Good evening. Welcome to the AOSSM Fellows Webinar Series featuring tonight's topic, ACL Outcomes Update on MOON. Here's a brief overview of tonight's webinar, which will include our panelists presenting and discussing recent results from MOON studies. Our faculty panelists tonight include moderator, Dr. McCarty, who is Chief of Sports Medicine and Shoulder Surgery at UCHealth and Associate Professor of Orthopedics at University of Colorado, presenter, Dr. Spindler, who is Vice President of AOSSM, Vice Chairman of Research, ORI and Co-Director at Musculoskeletal Research Center, Doctor of Orthopedic Clinical Outcomes at the Cleveland Clinic Sports Health Center, and Professor of Surgery at Cleveland Clinic Lerner College of Medicine. In addition, we have two panelists, Dr. Kading, who is Johnson Wilson Professor of the Department of Orthopedics at The Ohio State University and Executive Director of the Sports Medicine Center at The Ohio State University Wexner Medical Center and James and Crane Sports Medicine Institute, and panelists, Dr. Wolfe, who is John and Kim Callahan Endowed Chair in Sports Medicine, Director of University of Iowa Sports Medicine, and Professor of Orthopedics and Rehabilitation at University of Iowa. Before we get started this evening, we would like to remind the questions drop-down arrow on the right-hand side of the panel. This slide shows where you input your question and click send. Questions may be answered toward the end of this webinar. With that, I will now turn over to our moderator, Dr. Eric McCurdy. Hey, well, thank you for joining us. I am really excited about being here tonight to help moderate the presentation and then the discussion afterwards on ACL outcomes, as represented by the MOON group. And that MOON group has been around for about 20 years. I've been a part of it, been friends with all the people and the great colleagues that have been part of this, and the instigator and the head investigator and a great friend of mine is Kurt Spindler. Kurt, I've known for a long time. I was his first hire at Vanderbilt as a sports medicine partner back in 1999 and can't say enough about him. He is the upcoming president for the AOSSM in another year and currently vice president and is a fantastic researcher. He's a terrific team physician, terrific clinician, and most important, he's just a great friend and a great person. So, I'll turn it over to you, Kurt, and we look forward to what you have to talk about and we'll have some questions at the end. Thank you, Eric. You're way too kind. My pleasure. I don't see the control bar down here to advance the slides. There it is. Okay, good. So, we want to give a little... Not advancing. Just hit the next slide, please. So, disclosures, mostly grant funding, very little consulting, and a couple scientific advisory boards. Next slide. I can do it. So, introduction, what we want to look at, a couple things I want to cover. I'm not going to read you all the slides and tell you I'm going to hit the highlights. We really want to answer the goals, clinically relevant questions for patients and providers at the individual level for shared decision-making to optimize your ACL reconstruction outcomes. We're going to ask and answer questions. We're going to talk about return to sport and activity. We're going to look at risk factors for outcomes 10 years later. We're going to show you how to choose the best autograph for a 14-20 year athlete. And then I want your insight in how to implement the best practice evidence into practice. Next slide. Mine's not working. So, what is the definition of MOON? Questions for you, we'll answer that. Name some strategies to improve return to sport. And at the time of ACL reconstruction, what is the worst risk factor for 10-year outcomes, poor 10-year outcomes? Is it articular cartilage injury? Is it female gender? Is it meniscus treatments? Autograph choice or high-grade laxity? Well, and the second thing is, can you define what high-grade knee laxity is? Bob Magnuson at Ohio State coined that, and it turns out to be a major risk factor for failure. What's the best autograph? What causes failure on the contralateral side of an ACL reconstruction? And a little bit about how do we make decisions in practices? What do P-values mean? What do percentage changes mean, odd ratio or absolute differences? And finally, your input into strategies about how to use this in practice. So MOON is a multi-center cohort, it's looked at outcomes and failure. It has a specialized or nested cohort of about 425 out of the 3,500 that come back on site for arthritis. We've been very fortunate, we have a 20-year history, been funded by the NIH for 14 years. The goal was sample size, timeliness, and generalizability. So MOON, there are many participating sites, Cleveland Clinic, Duke Hospital Special Surgery, Ohio State, Colorado, Iowa, Wisconsin, Vanderbilt, and Washington University of St. Louis. So our faculty are the people who do the work, are the people at the individual sites, research coordinators, research assistants, PhDs, and statisticians, and they're listed here, and they're some of the real heroes that do all the work and couldn't be done without them. So one of the things we looked at is really important because the ACL reconstructions we performed from 2002 to 2008, and we showed by cadaver studies on 12 surgeons, 72 cadavers at our tunnel placements are accurate as of today. We also, we looked at trans-tibial, anterior medial, and rear incision. And several of my partners, not me, eight surgeons at four sites actually CAT scanned their patients to show that their tunnels are also in good position clinically. So we know that our tunnels are in the ballpark. So the results today that we're getting now 10 and 20 years later are applicable to the tunnels where we're putting them today, which is important. So I wanted to introduce, I'm sorry, that's why I keep flipping forward, I apologize. So we want to look at return to sport, and our goal is to get the highest function activity. And the single most important decision about someone returning to high level sports is really your graph choice that you choose on that athlete, followed by how you evaluate the risk and reduce the risk of the contralateral side. So we'll show you some return to sport in football and in soccer, we'll look at some predictors and we'll look at some ways to improve it with sports training. So in football, McCullough showed this in 2002 in Moon that only 70% of our patients returned to high school and college football, and out of the 30% that did not, half of them reported some element of fear. Brophy looked at soccer within Moon and published that, 70% returned to soccer, males more likely than females, and they followed this out about six years. Marks activity level, the marks activity level is what we use, and basically what it comes down to is how many times you run, cut, decelerate, or pivot, do you do it less than once a month or four times a week? So if you're a competitive athlete, you're in a 12 to 16 range. Okay, so the population means when you look at that carried over 10 years, you see their baseline, you're 12, their activity level drops to 8.6 or 9, 7, and then 6. So people get less active over time. So if you look at the predictors here and you follow it out at two years, six years, and 10 years, you can see it's pretty consistent that older age, less active, females appear less active, probably because they have less opportunity, higher BMI, smokers, and revision surgery, but there's not a lot of modifiable things that we can do in the OR for our patients in order to affect that. So what about rehabilitation? There's a couple ways to do this. There are two studies that were compared with an NIH-funded Moon cohort with the NIH-funded Delaware-Oslo cohort, and what they looked at is prehab is important. Ten additional sessions of neuromuscular training before the surgery improved it. They also looked at the return to sports training. Ten additional return to sports improved outcomes, and the outcomes we looked at are IKDC-conclusive and return to play. So when you look at this, the first study is where they looked at 10 neuromuscular sessions before ACL reconstruction. The second study, comparing Moon cohort, looked at 10 return to training sessions afterwards, and they compared that to the group in Moon, which didn't have either one of those. And so what you found in study one is that return to sport was increased by 9 percent, probably relevant, and increased in sports and recreation 15, which is a relevant increase as well. If you looked at return to sports training, when you did it after they finished their traditional rehab, the marks level increased by three. We think that is clinically relevant. Sports and rec by 12, and pass, which is the patient's acceptable symptom state, increased by 22, so 100 percent. And I don't think that's something that, at least I don't do, and in my practice I wish we did, that we get everyone to do 10 additional sessions after they finish their rehab. So let's look at 10-year results. And this is the, we published this in 2018, it was the O'Donoghue Award for that year. 1,900 ACLs, this is half of the cohort, 83, 86, 86 percent follow-up, a complicated multivariate regression model with many factors that were looked at that we thought could affect the outcome. So the big surprise, which is great for us, is that if you look at these overlapping lines here, the two-year outcomes by the population, the six-year outcomes, and the 10-year outcomes are the same. There was no drop-off, and I would have never anticipated that. I don't think anyone would have anticipated that the population would be normal or stay as good at two years as six years and 10 years. So it shows a very durable operation. If we look at the IKDC, it shows the same thing. Starts at 52, it's up to 80, 81, and 80.3. So the populations are staying well. If you look at the marks, we showed that before, the activity levels decline. So if you look at what predicts these worse outcomes, and I highlighted in yellow, what the biggest predictor is any kind of second surgery. So any subsequent surgery, whether it's meniscus, articular cartilage, cyclops, any revision ACL, is a huge predictor of worse outcome. Any articular cartilage pathology that is in any part of the knee, whether it's patellofemoral, lateral, or medial compartment, and then there's your typical demographic profiles. Predictor usually doesn't matter for most things in the COUS, but it does matter for the IKDC, smoking bad, higher BMI being bad. Now notice there are things that are missing here. Meniscus injury and treatment is not a predictor of 10-year outcome. So medial and lateral meniscus injury and treatment are not predictors of 10-year outcome. Shelborn said that 20 years ago and everyone laughed at him, but I guess Shelborn is right. Graft type does not predict your patient-reported outcome. It does have an effect on failure. Competition or sport, we looked at surgeon. We looked at the surgeons in the database and surgeon does not matter. If it did matter, I wouldn't show you because we wouldn't be able to disclose that. MCL or LCL doesn't matter and high-grade laxity doesn't matter for patient-reported outcomes. Now it's one thing to say the mean is the same. That's great, but half the people could be getting better and half the people could be getting worse. What happens to the individual patient? What we did here is pretty simple. Everything within the red lines means it didn't change. It's plus or minus 10. Everything above the red line got better. Everything below the red line got worse. So this is individual patients, their 10-year outcome minus their two-year outcome. What you can see across the board is anywhere between 10 to 20 percent of people got worse and a fair number of people got better. So on an individual basis, they're staying the same. If we look at the IKDC, again, only 16.8 percent of people had a more than 10-point drop in their IKDC from year 10 to year 2, but we know that most of the people, half the people are dropping their activity. So whether they're preserving their pain and function by dropping their activity or not, we don't really know. So in conclusion, ACLs remain stable from 2 to 10 years. We maintain a great COUS and IKDC with a steady decline in marks. Multivariate analysis identified some modified predictors to look at in the future. At 10 years, only a small percentage had patient-reported outcomes, pain, and symptoms of post-traumatic OA. That's good. And we didn't have enough data, believe it or not, to look at meniscus injury and treatment coupled with articular cartilage. So despite having 83 percent follow-up of 1,600 ACLs, we couldn't, we're underpowered to look at meniscus and articular cartilage, which we're doing now. And again, there's no on-site follow-up in this group. That's a separate group that we look at where we have physical examination, x-ray, and ophthalmology. So what about autograft choice? We know from background, there are no randomized controlled trials that control for gender, sport, and knee laxity in a high school athlete. It's almost impossible to do. There's no systematic review on this, and it's extremely plausible to carry out a complicated randomized trial, accounting for these factors that most people clinically think are relevant. Kating and Ed Moon published this. The red line is allograft. The green line and the black line that you see right here are autograft, the green being hamstring and the black being BTB, and it always confused us whether there was really a difference here in the young population. And this was based on 2,400 primary ACLs with 92 percent follow-up at two years. So when you look at – so what we wanted to say was we couldn't look at failure at two years because there weren't enough failures to power the model, so we looked at failures at six years and said, what happens on this 14 to 22 that were only athletes in this group right here? And so – this is out of order, I apologize. So in this study designs a prospective cohort, we had 839 primary ACLs. They were autograft BTB versus autograft hamstring, 92 percent follow-up, six-year outcome was re-injury to either knee, and a regression analysis control for the major factors we think are important in failure. So when you look at that, what causes ipsilateral failure is high-grade knee laxity, autograft-type hamstring more, younger age. What causes contralateral failure is sportive injury in football. So I can show you these nomograms, which are useless in practice because no one's going to take out a piece of paper and do it, and I'd like you to get your phones ready. I can show you the nomogram for the opposite side. So if you look at it, ACL graft choice can be best done with an autograft risk calculator, and you can get that on that website or we'll show you a QR code, and the opposite side you can look at the incidence of injury and look at secondary prevention. Both sex and BMI are not predictors of subsequent injury. So if you take out your phone and just put it on camera, and you don't have to click a picture and you put it on the QR code, it automatically takes you to the website, and then you can add whatever, any information you want. Basically, it's going to ask for the sport, it's going to ask for the height and weight, it's going to ask for the gender, it's going to ask for the age, and it'll, it'll ask you to fill out the marks, and from there it'll give you a, it'll give you a predicted failure for autograft BTB and autograft hamstring, and it'll give you a predicted failure if you think that someone has high grade knee laxity. So if you want to know, if you ask me what the best graft is, I don't know. I have to use a calculator because I can't calculate all those things in my head. And there are many examples where the hamstring and BTB are not, not very different at all, and they really are the same. So last thing, how do we interpret, how do we interpret literature, and how do we look at that in our clinical practice? And so Greg Melita's had a great slide when he presented it. He's the, he is the ACL registry person at Kaiser. So he looked at the odds ratio of autograft hamstring versus patella tendon. He looked at it in three entirely separate groups. He looked at the registry or the cohort at Kaiser. He looked at the European registry with over 40,000, and Moon has about 2,300 when you look at, when you look at failure. Now, because of the way the registry is set up in Europe, and because they all have to come back and be operated again, it really has about 90 to 95% follow-up at, at two years. If you look at Kaiser, it also has about, it also has about 20% follow-up. So the odds ratios of these, of these were 1.5, 1.6, and 1.5. That's three, those are three, those are three different numbers, three independent databases. Most of us are in the Midwest or in the South. The Kaiser is mostly in California and the others in Europe, which means that there's a 50% increase in failure. So how do you interpret that? A 50% increase in failure, should we all be doing, should we all be doing BTBs? Or how do you, how do you apply an odds ratio to practice? That's the real, that's the real important part. And if we look at MOON data on allograft, we know that the, across all ages, the risk of failure from an autograft, allograft has three times the risk of failure versus autograft. Doesn't matter whether you're 40 or whether you're 18, does that mean that all allografts are bad? How do you put, how do you put that back into practice? So what I want to do is, is go back and spend some time, basically what you want to understand is what's the absolute difference. The absolute differences tell you the clinical relevance for you and your patient. And it's easy. So if I have an odds ratio in a population that is 1.5 versus patella tendon, and my failure rate is 3%, what we're saying is that a hamstring failure rate is 4.5. And with the patella tendons is 3%. So the absolute difference is 1.5%. I doubt anyone thinks that's clinically relevant that is a surgeon. I don't think patients probably think it's clinically relevant either. So a difference of 1.5% wouldn't change it. Now when you look at allograft in three to one, if you're 18, if you, if that, if you look at that curve, it expands, it widens out over as you get younger. Well, if you're 18 years old, your failure rate is 20% with an allograft, somewhere between six and seven for an autograft, three to one ratio. If you're 40 years old, the failure is 2.4 versus 0.8. A difference of 1.6 makes no difference at all in a 40 year old. And one could argue that the advantages of an allograft and a 40 year old might outweigh an autograft. So you can't be applying things like a P value and odds ratio without understanding what it really means to the patient, what it means to the absolute difference. And finally, if you want to know what the best autograft is, we have debated this among the MOON individuals for almost 19 years at this point in time. And basically it's not always BTB, it's not always hamstring. Sometimes it's both. And you really need, you really need a risk calculator to do that. And most experienced clinicians don't like evidence-based medicine because it doesn't, because a randomized trial applies to the population, not to an individual. And it's only when you develop a personalized risk calculators and nomograms, you get it down to the actual person. So answers to the MOON questions. What does MOON stand for? Multicenter Orthopedic Outcome Network. How do you improve strategies to return to sport? Pick the proper autograph. Don't pick, don't, if something's going to fail, many more, higher percentage, five and 10% more, they're not going to get back to sport. Do some prehab, look at return to sport strategies. What things are matter at the time of ACL reconstruction? Grade three and grade four articular cartilage, yes. Female gender, yes, for IKDNC inactivity, but not COUS. Meniscus tears in treatment, no, they don't matter except for the case if your initial treatment fails and results in subsequent surgery, that's a problem. So does that mean we should take out all meniscus tears or not? Probably not. We can discuss that. It means we probably shouldn't be changing our strategy to try to repair everything and having a lot of failures because that's worse. Back choice doesn't, does not matter for IKDNC COUS or activity. It does matter for failure. High grade laxity does not matter for IKDNC COUS. It does matter for a lower marks and failure. And if you think about it, we always, at least a lot of us thought that that knee that was grossly loose in the OR, that we had a pivot lock and jumped out of place. Usually they have recruited and was a hard person to get back to play sports and turns out that is the case. And so finally, what does high grade knee laxity mean? It means a lockman greater than 10 or it means a pivot lock. I didn't put it also could be in an entry or draw greater than 10. That's something Bob Magnuson thought about coined and looked at. And again, what, what ACL autograph is best for a 14 to 22 year old use the calculator. What causes failure on the contralateral side? It is not whether it's a ABTB or not, whether it's a hamstring, it's really what's for football had the highest, highest risk of injury. And how do you make decisions in practice? You basically make decisions on P value. You don't make decisions on P values, percentage changes, or odds ratio. You look at absolute differences and absolute differences can be looked at as number needed to harm a number needed to treat. For example, if I, if I have an 18 year old and I put an allograft, the number needed to harm is seven. For every seven people I put an allograft in, I'll have an additional failure. That is not a good thing. And then finally things that you are, you all are much better than, than, than we are since we are much older than you is strategies about how could you use that? How could you use information at your fingertips in your practice? How could you make a decision when you're in the OR and you see a meniscus tear, whether to leave that alone? So is that, what, what is the strategy if I leave that eight millimeter partial tear in the lateral meniscus, should I repair it or leave it alone? What are the results? Well, those are information that, that we could build. We could build simple risk calculators that could give her the information in a matter of seconds. The answer is if that small less than what, less than a 10, 10 millimeter tear on the lateral side, if it's stable and you leave it alone, your chance of reoperating in that is on the order of two or 3% and it actually does not affect the outcome at all. But there are many strategies that, that we can look at and the question is how do we get it into your hands and your patient's hands, at least to make the best estimate that what we can do. So we couldn't do this without the NIH funding. We're very grateful that, couldn't do that without my, my first series of partners, Jed Kuhn and Eric McCarty. This is Eric McCarty looking at a University of Colorado there with a high tech x-ray, as you can see, he's looking at it on the sidelines and, and the small funding agencies that provided the initial startup money for MOON. It required $1.2 million for MOON from 2001 to 2006 that was provided by these different entities and companies, including a personal tax on myself, Jed and Eric, and they still like me, I can't believe it. So our publications are here and I've highlighted the ones that we've referenced in here so you can look at them. There are, there are many publications, the ones later on are better because obviously the longer out in the whole list of publications we do. And I think the real, the real interaction is when we answer questions and interaction between the members of MOON. In the beginning, we always debated what was the best graft. And now we, now the question is, it's not that clear. It depends on the individual and the person. And we've all, we also debated about what meniscus to repair or not repair. And we've sort of answered those questions, but we all came at it from a different view. So I look, we look forward to your questions and I actually really look forward to interaction of how do we use the, how do we use the digital environment we live in, in a way that can give you access to information you want at your fingertips to make decisions when you're in the OR or with your patients or after your patient. So thank you. And I can't thank enough all my colleagues in MOON and particularly all the people that have worked on it for years. And one of the things that my partner told me was, he said, Kurt, how many people are in MOON? And I gave him a number. He said, how many people have left in 19 years? I said, zero. And so everyone is still intact and we, we don't always get along. We always give each other a hard time, but we've learned a lot and I look forward to answering questions. Thank you. Hey Kurt, thank you very much. And I'm going to ask Chris Kading and Brian Wolfe if you'll turn your webcams on so that we can see you guys and while we're getting them on, Kurt, I, you know, I've been there since the beginning of this. And I think it, it's very important that everybody understands where this concept came from and why you started MOON. You briefly touched upon it, but could you let the, the fellows and the audience know where this came from and how you got all these people together to, to collaborate? Well, I, it became in my interim, my fellowship with John Bergfeld and Jack Andrish and then Rick Parker was around too. It became clear that the outcomes of it, of your ACL reconstruction was not just dependent upon your graft or your surgeon. There was these myriad of different injuries to the articular cartilage. There were bone bruises. There were meniscus tears, meniscus treatment. People were different sports, people, different weights, people, different genders, people at different activities that there is a myriad of things that could change your function. And the only way to do that, what you'd have to follow a thousand patients. We had no idea how to do this back in 1991, but Jack Andrish and Rick Parker and I followed our patients for about nine years. All we did was collect the patient. All we did was collect what we did in the OR. We had no idea what we're doing. And then we got crazy. And in about nine years later, we said, I wonder if we can find these people because patient reported outcomes came out, Lysum, the COUS and the IKDC. What about if we call these people up, would they really fill out their pain and function? And it turned out they did. And so at that point we said, you know, maybe we ought to do it the right way. Maybe we ought to plan it in a way that's a good prospective cohort, have the right outcome measures first, everyone collect the same thing. And so we got a group of individuals together that were very interested in that. Chris was a warthog at the clinic and Chris was collecting his own database and he liked the idea. And so we started working together and Eric was with me and then we grabbed Bob Marks and we grabbed Rick Wright and we grabbed a bunch of people that were very, very interested in doing it. And we had Sandy Kirkley who was alive, who's the only one that knew what she was doing. She was trained as a, she had her MPH in McMaster. She was one of Ned Amendola's partners and she really guided us through the whole process in the beginning that led us to, to do this. And so we sort of put it together and then from there it just sort of, it became a great learning module and now it's created a lifelong friendship for most of us. So Chris Kading, you know, Dr. Spindler mentioned you. Why did you get interested in this and why would you follow this guy to this thing that he wanted to do? I mean, what interested you in that? So it's actually, there's some parallels. I actually started my own little database. Again, similar to what Kurt just said, I clearly didn't know what I was doing. I was well intended and I actually had a database, I was up to about 1,000 patients, but I realized I'm putting a lot of work into this, but I'm not sure I'm doing it as well as I could or should. And there's nothing more frustrating than starting a research project, putting a lot of time, effort, and money and resources into it, and realize, you know what, I'm not sure I did this quite right, and I'm not sure I'm gonna have a lot of scientific validity or robustness to my study. And it was at a AOSSM meeting, I think it might've been probably about 2000, 99 or 2000, and ran into Kurt, and I'd share with him, hey, I got this database. And he says, gee, Chris, we're talking about pulling these together. And I was convinced you needed to have prospective data collected on patient outcomes. I realized I needed to learn more how to do it. And Kurt made it sound, it was a lot more work than maybe Kurt just outlined, a lot of thought, a lot of discussions, a lot of consultants with other biostatistics experts on how to put this together. In fact, the first MOON meeting, it was in 2000, but we didn't start to enroll patients for two years because it took us two years to think through all the different processes and make sure we were doing it right. So it's been a phenomenal run for me. And I think when you talk about the great success of the MOON, we'd be remiss if not recognizing ultimately it was Kurt's vision and his passion and his persistence that led to that success. You know, Chris, I remember that first meeting and the three of us were there, but Brian Wolf, you were not, you were still a resident. And then you were a fellow HSS. You came into it a couple of years after it started, Brian. You were with Ned Amendola at Iowa. What were your thoughts of it? And in particular, I'd like to know how did this help you with graph position? And you had a really neat study with the MOON providers that we didn't really talk about except at the very beginning. Would you mind just giving us your thoughts on it, Brian? Sure. So I was very fortunate in that I literally left fellowship and kind of joined Ned Amendola at Iowa and MOON was just starting. I think my first meeting was 2002 when I was still in fellowship, but I knew I was coming back. And, you know, MOON has been really great for me during it basically has built my entire academic career getting involved with the group because there was all this data being collected and Kurt and other senior members in the group really looked to those of us who were behind them to try to take the data and write papers and answer questions. And so their willingness to share that with those of us, you know, especially those of us just coming out and joining practices at these institutions that were involved was really an unbelievable opportunity. And, you know, at one of those meetings and we would have these meetings, there was a bit of a discussion about whether the more senior members of the group were better or more accurate than the younger members and whether the hamstring guys were more accurate than the patellar tendon guys. And then the whole question about doing a two incision or an independent drilling versus trans-tibial. So there were a bit of these arguments and the next thing, you know, I'm running a study about to analyze this and Kurt alluded to that in one of his earlier slides. So, and this was also right at the time that Dr. Fu at Pittsburgh was coming out with the anatomic ACL. So there was a lot of, you know, the concept of tunnel placement was very pertinent at the time and it still is. And so we did a three-dimensional CAT scans kind of before that was a common thing in orthopedics. We did that on ACLs in a cadaver lab. So we did 72 ACLs on cadavers and one day, it's a pretty amazing one day episode of drilling tunnels on cadaver knees. And then we also did it on 80 patients at a few of the institutions. So we had a big data set and basically showed that our group was very reliable and reproducible. And no matter what technique you use, you can put an ACL tunnel where it needs to be relative to the anatomic footprint. And I think it really kind of helped validate a lot of our data and took away some questions about technique that as long as you're doing it well, it can, you can do it right. So the moon has spurned off a whole solar system, Kurt. We have Pluto studies, Venus study, Mars studies, Jupiter studies, rock studies. I mean, where did moon come from? And did you ever think you would have a whole solar system of studies as it turned out? No, not at all. I think that when we started, we were the first group, multi-center group to work in sports medicine. There were some other big multi-center groups. There was a group in spine. There was another group in trauma, but in sports there wasn't. Everyone worked within their institution. So I think that when we collaborated together and we began to have some success, I think people thought that was now, it was a good thing. And then really Mars came next and Mars is the revision study. And basically we knew that revisions were a bad outcome. We went to publish the results in our first study and the editor threw it out, said, well, you don't have enough revisions in there, it's unstable. So that got cut on the floor, which made Rick Wright really happy. He was so mad because he refined that article many times. And so we then opened it up to AOSSM and said, look, we need 75 or 80 individuals to collect enough revisions in two years to be able to figure it was. So it became a great opportunity for the sports medicine society. Everyone, it was interesting because 125 people came to be trained by Rick and myself and 83 people actually completed it and participated in the study, which is just amazing. Even better, half the people in Mars are in private practice, not in academic centers. They're in the real world out there, like Dan Cooper produced in the real world, did more revisions than anyone else in the whole group. And so it really was a mix of people across the country in academic and private practice that really represents what goes on in Mars. So it's nice to see other studies go on. The more studies we have, the more information we'll get. And I remember asking Sandy Kirkley, who helped a bunch of characters like myself and Katie and then Amendola, we don't know what we're doing and you know what you're doing and you've already done eight randomized trials. And her comment to me was, there's only so many trials I can do and the more good trials and the more good studies out there the better for my patients and better for our patients. So I think that's still the philosophy we go by today. If we can help other people investigate other things like OCDs and ROC or hip arthroscopy group or Mars, that's really a good thing because that's great for our patients. And then we all have in our patients have better outcomes which is better for our society. Well, it's been just immensely successful, Kurt. There's several questions that have come up from the audience. And I think this is really important to address. We have a lot of young surgeons. They want to know what's important for them as they go into practice. And this really could go to you Kurt or Chris or Brian what do they do as they're trying to collect outcomes and how do they do it? And what are the obstacles that you face that maybe they don't have to face or maybe they do face? Cause it's very important as these young surgeons go out and start their practices soon. Brian or Chris. I have a couple of comments on that. One is I would encourage all the young orthopedists out there, whether you're in private practice or academics to pursue prospective clinical outcome studies. They're very powerful. They can be very impactful. They almost by definition can answer clinically relevant questions. But there's a couple of caveats here but they're also very expensive and time consuming and they require a lot of man hours. So yes, I encourage you to do it. I think you'll find it personally, professionally very rewarding, but I'd be thoughtful. Meaning if you're going to go through the effort of putting together a multi-center trial one, make sure you're asking a research question that's worth asking and putting all that money and effort into. If the question has already been answered by MOON why do you want to reproduce the exact same clinical questions that MOON answered? Now we didn't answer all the questions that's more you see our questions out there but my point is make sure you have a good research question that's worth expending those resources on. Number two, make sure you're thoughtful as you power your research question. So you have enough sites involved in multi-center study. So you can answer the question with some scientific validity. At the same time, you don't want too many sites either because each site you add is going to add a lot of level of complexity to your trying to get a functional multi-center consortium to work. Every site you add has a different compliance office. They have a different legal office. They have different cultures. Then you have the personality of the surgeons. The complexity can become overwhelming and kill your study if you try to include too many sites. But again, you don't want to go through all this and not have enough sites and all of a sudden you're underpowered and you put a lot of time and effort into this and didn't get anything relevant or meaningful out of it. And then be careful about who you join. Make sure this is a team sport. And Kurt was very fond of saying at the beginning of our moon meetings is check the eagle at the door. We're all working together. We're trying to make this moon project successful. So be careful who you select. Be thoughtful about the question you're going to ask. Be thoughtful about what sites you bring on board. If you do those things and make the commitment to it and realize it's not going to be easy, you'll find it rewarding. Again, both personally and professionally. Hey, Brian. So you've got residents at Iowa, you've got fellows. And what do you tell them in terms of getting out into practice and registries? There are some registries out there. And do you encourage them to do that? Is there some other tools that they might have to collect data on their own? Yeah, it's a really good question. I think to add on to what Chris already said, I would emphasize starting right away. So everybody always has these ideas and what everybody finds when they get into practice is that you get busier and busier. And so trying to start things later on is more difficult. I would also say that there are so many more tools these days to collect outcomes compared to 20 years ago when moon was starting. So I don't think a lot of people will know that a lot of moon was paper forms, Scantron forms for years. And now if you're at an academic institution and you have accessibility to red cap, that's an easy way to try to do some of these things that's shared between institutions. But there are proprietary outcomes, measures that many practices already have built in. So this is not an academic institution thing anymore. A lot of practices have these things built in and it's working with your group, it's working with your hospital and trying to figure out a system that will work for you and then being diligent. Because the hardest thing is as you get busier is to enroll people, is to keep checking the boxes and get patients enrolled. Because time goes quickly and before you know it, it's four or five years down the road and you wish you would have collected these particular procedures or those particular problems. So I just emphasize starting right away and working with your hospital, your practice. And so there's so many more tools out there now, even at the trade shows or at the academy or AOSSM, one of the vendors that are available for collecting outcomes, it's just night and day different than what we were dealing with 20 years ago. No, I appreciate that. And I think, I was always impressed Kurt with you because at first you funded MOON, you funded it, we all funded it, we didn't have industry to support to start it. And that's how a lot of us have to start up. It's gonna take some of your own money, it's gonna take some dedication and Kurt, you were always good about taking my money and put it in towards MOON. But I appreciate that because it was worth it and I've learned that you've got to put in effort, time, but also money. So we're gonna get some practical questions, we have some really good questions from the audience. And here's the one that a couple of people have asked, through the years, as we first started MOON, quad tendon wasn't such a big question or graph that was used, now it's utilized quite a bit. Kurt, where do you see quad tendon and face all this? I know we didn't have a lot of data on quad, in fact, I don't know how many quad tendons that we had in the MOON database. What's your thought on the quad tendon? Oh, we don't have any quad tendons, to my knowledge in the database. If we do, it's just a handful, it wasn't being done. I just think it's going to be another autograph, it's gonna sit somewhere between BTV and hamstring. It might make a difference whether you take bone or don't take bone, it might make a difference whether you fix it. I don't think it's gonna be better. I don't think it's gonna be markedly better or markedly worse. It's just gonna be another choice. Chris, I'm gonna ask you the same question. Have you done any quad? And what are your thoughts on quad? Yes, I like quad. And most good research lends itself to more questions. So MOON shows that there's a difference in young, active people participating in cutting sports between hamstring and patella tendon autographs. And that raises a very good question of why. All right, we know at time zero, a well done quadruple hamstring is probably stronger than a central third patella tendon. Yet we're pretty convinced that it fails more frequently. So why? And so that's a great question for some of those young guys out there to help solve that. I have a couple of theories. You know, there's more surface area to quadruple graft and I wonder if that doesn't lend with the neovascularization and the ligamentization, it's some kind of dip in the strength. And right around six, nine months when they go back, they tend to re-tear. Because that's the one difference I can see between a patella tendon and a hamstring. I'm not sure the bone healing, I don't know if people give credit to the patella tendon being successful because of bone to bone healing. But in my experience, the grafts don't fail in the tunnels, they fail inter-articulately. So what I'm leading to is I think the quad tendon, it has densely packed collagen, maybe not quite as densely packed as patella tendon because it has some natural layers in it. But it definitely has, it's more densely packed than a quadrupled hamstring. So I wouldn't be surprised, as Kurt says, it's somewhere between the two, but I'm predicting it ends up a little closer to a patella tendon than a hamstring. That's, again, I'm just speculating, but another good question for someone else to sort out. That's right, that's the next planet. We have some planets left out there. So Brian Wolfe, I'd like your thoughts on quad too. Are you using it and do you have any thoughts on it? Yeah, I actually use quite a bit of quad tendon. Based on the moon data and the Mars data, it's become a good option for me for revisions, especially revisions from a previous hamstring graft due to cosmesis and incisions and things. And I think it's also a good option for young athletes that potentially are gonna be down on their knees. That could be a rest, we do a lot of wrestling in Iowa. It's become very popular. Actually, some patients come in asking for it if they're down on their knees a lot or a softball catcher or something like that. So I find myself doing more and more. I think the outcomes for me so far have been very promising and very favorable. And I think it's kind of here to stay. I think it'll be interesting to see what the data shows us in another five or 10 years, but we do need another group to collect that data and give us the answer. That's right, sir. All those surgeons out there and those young ones, you got a question and I got a thought on it too. I like quad, I haven't been using it for a few years, but I think in those young athletes that, if you don't wanna use our hamstring, this is a good one. And I wonder if the hamstring failure was higher in our younger group because of what Tim Hewitt's work on the activation of the hamstrings for those young female athletes. I don't know, but I think it's a good question. But quad is here to stay. It's a great graph. Kurt Spindler, what are your thoughts on this question came up, fixation. There's a newer fixation that has been in the past five, six, seven years since the moon. We started the database. Do you think any of the fixation of these newer techniques makes any difference in the outcomes in a hamstring or a patella tendon? I think we've reached the point about choosing different autographs and choosing different fixation techniques that they're all good enough. And we're not gonna make a fundamental change in improving our outcomes that way. Because in the past review of, if in systematic reviews of different fixation, whether it's absorbable or metal, whether it's aperture or whether it's on the cortex or the exact device has not shown any clinically relevant outcome differences at all. And so I don't think any of the newer fixation is going to be the problem. As Chris said before, when we see failures, we don't see failures from the fixation. We see failures, in particular where the ligament breaking. So I don't think that matters. I think that's a company driven question. And I think that fundamentally we have to understand, is our graft strength strong enough when we have them go back? Do we have them neuromuscularly ready to go back? And we still never solve the problem of post-traumatic arthritis. The fact that they, even after a reconstruction, we don't protect them well enough. It doesn't prevent them from getting some post-traumatic OA. You know, Chris, Katie, I know you've used allograft in the past. You had a really sentinel paper on allograft. Can you tell audience, you know, what your use of allograft is currently and if you use it and what type of allograft? So way back when we started looking at failures in the moon database, I was interested in failures. A couple of comments on the failure. One, I'm going to throw this out here before I forget. I'll never forget when I first started looking at some of the moon data and looking at predictors of failure, I was convinced, I would have bet Kurt a steak dinner that gender would have been a predictor. We all know that female gender is a risk for native ACL. And I'm thinking, well, gee, if it's a risk factor with native ACL, everything's the same, right? We haven't changed our alignment, the neuromuscular, everything's there. We just put different graft in. They have to be at increased risk for tearing a ACL reconstruction. And when the stats people came back and said, nope, no difference, not even close. And I said, you got to check it again. Your data is interfering with my opinion. So sure enough. So this is the, you know, I like to always use that example, how we can't just trust our own opinion all the time. We actually simply got to look at the data. Now, allografts. So I was a little suspicious of allografts. When we looked more closely, it was pretty impressive. In young active patients, the allografts fell at a high rate. Now, of course, that raises the next question. Why and what type of allograft? Now, one allograft is not like another allograft, right? We kind of lump them together. So currently here's my take on allografts. I do use them, but nowhere near what I used to. I'll use them in multi-ligaments. I'll use them in older patients. Now, once you hit about 40, if you look at that graft Kurt showed, the absolute difference becomes probably clinically not significant. I also believe that the less processed the allograft, the better it is. The more the graft is processed, the more we have higher failure rates. I think that's a nice trend that's been shown. Without going any more, that's kind of where I'm at with allografts. Hey, thank you, Chris. Brian, you're head of the sports there at Iowa, got some great teams in the Big Ten. What's your preferred graft type for your collegiate athletes? For the last several years, and I think it's been kind of this way since Ned Amendola was here, we've done patellar tendon grafts for our Iowa athletes, for the vast majority of people. And I've continued that on. There are exceptions obviously, but that's been our number one graft for me in college and high school athletes is a patellar tendon graft, unless there's some other extenuating circumstances that we want to do something slightly different. And I do all different grafts. I do hamstring grafts and patellar tendon grafts and quad tendon grafts. I have no exclusions per se, but it is a discussion. And if I have some influence in the situation with my Iowa athletes, they get a BTP. So what about their wrestlers? Do you have any concern with the wrestlers on their knees or do they get a BTP as well? So I would say over the last three years that we have started to do more quad tendon in our wrestlers, not in all of them. It's a discussion. So it's, and Dr. Robbie Westerman, who's my partner, is now kind of the main team doctor for Iowa wrestling. And he has grown fond of using quad tendon and we get quite a few high school and small college and other college wrestlers here. And that's also been a good option to use quad tendon because again, they are down on their knees and that's worked out well and so far in our hands. All right, Chris Kinney at The Ohio State University, what is your preferred graft for all those athletes you've got, especially your football players, but any of the collegiate athletes? I'll give you a little bit longer answer. I was on that hamstring train for a while and that's another thing that Moon changed for me, especially when it was reinforced by more and more registries last three, four, five years. I was not unhappy with a quadruple semitendinosus taking a single hamstring, quadrupling it and bringing them back in a slow fashion. But when I looked at the data, sure enough, I'm now convinced that there's no question in the young cutting sport athlete, someone under the age of 25 who's involved in organized competitive cutting sport, soccer, football, basketball, rugby, lacrosse, I'm using a patella tendon. Right, and Kurt, I know what your answer is, but you're still gonna have to tell us because I was a resident with you in the mid 90s and you were showing me how this patella tendon graft was done with a two incision. And is there any change since then? Would you still use it in your collegiate pro athletes, the patella tendon, any thoughts? Yeah, I still would. I don't think there's something better out there, though we don't know what quad tendon could be just as good and have some advantages, particularly in someone who's kneeling and wrestling. So how quad tendon stacks up against it would be quite fascinating. It would be a nice study. It doesn't have to be a big study. You could just take wrestlers or football players. And what's nice about the risk calculator is you could take the highest risk athletes. It's gonna be football. And then you could randomize them between quad and patella tendon. You can get a really nice study and see how they do. My gut tells me and my guess tells me that their patient reported outcomes will be very similar. They may be different than kneeling discomfort. And you won't be, because the failure rates are relatively low, you won't be able to power that study for failure. So you won't know if one fails more than the other, but it'll definitely be low. So we have about five minutes and I wanna make sure that we give you all, the panel, a chance to give any last thoughts on MOON, what it's meant to you for your career, for your practice, and any advice that you have for the young surgeons. And I'll start with the youngest of the MOON on the panel right now. I'll start with you, Brian. We'll go to Chris after that. I heard you get the last word as usual. So Brian. Well, I'm only a few years younger than you, Eric. So you're still a very young buck yourself. I'm a lot more gray. You know, MOON's been great for my career. It's really established my network who I look to as mentors and friends and collaborators. So I would encourage all of the fellows and young residents coming out to build a group, to work together, to collaborate, you can answer questions and it drives the other things. As you mentioned, it's driven to MOON Shoulder, which is now an instability and rotator cuff. It's done a lot of different things. And I think we'll see the next wave of that, but I would really just encourage people to collaborate, to work together. And it's more than just research and academics. You build a network of people that you trust, that you reach out to when you have questions and problems, when you have a conundrum that you don't know how to fix, or you don't know the right answer to, and you can bounce questions off. And the more you can do those kinds of things, I think the better it is for your career, especially early on. Yeah, thank you, Brian. Dr. Katie. So I echo everything Brian just said and add one or two things. It's been incredibly rewarding and satisfying professionally, academically. It's been stimulating. It's rewarding to feel like we've made some impact and helped to further the field of sports medicine, helped our patients. But I tell you, and Brian touched on this, you develop certain friendships that are lifelong, and that's been very rewarding as well. That's the personal side that I've really enjoyed. And it reminds me of that cliche, if you wanna go fast, you go alone, but if you wanna go far, you go with a group. And group dynamics are not easy, but boy, you get a good group together, you can do some great things. Thank you, Chris. And Kurt, last thoughts, reflections from you? I think that it's been amazing what I've learned and what we've learned as interacting in a group among a group of individuals, where real learning takes place when there's really meetings among us where there's really no holds barred and we tell each other what we think, and then we let the data determine what it is. And that's always been fun. But the most fun is really the collaborations and the friendships that go well beyond and the things that we do together at meetings and go to meetings and our team coverage and asking people questions that you know well and say, hey, what would you do with this trouble case? And you trust the person, because you know the person, because you've interacted with them, and you know you're gonna get an honest opinion. So it's the friendships and those things that are the most fun. And hopefully the next generation of folks that are coming up and the fellows listening, you'll tell us and you'll teach us how to get information into your hands in a way that you need it when you need it, so we can give you the best information. And you'll teach us other questions that you have that we haven't thought of. So I think that the most diverse groups that we have, and everyone asks questions and questions that are relevant, then we can begin to investigate them. And that's really a lot of fun when you can work together with someone, accomplish things as a team, and then hopefully have an impact and make it better for our patients. Well, thank you, Kurt. Thank you, Chris. Thank you, Brian. And I wanna thank the audience for tuning in, especially to the fellows and residents. Thank you for being so patient during this tough time of the coronavirus, because this is a time of training for you and you're missing out on different cases, different times in the clinic. And hopefully something like this tonight is giving you some wisdom, some tools for you to look at when you go to your practice. And we appreciate you because you're the future of AOSSM, you're the future of our society. And we thank you. And we thank you for this time. I think Alexandra is gonna be getting on the line for any wrap up. And again, we thank you all. Thank you, Dr. McCarty. And thank you to all of our panelists for the time and preparation that went into preparing for tonight's webinar. All right. We look forward to next week. This is our webinar topic, Common Practices in Hip Arthroscopy. We look forward to seeing you same time next week and appreciate all of your participation tonight and wish you a good evening. Thank you so much. Thank you. Thank you. Thank you, everyone. Thanks. Great job, Eric, Chris, Brian. Thanks, Kurt. Thanks, everybody. Good job. Thank you. Good night.

AOSSM Fellows Webinar Series

ACL Outcomes Update

MOON studies

panel discussion

Dr. McCarty

Dr. Spindler

ACL reconstruction

return to sport

risk factors

rehabilitation strategies