In part I of this two-part Masterclass article, Chris Mallac discusses in detail the postoperative rehab requirements following a unique ACL reconstruction method – a Ligament Advanced Reinforcement System (LARS) procedure.
Anterior cruciate ligament (ACL) rupture is a common injury suffered by many athletes in a variety of sports. It typically affects athletes involved in sports that require sharp deceleration and cutting/pivoting type movements such as all the football sports (soccer, rugby, AFL, NFL), basketball, netball, golf and tennis. It may also occur as the result of a direct blow to the outside of the knee, which causes a valgus knee collapse, imposing large tensile and torsional forces to both the medial collateral ligament (MCL) and ACL.
It has been estimated that 80% of all ligament reconstructions of the knee relate to the ACL1. It is accepted that ACL ruptures have poor intrinsic healing capabilities due to the fact that the ACL is enveloped by synovial fluid and lacks significant vascularisation2. This makes healing of this intra-articular ligament impossible due to the inability of the torn ligament to re-vascularize.
In many case therefore, this precipitates the need to reconstruct the ACL to achieve functional stability to withstand anteroposterior shear forces and to prevent rotational forces on the knee. This course of action will prevent any further meniscus breakdown, and early onset osteoarthritis due to the excessive shearing forces encountered by the ACL deficient knee3,4.
Surgical options following ACL rupture |
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The decision to reconstruct the ACL is multifactorial and both the attending surgeon and patient discuss the need to reconstruct along the following paradigm(3): 1.Degree of symptoms — such as uncontrollable instability or giving way of the knee. 2. Age — younger athletes will have longer exposure to potentially joint damaging instability episodes. Therefore, early reconstruction to develop functional stability may be preferred even though there exists a lengthy rehabilitation process. An older athlete nearing retirement may prefer to take their chances rather than stepping out of training/competition for 9-12 months. 3. Participation in a pivoting sport such as football (all codes), netball, basketball, tennis, dance to name a few. 4. Level of activity — elite athletes are well advised to always have an ACL reconstructed whereas a recreational athlete may have different needs.5. Failure or success of conservative management focusing on proprioception and hamstring strengthening |
Surgical techniques vary from surgeon to surgeon and from country to country. Indeed, it is not uncommon for two orthopaedic surgeons from the same sports medicine clinic to differ in their surgical choices. The options the surgeon has include:
The use of grafts falls into three different subtypes:
However synthetic grafts are now in their third generation and in the last 20 years the Ligament Advanced Reinforcement System (LARS) procedure has gained more popularity with orthopaedists8.
The LARS system was developed in France by a French surgeon called Professor JP Laboreau. This was developed over a lengthy period of time, finding a material and technique that would prevent the failure rates seen with other synthetic grafts, and to also avoid the morbidity seen with human tissue grafts involving the patella tendon and hamstring grafts.
LARS has been used successfully to reconstruct ACL ruptures in countries such as Australia, United Kingdom, France, Germany and Canada. However, the United States has still not approved the use of LARS in the USA, with the result that American athletes often seek surgical treatment in other countries.
A LARS is an intra-articular scaffold consisting of an interosseous component of multiple parallel fibres of Polyethylene Terephthalate (PET) polyester (see figure 1). The intra-articular segment is unique and different to other synthetic grafts in that it is twisted at 90 degree angles.
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