In the mid-90s, a group of more than 27,000 Swedish patients who had knee replacement surgery received a postcard in the mail asking one question: Are you satisfied with the outcome?
When an overwhelming 83% of respondents said “yes,” researchers spent the next two decades focused on the remaining 17%.
“What they found is that these patients say something just feels different,” says Dr. Joseph Maratt, knee replacement surgeon at Forté. “Because of that, there is greater awareness that every knee is slightly different, and one of the best ways to change the outcome for that 17% is to personalize knee replacement based on each person’s anatomy.”
How we personalize knee replacement
At Forté, patients receive computer-assisted knee replacements, which are more personalized than traditional knee replacement surgeries.
The first step is patient-specific surgical planning. A CT scan of your knee is used to create a 3D virtual model of your unique joint. After tracking a series of points around your knee, Maratt guides it through a range of motion to capture how much it will straighten, how far it can bend and how tight the ligaments are.
“What we often see is that if we just decided to put implants in based on the 3D model alone, you’d end up with a knee that feels too tight when you’re trying to bend it,” says Maratt. “Those are the things that, in the past, would make recovery really hard.”
Maratt uses the model to determine the optimal size, placement and alignment of your implant. With help from the computer guidance system, he can optimize where bone cuts should be and where implants will go so that ligaments are ideally tensioned.
“Think of it as a simulation tool that we can use to try different combinations of things and pick the one that makes the most sense before we make a single bone cut,” he says.
The benefits of personalized knee replacement
After adjusting the software, Maratt uses robotic arm technology to help perform the knee replacement. The personalization of the process ensures just the right amount of damaged material is removed, preserving more bone and soft tissues than traditional knee replacement surgery. Robotic instruments also increase the accuracy of your implant’s positioning, reducing the risk of complications.
“It ultimately leads to less pain in the post-op period,” says Maratt. “We can’t make a knee replacement painless, but it leads to a more normal feeling knee and a faster recovery.”
What to expect from the recovery process
With a new implant in place, you’ll begin your journey to strengthen your new joint.
“We will get you up standing, walking and moving around a few hours after surgery,” says Maratt. “A physical therapist will give you a few exercises to do and visit you at home for the first two weeks after you leave the hospital.”
Just as every knee is different, so is every patient’s experience. But Maratt says most patients hit a series of milestones as they participate in physical therapy following computer-assisted knee replacement surgery:
How to know when the time is right
Determining your readiness for knee replacement surgery is a personal decision. While Maratt says he can help you understand when surgery is appropriate for your situation, only you can decide when the time is right.
“My advice is to take note if you’re unhappy with the choices you’re making, such as choosing to sit in your hotel room rather than going sightseeing with your family,” says Maratt.
“When you get to that point, don’t become sedentary,” he says. “Get back to the things in life that you like doing.”
To learn more about Forté’s knee replacement offerings using the latest techniques and technologies for the best results and fastest recovery, visit forteortho.com or call 317.817.1200.
If you suffer from severe knee arthritis that doesn’t respond to non-operative treatments, you may be considering knee replacement surgery. The procedure is a good option for patients with daily pain and limitations, as it’s reliable at relieving pain and restoring function.
“Modern knee replacement is truly an amazing procedure,” says Dr. Joseph Maratt, knee replacement surgeon at Forté. “The performance of today’s implants is much closer to feeling like your own knee than the implants of the past.”
As you consider your next steps, you may be wondering what to expect from a new knee. Dr. Maratt answers some of the most common questions he receives about life after knee replacement surgery.
Will I be taller after knee replacement surgery?
Knee replacement surgery doesn’t change your height. At most, it can give you a few millimeters. For example, knee arthritis can cause a patient to develop a bowed leg. While knee replacement surgery can correct the bow, it’s unlikely to lead to any noticeable change in the length of your leg.
Will I be able to climb the stairs to my second-story bedroom?
Most patients do not have to change their sleeping arrangements! Whether you plan to have an outpatient surgery or stay overnight, our team will ensure you’re standing, walking and moving around a few hours after surgery. As part of this early recovery process, a physical therapist will help you learn to navigate stairs. You probably won’t want to climb up and down them 10 times a day, but if your goal is to come down in the morning and go up in the evening, you’ll be fine.
Will I be able to kneel on the floor after surgery?
It’s perfectly safe to kneel on the floor after knee replacement surgery. Will you like it? Not necessarily.
There is a desensitizing program I recommend to my patients. For example, you start by kneeling on a mattress for ten minutes a day for a week and then progress to a slightly firmer surface, such as a couch cushion. Over six weeks, you’ll work your way to kneeling on a yoga mat. The last step is to try to kneel on a hard surface, but most patients don’t like it. Most generally, you’ll be able to tolerate kneeling on soft surfaces.
Will I be able to play pickleball again?
Not to worry, you should be able to play pickleball around four months after surgery. We don’t recommend becoming an ultra-marathoner, but you can have a mostly unrestricted return to sports and activities. My best advice is to ease back into physical activity to help prevent a setback due to deconditioning.
Will my new implant set off airport security metal detectors?
Yes, your implant will set off airport security detectors, but you don’t need to worry about obtaining a card or note from your physician before traveling. Simply tell the TSA officer you had a knee replacement prior to your airport screening. Since the TSA has policies and procedures for devices such as pacemakers and implants, they will be able to adjust accordingly, and off you’ll go.
Is there an age limit to have knee replacement surgery? How old is too old?
There is no “too old” for knee replacement surgery. I’ve seen 85-year-old patients in the clinic who don’t have a single thing filled out on their form other than some knee pain. That person sometimes asks, “Should I have surgery now or wait until next year?” It can be tricky, but there’s no reason to wait other than avoiding the standard risks. So, I would say to have surgery when you feel as though you need it.
There also isn’t really a “too young.” I try to get my younger patients to maximize their non-operative options and make some acceptable lifestyle changes before turning to surgery. If you are in your late 40s or 50s, it’s fine, but you’ll probably have a revision at some point in your lifetime. I have done knee replacements on patients in their 20s and 30s, but thankfully, those cases are rare.
Schedule a Consultation
Our hip and knee replacement specialists, Dr. Kevin Condict, Dr. John Hur, Dr. Joseph Maratt and Dr. Lucian Warth perform hundreds of joint replacement surgeries each year using the latest technologies and techniques to get you the best results and fastest recovery. To schedule a consultation, visit forteortho.com or call 317.817.1200.
You can also read more from Dr. Maratt as he shares some of the benefits of computer-assisted knee replacement surgery.
A better, faster exercise recovery is a goal shared by many young athletes, as well as their parents and coaches.
While a number of things can help, including good nutrition, adequate hydration and active recovery, Forté athletic trainer and outreach operations manager Jillian Hacker is quick to point out that sleep also plays a major role in a young athlete’s recovery.
“High school student-athletes need eight to 10 hours of sleep a night, on average, to recover from school, from the day, and from any physical activity to be ready for the next day,” says Hacker.
Here, she and Dr. Michael Del Busto, a rehabilitation and sports medicine physician at Forté, share five strategies to improve an athlete’s sleep and optimize recovery.
Adding wind down time to your evening routine can help improve sleep. Recommendations include participating in a relaxing and quiet activity, such as reading or journaling, and limiting screen time starting approximately 30-60 minutes before bedtime.
Keeping sleep natural generally means avoiding sleep medications due to potential side effects. Natural ways to improve sleep include avoiding alcohol, staying active, setting your thermostat at an ideal temperature (typically between 65 and 72 degrees) and turning off unnecessary lights.
Athletes on a consistent practice schedule often sleep better than those without.
“The benefit of staying on a consistent schedule is that your body knows when it’s time to start winding down and when to wake up each day,” says Hacker. “While travel can complicate this process, trying to keep athletes on track and making adjustments when needed will help them perform better across time zones.”
It’s recommended to limit caffeine and avoid after lunch.
Limiting naps to between 20 and 90 minutes can ward off grogginess that can affect sports performance and ensure that your bedtime doesn’t get pushed later into the night.
While all five strategies can help young athletes improve sleep, leading to faster, better recoveries, Dr. Del Busto shares a bonus strategy that can also make a difference in sleep hygiene.
“It’s also a good idea, if possible, to have a dedicated sleep space,” says Del Busto. “People often use a bedroom for things besides sleep, such as homework and watching movies. Reserving a space for sleep will help you fall asleep faster and sleep better.”
Focusing on these strategies can help your athletes feel more prepared for practices and games and perform to the best of their abilities.
These recommendations have been excerpted from Coaches Corner, a free monthly webinar series for coaches, athletic directors and athletic trainers. The series, developed and presented by Forté, in partnership with IHSAA, aims to arm coaching and support teams with helpful information to consider when working with their athletes. Subscribe online so you don’t miss an episode.
Ice and heat are valuable tools for treating injuries and reducing pain. The benefits include being easy to use and helping with a wide range of issues; however, it’s important to know when to use one over the other.
Forté athletic trainer and outreach operations manager Jillian Hacker says one of the most common questions she’s asked is when to treat an athlete with ice versus heat. Here, she and Dr. Michael Del Busto, a rehabilitation and sports medicine physician at Forté, explain how to know which is best for your injury and why.
The Effects and Benefits of Ice
Ice can help an injured athlete by reducing swelling and relieving pain. Ice does so by:
Additionally, ice is often a popular pick because you can work with what you have available. An ice pack or bag of frozen vegetables often does the trick. Other methods include an ice bath or ice massage.
When Ice is the Best Option
No matter your method of application, ice is most beneficial when used in the first 24-48 hours after suffering an injury or post-workout.
“The most important thing to note is that we want to use ice after exercise,” says Hacker. “Ice decreases nerve excitability and muscle function. It’s not appropriate before working out because prior to an athletic event, we want those nerves and muscles to be ready to go. We don’t want them to shut down.”
While ice is most beneficial for acute injuries, it can also be used for a chronic injury during a flare up. Just beware ice applied to a chronic injury can cause stiffness.
The Effects and Benefits of Heat
Heat can help an injured athlete by addressing pain and encouraging healing in the following ways:
Methods for administering heat can be as simple as using a heating pad or a warm towel. You can also use a hot bath or whirlpool.
When Heat is the Best Option
Heat is best suited for treating chronic injuries. One of the biggest benefits of heat is its ability to help warm up stiff and scarred tissues before exercise.
“You can use heat for backaches and stiffness,” says Hacker. “It’s a good option before a workout because of its ability to bring blood flow to the area.”
You can also use heat after an injury, but it’s important to do so cautiously. Best practices include waiting 48 hours or more after an injury to prevent increasing blood flow to the area and causing more swelling.
Best When Used in Moderation
Whether treating injuries with heat or ice, you want to use both in moderation. It’s recommended to use either modality for up to 20 minutes at a time every 2 hours to prevent burns or frostbite.
“People don’t always take these issues seriously, and that can have negative effects,” says Del Busto. “I can’t tell you how many athletes fall asleep while using an ice pack or heating pad and then get a skin injury.”
Ice and heat can provide significant pain relief when used appropriately. Following these guidelines for using ice and heat can help you get the most out of your treatments.
These recommendations have been excerpted from Coaches Corner, a free monthly webinar series for coaches, athletic directors and athletic trainers. The series, developed and presented by Forté, in partnership with IHSAA, aims to arm coaching and support teams with helpful information to consider when working with their athletes. Subscribe online so you don’t miss an episode.
No matter the activity or ability level, a sports injury can be devastating both physically and mentally to young athletes. As parents and coaches, we want to do what we can to help them stay safe, healthy and in competition. Below, Forté athletic trainer and outreach operations manager Jillian Hacker provides three tips to help prevent sports injuries and the benefits of each.
Incorporate a Dynamic Warmup
It’s no secret that stretching is essential for preventing and managing injuries. The two main types, static and dynamic, are helpful in different ways. When you think of traditional stretches, such as holding a single position for a period of time, you’re describing a static stretch that lengthens muscles and increases flexibility. A dynamic stretch, in comparison, uses sport-specific movements to prepare muscles, ligaments and soft tissues for exercise. A warmup incorporating dynamic stretches can help your athletes prevent injuries by increasing the speed and power needed for their sport.
“You only get a certain amount of time with your athletes, and using a dynamic warmup gets them moving a little bit quicker,” says Hacker. “These exercises get their muscles ready to go and introduce the athletes to what they’re going to have to do throughout practice or competition, which is important both physically and mentally.” Examples of dynamic stretches that can be incorporated into a warmup include an inchworm, lunge walk, knee hug, side lunge and hip opener.
Utilize Resistance Training
Numerous studies have shown that incorporating resistance training, also known as strength or weight training, into a practice routine has wide-ranging benefits, including injury prevention.
Resistance training helps prevent injuries by increasing lean body mass, allowing athletes to safely produce the high power and speed needed for sports. It increases bone mineral density, which helps prevent stress fractures. It also boosts muscle endurance, allowing muscles to tolerate longer bouts of sports activities.
“Large forces on the body can cause injury, but if the body is stronger, it can accept those forces at a better rate,” says Hacker. “If we train the body to know how to handle those forces, then injuries are less likely to occur.”
Follow Environmental Safety Regulations
Coaches and parents can also help prevent sports injuries by following environmental safety recommendations. Examples include being aware of and heeding severe weather alerts such as heat advisories and storm warnings.
It is recommended to suspend activities when the leading edge of a storm is within six miles of play and wait 30 minutes after the last flash of lightning and crash of thunder before resuming practice.
“Everyone should be moved inside during a storm,” says Hacker. “You want to relocate to indoor facilities such as a gym or school building because lightning can still enter open spaces such as dugouts, tents or garages.”
Additionally, athletes should be acclimatized to heat over one to two weeks to help prevent heat-related illnesses, such as heat cramps, heat exhaustion and heat stroke, which can be deadly.
“The National Athletic Trainers Association offers guidelines on gradually increasing activities and sports equipment to best protect athletes,” says Hacker. “On the first day, football players may have a single three-hour practice only in helmets and then gradually build up each day until they’re in full pads.” NATA also provides guidelines for rest, hydration and practice length as the heat index rises. Learn more about best practices related to specific healthcare topics.
These recommendations have been excerpted from Coaches Corner, a free monthly webinar series for coaches, athletic directors and athletic trainers. The series, developed and presented by Forté, in partnership with IHSAA, aims to arm coaching and support teams with helpful information to consider when working with their athletes. Subscribe online so you don’t miss an episode.
As the River States Conference volleyball tournament came to a close in early November, IU Kokomo players were celebrating an undefeated conference season and tournament. As one of the team’s biggest advocates, athletic trainer Fabian Munoz also had a lot to celebrate.
“We had a lot of injuries this year,” says Munoz. “It felt good to help keep them on the court and see them be successful.”
Munoz serves dual roles as an athletic trainer at Forté Sports Medicine and Orthopedics who is also embedded year-round with IU Kokomo Athletics. This unique position is part of Forté’s outreach program, which creates partnerships with teams and clubs across the state to better serve athletes of all sports, ages and abilities.
As part of an embedded partnership, Forté’s athletic trainers work alongside teams to help enhance the student-athlete experience in four significant ways.
Providing Injury Prevention, Triage and Treatment
An athletic trainer is a medical care professional whose training encompasses the prevention, examination, diagnosis, treatment and rehabilitation of acute and chronic injuries and medical conditions.
When athletic trainers are embedded with a team, they can implement injury prevention programs and warm-ups designed to keep student-athletes healthy and ready to play. Additionally, the immediate triage and sports medicine treatments they provide when an injury does occur can help shorten recovery times.
Expediting Access to Top Specialists
In the event of an injury, Forté’s embedded athletic trainers are also equipped to help student-athletes, parents and coaches expedite the next steps in the treatment process. Munoz and his colleagues have direct access to and relationships with Forté’s orthopedic specialists and physical therapists. This guarantees their athletes are seen – fast.
“We can treat most issues in-house, but we can also streamline the athlete’s ability to be seen by a physician when needed,” says Munoz.
Personalizing Physician Recommendations
The benefits of working with an embedded athletic trainer also go beyond expedited appointment scheduling.
Courtney Cox, a Forté athletic trainer embedded with the Indiana Fire Academy, says her soccer players can experience a variety of acute injuries, from ACL tears and ankle sprains to wrist fractures and concussions. When these injuries happen, Cox provides players and their family members with personalized physician recommendations.
“We have the benefit of knowing the specialties of each of the physicians at Forté,” says Cox. “We can recommend who an athlete should see based on their injury.”
Return to Play
Additionally, embedded athletic trainers can help injured student-athletes reach the finish line in their recovery and get back to play as quickly and safely as possible.
“I attend many Forté appointments with my injured athletes,” says Cox. “When they come back to training with me, I know exactly where they’re at in their recovery and their progression in return to play because I was on hand during visits with their physicians and physical therapists.”
Creating Special Bonds
Ultimately, the relationships built with embedded athletic trainers over seasons and through shared experiences create special bonds that better serve student-athletes and their support teams.
“Parents and coaches are always super grateful that they don’t have to do research on their own,” says Cox. “They know us, and they know we want the best for their kids. Because of that, they’re willing to trust us.”
The success achieved together can also feel that much sweeter, as in the case of IU Kokomo’s win at the 2023 River States Conference volleyball tournament.
“My favorite moment was seeing the ladies finish a regular season sweep and a conference tournament sweep,” says Munoz. “We ended on a high note with everyone staying healthy and having a lot of success.”
Want to learn more about Forté’s Outreach Program? Forté’s athletic trainers currently serve 10 individual sports organizations, two dance companies, the Indianapolis Colts cheerleaders and six public safety departments. Find out more about Forté’s Outreach Program online or by calling 317.817.1200.
More resources for you:
Total shoulder replacement is a procedure to resurface both sides of your shoulder joint with implants meant to feel and function like your natural shoulder.
There are two types of total shoulder replacements – primary and reverse. The primary replacement, which involves replacing the ball and socket sides of the joint with parts that closely resemble the natural shapes of your bones.
While the procedure effectively relieves pain and improves function, it’s not appropriate for every situation. Dr. Dale Snead, an upper extremity injury specialist at Forté, helps break down the differences between a primary and reverse shoulder replacement and how to know when a reverse is the better option.
What is a reverse shoulder replacement?
To understand who benefits from a reverse shoulder replacement, it helps to understand the procedure itself. Like primary shoulder replacement, a reverse involves resurfacing both sides of the joint so that they still fit together like a ball and socket. However, the positions of the implants are reversed.
A metal ball implant is attached to your shoulder blade where the socket used to be, and a plastic socket liner fits at the end of your upper arm bone.
Who may need a reverse shoulder replacement?
While primary shoulder replacement only works for arthritis patients whose tendons are still intact. You may be a better fit for a reverse shoulder replacement if you:
A reverse procedure works well in these cases because you don’t need the full use of your shoulder muscles or tendons to stabilize your shoulder joint and help it function. Additionally, your surgeon doesn’t need as much healthy bone to work with while attaching your implants.
How do surgeons plan for and execute a reverse shoulder replacement?
Like primary shoulder replacements, Forté surgeons performing reverse procedures utilize new technology for patient-specific surgical planning. The first step involves taking a CT scan of your shoulder.
The CT image is used to create a 3D virtual model of your joint that will be used to simulate the surgery prior to your procedure. This enhanced surgical planning enables your surgeon to determine:
Your surgical team will also use the software to create a customized guide to help align the implants as planned during your shoulder replacement surgery.
“These patient-specific guides are vital,” says Snead. “I use them every time, with every patient, so that the components are in the best place for your unique anatomy and provide the best possible outcome.”
What can I expect after reverse shoulder replacement?
Like a primary procedure, patients with a reverse shoulder replacement typically experience complete pain relief; however, a reverse is not as effective at restoring function and strength. That’s because the same engineering that allows your muscles and tendons to work more effectively can also limit range of motion.
“The reverse procedure isn’t as good at restoring function as an anatomic replacement would be, but it’s a better range and quality of movement than the patient would have had,” says Snead.
How do I know when the time is right for a reverse shoulder replacement?
Choosing to move forward with a reverse shoulder replacement is a personal decision. While your surgeon can help you understand what would be appropriate for your situation, only you can decide when the time is right.
“When someone asks, ‘Should I do this?’, my response is to ask how much it affects you,” says Snead. “If pain keeps you up at night or you’re grumpy all the time, and no one wants to be around you, it might be time to try something different.”
“It’s rare to get too far where we can’t help you with your shoulder,” Snead says. “Reverse shoulder replacement allows us to treat patients with conditions that previously had no solution.”
To find out if you are a good candidate for reverse shoulder replacement, call 317.817.1200 to schedule a consultation.
You can also check out our additional resources for shoulder replacements:
There’s a lot of talk about stem cells, orthobiologics and regenerative medicine in orthopedics. Can they naturally heal tissues and pain? We invite you to join sports medicine physician Dr. Matthew Negaard for a free breakfast and a discussion on evidence-based and practical approaches to stem cells, orthobiologics and regenerative medicine.
This seminar is open to the general public.
AGENDA
WHEN
Saturday, January 6, 2024 | 9 - 10:30 am
WHERE
Orthopedic Center of Excellence
10767 Illinois St. Suite A2800, Carmel, IN 46033
Free parking is available in the attached garage.
REGISTER NOW
Within 36 hours of shoulder replacement surgery, U.S. Army veteran Biane Kidwell could tell the procedure had been successful.
“There was a distinct difference between the shoulder pain I had for years and the post-op pain,” says Kidwell, a former paratrooper. “The pain I’d been living with was completely gone.”
As significant as a successful outcome was, being seen and heard by the surgeon who performed it was equally so.
Forté Specialist Offers Treatment Solution
Kidwell says Forté shoulder and elbow specialist Dr. Michael Bender took her concerns seriously during their first meeting. He didn’t shy away from her complex medical history – which resulted from a decade of military service filled with injuries and traumas.
“He did not offer the two demoralizing and insulting responses I most often receive from doctors, which are, ‘You can live with it,” and ‘Nothing’s wrong. You’re just an anxious woman,’” says Kidwell.
Instead, Bender performed a thorough exam of her left shoulder, reviewed prior tests and offered Kidwell a treatment solution – reverse shoulder replacement surgery. Reverse shoulder replacement involves switching the placement of the ball and socket implants. It is an effective option for patients like Kidwell who have had multiple rotator cuff injuries and surgeries.
Respect and Kindness for Patients with PTSD
Kidwell agreed to the surgery, but she knew there would be challenges to her surgical experience.
She has complex post-traumatic stress disorder, or C-PTSD, and can experience traumatizing flashbacks as she awakens from surgery.
“More than 50 surgeries have taught me the best strategies to handle these flashbacks, so prior to surgery, I share them with my surgeon and anesthesiologist,” says Kidwell. “They include using my first name and telling me I’m safe.”
After surgery, Kidwell’s shoulder was wrapped in a shoulder sling and ice wrap that enveloped her entire shoulder, front and back. She says she felt trapped as she started to wake up, which caused a panic attack and then a distressing flashback.
“I panicked and tried to remove the sling and ice wrap,” says Kidwell. “I tried to get out of bed, thinking I needed to escape, and suddenly, Dr. Bender was there.”
“What broke through the fear and panic was his calm manner, respect and kindness,” she continues. “There was zero recrimination – no yelling at me to calm down. He swiftly removed the sling and ice wrap, all the while talking to me gently and telling me I was safe.”
Kidwell says the C-PTSD-fueled panic attack and flashback receded within minutes.
“I cannot adequately express how unusual his response was,” says Kidwell. “In my experience, most medical personnel bark at you to ‘Just calm down!’”
Kidwell says she highly recommends Bender for his surgical skill, caring demeanor and ability to handle PTSD-triggered reactions post-surgery.
Looking to the Future from a Place of Gratitude
Kidwell is four months into her recovery and says Dr. Bender’s work has greatly improved her quality of life.
“I can now reach above my head into a cabinet, do yoga within current physical therapy guidelines and flip down the sun visor while driving,” says Kidwell. “It all seems so simple, but it matters.”
The former paratrooper is nearing the end of PT and setting new goals, such as skydiving again if given the okay by her doctors, gardening and returning to daily hiking. She is also considering a return to work as a patient advocate, a job she held in the past.
As Kidwell looks to the future, she’s doing so from a place of deep gratitude and renewed hope.
“When we encounter people who treat us with dignity, respect and kindness, we need to speak up and say thank you,” she says. “I am thankful Dr. Bender accepted me as a patient. He chose to say, ‘I think this can be fixed,’ and then he did just that.”
As of publication, U.S. Army veteran Biane Kidwell is four months into her recovery from reverse shoulder replacement on her left shoulder. She is also recovering after receiving VA approval for a procedure on her right shoulder, also performed by Dr. Bender.
To learn more about Forté’s joint replacement offerings, visit forteortho.com. To schedule a consultation with one of Forté’s joint replacement specialists, call 317.817.1200.
Our Forté Fast orthopedic urgent care clinic in our Noblesville location will close at 12:00 pm on Friday, April 26th.
