2024 IFFAS, Roger Mann, and Leonard Goldner Award Winning Research

Summary

The AOFAS Orthopod-Cast

Episode: 2024 IFFAS, Roger Mann, and Leonard Goldner Award Winning Research
Date: October 16, 2024
Hosts: Nick Strasser, Joe Park (AOFAS Podcast Committee)
Guests: David Gordon (IFFAS Award winner), Dr. Elizabeth Cody (Roger Mann Award winner), Dr. Cesar de Cesar Netto (Leonard Goldner Award winner)

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Episode Overview

This episode, recorded live at the AOFAS 2024 meeting in Vancouver, BC, features discussions with recipients of three prestigious foot and ankle orthopedic research awards. The hosts engage award-winning researchers about the genesis, findings, and take-home messages of their studies, offering listeners insight into high-impact research shaping current and future clinical practice. Topics include long-term outcomes in minimally invasive bunion surgery, implications of radiographic lucency in total ankle arthroplasty, and cutting-edge diagnostics for syndesmotic instability.

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Key Discussion Points & Insights

1. Minimally Invasive Chevron/Akin for Hallux Valgus (David Gordon, IFFAS Award)

Study Genesis & Data Collection

• David Gordon describes collecting prospective outcome data since starting his consultant practice and notes the challenge and diligence required for such long-term research.
  • "It's a single surgeon series, all my work... I started as a young consultant... built that into my practice immediately." (C, 01:18)
• Paper-based outcome forms transitioned to digital; consistent follow-up enabled robust long-term data.

Key Findings

• Largest and longest series to date (mean follow up 6.7 years).
• Validates the effectiveness and durability of minimally invasive techniques for bunion correction.
  • "We know now after this long time period... that it's a successful operation." (C, 02:24)
  • Overcomes early skepticism and provides confidence for wider adoption.

Study Parameters

• Primary focus: Patient-reported outcome measures (PROMS), especially the Manchester Oxford Foot Questionnaire (MOXFQ), assessing pain, function, and social interaction via patient self-report.
  • "Using PROMS was the foundation of this paper... combine those three domains into the index and that's the overall score." (C, 04:46)
• Cohort: 333 patients at 2 years, with 292 followed to 6.7 years.
• Radiological outcomes not included in this paper but planned for future analysis.

Learning Curve & Clinical Implications

• Minimally invasive surgery offers less pain and opiate use.
  • "The aim of minimally invasive surgery as we know in the literature: less pain, less opiate use." (C, 03:59)
• Technical difficulty and need for training/support emphasized.

Notable Quotes & Moments

• On the real value of long-term data:
  • "There's no way to ruin an outcome like long-term follow-up... sometimes you think you're doing a great job and it turns out you're really not." (D, 07:16)
• The importance of patient-centered outcomes:
  • "You ask the patient how they are and how they're doing, that's the most important thing." (C, 06:30)

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2. Periprosthetic Tibial Lucency After Low Profile Total Ankle Arthroplasty (Elizabeth Cody, Roger Mann Award)

Study Motivation

• Elizabeth Cody sought to clarify the clinical significance of tibial lucency seen on X-ray after low-profile total ankle replacements—in particular, how this should impact patient counseling and management.
  • "You'll see patients where you have an implant that looks loose... but they're really happy not having any pain... what is the clinical significance of that lucency?" (F, 09:18)

Key Findings

• Multiple low-profile implants included: Vantage, Infinity, Adaptus, Cadence; study included various surgeons.
• Found that 6.5% of implants developed lucency; just over half of those patients were clinically doing well at 2 years.
  • "Over 50%, so close to some 60% of the patients were doing well clinically at final follow up." (F, 13:46)
• Lucency and loosening are not necessarily interchangeable; true loosening confirmed only intraoperatively.
  • "Surgeons often, I think, use interchangeably... but we don't know for sure that it's loose." (F, 11:32)
• No immediate changes to management, but more candid and nuanced patient counseling now possible.
  • "I do see them back more often if they have that finding." (F, 12:19)
  • "I use way more stemmed implants than I used to, in part to avoid this problem..." (F, 10:53)

Clinical Pearls

• Lucency may not warrant immediate revision, and careful longitudinal follow-up is appropriate.
  • "If it seems to be stable, and they know the alternative is another big surgery... often they're good enough that they don't want that." (F, 12:19)
• Patients frequently prefer to wait rather than undergo revision unless dysfunction is severe.

Next Steps

• Plans for continued follow-up using the total ankle database to clarify long-term outcomes past two years.

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3. Semi-Automated 3D Distance Mapping for Syndesmotic Instability (Cesar de Cesar Netto, Leonard Goldner Award)

Study Overview

• Developed and validated a semi-automated technique for diagnosing subtle syndesmotic injuries using non-weightbearing CT scan with external rotation stress—a practical alternative for settings lacking weightbearing CT.

Key Insights

• Original manual measurements on stressed CT showed high diagnostic accuracy; new study used automated distance mapping, with even higher precision (tenths of a millimeter).
  • "The thresholds, the values that we're able to see are much smaller than we were able to measure... for the distance mapping we can get below millimeters, tenth of the millimeters." (E, 16:28)
• Cadaveric studies established the methodology's validity before use in clinical cohorts.

Limitations & Future Directions

• Current cohort does not include operative correlation (arthroscopic gold-standard confirmation).
• Next steps: Apply the technique to surgical cases and perform multi-center studies for greater generalizability.
  • "That's the next step that we're doing both with weight bearing CT and with non weight bearing CT." (E, 17:49)
• Algorithm openly shared for broader adoption, especially in resource-limited settings.

Clinical Impact & Broader Value

• Offers valuable diagnostic tool for syndesmotic injuries, especially where weightbearing CT is not available.
• Potential applicability to MRI—limited by acquisition time and motion artifact.

Notable Quotes

• "If you can see in the cadaver just by cutting the ligaments, you should be able to see in any clinical conditions if the ligaments are really gone." (E, 20:02)
• "[The clinical dilemma is] when to pull the trigger of doing surgery... there's still a lot of clinical expertise that's involved." (D, 17:59)

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Notable Quotes & Memorable Moments

• "There's no way to ruin an outcome like long-term follow-up." – Joe Park, 07:16
• "These are the results. Once you get there and start become competent... this is the result for the better of the patients." – David Gordon, 03:59
• "You ask the patient how they are and how they're doing, that's the most important thing." – David Gordon, 06:30
• "Lucency and loose are not necessarily interchangeable... all of them were found to be loose, but... I don’t know that you can use the terms interchangeably." – Elizabeth Cody, 11:32
• "If you can see in the cadaver just by cutting the ligaments, you should be able to see in any clinical conditions if the ligaments are really gone." – Cesar de Cesar Netto, 20:02
• "As a clinician, I think [new measurements] help to point you in the right direction. But there's still a lot of sort of clinical expertise that's involved." — Joe Park, 17:59

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Timestamps for Important Segments

• 00:27 – Introduction of award-winning guests and topic overview
• 01:18 – David Gordon on the genesis of the minimally invasive chevron study
• 02:24 – Discussion of findings and implications for minimally invasive bunion surgery
• 04:46 – Explanation of PROMs and study outcome measures
• 07:16 – Reflections on long-term follow-up and its humbling nature
• 09:03 – Elizabeth Cody introduces her study on tibial lucency and total ankle replacements
• 10:53 – Changes in implant approach and patient follow up
• 12:19 – Managing patients with radiographic lucency
• 15:24 – Cesar de Cesar Netto explains 3D distance mapping and syndesmotic instability diagnostics
• 16:28 – Comparison of automated mapping versus manual measurements; clinical validation
• 20:02 – Discussion of cadaver validation and future applications

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Summary Takeaways

• Commitment to robust, long-term outcomes research is vital for practice-changing evidence in foot and ankle surgery.
• Minimally invasive surgery for hallux valgus is validated long-term: patient-centered outcomes are essential, and adopting new technique requires perseverance and training.
• Periprosthetic lucency after total ankle arthroplasty is common yet not always clinically significant; nuanced patient dialog and enhanced implant selection (e.g. stemmed implants) can improve care.
• Innovative imaging approaches for syndesmotic instability offer promise, particularly in settings without advanced equipment; cross-disciplinary and multi-center collaboration is encouraged.

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This episode highlights the translation of rigorous research to day-to-day foot and ankle orthopedics, emphasizing both the importance of long-term outcomes and adaptability of new technologies and methodologies in diverse clinical settings.

Transcript

[A]

Welcome to AOFAS Ortho Podcast where leaders in foot and ankle orthopedic surgery discuss the issues that affect you and your practice. Please note that the views expressed on this podcast do not necessarily represent the views of the AOFAS or its members.

[B]

Welcome to the AOFAS Ortho Podcast. My name is Nick Strasser. I'm here with my co host Joe park and we are recording live at the AOFAS 2024 meeting in Vancouver BC. We're recording and visiting with some of the award winners. We have the efas Award winner, Mr. David Gordon here to talk about his work and the award winning paper, Minimally Invasive Chevron Aiken for Hallux Valgus Surgery A Prospective Observational Study with mean of 6.7 year. Follow welcome to the podcast.

[C]

Thank you very much. Pleasure to be here and delighted.

[B]

Well, congratulations on the award. That's a really great paper and we're excited for you. I would love to hear more about the genesis of this. I mean we were talking a little bit already, but these are all of your patients, is that correct?

[C]

Yeah, that's right. It's a single surgeon series, all my work and when I've been doing MI surgery for Hallux wags for about 12 years now. So when I started as a young consultant I was always very passionate about patient outcomes, even as a, as a registrar in training. So I built that into my practice when I was a consultant immediately. So started off with paper forms and then digitized it. And because I started minimally invasive surgery quite early on, I just had, you know, that data from the get go. So these are the fruits of both my labor and obviously the co authors. But yeah, so I just kept working hard and collected the data, made sure it was up to date and this is the result for the better of the patients.

[D]

So for those of us who tried to do research, it's always humbling how hard it is. And you were saying how it started with 300 something, but you were able to maintain almost half of those for, I mean it's pretty amazing, up to seven years. What would you say was the most interesting finding that you had in the study?

[C]

I think the fact that we know now after this long time period, which is the longest follow up for this data set and this operation, also the largest series for this time point that it's a successful operation. So when minimally invasive surgery came to the us like when it came to the uk, lots of naysayers, disbelievers, people thought it wouldn't work. And yeah, this proves them wrong and it gives everybody the confidence to, if they want to change the type of operation they use the Hallux Vargas that this operation is successful in the long term or the midterm.

[B]

Yeah, I think the general consensus or some of the. We do see those naysayers here in the United States and a lot of people saying the X rays look crazy and patients seem to do pretty well early on, less pain, less swelling, but really what is going to be the long term follow up. So I think this will be very valuable to our literature and giving us some confidence of what to tell patients moving forward.

[D]

Yeah, I think, you know, for me, I don't do a lot of mis and I think for those of us who are perhaps slow adopters, I think it's these kind of studies that you can quote to your patients and you know, hopefully we can improve the care that they receive. I mean doing a bunion surgery, people think it's so simple, but really it's quite humbling and often causes a lot more disability than we I knew certainly as a resident, you know, it seems so straightforward, but it really can be a long recovery and all that.

[C]

So yeah, I mean the aim of minimally invasive surgery as we know in the literature, less pain, less opiate use. I've published series on looking at severe cohort as well and it's the techniques applicable to that group as well with good outcomes. But like any new technique there is, particularly with this operation, is difficult to learn. You need some support, both from your colleagues, perhaps industry as well. But once you get there and start become competent, you know, these are the results.

[B]

So speaking of results, can you give us just like a really quick summary of what kind of things you looked at? Was it, was it the patient outcome scores? Did you look at X rays, range of motion, clinic visits? Like what were your, what were your parameters for your follow up on the study?

[C]

I mean for me I think research needs to be, we need to answer questions clearly and that's the starting point. So for me a very simple question is and what patients want to know is, you know, will they be better off to surgery? And one way you can assess that is with a patient reported outcome measure. And what's great about PROMS is it's very easy to do. You just can email a patient, they fill in a form, they do it online, so it's very accessible. And every surgeon, I believe should be collecting proms, even if it's on the most common operation they do so they can know how they're doing, they can know how their patients are doing and use that feedback loop to improve care and their own skills. So for me using PROMS was the foundation of this paper and we used a number of proms but the predominant PROM was the Manchester Oxford Foot Questionnaire which is a functional questionnaire page. Patient's just fitted out, doctor doesn't need to be involved, doctor doesn't input anything. There's no range of motion, it's just how the patient feels various domains. There's walking and standing, social interaction and pain. And you combine those three domains into the index and that's the overall score and it's very repeatable. So you can do it pre op and then send them an email in my autobainter system at any time point you want. So the two year time points which we published in the JBGS America, that was a cohort of 333 patients. We ended up reporting 292 Edison loss to follow ups. And then this paper at the 6.7 year is that same two year cohort but followed up to a minimum of five years, a mean of 6.7. But we had a few drop offs because you've got to track these patients down. So this paper doesn't have any radiological data however just got ethical approval to do exactly that. So we can X ray those patients at this time point and it's probably by the time they come for X ray, probably be six, sorry seven, seven and a half years and then we can start looking at the more detail of the radiological correction, radiological recurrence, if there is sesamoid position or all those anatomical features. But principally I think, and I'm a believer in, you know, you ask the patient how they are and how they're doing, that's the most important thing.

[D]

And would they do it again? Perhaps. Right. Would they tell their sister to get it?

[C]

Yeah, great question. Yeah, it's a good question. I mean that's not a question on the mock cfq. And you can go, oh I could ask this, I could ask this, I could this, we got to stop somewhere. And yeah.

[D]

One of my mentors in residency, he'd always say to me, you know Joe, there's no way to ruin an outcome like long term follow up. Right. Meaning sometimes you as a surgeon think you're doing a great job and it turns out you're really not. But I think this is, that's why this is remarkable. So hopefully this kind of changes the mentality even here in the States. And I mean thank you for coming to our meeting and you know, it's really.

[C]

Yeah, no, it's a pleasure to meet you. Yeah, I mean it's great to have the paper accepted, let alone be nominated for the IAAFAS award. So we were very, the whole team were really chuffed to be even nominated and then we had to write the paper in pretty much quick turnaround time which everyone stepped up and did. So it's fantastic to win. So thank you to ifos ifas too.

[D]

So just for my selfish means, I'm going to be program chair in two years. So hopefully maybe you could publish the nine year follow up or something like that. But just please join us and I think it's amazing to have the international contributions of people like you and it really makes our society so much stronger. So thank you.

[C]

My pleasure.

[D]

We're here with our award winner. So we just grabbed them. Thank you both for joining us. But for the Roger Mann award we have Dr. Elizabeth Cody, periprosthetic tibial lucency following low profile total ankle arthroplasty and my good friend Cesar here for the semi automated 3D distance mapping of conventional non weight bearing CT scan with external rotation stress demonstrates high diagnostic accuracy for subtle syndesmotic instability. And that was the Leonard Goldner award winning paper.

[B]

Congratulations to both of you.

[E]

Thanks for having us. Thank you.

[F]

Thank you.

[B]

Let's start with the Total Ankle project and tell us a little bit about what you were looking at. Obviously looking at some lower profile implants and then seeing what the rate of lucency is with those. But tell us a little bit more about that.

[F]

Yeah, so doing a lot of ankle replacements. I used to do almost all low profile implants. You know, anyone doing a lot of those, you notice you'll see patients every now and then where you have an implant that looks loose. And not all of those people are doing badly. You know, it might look loose, but maybe you're only six months in and you want to give it more time or you know, it's a year out and you really don't like the look of it. But they're really happy not having any pain. So I just, I was interested in trying to figure out more what the clinical significance is of that lucency that you see radiographically and also how those people do, you know, what proportion of those patients are going to be okay? Because I think it's a useful thing clinically if you can talk to a patient either, you know, wherever they are in their follow up and say, well, there is x percent chance that you're going to be totally fine or x percent chance that this will end up having to be revised. So I think that's very helpful clinically. So that was the goal to try to answer some of those questions.

[D]

And specifically, which low profile implants did you use?

[F]

So in the study it was, I think there were maybe five or six surgeons whose total ankles were included in the study, but it included Vantage, Infinity, Infinity, Adaptus, and Cadence. So I used to primarily do Vantage, now I primarily do Infinity, and the other surgeons have done also a variety of those implants.

[B]

And so you said before you were 6.5% Lucency. And then just practically speaking, how do you know if it's something you need to be more concerned about or you watch them more closely or how does this change how you manage things?

[F]

Well, it doesn't really change how much how I manage things, but it does change how I advise patients and, you know, what kind of information I can give them as far as how they're likely to do. Based off of the study, I. Well, based off the study and my general experience, I have switched to using more stable implants like more robust tibial fixation. So like stems. So I use way more stemmed implants than I used to in part to avoid this problem of loosening, because a lot of the patients are symptomatic, even if fewer than half of them ended up requiring revision. So I do think it's still a problem you want to avoid.

[B]

It sounds like you've started using more stemmed implants.

[F]

Yes.

[E]

Up front.

[B]

Is that fair?

[F]

Yes. Yeah. So I am using more stemmed implants, but I do think it's still helpful when you can say to a patient, well, this may end up being okay. I don't think we have to go and revise you, even though radiographically it kind of looks loose. Oh yeah. The other thing I was going to say is you were asking about like kind of loosening versus loosen C. So the study was looking at lucency around the implant. So we don't know that that means loosening. You know, it kind of looks like loosening, but that's. Those are terms that surgeons often, I think, use interchangeably will say, oh, this implant is loose, because it looks like that, but we don't know for sure that it's loose. You know, the people who had this finding and were taken back for revision, all of them were found to be loose. But I don't know that you can use the terms lucency and loose interchangeably.

[B]

Does it change how often you see Them back in follow up.

[F]

Yes, I do see them back more often if they have that finding. So let's say I see them at a year and they have that kind of radiographic appearance of loosening, but they're not doing badly enough that they want to revision. They kind of just want to give it more time and see how it goes. I'll see him back maybe in six months and see what it looks like. And as long as things haven't gotten worse, they're stable. I can push it out even longer the next time. But I don't think there's any harm in watching them if it seems to be stable. And they know the alternative is another big surgery. And often they're good enough that they don't want that.

[D]

I think those are the tough conversations where you look at, they say, Dr. Park, I still hurt so much. And then I say, okay, well we can go and do this huge revision and you know, are you doing better than you were pre op? And they're like, oh yeah, yeah, I'm still way better than pre op. And I say, okay, well let's, let's talk about the revision. They said, no, thank you, yes, it's okay, I'll come back in six months. But I think sometimes, you know, those are the, as a patient, maybe just saying, oh, you know, you have some pain and it matches with some lucency, perhaps that's even therapeutic in a way. But they still have to make that decision. Anecdotally, I've gone in and found that when they're loose, I've been back grafting and doing a little bone cement in the front, trying to give them some stability. Has worked well, these low profile implants, but it's very humbling, right? You did a beautiful surgery and they were doing well perhaps, and suddenly they're kind of calling and complaining.

[F]

And I think, and one thing I will say is, so even though in the study, if you read the PowerPoint or whatever or the abstract, it says that over 50%, so close to some 60% of the patients were doing well clinically at final follow up. Yes, that is true. But at the same time I don't think they're perfect. And you know, I do bet with longer term follow up, we are going to see more of those fail probably at a higher rate than the other group that didn't have those lucencies.

[B]

So remind me again what the follow up was on this, on this paper.

[F]

Just over two years.

[B]

Just over two years. So is there a plan to continue to follow these out to Five.

[F]

Well, we used a total ankle database, so we can always look at them again using the database in the future.

[B]

That'll be great. Well, congratulations on the award. I think it's actually, it's a very practical question to ask because I think it's something we've all seen in our practice. And so it's always fun when something like this comes out that you can actually use on a day to day basis in clinic. So congratulations to you and all your co authors.

[F]

Thank you. Great.

[D]

Okay, and then, Cesar, so we're going to move on to your study and obviously you have lots of co authors, so you have lots of people to thank. But you're currently at Duke and this is a pretty great study. I think, you know, diagnosing syndesmonic instability is hard and I think it's the same conversation as the loose total ankle, which is, do you hurt bad sometimes in these elite athletes or whoever it is that you're seeing, you have to have that discussion of is it bad enough to fix it and have you found that this changes your practice? Do you feel like you know better who to fix and who not to fix?

[E]

Yeah, well, I think, I think great, great points. I think we're applying all these new concepts to try to be more accurate on the diagnosis. So this is actually like a follow up of a study that we already published in American Journal maybe a year ago, where in Brazil we don't have weight bearing ct. We actually have one weight bearing ct. So there's a lot of excitement for weight bearing ct. But all that we were doing here, we could, couldn't apply any patients there because of the absence of that. So we developed this way of stressing the syndesmosis in a regular CT scan. And we started with doing basic measurements that were in the literature. So the first study we published was on doing direct measurements and traditional measurements between the tibia and the fibula in the front midpoint and the back point and actually showed a very high diagnostic accuracy. And those are all acute ankles for where you don't know if they are, if there is a syndesmonic injury or not. They have pain. They all had pain on the area of the syndesmosis. Some of them. We did MRI of all of them. So we knew the ones that you could see the diagnosis of the MRI with injury of the ligaments, the ones that did not. And that's the way we separated the groups and then we applied the diagnostic criteria and we had pretty good diagnostic accuracy. This follow up study was to Apply the new technology, the distance mapping that we also did in cadavers and we showed a very high accuracy for cadaveric studies. And this study is when we apply this to first time in a cohort of patients that we had in this, it's our prospective cohort. And the diagnostic accuracy actually is equivalent to what we did with the manual measurements. But the thresholds, the values that we're able to see are much smaller than we were able to measure on the millimeters in the manual measurements. And for the distance mapping we can get below millimeters, tenth of the millimeters. So it's pretty exciting. The part of this that we need to apply better is the next step is to apply the ones that underwent surgery. Right. Because then the diagnostic accuracy comes from gold standards to arthroscopy in the literature. So this study, one of the limitations that we didn't compare with artroscopy that would kind of confirm that that syndesmosis was unstable. So that's the next step that we're doing both with weight bearing CT and with non weight bearing ct. And that's going to be coming hopefully in the next coming years, next year, next award, next award.

[D]

Well said, well said. I mean, I think just going back to that, I think the clinical dilemma though of like when to pull the trigger of doing surgery. I think when you're sitting there talking to a patient and you say, you know, this is open 3.2 versus some other smaller amount. I think as, again as a clinician, I think it helps to point you in the right direction. But there's still a lot of sort of clinical expertise that's involved. And again, I think this is an unsolved problem. You know, like you see that, like you probably see it, you know, I know you see it at Duke. You see someone have an acute syndesmotic injury on the field and then you have no idea what to do for the next two to six weeks. And Nick says, sees that at Vanderbilt and I guess all the professional teams in New York, I guess that you guys see.

[B]

Well, what I like about this so much is, I mean I don't think the weight bearing CT scan or the lack of having a weight bearing CT scan in Brazil is not isolated to. I mean there's even places like I don't have a weight bearing CT scanner. And so if there is some tool that or measurements or means to be able to identify that, I think that would be really useful and then even maybe challenging it further. Is there an opportunity to apply in like an MRI or something like that with this particular stress that you're applying in the CT scan.

[E]

Yeah, well, totally. The problem with the MRI is the acquisition time is longer. And so we are kind of stressing the ankle of this patient. So we put them in 45 degrees of external rotation. We only included the ones that were able 45 degrees. But that is not all coming from the ankle, of course. That's why we did three positions, neutral with the knee extended and with the knee flexed with the knee flex was trying to get the hip out of the equation. And then of course a lot of that stress doesn't go to the ankle. We can't control patients to, to make the position we could control but not the dorsiflexion, the different quantities of dorsiflexion. But this could be applied. But I think motion artifact would be a problem for the mri. I think the big deal of this study is the first time that we're applying the distance mapping in a cohort of real patients. We also just got accepted the cadaver study that I think is an important one. That's where we validated these distance measurements. And so what we did was just cutting the ligaments in cadavers so there's no trauma, so there's no displacement of the fibula. And we got like our accuracy for the distance mapping was 0.3 millimeters. So if you can see in the cadaver just by cutting the ligaments, you should be able to see in any clinical conditions if the ligaments are really gone. That's the. And so this is the first time that we apply the same algorithm that we did for the cadavers in a cohort of patients. So the next step, like I said, it would be interesting to see the ones that we operate and check interoperatively and then you have a true diagnostic accuracy with a gold standard.

[D]

I think both these studies are amazing and I think thinking into the future, I think it's a lot of opportunities for multi center studies. I know we've discussed, discussed that before, but just a lot of us have these same clinical dilemmas and if we can collaborate and get our ends way up, I think that helps this conversation.

[B]

Yeah. Well, thank you to both of you for visiting with us today and congratulations to you and your co authors and looking forward to seeing more from both of you next go round.

[F]

Thank you.

[A]

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