Thanks very much for four very nice papers and great presentations. Any questions from the audience? I have a question on the Achilles paper. So I noticed that there was still tendon elongation in both groups after the six weeks. Has that prompted you guys to change your protocol in terms of continuing some sort of protection after the six week time point for your Achilles repairs? No essentially after six weeks both groups underwent the same rehab protocol. Even if they lengthened we still had them undergo the same exact protocol. And there was a recent study out of Denmark in AJSM that followed their patients up to six months and also showed significant elongation. They had three groups, three different protocols, and they all pretty much elongated almost the same amount. So it wouldn't cause us to change anything in our protocol long term. It's a question on the same paper, sort of a triple question actually. So one, were the beads fixed in any way? So how do you know if they just migrated or not? And is the lengthening not just reversal of the shortening that the surgery causes? So can you correlate excessive lengthening or did your outliers who lengthened a lot lose power or lose function? They're the two questions. Because so what, they lengthened, but if functionally they're good it doesn't matter. Right. I agree with you. The lengthening hasn't affected the functional outcomes of these patients. One, each of the beads was laser etched with a hole, which allowed us to suture in the beads. There's been three previous radiographic bead studies all done out of the country in Denmark and Finland, and all of those studies did not have any method of placing the bead. They just implanted the bead within the tendon, so you can't tell if it migrated or not. But for our study we were able to get it laser etched, which I think helps hold it in place. And they were buried within the substance, so they didn't cause any protrusion underneath the skin. They're fairly small as well. And then for the, I agree with you, second part of the question, they all elongate. Some people elongate more than others, but it doesn't seem to have an effect on functional outcomes. Yeah. So did you, if your outliers, the people who lengthened the most, which group were they in? Can you say? Or were they in both groups? Yeah. Both groups. It seems to be a correlation between, you know, if looking at the exact numbers, it was the traditional group that showed 1.8 centimeters of lengthening, and the accelerated group actually showed 1.5, so. So for the fellows out there from Italy, Rick, are you early weight bearers after your Achilles tendon repairs? Similar to this, rest for 10 days to two weeks, then allow them to. Weight bearers tolerated after that with a wedge? Okay, now a guy from the United Kingdom is kind of similar to a Canadian. How many do you, how many do you not operate on? So you recommend surgery for most of your patients? Yeah. Yeah. Same in Italy? Okay. Yeah. Sir. This is a question about the fifth MET fractures and NSAIDs, and we, I've used Toradol postoperatively forever, and so the real question, you don't know when they're weight-bearing, things like that. It's a great initial evaluation. What are you doing at Kansas with your Jones fractures postoperatively, you're giving them NSAIDs? Yeah. At Kansas postoperatively, our foot and ankle surgeons and our, primarily our trauma surgeons are treating those, and they are not giving NSAIDs for high-risk fractures in general, and the trauma surgeons, there's one that won't give any NSAIDs, one that will give NSAIDs to fractures that are non-high-risk, so we're not giving them for the most part. That's a, you know, papers two and three are very complementary papers, as it turns out, because, you know, one deals with opioids, and there are obvious problems with opioids, and addressing pain management after surgery, and the second one, of course, is if you don't want to give opioids, we want, you know, everybody wants to give anti-inflammatories, and one thing we might be better, we need to be better at is using multimodal pain management, which certainly the total hip and total knee surgeons and spine surgeons, higher requirement opioid typically cases have been on the forefront of. If you, do you know the data, if you, I was at a, at a meeting recently where they looked at meta-analyses of the anti-inflammatory paper, and really, if you look at a meta-analysis, my understanding was, is the evidence is not great, and, and, and, again, some of the limitations of the study may come into effect here, particularly the location of the fracture, and the relative likelihood, depending on where the fracture is, of needing surgery, but it's a huge issue that we need to think about, because if we can use anti-inflammatories, we can decrease opioid use a lot. Steven? It was the, along the same lines, so in my practice, four years ago, I started giving all my patients Neurontin preoperatively, or Pregobalan, and that's halved our opiate usage, but actually, there are a couple of big issues with opiates. It's not really a question. I'm sorry, but there's a couple of big issues with opiates. One is neuromy, what's called neuroplasticity, so within seven days, you become tolerant of opiates, so their effect starts decreasing, so in fact, you probably should only ever prescribe opioids for five days, three to five days, something like that, and that would immediately solve your problem, but most of my patients, they should, don't worry, I have a whole bunch of Zydol in the press. If I get sore, I'll take one, so I agree, it's a big issue with a whole load of opiates residing in most home situations across the country. My one question is about the ACL study. Does your inflammatory marker profile not just show a haemarthrosis at the beginning, because almost all those patients will have a haemarthrosis, so you would expect, if you did a ELISA on a knee full of blood, to see very similar kind of inflammatory pattern, wouldn't you? So, that's a great question, so we've actually all, we've kind of sorted out a lot of that, so yeah, it is a haemarthrosis, and we're centrifuging out to basically get rid of all the blood components, and we actually have comparisons to haemarthrosis for other reasons, and the marker profile's different, so there is a pathology-specific profile that happens after injury that's not just related to blood products. What that makeup is, we're working on, we're still in the early phases of this, but we need to understand who the players are before we can start playing, we're probably going to have to go backwards and go to an animal model, but to see augmenting cytokine A, blocking cytokine B, what's the impact on the healing process and the overall outcome, but it's more than just the haemarthrosis. So etiologically, where does that come from, then? Are you saying that that comes from the actual cruciate ligament rupture in itself? I think, well, especially in the setting of the ACL rupture, I think it's the exposure of the articular cartilage to the impact during the pivot shift. So basically, the impact there... Or the subchondral bone, perhaps. Or the subchondral bone, but it's the idea is that the seed for post-traumatic arthritis, in my opinion, is planted at the second of injury, and we just have to better understand what the natural history of that is in order to change it. So if you had two groups, one with bone bruises and one without, and you compared those two groups, that would be very interesting. Yeah, it's on our list. Any other questions from the audience? With our thanks. Thank you. Good job. Appreciate your coming.

tendon elongation

Achilles repairs

rehab protocol

fixation of beads

functional outcomes