LARS LigamentWhat’s the fuss all about?

Media Love LARS

• “Miracle op to melt down surgeons' phones”

• “Is LARS revolution about to start?”

• “Rodan's LARS recovery stuns coaches”

• “Rodan back two weeks after knee surgery”

Players, Coaches and Clubs Love LARS

Club Doctors Love LARS

• "It's a ridiculous recovery,“ • "This will become the norm"

High Level of Patients Awareness

• Asking for them or about them.

Lots of Hype – Evidence based answers

• Should we be incorporating this graft into our practice?– Better than autograft?– Durability?– Do they cause OA?– Can they be revised?

• Which patients should it be used on?– Any Specific Advantages?– Optimal time to insert?

LIGAMENT ADVANCEDREINFORCEMENT SYSTEM (LARS) ARTIFICIAL LIGAMENT

• Polyethylene Terephthalate (PET).

• PET - Encourage ingrowth

• Intra-articular segment– Twist

Methods

• A systemic review process was undertaken

• Any article reporting on outcomes of the LARS ligament

10 Specific Outcomes Measures

• Loss of Range of motion (flexion or extension loss > 5 degree) • Lachman Grade >II• Pivot shift grade >II• IKDC score (% of patients scored A or B)• Lysholm score and Tegner Score• KT-1000• Muscle strength (flexion and extension strength), • Surgery Complications

– Specifically graft rupture or revision, – synovitis – osteoarthritis

LARS Literature

• 12 papers found reporting on the LARS

• 6 publications in Chinese literature.

• 4 compared to autograft (1 PT 3 HT)

12 LARS Papers

• Total 655 LARS grafts.

• Methodology – retrospective case series.

• Av. Age patients 21 – 46• Av. Time to surgery 7 months• Av. Follow up 28 months (4-60 months)

Reported Outcomes• Lachman grade

– 12% Grade II or more (60 of 499 grafts, 7 articles)

• Pivot shift– 5% grade II or more (20 of 515 grafts, 7 articles)

• 14 reported ruptures (2%)

• Lysholm Post op value of 82.8 – 98.7

• 1 case synovitis reported

  Article YearJournal

Number Av Age Time to surgery

Av F/UMonths

1 Derricks 1995Operative techniques Sports

Medicine 220 33.4   30

2 Lavoie 2000 Knee 47 31.6   22

3 Duval ** 2002 JBJS 26 31 5 24

4 Qi S 2005 Chin J Min Inv Surg 16 33.7 19 4

5 Chen S ** 2007 Chin J Sports Med 23 28.2 2 15

6 Dong 2007 Chin J Orthop Trauma 21 35.7 1.5 9

7 Cerelli 2007 SIOT 25 46 10 60

8 Fan** 2008Zhongguo Xiu Fu Chong Jian

Wai Ke Za Zhi 15     18

9 Liu ** 2009 International Orthopaedics 28 36 8 49

10 Chen M 2009Chin J Reparative and Recon

Surgery 32 21 3.2 24

11 Gao 2010 Arthroscopy 159 30 5 50

12 Huang 2010 Chin Medical Journal 43     29

        655  21-46 6.7 27.8

4 Comparison Papers

• No difference in the 10 outcome measures at final follow up (15 – 49 months).

• LARS patients reached full recovery sooner.

Correspondence Dr Nicolas Duval

• Best results are in early ACL repair augmented by LARS – Expect 80 to 90% good results at 10 years.

• Chronic ACL tear - 50% failure at 10 years

• Revision ACL surgery - 40% failure at 10 years.

Is there an optimal time to insert?

• acute injuries • good ACL stump • well vascularised

Tissue Ingrowth• 2 Papers • Yu – (Chinese) Rabbits

– If the stump was left - Connective tissue covering– at 6 months irregular collagen bundles with no

mature ligamentisation.

• Trieb– Invitro cellular ingrowth into LARS– Invivo – Ingrowth in a quads tendon.

Long Term Results LARS

Other PET grafts– Stryker Graft– Proflex– Lygeon– Leeds-Keio– ABC Surgicraft – Ligastic

Poor Results

• High failure rates

• Poor Outcome Scores (Lachman, Pivot, IKDC)

• Concerns regarding development of OA

Pittsburgh Group

Electron Microscopy

Conclusion• There is sparse and poor quality literature

• Early results of LARS good.

• Faster recovery but NOT BETTER than autograft.

• Concern based on previous PET grafts possibility late failure and iatrogenic OA

Recommendations

• Reporting and follow up is important.

• Randomised trials.

• Patients - informed of our knowledge of LARS.

• Need for ACL register?

Thankyou