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Maj. Gen. Greg. Papadopoulos MD, Lt. Col Sp. Darmanis MD, D. Kiatos PHT Orthopedic and Trauma Department Athens Military Hospital and Iaso General Hospital.

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Presentation on theme: "Maj. Gen. Greg. Papadopoulos MD, Lt. Col Sp. Darmanis MD, D. Kiatos PHT Orthopedic and Trauma Department Athens Military Hospital and Iaso General Hospital."— Presentation transcript:

1 Maj. Gen. Greg. Papadopoulos MD, Lt. Col Sp. Darmanis MD, D. Kiatos PHT Orthopedic and Trauma Department Athens Military Hospital and Iaso General Hospital Athens, Greece Iasimo Rehabilitation Centre, Athens, Greece Treatment of unstable knee ACL deficiency using the new generation LARS artificial ligament Long-term follow-up of 162 operated knees in 155 patients

2 Background  Traditional ACL-R has achieved good-to-excellent results in only 60% of patients Fu et al 2008  63% of ACLRs returned to their pre-injury activity level after 12 months  44% returned to competitive sport at 36.7 months post-op Ardern & Feller et al 2011  Mid (≤ 96months) to long -term (15 yrs) failure rates quoted at between % for autografts Pinczewski 2011, Magnusson 2011, Li 2010 Table 1: Sports Attempt at 12 Months for Most Commonly Played Sports (CI, confidence interval) Seasonal SportsYear-round Sports OverallAustralian Rules FootballSoccerBasketballNetball n Full competition n (%) 95% CI 168 (33.4) (42.1) (29.4) (38.8) (18.5) Training and/or modified competition n (%) 95% CI 169 (33.6) (35.0) (33.3) (28.2) (30.3) No attempt n (%) 95% CI 166 (33.0) (20.8) (36.3) (32.9) (50.4)

3 Background  Over 78% patients experience donor site pain with HT at up to 3 yrs post-op  Between 3-27% HT strength deficits compared with non-operated side Feller et al 2011  Incomplete graft ligamentisation at up to 2 years after ACLR Janssen 2011, Claes 2011  Autologous grafts approached only 50–60% of the intact ACL failure strength at up to 12 mnths in sheep studies Scheffler 2005, 2008 Table 2. Clinical Evaluation Data CharacteristicST-GST IKDC subjective knee form score [mean ± SD (range)]91.6 ± 8.1 (67 to 100)94.4 ± 3.6 (85 to 100) Side-to-side difference in knee laxity [mean ± SD (range)] (mm)1.0 ± 2.8 (-7 to 5)1.4 ± 2.9 (-5 to 5) Postoperative hamstring pain (yes:no)18:1211:9 Side-to-side difference in active knee range of motion [mean ± SD (range)] (°)2.3 ± 7.8 (-17 to 17)24 ± 4.9 (-7 to 11) Side-to-side difference in passive knee range of motion [mean ± SD (range)] (°)1.9 ± 5.1 (-10 to 12)3.0 ± 4.6 (-4 to 11) Abbreviation: IKDC, International Knee Documentation Committee

4 Why LARS?  Avoids donor site morbidity or any other iatrogenic injury  Provides the possibility of natural ligament healing and early proprioception Murray 2011, Ahn 2011  Permits early rehabilitation leading to a faster return to work and sport What is LARS?  Soft tissue internal fixator – scaffold type  PET (polyethylene terephthalate) with unique, pre-twisted ‘free fibre’ design  Human ACL: 1730 Nt  LARS AC-100: 4700 Nt  AC-120: 5000 Nt

5 Study objectives & design  Objective  To report long-term functional follow-up of LARS ligaments in patients with an unstable knee and ACL deficiency  Study design  Monocenter prospective case-series  Independant, blinded data analysis by AO foundation  Follow-up examinations at upto 14 yrs (Average follow up 11 yrs) −Lachman - Noulis test −Pivot shift test −IKDC subjective

6 Patients  Eligibility criteria  Patient with mature skeleton  Unstable knee with ACL deficiency  Treated with LARS by same surgeon (Dr Papadopoulos)  Standardized rehabilitation program (same Center)  Consented to long term follow up  Exclusion: complicated ligament injuries, dislocation or fractures, non-compliant patients  8-year enrollment period: Jan 1996 to Dec 2003  155 patients (162 knees)  Male:female = 123:32  Mean age = 38 years (range 15-68)  Side = 76 R, 72 L, 7 R+L

7 Injury characteristics ACL stump classification Grade IIIIIIIV ACL stumpPlastic deformation Attached to PCLDegenerated or attached to PCLComplete degeneration AnatomyIntact Torn Length of the stumpNormal Approx. 2/3Approx. 1/2Around ¼ or nothing (empty notch) ACL ruptures Total Acute % Anatomy %

8 Status of knee lesions Chondral lesions Associated meniscus and ligamentous lesions

9 Operation technique  Notchplasty = 18%  Recommended LARS technique followed  Preservation of stump where possible  No tension philosophy

10 Rehabilitation program  No brace post-operative (OP)  Immediate active quadriceps exercises  Immediate full weight bearing  CPM started on 2 nd –3 rd post-OP day  Normal walking weeks post-OP  Jogging progressive training from 4-6 weeks post-OP  Return to vigorous activities sports practiced 8-12 weeks post-OP

11 Results: Lachman-Noulis No change in Lachman- Noulis test results over time, with up to 14 years FU Each of the 162 knees were evaluated twice 2 years apart

12 Results: Pivot Shift No change in Pivot Shift test results over time, with up to 14 years FU Each of the 162 knees were evaluated twice 2 years apart

13 Results: IKDC No overall significant change in IKDC score over time, with up to 14 years FU Each of the 162 knees were evaluated twice 2 years apart (mixed model with repeated measure)

14 Results: IKDC adjusted for age <=30 >30-40 >40 There is a significant age effect : Patients in the older group have lower mean IKDC than younger patients by -2.5 points There is some time-related decrease in IKDC, however the change is not significant

15 Results*: Knee pain during daily activity 5 - I have no pain in my knee. 4 - I have some pain in my knee but this does not affect my daily activities. 3 - The pain affects my daily activities a little. 2 - The pain affects my daily activities moderately. 1 - The pain affects my daily activities a lot. 0 - The pain in my knee is severe. I can’t do my daily activities. *at final follow up time point

16 Results*: Knee stiffness during daily activity 5 - I have no stiffness in my knee. 4 - I have some stiffness in my knee but this does not affect my daily activities. 3 - The stiffness in my knee affects my daily activities a little. 2 - The stiffness in my knee affects my daily activities moderately. 1 - The stiffness in my knee affects my daily activities a lot. 0 - The stiffness in my knee does not allow me to do my daily activities. *at final follow up time point

17 Results*: Knee stability Noyes Personal Questionaire 20 - I have no giving way sign I feel my knee unstable when I participate in contact sports or do heavy work I feel my knee unstable when I go jogging, which restricts my sports activities or heavy work. 8 - I feel my knee unstable and I cannot participate in sports. 4- I often have giving way sign even when I walk. 0 - I have a big problem of stability when I must turn or suddenly change direction. *at final follow up time point

18 Results*: Knee activity level Noyes Personal Questionaire 20 - I have no restrictions. I have a normal knee. I can participate in contact sports I participate in sports but with lower demands I can do weekend sports with some symptoms. 8 - I cannot participate in sports at all. Only jogging with symptoms. 4 - I have problems in my daily activities. 0 - I have severe problems in my daily activities. *at final follow up time point

19 Results*: Edema Noyes Personal Questionaire 10 - I have no edema in my knee. 8 - My knee is edematous from time to time when I participate in competitive sports or do heavy work. 6 - My knee is edematous after sports or moderate work. 4 - The edema limits my sports activities more than 4 times a year. 2 - My knee is edematous after running and the edema disappears after relaxing. 0 - My knee is edematous even when I walk and this remains after relaxing *at final follow up time point

20 Revisions Overall failure rate: 5.5% (9 Knees) −2 knees, 1.2% due to graft rupture (technical error) −3 knees, 1.8% due to persisting joint instability following trauma (re-tightening ) −4 knees, 2.5% due to new trauma to the knee  Revised to: – Autogenous (3) – LARS (2) – Stand by (1) – Mini revision (3)  Minor complications – Superficial infection in the tibial portal – 3 knees, 1.8% – Lack of extension – 2 knees, 1.2% – Staple removal – 2 knees, 1.2%  0% synovitis

21 Revisions  Analysis of a failure case  We found revision of a LARS to be a simple procedure 1. Remove all fixation 2. Apply a very strong clamp applying mild traction 3. If the ligament wont strip out, pass a blunt K wire into tunnel, drill over with 4.5mm drill at low speed

22 Discussion  In our centre, LARS ACL has demonstrated excellent patient outcomes at an average follow up of 11 yrs  These failure rates are comparable to published HT and PT results at the same average follow up interval Pinczewski 2007 Wipfler 2011  Acute cases of ACL injury and those of chronic laxities with well- vascularised ACL-stump are the best indications to use the LARS ligament  Weaknesses: No radiographic follow up, further objective/subjective testing could have been included in this study

23 Conclusions  LARS has not exhibited high rates of complications associated with previous synthetics  LARS avoids donor site complications associated with autografts  Does not “burn any bridges” for possible revision surgery  Provides the possibility of natural ligament healing and early proprioception Murray 2011, Ahn 2011  Permits early rehabilitation leading to a faster return to work and sport

24 Thank you for your attention


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