1. LARS Ligament What’s the fuss all about?

2. Media Love LARS “Miracle op to melt down surgeons' phones”
“Is LARS revolution about to start?” 2

3. Players, Coaches and Clubs Love LARS
“Rodan's LARS recovery stuns coaches”
“Rodan back two weeks after knee surgery”

4. Club Doctors Love LARS "It's a ridiculous recovery,“
"This will become the norm"

5. High Level of Patients Awareness
Asking for them or about them.

6. 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?

7. LIGAMENT ADVANCED REINFORCEMENT SYSTEM (LARS) ARTIFICIAL LIGAMENT
Polyethylene Terephthalate (PET).
PET - Encourage ingrowth
Intra-articular segment
Twist 7

8. Methods A systemic review process was undertaken
Any article reporting on outcomes of the LARS ligament

9. 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

10. LARS Literature 12 papers found reporting on the LARS
6 publications in Chinese literature.
4 compared to autograft (1 PT 3 HT) 10

11. 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)

12. Reported Outcomes Lachman grade Pivot shift 14 reported ruptures (2%)
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

13. 655 21-46 6.7 27.8 Article Year Journal Number Av Age Time to surgery
Article
Year
Journal
Number
Av Age
Time to
surgery
Av F/U
Months 1
Derricks
1995
Operative 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
Chen S **
2007
Chin J Sports Med 23
28.2 15 6
Dong
Chin J Orthop Trauma 21
35.7
1.5 9 7
Cerelli
SIOT 25 46 10 60 8
Fan**
2008
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 18
Liu **
2009
International Orthopaedics 28 36 49
Chen M
Chin J Reparative and Recon Surgery 32
3.2 11
Gao
2010
Arthroscopy
159 50 12
Huang
Chin Medical Journal 43 29
655
 21-46
6.7
27.8

14. 4 Comparison Papers
No difference in the 10 outcome measures at final follow up (15 – 49 months).
LARS patients reached full recovery sooner.

15. 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. 15

16. Is there an optimal time to insert?
acute injuries
good ACL stump
well vascularised

17. Tissue Ingrowth 2 Papers Yu – (Chinese) Rabbits Trieb
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.

18. Long Term Results LARS Other PET grafts Stryker Graft Proflex Lygeon
Leeds-Keio
ABC Surgicraft
Ligastic

19. Poor Results High failure rates
Poor Outcome Scores (Lachman, Pivot, IKDC)
Concerns regarding development of OA

20. Pittsburgh Group

21. Electron Microscopy

22. 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

23. Recommendations Reporting and follow up is important.
Randomised trials.
Patients - informed of our knowledge of LARS.
Need for ACL register?

24. Thankyou