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Sports Knee Surgery ACL Graft Choice . Dr Jonathan Mulford Who am I?. ACL Surgery. What do you think of the LARS?. What Are you asking me?. What is the best graft? What would you have?. Graft Choice. Autograft – Patients own tissue Allograft – someone else's tissue

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sports knee surgery acl graft choice

Sports Knee Surgery ACL Graft Choice

Dr Jonathan Mulford

acl surgery
ACL Surgery

What do you think of the LARS?

what are you asking me
What Are you asking me?

What is the best graft? What would you have?

graft choice
Graft Choice

Autograft – Patients own tissue

Allograft – someone else's tissue

Synthetic - Artificial

which graft
Which Graft

Leo P – Hamstrings

Merv C – Patella tendon

Americans Allograft

Koreans Quads Tendon

Footy show says Synthetic Graft



LARS option: Fisher aims for fast return

David Rodan back on training track two weeks after knee surgery

Miracle op to melt down surgeons' phones

Rodan surgery to become the norm

Covell's career on knife's edge

Moltzen plays it safe

which graft would you have





Allograft significantly lower normal stability rates than autograft

Allograft abnormal stability rate 3 times greater than autograft.


Good Things

Bad Things

  • Pros
    • Quick harvest
    • Reliable
    • Can use for double bundle
    • Small incisions
    • Early rehab not too bad.
hamstring graft
Hamstring Graft
  • Cons
    • Subtle hamstring discomfort
    • Graft gets weaker intially as revascularises
    • Fixation to bone can takes longer than BTB
    • Stretches a little more than BTB
    • Graft size not predictable
patella tendon
Patella Tendon

Good Things

Bad Things

patella tendon17
Patella Tendon
  • Pros
    • Bone heals to bone quickly
    • Stiffer graft (doesn’t seem to stretch as much)
    • No hamstring problems
    • Better if
      • larger heavier patients and
      • collision sports
      • ligament lax individuals
      • Known Hamstring problems
btb graft
BTB graft
  • Cons
    • Arguably anterior knee pain (Bone graft)
    • Longer to harvest graft
    • Larger incisions
    • uncomfortable initially
    • Risk of patella fracture and tendinopathy
quads tendon
Quads Tendon

Good Things

Bad Things

quads tendon20
Quads Tendon
  • Pros
    • Strong graft
    • Good for revision graft
    • May be useful for double bundle
    • May have less morbidity then Patella and hamstrings
  • Cons
    • Quads weakness
    • Anterior knee pain
    • Not commonly used

What does the literature tell us.

Remember there is a lot of poor literature.

what about quads
What about Quads?

Currently performing Systematic review.

No difference to BTB

Quads strength? /

less anterior knee pain ? /

patient specific approach
Patient Specific Approach

Choose graft that matches the patients needs.

Discuss the pros and cons of each graft.

artificial graft
Artificial Graft

Have been used for over 30years

Avoids the donor site morbidity, quicker recovery, cheat biology.

Problem has been their durability – they have not matched autograft in this regard.

as a result long rehab that
As a result Long rehab that

Lion opts for LARS 11/5/2010


What’s good?

What’s bad?

history artificial grafts
History Artificial Grafts

1918 silk sutures – failed 3 months

First graft 1973 - Proplast made of polytetrafluoroethylene (PTFE)

Results with this system yielded an average time to breakage of just over 1 year.

classification of synthetic grafts
Classification of Synthetic Grafts
  • Ligament Augmentation Devices
    • (polypropylene, polyester)
    • initial strength until revascularisation,
    • stress shielding of autogenous tissue and prevented adequate strength.
  • Total Prosthetics
    • permanent replacement with no revascularisation.
    • Excellent short-term results, long-term efficacy results were poor due to wear and ensuing rupture of the prosthesis.
carbon fibre prosthetics

Began late 70s

carbon wear particles

coated with collagen and absorbable polymers

Good Early results

longer term - unacceptable stretching and complete rupture as major complications.


tightly woven polyester strips.

Early results were good

however by 4 years about 50% had failed due to stretching of the graft.

leeds keio artificial ligament

a polyester mesh

intended as a scaffold for soft tissue ingrowth

Good early results.

a large number of long-term graft ruptures despite excellent early results

kennedy ligament augmentation device lad 1980

Ligament Augmentation Device (LAD) in 1980.

Idea - protect the autogenous tissue graft early

Problem - Stress shielding resulted.

Later - effusion and synovitis.

ligament advanced reinforcement system lars artificial ligament
  • polyethylene terephthalate (PET).
  • intra-articular segment
    • Twist
    • PET Encourage ingrowth
  • wear resistance of 22 million of cycles = 10 years of straining use.
literature on lars
Literature on LARS

One case synovitis reported short term.

Short term results in a handful of papers are good.

Fast recovery and return to sport/activity.

risk of rupture remain and must be addressed through long-term follow-up studies.

longest follow up lars
Longest Follow-up LARS

ACL Reconstruction Using Artificial Ligament: Five Years Follow Up

S.I.O.T. 2007; 33(suppl.1) : 8238-8242G. Cerulli et at. 25 patients older than 40 - Lars® artificial ligaments at a five-years follow-up with very good results.

dr nicolas duval using lars since 1993
Dr Nicolas Duval using LARS since 1993

Best results are in early ACL repair augmented by LARS

In older patients (more than 50) I use the LARS in any condition because of the low morbidity and easy rehab.

why is rehab faster
Why is rehab “Faster”

No Donor site Morbidity

Graft not going to weaken early.

lars indications
LARS Indications

Sportsmen who have acute injury require fast recovery for particular target time AND prepared to take the risks possible long term failure.

Older patients with less demands however functional instability and want less involved rehab.


Patient Specific Approach

  • Choose graft that matches the patients needs.
  • Discuss the pros and cons of each graft.
the future scaffolds and growth factors with repair
The future – Scaffolds and Growth Factors with Repair.
  • tissue engineering techniques
    • Grafts that regenerate a mechanically robust and natural ACL
    • cell-specific growth factors that influencing the maturation and healing response of ligament tissue will also be available.