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Background: Patients undergoing anterior cruciate ligament reconstruction (ACLR) are at an increased risk for posttraumatic osteoarthritis (PTOA). While we have previously shown that meniscal treatment with ACLR predicts more radiographic PTOA at 2 to 3 years postoperatively, there are a limited number of similar studies that have assessed cartilage directly with magnetic resonance imaging (MRI). Hypothesis: Meniscal repair or partial meniscectomy at the time of ACLR independently predicts more articular cartilage damage on 2- to 3-year postoperative MRI compared with a healthy meniscus or a stable untreated tear. Study Design: Cohort study; Level of evidence, 2. Methods: A consecutive series of patients undergoing ACLR from 1 site within the prospective, nested Multicenter Orthopaedic Outcomes Network (MOON) cohort underwent bilateral knee MRI at 2 to 3 years postoperatively. Patients were aged Results: The cohort included 60 patients (32 female; median age, 18.7 years). Concomitant meniscal treatment at the time of index ACLR was performed in 17 medial menisci (13 meniscal repair and 4 partial meniscectomy) and 27 lateral menisci (3 meniscal repair and 24 partial meniscectomy). Articular cartilage damage was worse in the ipsilateral reconstructed knee ( P < .001). A meniscal injury requiring surgical treatment with ACLR predicted a worse CDS for medial meniscal treatment (medial compartment CDS: P = .005; whole joint CDS: P < .001) and lateral meniscal treatment (lateral compartment CDS: P = .038; whole joint CDS: P = .863). Other predictors of a worse relative CDS included age for the medial compartment ( P < .001), surgically observed articular cartilage damage for the patellofemoral compartment ( P = .048), and body mass index ( P = .007) and age ( P = .020) for the whole joint. Conclusion: A meniscal injury requiring surgical treatment with partial meniscectomy or meniscal repair at the time of ACLR predicted worse articular cartilage damage on MRI at 2 to 3 years after surgery. Further research is required to differentiate between the effects of partial meniscectomy and meniscal repair.

Supplemental material, sj-docx-1-ajs-10.1177_03635465231151389 for Meniscal and Articular Cartilage Predictors of Outcome After Revision ACL Reconstruction: A 6-Year Follow-up Cohort Study by Rick W. Wright, Laura J. Huston, Amanda K. Haas, Jacquelyn S. Pennings, Christina R. Allen, Daniel E. Cooper, Thomas M. DeBerardino, Warren R. Dunn, Brett (Brick) A. Lantz, Kurt P. Spindler, Michael J. Stuart, John P. Albright, Annunziato (Ned) Amendola, Jack T. Andrish, Christopher C. Annunziata, Robert A. Arciero, Bernard R. Bach, Champ L. Baker, Arthur R. Bartolozzi, Keith M. Baumgarten, Jeffery R. Bechler, Jeffrey H. Berg, Geoffrey A. Bernas, Stephen F. Brockmeier, Robert H. Brophy, Charles A. Bush-Joseph, J. Brad Butler, John D. Campbell, James L. Carey, James E. Carpenter, Brian J. Cole, Jonathan M. Cooper, Charles L. Cox, R. Alexander Creighton, Diane L. Dahm, Tal S. David, David C. Flanigan, Robert W. Frederick, Theodore J. Ganley, Elizabeth A. Garofoli, Charles J. Gatt, Steven R. Gecha, James Robert Giffin, Sharon L. Hame, Jo A. Hannafin, Christopher D. Harner, Norman Lindsay Harris, Keith S. Hechtman, Elliott B. Hershman, Rudolf G. Hoellrich, David C. Johnson, Timothy S. Johnson, Morgan H. Jones, Christopher C. Kaeding, Ganesh V. Kamath, Thomas E. Klootwyk, Bruce A. Levy, C. Benjamin Ma, G. Peter Maiers, Robert G. Marx, Matthew J. Matava, Gregory M. Mathien, David R. McAllister, Eric C. McCarty, Robert G. McCormack, Bruce S. Miller, Carl W. Nissen, Daniel F. O’Neill, Brett D. Owens, Richard D. Parker, Mark L. Purnell, Arun J. Ramappa, Michael A. Rauh, Arthur C. Rettig, Jon K. Sekiya, Kevin G. Shea, Orrin H. Sherman, James R. Slauterbeck, Matthew V. Smith, Jeffrey T. Spang, LTC Steven J. Svoboda, Timothy N. Taft, Joachim J. Tenuta, Edwin M. Tingstad, Armando F. Vidal, Darius G. Viskontas, Richard A. White, James S. Williams, Michelle L. Wolcott, Brian R. Wolf and James J. York in The American Journal of Sports Medicine

Supplemental material, sj-pdf-1-ajs-10.1177_03635465231172769 for Predictors of Return to Activity at 2 Years After Anterior Cruciate Ligament Reconstruction Among Patients With High Preinjury Marx Activity Scores: A MOON Prospective Cohort Study by Andrew J. Sheean, Yuxuan Jin, Laura J. Huston, Robert H. Brophy, Charles L. Cox, David C. Flanigan, Morgan H. Jones, Christopher C. Kaeding, Robert A. Magnussen, Robert G. Marx, Matthew J. Matava, Eric C. McCarty, Richard D. Parker, Michelle L. Wolcott, Brian R. Wolf, Rick W. Wright and Kurt P. Spindler in The American Journal of Sports Medicine

Supplemental Material, sj-pdf-1-ojs-10.1177_23259671211065447 for Design Features and Rationale of the BEAR-MOON (Bridge-Enhanced ACL Restoration Multicenter Orthopaedic Outcomes Network) Randomized Clinical Trial by BEAR-MOON Design Group, Kurt P. Spindler, Peter B. Imrey, Sercan Yalcin, Gerald J. Beck, Gary Calbrese, Charles L. Cox, Paul D. Fadale, Lutul Farrow, Robert Fitch, David Flanigan, Braden C. Fleming, Michael J. Hulstyn, Morgan H. Jones, Christopher Kaeding, Jeffrey N. Katz, Peter Kriz, Robert Magnussen, Ellen McErlean, Carrie Melgaard, Brett D. Owens, Paul Saluan, Greg Strnad, Carl S. Winalski and Rick Wright in Orthopaedic Journal of Sports Medicine

Supplemental material, sj-docx-1-ajs-10.1177_03635465221104470 for Descriptive Characteristics and Outcomes of Patients Undergoing Revision Anterior Cruciate Ligament Reconstruction With and Without Tunnel Bone Grafting by Steven F. DeFroda, Brett D. Owens, Rick W. Wright, Laura J. Huston, Jacquelyn S. Pennings, Amanda K. Haas, Christina R. Allen, Daniel E. Cooper, Thomas M. DeBerardino, Warren R. Dunn, Brett Brick A. Lantz, Kurt P. Spindler, Michael J. Stuart, John P. Albright, Annunziato (Ned) Amendola, Christopher C. Annunziata, Robert A. Arciero, Bernard R. Bach, Champ L. Baker, Arthur R. Bartolozzi, Keith M. Baumgarten, Jeffery R. Bechler, Jeffrey H. Berg, Geoffrey A. Bernas, Stephen F. Brockmeier, Robert H. Brophy, Charles A. Bush-Joseph, J. Brad Butler, James L. Carey, James E. Carpenter, Brian J. Cole, Jonathan M. Cooper, Charles L. Cox, R. Alexander Creighton, Tal S. David, David C. Flanigan, Robert W. Frederick, Theodore J. Ganley, Elizabeth A. Garofoli, Charles J. Gatt, Steven R. Gecha, James Robert Giffin, Sharon L. Hame, Jo A. Hannafin, Christopher D. Harner, Norman Lindsay Harris, Keith S. Hechtman, Elliott B. Hershman, Rudolf G. Hoellrich, David C. Johnson, Timothy S. Johnson, Morgan H. Jones, Christopher C. Kaeding, Ganesh V. Kamath, Thomas E. Klootwyk, Bruce A. Levy, C. Benjamin Ma, G. Peter Maiers, Robert G. Marx, Matthew J. Matava, Gregory M. Mathien, David R. McAllister, Eric C. McCarty, Robert G. McCormack, Bruce S. Miller, Carl W. Nissen, Daniel F. O’Neill, Richard D. Parker, Mark L. Purnell, Arun J. Ramappa, Michael A. Rauh, Arthur C. Rettig, Jon K. Sekiya, Kevin G. Shea, Orrin H. Sherman, James R. Slauterbeck, Matthew V. Smith, Jeffrey T. Spang, Steven J. Svoboda, Timothy N. Taft, Joachim J. Tenuta, Edwin M. Tingstad, Armando F. Vidal, Darius G. Viskontas, Richard A. White, James S. Williams, Michelle L. Wolcott, Brian R. Wolf and James J. York in The American Journal of Sports Medicine

BackgroundAlthough graft choice may be limited in the revision setting based on previously used grafts, most surgeons believe that graft choice for anterior cruciate ligament (ACL) reconstruction is an important factor related to outcome.HypothesisIn the ACL revision setting, there would be no difference between autograft and allograft in rerupture rate and patient-reported outcomes (PROs) at 6-year follow-up.Study designCohort study; Level of evidence, 2.MethodsPatients who had revision surgery were identified and prospectively enrolled in this cohort study by 83 surgeons over 52 sites. Data collected included baseline characteristics, surgical technique and pathology, and a series of validated PRO measures. Patients were followed up at 6 years and asked to complete the identical set of PRO instruments. Incidence of additional surgery and reoperation because of graft failure were also recorded. Multivariable regression models were used to determine the predictors (risk factors) of PROs, graft rerupture, and reoperation at 6 years after revision surgery.ResultsA total of 1234 patients including 716 (58%) men were enrolled. A total of 325 (26%) underwent revision using a bone-patellar tendon-bone (BTB) autograft; 251 (20%), soft tissue autograft; 289 (23%), BTB allograft; 302 (25%), soft tissue allograft; and 67 (5%), other graft. Questionnaires and telephone follow-up for subsequent surgery information were obtained for 809 (66%) patients, while telephone follow-up was only obtained for an additional 128 patients for the total follow-up on 949 (77%) patients. Graft choice was a significant predictor of 6-year Marx Activity Rating Scale scores (P = .024). Specifically, patients who received a BTB autograft for revision reconstruction had higher activity levels than did patients who received a BTB allograft (odds ratio [OR], 1.92; 95% CI, 1.25-2.94). Graft rerupture was reported in 5.8% (55/949) of patients by their 6-year follow-up: 3.5% (16/455) of patients with autografts and 8.4% (37/441) of patients with allografts. Use of a BTB autograft for revision resulted in patients being 4.2 times less likely to sustain a subsequent graft rupture than if a BTB allograft were utilized (P = .011; 95% CI, 1.56-11.27). No significant differences were found in graft rerupture rates between BTB autograft and soft tissue autografts (P = .87) or between BTB autografts and soft tissue allografts (P = .36). Use of an autograft was found to be a significant predictor of having fewer reoperations within 6 years compared with using an allograft (P = .010; OR, 0.56; 95% CI, 0.36-0.87).ConclusionBTB and soft tissue autografts had a decreased risk in graft rerupture compared with BTB allografts. BTB autografts were associated with higher activity level than were BTB allografts at 6 years after revision reconstruction. Surgeons and patients should consider this information when choosing a graft for revision ACL reconstruction.

Supplemental material, sj-pdf-1-ajs-10.1177_03635465211025003 for Neither Residual Anterior Knee Laxity Up to 6 mm nor a Pivot Glide Predict Patient-Reported Outcome Scores or Subsequent Knee Surgery Between 2 and 6 Years After ACL Reconstruction by Robert A. Magnussen, Emily K. Reinke, Laura J. Huston, Isaac Briskin, Charles L. Cox, Warren R. Dunn, David C. Flanigan, Morgan H. Jones, Christopher C. Kaeding, Matthew J. Matava, Richard D. Parker, Matthew V. Smith, Rick W. Wright and Kurt P. Spindler in The American Journal of Sports Medicine

Supplemental material, sj-pdf-1-ajs-10.1177_0363546521995182 for The Clinical Radiographic Incidence of Posttraumatic Osteoarthritis 10 Years After Anterior Cruciate Ligament Reconstruction: Data From the MOON Nested Cohort by The MOON Group in The American Journal of Sports Medicine

BackgroundPatient-reported outcomes (PROs) are a valid measure of results after revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes when compared with primary ACL reconstruction. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for patients.Purpose/hypothesisThe purpose was to describe PROs after revision ACL reconstruction and test the hypothesis that patient- and technique-specific variables are associated with these outcomes.Study designCohort study; Level of evidence, 2.MethodsPatients undergoing revision ACL reconstruction were identified and prospectively enrolled by 83 surgeons over 52 sites. Data included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments: International Knee Documentation Committee (IKDC), Knee injury and Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Index, and Marx Activity Rating Scale. Patients were followed up at 2 years and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors to determine the positive and negative predictors of PRO scores at 2 years after revision surgery.ResultsA total of 1205 patients met the inclusion criteria and were successfully enrolled: 697 (58%) were male, with a median cohort age of 26 years. The median time since their most recent previous ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained from 989 patients (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male sex, and having a longer time since the most recent previous ACL reconstruction, while negative predictors included having a lateral meniscectomy before the revision ACL reconstruction or having grade 3/4 chondrosis in either the trochlear groove or the medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between the most recent previous ACL reconstruction and revision surgery were significant positive predictors for having a better (ie, higher) 2-year KOOS, while having a lateral meniscectomy before the revision ACL reconstruction was a consistent predictor for having a significantly worse (ie, lower) 2-year KOOS. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male sex, and being a nonsmoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery.ConclusionPROs after revision ACL reconstruction are associated with a variety of patient- and surgeon-related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectations as well as potentially improve outcomes.

BACKGROUND: Patient reported outcomes (PROs) are a valid measure of results following revision anterior cruciate ligament (ACL) reconstruction. Revision ACL reconstruction has been documented to have worse outcomes compared with primary ACL reconstructions. Understanding positive and negative predictors of PROs will allow surgeons to modify and potentially improve outcome for these patients. HYPOTHESIS/PURPOSE: The purpose of this study was to describe PROs following revision ACL reconstruction and test the hypothesis that patient and technique specific variables are associated with these outcomes. STUDY DESIGN: Cohort study METHODS: Revision ACL reconstruction patients were identified and prospectively enrolled by 83 surgeons over 52 sites. Data collected included baseline demographics, surgical technique and pathology, and a series of validated PRO instruments (IKDC, KOOS, WOMAC and Marx activity rating score). Patients were followed up at 2 years, and asked to complete the identical set of outcome instruments. Multivariate regression models were used to control for a variety of demographic and surgical factors, in order to determine both the positive and negative predictors of PRO scores at 2 years following revision surgery. RESULTS: 1205 patients met the inclusion criteria and were successfully enrolled. 697 (58%) were males, with a median cohort age of 26 years. The median time since their last ACL reconstruction was 3.4 years. Two-year questionnaire follow-up was obtained on 989 subjects (82%). The most significant positive predictors of 2-year IKDC scores were a high baseline IKDC score, high baseline Marx activity level, male gender, and having a longer time between a patient’s last ACL reconstruction, while negative predictors included having a previous lateral meniscectomy prior to the revision ACL reconstruction or having Grades 3/4 chondrosis in either the trochlear groove or medial tibial plateau at the time of the revision surgery. For KOOS, having a high baseline score and having a longer time between their last ACL reconstruction and revision surgery were significant positive predictors for having better (i.e. higher) 2-year KOOS scores, while having a previous lateral meniscectomy prior to the revision ACL reconstruction was a consistent predictor for having significantly worse (i.e. lower) 2-year KOOS scores. Statistically significant positive predictors for 2-year Marx activity levels included higher baseline Marx activity levels, younger age, male gender, and being a non-smoker. Negative 2-year activity level predictors included having an allograft or a biologic enhancement at the time of revision surgery. CONCLUSIONS: PROs following revision ACL reconstruction are associated with a variety of patient and surgeon related variables. Understanding positive and negative predictors of PROs will allow surgeons to guide patient expectation as well as potentially improve outcome for these patients.

BackgroundAnterior cruciate ligament (ACL) revision cohorts continually report lower outcome scores on validated knee questionnaires than primary ACL cohorts at similar time points after surgery. It is unclear how these outcomes are associated with physical activity after physician clearance for return to recreational or competitive sports after ACL revision surgery.HypothesesParticipants who return to either multiple sports or a singular sport after revision ACL surgery will report decreased knee symptoms, increased activity level, and improved knee function as measured by validated patient-reported outcome measures (PROMs) and compared with no sports participation. Multisport participation as compared with singular sport participation will result in similar increased PROMs and activity level.Study designCross-sectional study; Level of evidence, 3.MethodsA total of 1205 patients who underwent revision ACL reconstruction were enrolled by 83 surgeons at 52 clinical sites. At the time of revision, baseline data collected included the following: demographics, surgical characteristics, previous knee treatment and PROMs, the International Knee Documentation Committee (IKDC) questionnaire, Marx activity score, Knee injury and Osteoarthritis Outcome Score (KOOS), and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). A series of multivariate regression models were used to evaluate the association of IKDC, KOOS, WOMAC, and Marx Activity Rating Scale scores at 2 years after revision surgery by sports participation category, controlling for known significant covariates.ResultsTwo-year follow-up was obtained on 82% (986 of 1205) of the original cohort. Patients who reported not participating in sports after revision surgery had lower median PROMs both at baseline and at 2 years as compared with patients who participated in either a single sport or multiple sports. Significant differences were found in the change of scores among groups on the IKDC (P < .0001), KOOS-Symptoms (P = .01), KOOS-Sports and Recreation (P = .04), and KOOS-Quality of Life (P < .0001). Patients with no sports participation were 2.0 to 5.7 times more likely than multiple-sport participants to report significantly lower PROMs, depending on the specific outcome measure assessed, and 1.8 to 3.8 times more likely than single-sport participants (except for WOMAC-Stiffness, P = .18), after controlling for known covariates.ConclusionParticipation in either a single sport or multiple sports in the 2 years after ACL revision surgery was found to be significantly associated with higher PROMs across multiple validated self-reported assessment tools. During follow-up appointments, surgeons should continue to expect that patients who report returning to physical activity after surgery will self-report better functional outcomes, regardless of baseline activity levels.

Supplemental material, DS_10.1177_0363546518819444 for Influence of Baseline Magnetic Resonance Imaging Features on Outcome of Arthroscopic Meniscectomy and Physical Therapy Treatment of Meniscal Tears in Osteoarthritis by Lindsey A. MacFarlane, Heidi Yang, Jamie E. Collins, Ali Guermazi, Morgan H. Jones, Kurt P. Spindler, Amelia R. Winter, Elena Losina and Jeffrey N. Katz in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546519856348 for Relationship Between Sports Participation After Revision Anterior Cruciate Ligament Reconstruction and 2-Year Patient-Reported Outcome Measures in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546519829770 for Comparison of Standard and Right/Left International Knee Documentation Committee Subjective Knee Form Scores by Justin A. Magnuson, Greg Strnad, Clair Smith, Morgan H. Jones, Paul Saluan, James J. Irrgang and Kurt P. Spindler in The American Journal of Sports Medicine

Supplemental material, DS_10.1177_0363546519892570 for Associations of Preoperative Patient Mental Health and Sociodemographic and Clinical Characteristics With Baseline Pain, Function, and Satisfaction in Patients Undergoing Rotator Cuff Repairs by Sambit Sahoo, Eric T. Ricchetti and Alexander Zajichek in The American Journal of Sports Medicine

Background: Prospectively-collected patient-reported outcomes (PROs) following shoulder instability surgery are limited. Attention has been drawn to standardizing these outcome measures in the adolescent literature. Hypothesis/Purpose: The purpose of this study was to evaluate which factors predict unfavorable PROs following shoulder instability surgery, including a “No” response to the Patient Acceptable Symptom State (PASS) question. We hypothesized that poor outcomes are associated with adolescent males, bone loss, larger labral tears, and articular cartilage injury. Methods: A cohort of patients age 13 years and older undergoing shoulder instability surgery were prospectively enrolled in point-of-care data collection at a single institution across 12 surgeons from 2015-2017. Demographics, ASES and SANE responses, and surgical findings were obtained at baseline. ASES, SANE, and PASS responses as well as revision surgery were queried at least one year post-operatively. Patients with isolated posterior labral tears and prior ipsilateral shoulder surgery were excluded. Regression analyses were performed. Results: A total 268 patients met inclusion criteria of which 201 completed follow-up responses (75%). Non-responders had a greater BMI, smaller proportion of glenoid bone loss, fewer Hill-Sachs lesions, and lower baseline ASES scores by 7.5 points (p < 0.05). Responders’ mean age was 25.5 years and 23% were female. Revision surgery occurred in 2.5% of these patients, and 81% responded “Yes” to PASS. A “Yes” response correlated to mean 31-point improvement in ASES and 34-point improvement in SANE scores. On univariate analysis, “No” responders were more likely to have a smoking history, a larger proportion of glenoid bone loss, and revision surgery (p < 0.05). However, on multivariate analysis, only combined labral tears (anterior/inferior plus superior or posterior tears) and injured capsules were associated with greater odds of responding “No” to PASS and with lower ASES and SANE scores (p ≤ 0.05) (Table 1). Age, sex, Hill-Sachs lesions, and grade III/IV articular cartilage injuries were not associated with variation in any PROs. Conclusion: In this prospective cohort, patients largely approve of their symptom state at one year or greater following shoulder instability surgery. A PASS “Yes” response occurred in 81% of patients and correlated to a clinically and statistically significant improvement in ASES and SANE scores. Combined labral tears and injured capsules were negative prognosticators across PROs, whereas age, sex, and Hill-Sachs lesions were not. Table: Table 1. Significant variables predicting PASS "No" responses, poorer ASES/SANE scores, and revision surgery. P values less than or equal to 0.05 are listed. VARIABLE CATEGORY PASS ASES SANE REVISION SURGERY Sex Male (vs Female) Age - BMI - Years of Education - Smoking Status Quit (vs Never) Current (vs Never) 0.033 Baseline VR12 MCS - Glenoid Bone Loss 20% (vs None) 0.004 Anchor Quantity - Labral Tear Location Superior(vs Anterior/Inferior) Combined(vs Anterior/Inferior) 0.050 0.023 0.009 Laterality Right (vs Left) Hill-Sachs Lesion Yes, Engaging (vs No) Yes, Non-engaging (vs No) Capsule Status Injured (vs Normal) 0.033 0.003 0.001 0.019 Humeral and/or Glenoid Articular Cartilage Injury Grade III/IV Lesion(vs Normal to grade II)

BackgroundThe occurrence of physiologic knee hyperextension (HE) in the revision anterior cruciate ligament reconstruction (ACLR) population and its effect on outcomes have yet to be reported. Hypothesis/Purpose: The prevalence of knee HE in revision ACLR and its effect on 2-year outcome were studied with the hypothesis that preoperative physiologic knee HE ≥5° is a risk factor for anterior cruciate ligament (ACL) graft rupture.Study designCohort study; Level of evidence, 2.MethodsPatients undergoing revision ACLR were identified and prospectively enrolled between 2006 and 2011. Study inclusion criteria were patients undergoing single-bundle graft reconstructions. Patients were followed up at 2 years and asked to complete an identical set of outcome instruments (International Knee Documentation Committee, Knee injury and Osteoarthritis Outcome Score, WOMAC, and Marx Activity Rating Scale) as well as provide information regarding revision ACL graft failure. A regression model with graft failure as the dependent variable included age, sex, graft type at the time of the revision ACL surgery, and physiologic preoperative passive HE ≥5° (yes/no) to assess these as potential risk factors for clinical outcomes 2 years after revision ACLR.ResultsAnalyses included 1145 patients, for whom 2-year follow-up was attained for 91%. The median age was 26 years, with age being a continuous variable. Those below the median were grouped as "younger" and those above as "older" (age: interquartile range = 20, 35 years), and 42% of patients were female. There were 50% autografts, 48% allografts, and 2% that had a combination of autograft plus allograft. Passive knee HE ≥5° was present in 374 (33%) patients in the revision cohort, with 52% being female. Graft rupture at 2-year follow-up occurred in 34 cases in the entire cohort, of which 12 were in the HE ≥5° group (3.2% failure rate) and 22 in the non-HE group (2.9% failure rate). The median age of patients who failed was 19 years, as opposed to 26 years for those with intact grafts. Three variables in the regression model were significant predictors of graft failure: younger age (odds ratio [OR] = 3.6; 95% CI, 1.6-7.9; P = .002), use of allograft (OR = 3.3; 95% CI, 1.5-7.4; P = .003), and HE ≥5° (OR = 2.12; 95% CI, 1.1-4.7; P = .03).ConclusionThis study revealed that preoperative physiologic passive knee HE ≥5° is present in one-third of patients who undergo revision ACLR. HE ≥5° was an independent significant predictor of graft failure after revision ACLR with a >2-fold OR of subsequent graft rupture in revision ACL surgery. Registration: NCT00625885 ( ClinicalTrials.gov identifier).

BackgroundArticular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage.HypothesisLarger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction.Study designCase-control study; Level of evidence, 3.MethodsSubjects who had primary and revision data in the databases of the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) were included. Reviewed data included chondral surface status at the time of primary and revision surgery, meniscus status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartment according to progression on the modified Outerbridge scale (increase ≥1 grade) or >25% enlargement in any area of damage. Logistic regression identified predictors of significant chondral surface change in each compartment from primary to revision surgery.ResultsA total of 134 patients were included, with a median age of 19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 (23.9%) in the medial compartment, and 31 (23.1%) in the patellofemoral compartment. For the lateral compartment, patients who had >33% of the lateral meniscus excised at primary reconstruction had 16.9-times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus ( P < .001). For the medial compartment, patients who had

Supplemental material, DS_10.1177_0363546517749850 for Ten-Year Outcomes and Risk Factors After Anterior Cruciate Ligament Reconstruction: A MOON Longitudinal Prospective Cohort Study by The MOON Knee Group in The American Journal of Sports Medicine

BACKGROUND: Articular cartilage health is an important issue following anterior cruciate ligament (ACL) injury and primary ACL reconstruction. Factors present at the time of primary ACL reconstruction may influence the subsequent progression of articular cartilage damage. HYPOTHESIS: We hypothesized that larger meniscus resection at primary ACL reconstruction, increased patient age, and increased body mass index (BMI) are associated with increased odds of worsened articular cartilage damage at the time of revision ACL reconstruction. STUDY DESIGN: Prospective cohort study METHODS: Subjects who had both primary and revision data contained in the Multicenter Orthopaedics Outcomes Network (MOON) and Multicenter ACL Revision Study (MARS) databases were included. Data reviewed included chondral surface status at the time of primary and revision surgery, meniscal status at the time of primary reconstruction, primary reconstruction graft type, time from primary to revision ACL surgery, as well as demographics and Marx activity score at the time of revision. Significant progression of articular cartilage damage was defined in each compartments according to progression on the modified Outerbridge scale (increase of ≥1 grade) or a greater than 25% enlargement in any area of damage. Logistic regression was used to identify predictors of significant chondral surface change in each compartment from primary to revision surgery. RESULTS: A total of 134 patients were included with a median age19.5 years at revision surgery. Progression of articular cartilage damage was noted in 34 patients (25.4%) in the lateral compartment, 32 patients (23.9%) in the medial compartment, and 31 patients (23.1%) in the patellofemoral compartment. In the lateral compartment, patients who had greater than 33% of their lateral meniscus excised at primary reconstruction had 16.9 times greater odds of progression of articular cartilage injury than those with an intact lateral meniscus (p < 0.001). In the medial compartment, patients who had less than 33% of their medial meniscus excised at the time of the primary reconstruction had 4.8 times greater odds of progression of articular cartilage injury than those with an intact medial meniscus (p = 0.02). Odds of significant chondral surface change increased by 5% in the lateral compartment and 6% in the medial compartment for each increased year of age (p ≤0.02). In the patellofemoral compartment, the use of allograft was associated with a 15-fold increased odds of progression of articular cartilage damage relative to a patellar tendon autograft (p < 0.001). Each one unit increase in BMI at the time of revision surgery was associated with a 10% increase in the odds of progression of articular cartilage damage (p = 0.046) in the patellofemoral compartment. CONCLUSION: Excision of the medial and lateral meniscus at primary ACL reconstruction increases the odds of articular cartilage damage in the corresponding compartment at the time of revision ACL reconstruction. Increased age is a risk factor for deterioration of articular cartilage in both tibiofemoral compartments, while increased BMI and the use of allograft for primary ACL reconstruction are associated with an increased risk of progression in the patellofemoral compartment.

BackgroundRevision anterior cruciate ligament (ACL) reconstruction has been documented to have worse outcomes compared with primary ACL reconstruction.HypothesisCertain factors under the control of the surgeon at the time of revision surgery can both negatively and positively affect outcomes.Study designCase-control study; Level of evidence, 3.MethodsPatients undergoing revision ACL reconstruction were identified and prospectively enrolled between 2006 and 2011. Data collected included baseline demographics, intraoperative surgical technique and joint disorders, and a series of validated patient-reported outcome instruments (International Knee Documentation Committee [IKDC] subjective form, Knee Injury and Osteoarthritis Outcome Score [KOOS], Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC], and Marx activity rating scale) completed before surgery. Patients were followed up for 2 years and asked to complete an identical set of outcome instruments. Regression analysis was used to control for age, sex, body mass index (BMI), activity level, baseline outcome scores, revision number, time since last ACL reconstruction, and a variety of previous and current surgical variables to assess the surgical risk factors for clinical outcomes 2 years after revision ACL reconstruction.ResultsA total of 1205 patients (697 male [58%]) met the inclusion criteria and were successfully enrolled. The median age was 26 years, and the median time since their last ACL reconstruction was 3.4 years. Two-year follow-up was obtained on 82% (989/1205). Both previous and current surgical factors were found to be significant contributors toward poorer clinical outcomes at 2 years. Having undergone previous arthrotomy (nonarthroscopic open approach) for ACL reconstruction compared with the 1-incision technique resulted in significantly poorer outcomes for the 2-year IKDC ( P = .037; odds ratio [OR], 2.43; 95% CI, 1.05-5.88) and KOOS pain, sports/recreation, and quality of life (QOL) subscales ( P ≤ .05; OR range, 2.38-4.35; 95% CI, 1.03-10.00). The use of a metal interference screw for current femoral fixation resulted in significantly better outcomes for the 2-year KOOS symptoms, pain, and QOL subscales ( P ≤ .05; OR range, 1.70-1.96; 95% CI, 1.00-3.33) as well as WOMAC stiffness subscale ( P = .041; OR, 1.75; 95% CI, 1.02-3.03). Not performing notchplasty at revision significantly improved 2-year outcomes for the IKDC ( P = .013; OR, 1.47; 95% CI, 1.08-1.99), KOOS activities of daily living (ADL) and QOL subscales ( P ≤ .04; OR range, 1.40-1.41; 95% CI, 1.03-1.93), and WOMAC stiffness and ADL subscales ( P ≤ .04; OR range, 1.41-1.49; 95% CI, 1.03-2.05). Factors before revision ACL reconstruction that increased the risk of poorer clinical outcomes at 2 years included lower baseline outcome scores, a lower Marx activity score at the time of revision, a higher BMI, female sex, and a shorter time since the patient's last ACL reconstruction. Prior femoral fixation, prior femoral tunnel aperture position, and knee flexion angle at the time of revision graft fixation were not found to affect 2-year outcomes in this revision cohort.ConclusionThere are certain surgical variables that the physician can control at the time of revision ACL reconstruction that can modify clinical outcomes at 2 years. Whenever possible, opting for an anteromedial portal or transtibial surgical exposure, choosing a metal interference screw for femoral fixation, and not performing notchplasty are associated with significantly better 2-year clinical outcomes.

BackgroundWhile revision anterior cruciate ligament reconstruction (ACLR) can be performed to restore knee stability and improve patient activity levels, outcomes after this surgery are reported to be inferior to those after primary ACLR. Further reoperations after revision ACLR can have an even more profound effect on patient satisfaction and outcomes. However, there is a current lack of information regarding the rate and risk factors for subsequent surgery after revision ACLR.PurposeTo report the rate of reoperations, procedures performed, and risk factors for a reoperation 2 years after revision ACLR.Study designCase-control study; Level of evidence, 3.MethodsA total of 1205 patients who underwent revision ACLR were enrolled in the Multicenter ACL Revision Study (MARS) between 2006 and 2011, composing the prospective cohort. Two-year questionnaire follow-up was obtained for 989 patients (82%), while telephone follow-up was obtained for 1112 patients (92%). If a patient reported having undergone subsequent surgery, operative reports detailing the subsequent procedure(s) were obtained and categorized. Multivariate regression analysis was performed to determine independent risk factors for a reoperation.ResultsOf the 1112 patients included in the analysis, 122 patients (11%) underwent a total of 172 subsequent procedures on the ipsilateral knee at 2-year follow-up. Of the reoperations, 27% were meniscal procedures (69% meniscectomy, 26% repair), 19% were subsequent revision ACLR, 17% were cartilage procedures (61% chondroplasty, 17% microfracture, 13% mosaicplasty), 11% were hardware removal, and 9% were procedures for arthrofibrosis. Multivariate analysis revealed that patients aged

The Multicenter Orthopaedic Outcomes Network (MOON) is an NIH-funded prospective, longitudinal cohort of over 3,500 patients who have undergone anterior cruciate ligament reconstruction (ACLR) by 14 sports medicine surgeons at 7 academic medical centers. Patient reported outcome questionnaires (PRO's) are completed at baseline and multiple timepoints after surgery, and a nested cohort of patients return for radiographs to assess the development of joint space changes. We review the risk factors for worse patient reported outcomes, the predictors of clinically significant symptoms of post-traumatic osteoarthritis (PTOA), and the factors associated with more radiographic joint space narrowing. Baseline PRO's were highly predictive of follow-up scores. Factors associated with worse PRO's at 2 and 6 years included female sex, higher BMI, smoking, less education, allograft, medial meniscectomy, or repair, and chondral injury. Partial lateral meniscectomy was unexpectedly associated with better PRO's. Factors associated with clinically significant symptoms of PTOA at 2 and 6 years included subsequent surgery, meniscal pathology, and chondral injury. Factors associated with narrower medial compartment joint space width included medial meniscectomy, medial meniscus repair, and increased age. Medial joint space width was slightly wider overall for the ACLR knees compared to the contralateral normal knees. Future studies will evaluate PRO's and radiographs at 10-year follow-up. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1366-1374, 2017.

Background: There is a strong correlation between glenoid defect size and recurrent anterior shoulder instability. A better understanding of glenoid defects could lead to improved treatments and outcomes. Purpose: To (1) determine the rate of reporting numeric measurements for glenoid defect size, (2) determine the consistency of glenoid defect size and location reported within the literature, (3) define the typical size and location of glenoid defects, and (4) determine whether a correlation exists between defect size and treatment outcome. Study Design: Systematic review; Level of evidence, 4. Methods: PubMed, Ovid, and Cochrane databases were searched for clinical studies measuring glenoid defect size or location. We excluded studies with defect size requirements or pathology other than anterior instability and studies that included patients with known prior surgery. Our search produced 83 studies; 38 studies provided numeric measurements for glenoid defect size and 2 for defect location. Results: From 1981 to 2000, a total of 5.6% (1 of 18) of the studies reported numeric measurements for glenoid defect size; from 2001 to 2014, the rate of reporting glenoid defects increased to 58.7% (37 of 63). Fourteen studies (n = 1363 shoulders) reported defect size ranges for percentage loss of glenoid width, and 9 studies (n = 570 shoulders) reported defect size ranges for percentage loss of glenoid surface area. According to 2 studies, the mean glenoid defect orientation was pointing toward the 3:01 and 3:20 positions on the glenoid clock face. Conclusion: Since 2001, the rate of reporting numeric measurements for glenoid defect size was only 58.7%. Among studies reporting the percentage loss of glenoid width, 23.6% of shoulders had a defect between 10% and 25%, and among studies reporting the percentage loss of glenoid surface area, 44.7% of shoulders had a defect between 5% and 20%. There is significant variability in the way glenoid bone loss is measured, calculated, and reported.

Objectives: ACL reconstruction effectively restores knee stability and allows a return to athletic activities after ACL injury, but patients are still at higher risk of developing post-traumatic OA. Patient reported outcomes from the Multicenter Orthopaedic Outcomes Network (MOON) prospective longitudinal cohort of over 1500 patients undergoing ACL reconstruction showed no increase in OA symptoms (KOOS subscale) at 2 or 6 years after surgery. Therefore, identification of structural changes of OA that may precede the onset of symptoms is of critical importance for determining risk factors for the initiation and progression of post-traumatic OA in addition to measuring the effectiveness of potential disease-modifying treatments. One structural measure of OA is radiographic joint space width (JSW). We previously demonstrated that meniscus treatment and age predict narrower medial compartment JSW. Methods: 335 patients from the MOON cohort (154 males, 181 females, median age 18 years at the time of surgery) were recruited at a minimum of 2 years following surgery for on-site evaluations including bilateral metatarsophalangeal joint (MTP) radiographs to assess JSW. To minimize bias related to pre-existing knee injury or OA, subjects were 35 years or younger, were injured playing a sport, had primary ACL reconstruction without prior meniscus or articular cartilage surgery, did not undergo subsequent ACL revision, and had a surgically normal contralateral knee. Radiographic JSW was measured in the lateral compartment of both knees using a validated semiautomated method. The association of age, sex, BMI, meniscus treatment, and articular cartilage treatment with lateral compartment JSW differences (JSD) between the reconstructed and normal knees was examined using multivariable generalized linear models. The Holm-Bonferroni method was used to account for multiple comparisons. Results: The mean lateral compartment JSW was 7.73 mm and (95% CI 7.61-7.85 mm) for ACL reconstructed knees and 7.82 mm (95% CI 7.71-7.94 mm) for contralateral normal knees, with a mean JSD of 0.10 mm (p

Objectives: Shoulders with recurrent anterior shoulder instability often have combined defects of the humeral head and glenoid. The aim of this study is to define the relationship of combined humeral head and glenoid defects on anterior shoulder instability. We hypothesize that combined humeral head and glenoid defects will produce greater instability than either defect found alone, and that the size of humeral head and glenoid defects which are “critical” and need to be repaired in order to restore glenohumeral stability will be smaller when the defects are found together than when either defect is found alone. Methods: Eighteen shoulder specimens (mean age 57 years) were tested at 60° of glenohumeral abduction and 80° of glenohumeral external rotation (equivalent to 90° of abduction and 90° of external rotation relative to the trunk). Humeral head defect sizes included 6%, 19%, 31%, and 44% of the humeral head diameter. Glenoid defect sizes included 10%, 20%, and 30% of the glenoid width. Outcome measures included Percent of Intact Stability Ratio (stability ratio for a given trial divided by the stability ratio in the intact state for that specimen) and Percent of Intact Translation (distance to dislocation for a given trial divided by the distance to dislocation in the intact state for that specimen). Results: There was a progressive decrease in stability as humeral head defect size increased and as glenoid defect size increased. The decrease in Percent of Intact Stability Ratio reached statistical significance for humeral head defects of 44%, for glenoid defects of 30%, and additionally for a combined 19% humeral head defect with a 20% glenoid defect. The mean Percent of Intact Stability Ratio was 65% for a combined 19% humeral head defect with a 20% glenoid defect. The decrease in Percent of Intact Translation reached statistical significance for humeral head defects of 31% and 44%, for glenoid defects of 20% and 30%, and additionally for a combined 19% humeral head defect with a 10% glenoid defect. The mean Percent of Intact Translation was 69% for a combined 19% humeral head defect with a 10% glenoid defect. Conclusion: The humeral head and glenoid defect sizes required to produce instability are smaller when the defects are found together than when either defect is found alone. In patients with combined humeral head and glenoid defects bony reconstruction may be indicated for humeral head defects as small as 19% of the humeral head diameter and glenoid defects as small as 10-20% of the glenoid width.

Increased knee pain at the time of anterior cruciate ligament reconstruction may potentially predict more difficult rehabilitation, prolonged recovery, and/or be predictive of increased knee pain at 2 years.A bone bruise and/or other preoperative factors are associated with more knee pain/symptoms at the time of index anterior cruciate ligament reconstruction, and the presence of a bone bruise would be associated with specific demographic and injury-related factors.Cohort study (prevalence); Level of evidence, 2.In 2007, the Multicenter Orthopaedic Outcomes Network (MOON) database began to prospectively collect surgeon-reported magnetic resonance imaging bone bruise status. A multivariable analysis was performed to (1) determine if a bone bruise, among other preoperative factors, is associated with more knee symptoms/pain and (2) examine the association of factors related to bone bruise. To evaluate the association of a bone bruise with knee pain/symptoms, linear multiple regression models were fit using the continuous scores of the Knee injury and Osteoarthritis Outcome Score (KOOS) symptoms and pain subscales and the Short Form 36 (SF-36) bodily pain subscale as dependent variables. To examine the association between a bone bruise and risk factors, a logistic regression model was used, in which the dependent variable was the presence or absence of a bone bruise.Baseline data for 525 patients were used for analysis, and a bone bruise was present in 419 (80%). The cohort comprises 58% male patients, with a median age of 23 years. The median Marx activity level was 13. Factors associated with more pain were higher body mass index (P.0001), female sex (P = .001), lateral collateral ligament injury (P = .012), and older age (P = .038). Factors associated with more symptoms were a concomitant lateral collateral ligament injury (P = .014), higher body mass index (P.0001), and female sex (P.0001). Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction. None of the factors included in the SF-36 bodily pain model were found to be significant. After controlling for other baseline factors, the following factors were associated with a bone bruise: younger age (P = .034) and not jumping at the time of injury (P = .006).After anterior cruciate ligament injury, risk factors associated with a bone bruise are younger age and not jumping at the time of injury. Bone bruise is not associated with symptoms/pain at the time of index anterior cruciate ligament reconstruction.