ACL Reconstruction: The MOON Group: What does Data Show?

Transcription

1 2015 CU Sports Medicine Fall Symposium Oct. 2 ACL Reconstruction: The MOON Group: What does Data Show? Kurt P. Spindler, MD Vice Chairman Research ORI Director, Orthopaedic Clinical Outcomes Academic Director, Cleveland Clinic Sports Health Orthopaedic Rheumatologic Institute Cleveland Clinic Adjoint Professor Orthopaedics Vanderbilt University Medical Center 2012 Winner Ann Doner Vaughan Kappa Delta Award

2 Disclosures Kurt P Spindler 1. Current FUNDING a. NIH R01 = MOON (K Spindler PI) b. NIH R01 = MeTeOR study (J Katz - PI) c. NIH R01 = ACLR Healing (B Fleming- PI) d. NIH RO1 = ACL Healing (M Murray PI) e. Unrestricted Educational Gifts DonJoy AOSSM = MARS f. Research Grant: Smith & Nephew Calaxo g. Research Grant: Arthritis Foundation 2. Patent: Intra-articular Healing Ligaments 3. Consultant: NFL, Service Excellence, Mitek 4. Scientific Advisory Board: Cytori Sports Health

3 KP Spindler and RW Wright: N Engl J Med 359;20: , Nov 13, 2008 Sports Health

4 Anterior Cruciate Ligament (ACL) Normal ACL ACL Tear Scope ACL Tear Sports Health

5 Medial and Lateral Meniscus Normal meniscus Bucket handle MM Partial LM tear Spindler and Wright. N Engl J Med 359:20, , Nov 13, 2008 Sports Health

6 Articular Cartilage Normal LFC Focal defect LFC Normal MFC Spindler and Wright. N Engl J Med 359:20, , Nov 13, 2008 Early GII Chondromalacia MFC Sports Health

7 MOON ACLR Multicenter Cohort: 1. Patient-Reported Outcomes and Failure 2. Specialized Cohort: Initiation and Predictors of OA Year Development & History MOON 2. NIH Initial 2 Year Follow-up ( 06-10) & Competitive Renewal 6 Year F/U ( 10-15) Competitive Supplement add 1241 ( 13-15) Competitive Renewal 10 Year F/U ( 15-20) 3. Why MULTICENTER? a. Sample size Outcomes events occur < 10% of time b. Timeliness obtain relevant results within years c. Generalizability to treatment of ACL tears

8 VANDERBILT UNIVERSITY Kurt P. Spindler, MD Warren R. Dunn, MD, MPH Charles L. Cox, MD, MPH CLEVELAND CLINIC FOUNDATION Richard D. Parker, MD Jack T. Andrish, MD Morgan H. Jones, MD, MPH John A. Bergfeld, MD THE OHIO STATE UNIVERSITY Christopher C. Kaeding, MD David C. Flanigan, MD Robert Magnussen, MD UNIVERSITY OF IOWA Ned Amendola, MD Brian J. Wolf, MD, MS WASHINGTON UNIVERSITY ST. LOUIS Rick W. Wright, MD Matthew J. Matava, MD Robert H. Brophy, MD Matthew V. Smith, MD HOSPITAL FOR SPECIAL SURGERY Robert G. Marx, MD UNIVERSITY OF COLORADO Eric C. McCarty, MD Michelle L. Wolcott, MD Armando F. Vidal, MD

9 Site Support Staff VANDERBILT UNIVERSITY Laura Huston, MS Frank Harrell, Jr., PhD Emily Reinke, PhD Sam Nwosu, MS John Shaw Zhouwen Liu, MS Suzet Galindo-Martinez Thomas DuPont Brooke Rode * JoAnn Alvarez Erica Scaramuzza * Angel An, MS * Lynn Cain CLEVELAND CLINIC FOUNDATION Leah Schmitz, PA-C * Lynn Borzi, MBA, RN Michelle Hines, RN * Julia Brasfield, PA-C Maxine Cox * Kristin Banjac, PA-C Sharon Komninos * Pam Koeth, PA-C THE OHIO STATE UNIVERSITY Angela Pedroza, MPH Kari Stammen Rose Backs, PA-C, ATC Amber Thompson UNIVERSITY OF IOWA Catherine Fruehling-Wall * Carla Britton, PhD WASHINGTON UNIVERSITY ST. LOUIS Amanda Haas, MA Linda Burnworth Robyn Gornati Deb Hanson Michelle Cooper HOSPITAL FOR SPECIAL SURGERY Lana Verkuil * Kaitlyn Lillemoe * Patrick Grimm * Brian Boyle * Jessica Ryu UNIVERSITY OF COLORADO Cyndi Long * Paula Langner * Christine Bennett * John Gines Key: * denotes former contributor

10 MOON Coordinator Centers Vanderbilt and Cleveland Clinic PROJECT DIRECTORS Laura J. Huston, MS Emily K. Reinke, PhD RESEARCH ANALYSTS John Shaw Suzet Galindo-Martinez Erica Scaramuzza Brooke Rode EDITORIAL ASSISTANT Lynn S. Cain BIOSTATS Frank E. Harrell, Jr, PhD Chair VUMC Michael Kattan, PhD Chair CCF Zhouwen Liu, MS Thomas DuPont Sam Nwosu, MS HEALTH SERVICES RESEARCH CENTER Robert S. Dittus, MD, MPH CONSULTANTS Braden C. Fleming, PhD Martha M. Murray, MD Warren R. Dunn, MD, MPH

11 Scientific Validity MOON Group To establish the consistency of measurements and techniques across 7 sites, multiple validity studies have been performed: 1. Inter-rater Agreement of Meniscus Tears and Treatment. Dunn, AJSM, Inter-rater Agreement of Articular Cartilage Classification. Marx, AJSM, Systematic Review of Autograft ACLR: Does Graft Choice Really Matter? Spindler, AJSM, Intra- & Inter-surgeon Agreement on ANATOMIC Femoral and Tibial Tunnels ACLR. McConkey AJSM 2012 & Wolf AJSM 2013

12 Intra- and Inter-Surgeon Agreement ACLR Tunnel Placement McConkey AJSM 2012 & Wolf AJSM Intra & Inter-surgeon variability a. 12 surgeons - 6 knees: CADAVER b. Tunnels reproducible across technique and experience c. Statistical differences, but doubt clinically relevant 2. Intra & Inter-surgeon variability a. 8 4 sites: PATIENTS b. Small variations between and among surgeons c. Statistical difference, but doubt clinically relevant

13 Entire MOON (PRO) Cohort F/U Enrollment Years N 2 Years 6 Years 10 Years PRO Forms % 83% 82% KOOS % 82% 04 = 81% IKDC % 81% Marx Total % 82% 82% SF-36 >90% f/u failure and additional surgery (via phone)

14 MOON NESTED Cohort 2 Yr f/u (Standing MTP XR for JSN) Enrollment Years TOTAL Completed ONSITE Onsite: MTP standing XR for joint space measurements KT-1000 AP laxity & independent blinded PE Patient-Reported Outcomes (KOOS, Marx, etc.) Functional HOP testing

15 PATIENT RISK FACTORS ON ACLR OUTCOME: DEMOGRAPHICS Is Age a risk factor for ACLR failure? Is Gender a risk factor for future activity after ACLR? Is Baseline Activity Level a risk factor for future activity after ACLR? Yes: increased failure of ACLR in younger individuals Yes: lower activity level (Marx) in females Yes: higher activity level in individuals with higher baseline activity level 4 Is BMI a risk factor for ACLR activity and patient-reported outcome (PRO)? Yes: higher BMI predicts lower activity and worse outcomes 5 6 Is Smoking a risk factor for ACLR activity and PRO? Is Education a risk factor for ACLR outcome? Yes: lower activity level and worse outcomes Yes: less education years worse outcome

16 PATIENT RISK FACTORS ON ACLR OUTCOME: INJURY EXTENT 1 Is a Grade 1 or 2 MCL injury a risk factor for ACLR outcome? No: Not a risk factor 2 Is a LCL injury a risk factor for ACLR outcome? Yes: More symptoms in individuals with LCL injury 3 Is a Medial Meniscal repair a risk factor for ACLR outcome? Yes: worse outcome with repairs 4 Is a Lateral Meniscal repair a risk factor for ACLR outcome? No: lateral meniscal repair same as no lateral meniscal tear 5 Is an Articular Cartilage injury a risk factor for ACLR outcome? Yes: worse outcomes with Grade III/ Grade IV chondromalacia

17 SURGICAL DECISIONS ON ACLR OUTCOMES 1 What is the risk of ACLR graft failure at 2 years? Autograft: 1-6% Allograft: 2-20% Kaeding AJSM What is the best graft source (autograft or allograft)? Lower failure AUTOGRAFT especially Younger (see Figure 1) 3 What is the reoperation rate for failure of meniscus repair during ACLR? 4-6% 2488 Primary ACLR >92% 2years

18 RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS) 1 Will I be able to return to sports? Unknown except FB & Soccer 2 What are my chances to return to play American Football? 3 What are my chances to return to 4 play Soccer? What will my future activity level be after ACLR based on the Marx Activity Scale? 5 What will my future patient-reported outcome on the KOOS? High School ~70% College ~70% 50% cited fear as critical factor for not returning ~70% Males more likely to return than females to RTP Decreased activity with a 4 point loss on the Marx activity scale at 2 years. Improved, but not normal 6 What will my future patient-reported outcome be after ACLR based on the IKDC? Improved, but not normal

19 PAIN SUBSCALES AND ACTIVITIES OF DAILY LIVING INSTRUMENTS PRO 1 2 What causes knee pain at time of surgery for ACLR? KOOS Pain Subscale BMI, female gender, older age, and LCL injury Bone bruise not associated with pain after ACLR Improved outcomes with higher baseline scores, lower BMI, nonsmoker, and untreated lateral meniscal tears Poorer outcomes with lower education, medial meniscal repair, grade IV MFC, MTP, LTP, grade III LTP, MTP, revision ACLR 3 KOOS ADL Subscale Improved outcomes with higher baseline scores, lower BMI, nonsmoker Poorer outcomes with lower education, contralateral ACLR, medial meniscal repair, no lateral meniscal tear, Grade III/IV trochlea, revision ACLR 4 KOOS QoL (Knee Related Quality of Life) Improved outcomes with Higher baseline score, non-smoker, untreated LM tear 5 SF-36 PCS (physical function) Poorer outcomes with lower education, contralateral ACLR, MM repair, grade IV MFC, LFC or MTP, revision ACLR Improved outcomes with higher baseline score, lower BMI, younger age, excised or untreated LM tear Poorer outcomes with revision ACLR, lower education, smoker, grade III/IV LTP 6 SF-36 MCS (mental function) Improved outcomes with higher baseline score, higher baseline Marx Poorer outcomes with less education, smoker/quit

20 RISKS FOR ADDITIONAL ARTHROSCOPIC SURGERY 1 2 What is the risk of ipsilateral knee ligament reconstruction failure at 2 years? What is the risk of an ACL tear in the normal contralateral knee at 2 years? 6 years? 2 years 4.9% 6 years 7.7% Median time to event: 17.1 months (See Figure 1 for Individual Risk) 2 years 2.5% 6 years 6.4% Median time to event: 27.3 months 3 (See Figure1 for Individual Risk) What is my risk of infection after ACLR? 0.4% 4 What is the risk of surgery for arthrofibrosis? 2 years 4.1% 6 years 5.4% Median time to event: 13.1 months (cyclops), 2.2 months (MUA), 18.2 months (synovectomy) 5 6 What is my risk of meniscal repair failure? 2 years 4% re-operation What is my risk of hardware removal? 2 years 0.6% 6 years 1.3%

21 Marx 2 & 6 Years Cox AJSM ACLR with 85% min 6 yr f/u with multivariable statistical modeling Marx Outcome 2. Marx activity (scale 0-16) t0=12, t2=9, t6=7 3. Proven Predictors of MARX Athletic activity a. Age h. Grade 4 CM MFC b. Gender i. Competition level c. BMI j. specific sport d. Smoking e. educational status f. revision ACLR g. time from surgery

22 Marx 2 & 6 Years 1. NOT significant predictors Marx! a. meniscus injury and treatment b. autograft choice c. Grade 1-4 CM at surgery except MFC

23 Cost-Effectiveness Analysis of Early Reconstruction versus Rehabilitation & Delayed Reconstruction for ACL Tears Mather AJSM June Data Sources: KANON RCT & MOON 2. Markov Decision Modeling 3. Costs based 2012 US 4. SF-6D (component of SF-36) 5. RESULTS: Early ACLR results had both: increase 0.30 QALYs (Quality adjusted life years) lower cost $1797 (2012$) Threshold 17% failure 6. Societal Point of view early ACLR is more cost effective and preferred strategy

24 Baseline Predictors of Health-Related Quality of Life After ACLR A Longitudinal Analysis of a Multicenter Cohort at Two and Six Years Dunn JBJS Am April Data MOON = 1512 ACLR 2. Follow-up = 93% with Multivariable Analysis 3. ACLR effect size 1.2 for PCS score SF Mean utility gained at six years after ACL reconstruction was 5.3 quality-adjusted life years(qalys) 5. Identified predictors Better and Worse PCS SF-36 which similar to KOOS & IKDC

25 Prospective Analysis of 2488 Primary ACLR From the MOON Cohort Risk Factors and Predictors of Subsequent ACL Injury in Either Knee After ACLR (Kaeding April AJSM 2015 ) 1. MOON AOSSM Presented Primary ACLR % 2 years 4. AVOID failure by NOT using allografts high school and college! 5. RESULTS: Age and activity were predictors of increased risk of both ipsilateral and contralateral ACL tear Ipsilateral ACLR Graft failure

26 Factors Associated with Infection Following Anterior Cruciate Ligament Reconstruction Brophy JBJS Am March Data MOON = 2198 ACLR 2. Follow-up > 85% with Multivariable anlaysis 3. Infection was defined as an ACLR required postoperative surgical irrigation and debridement. 4. Overall rate infection = 0.77% 5. Diabetes significant Increased risk OR = Autograft BTB significantly lower risk infection then Autograft HG or Allografts

27 Meniscus treatment and age associated with narrower radiographic joint space width 2 to 3 years after ACLR: data from the MOON onsite cohort (Jones, M Osteoarthritis and Cartilage 2015) N=261 yrs 1. Measure joint space width min 2 yr after primary ACLR within MOON nested cohort Normal and untreated small stable tear not different 2. Medial meniscus repair significantly more narrowing than normal untreated; however, medial meniscus repair was significantly less narrowing than excision 3. Caveat: repair based primarily on tear type and vascularity thus surgeon cannot switch from excision to repair JSN

28 Powerful Role AGE in JSW MOON ORBITS JSN Jones, M Osteoarthrtis & Cartilage 2015

29 KOOS Pain as a Marker for Significant Knee Pain Two and Six Years after Primary ACLR: A MOON Prospective Longitudinal Cohort Study Wasserstein Osteoarthritis & Cartilage Data MOON = 1761 Primary ACLR 2. 6 years > 86% with Multivariable analysis 3. Significant Knee PAIN present 9-39% ACLR 6yrs 4. Dominant risk factor is a Second Surgery either revision or simple scope 5. Demographics and articular cartilage and meniscus injury also influenced knee pain but to a lesser extent then second surgery

30 Can MOON Evaluate: ELITE Athlete or Why Revision ACLR Worse Outcomes 1. Elite athlete: NO! inadequate sample size 2. Revision ACLR = NO! Worst Predictor of Outcome! a. MARS was born to evaluate predictors (84 surgeons, 53 sites have enrolled 1200) b. Funded NIAMS PI: Rick Wright MD c. >80% 2 yr f/u in Fall 2013 d. AOSSM Award paper submitted 11/1/13 results presented AOSSM 2014

31 MOON Publications 1. Dunn WR, Wolf BR, Amendola A, Andrish JT, Kaeding C, Marx RG, McCarty EC, Parker RD, Wright RW, Spindler KP. Multirater agreement of arthroscopic meniscal lesions. Am J Sports Med Dec;32(8): Marx RG, Connor J, Lyman S, Amendola A, Andrish JT, Kaeding C, McCarty EC, Parker RD, Wright RW, Spindler KP; Multicenter Orthopaedic Outcomes Network. Multirater agreement of arthroscopic grading of knee articular cartilage. Am J Sports Med Nov;33(11): Wright RW, Dunn WR, Amendola A, Andrish JT, Bergfeld J, Kaeding CC, Marx RG, McCarty EC, Parker RD, Wolcott M, Wolf BR, Spindler KP. Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study. Am J Sports Med. 2007Jul;35(7): Wright RW, Dunn WR, Amendola A, Andrish JT, Flanigan DC, Jones M, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Vidal A, Wolcott M, Wolf BR, Spindler KP; MOON Cohort. Anterior cruciate ligament revision reconstruction: two-year results from the MOON cohort. J Knee Surg Oct;20(4): Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J Knee Surg Jul;21(3): Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. A systematic review of anterior cruciate ligament reconstruction rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation, and miscellaneous topics. J Knee Surg Jul;21(3): Toman CV, Dunn WR, Spindler KP, Amendola A, Andrish JT, Bergfeld JA, Flanigan D, Jones MH, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD, Wolcott M,Vidal A, Wolf BR, Huston LJ, Harrell FE Jr, Wright RW. Success of meniscal repair at anterior cruciate ligament reconstruction. Am J Sports Med Jun;37(6): Fetzer GB, Spindler KP, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Flanigan DC, Jones M, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker RD,Wolcott M, Vidal A, Wolf BR, Wright RW. Potential market for new meniscus repair strategies: evaluation of the MOON cohort. J Knee Surg Jul;22(3): Borchers J, Pedroza A, Kaeding CC. Activity level and graft type as risk factors for ACL graft failure: A case control study of the MOON cohort. Am J Sports Med Dec;37(12):

32 MOON Publications 10. Magnussen RA, Granan LP, Dunn WR, Amendola A, Andrish JT, Brophy R, Carey JL, Flanigan D, Huston LJ, Jones M, Kaeding CC, McCarty EC, Marx RG, Matava MJ, Parker RD, Vidal A, Wolcott M, Wolf BR, Wright RW, Spindler KP, Engebretsen L. Crosscultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol Arthrosc Jan;18(1): Dunn WR, Spindler KP, Amendola A, Andrish JT, Kaeding CC, Marx RG, McCarty EC, Parker RD, Harrell FE Jr, An AQ, Wright RW, Brophy RH, Matava MJ, Flanigan DC, Huston LJ, Jones MH, Wolcott ML, Vidal AF, Wolf BR; MOON ACL Investigation. Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med Sep;38(9): Dunn WR, Spindler KP; MOON Consortium. Predictors of activity level 2 years after anterior cruciate ligament reconstruction (ACLR): a Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med Oct;38(10): Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, Dunn WR, Marx RG, McCarty EC, Parker RD, Wright RW, Spindler KP. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective longitudinal cohort. Sports Health Jan;3(1): Spindler KP, Huston LJ, Wright RW, Kaeding CC, Marx RG, Amendola A, Parker RD, Andrish JT, Reinke EK, Harrell FE Jr; MOON Group, Dunn WR. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate ligament reconstruction: a population cohort study. Am J Sports Med Feb;39(2): Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW; MOON Consortium and the MARS Group. Intraarticular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS study groups. Am J Sports Med Sep;39(9): Reinke EK, Spindler KP, Lorring D, Jones MH, Schmitz L, Flanigan DC, An AQ, Quiram AR, Preston E, Martin M, Schroeder B, Parker RD, Kaeding CC, Borzi L, Pedroza A, Huston LJ, Harrell FE Jr, Dunn WR. Hop tests correlate with IKDC and KOOS at minimum of 2 years after primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc Nov;19(11): Wright R, Spindler K, Huston L, Amendola A, Andrish J, Brophy R, Carey J, Cox C, Flanigan D, Jones M, Kaeding C, Marx R, Matava M, McCarty E, Parker R, Vidal A, Wolcott M, Wolf B, Dunn W. Revision ACL reconstruction outcomes: MOON cohort. J Knee Surg Dec;24(4): Warme BA, Ramme AJ, Willey MC, Britton CL, Flint JH, Amendola AS, Wolf BR; MOON Knee Group. Reliability of early postoperative radiographic assessment of tunnel placement after anterior cruciate ligament reconstruction. Arthroscopy Jul;28(7):

33 MOON Publications 19. Sullivan JP, Matava MJ, Flanigan DC, Gao Y, Britton CL, Amendola A; MOON Group, Wolf BR. Reliability of tunnel measurements and the quadrant method using fluoroscopic radiographs after anterior cruciate ligament reconstruction. Am J Sports Med Oct;40(10): McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD; MOON Group, Reinke EK. Return to high schooland college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Am J Sports Med Nov;40(11): Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, McCarty EC, Spindler KP. Return to play and future ACL injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J Sports Med Nov;40(11): McConkey MO, Amendola A, Ramme AJ, Dunn WR, Flanigan DC, Britton CL; MOON Knee Group, Wolf BR, Spindler KP, Carey JL, Cox CL, Kaeding CC, Wright RW, Matava MJ, Brophy RH, Smith MV, McCarty EC, Vida AF, Wolcott M, Marx RG, Parker RD, Andrish JF, Jones MH. Arthroscopic agreement among surgeons on anterior cruciate ligament tunnel placement. Am J Sports Med Dec;40(12): Spindler KP, Parker RD, Andrish JT, Kaeding CC, Wright RW, Marx RG, McCarty EC, Amendola A, Dunn WR, Huston LJ, Harrell FE Jr; MOON Group. Prognosis and predictors of ACL reconstructions using the MOON cohort: a model for comparative effectiveness studies. J Orthop Res Jan;31(1): Wolf BR, Ramme AJ, Wright RW, Brophy RH, McCarty EC, Vidal AR, Parker RD, Andrish JT, Amendola A; MOON Knee Group. Variability in ACL tunnel placement: observational clinical study of surgeon ACL tunnel variability. Am J Sports Med Jun;41(6): Hettrich CM, Dunn WR, Reinke EK; MOON Group, Spindler KP. The rate of subsequent surgery and predictors after anterior cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort. Am J Sports Med Jul;41(7): Magnussen RA, Flanigan DC, Pedroza AD, Heinlein KA, Kaeding CC. Platelet rich plasma use in allograft ACL reconstructions: two-year clinical results of a MOON cohort study. Knee Aug;20(4): Mather RC 3rd, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, Bach BR Jr, Spindler KP; MOON Knee Group. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am Oct 2;95(19): Duffee A, Magnussen RA, Pedroza AD, Flanigan DC; MOON Group, Kaeding CC. Transtibial ACL femoral tunnel preparation increases odds of repeat ipsilateral knee surgery. J Bone Joint Surg Am Nov 20;95(22):

34 MOON Publications 29. Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT, Parker RD, Kaeding CC, Magnussen RA. The influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy Dec;29(12): Wolf BR, Ramme AJ, Britton CL, Amendola A; MOON Knee Group. Anterior cruciate ligament tunnel placement. J Knee Surg Jan 10. [Epub ahead of print] 31. Wright RW, Haas AK, Anderson J, Calabrese G, Cavanaugh J, Hewett TE, Lorring D, McKenzie C, Preston E, Williams G, MOON Group. Anterior cruciate ligament reconstruction rehabilitation: MOON guidelines. Sports Health Jan 17 [Epub ahead of print]. 32. Cox CL, Spindler KP, Leonard JP, Morris BJ, Dunn WR, Reinke EK. Do newer-generation bioabsorbable screws (Calaxo and Milagro ) become incorporated into bone at 2 years after ACL reconstruction with patellar tendon graft? A cohort study. J Bone Joint Surg--AM Feb 5; 96(3): PMID: Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, McCarty, EC, Wolf BR, Harrell FE Jr, Spindler KP. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx activity level outcomes after ACL reconstruction? A 6-year MOON cohort study. Am J Sports Med Mar 19 [Epub ahead of print]. 34. Mather RC III, Hettrich CM, Dunn WR, Cole BJ, Koenig L, Bach BR Jr, MOON Knee Group, Spindler KP. Cost-effectiveness analysis of early reconstruction versus rehabilitation and delayed reconstruction for ACL tears. Am J Sports Med Westermann RW, Wright RW, Huston LJ, MOON Group, Wolf BR. Meniscal repair with concurrent anterior cruciate ligament reconstruction: operative success and patient outcomes at 6-year follow-up. Am J Sports Med Lynch TS, Parker RD, Patel RM, Andrish JT, MOON Group, Spindler K. The impact of the Multicenter Orthopaedic Outcomes Network (MOON) research on anterior cruciate ligament reconstruction and orthopaedic practice. J Amer Acad Orthop Surg Jones, M et.al Meniscus Treatment and Age-associated with narrower radiographic joint space width 2-3 years after ACLR: Data from the MOON onsite cohort Osteoarthritis and Cartilage OAC Brophy, RH et.al Diabetes and not using Bone-Tendon-Bone autograft increase the risk of Infection after ACLR JBJS Am Wasserstein, D et.al The KOOS Pain as a Marker for Significant Knee Pain Two and Six years after Primary ACLR: MOON prospective longitudinal cohort study OAC 2015

35 Outcome Concepts are NOT New! 1. Katzenstein 1908: long-term f/u 2. Codman 1925: end result 3. Kirkley 2000: EBM, Outcomes, & Networks Sports Health

36 Right Idea = Men Repair & 7 yr F/U 1. Katzenstein in 1908! a. First successful meniscus repair Berlin, Germany b. Reviewed long-term meniscus excision = varus and arthritis c. Advocated Knee Surgery Preop Quad therapy NO immobilization d yr f/u 2. Courtesy Hans Paessler Germany March 2006 Sports Health

37 End Result or Outcomes Not NEW Courtesy Jed Kuhn Sports Health

38 Outcomes Legend in Our Time! 1. Dr. Sandy Kirkley 2. MPH Outcomes 3. Published 39 papers (8 RCTs) 4. Tragic Member & Mentor to MOON 6. Orthopaedic Surgeon 7. Outcomes Researcher 8. Mother 9. She was RIGHT EBM and Outcomes will become basis of Orthopaedic Decision Making Sports Health

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40 Grant Funding and Gifts

41 Thank-You! Cleveland Clinic Main Campus Sport Health Garfield Heights Sports Health

42 Department of Orthopaedics Vanderbilt Sports Medicine