And we've gotten some questions from the audience, some we can ask for the whole panel. But one came that was really specific that I'd like to start with. Because I think it has a lot of educational value. Per the MOON shoulder data, briefly explain the physical therapy program for these patients. And tell us what you think the main points you would stress that physical therapists are. Is this home-based or is there formal physical therapy components only? Sure. So we did a systematic review of the literature to look at the features in randomized trials that showed physical therapy to be effective for treating mostly impingement. But any kind of rotator cuff disease. And there were really, we could break it down to a number of different elements. First, there was evidence that said home therapy was highly effective. So in our protocol they worked with a therapist until the point that they could do the therapy at home. And then they were allowed to do it at home. The therapy involved flexibility, strengthening, and some modalities. Although ultrasound and other things were found to be not effective at all. So those weren't part of our protocol. One of the biggest things that we noted is our, and I didn't include this in our data. But the work score early was correlated with scapular dyskinesis, interestingly enough. So focusing on that is a big part of the physical therapy protocol as well. Thank you. Here's a personal question I have. I've wondered, you're talking about standardizing the physical therapy. Well, what about the surgery? How do you strike a balance between standardizing the surgical technique and letting each surgeon do their own thing? Maybe several of our panelists could comment. I'm sorry, Bruce. Could you repeat again what you're asking? Yeah. How far do you go as far as standardizing the surgery when you have a group of surgeons who each has their own maybe individual take on the way they like to do things? How draconian are you? How do you strike that balance? No, I think it was not extremely draconian in terms of that. I think compared to some surgeries, there may be less variety with this surgery versus, say, an ACL reconstruction and a rotator cuff. I think the primary issue was making sure that additional surgery on cartilage or other aspects of the knee were not included. And then I think it was much more focusing on adjuvant treatment in terms of medications, injections, and physical therapy. The surgery itself was not spelled out or detailed in great extent, because I think, again, the variability was not as much as it might be with other procedures. I'll comment on the MARS. There was no standardization of surgery. So 83 surgeons chose what they want to do. The important factor is that there was good documentation of all the techniques in surgery, including blended tunnel, new tunnel, blown-out tunnel, fixation technique, et cetera, et cetera, as well as cartilage treatment as well. So the documentation was key, but no standardization. And then I'll also comment from the anchor perspective. Ours has evolved over time. Our legacy cohorts, there really was no standardization. That included open procedures as well as arthroscopic procedures. With time, as things have changed and we've become a little more in line, our more recent cohort is, our goal is to have it very standardized. And in our current RCT, very standardized. A lot of work to get surgeons to agree upon that, you know, several meetings, several calls. But we have been able at least to get them to agree upon it. And hopefully that will make the data even more significant. I would also just comment that I think the less draconian it is, the more impactful it can be. Because one of the variables you look at is technique and the way things are done, where anchors are placed, what screws were used. So that's the beauty of prospective cohort studies, is you are able to analyze those things. For example, beach chair versus lateral. For example, medial portal versus independent drilling in ACL, and that's really the beauty of collecting a lot of data, as was mentioned in Mars, is just having all those details from surgery. Because you may figure out things that are better just based on what was collected. And I'll comment on it from the Jupiter patella instability perspective. Obviously a huge amount of variability, not just in the surgical technique, but in which surgery is chosen for the specific, for the same problem. Recurrent dislocators, some of them have just an MPFL, some of them don't. We just chose to standardize that all MPFLs, any medial soft tissue surgery was going to be a reconstruction. So we would have a large sample size of that. We felt there was enough data out there to suggest that repairs don't do as well. And so we decided to eliminate that as well as some of the more historic things like reefing and imbrication. So that was our standardization. But then adding in all of the a la carte so that we could analyze afterwards which things helped or didn't help. One question came in. It was targeted at Kevin Shea. But I'd like to, each presenter to answer, how has the ROC data changed practice? Maybe if each person could give one or two things that you think your study has changed clinical practice. I think a couple things. I think a couple things. I think we're developing a better understanding of who may heal. Because we probably have under the age of 12 or 13 with open growth plates, there's probably at least 50 to maybe 65% of kids will heal with non-operative approaches. So I think that's changed the way people thought about that. We tend to operate less on some of these younger kids. But once they become a little bit older or they're approaching FISO closure, their failure rates are quite high. And so we've probably increased our early surgery rate in the older patients. But maybe decreased the surgery rate in some of the younger patients. So I think that's probably some of the key things we've done early on is that change in who gets surgery or who doesn't get surgery early on in the decision making. For the MARS, I think the number one takeaway is for a young active individual, don't use an allograft. Do everything you can to use an autograft for that individual. And I'd say the same thing goes for primary ACL reconstruction. And we don't know exactly why. Allografts have a higher failure rate. I think it could be radiation. People say, oh, I don't use irradiated grafts. But they're still chemically treated. And the reality is we don't know exactly what happens to the graft before we open it in the OR. So I think unless you're prepared to accept a three-fold higher retail rate, no matter the patient, try to avoid it if possible at all. Yeah, so from Anchor, I think just in very general terms, accessibility I think was a big target that we had in the beginning. And hopefully educating physicians and orthopedic surgeons and patients about these disorders has impacted the field in a major way. And then acceptability of the procedures showing that they are safe, they are effective procedures. So those are kind of global hopefully impacts that we've had on the field. So my disclosure is I really like to fix rotator cuff tears. But I'm fixing far fewer than I did previously. When I was young, I was taught they all needed to be fixed. And now I offer to the patients. I say we have two treatments. Both of them work well. We have 10-year data at least on nonoperative treatment. And it seems to work well. But some patients fail that and need to have surgery. We're actually engaged in a randomized trial right now. We're going to collect 316 patients and randomize them to operative versus nonoperative treatment for cuff tears. And we're about halfway through the enrollment. When you have two treatments that are both effective, we need to know which one is best and for whom. And that's what we're trying to figure out. We are obviously very much in our infancy. So we don't have a lot of things that we've learned that are changes in practice. But I think the biggest thing is the standardization of radiographic imaging and which things we should be measuring. And I think that as we look at those, we should all aim that even the studies that are non-multicenter should start to use these reliable measurements so that we can compare those studies to each other and get better quality systematic reviews. And I think Meteor shows that patients with meniscus tears and osteoarthritis can do very well with conservative treatment. But some patients who do not improve can also benefit from arthroscopic surgery. So it's, you don't need to rush to surgery. But it is a viable option in some patients. Here's a question that was directed at Brian Wolfe. But I think it would be good for other people to jump in. Are there plans in the future within the multicenter research studies to look at health equity slash inequity? Yeah, I think that's a really good question. And at least in Moon Shoulder and Stability and Morgan Jones and Moon Knee, we have looked at socioeconomic status and some of these other, you know, accessibility and, you know, non-surgical variables which probably leads to access to care and definitely impacts outcomes. So that's a very good point to be thinking about up front. You can secondarily go back and evaluate these patients and try to address some of these issues later. But the more you can collect up front in terms of, you know, demographics, socioeconomic status and all these other variables that we sometimes blow over, it's extremely important. And as we analyze these things, it is actually more important than we probably even realized when we started collecting the data. So I'll just, Dr. Ryder is old enough to know, in the old days, we used to look at KTs all the time. And then we had to look at outcomes. And it was hard to get people to accept patient-reported outcomes. And then we're looking at psychological things that influence outcomes and social and economic disparity things. So when we're starting to set up these trials, if you're starting to set it up, you have to have a broad net to capture anything that might influence outcome. It's not as simple as a KT. Excellent. One of the questions came in. They were, what, and it was directed towards Brick Lance. What do you attribute to the high follow-up rates at two years? 92% follow-up is very impressive. So I want to thank Laura and Amanda. I mean, seriously, because they, every site, so the 53 sites had another person. At my site, we had Aaron Owen. But they were in contact very frequently. The patients were called. It was a lot of phone calling by a lot of teams. So that's number one. And getting the patient engaged is key from the very beginning. You know, expressing to the patient, this is going to be valuable research. This larger study's never been done before. We want you to be included. Would you please, so having that conversation with the patient, I think, is key. Here's a question. I think we could just have a show of hands. Are any of these multicenter networks recruiting or enrolling new patients? I'm sorry, Bruce, could you repeat that? Are any of you recruiting or still enrolling new patients? Yeah, so no, the MARS data, the enrollment ended 2011. So now we are just sorting out the 10-year follow-up at this point in time. But no, we're not enrolling new patients. Now we are doing, well, there's a little side project. We're doing some video analysis. But other than that, no. Jupiter finished its enrollment for Jupiter 1.0 and 2.0. And that's what's closed out. And we're going to follow it up. We are about to start enrollment this fall for a study looking at risk factors for failure of isolated MPFL reconstruction. So in ANCHOR, again, a little different because our early cohorts were somewhat diverse in terms of technique and indication for surgery, that kind of thing. So we now have three new cohorts or studies ongoing that have open enrollment. One is a more contemporary arthroscopic treatment of FAI cohort, which we need to do because our legacy cohort is not current in terms of our techniques. The second is a borderline acetabular dysplasia cohort. That's perhaps one of the most controversial things in hip preservation, how we best manage those patients. And then the third is an RCT looking at PAO surgery for dysplasia, plus or minus hip arthroscopy, which again is a controversy. And really, we do not have any high-level data for that decision making. So the MOON shoulder group is still enrolling some instability patients. We have over 1,500 instability patients, over 1,000 anterior bancars. But we're still enrolling posterior and revision surgeries. Our group is also starting a shoulder arthritis study and an ulnar collateral ligament of the elbow study. And we probably will be enrolling in those cohorts in the next couple years. Meteor is not enrolling, but is still collecting some data and analyzing data. Rock is the same, still enrolling patients. MOON just long-term, MOON knee long-term follow-up. We have time for one more question. And we got a thoughtful question about post-operative bracing. And it can apply to certainly the ACL groups and also to the patellar instability groups. Do you recommend bracing for post-operative care and special attention to returning to high-risk sports? So for the MARS study, graft re-rupture was not affected by brace wear, either perioperatively or in sports. So as far as you're looking, just at graft re-rupture. The post-op brace, interestingly, now again, we don't know what the chicken or the egg is here. But using a post-op brace had a significant increased rate of additional operations in the future. And then lastly, just that COOS was increased using an ACL brace upon return to sport. But that was the only PRO that was improved. So in terms of post-op brace use after ACL reconstruction, actually Curt taught me the three reasons. And I tell this to patients why I don't recommend a brace. One is that there's no good literature to support the use of a brace to decrease the risk of re-injury. Two is patients usually don't like it because it slides off and it's kind of annoying. And the third reason is the risk of injury to the normal knee is at least as high as it is to the reconstructed knee. So I'm really not sure which knee to put the brace on. And I say it to the patient just like that. And at that point, usually the conversation's over. And I say, but if you want a brace, no problem I'll prescribe one. Thank you. From the perspective of Jupiter, we currently haven't looked at that yet. That's one of the things we're going to look at. Because some of our surgeons brace after NPFL, some do not. So we'll be analyzing that in the final when we do our follow-up. I think it's time for a coffee break. I'd like to thank our wonderful panelists as well as our program chairs for assembling such a fantastic panel. Thank you.

physical therapy program

rotator cuff disease

home therapy

surgical techniques

data collection