minutes for questions if anyone wants to come up. There was a question for the NPFL. If you see some lateral tilt on the pre-op MRI, do you ever address that surgically or your indications for it? And if you do, how do you actually address it? So typically even if there's tilt on MRI, the exam and under anesthesia I would say is more important. And if at that point we feel that it's really tight, we would do a lengthening laterally instead of a release. A lengthening through the same incision, separate incision? Through, we we would do it through the same incision and just move it slightly up so that we could access. Thank you. Question for Crystal. Can, speaking with Fisil respecting femoral side of tunnels, can vertical and anatomic coexist? Because I always am struggling with this. So if you could help me with that. Yeah, no, absolutely. I think, so I typically use a outside, you know, inside out drilling technique. And so my starting point is always within the center of the femoral footprint. I think when you're positioning your guide, depending on the technique that you use, you can certainly drop your hand a little bit if you're not being careful. And so I think you end up being more horizontal. And I think you can keep the same starting point and transition your angle of drilling and still have the footprint be the center of your tunnel, but come slightly more vertical. So not doing a trans-tibial, you know, like completely vertical technique, but rather using the same footprint, adjusting your guide to be slightly more vertical with your path. So to Alfred's point, John Rebo from North Carolina wrote a paper last year on that exact thing. There's a technique that Dana Piasecki developed at North Carolina called a hybrid trans-tibial technique, essentially a guide you can put in through the AM portal that then can hook a flexible pin coming through the tibia. You can put it anywhere you want on the femur and allows you to have, we actually published a note just in this year, looking at the vertical position of the tunnel compared to AM or trans-tibial. You basically get the aperture of an AM tunnel, but the trajectory of a trans-tibial tunnel. And then another plug, similar to Brian Lau's technique on for the MPFL for LATs and kids, I've evolved to doing the exact same thing on the lateral side, where I use a small little soft anchor just distal to the physis. And I would say, you know, you guys are doing it in hyperextenders and all trans-physials I've gone to using an LAT. I'm curious, just on the panel, if adoption of LAT is increasing, certainly has in my practice. So I haven't switched to doing it routinely. We've kind of all had a lot of discussion about this. So my trans-physial graft choice right now is quad tendon and our data out of Atlanta shows low single-digit failure rates with that right now at two years. And so I have not routinely adjusted to adding an LAT. I think there's great data on it. My question becomes a little bit of, how much lower can I go from low single digits right now? And so for a little bit of ease of research and maintaining some homogeneity of what we're doing, we've just done it in a revision setting or with significant hyperextension. Same here, just revision settings, not primaries. One last NPFL question. With your technique, are you checking isometry at all of your graft? It's hard to check it the same way as when you're setting the patella first and then the femur. We do it more by just setting the tension with the knee in 30 to 45 degrees of flexion and then marking the graft. But it's not like where you kind of wrap it around and check it the same way when you're doing it the other way around. All right. Thank you for all the talks today. Thank you for attending and we'll get you on to your next sessions. Thank you.

surgical techniques

lateral tilt

pre-op MRI

femoral tunnels

graft isometry