LARS Ligament What’s the fuss all about?

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

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

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

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) 10

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 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

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

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. 15

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

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.

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