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 multi-center 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. Well, I mean, even as a follow-up, particularly for that younger aspect of that 10 to 19-year-old cohort, how do you differentiate what may be a stress versus early Colars in that group, which is, you know, obviously a concern, but much different from what we're gonna see in adults with neutral bloods? Yeah, I think our understanding of Colars 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, so. I had a great paper as well, and all the papers are really, really informative, but I had a question on the two Iowa papers that I presented to you at the end of our talk. This is a really important area to have these kind of, figuring out these subtle injuries, sub-hysmotic injuries, which ones are significant and which ones are not significant. So I guess after your studies, you know, looking at the volume, looking at extra-quotation stress, is there a tolerance level for the sub-hysmosis? In other words, is there a level of increased volume where it's okay, even though it's increased? You know, or is there an amount of extra-quotation that you can tolerate? You know, I think that's still a difficult question. I think your research really puts a lot of, you know, kind of new ideas and information into the pot, so great report. 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, like, 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, like, kind of more subtle instability. Yeah, I think certainly that these images are a piece of the puzzle for the treatment algorithm, and so I think that 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. So, I have a few. I mean, 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 the sprain, you know, the ability to get a weight-bearing X-ray or a low-weight-bearing CT single-legged, you know, is that the reason why you pick up a chronic but can't pick up an acute? And then as a technical question, are they standing in this with their arms on the handles and both feet down, kneeling? I mean, a lot of that's gonna matter as to what they can truly tolerate to really see if they're gonna 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? 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, I mean, either one of you looked at the combo of 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 uninjured, it wouldn't apply. Any thoughts to that as far as, you know, deltoid, if you've got deltoid and syndesmosis, if you just said it makes the syndesmosis, deltoid's okay, and it kind of comes up even in 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 wanna, 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, push you to 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, and I've done deltoid. Interesting study, so how do you actually do the attach the augmentation to the talus of 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, but yeah, I don't know, Bob, if you wanna comment on that. Not me. So what you're going through, I was involved just in the study design phase of the blood fellowship, but I worked with Dr. Klein. We tried several different approaches, mostly looking at safety, just because it's very challenging to put augmentation in. So we used the cystotachumab in the talus. With the Sess Attacker, we want to see if we can get a more safe approach, using the floor sculptor guidance and pin first on the floor plan documentation. And then you place that deep, close to the end of the sheet, so that you don't let it come asaw across the re-packaging. So we re-jacket it once we tint it in a way so we can get exposed. Use that as a cover over the top? Yes, exactly. I mean, 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, you know, the key is how do you do it? How do you do it safely? And when is it absolutely necessary? Because it's certainly a little bit more technically challenging, even with the radiographic, you know, identifiers of that. And what are the implications of the tendon rubbing on the internal brace for however long it's there? Absolutely. We actually looked at augmenting posterior genitalia 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 a lab study, is to do an AITFL internal brace. Do you have to do that dissection on every single syndesmonic disruption? The answer is no. So for us, the key is when is the disruption bad enough with the pathology and warranting the need to do that further dissection? Do that compared with just trying to get the sleeve and realizing, you know, stabilize the syndesmosis, we're fixing the fracture. When do we have to go to that next, what I call, a decent week? Yeah, I think those are good comments. I mean, again, I'm evolving as well through this whole thing. I think you guys have done a lot of good work with him and Dr. Flanagan at Yale. So keep on going. Thanks. Any other questions? Obviously, we're running a little bit ahead of time. All right, well, thank you again for the presentation.

stress injuries

bone workup

external-rotation stress

weight-bearing CT scans

deltoid repair