So we have plenty of time for questions, so if we could have the speakers come up and have a seat at the table. I want to congratulate you all on excellent talks. And we'll open up the floor to the audience for questions. Just one moment, let them. The Mayo Clinic study, the RIP study, why didn't you assign something for Patel-Alta? It seems to me that's about one of the biggest factors. Can you just give them one second to have a seat first so that they know who you're talking to? Hang on. Okay, can you repeat the question, please? All right, for the Mayo Clinic study, the RIP study, why don't you assign something to at least one point to Patel-Alta? You gave trochlear dysplasia one, and you gave young age two, and of the two, those dysplasia and Alta probably are more important than young age. Thank you for the question. So I believe that going from univariate to multivariate highlights the fact that many factors are multicollinear, so they seem to track together, and so we can have those that rise to the top that have the greatest predictive ability stay, whereas those that contribute independently might drop out, and that's something that's been found with other studies. So Dr. Arndt's group up in the Twin Cities recently published a large group of patients that similarly, they did some multivariable analysis, and while Patel-Alta, in particular, Ketan and Shams' index greater than 1.3 did have predictive value for them on their univariate analysis, it also fell out on their multivariate analysis, so perhaps there's better measures or different measures that more accurately predict instability when taken as a whole. Whatever that means, sorry. So basically he's saying that they did an analysis, they did the regression, that particular thing did not correlate, so they didn't keep it. Hard to believe. Second question to Dr. Bravman and Colonel, is it Captain or Colonel? Captain. Captain. Seems like the results aren't very good. You got 25% in Mr. Bravman, Dr. Bravman's support, that had continuing difficulty. What was that from? And similarly in the military. Lots of people are not getting better. I think our results, I don't know if patients aren't getting better. I think that our average age of 23 up to about 30 I think represents a significant time change in most people's lives activity-wise, and it's something that we didn't specifically evaluate with a detailed questionnaire, though 50% that did return to A sport, though not their pre-injury level of sport, I think that's common for many people in that age group regardless, and I think the stability of the knee with no recurrence of instability and a low rate of recurrent operations, I think is actually probably normal in a normal-based population, so I think it represents what we're really seeing in the real world. I think the comment really is that for the younger patients and the higher-level tegners coming in, they did have a higher rate of return to their pre-injury level of sport, so I think it's very much dependent on the particular patient and their stage in life and their competitive level. You said there was 23% or 27% that had dysfunction. What was the dysfunction, the residual dysfunction? It's on your screen. I don't think, it was 27% in our study that had a concomitant osteotomy? No, on your circle graph at the very end, there was 23% or 27% that said. Oh, that's, yeah, that was a, thank you. That was a subjective question that was not further characterized, and so that was some problem with their knee that they perceived either pain or disability but not instability. So I don't know, maybe now that we're learning from the other papers in the study, maybe our graft is tensioned inappropriately or maybe we're developing arthrosis in these patients and maybe pain is predominating, but. If I may now, you guys can talk offline a little bit more. There are other questions we'd like to get to. Thank you. Quick question for Dr. Yankee, Adam. Interesting study. So do you think the difference is between proximal and a complete transection of the MPC? Do you think it's strictly because of the soft tissue origin to quad of the proximal portion versus like the osseous restraint distally, or do you think it's because of the obliquity of the proximal portion down to the femoral insertion versus more straight across the way we, typically a lot of times people will reconstruct or repair MPFL, or is it something different or a combination? Yeah, it's a great question. I think it's a combination of a few of those different factors. You know, if you can imagine, like you said, you have a direct connection between the osseous attachments and the obliquity might mean that these take up tension first and that are more linear, and then the oblique ones come into play as a secondary restraint and potentially mainly an extension based on what we saw with our data. I'd like to ask the panel what their protocol is now for counseling their patients about having MPFL reconstruction. If any of these studies change what you do, and does the recurrence rate, do you stratify that for athletes versus non-athletes? I can start that one if that's okay. Mine's a little bit easier from a military perspective. I know exactly what physical demands are put on the patient based on their military occupational specialty, so I have a little bit easier time telling somebody that sits at a desk and works on the computer all day that they'll probably get back to their military-specific demands versus an infantry person who's gonna jump out of airplanes and want to be able to have pain-free knee mechanics after that. So from a counseling perspective, I don't know that I would change anything based on the data. It's good to know that we actually found similar data from the civilian side with high-level athletes compared to our military personnel. It's reassuring that we're performing at the level of the civilians. Yeah, I don't have much to add to that. I think I'm encouraged by our data set that the younger patients that come in with higher activity scores seem to get back to that pre-injury level of activity at a greater rate, and I think that for me is the take-home that I counsel patients on. Anybody else at the panel wanna speak up? I think that if you look at older studies, they mainly just looked at recurrence rates, and we know that we're pretty good at preventing recurrence of dislocation, but it's all this other factors that are being presented that matter, and when you counsel a patient, you need to be complete, because they may be upset if they hear, well, I didn't know I wasn't gonna be able to get back. I may not be dislocating anymore. So I think it just helps have that discussion and be more open with them, and ultimately that may help outcomes. All right, it's five o'clock, so unless there are any other burning questions, we'll wrap it up. Congratulations to the speakers.

panel discussion

Mayo Clinic study

RSI study

Patel-Alta

predictive ability