2015 cu sports medicine fall symposium oct. 2 acl ... cu sports medicine fall symposium oct. 2 ......
TRANSCRIPT
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
2015 CU Sports Medicine Fall Symposium Oct. 2
2012 Winner Ann Doner Vaughan Kappa Delta Award
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
2004
2012
Sports Health
Medial and Lateral Meniscus
Spindler and Wright. N Engl J Med
359:20, 2135-2142, Nov 13, 2008
Bucket handle MM
Partial LM tear
Normal
meniscus
Sports Health
Articular Cartilage
Spindler and Wright. N Engl J Med
359:20, 2135-2142, Nov 13, 2008
Normal LFC
Normal MFC
Focal defect LFC
Early GII Chondromalacia MFC
Sports Health
MOON ACLR Multicenter Cohort:1. Patient-Reported Outcomes and Failure
2. Specialized Cohort: Initiation and Predictors of OA
1. 20+ 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
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
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
Site Support Staff
Key: * denotes former contributor
BIOSTATSFrank E. Harrell, Jr, PhD Chair VUMC
Michael Kattan, PhD Chair CCF
Zhouwen Liu, MS
Thomas DuPont
Sam Nwosu, MS
HEALTH SERVICES
RESEARCH CENTERRobert S. Dittus, MD, MPH
CONSULTANTSBraden C. Fleming, PhD
Martha M. Murray, MD
Warren R. Dunn, MD, MPH
PROJECT DIRECTORSLaura J. Huston, MS
Emily K. Reinke, PhD
RESEARCH ANALYSTSJohn Shaw
Suzet Galindo-Martinez
Erica Scaramuzza
Brooke Rode
EDITORIAL ASSISTANTLynn S. Cain
MOON Coordinator Centers
Vanderbilt and Cleveland Clinic
Scientific Validity MOON Group
1. Inter-rater Agreement of Meniscus Tears and Treatment. Dunn, AJSM, 2004
2. Inter-rater Agreement of Articular Cartilage Classification. Marx, AJSM, 2005
3. Systematic Review of Autograft ACLR: Does Graft
Choice Really Matter? Spindler, AJSM, 2004
4. Intra- & Inter-surgeon Agreement on
ANATOMIC Femoral and Tibial Tunnels
ACLR. McConkey AJSM 2012 & Wolf AJSM 2013
To establish the consistency of measurements and techniques
across 7 sites, multiple validity studies have been performed:
Intra- and Inter-Surgeon Agreement
ACLR Tunnel PlacementMcConkey AJSM 2012 & Wolf AJSM 2013
1. 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 Surgeons @ 4 sites: PATIENTS
b. Small variations between and
among surgeons
c. Statistical difference, but doubt
clinically relevant
Entire MOON (PRO) Cohort F/U
Enrollment
Years
N 2 Years 6 Years 10 Years
PRO
Forms
2002-2003 1080 85% 83% 82% KOOS
2004-2005 1217 82% 82% ‘04 = 81% IKDC
2007-2008 1250 81% 81% Marx
Total 3547 85% 82% 82% SF-36
>90% f/u failure and additional surgery (via phone)
MOON NESTED Cohort 2 Yr f/u
(Standing MTP XR for JSN)
Onsite: MTP standing XR for joint space measurements
KT-1000 AP laxity & independent blinded PE
Patient-Reported Outcomes (KOOS, Marx, etc.)
Functional HOP testing
Enrollment
Years
2005 2006 2007 2008 2009 2010 TOTAL
Completed
ONSITE
59 21 67 68 55 47 317
PATIENT RISK FACTORS ON ACLR OUTCOME: DEMOGRAPHICS
1 Is Age a risk factor for ACLR failure? Yes: increased failure of ACLR in
younger individuals
2 Is Gender a risk factor for future
activity after ACLR?
Yes: lower activity level (Marx) in
females
3 Is Baseline Activity Level a risk
factor for future activity after ACLR?
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 Is Smoking a risk factor for ACLR
activity and PRO?
Yes: lower activity level and worse
outcomes
6 Is Education a risk factor for ACLR
outcome?
Yes: less education years worse
outcome
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
SURGICAL DECISIONS ON ACLR OUTCOMES
1 What is the risk of
ACLR graft
failure at 2 years?
Autograft: 1-6%
Allograft: 2-20%
2 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% f/u @ 2years
Kaeding AJSM 2015
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?
High School ~70%
College ~70%
50% cited fear as critical factor for
not returning
3 What are my chances to return to
play Soccer?
~70%
Males more likely to return than
females to RTP4 What will my future activity level
be after ACLR based on the Marx
Activity Scale?
Decreased activity with a 4 point
loss on the Marx activity scale at 2
years.
5 What will my future patient-reported
outcome on the KOOS?
Improved, but not normal
6 What will my future patient-reported
outcome be after ACLR based on
the IKDC?
Improved, but not normal
PAIN SUBSCALES AND ACTIVITIES OF DAILY LIVING INSTRUMENTS PRO
1
What causes knee pain at time of
surgery for ACLR?
BMI, female gender, older age,
and LCL injury
Bone bruise not associated with pain after ACLR
2
KOOS Pain Subscale Improved outcomes with higher baseline scores, lower BMI, non-
smoker, 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, non-
smoker
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
Poorer outcomes with lower education, contralateral ACLR, MM
repair, grade IV MFC, LFC or MTP, revision ACLR
5
SF-36 PCS (physical function)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
RISKS FOR ADDITIONAL ARTHROSCOPIC SURGERY
1 What is the risk of ipsilateral kneeligament reconstruction failure at 2 years?
2 years — 4.9%
6 years — 7.7%Median time to event: 17.1 months
(See Figure 1 for Individual Risk)
2 What is the risk of an ACL tear in the
normal contralateral knee at 2 years? 6 years?
2 years — 2.5%
6 years — 6.4%
Median time to event: 27.3 months
(See Figure1 for Individual Risk)
3 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 What is my risk of meniscal repair
failure?
2 years — 4% re-operation
6 What is my risk of hardware removal? 2 years — 0.6%
6 years — 1.3%
Marx Activity @ 2 & 6 Years
Cox AJSM 2014
1. 1512 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
Marx Activity @ 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
Cost-Effectiveness Analysis of Early
Reconstruction versus Rehabilitation &
Delayed Reconstruction for ACL TearsMather AJSM June 2014
1. 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
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 2015
1. Data MOON 2002-2004 = 1512 ACLR
2. Follow-up = 93% with Multivariable Analysis
3. ACLR effect size 1.2 for PCS score SF-36
4. 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
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 2014
2. 2488 Primary ACLR
3. 92.7 % f/u @ 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
Factors Associated with Infection Following
Anterior Cruciate Ligament ReconstructionBrophy JBJS Am March 2015
1. Data MOON 2002-2005 = 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 = 18.8
6. Autograft BTB significantly lower risk infection
then Autograft HG or Allografts
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)
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
N=261 ACLR @2.5 yrs
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 2015
1. Data MOON 2002-2005 = 1761 Primary ACLR
2. Follow-up @ 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
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
MOON Publications1. 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. 2004 Dec;32(8):1937-40.
2. 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. 2005
Nov;33(11):1654-7.
3. 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):1131-4.
4. 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. 2007 Oct;20(4):308-11.
5. 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. 2008 Jul;21(3):217-24.
6. 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. 2008 Jul;21(3):225-34.
7. 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. 2009 Jun;37(6):1111-5.
8. 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. 2009 Jul;22(3):180-6.
9. 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. 2009 Dec;37(12):2362-7.
MOON Publications10. 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. Cross-
cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol
Arthrosc. 2010 Jan;18(1):98-105.
11. 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. 2010
Sep;38(9):1778-87.
12. 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. 2010 Oct;38(10):2040-50.
13. 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. 2011 Jan;3(1):73-81.
14. 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. 2011 Feb;39(2):348-59.
15. Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW; MOON Consortium and the MARS Group. Intra-
articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS
study groups. Am J Sports Med. 2011 Sep;39(9):1889-93.
16. 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. 2011 Nov;19(11):1806-16.
17. 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. 2011 Dec;24(4):289-94.
18. 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. 2012
Jul;28(7):942-51.
MOON Publications19. 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. 2012 Oct;40(10):2236-41.
20. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD; MOON Group, Reinke EK. Return to high school-
and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON)
cohort study. Am J Sports Med. 2012 Nov;40(11):2523-9.
21. 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. 2012 Nov;40(11):2517-22.
22. 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. 2012 Dec;40(12):2737-46.
23. 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. 2013 Jan;31(1):2-9.
24. 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. 2013
Jun;41(6):1265-73.
25. 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. 2013
Jul;41(7):1534-40.
26. 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. 2013 Aug;20(4):277-80.
27. 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. 2013 Oct 2;95(19):1751-9.
28. 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. 2013 Nov 20;95(22):2035-42.
MOON Publications29. 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. 2013 Dec;29(12):1948-53.
30. Wolf BR, Ramme AJ, Britton CL, Amendola A; MOON Knee Group. Anterior cruciate ligament tunnel placement. J Knee Surg.
2014 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. 2014 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. 2014 Feb 5; 96(3):244-250. PMID: 24500587.
33. 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. 2014 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. 2014
35. 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 2014.
36. 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 –
2015.
37. 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 2015
38. Brophy, RH et.al Diabetes and not using Bone-Tendon-Bone autograft increase the risk of Infection after ACLR JBJS Am 2015
39. 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
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
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. 7 cases @ 1-7 yr f/u
2. Courtesy Hans Paessler
Germany March 2006
Sports Health
1. Dr. Sandy Kirkley
2. MPH Outcomes
3. Published 39 papers (8 RCTs)
4. Tragic death @ 41
5. 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
Outcomes Legend in Our Time!
Sports Health