Okay. So continue to think about questions. Obviously, we've got a little bit more time for them. One of them was a question of Dr. Hayward. So did you measure vitamin E levels, especially with so many patients in the Northeast, and what do you think as a follow-up, and what do you think the role is for that, and maybe goals for that? Yeah, with the rate of prior BSIs in our cohort, including navicular BSIs, that's a real priority. Due to the retrospective nature of the study and the multicenter features, that information was just not reliable enough in our chart review to glean real takeaways. But I think we all know that stress injury, particularly in adolescent, really requires a metabolic bone workup in this high-risk area, and maybe not even if there's a recurrence. In other words, a primary fracture of this type may be required, particularly with what we're learning about REDS and nutritional issues. So we didn't measure them, but one should. Even as a follow-up, particularly for that younger aspect of the N19 cohort, how do you differentiate what may be a stress versus early cohort in that group, which is obviously a concern, but much different from what we're going to see in adults in the future? I think our understanding of Kohler's allowed us to study these advanced images pretty well and rule that out in most cases. So I think that's an important thing to know about, but usually a little bit younger when onset than the cohort with our mean age of 15. I had a great paper from Kohler, but I have a question for the two Iowa papers. This is a really important area, and I think it's kind of figuring out these subtle injuries, symptomatic injuries, which ones are significant and which ones are not significant. So I guess out of your studies, you know, looking at the volume, looking at extracortisial stress, is there a tolerance level for dysosmosis? In other words, is there a level of increased volume where it's okay, even though it's increased? Or is there an amount of extracortisial that you can tolerate? I think that's still a difficult question. I think your research really puts a lot of new ideas and information into the pot, so great work. Yeah, I think that in terms of whether or not it's okay, I would probably rely more on your clinical exam, and that if they're painful, then it's most likely not okay. I think the key takeaway from the weight-bearing CT study that I presented, where they had significantly lower diagnostic accuracy with just physiologic standing weight-bearing CT, I think in a chronic setting, you're seeing these athletes that had potentially more of a subtle type injury that was missed in the acute setting, because everyone knows that a high ankle sprain, you get stress radiographs, but they're sometimes very difficult to interpret. And I think with the Crawburn study that Dr. Den Hartog put up there, in that they loaded the cadaveric ankles without an external rotation stress, there was no opening. I think it shows the importance of doing external rotation stress to an athlete with a chronic injury, to better unmask that more subtle instability. Yeah, I think certainly that these images are a piece of the puzzle for the treatment algorithm, and so I think the real reason behind the study that I presented was that we have no true baseline data on how external rotation stress affects the area. And so hopefully that we can use these numbers kind of going forward when assessing our athletes, and if there's a difference between their external rotation stress and their weight-bearing, that could give us kind of a bigger piece of what's going on. In the acute, can you do a weight-bearing CT with pain? Depends on the patient's tolerance. Yeah, but I think that becomes the question, even as he's getting ready to talk about a sprain. The ability to get a weight-bearing X-ray or a weight-bearing CT single-legged, is that the reason why you can pick up a chronic but can't pick up an acute? And as a technical question, are they standing in this with their arms on the handles and both feet down, kneeling? A lot of that's going to matter as to what they can truly tolerate to really see if they're going to stress like they do when they try to function. Also, as a follow-up question, were there any gender-based differences on the volumes or the areas that you calculated? As in plain films, there's been several reports saying that there's gender-based differences on the widening. In the data that I presented, no, but a strong caveat is we had 11 patients, so it was really kind of tough to tease out more of a demographic kind of data. Yeah, I would say the same for my study. There was another question from the audience that was, you know, and I think it would have been addressed really well by the Lundy paper in the Lundy study. I don't know how many people have looked at the abstract, but it was, you know, either one of you looked at the combo deltoid and syndesmotic injury and whether deltoid repair is necessary if the syndesmosis is fixed. I mean, that was the crux of the Lundy study, and obviously when you're looking at an injury that wouldn't apply. Any thoughts to that as far as, you know, deltoid? If you've got deltoid and syndesmosis, you just said it makes the syndesmosis, deltoid's okay, and it kind of comes over even into your paper a little bit. Yeah, so in our paper, we definitely thought about taking out the syndesmosis when we were in our study design phase, and we decided not to just because we didn't want to, we wanted to just study the deltoid in isolation and not sort of compound our results with repairs that could have been more or less good on the syndesmosis. So, at the end of the day, I mean, I would say if the anterior portion is cut and you fix the syndesmosis of the deltoid, if the anterior deltoid is cut, you might be okay. You probably will have some good stability there, but if the full deltoid is cut, probably not so much. That would be my guess. It is interesting, though, when you do a lot of scope treatments of fractures or just plain isolated syndesmotic injuries, a lot of times the anterior portion of the deltoid's actually ripped off like almost like a rotator cuff tear, like a crescent off of that anterior portion of the medial malleolus, and so some of my higher level athletes, I'm actually doing arthroscopic repair of that area because I'm worried that they might get hind foot valgus, long-term adult flat foot problems, posterior tip tendon dysfunction, which is one of the things that sometimes rears its ugly head later on. Yeah, I think that makes sense. So it's an excellent study that you're doing. I'm Dr. Brady, the deltoid. Interesting study. So how do you actually do attach the augmentation to the talus and the medial malleolus to reproduce the deep deltoid? You said that was one of the groups. So I was the engineer on the study, not the surgeon, but the surgeon is right there, so you could talk to him about it a little bit more. Yeah, I don't know, Bob, if you want to comment on that. I think that's one of the hardest things. Obviously it's a little bit easier to replace and repair that superficial portion of the interior sleeve, but getting deeper, the key is how do you do it safely, but is it absolutely necessary? It's certainly a little bit more technically challenging, even with the radiographic, you know, and the fibers of that. And what are the implications of the tendon rubbing on the internal brace for however long it's there? Absolutely. We've looked at augmenting most of your terms, Mike, and then went away from that. We decided it was just not safe to get all the way back there, and then the study also shows that it's just not really necessary. Well, I think that the ultimate thing is also that a similar group did the study on what's the best way to stabilize the syndesmosis. Well, at time zero, in the lab study, is to do an AITFL internal brace. Do you have to do that dissection for every single syndesmonic disruption? The answer is no. So for us, the key is when is the disruption bad enough for the pathology and the warranting we need to do that pervious section, do that compared to just trying to get the sleeve and realizing, you know, stabilize the syndesmosis for fixing the fracture, when do we have to go to that next, what I call a decent week. I'm not sure what your thoughts are on that. Yeah, I think those are good comments. Again, I'm evolving as well through this whole thing. I think you guys have done a lot of good work. It's not my plan, and I failed. So keep on going. Thanks. Any other questions? I'm sort of running a little bit ahead of time. All right, well, thank you again for this. Thank you.

bone injuries

treatment

vitamin E levels

metabolic bone workup

stress injury