Disclosures: B. Wolf variations between and among surgeons ... Data Sources: KANON RCT & MOON

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ACL Outcomes:Take Homes from the MOON Group

Brian R. Wolf, MD, MSCongdon Professor and Vice-Chair of Orthopaedic Surgery

Director, University of Iowa Sports Medicine

Head Team Physician

University of Iowa, Iowa City, Iowa, USA

ICJR / MAOA 2015

Images B. Wolf Personal File

Disclosures: B. Wolf

Grant support: OREF; Arthrex, Smith and Nephew

Consultant: ConMed

Editorial Board: Orthopaedic Journal of Sports Medicine

Committees: Program Committee: AOSSM (chair), MAOA

Nominating Committee: MAOA

Council of Delegates: AOSSM

Corporate Relations Committee: AOSSM

BOS Fellowship Match Committee (chair): AAOS

Disclosures: MOON

Current FUNDING

NIH R01 = MOON (K Spindler – PI)

NIH R01 = MeTeOR study (J Katz - PI)

NIH R01 = ACLR Healing (B Fleming- PI)

NIH RO1 = ACL Healing (M Murray – PI)

Unrestricted Educational Gifts

DonJoy

AOSSM = MARS

Research Grant: Smith & Nephew Calaxo

Research Grant: Arthritis Foundation

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Determining the Impact and outcomes of ACL injury:

What is MOON?

Multi-center Orthopaedic Outcomes Network

7 Academic US Centers (began in 2001) Started with 8 surgeons, now 20 surgeons

Why MULTICENTER?

Increase Sample size Outcomes events occur < 10% of time

Timeliness - Obtain clinically relevant results in years

Generalizability to U.S. in treatment of ACL tears

Goal: Prospective Cohort of ACL reconstruction patients Analyze risk factors for success, failure, and OA


VANDERBILT SPORTS MEDICINECharles L. Cox, MD, MPH

CLEVELAND CLINIC FOUNDATIONKurt P. Spindler, MDRichard D. Parker, MDJack T. Andrish, MDMorgan H. Jones, MD, MPH

THE OHIO STATE UNIVERSITYChristopher C. Kaeding, MDDavid C. Flanigan, MD

UNIVERSITY OF IOWANed Amendola, MDBrian R. Wolf, MD, MSCarolyn M. Hettrich, MD, MPH

WASHINGTON UNIVERSITY – ST. LOUISRick W. Wright, MDMatthew J. Matava, MDRobert H. Brophy, MDMatthew V. Smith, MD

HOSPITAL FOR SPECIAL SURGERYRobert G. Marx, MD

UNIVERSITY OF COLORADOEric C. McCarty, MDMichelle L. Wolcott, MDArmando F. Vidal, MD

CONSULTANTSWarren R. Dunn, MD, MPHBraden C. Fleming, PhDMartha M. Murray, MD

VANDERBILT UNIVERSITYLaura Huston, MS Frank Harrell, Jr., PhDEmily Reinke, PhD Sam Nwosu, MSJohn Shaw Zhouwen Liu, MSSuzet Galindo-Martinez Thomas DuPontBrooke Rode * JoAnn AlvarezErica Scaramuzza * Angel An, MS* Lynn Cain

CLEVELAND CLINIC FOUNDATIONLeah Schmitz, PA-C * Lynn Borzi, MBA, RNMichelle Hines, RN * Julia Brasfield, PA-CMaxine Cox * Kristin Banjac, PA-CSharon Komninos * Pam Koeth, PA-C

THE OHIO STATE UNIVERSITYAngela Pedroza, MPHKari StammenRose Backs, PA-C, ATCAmber Thompson

UNIVERSITY OF IOWACatherine Fruehling-Wall* Carla Britton, PhD

WASHINGTON UNIVERSITY – ST. LOUISAmanda Haas, MA Linda BurnworthRobyn Gornati Deb HansonMichelle Cooper

HOSPITAL FOR SPECIAL SURGERYLana Verkuil * Kaitlyn Lillemoe* Patrick Grimm * Brian Boyle

* Jessica Ryu

UNIVERSITY OF COLORADOCyndi Long * Paula Langner* Christine Bennett * John Gines

Site Support Staff

Key: * denotes former contributor




* Jessica Ryu








* Jessica Ryu





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Scientific Validity MOON Group

Definition Uniformity Establish group consensus on pathology definitions Evaluate group agreement on evaluating concomitant

intra-articular pathology and injuries Inter-rater Agreement of Meniscus Tears and Treatment.

Dunn, Wolf AJSM, 2004

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

Systematic Review of Autograft ACLR: Does Graft Choice Really Matter? Spindler, AJSM, 2004

Surgeon Variability on Femoral and Tibial Tunnel placement. Wolf, AJSM 2012, 2013; J Knee Surg 2014

Entire MOON (PRO) Cohort F/U

Enrollment Years

N 2 Years 6 Years 10 YearsPRO

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 measurementsKT-1000 AP laxity & independent blinded PE Patient-Reported Outcomes (KOOS, Marx, etc.)Functional HOP testing

EnrollmentYears

2005 2006 2007 2008 2009 2010 TOTAL

CompletedONSITE

59 21 67 68 55 47 317

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PATIENT RISK FACTORS ON ACLR OUTCOME: DEMOGRAPHICS1 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


Yes: worse outcome with repairs

4 Is a Lateral Meniscal repair a risk


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: Graft Choice

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

AUTOGRAFTespecially Younger

(see Figure 1)

Failure Rate @ 2 yrs:

18 yr: ALLO 20% vs

Auto 6%

40 yr: ALLO 3% vs

Auto 1%

Ipsilateral ACLR Graft failure

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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

2488 Primary ACLR

92.7 % f/u @ 2 years

AVOID failure by NOT using allografts in high school and college pts!

RESULTS:

Age and activity were predictors of increased risk of both ipsilateral and contralateral ACL tear

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 RTP

4 What will my future activity level be after ACLR based on the Marx

Activity Scale?

Decreased activityTime of injury = 12

→ @2yrs = 9→ @6yrs = 7

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

1What 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

2KOOS 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

3KOOS 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

4KOOS 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

5SF-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

6SF-36 MCS (mental function)

Improved outcomes with higher baseline score, higher baseline Marx

Poorer outcomes with less education, smoker/quit

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KOOS Subscale:Knee-Related QOL

Population KOOS Results by Time

KOOS Pain as a Marker for Significant Knee Pain Two and Six Years after Primary ACLR: A MOON Prospective Longitudinal Cohort StudyWasserstein Osteoarthritis & Cartilage 2015

Data MOON 2002-2005 = 1761 Primary ACLR Follow-up @ 6 years > 86% with Multivariable analysis

Significant Knee PAIN present 9-39% ACLR 6yrs

Dominant risk factor is a Second Surgery Either revision or simple scope

Demographics and articular cartilage and meniscus injury also influenced knee pain but to a lesser extent then second surgery

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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 the risk of infection after ACLR? 0.4%-0.77%Diabetes – OR 18.8

Auto BTB < ALL < Auto HS

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 the risk of hardware removal? 2 years — 0.6%6 years — 1.3%

6-Year Meniscus OutcomesWestermann, Wolf AJSM ‘14; Duchman, Wolf AJSM ’15

Question Answer Predictors

Healing of Meniscus repairs

with ACLR

14% failure rate of repairs for both medial and lateral

meniscus repairs

UnclearMedial tears failure sooner than lateral tears (2.1 yrs vs. 3.7 yrs)

Fate of meniscus tears left in situ at

time of ACLR

No reoperation for 98% lateral and 94% medial

tears left in situ

Tear ≥ 10mmYounger age


ACLR Tunnel Placement w/ 3D CTTrans-tibial vs. Medial Portal vs. 2-Incision

McConkey AJSM ‘12 & Wolf AJSM ’13, Wolf J Knee Surge ‘14

Intra & Inter-surgeon variability 12 surgeons - 6 knees: CADAVER

Tunnels reproducible across techniques and surgeon experience level

Statistical differences, but doubt clinically relevant

Intra & Inter-surgeon variability 8 Surgeons @ 4 sites: PATIENTS

Small variations between and among surgeons

Statistical difference, but doubt clinically relevant

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Does technique matter?

229 ACL using AM portal tech, 207 using trans-tibial technique

6 year f/u

No difference in KOOS outcomes

2.5 greater risk of undergoing further knee surgery for trans-tibial group

Marx Activity Scale

Marx Activity @ 2 & 6 YearsCox AJSM 2014

1512 ACLR with 85% min 6 yr f/u with multivariable statistical modeling Marx Outcome

Marx activity (scale 0-16) Time of injury = 12, → @2yrs = 9, → @6yrs = 7

Proven Predictors of MARX Athletic activity

a. Age f. revision ACLR

b. Gender g. time from surgery

c. BMI h. Grade 4 CM MFC

d. Smoking i. Competition level

e. educational status j. specific sport

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Marx Activity @ 2 & 6 Years

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

Data Sources: KANON RCT & MOON

Markov Decision Modeling

Costs based 2012 US

SF-6D (component of SF-36)

RESULTS: Early ACLR results had both:

increase 0.30 QALYs (Quality adjusted life years)

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

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 YearsDunn, Wolf JBJS Am April 2015

Data MOON 2002-2004 = 1512 ACLR Follow-up = 93% with Multivariable Analysis

ACLR effect size 1.2 for PCS score SF-36

Mean utility gained at six years after ACL reconstruction was 5.3 quality-adjusted life years(QALYs)

Identified predictors Better and Worse PCS SF-36 which similar to KOOS & IKDC

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Factors Associated with InfectionFollowing Anterior Cruciate Ligament ReconstructionBrophy JBJS Am March 2015

Data MOON 2002-2005 = 2198 ACLR Follow-up > 85% with Multivariable analysis

Infection was defined as an ACLR required postoperative surgical irrigation and debridement.

Overall rate of infection = 0.77%

Diabetes significant Increased risk: OR = 18.8

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 cohortJones, M Osteoarthritis and Cartilage 2015

Normal and untreated small stable tear not different

Medial meniscus repair significantly more narrowing than normal / untreated

However, medial meniscus repair was significantly less narrowing than excision

Caveat: repair based primarily on tear type and vascularity thus surgeon cannot switch from excision to repair

JSN

N=261 ACLR @2.5 yrs

Can MOON Evaluate: ELITE Athlete or Why Revision ACLR Worse Outcomes

Elite athlete: NO ! Inadequate sample size

2. Revision ACLR = NO!2. Worst Predictor of Outcome!

MARS was born to evaluate predictors (84 surgeons, 53 sites, enrolled 1200) Funded NIAMS PI: Rick Wright MD

>80% 2 yr f/u in Fall 2013

AOSSM O’Donahue Award

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MOON Publications 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.

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. 2005Nov; 33(11):1654-7.

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 cruciateligament 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.

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.

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 reconstructionrehabilitation: part I: continuous passive motion, early weight bearing, postoperative bracing, and home-based rehabilitation. JKnee Surg. 2008 Jul; 21(3):217-24.

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 reconstructionrehabilitation: 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.

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.

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.

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 ligamentreconstruction (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 prospectivelongitudinal 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.

12

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 Aug; 27(4):309-17.

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. 2015 May; 7(3):239-43.

32. 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 May; 42(5):1058-67.

33. 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 May; 42(7):1583-91.

34. 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 Jul; 42(9):2184-92.

35. Bogunovic L, Kruse LM, Haas AK, Huston LJ, Wright RW. Outcome of all-inside second generation meniscal repair: minimum 5-year follow-up. J Bone Joint Surg Am. 2014 Aug; 96(15):1303-1307.

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 Am Acad Orthop Surg. 2015 Mar; 23(3):154-63.

37. Jones MH, Spindler KP, Fleming BC, Duryea J, Obuchowski NA, Scaramuzza EA, Oksendahl HL, Winalski CS, Duong CL, Huston LJ, Parker RD, Kaeding CC, Andrish JT, Flanigan DC, Dunn WR, Reinke EK. Meniscus treatment and age associated with narrower radiographic joint space width 2 - 3 years after ACL reconstruction: Data from the MOON onsite cohort. Osteoarthritis Cartilage. 2015 April; 23(4):581-588.

38. Brophy RH, Wright RW, Huston LJ, Nwosu S, MOON Knee Group, Spindler KP. Factors Associated with infection following anterior cruciate ligament reconstruction. J Bone Joint Surg Am. 2015 Mar; 97(6):450-454.

MOON Publications39. Dunn WR, Wolf BR, Harrell FE Jr, Reinke EK, Huston LJ, Nwosu SK, Kaeding CC, Parker RD, Wright RW, Andrish JT, McCarty

EC, Amendola A, Marx RG, Wolcott ML, Liu Z, Alvarez JM, Spindler KP. Baseline predictors of health-related quality of life after anterior cruciate ligament reconstruction: a longitudinal analysis of a multicenter cohort at two and six years. J Bone Joint SurgAm. 2015 Apr; 97(7):551-557.

40. Kaeding CC, Pedroza A, Reinke EK, Huston LJ, MOON Group, Spindler KP. Risk factors and predictors of subsequent ACL injury in either knee after ACL reconstruction: prospective analysis of 2488 primary ACL reconstructions from a multicenter study. Am JSports Med. 2015; 43(7):1583-90.

41. Wasserstein D, Huston LJ, Nwosu S; MOON Group, Spindler KP. KOOS pain as a marker for significant knee pain two and six years after primary ACL reconstruction: a Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort study. Osteoarthritis Cartilage. 2015 Oct; 23(10):1674-84.

42. Duchman KR, Westermann RW, Reinke EM, Huston LJ, Spindler KP, Amendola A, MOON Knee Group, Wolf BR. The fate of meniscus tears left in situ at the time of anterior cruciate ligament reconstruction: a 6-year follow-up multicenter study. Am J Sports Med. 2015 Nov; 43(11):2688-95.

43. Magnussen RA, Reinke EK, Huston LJ; MOON Group, Hewett TE, Spindler KP. Factors associated with high-grade lachman, pivot shift, and anterior drawer at the time of anterior cruciate ligament reconstruction. Arthroscopy. 2016 Jan 25. [Epub ahead of print] PubMed PMID: 26821957.

44. Brophy RH, Huston LJ, Wright RW, Nwosu SK, Kaeding CC, Parker RD, Andrish JT, Marx RG, McCarty EC, Amendola A, Wolf BR, Dunn WR, Wolcott ML, Spindler KP. Outcomes of ACL reconstruction in patients with diabetes. Med Sci Sports Exerc. 2016 Jan 13. [Epub ahead of print] PubMed PMID: 26765634.

45. Failla MJ, Logerstedt DS, Grindem H, Axe MJ, Risberg MA, Engebretsen L, Huston LJ, Spindler KP, Snyder-Mackler L. Does extended preoperative rehabilitation influence outcomes 2 years after ACL reconstruction: a comparative effectiveness study between MOON and Delaware-Oslo ACL cohorts. Am J Sports Med. 2016 (Accepted March 29, 2016).

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Disclosures: B. Wolf variations between and among surgeons ... Data Sources: KANON RCT & MOON

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