us feel terrible as [00:05:00] surgeons and we want to get better. And how do we get better? Well, maybe we, we get some help in how we implant these devices and we don't just rely on our surgical skills so much. And we cross check, we make sure things are in the right place. And we know that technology is very, very good in precision.

And it, and it has been demonstrated to be so for a very long time, even navigation demonstrated improved precision. Hip replacements is a little bit more of a tricky sell because actually they feel so much more successful to both patients and surgeons. I think we're seeing a change in that as we're moving to surgeons that are much higher volume.

And when you start to do higher volumes, you start to perceive those patients that may not be doing as well as, as you commonly expect. And we know that actually when you delve into the literature, the proportion of patients who may be less than amazed at their wonderful hip replacement. It is pretty disheartening really.

And we've, we've published about in the journal really. And I think it's more about [00:06:00] that value proposition. And there definitely is, I think, when you look at the research out there now, a value proposition to continue to improve in hip replacements. So I think it's, it's honest to try to get better and that's just standing still isn't right for, for our patients.

I think technology brings with it the opportunity to do that, but we need to do it in a careful evidence based approach. I think what Fares talked about earlier is really important, which is the target that we're heading for. And I think that's absolutely key. And if you look at the volume of literature, even over the last five years on knee replacement and hip replacement, we're refining that target almost by the month with more information about where we should be shooting for. So not only these systems are precise, but then they become accurate. And that's really where we make the changes. Yeah, thanks.

And I think that's a really nice, I mean, I think, like you say, there is a, I suppose, a tendency sometimes to think, oh, will this do, and particularly in the environment we sometimes work in, I think you're right, we should always be striving to [00:07:00] improve for our patients more than anything, isn't it? And Robert, maybe I could just come back to you with a point there, you know, about robotic development, and we've just talked about that, you know.

Maybe as a broader view as well, introducing these new technologies, you've sort of alluded to it, is really important. How we do it is really important. And it can't just say, well, we've got one study that says this works. So all of the implants in this arena work. And we've talked about these things before in podcasts before, haven't we?

We have indeed. And there's so many layers to this. I mean, the reality is the entire world has moved to a computerized sort of structure behind it. Anything we look at in our lives, you know, the iPhone, et cetera. And, you know, the analogy doesn't always wash to surgery, but in reality, everything is moving in that technological direction.

So it's kind of happening around us anyway. And what we do evolves regardless. We have to accept that. Anytime when you're introducing something into the system, you've got to do it in a way that is safe for patients. We're aiming to make it better for patients, but it has to be safe for [00:08:00] them. And we've got to remember the reality is innovation happens in partnership with industry, and they've got their direction and what they're trying to achieve, which is not necessarily always exactly the same as we're trying to do.

So that's why it's really important that whenever something like this is introduced, appropriate data is collected. It is introduced as I've always said, in a place where you know where you start and hence you can measure the increment, whether you're, you know, we're going to be talking about a high quality randomized study, but even if you're going to change your practice to something where you can't do it in a randomized study, you've got to understand where you start in order to determine where you're going to go next and whether that makes a change.

And I think people need to remember that. Absolutely, Prof. And I think that sort of drags us onto something, I just wanted to ask you Ed, before we move on to the race studies with, with, with Pete and Andy you know, one of the things that's often talked about, and I want to come back to this point, so maybe just briefly, there is an issue, well, maybe one of the limiting factors with robotics, is cost, isn't it?

And, [00:09:00] you know, what, what do you think of that, Ed? What is, is that, is that something that is going to be insurmountable, do you think? No, I mean, sorry, it is an issue. Absolutely. Cost is an issue with everything we do. And I think we're seeing that globally. It's not just the UK that's struggling with that.

Costs are really important. But I think, well, there's two points here. The first thing is that when you introduce new technology, they're always incredibly expensive. And we saw that, I remember when the first iPhone came in and people were like, well, why on earth would you spend that much money on a phone?

Yeah, we all, we all do that. And costs of devices have come down rapidly. Okay. And as you go to scale, the cost comes down. So clearly the cost of this technology will come down. But the other point is around health economics and, and, and I think this is a, this is a huge topic and will be an emerging topic.

I think we've done that very poorly. And I mean, it's really upsetting, particularly in the NHS, when we talk about costs and we just look at the cost of unwrapping an implant when we say that's the cost of a hip or knee replacement. [00:10:00] Well, clearly there's a lot more that goes into it now that is the cost, not to mention the cost, the full economic costs, which we're trying to address in studies like this, which is very, very difficult.

And I think it, well, it saddens me that, that at the moment, not just in the UK, but around the world, choices on healthcare are made by very naive health economic calculations. And I would hope, particularly studies like this and further studies, we put more emphasis on the health economics so that we can go to those policy makers that make these decisions and, and try to educate them about what cost actually means and what cost means for society and for patients, so that we can start making the right choices.

And yes, it might be that we spend a bit more, at the beginning. But if that then saves us money later on, that is well worth it in the long run. Prof, do you want to come add something to that? Dux, if I could come in with a couple [00:11:00] of points. I think the first one is if we look at the literature as a whole because orthopaedic surgeons tend to review for orthopaedic journals, there is a plethora of very poor quality so called health economic studies across our entire specialty that are published.

That's one area, as Ed says, that really needs to be addressed. We've put out some editorials in the journal. We've tried to raise the bar from that perspective, but others need to follow. And it's become a problem that's been recognized worldwide now that the people do kind of make up their metrics and then come out with the answer they want.

And, and frankly, in the UK, that's influenced health policy massively. That'll be, I'm sure another podcast we do over the choice of stem these days in the 70 year old patient. You know, there, there, there is, you know, there are lots of assumptions and lots of things around that. So I think that, you know, that, that is one key issue.

The other issue, which I just want to remind everyone is whose health economics are you looking at? Because often when you look at health economics, one is obsessed with the system. And in the UK, it's the NHS, [00:12:00] et cetera, and sure, the funders and the commissioners and the research bodies insist on that.

But actually, that patient, sometimes, and this was best illustrated when we debated clavicular fractures, for example, the health economics for that patient may warrant a completely different intervention. So I think we need to bear that in mind. And I know the good health economic studies do, but frankly, not everyone does.

No, I think that's very appropriate, and like we said, the complexity of the health economics and where you view it from is really important. So I think that probably takes us very nicely on to Andy and Pete and moving on to the RACER trials, which are being led out of Warwick. Andy, maybe I'll start with yourself with RACER-Knee.

Could you sort of give us a brief overview of the trial, how that was designed, you know, the processes and how it's going so far? Yeah, absolutely. Yeah, RACER has been been really fun journey so far continues to be, and this started, goodness, it's quite a long time ago these things happen, you know, the big tasks.

This started a number of years ago in a hotel cafe, when we met with Ed, who, come to us and said, [00:13:00] well, we know we do randomized trial work and we've got this robot and you really, really need a trial on this. And, and, you know, I'm really grateful that he, we started that conversation because it was one of those that it doesn't take you long to think, yeah, that would be really good.

You know, we really need this and, and the more, and actually as we've watched, you know, robotics around the world have just grown so rapidly that it's gone from being a relatively small early topic that looked exciting to, you know, really big important topic in orthopaedics. So we just hit that wave at the right time, which is really cool.

You know, we looked at it, it was beginning to be obvious that robotics was going to grow and become important and also beginning to be obvious that both the clinical effectiveness we needed to understand, and we needed to understand that because it was a new technology and also because it was going to become an increasingly important technology and that cost effectiveness and health economics were important. So we put in an application to NIHR to do knee replacement, because we thought that was probably the question at first that was the most striking. And we pretty quickly [00:14:00] clocked that actually hip replacement was important as well and people talk to that.

And so we followed that up with an application to, for to do the same for hip replacement and of course, benefiting on the back that we'd already done a lot of the work for knee replacement. So we were able to build from that. And you know, NIHR supported it and were very behind it all the way, which is great.

So we got funded and then funded again to do the hip and, and the journey started. And we started recruiting at an exceptionally clever time of the very end of 2019. And because of course, none of us saw the pandemic happening about the worst possible time that you could start recruiting to an arthroplasty trial.

Yeah. But actually, you know, we did, I mean, all credit to, to everyone involved, NIHR, our sites, you know, the support we've had with Stryker, which is also quite important, I think, and to recognize, you know, we're an independent trial, but we couldn't do it without industry cooperation. And the, you know, we kept ticking over in COVID, the sites kept pushing and then as COVID started to wane, new sites came on board, we continued to [00:15:00] push.

And as of this Monday, we have completed recruitment to RACER-Knee, which is really exciting. So, yeah, we've actually timed this podcast with beautiful timing. 39 patients are now recruited to RACER-Knee, which means it's over its target. So really cool. And now, of course, we're in follow up. So we've got a year, primary outcome is a year.

We'll follow people up primary outcomes, the forgotten joint score with there's obviously a load of secondary outcomes that are all really fascinating. I could talk for hours on this topic, cost effectiveness work and we'll aim to publish once we've analyzed that data. So that's probably going to be, you know, early to mid 25.

Brilliant. That's really good news, Andy, that's recruiting, like you say, with the issue of the pandemic and the hurdles that that creates, and that's an amazing achievement and a great achievement for not only you guys, but the UK community as a whole. That's, that's brilliant. And so, Pete, if I could come to you about RACER-Hip, where's that sort of, again, the evolution of that and where that is at the moment?

Yeah, thanks. Well, I think RACER-Hip, as Andy already alluded to, really fell nicely after RACER-Knee, and really a [00:16:00] testament to Prof Davis here, because it was him that kind of, as an enthusiast, someone who understood robotic technology, kind of realized that we were at that really sweet spot of knowing when to do a trial because, you know, trials are difficult things to undertake and the timing is critical there's too early and there's too late.

And I think we've hit that with the RACER studies we're at a stage where the technology is mature enough. So people are using it. We've got a good understanding of how, how to use it, but it hasn't grown to the extent that everyone's using it. And we're sort of saying, well, no, this, this is standard practice.

So Ed's really spotted that. And then things have flown from there really. The RACER-Knee study opened doors for RACER-Hip. So the, the core bits, really the, the, the collaboration with industry, which is pretty unique, actually, and something we should be proud of in the [00:17:00] UK Health Service, that ability to get funded and do work independently, but with collaboration with industry is pretty, pretty unique.

And hopefully has allowed us to do some, a really robust research study. And you know, when we looked at the hip, which followed on from the knee, we, one of the big issues I suppose, was people we thought might say, well, you know, knees already got the answers. Can you not extrapolate them across? 

And whilst we all gathered around and decided that no, we didn't think that was was right. We have to get sort of support for that. And we went to the British Hip Society. We talked to patients. We talked to all the stakeholders and we got sort of the same resounding sort of statement, really, which was no, it was really important that we did hip at the same time as knee, because I don't, I think if we hadn't done that, it wouldn't have happened because I think, you know, knee would have finished the results would have been [00:18:00] published and I suspect redoing the trial later down the line would have been impossible. 

So we've been really lucky and I think, you know, we've been able to learn so much from the RACER-Knee study and sort of iteratively improve on with the RACER-Hip study and you know, I'm pleased to report in the same way as Andy, we're nearly finishing recruitment. So we'll be able to sort of hopefully share the results of that trial with, with the sort of community fairly soon. Very similar modeling to the RACER-Knee studies. So primary outcome will be one year post-surgery and randomization, but we're going to follow up patients for 10 years. So those really important things about whether patients need redo surgery and other aspects. That's, that's great. That's great. And I think like you say, it's again, it's great that that's almost reaching conclusion.

I think it's really interesting hearing both of you speak there because I think one of the great things, you know, there's a lot of trials and tribulations about working in the NHS, as we all know, but one of the great things is that when the new technology like this comes along, we do [00:19:00] embrace it, but we also ensure it's the right thing to do.

And I don't know if every healthcare system is just the same. And I think that's a real testament to the UK and to teams like yourself that are actually trying to make sure is this the right thing? Is this the right way to spend money to improve our patients outcomes? I think that's a real testament to us.

So can I, I mean, just to comment on that, I think that's a brilliant comment and actually really important that in the UK we, you know, sometimes we don't celebrate our strengths. I think it'd be very hard to deliver this study in any other healthcare setting. And actually, you know, many healthcare settings have tried and found it very difficult.

And so I think we have a lot to be proud of. I mean, I think we've got this massive interconnected healthcare system that can deliver great trials and, and, you know, investing in that as a community and working collaboratively together is a really positive thing. And I think we have a community that that recognize what we've been talking about, which is the need to test things with data and, and that's a real good feature of the UK. So I think there is, [00:20:00] you're absolutely right. There's a real good news story, you know, for the UK about that. We can be really proud of.

I totally agree, Andy. So sort of moving on sort of just to finish up, I was going to ask you all four of you two questions and we can sort of go around in order, but sort of about the designs of the trials, you know, maybe Prof I'd maybe come back to you first, you know, for, for one of the final questions, you know, I think these trials, as we've clearly shown, show a real template of how you should be assessing and introducing and, and making sure that the new technologies that we bring to the, bring to the, the table are, are right.

But just to one of the final points about the primary, the outcomes, you know, and, you know, we've mentioned it Forgotten Joint Score, which I agree. And if you integrate in the annotation and explaining why that was chosen, which is very clear, but do we feel that is actually in the greater picture? Is that really fit for purpose?

You know, and I know it's a difficult question and again, you can have a whole other podcast on it, but is it the right thing to be using? I know we've got to hang it off that, but is that the right thing that we should be looking at, do [00:21:00] you think? 

And maybe I'll kick off and, and, you know, Andy and Pete will be able to elaborate and NIHR has certain requirements of their trials, which, you know, kind of lead you to certain, primary outcome measures.

I think the reality in arthroplasty, our effect size is so large that then relying on a difference in PROM sets us up to fail. And, you know, that may be why the studies got funded. So it's, you know, it's a tricky thing to do. On, on top of that, we've kind of layered this massive emphasis on MCID.

And I think it's something we're starting to probe and challenge, because in reality, what you're asking for is a staggering improvement. And then beyond that, you've got, you know, a pragmatic trial is the way to go for generalizability. But in reality, we've said at the beginning of this podcast that the target may be the most important thing in navigation was accurate and precise, but actually we had, we didn't know what the target was.

So I think the secondary analyses and the, the secondary outcomes are going to be really, really critical here. I mean, [00:22:00] I think you know, Andy, Ed and Peter really to be congratulated on having this, these large, very powerful data sets now, and we've got to make sure we don't just get stuck with the primary outcome.

The primary outcome may, of course, show a difference. We don't know, but I think the secondary outcomes are equally important. Absolutely. Ed, what would you like to add to that? I think everything that's been said is quite correct. And I think we're finding our way, as I said earlier, you know, we've made huge leaps and bounds on finding the target for both knee and hips way quicker now that technology's come into play than we ever did before.

I think we're striving forward on improving our outcomes. I'll let Andy and Pete maybe talk a little bit about how we might be able to improve those just with the data from the study on that and what sort of problems we look at. The other thing I suppose, which is a little bit controversial, we need to bear in mind is that, of course, we hold up randomized control studies as kind of the gold standard, but actually, when you start [00:23:00] conducting randomized control studies, you start to see the potential holes in randomized control studies.

And that is generalizability. You know, we'd like to think that when you recruit to a study like this, you are picking all types of different surgeons, but actually surgeons were prepared to take the time to recruit to randomize control trials that that are prepared to take it, probably not are probably not generalizable.

And I think that's, that's why we need to look at other types of studies, you know, where those are registries where a large studies. So we start to put the jigsaw together. And so I think we need to be cognizant of that as we move forward, randomized controlled trials are, you know, are the gold standard, but it's very different doing a randomized controlled surgical trial than it is doing a randomized controlled trial in pharma, isn't it?

They're very, very different as far as generalizability goes. So I don't want to downplay that because, of course, the RACER trials are phenomenal [00:24:00] studies. But I think it's just probably that that health warning on it that that that we do need to bear in mind that we do need to put the jigsaw together.

No, I think that's a very good point. And again, something we've discussed before at podcast. I know we've discussed that the BJJ is that, you know, we, we always aim for those RCTs and it is great, but it doesn't always give you the answer for everybody. And I think we, as long as we're aware of that, I don't think there's an issue, but like you say, there, there are maybe other ways.

That we can look at other things like you say, and, and, and yeah, I think like you say, randomizing patients to RCTs is a, is a bias anyway, isn't it? Cause when you're a center, so it's no, I agree. Andy and Pete, have you guys got anything to add to that? Sorry. So, so I think this pattern of you know, primary and secondary outcomes and understanding those and looking at how we can improve outcomes is a really important topic and continues to be a really important topic in orthopaedics.

And I'd agree with what Ed says as well. We have to look at all evidence in context. But to feed to the first point, I think, you know, yes, we have to have primary outcomes and we have to have robust statistical [00:25:00] analyses, but you know, we have a huge range of outcomes here because we're building a picture as well.

And we need to understand that picture and narrative and we're doing a lot of work in the background around this as well. We didn't want RACER to just sort of stand alone as this, you know, thing that we've sort of produced a lot of outcomes and haven't thought about. And we have an excellent PhD student called Chetan Khatri.

He's done a huge amount of work looking at the comparative importance of different outcomes and also about ways that we can improve the way we scale and score things like Forgotten Joint Score and Oxford Knee Score. In fact, we've worked with Edinburgh as well. And so and I think that will work is going to add, you know, really valuable insights.

I mean, I've got, you know, we have absolutely no insight. I should clarify for your listeners. We have absolutely no insight into what the racer trials are going to show. There comes a point at the end of these randomized trials where, you know, me, Ed and Pete will sit in a room and the statisticians will tell us the thing that they've known for years.

Yeah. And we won't, we have no idea. And so I say this from [00:26:00] a completely naive view, but I think, you know, it may be a interesting or complex pattern of outcomes and we need to understand what that means. And we're putting a lot of work into trying to get our head around interpreting that. And that will be of value for lots of future trials and how we interpret trials as well.

So, you know, I think that'd be a really interesting body of work that comes out of this. Absolutely. Yeah, there's a lot of thought to be done in the future. But yeah, who knows? It'll be fascinating. 

I agree. Anything to add to that, Pete? Yeah, just briefly, Andy's absolutely right. Knee is pioneered again for hip. You've got a PhD student looking at exactly that, that comment, really, that recognition that the primary outcome perhaps isn't isn't everything and we do need to sort of add in all those secondary outcomes to get the overall picture and and I think really, NHIR recognized that because they funded our study for 10 years.

So we need answers quickly because we've got to move forward. So we will have fairly rapid answers, but of course the whole answer won't come for 10 years. But we have a [00:27:00] really good sense of whether that those patients have been revised or what's happened to them. So and I think NIHR has recognized that, that it's not all hinged on the primary outcome, but it's a, it's a waiting game, I'm afraid.

No one likes that. No, no, that's a very good point, Pete. Did you want to add something there, sorry Fares? Yeah, Dux, I was going to come in with a couple of things. I think the first one is that even during the time that these trials have run, the technologies evolved. And I think we've got to be cognizant of that, that, you know, spinal pelvic understanding has improved and the software has come with it, that the knee software has changed.

So all these things are always going to be in evolution anyway. And so the trials teach us a lot. But we have to keep learning as we go. The other bit is really just to sort of put a, put a note out there that actually the hip and the knee are different. And it may be that in the knee patient satisfaction and the sort of clinical perspective will show a difference.

Maybe they won't, but, you know, that's more likely we all perceive as I'd said in the knee, but you come to the hip and it may be [00:28:00] complication rates that are different. It may be as several large American studies have shown already the instability comes down, but actually the problems look the same. So it's really a fascinating area.

It's going to be a fun couple of years these guys have done an unbelievable job. It's a, it's a great privilege to have sat on the sidelines while they've done this work, but they have done an unbelievable job, but UK arthroplasty surgery, and it's going to be a great three years. Really while the, the, the analysis evolves and comes out.

Yeah, I completely agree, Prof. And I'd echo those, those compliments as well. And I was actually going to ask you all for my last question, whether you thought that robotics will ever be cost effective, but I've decided not to answer you ask that question because we just need to wait. Don't we after the discussion that we've just had.

So I think that's probably a good, a good place for us to finish up. So thank you all for a really great discussion and congratulations, like you say, to the guys and a really great study. And then, like I say, I do think it's a real a celebration of, you know, of, of the quality of work that can be done in the UK in the right way.

I really do. And it's, it's good to celebrate [00:29:00] things like that. And there's clearly a lot of robust data on the way and it was great to have you all with us and to our listeners we do hope you have enjoyed joining us and obviously encourage you to share your thoughts regarding this podcast and all of our series through social media and like, and feel free to post about anything we've discussed here today.

And thanks again for joining us. Take care everyone.