It's certainly an honor to be here, and thank you, Ed, and thank you for the folks involved. And any time a surgeon talks about their recoveries of ACLs, it's really a misnomer because the rehabilitation and the training and all that is a critical aspect of it, and it's all one package, one team package. So these are my disclosures. As an orthopedic surgeon, mostly grant funding, I do have royalties with an outcome system with OBERT. So one of the things that we tried to do in MOON is that we created a website for patients because we put our rehabilitation protocols and our risk calculators on there so that patients could look at the best evidence. There's no commercial. There's nothing commercial about this website at all. We did it as a group. So when you have an ACL, obviously the ACL is torn, but that's the only thing they have in common. They have a whole myriad of different meniscal injuries that can occur from bucket handles to partial tears, and they have a myriad of articular cartilage injuries to little scuffs to little cracks, and they have different injuries sometimes to their MCL. So there's no such thing, as we know, as truly an isolated ACL. And so I'm going to give you data from our cohort, and it's been a 20-year history. A motto of the group in MOON was Teams Defeat Individuals. We established that in 2001. We've been very fortunate to be funded for many years from the NIH, and we did a multi-center study so that we could have sample size to look at rare events and also to have generalizability within the group. And so the group is here, probably well known. Those are the individual insurgents. The most important people are the staff behind the scenes that keep us going as a full-time job. So one of the things you have to look at when you have a database is to say, do the things that we operated on in 2002-2008, are they relevant to the type of surgery we do today? And that's a legitimate question. And so we did several papers, five papers, on showing our tunnel placements are consistent. Most of our techniques were either rear entry in, or they were some trans-tibial, some entry medial. But we've shown in cadavers that our tunnels are real consistent between surgeons and individuals. We also showed that within patients, we CAT-scanned patients three months later to show, again, our tunnels are consistent. So I think our tunnels were good back then, and that's not a problem for us. And then one question that comes up as well is to say, have we improved ACL reconstructions in the last two decades? And in my mind, the answer is no. So we had a unique opportunity. We can look at Rick Parker, myself, and Jack Andrish, and we had the MOON data is seen in the first two columns. We looked at Coos-Neve later quality of life and Coos pain, show you the age distributions. And our group is about 50-50 male-female. We have an outcome system in Cleveland Clinic, so we're able to track Kurt Spindler and Rick Parker again. So you can say that, I'm sorry, I'll go back one, can you go back one slide? Thank you. Sorry about that. So you can say Rick Parker and Kurt Spindler can't learn because obviously they haven't gotten better because they're the same. But if you actually look at two young guys, Latul Faro and Paul Salwin, both very experienced, do more ACLs, their results are the same. And they're trained in a different generation. So I would submit to you that we have six different ways to do it, but our overall results are the same. And I think most people, at least within our MOON group, would agree with that. So what's our objective today? How do we get someone back to sport with ACL? And I'm going to submit to you that the single most important factor, you decide preoperatively what graft you use. Your graft choice is important. Because if I look at failure rates, if I obviously have failure, you don't go back to sports. And so graft choice is important. And I think you also have to look at, we have to think about, and we need our therapists and trainers to help us, that contralateral ACL is at equal risk to the same knee we operated on. And I think you really have to work really hard on that. I want to look at some data that we had on soccer and football. I want to talk about, we measured activity as a marks activity scale. And also looking at some things that I got to give Lynn Snyder-Mackler credit, the therapist credit, how you can do things to improve pre-op and post-op to return to play, things that we published. So first, in football, we can see we're not as good as we think. 70% of our high school and college players returned to play. And out of the ones that didn't, there was a component of re-injury, a fear of re-injury. And so half of the 30% didn't return to play, had a fear of re-injury. That probably could be managed better. And then Rob Brophy, who's here, looked at soccer, and 70% returned to play soccer. And again, males are more likely than females, and that may be to opportunities that seem to get less opportunities for females in organized sports as they get older. So the marks activity level is one of the things that is very much for an aggressive athlete, is cutting and pivoting. So if you run a marathon, you get three. But if you play soccer, if you play football, you play lacrosse, and you cut and pivot multiple times a week, running, cutting, decelerating, you're really using that knee. So 16 is really high, and obviously most middle-aged people are down to zero, one, or two. And so when you look at what predicts the activity level, and we followed it out at two, six, and 10 years, what you find out is that their revision ACL is a problem. So you don't want failure. Grade four defect makes a difference in the medial formal condyle at six years, not at two years. And high grade laxity was not measured at two and six years. High grade laxity means that knee that's really loose. The knee that, and we define loose, it's Bob Magnuson defined it, as someone who has greater than 10 on a Lachman, and someone who has a pivot lock. It's that really loose knee, and that has less likely to go back at 10 years. And then if you've had a previous excision of your meniscus. So you had prior surgery, removed your meniscus, didn't fix your ACL. And the rest of the things are more demographic factors, lower baseline, older age, female gender, higher BMI, things you can't modify over time. And so when we looked at their prognosis over time and published that, we had a data set of half of the cohort at 1,600, and we had about over 80% follow-up on this, and we looked at what factors determined whether someone got back, and we're going to focus on return to play in Mark's activity. And so what we can see on the Mark's activity is there's a steady decline. Why it declines, I don't know. Whether there's less opportunity to play. Obviously a 18-year-old high school athlete may have less opportunity to play, not a college caliber athlete. It declines a lot in the first two years, declines a little bit at six, and stays about the same at 10. And we also see that the IKDC, as a measure, doesn't decline. So if we look at individuals, whatever outcome they have at two years, 80% of them have at 10 years. It's the same thing for the COOS. But you can see the Mark's activity level, 50% drop down. So when we actually look at it again, those factors come out to be the same thing again. They're demographic factors, but again, factors that are really important in Mark's activity turn out to be not a lot of modifiable factors there in what someone returns to play. So one of the things that we learned, and we learned that from Lynn Snyder-Macker's work with the Delaware-Oslo cohort, there are things in rehabilitation that we can do, both preoperatively and postoperatively. And it hasn't gained traction. It hasn't even gained traction within our group, it's sad to say. But they funded one study that looked at prehab and said, if we do 10 additional neuromuscular training sessions, does it make a difference? And the second study they looked at was, what about if we did a return to sports training program? Both these are published, and they added 10 sessions again. And they looked at outcomes, both return to sport, they looked at past, and they looked at some typical metrics like IKDC and COOS. So let me put it graphically. And so the way the study was done is they matched people from the Delaware-Oslo cohort against injury type, age, activity, and they matched them with the MOON cohort to see which was better. And so if you have an ACL tear, normal situation is we do some impairment resolution, and they go on to ACL reconstruction. And in study one, what they did is they had 10 sessions of neuromuscular training before. And in the second study, they said, OK, we have standard ACL reconstruction protocol. We have our MOON protocol. What happens if you add 10 more neuromuscular training sessions? Doesn't make a difference in getting the athlete back to sport. So let's show you the results. In patient one, they were able to increase return to sport by 9% just doing prehab. Now, we're not hurt by doing that. We don't do that. Remember, all of our athletes want to go as quick as possible, and I think most of us try to slow them down now. But we actually force them to do 10. I'm not so sure we do. It also increased another metric of sports activity called the COOS Sport and Recreation by 15 points, which is clinically relevant difference. Now if you look at the second study, where they just put 10 return to sport training programs, they increased the marks activity by 3, which we don't know what the minimum clinically relevant difference is. We guesstimate that it's 2, but that's never been studied. They increased the COOS Sport and Recreation by 12, and they increased the PASS. PASS is patient acceptable symptom state. Are you happy with your knee? Is it good or bad? They increased that by 22% to 100%. And I think that if you look at that, if you look at PASS and acceptable, I think most of our patients never really finish their rehab. As soon as they finish their rehab, they never go on to that next session, which focuses specifically on the type of sport they want to do. So now the last thing I want to talk about is autograph choice. So Chris Kading, we published this study in AGSM. The first study published on failures of allografts was in Sports Health in 2011. And you could see that the red bar is allograft. I think people accept that in the young population. It's probably not good. But what about the divergence of down here? What about the black and the green, which is autograft BTB versus autograft hamstring? In the overall cohort, they diverge. But you can't say in the overall cohort whether that's different or not. And so how do you control for age, gender, BMI, sport, and knee laxity in a randomized trial? Pretty difficult. Not impossible, but pretty close. So we wanted to know the 14- to 22-year-old, does it make a difference in that athlete and 14- to 22-year-old? So this only took 14 years and a few million dollars. And so this is 839 primary ACLs from 2002 to 2008. We compared autograft BTB versus hamstring. They had to be injured in sports. So that means that in the whole cohort, we have 3,500. But in order to isolate the 14- to 22-year-old true athlete, now we're not saying the lead, but true athlete, so there's only 900 of them there, they are prospectively followed at six years. At 92%, we know where they've had revision. We also know where they had disruption in the other knee. And we control for the factors that seem to be important, that we either were proven before or hypothesized. And so you look at that, what you find out is that what ipsilateral side is graft choice, is knee laxity, and age. Those are dominant factors. If you look at the opposite side, it has nothing to do with, in our study, nothing to do with graft choice. It's all to do with sport. And so what happens, at least within the cohort, at least within the group of ours, is that a lot of the individuals that did both, there were groups that people just did hamstrings, people just did BTBs, and there was a group that did both, the splitters. And they would choose football, they had a football player that always put a BTB in it. So the opposite side is really determined by the sport played in our data. And so if you look at a 14-year-old football player, according to our calculations, the six-year failure rate, if you put a hamstring, is 45%. Bad. But the failure rate in a BTB is bad, too. I don't think I've ever told anyone they have a one in three chance of failing, and that's a high-risk individual, because you have age, football, male, and sport. Now if you look at a 14-year-old basketball player, six-year failure rate is 5% with a BTB. And if you go to hamstrings, it's 9%. And I'm not so sure that difference may or may not be clinically relevant. You can judge for that. But that's our best estimate of that. And so you can individualize, you can determine that for any patient. So now when a patient comes in and wants to know their failure rate for a BTB or hamstring, I have to use a calculator every time, because I can't calculate that in my head. And sometimes it doesn't matter, and sometimes the differences are by 15% or whatever. So you can look at that. You can just put, that's a QR code, so you put your phone up to it, you put it in, and you can display what it is. Now that calculator is also on the website, and we just recently published a paper with Al Getgood in the Stability One study, which was hamstrings plus or minus LAT, 660 athletes under 25. And we actually were able to externally validate the calculator. And it turned out that the accuracy of it was just as good in the external data set as it was in ours. But again, these calculators are the best estimates. They're not one-to-one. It's not going to predict 100%. It's going to be right. It's going to be better than chance. And the question is, what's the alternative? The alternative is a physician's good judgment, and you can decide whether that calculator works or not. So if we want to optimize, if we want to get someone back to sport, I think you have to optimize the right graft choice for each patient. I hate to admit that, because we had an argument for 20 years. The splitter said you have to customize each patient. And I didn't agree with that, but they're right, unfortunately, which is fine. And you can look at that, and you can judge that for yourself. I do think that we need to do some better prehab. And it was 10 sessions. I do think that makes a difference. You can decide whether increasing return to sport 10% is valuable or not. And then finally, I do think that what's missed in our programs is a return to sport. When you're done with your rehab, let's give them 10 sessions about going back to sport. Let's give them 10 sessions to customize what it is. And I think that has to be done in a cost-effective way. And probably has to be done maybe by trainers, maybe by a group, a group for soccer, a group for football. I think we can do that to improve it. And I think you have to look at the, I think we make a lot of judgments on what's important to someone to go back to play at two years. You can't say because they've had a meniscus repair. You can say if you want to, a meniscus repair will give them less likely to go back to play at two years. Data doesn't support that. You could say that a meniscectomy gives them more, less probability to go back to play at two years. Data doesn't support that. And so what the data supports is what I've shown you in our cohort. So I think that you can counsel someone whether they should go back to play with that meniscal loss or meniscal repair, whether it increases post-traumatic arthritis. That we're not sure of. But as far as returning back to play, you can counsel the modifiable factors. That's my buddy. For the young people in the crowd, do you know what, in the bottom right-hand corner, you know what he's holding up? It's an x-ray. Those are the old days in the 90s. That's Eric McCarty. At Alabama, in the old days in the 90s when we had to go back and get the x-ray, dip the x-ray and bring it out in the field to look at it. So crazy times. Now it's digital. It's in media right away. So just sort of funny. So thank you. I have to thank all the support that I've had over the years, the NIH, and just a list if you want to know some of the references are here. So thank you so much.

ACL reconstructions

return to sport after surgery

rehabilitation and training

MOON cohort study

graft choice