ACL Reconstruction: The MOON

Group: What does Data Show?Kurt P. Spindler, MD

Vice Chairman Research ORI

Director, Orthopaedic Clinical Outcomes

Academic Director, Cleveland Clinic Sports Health

Orthopaedic Rheumatologic Institute Cleveland Clinic

Adjoint Professor Orthopaedics

Vanderbilt University Medical Center

2015 CU Sports Medicine Fall Symposium Oct. 2

2012 Winner Ann Doner Vaughan Kappa Delta Award

Disclosures Kurt P Spindler

1. Current FUNDING

a. NIH R01 = MOON (K Spindler – PI)

b. NIH R01 = MeTeOR study (J Katz - PI)

c. NIH R01 = ACLR Healing (B Fleming- PI)

d. NIH RO1 = ACL Healing (M Murray – PI)

e. Unrestricted Educational Gifts

• DonJoy

• AOSSM = MARS

f. Research Grant: Smith & Nephew Calaxo

g. Research Grant: Arthritis Foundation

2. Patent: Intra-articular Healing Ligaments

3. Consultant: NFL, Service Excellence, Mitek

4. Scientific Advisory Board: Cytori

2004

2012

Sports Health

KP Spindler and RW Wright:

N Engl J Med 359;20:2135-2142, Nov 13, 2008

Sports Health

Anterior Cruciate Ligament (ACL)

Normal ACL ACL Tear Scope ACL Tear

Sports Health

Medial and Lateral Meniscus

Spindler and Wright. N Engl J Med

359:20, 2135-2142, Nov 13, 2008

Bucket handle MM

Partial LM tear

Normal

meniscus

Sports Health

Articular Cartilage

Spindler and Wright. N Engl J Med

359:20, 2135-2142, Nov 13, 2008

Normal LFC

Normal MFC

Focal defect LFC

Early GII Chondromalacia MFC

Sports Health

MOON ACLR Multicenter Cohort:1. Patient-Reported Outcomes and Failure

2. Specialized Cohort: Initiation and Predictors of OA

1. 20+ Year Development & History MOON

2. NIH Initial 2 Year Follow-up (’06 -’10) &

Competitive Renewal 6 Year F/U (’10 -’15)

Competitive Supplement add 1241 (‘13 -’15)

Competitive Renewal 10 Year F/U (’15 -’20)

3. Why MULTICENTER?

a. Sample size Outcomes events occur < 10% of time

b. Timeliness obtain relevant results within years

c. Generalizability to treatment of ACL tears

VANDERBILT UNIVERSITY

Kurt P. Spindler, MD

Warren R. Dunn, MD, MPH

Charles L. Cox, MD, MPH

CLEVELAND CLINIC FOUNDATION

Richard D. Parker, MD

Jack T. Andrish, MD

Morgan H. Jones, MD, MPH

John A. Bergfeld, MD

THE OHIO STATE UNIVERSITY

Christopher C. Kaeding, MD

David C. Flanigan, MD

Robert Magnussen, MD

UNIVERSITY OF IOWA

Ned Amendola, MD

Brian J. Wolf, MD, MS

WASHINGTON UNIVERSITY – ST. LOUIS

Rick W. Wright, MD

Matthew J. Matava, MD

Robert H. Brophy, MD

Matthew V. Smith, MD

HOSPITAL FOR SPECIAL SURGERY

Robert G. Marx, MD

UNIVERSITY OF COLORADO

Eric C. McCarty, MD

Michelle L. Wolcott, MD

Armando F. Vidal, MD

VANDERBILT UNIVERSITY

Laura Huston, MS Frank Harrell, Jr., PhD

Emily Reinke, PhD Sam Nwosu, MS

John Shaw Zhouwen Liu, MS

Suzet Galindo-Martinez Thomas DuPont

Brooke Rode * JoAnn Alvarez

Erica Scaramuzza * Angel An, MS

* Lynn Cain

CLEVELAND CLINIC FOUNDATION

Leah Schmitz, PA-C * Lynn Borzi, MBA, RN

Michelle Hines, RN * Julia Brasfield, PA-C

Maxine Cox * Kristin Banjac, PA-C

Sharon Komninos * Pam Koeth, PA-C

THE OHIO STATE UNIVERSITY

Angela Pedroza, MPH

Kari Stammen

Rose Backs, PA-C, ATC

Amber Thompson

UNIVERSITY OF IOWA

Catherine Fruehling-Wall

* Carla Britton, PhD

WASHINGTON UNIVERSITY – ST. LOUIS

Amanda Haas, MA Linda Burnworth

Robyn Gornati Deb Hanson

Michelle Cooper

HOSPITAL FOR SPECIAL SURGERY

Lana Verkuil * Kaitlyn Lillemoe

* Patrick Grimm * Brian Boyle

* Jessica Ryu

UNIVERSITY OF COLORADO

Cyndi Long * Paula Langner

* Christine Bennett * John Gines

Site Support Staff

Key: * denotes former contributor

BIOSTATSFrank E. Harrell, Jr, PhD Chair VUMC

Michael Kattan, PhD Chair CCF

Zhouwen Liu, MS

Thomas DuPont

Sam Nwosu, MS

HEALTH SERVICES

RESEARCH CENTERRobert S. Dittus, MD, MPH

CONSULTANTSBraden C. Fleming, PhD

Martha M. Murray, MD

Warren R. Dunn, MD, MPH

PROJECT DIRECTORSLaura J. Huston, MS

Emily K. Reinke, PhD

RESEARCH ANALYSTSJohn Shaw

Suzet Galindo-Martinez

Erica Scaramuzza

Brooke Rode

EDITORIAL ASSISTANTLynn S. Cain

MOON Coordinator Centers

Vanderbilt and Cleveland Clinic

Scientific Validity MOON Group

1. Inter-rater Agreement of Meniscus Tears and Treatment. Dunn, AJSM, 2004

2. Inter-rater Agreement of Articular Cartilage Classification. Marx, AJSM, 2005

3. Systematic Review of Autograft ACLR: Does Graft

Choice Really Matter? Spindler, AJSM, 2004

4. Intra- & Inter-surgeon Agreement on

ANATOMIC Femoral and Tibial Tunnels

ACLR. McConkey AJSM 2012 & Wolf AJSM 2013

To establish the consistency of measurements and techniques

across 7 sites, multiple validity studies have been performed:

Intra- and Inter-Surgeon Agreement

ACLR Tunnel PlacementMcConkey AJSM 2012 & Wolf AJSM 2013

1. Intra & Inter-surgeon variability

a. 12 surgeons - 6 knees: CADAVER

b. Tunnels reproducible across

technique and experience

c. Statistical differences, but doubt

clinically relevant

2. Intra & Inter-surgeon variability

a. 8 Surgeons @ 4 sites: PATIENTS

b. Small variations between and

among surgeons

c. Statistical difference, but doubt

clinically relevant

Entire MOON (PRO) Cohort F/U

Enrollment

Years

N 2 Years 6 Years 10 Years

PRO

Forms

2002-2003 1080 85% 83% 82% KOOS

2004-2005 1217 82% 82% ‘04 = 81% IKDC

2007-2008 1250 81% 81% Marx

Total 3547 85% 82% 82% SF-36

>90% f/u failure and additional surgery (via phone)

MOON NESTED Cohort 2 Yr f/u

(Standing MTP XR for JSN)

Onsite: MTP standing XR for joint space measurements

KT-1000 AP laxity & independent blinded PE

Patient-Reported Outcomes (KOOS, Marx, etc.)

Functional HOP testing

Enrollment

Years

2005 2006 2007 2008 2009 2010 TOTAL

Completed

ONSITE

59 21 67 68 55 47 317

PATIENT RISK FACTORS ON ACLR OUTCOME: DEMOGRAPHICS

1 Is Age a risk factor for ACLR failure? Yes: increased failure of ACLR in

younger individuals

2 Is Gender a risk factor for future

activity after ACLR?

Yes: lower activity level (Marx) in

females

3 Is Baseline Activity Level a risk

factor for future activity after ACLR?

Yes: higher activity level in

individuals with higher baseline

activity level

4 Is BMI a risk factor for ACLR activity

and patient-reported outcome (PRO)?

Yes: higher BMI predicts lower

activity and worse outcomes

5 Is Smoking a risk factor for ACLR

activity and PRO?

Yes: lower activity level and worse

outcomes

6 Is Education a risk factor for ACLR

outcome?

Yes: less education years worse

outcome

PATIENT RISK FACTORS ON ACLR OUTCOME: INJURY EXTENT

1 Is a Grade 1 or 2 MCL injury a risk

factor for ACLR outcome?

No: Not a risk factor

2 Is a LCL injury a risk factor for

ACLR outcome?

Yes: More symptoms in individuals

with LCL injury

3 Is a Medial Meniscal repair a risk

factor for ACLR outcome?

Yes: worse outcome with repairs

4 Is a Lateral Meniscal repair a risk

factor for ACLR outcome?

No: lateral meniscal repair same as

no lateral meniscal tear

5 Is an Articular Cartilage injury a

risk factor for ACLR outcome?

Yes: worse outcomes with Grade III/

Grade IV chondromalacia

SURGICAL DECISIONS ON ACLR OUTCOMES

1 What is the risk of

ACLR graft

failure at 2 years?

Autograft: 1-6%

Allograft: 2-20%

2 What is the best

graft source

(autograft or

allograft)?

Lower failure

AUTOGRAFT

especially Younger

(see Figure 1)

3 What is the

reoperation rate

for failure of

meniscus repair

during ACLR?

4-6%

2488 Primary ACLR >92% f/u @ 2years

Kaeding AJSM 2015

RETURN TO SPORTS, ACTIVITY LEVELS, AND SPORT OUTCOME INSTRUMENTS (IKDC & KOOS)

1 Will I be able to return to sports? Unknown except FB & Soccer

2 What are my chances to return to

play American Football?

High School ~70%

College ~70%

50% cited fear as critical factor for

not returning

3 What are my chances to return to

play Soccer?

~70%

Males more likely to return than

females to RTP4 What will my future activity level

be after ACLR based on the Marx

Activity Scale?

Decreased activity with a 4 point

loss on the Marx activity scale at 2

years.

5 What will my future patient-reported

outcome on the KOOS?

Improved, but not normal

6 What will my future patient-reported

outcome be after ACLR based on

the IKDC?

Improved, but not normal

PAIN SUBSCALES AND ACTIVITIES OF DAILY LIVING INSTRUMENTS PRO

1

What causes knee pain at time of

surgery for ACLR?

BMI, female gender, older age,

and LCL injury

Bone bruise not associated with pain after ACLR

2

KOOS Pain Subscale Improved outcomes with higher baseline scores, lower BMI, non-

smoker, and untreated lateral meniscal tears

Poorer outcomes with lower education, medial meniscal repair,

grade IV MFC, MTP, LTP, grade III LTP, MTP, revision ACLR

3

KOOS ADL Subscale Improved outcomes with higher baseline scores, lower BMI, non-

smoker

Poorer outcomes with lower education, contralateral ACLR, medial

meniscal repair, no lateral meniscal tear, Grade III/IV trochlea,

revision ACLR

4

KOOS QoL (Knee Related Quality of Life)Improved outcomes with Higher baseline score, non-smoker,

untreated LM tear

Poorer outcomes with lower education, contralateral ACLR, MM

repair, grade IV MFC, LFC or MTP, revision ACLR

5

SF-36 PCS (physical function)Improved outcomes with higher baseline score, lower BMI, younger

age, excised or untreated LM tear

Poorer outcomes with revision ACLR, lower education, smoker,

grade III/IV LTP

6

SF-36 MCS (mental function)Improved outcomes with higher baseline score, higher baseline

Marx

Poorer outcomes with less education, smoker/quit

RISKS FOR ADDITIONAL ARTHROSCOPIC SURGERY

1 What is the risk of ipsilateral kneeligament reconstruction failure at 2 years?

2 years — 4.9%

6 years — 7.7%Median time to event: 17.1 months

(See Figure 1 for Individual Risk)

2 What is the risk of an ACL tear in the

normal contralateral knee at 2 years? 6 years?

2 years — 2.5%

6 years — 6.4%

Median time to event: 27.3 months

(See Figure1 for Individual Risk)

3 What is my risk of infection after ACLR? 0.4%

4 What is the risk of surgery for

arthrofibrosis?

2 years — 4.1%

6 years — 5.4%

Median time to event:

13.1 months (cyclops),

2.2 months (MUA),

18.2 months (synovectomy)

5 What is my risk of meniscal repair

failure?

2 years — 4% re-operation

6 What is my risk of hardware removal? 2 years — 0.6%

6 years — 1.3%

Marx Activity @ 2 & 6 Years

Cox AJSM 2014

1. 1512 ACLR with 85% min 6 yr f/u with

multivariable statistical modeling Marx Outcome

2. Marx activity (scale 0-16) t0=12, t2=9, t6=7

3. Proven Predictors of MARX Athletic activity

a. Age h. Grade 4 CM MFC

b. Gender i. Competition level

c. BMI j. specific sport

d. Smoking

e. educational status

f. revision ACLR

g. time from surgery

Marx Activity @ 2 & 6 Years

1. NOT significant predictors Marx !

a. meniscus injury and treatment

b. autograft choice

c. Grade 1-4 CM at surgery except MFC

Cost-Effectiveness Analysis of Early

Reconstruction versus Rehabilitation &

Delayed Reconstruction for ACL TearsMather AJSM June 2014

1. Data Sources: KANON RCT & MOON

2. Markov Decision Modeling

3. Costs based 2012 US

4. SF-6D (component of SF-36)

5. RESULTS: Early ACLR results had both:

increase 0.30 QALYs (Quality adjusted life years)

lower cost $1797 (2012$) Threshold 17% failure

6. Societal Point of view – early ACLR is more cost

effective and preferred strategy

Baseline Predictors of Health-Related Quality of

Life After ACLR A Longitudinal Analysis of a

Multicenter Cohort at Two and Six Years

Dunn JBJS Am April 2015

1. Data MOON 2002-2004 = 1512 ACLR

2. Follow-up = 93% with Multivariable Analysis

3. ACLR effect size 1.2 for PCS score SF-36

4. Mean utility gained at six years after ACL

reconstruction was 5.3 quality-adjusted life

years(QALYs)

5. Identified predictors Better and Worse PCS SF-36

which similar to KOOS & IKDC

Prospective Analysis of 2488 Primary ACLR From

the MOON Cohort Risk Factors and Predictors of

Subsequent ACL Injury in Either Knee After ACLR

(Kaeding April AJSM 2015 )

1. MOON AOSSM

Presented 2014

2. 2488 Primary ACLR

3. 92.7 % f/u @ 2 years

4. AVOID failure by NOT

using allografts high

school and college!

5. RESULTS:

Age and activity were

predictors of increased risk

of both ipsilateral and

contralateral ACL tear

Ipsilateral ACLR Graft failure

Factors Associated with Infection Following

Anterior Cruciate Ligament ReconstructionBrophy JBJS Am March 2015

1. Data MOON 2002-2005 = 2198 ACLR

2. Follow-up > 85% with Multivariable anlaysis

3. Infection was defined as an ACLR required

postoperative surgical irrigation and debridement.

4. Overall rate infection = 0.77%

5. Diabetes significant Increased risk OR = 18.8

6. Autograft BTB significantly lower risk infection

then Autograft HG or Allografts

Meniscus treatment and age associated with

narrower radiographic joint space width 2 to 3 years

after ACLR: data from the MOON onsite cohort(Jones, M Osteoarthritis and Cartilage 2015)

1. Measure joint space width min 2

yr after primary ACLR within

MOON nested cohort

Normal and untreated small

stable tear not different

2. Medial meniscus repair

significantly more narrowing

than normal untreated; however,

medial meniscus repair was

significantly less narrowing than

excision

3. Caveat: repair based primarily

on tear type and vascularity thus

surgeon cannot switch from

excision to repair

JSN

N=261 ACLR @2.5 yrs

Powerful Role AGE in JSW MOON ORBITS

JSN

Jones, M Osteoarthrtis & Cartilage 2015

KOOS Pain as a Marker for Significant Knee Pain

Two and Six Years after Primary ACLR: A MOON

Prospective Longitudinal Cohort Study

Wasserstein Osteoarthritis & Cartilage 2015

1. Data MOON 2002-2005 = 1761 Primary ACLR

2. Follow-up @ 6 years > 86% with Multivariable

analysis

3. Significant Knee PAIN present 9-39% ACLR 6yrs

4. Dominant risk factor is a Second Surgery either

revision or simple scope

5. Demographics and articular cartilage and

meniscus injury also influenced knee pain but to a

lesser extent then second surgery

Can MOON Evaluate: ELITE Athlete or

Why Revision ACLR Worse Outcomes

1. Elite athlete: NO !

inadequate sample size

2. Revision ACLR = NO!

Worst Predictor of Outcome!

a. MARS was born to evaluate

predictors (84 surgeons, 53

sites have enrolled 1200)

b. Funded NIAMS PI: Rick Wright MD

c. >80% 2 yr f/u in Fall 2013

d. AOSSM Award paper submitted

11/1/13 results presented AOSSM

2014

MOON Publications1. Dunn WR, Wolf BR, Amendola A, Andrish JT, Kaeding C, Marx RG, McCarty EC, Parker RD, Wright RW, Spindler KP. Multirater

agreement of arthroscopic meniscal lesions. Am J Sports Med. 2004 Dec;32(8):1937-40.

2. Marx RG, Connor J, Lyman S, Amendola A, Andrish JT, Kaeding C, McCarty EC, Parker RD, Wright RW, Spindler KP; Multicenter

Orthopaedic Outcomes Network. Multirater agreement of arthroscopic grading of knee articular cartilage. Am J Sports Med. 2005

Nov;33(11):1654-7.

3. Wright RW, Dunn WR, Amendola A, Andrish JT, Bergfeld J, Kaeding CC, Marx RG, McCarty EC, Parker RD, Wolcott M, Wolf BR,

Spindler KP. Risk of tearing the intact anterior cruciate ligament in the contralateral knee and rupturing the anterior cruciate

ligament graft during the first 2 years after anterior cruciate ligament reconstruction: a prospective MOON cohort study. Am J

Sports Med. 2007Jul;35(7):1131-4.

4. Wright RW, Dunn WR, Amendola A, Andrish JT, Flanigan DC, Jones M, Kaeding CC, Marx RG, Matava MJ, McCarty EC, Parker

RD, Vidal A, Wolcott M, Wolf BR, Spindler KP; MOON Cohort. Anterior cruciate ligament revision reconstruction: two-year results

from the MOON cohort. J Knee Surg. 2007 Oct;20(4):308-11.

5. Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty

EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. A systematic review of anterior cruciate ligament reconstruction

rehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. J

Knee Surg. 2008 Jul;21(3):217-24.

6. Wright RW, Preston E, Fleming BC, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Kaeding C, Kuhn JE, Marx RG, McCarty

EC, Parker RC, Spindler KP, Wolcott M, Wolf BR, Williams GN. A systematic review of anterior cruciate ligament reconstruction

rehabilitation: part II: open versus closed kinetic chain exercises, neuromuscular electrical stimulation, accelerated rehabilitation,

and miscellaneous topics. J Knee Surg. 2008 Jul;21(3):225-34.

7. Toman CV, Dunn WR, Spindler KP, Amendola A, Andrish JT, Bergfeld JA, Flanigan D, Jones MH, Kaeding CC, Marx RG, Matava

MJ, McCarty EC, Parker RD, Wolcott M,Vidal A, Wolf BR, Huston LJ, Harrell FE Jr, Wright RW. Success of meniscal repair at

anterior cruciate ligament reconstruction. Am J Sports Med. 2009 Jun;37(6):1111-5.

8. Fetzer GB, Spindler KP, Amendola A, Andrish JT, Bergfeld JA, Dunn WR, Flanigan DC, Jones M, Kaeding CC, Marx RG, Matava

MJ, McCarty EC, Parker RD,Wolcott M, Vidal A, Wolf BR, Wright RW. Potential market for new meniscus repair strategies:

evaluation of the MOON cohort. J Knee Surg. 2009 Jul;22(3):180-6.

9. Borchers J, Pedroza A, Kaeding CC. Activity level and graft type as risk factors for ACL graft failure: A case control study of the

MOON cohort. Am J Sports Med. 2009 Dec;37(12):2362-7.

MOON Publications10. Magnussen RA, Granan LP, Dunn WR, Amendola A, Andrish JT, Brophy R, Carey JL, Flanigan D, Huston LJ, Jones M, Kaeding

CC, McCarty EC, Marx RG, Matava MJ, Parker RD, Vidal A, Wolcott M, Wolf BR, Wright RW, Spindler KP, Engebretsen L. Cross-

cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol

Arthrosc. 2010 Jan;18(1):98-105.

11. Dunn WR, Spindler KP, Amendola A, Andrish JT, Kaeding CC, Marx RG, McCarty EC, Parker RD, Harrell FE Jr, An AQ, Wright

RW, Brophy RH, Matava MJ, Flanigan DC, Huston LJ, Jones MH, Wolcott ML, Vidal AF, Wolf BR; MOON ACL Investigation.

Which preoperative factors, including bone bruise, are associated with knee pain/symptoms at index anterior cruciate ligament

reconstruction (ACLR)? A Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med. 2010

Sep;38(9):1778-87.

12. Dunn WR, Spindler KP; MOON Consortium. Predictors of activity level 2 years after anterior cruciate ligament reconstruction

(ACLR): a Multicenter Orthopaedic Outcomes Network (MOON) ACLR cohort study. Am J Sports Med. 2010 Oct;38(10):2040-50.

13. Kaeding CC, Aros B, Pedroza A, Pifel E, Amendola A, Andrish JT, Dunn WR, Marx RG, McCarty EC, Parker RD, Wright RW,

Spindler KP. Allograft versus autograft anterior cruciate ligament reconstruction: predictors of failure from a MOON prospective

longitudinal cohort. Sports Health. 2011 Jan;3(1):73-81.

14. Spindler KP, Huston LJ, Wright RW, Kaeding CC, Marx RG, Amendola A, Parker RD, Andrish JT, Reinke EK, Harrell FE Jr;

MOON Group, Dunn WR. The prognosis and predictors of sports function and activity at minimum 6 years after anterior cruciate

ligament reconstruction: a population cohort study. Am J Sports Med. 2011 Feb;39(2):348-59.

15. Borchers JR, Kaeding CC, Pedroza AD, Huston LJ, Spindler KP, Wright RW; MOON Consortium and the MARS Group. Intra-

articular findings in primary and revision anterior cruciate ligament reconstruction surgery: a comparison of the MOON and MARS

study groups. Am J Sports Med. 2011 Sep;39(9):1889-93.

16. Reinke EK, Spindler KP, Lorring D, Jones MH, Schmitz L, Flanigan DC, An AQ, Quiram AR, Preston E, Martin M, Schroeder B,

Parker RD, Kaeding CC, Borzi L, Pedroza A, Huston LJ, Harrell FE Jr, Dunn WR. Hop tests correlate with IKDC and KOOS at

minimum of 2 years after primary ACL reconstruction. Knee Surg Sports Traumatol Arthrosc. 2011 Nov;19(11):1806-16.

17. Wright R, Spindler K, Huston L, Amendola A, Andrish J, Brophy R, Carey J, Cox C, Flanigan D, Jones M, Kaeding C, Marx R,

Matava M, McCarty E, Parker R, Vidal A, Wolcott M, Wolf B, Dunn W. Revision ACL reconstruction outcomes: MOON cohort. J

Knee Surg. 2011 Dec;24(4):289-94.

18. Warme BA, Ramme AJ, Willey MC, Britton CL, Flint JH, Amendola AS, Wolf BR; MOON Knee Group. Reliability of early

postoperative radiographic assessment of tunnel placement after anterior cruciate ligament reconstruction. Arthroscopy. 2012

Jul;28(7):942-51.

MOON Publications19. Sullivan JP, Matava MJ, Flanigan DC, Gao Y, Britton CL, Amendola A; MOON Group, Wolf BR. Reliability of tunnel

measurements and the quadrant method using fluoroscopic radiographs after anterior cruciate ligament reconstruction. Am J

Sports Med. 2012 Oct;40(10):2236-41.

20. McCullough KA, Phelps KD, Spindler KP, Matava MJ, Dunn WR, Parker RD; MOON Group, Reinke EK. Return to high school-

and college-level football after anterior cruciate ligament reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON)

cohort study. Am J Sports Med. 2012 Nov;40(11):2523-9.

21. Brophy RH, Schmitz L, Wright RW, Dunn WR, Parker RD, Andrish JT, McCarty EC, Spindler KP. Return to play and future ACL

injury risk after ACL reconstruction in soccer athletes from the Multicenter Orthopaedic Outcomes Network (MOON) group. Am J

Sports Med. 2012 Nov;40(11):2517-22.

22. McConkey MO, Amendola A, Ramme AJ, Dunn WR, Flanigan DC, Britton CL; MOON Knee Group, Wolf BR, Spindler KP, Carey

JL, Cox CL, Kaeding CC, Wright RW, Matava MJ, Brophy RH, Smith MV, McCarty EC, Vida AF, Wolcott M, Marx RG, Parker RD,

Andrish JF, Jones MH. Arthroscopic agreement among surgeons on anterior cruciate ligament tunnel placement. Am J Sports

Med. 2012 Dec;40(12):2737-46.

23. Spindler KP, Parker RD, Andrish JT, Kaeding CC, Wright RW, Marx RG, McCarty EC, Amendola A, Dunn WR, Huston LJ, Harrell

FE Jr; MOON Group. Prognosis and predictors of ACL reconstructions using the MOON cohort: a model for comparative

effectiveness studies. J Orthop Res. 2013 Jan;31(1):2-9.

24. Wolf BR, Ramme AJ, Wright RW, Brophy RH, McCarty EC, Vidal AR, Parker RD, Andrish JT, Amendola A; MOON Knee Group.

Variability in ACL tunnel placement: observational clinical study of surgeon ACL tunnel variability. Am J Sports Med. 2013

Jun;41(6):1265-73.

25. Hettrich CM, Dunn WR, Reinke EK; MOON Group, Spindler KP. The rate of subsequent surgery and predictors after anterior

cruciate ligament reconstruction: two- and 6-year follow-up results from a multicenter cohort. Am J Sports Med. 2013

Jul;41(7):1534-40.

26. Magnussen RA, Flanigan DC, Pedroza AD, Heinlein KA, Kaeding CC. Platelet rich plasma use in allograft ACL reconstructions:

two-year clinical results of a MOON cohort study. Knee. 2013 Aug;20(4):277-80.

27. Mather RC 3rd, Koenig L, Kocher MS, Dall TM, Gallo P, Scott DJ, Bach BR Jr, Spindler KP; MOON Knee Group. Societal and

economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013 Oct 2;95(19):1751-9.

28. Duffee A, Magnussen RA, Pedroza AD, Flanigan DC; MOON Group, Kaeding CC. Transtibial ACL femoral tunnel preparation

increases odds of repeat ipsilateral knee surgery. J Bone Joint Surg Am. 2013 Nov 20;95(22):2035-42.

MOON Publications29. Mariscalco MW, Flanigan DC, Mitchell J, Pedroza AD, Jones MH, Andrish JT, Parker RD, Kaeding CC, Magnussen RA. The

influence of hamstring autograft size on patient-reported outcomes and risk of revision after anterior cruciate ligament

reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) cohort study. Arthroscopy. 2013 Dec;29(12):1948-53.

30. Wolf BR, Ramme AJ, Britton CL, Amendola A; MOON Knee Group. Anterior cruciate ligament tunnel placement. J Knee Surg.

2014 Jan 10. [Epub ahead of print]

31. Wright RW, Haas AK, Anderson J, Calabrese G, Cavanaugh J, Hewett TE, Lorring D, McKenzie C, Preston E, Williams G, MOON

Group. Anterior cruciate ligament reconstruction rehabilitation: MOON guidelines. Sports Health. 2014 Jan 17 [Epub ahead of

print].

32. Cox CL, Spindler KP, Leonard JP, Morris BJ, Dunn WR, Reinke EK. Do newer-generation bioabsorbable screws (Calaxo® and

Milagro®) become incorporated into bone at 2 years after ACL reconstruction with patellar tendon graft? A cohort study. J Bone

Joint Surg--AM. 2014 Feb 5; 96(3):244-250. PMID: 24500587.

33. Cox CL, Huston LJ, Dunn WR, Reinke EK, Nwosu SK, Parker RD, Wright RW, Kaeding CC, Marx RG, Amendola A, McCarty,

EC, Wolf BR, Harrell FE Jr, Spindler KP. Are articular cartilage lesions and meniscus tears predictive of IKDC, KOOS, and Marx

activity level outcomes after ACL reconstruction? A 6-year MOON cohort study. Am J Sports Med. 2014 Mar 19 [Epub ahead of

print].

34. Mather RC III, Hettrich CM, Dunn WR, Cole BJ, Koenig L, Bach BR Jr, MOON Knee Group, Spindler KP. Cost-effectiveness

analysis of early reconstruction versus rehabilitation and delayed reconstruction for ACL tears. Am J Sports Med. 2014

35. Westermann RW, Wright RW, Huston LJ, MOON Group, Wolf BR. Meniscal repair with concurrent anterior cruciate ligament

reconstruction: operative success and patient outcomes at 6-year follow-up. Am J Sports Med 2014.

36. Lynch TS, Parker RD, Patel RM, Andrish JT, MOON Group, Spindler K. The impact of the Multicenter Orthopaedic Outcomes

Network (MOON) research on anterior cruciate ligament reconstruction and orthopaedic practice. J Amer Acad Orthop Surg –

2015.

37. Jones, M et.al Meniscus Treatment and Age-associated with narrower radiographic joint space width 2-3 years after ACLR: Data

from the MOON onsite cohort Osteoarthritis and Cartilage OAC 2015

38. Brophy, RH et.al Diabetes and not using Bone-Tendon-Bone autograft increase the risk of Infection after ACLR JBJS Am 2015

39. Wasserstein, D et.al The KOOS Pain as a Marker for Significant Knee Pain Two and Six years after Primary ACLR: MOON

prospective longitudinal cohort study OAC 2015

Outcome Concepts are NOT New !

1. Katzenstein 1908: long-term f/u

2. Codman 1925: “end result”

3. Kirkley 2000: EBM, Outcomes, &

Networks

Sports Health

Right Idea = Men Repair & 7 yr F/U

1. Katzenstein in 1908!a. First successful meniscus repair

Berlin, Germany

b. Reviewed long-term meniscus

excision = varus and arthritis

c. Advocated Knee Surgery

• Preop Quad therapy

• NO immobilization

d. 7 cases @ 1-7 yr f/u

2. Courtesy Hans Paessler

Germany March 2006

Sports Health

End Result or Outcomes Not NEW

Courtesy Jed KuhnSports Health

1. Dr. Sandy Kirkley

2. MPH Outcomes

3. Published 39 papers (8 RCTs)

4. Tragic death @ 41

5. Member & Mentor to MOON

6. Orthopaedic Surgeon

7. Outcomes Researcher

8. Mother

9. She was RIGHT – EBM and

Outcomes will become basis of

Orthopaedic Decision Making

Outcomes Legend in Our Time!

Sports Health

Grant Funding and Gifts

Thank-You !

Cleveland Clinic Main Campus Sport Health Garfield Heights

Sports Health

Vanderbilt Sports Medicine

Department of Orthopaedics