in my talk, because I want to have some time for discussion. I just want to thank all of you for attending. And most of you know I planned this session. And the topics that we covered are topics that when I went to our forum group and said, you know, we want to have a topic called advocacy, and I called it purposely. It's not what you think it is, because it's not about how we get paid more for each of our CPT codes and things like that. But this is what our group came up with, and I love the mix, you know, advocating for each other, for our athletes, for our patients and partners of diverse backgrounds. And mine is probably the least emotional of all of these, but, or, you know, emotion deriving, I would say, unless you're dealing with your own child's knee. But, you know, I wanted to bring up this topic of, while return to play and graft survivorship, you know, avoiding rupture, of course, important things to study and measure, are they really, like, the right ultimate outcome we want to consider for the health of our patient's knees? So, the bluff, you know, the bottom line up front, of course, ACL tears are common conditions. Reconstruction does not necessarily prevent post traumatic arthritis. While we do a really good job stabilizing knees, we don't really necessarily have the key yet to preventing that. ACL re-injury and contalor injury are not rare, and particularly in certain populations, like we've learned from our moon group, the younger, more active patients, female patients, certain sports. Classic measures of success, like, do we get people back to their sport and at the same level? Well, that's an immediate gratifying outcome. Are they necessarily what matters 10 or 20 years from now? So, kind of the discussion that we might have time to touch on, or maybe not, depending on what we decide to circle back to from all of these important topics, are how do we and should we advocate for our athletes and the health of their knees, and how do we educate them about their joint health? So, more than 400,000 ACL injuries occur annually, and as I mentioned, recurrence rates, of course, vary by sport, gender, and return to play status. And some of the literature may mislead us a little bit about actually how safe return to play is, because if we look at kind of overall re-tear rates or re-injury rates, whether it be ipsilateral or contralateral, a lot of the times the numbers we see are for like an entire study group, maybe not necessarily the group or the subgroup that returned to play, and the subgroup that returned to play at their prior level. So, for instance, in the study by Britt et al., less than half of adolescent soccer players in that group returned to the same level of play, and the study by Allen in 2016, if you look at just that return to play subgroup, you obviously are going to see a higher re-injury rate, which makes sense. It gets back to what we know also from the Moon data, the higher level activity, you know, more re-injury. So, if we look at the Swedish National Registry recently, 51% of soccer players returned to soccer, and again, it makes sense, there's a big difference for those who returned to play. There was a 2.9 and a 2.1 odds ratio, respectively, for re-injury versus, also for, and for contralateral injury, versus the non-return to play group. Risk of post-traumatic arthritis is variable if you look at different studies, but kind of broad sweeping statement, a lot of these studies look at post-traumatic arthritis over 10 years out, so in that 10 to 20 year time frame, kind of a number you'll see out there, 50% occurrence rate to some extent. Recent meta-analysis showed that in the ipsilateral ACL reconstructed knee, the rate was 52% versus the contralateral knee, 16%. And in another study, 2019 meta-analysis, if we're looking at risk of symptomatic arthritis, so not just radiographic evidence, we see something more like 35% in the ACL injured knee. So, the risk of post-traumatic arthritis may be greater than the risk of a recurrent tear, even in some of our highest risk age groups, and when I think about that, when I'm talking to my patients, you know, the first thing we're kind of counseling about is, you know, the length of time to return them to play. We're kind of pushing that to a year because we want to study how do we reduce re-injury, how do we get you maximally and optimally rehabilitated to reduce re-injury, but how much are we really telling them about this other thing that's likely going to happen than possibly even more frequently than re-injury. So, we know there are many contributors to post-traumatic arthritis. There are biomechanical causes associated with meniscal injury or deficiency. Clearly, in recent literature, there's a big push to understand more the sort of synovial biomarkers and the inflammatory cascade that occurs within the environment of the knee as that contributes to post-traumatic arthritis, and I like the schematic kind of just sort of summarizing some of these processes that occur in the setting of a traumatized knee. So, what can we do? You know, we're trying to help this problem, even though we haven't fully solved it. We know that anatomic reconstructions may be more beneficial than the non-anatomic reconstructions in terms of minimizing some of the wear on the cartilage. We've seen that in our own group at Duke, and in this study looking at anatomic reconstruction, they found that there was a 23% versus a 44% risk of developing PTOA. We can maybe perhaps change the synovial environment, maybe we've done a pilot at our institution using anakinra. Letterman has looked at preoperative steroid use, not really totally bending that curve, but that's a hot area of study, of course. But what about just, should we explore the option of a more chondroprotective activity, or maybe sports with lesser injury or retear rate? And I think sometimes that's sort of not what we think about first because it's so prevalent in our orthopedic literature to say, look, my study showed a respectable rate of return to play and a respectable rate of return to play at the same level, and I think it tends to be what we focus a little bit on, and I don't know if it's always the right thing. So I personally think it's okay to talk to your patients about optimizing, of course, optimizing their post-op rehab to minimize risk, but explore, do they have interest in any non-cutting or linear sports? Do they have, if it's a kid that has, you know, a chondral issue or a meniscal issue, you know, I think it's okay to explore, do they have interest in less impactful or more chondroprotective activities? And I think sometimes about my own child, if my own child were to have an ACL tear, what I might want to send them back to. And I think this is just to stimulate thought processes for all of us and maybe a discussion point of, you know, are we too much in our profession maybe leaning too hard on the, you know, return to play as, like, the ultimate goal or, you know, success of what we do for patients? So I like to think about this as a shared decision-making process, and this might not be, maybe we're all doing this to some extent, we probably are, but there's a lot, I think, goes into that in this discussion with the family and the patient. Is this a bilateral injury? Is it a revision setting? What is their meniscus like, their age, and gender, and sport? Are they really high risk? What's their year eligibility? Is there a scholarship situation going on? And is it really going to severely affect their mental identity, their self-identity? You know, I have some patients where the parents will say to me, if he doesn't go back to basketball, he's just going to be severely depressed. And, you know, so these are real things to consider. So again, the topics for discussion that I mentioned here. And this would just be an example. I think this one's easier because it's a revision setting, but this is a patient of mine. He's 17 years old, prior allograft ACL reconstruction at the age of 14 with a Fisial Sparing Technique. Retairs, but interestingly, he says for the last two years, he's been icing his knee after every game. It swells routinely. And I thought to myself, it's really strange that this patient and his family, no one ever told them, or maybe someone told them, but they somehow didn't grasp that it's just not normal for a 17-year-old, or 15- or 16-year-old's knee to swell after every game. So he's got neutral alignment. He had a failed reconstruction, which was revised with a quad autograft revision. His meniscus had a radial tear within the bucket handle, which was repaired. And he had a chondral defect in his lateral formal condyle. That was fairly significant. I'm planning to go back with the stage to Macy. But, you know, so I had this discussion with him. At first, they were very, very adamant. He really needs to go back to basketball. But interestingly, when I talked to him, you know, he kind of came around to the fact that he wants to be an orthopedic surgeon. He's going to be on his feet a lot. We think his knee's not going to be optimal. I had some concerns about the radial tear in his meniscus, even if it healed. And, you know, it was a conversation we had. And I don't feel bad about not sending this patient back to basketball. I think it was a good option for him. And that's kind of sort of what we came to as a shared decision-making process. So really just food for thought and for discussion. So I think, you know, return to play for ACL reconstruction we know carries some risk of re-injury. There is, of course, benefit to sports. And I'm not against that in any way. I don't mean to go against what we as sports doctors do. But I think shared decision-making regarding return to sport should include a discussion of risk of re-injury, but also educating patients about their joint health and making them aware of, you know, what are signs of declining condyle health and sort of just help them make those decisions in terms of what sports they might pursue in the future. So thanks. I think with that, maybe we should just go to some discussion on any of the topics. And I wanted to thank everyone for their interest in all of these topics. So I think Dr. Scottie has a question.

advocacy

ACL tears

knee health

post-traumatic arthritis

patient education