Here's my disclosures. So the MOON is a multicenter cohort of ACL reconstruction patients going on for over 20 years now, funded by the NIH multiple times. And the first question is, why is it multicenter? Clearly the sample size is crucial because the outcome of re-tearing a graft is not common, so you need big numbers. Timeliness to obtain relevant results within years instead of generations. And generalizability to the treatment of ACL tears by having multiple surgeons and centers. You can see here the sites. There's been many. Most of them have stayed exactly the same. Few people have moved. And a lot of staff support. This is a snapshot in time. That's probably in the hundreds of people who've participated at various levels of research staff. Curt likes to say MOON is like Hotel California. No one has ever left MOON. All papers published have consensus and agreement through monthly conference calls and emails and circulation of the manuscripts. And if not, we don't publish. You can see that we have this intra- and inter-surgeon agreement on tunnel placement we did after a few years to make sure we were actually doing things similarly, both in cadavers and then in patients with post-op CT scans, and we found it to be actually quite good. So Curt Spindler is a big David Letterman fan, and so he likes these top 10 lists. So he asked me to do this for you, of course, in reverse order Letterman style. So the top 10 things we learned from MOON, multi-center groups are possible and impactful. There's many challenges in these cohort studies, need teamwork, extensive expertise in a lot of areas, sophisticated database management. The follow-up is very challenging, and we actually in MOON-NI have the surgeons responsible for their own patients' follow-up by email and phone call, and we circulate who's doing well and who's doing poorly in their follow-up, which stimulates surgeons to get more involved. Funding in caps because it's critical and difficult, multivariable analysis, and the challenge also to present these multivariate analyses. Number nine, we found that ACL reconstruction is cost-effective and increases quality of life. There was a paper by Mather and AGSM in 2014 showing an increase in quality-adjusted left years, and also Warren Dunn, who is sitting next to me right over there, also published in JBJS showing that ACL reconstruction improved quality-adjusted life years. Number eight, meniscus and articular cartilage requires more study. At 10 years, subsequent surgery was the biggest driver of worse outcome and osteoarthritis, and meniscus surgery repair and also resection were major predictors as well as subsequent surgery. So this needs a little more study to find out why. Return to sport. Number seven, return to sport and activity level also could use some improvement. You could see American football and soccer, about 70% return for high school and collegiate athletes. Half of the 30% in American football did not return, citing fear. And in soccer, males more likely to return than females. You could see activity score over the years goes down after ACL reconstruction out to 10 years here on the right, but we don't have control in this slide, control group of people in that same situation that didn't tear their ACL. So it may go down as well. Thing number six we learned, IKDC and COOS were our primary outcome measures, and the change in the IKDC from two to 10 years was pretty stable, 85% of them were very stable. You can see clustered around the middle for the most part. Thing number five, post-traumatic OA is a minority of patients at 10 years. We got a cohort of patients to come back for onsite follow-up, and at 10 years osteophytes only in 37%, joint space narrowing 23%, no side-to-side difference in ORSI grade. And to your onsite data here on the right, you could see normal meniscus, untreated tear, meniscus repair has more joint spaces, medial joint space narrowing, and meniscectomy more. And also you could see age has the similar effect of as patients get older on the X-axis, more joint space narrowing, not surprising. Thing number four we learned is that ACL reconstruction is a durable operation at 10 years. This is the baseline population means for the COOS profile, and at 2, 6, and 10 years, the lines are almost identical, and the same thing on the subscales, doesn't change a ton from two to 10 years. Thing number three we learned is to avoid allografts, and this was really important for me in my practice. You could see in the allograft group, here you have age. At the younger age, the difference is bigger. It's probably still much higher re-iterate an allograft in terms of frequency of injury, even at 40 years of age, and above, it's just that the re-injury rates are so much lower. And I basically have, based on this data, eliminated allografts for primary ACL reconstruction, basically totally. And also for high school and collegiate athletes, I think it's basically, you know, you have to use autograft tissue in these patients because of the extremely high risk of re-tear. If you go to our MOON group publications, you could also see ipsilateral graft tear. Risk factors include autograft, age, and laxity. Contralateral sport is a major risk factor, and interestingly, gender, not a risk factor for re-tear. And lastly, thing number one, teamwork is the key to success. Our founding principles were check your ego at the door. Teams do better than individuals, and this resulted in lifelong friendships, collaboration, and an internal trusted network. So, check us on our MOON website for patients, and I'd like to thank our funders, and Kurt and Rick Wright for the opportunity to present. Thank you.

MOON cohort study

ACL reconstruction

multicenter study

teamwork and collaboration

cost-effectiveness of ACL reconstruction