The Orthopaedic Trauma Society classification of open fractures

Listen to Mr Andrew Duckworth, Mr Alex Trompeter &  Professor Matt Costa discuss the editorial entitled 'Classification of open fractures: the need to modernize' & the paper 'The Orthopaedic Trauma Society classification of open fractures'.

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Click here to read the paper 'The Orthopaedic Trauma Society classification of open fractures'
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Transcript

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[00:00:00] Welcome everyone to our BJJ Podcast for the month of November. I am Andrew Duckworth and a warm welcome to this month edition from your team here at The Bone & Joint Journal. 

A big thank you to you all as always, to our readers and listeners for the comments and support as well as to our many authors. We hope you continue to find these podcasts, both helpful and informative. And as we approach the end of our series for the year, we hope we have delivered and covered an exciting and wide range of topics for, with our primary goal, always to improve the accessibility and visibility of the work we publish here at the journal for both you as our readers and listeners, as well as for our many authors.

 For this month's podcast, as we've done before, we'll be taking a slightly different format. As we'll not be discussing an original paper or instructional review. We'll be focusing on an editorial on behalf of The Orthopedic Trauma Society, the topic of which I'm sure will simulate some excellent and informative discussion. 

So today I am delighted to be joined by two of my trauma colleagues and friends here in the UK to discuss their editorial entitled Classification of open fractures: the need to modernize. In this editorial, the author has challenged the validity of the original grading [00:01:00] systems for open fractures and discuss the concept of an ideal system based on patient-reported outcomes and its possible effect on the use of resources in the 21st century. 

So firstly, I would like to welcome Mr Alex Trompeter from St. George's University hospital in London. Alex many thanks for taking the time to join us today. 

Thank you, having me - fantastic opportunity to discuss our work, and really honored to be here. 

It's great to have you Alex, thank you so much. 

And Alex is joined today by his co-author, and I have the pleasure of welcoming back our specialty editor of trauma  here at the journal, Professor Matt Costa, from Oxford. Welcome back Matt and. it's great to have you back with us today. 

Hi, Andrew. Thanks for inviting me. 

So, Alex if I could start with you, in terms of the editorial, obviously it's looking at the classification of open fractures. Can you give our listeners some background to the editorial and why the classification of open fractures is so important?

Sure. So, I mean, we all know that good classifications can guide treatment and prognosis, maybe facilitate research and ultimately [00:02:00] improve outcomes. I think historically in orthopedics, some classifications have come about because things can be classified and there's a little bit of a sort of gap in the market for classifications that people like to pounce on.

And many of the historic classifications are typically either complex, full of subjective terminology, surgeon bias, or more specifically, very surgeon and operation focused. And theyre not always historically patient centered and more importantly, not always as reproducible as people think. And one of the things that we've looked at and really thought about is that given that we define the way we deliver our open fracture care in the UK by a classification system that may not be as robust as we think, and that there's a tariff associated with that, so the money follows the patient, are we in a precarious position if we're using an unreliable system? [00:03:00] So our editorial strove to sort of unpick some of those issues with our accepted and classic accepted and standard classification systems. And, and in some ways it's a bit like a sort of journal club where you do a review of a classic paper. Many people often quote those classic papers, but dont really know the intricacies of them. And we're trying to sort of unpack a little bit of that and see if it stands up to modern  healthcare in terms of open fractures.

Yeah, I think that that's a really good overview. I think Alex, I think you're right. I think that's the issue with all the classification, well with many of the classification systems, we have not only in orthopedics, but I suppose throughout medicine as well. I think that sort of just before we sort of talk about open fracture classifications, Matt if I come to you,  through the large randomized trials  you've run in this area particularly open fractures with WOLF and things, but in other RCTs, how do you feel about the classification systems? Do you find them a useful thing? Are they a limitation?  How have you found them when you've run these trials? 

Well I think Alex [00:04:00] kind of picked up on this really. I mean, we all think the classifications are straightforward and we banded the various types and subtypes around in meetings all the time. But when you go back to the, so when you set up a research project, you have to reference paper very carefully. And although I think we'd all accept that different types of injury, different types of fracture have different outcomes,  some of the classification systems don't necessarily correlate with the outcomes that we think are important to patients. And when you really unpick the original descriptors, they're very difficult to apply in the context of a trial. So what is soft tissue stripping?  How much contamination is contamination?  So all of these terms that are very difficult to apply in the context of research and protocol.  

Thinking about WOLF, the other thing that really occurred to me and Alex has spoken to me about his ideas on this for quite a while. So it wasn't necessarily a new thing, but when we were looking at WOLF, one thing we noticed was that during the course of the trial, so WOLF was quite a long, slow burner. It was a two and a half year [00:05:00] recruitment window. So we had a chance to look at changing practice at the time, as well as what was happening in different units. 

We found that the number of primary closures of open fracture wounds was going up considerably. And we've sort of written about that, although not necessarily explicitly about that topic. So it went up from around 25% to over 50% of all open fractures were having primary wound closure, just in the two and a half years of the trial, which is a complete change in a way that we think about managing open fractures, and the open fracture classification of course, where were set up many years ago. And, you know, were very useful in that time, but our philosophy about how we manage them is changing. To the point where when I was a trainee, if I closed the wound primarily over an open fracture, it was my fault when that got infected or broke down.  I was, you know, I was hung out to dry to the point where we just never did it. It was kind of the rule. Whereas now if I can't get it closed, I've got a feeling of disappointment - let down every one. Now I've not managed to close that wound [00:06:00] primarily because I'm not satisfied with my debridement or there's some other problem or the wound is just too big. 

So, yeah, I think on many levels the classifications with difficult supply in a research context, but the research also cast a light on how modern management of open fractures has changed beyond what was really useful at the time when these classifications were made or certainly the very early ones.

That's interesting just before we come back Alex, I think that's an interesting point. Isn't it? Do you think it's a combination though of  our open fracture management has modernized and got better. But do you think the nature of our open injuries has changed from when these original classifications have come about? You know,  in terms of those high energy injuries, injuries at work and things like that, that they are less common than they used to be. You know, health and safety is better, cars are safer. Do you think that's fair?

Yeah, I think so. I mean, it's difficult, isn't it? Because all of the literature really around open fractures comes from the tibia and we know that diaphyseal fractures at the tibia, which were the bread and butter when I was training. It was like your rites of passage operation wasn't it? I [00:07:00] can nail a tibia, I'm an orthopedic surgeon.

 I just am seeing them. Now we see loads of metaphyseal fractures but a straight forward diaphyseal tibial fracture, it seems to be, you know, the epidemiology from, from your colleagues in Edinburgh and Scandinavia suggests that this is not just my experience. This is true, certainly in Western Europe. So those relatively low grade open fractures that came along with the diaphyseal tibia. Now the football injuries and so on. We're just not seeing them, we're seeing very high energy injuries now that people are surviving in car crashes, they probably wouldn't have survived previously. And increasingly low energy fractures in older patients with fragile bones, but also very fragile, soft tissues.

So yeah, no, I think the patients have changed as well. You're absolutely right, Andrew, but you know our management has changed along side that really. And so the two collided to the point well are these classifications any use to us now? 

Yeah, no, I think its a really nice way to put it. I think in terms of, or to think about it is that actually these it's not that necessarily [00:08:00] these classification systems are wrong now, but they haven't evolved with the way that our management and  our patients probably have at the time.

So how accessible is that coming back to you? If we go back to the beginning, you know, the Gustilo Anderson Classification, most commonly quoted for open fractures. For our listeners, can you just remind us how this was sort of developed? And discuss your thoughts on, you know, how it's maybe misquoted or misuse and the limitations that it has then and now.

So  it's an absolutely fascinating read if you've not genuinely read the Gustilo Anderson paper. And I'm sure if people are honest with themselves, they've probably read an abstract for it and never read the paper in its great detail. It is worth reading. And actually this goes and rings true for a lot of the classic papers that we sort of hang our hat on in orthopedics.

Because with my sort of reviewers hat on and various things like that, I don't think this would be published today when you look at the way the paper has been constructed and presented. It was, it was published in 1976 in the JBJS American. [00:09:00] And it was entitled The prevention of infection in the treatment of 1025 open fractures of long bones.

So the emphasis wasn't on developing a classification system, the emphasis initially just from the headline message was about trying to avoid infection in the management of open fractures. So we always need to just bear in mind when we're looking at research, what the goal of the research is, and then what the inferences are from the data.

More importantly, and really interesting was, this was a single centre series and it was both a retrospective and a prospective data set. So they had essentially two cohorts of patients. They have their 600 plus about 60%, 40% split of 60% or so in the retrospective group, who essentially were managed in the earlier part of their study period by their standard of [00:10:00] practice, as you could interpret at that time. Virtually everything got primarily closed. There was a whole range of historic methods of skeletal treatment, internal fixation, pins and plaster, and so on. A variety of antibiotics given to patients. And then about 86% were followed up just to one month. So their final point of follow-up was one month, once the soft tissues that healed and that was their outcome, sort of timepoint.

And actually they split that retrospective cohort into two groups. The earlier period which was the sort of first five or eight years of the study window and the later period. And they noticed that the earlier period had a higher infection rate than the later period. And somehow in the paper born out of this is an arbitrary division in timepoint between when things were less good and when things were slightly better in terms of defining infection.

 Infection was defined rather subjectively as wound drainage. [00:11:00] So again, you know, what about non draining but red wounds? What about the person who's got a draining sinus at 32 days and falls outside that time follow-up? There was a rather sort of undefined  criteria for infection. And then again they changed their practice  in the early, early retrospective to their later retrospective between primary and secondary closure. 

So it was all while the confused and you look at this paper and you're sort of sitting there going, all right. So you've got this sort of cohort of patients and you've done about this to some of them and this to some of them, but you're putting them all in the same pot and then they go and put in 40% more patients through a prospective study where they've suddenly decided to classify and stratify these patients into groups. And this is where we see the first move towards the Gustilo Anderson Classification as we know. 

And they haven't really explained where that comes from other than I think it's in and they sort of try and allude to it, it's to do with their outcomes and infection rates [00:12:00] broadly defining the worst patients, either the category threes that they call them, with segmental fractures, extensive, soft tissue damage, gunshot injuries and so on versus their more benign injuries with smaller wounds. 

And they start to use this really subjective terminology. So a Grade one is less than one centimeter and clean. I don't know how they defined clean.  And then,  things like extensive, soft tissue damage, or significant contamination. What's significant to one man and what it is to another are very difficult to distinguish, as Matt has said before.

And the emphasis on the paper as a whole was all about the microbiology and the outcome based around antimicrobial use and infection. All of the prospective groups, so this is the second half of the paper, suddenly got external fixation. They barely fixed anything [00:13:00] internally in the second half of the group. They primarily closed all the ones and twos and left all of the grade threes, open and secondary wound closure. Everybody got a random course of antibiotics and they were only again followed up for six weeks. 

So you've got this sort of completely different treatment approach to two groups of patients in the study, all put  into a single pot and they kind of come out with these headline messages that, yeah, the infection rate was really high, 10, 11, 12% in the earliest group of patients in the study, it was much lower than the later but the grade threes do  really badly with higher infection rates. And they kind of probably landed on the right answers in terms of infection. We know that the higher energy ones do worse. But how they got there. When you look at the science of the paper is a little bit, I would say fortuitous and they come, they kind of concluded in their study  this first paper that really open fractures required lots of wash out, [00:14:00] routine antibiotics, primary closure if they were simple and delayed closure if they were more challenging with soft tissues and avoided internal fixation in everything. 

So that was kind of their first paper. And I know I've whittled down a bit, but I think it's really important to pick it apart because everyone sits there and quotes it and, and I can bet your bottom dollar, not many people know that it wasn't really designed as a classification paper per se.

No. I think that is really interesting Alex. I think the way you've explained, it's really clear because I think like you say  all of us as trainees, you just see that classification system in a textbook, you learn it and you take it verbatim and like you say no idea where it's come from. And it's like a lot of things, and you say it very clear in the editorial as well, you know, the subjective nature of so many of these descriptions is it's just so intangible, isn't it? And we do it with everything. What does displace mean? All these things are just, they're very, very subjective and that's a really good overview so say actually, this thing is  the most quoted, I would say of the open fracture [00:15:00] classification systems out there.

But in terms of the other ones have developed since then, you talk about NICE in the editorial, the AAO classification, the OTA FSG 2010 one, and the Ganga score as well. How do you think these compare? Do they move it forward at all? Do they have pluses and minuses compared to it?

 So the OTA OFSG one with 2010, that was kind of an evolution of AOS 2007 one, but they, they kind of merged into one and the same ultimately, and they did strive to deal with the slight subjectivity and especially the published low capper interobserver reliability for the Gustilo Anderson. So, you know, we've talked about its limitations, but it's also proven from a scientific point of view to be rather unreproducible. And the OTA OFSG decided to try and address this. And they went about things in a very rigorous, very structured manner, trying to address all components of the injury.

And that has a double-edged [00:16:00] sword. It provides a lot of information, but it makes things overly detailed. It's not overwhelmingly user-friendly. It was very research focused with the main aim to get as much info as possible. And again if you go and read their paper, the process by which they went about developing this is, is quite interesting. And essentially it was seven guys in a room who kind of came up with the idea, then got their charms in and validated it and sort of ranked what they thought was important in terms of  factors to include. And so they settled on looking at the different components of the injury from skin muscle, artery contamination and bone loss.

But it doesn't have any correlation at all to any outcome whatsoever. It's literally just an arbitrary descriptor tool. So it's a classification on anatomy, if you like, it's a classification on mechanics and on injury, but it's not a [00:17:00] classification in any way based on outcome, and I think that's where they missed a big trick there.

 Gangas paper from The British Journal in 2006 was again, you know, people quote it, people like it. And it was a really good, interesting paper to read with great numbers, you know, a hundred plus high energy, Gus below three A&B fractures, but it wasn't designed as a classification tool for open fractures in general, it was designed as a decision-making algorithm to aid limb salvage versus reconstruction decisions. It took a variety of parameters, much like the mangled extremity score does of the patient's host status and physiology and the limb, and helped people with a decision-making tool around whether they wanted to embark on salvage or reconstruction for those really severe injuries.

 It is of no use in the slightly lower grade injuries. And again, it's very hard to sort of employ in a rapid fashion and it doesn't [00:18:00] necessarily correlate with outcome. I mean, that was correlating with a single center's experience of whether amputation came later or was it better to do it earlier? So it's outcome per se, but it's not patient reported outcome. It's not functional outcome. It's a surgeon decided outcome based on whether they get an amputation or not. Yeah. So it was again sort of interesting and one or two things in all of those scores were still slightly subjective or slightly missing the beat, which was, you know, things like there was no soft tissue damage over the fracture and the soft tissue damage was further away. For me, if it's open, it's open, the bacteria don't know where the fracture is in relation to the skin. And so those things again, you know, they, they invite conflict usually from the user they invite misclassification, they invite trouble. 

Yeah, no, Alex that's a really good overview, actually of all those classification systems and actually, you know, their strengths and limitations. And that was a good point.

 If I come back to you, [00:19:00] Matt,   you say in the editorial, there's a large variation in our ability to meet performance targets for open fracture. We've talked about that already. And the literature shows striking differences in the outcomes for open fractures as we know. Can you just sort of expand on that a bit in terms of where you think we are with our open fracture care in the UK and the standards that have been set and how we are meeting them if we are?

 So the BOAS association standards for management sites and fractures, which essentially are the same as the NICE guidance on the management of open facture deliberately so that they were designed to coincide. They're just an expansion really of the NICE guidance.  We're based around what , again, a lot of surgeons thought were important in terms of discerning outcome. And so  there's lots about timing and so on.  From the research side, what we found was that  there was huge variation around the country and how patients were managed. And also perhaps even more importantly, the qualitative work we did [00:20:00] alongside some of the trial work suggested that the things that  the surgeons thought were important weren't necessarily the same as what the patients thought were important. So the exact timing of what was going on was less relevant to the patients than the surgeons. The exact timing was less important than someone telling them what was going to happen when it was going to happen and sticking to the plan. Which is exactly what they wanted to hear. 

Moving further down the line in terms of where the difference in the variation around the different senses came from, it was a huge variation again, in a race of primary wound closure. Now, if you've got a target of trying to get definitive wound closure within 72 hours...we had a lot of argument about that. A lot of people said, we want to get it even shorter. The easiest way to hit that target is to close it on the day one when you're doing your first wound debridement. So those centres that were moving towards aggressively trying to close the wounds primarily, in some cases, we're getting, you know, 90% primary wound closure. And you'll know that you guys will know which centres they are and how they achieve that, which is really quite remarkable, but [00:21:00] they were able to do it. They were hitting the targets far more often than those that are taking a more traditional approach.

And there were two factors, and we've not put this in this. So we've got to be careful to not over-interpret this data and the numbers get smaller when you go into individual centres data. But there were two basic things that allowed people to get primary wound closure on day one. The first was if you were using external fixators definitively. And so some units were bending legs in half to get the wound closed and then stretching them out again later. The other units and more commonly were those that had a really properly developed orthoplastics unit. Where at the end of the primary wound debridement, both the plastic surgeon consultant and the orthopedic consultant said, we're happy this wound is as clean as it can possibly be. There's no good reason for leaving this open. So let's get it closed. And then working with plastics as well. Those very simple, but actually really important wound closure techniques just to  try and reduce the tension around wounds you are closing. Everyone gets more confidence in using those. And so you're able to close more and more. 

[00:22:00] And this went back to conversations as the everin the bar with, with Alex and colleagues about what really determines outcome here. And I mean, Alex has said very clearly all along, I think it's just whether this is wound is closed primarily or not. Is it a simple fracture you can close primarily or is it complex. And that was the essence of where the classification came from.

 The WOLF trial in particular, and then Wist where we had the open practice that were closed primarily, basically it was just an opportunity. We had a dataset with good quality follow-up reporting with things that patients told us were important to them, not just infection, but quality of life and disability and so on. And so we had the opportunity to test out whether this classification system really did correlate with patient outcomes and the things that patients thought were really important. And that was the opportunity we took advantage of in this paper really. And it turns out that that simple complex classification does seem to correlate quite nicely with both disability and quality of life.

  I was going to come on to Alex to talk about the classification in a [00:23:00] bit more detailed, but just to stick on that point for a second Matt, in terms of, I think what you're saying there though is that in terms of the classification system for open fractures and I suppose for many fractures, we're saying it's the patient-reported outcome but really, we want it to correlate with as best we can.  Is that a fair point, rather than in the past, it's very much been about infection and things like that. Do you think that's really what we've got to be chasing with all of our classification systems as best we can, your guide management and predict outcome?

Yeah, absolutely. I mean, I bang on about this  all the time, but, so infection itself is not necessarily... I mean, well, infection's always a bad thing, but it's not necessarily a terrible outcome from the patient's perspective. So  you can have a deep infection of an open fracture wound. If it's treated aggressively, you get your the samples, you get the right antibiotics, you've done your surgery appropriately, then the patient can go on to get complete resolution of that infection have a really good outcome. 

Equally you can have a wound that has no infection, but  we found the patients reporting 25% chronic pain issues [00:24:00] at one year after these injuries. Now that is what patients really hate. If you had an infection, if it's all, they don't care about it, but the chronic pain associated with a non-infected wound for reasons, we still don't fully understand, was a real problem for them. So infection, I don't think is necessarily the be-all and end-all for surgeons, but from the patient's perspective, they have infections.  All of us have had infections one way or another, the wound infection doesn't frighten patients. You talk to them about chronic pain issues, which are actually much more common, and they get very upset. So the patients told us very clearly that they didn't mind having further surgery, having protracted surgery didn't mind having complications, they accepted, they got complex injuries so we're going to have problems. What they wanted to know is they're going to get the quality of life back at the end of the treatment pathway. So, that's why we concentrate very much on the patient-reported outcomes, as you suggest Andrew rather than just thinking about the wound healing, bone healing and infection.

[00:25:00] Yeah, absolutely. And that makes a lot of sense. And I think we've probably kept our listeners in suspend for long enough. So if Alex, if you can sort of talk about the proposed classification and, which I will highlight to the reader as well, the editorial is accompanied by really  excellent infographic from The Knowledge Translation team. And I think it really compliments it really well, but can you sort of describe the proposed classification and where it falls into two distinct groups, which we've mentioned already and how you feel this really advances and helps in terms of our management of these patients?

Yeah. Sure. So  as we've both said, myself and Matt the current systems are really focusing on trying to be descriptive and therefore quite prescriptive when it comes to the injury and the intervention. And just like Matt said, the patient doesn't really know and probably, or definitely doesn't care what code or grade they're given.  That's of no value to the patient at all. The patient wants to know what their clinical journey and the ultimate outcome is likely to be. That's what matters to them. And ultimately, [00:26:00] probably matters to us most as healthcare providers, along with the socioeconomic burden of the injury and its treatment.

So our classification is specifically patient centric. It probably reflects resource consumption, although we haven't done the full-blown cost analysis or anything like that, that's something on our to do list, but it's likely to, and it reflects the complexity of the injury based around the impact on patient care and intervention and us, the patient's functional prognosis as married to the patient-reported outcome.

So broadly speaking open fractures can follow two distinct pathways. Those that behave similarly to their closed fracture counterparts, i.e. they have a treatment. They have their wound closed primarily. And they kind of go on to unite and heal and rehabilitate as really much the same as a closed fracture does. And we all know what those groups are. You know, we see them all the time. [00:27:00] They are pretty straightforward to manage. And then there are the whole group of patients with open fractures who just don't follow that pathway and they require complex reconstruction or have a torturous journey to recovery, or have a prolonged and protracted recovery that has a dramatic bearing on their long-term functional outcome, you know, short, medium, and long-term functional outcome, as Matt says. 

And that broadly leaves us with what we've termed simple and complex open fractures. Simple - you can sew the hole up, the fracture has gone to bed and it is essentially going to behave near enough, like a closed fracture all the way through its rehabilitation. Complex, broadly required some sorts of reconstructive intervention to facilitate healing. And that might be a reconstructive intervention to the skeleton. And we're talking here shortening or management of bone loss or the deformity of the fracture in order to accommodate the [00:28:00] closure of the wound. That's clearly going to give you a different functional outcome and recovery period, or it required a soft tissue reconstruction. Again, that will impact your recovery and rehabilitation, or it required a vascular reconstruction. And again, so really we only have three subgroups and they are similar to the Gustilo Anderson. We're not saying they weren't onto something, but  they are defined very clearly not in any way, subjectively and they correlate to the patient outcomes.

 And so it turns out when we look at fractures in this way, there is that surprisingly good correlation as Matt alluded to with the disability and functional outcomes reported by the patients with these injuries in both groups. 

That's  a really nice explanation Alex. And I think you mentioned some of the correlations with the patient-reported outcomes and just to sort of finish this up really, in terms of moving forward, do you envisage that this will be adapted with time? I notice you mentioned in the editorial about things  that are maybe not considered in any of the classification [00:29:00] systems, things like the patient, comorbidities,  other complications such as compartment syndrome. Do we need those factors in an open fracture classification system as well do you think?

So we've talked about this myself and Matt and the temptation of course, is to put all of this in because you want to be as inclusive as you can. And the minute you do that, you immediately undo the beautiful simplicity of the classification. And I think also gathering the data to be confident that  you could really map outcomes in such a diverse and broad group of patients. The numbers needed to really be able to robustly produce a classification in the same way we've done with this would become harder, not impossible, but it would become harder.

And I think, you know, we've got to be careful compartment syndrome I've always thought behaves like a sort of 3B tibia, but it isn't a closed fracture with compartment syndrome isn't an open fracture and we've got to just be really [00:30:00] careful that we don't shoe horn things in where they don't belong, even if they are suspiciously similar, because we're not behaving correctly from a sort of research point of view or methodological point of view in developing a classification. I dont kno if Matt feels similarly or differently. 

Yeah. What would you think of that Matt? Would you agree with that? 

Yeah, no, absolutely. Absolutely. Yeah. Yeah. 

And in terms of, Matt if we just finish up with you in terms of you know this is the open fracture classification system. Do you think we need to revisit more of our classifications in terms of would that A improve patient care and B do you think it would be easier in terms of running you know, a lot of the large trials that you run yourself? Is that something we should be doing more of do you think?

Yeah, I think so. I mean, you don't want to sort of mend it if it's not broken, I mean, so some of the classifications are fine and they work. We use them all the time.   The research, where you just brought home, we were struggling. So  the surgeons couldn't reliably use the [00:31:00] classifications that were existing at the point where we wanted them to randomize patients to different interventions so it has to be simple to be used practically. It needs to be reproducible. And then the research really, you know, as Alex has said, allowed us that opportunity to correlate with the patient outcomes.

And that's the key thing, really. Because if the classifications don't predict or on prognostic for the outcomes of patients think are important, then why are we bothering with them really? It doesn't really matter what we think it's what the patients think afterwards. So I think some of the classifications will be fine, but more work to look at whether they really do predict outcomes are important to patient, I think would be very valuable and probably across all of trauma and certainly orthopedics more broadly. 

No, no, I totally agree. Well, that's a good point for us to finish on and were just out of time. So thank you Matt and Alex. That was a really  good discussion, really informative. I really enjoyed it and I'm sure all our listeners did too. And I think it obviously is a really important topic that's familiar with all of us and see [00:32:00] it day-to-day.

So thank you both for joining us. 

Thank you. 

And to our listeners, we do hope you've enjoyed joining us today. And we encourage you to share your thoughts and comments through social media. Feel free to post or tweet about anything we've discussed here today. And thanks again for listening. Stay safe, everyone.