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Offline kneedad

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LARS question
« on: August 31, 2008, 03:51:28 PM »
Hi.
I am new so please be kind.
I have read and read this site and other but still have no Idea what to do.
My son tore his ACL last week playing football and did some miniscus damage too.
I live in Canada and need to choose how to have his knee fixed.
My situation and thoughts

My son is an elite football (not soccer) player and is (was) scholarship bound.
He is going to miss thiss year and must be ready 110% for next sept.

Having it done locally ( thanks to our Canadian way) will take a few months just to see the surgeon.
so from what I understand with a normal 9 - 12 month recovery this is not an option.

Our family has connections in the states with one of the best if not the best knee surgeons. ( not going to mention any ones names in this) He would prpbably do the Petella way. And would bump us ahead to do it in Sept. My concern with this is again recovery time.

Our other option is we have contacted a surgeon in Montreal who does the Lars.
who also can do it in Sept, he uses the lars with an ACL repair. His recovery is faster.

My thoughts, I understan the gold standard is the old way and having the ability to go to the best guy is what my heart is telling me, but this may cost our son his future in sports. recovery time is so vague as I understand it is what you put into it. a 9 month recovery is based on what? 6 hours a day at a clinic? he cant do this as he is still in school and can only do normal rehab, plus what he can do on his own.

If the Lars is shorter then it gives him a greater chance to be ready for sept.

In reading here I see that most people are against it, but what I dont understand is it seems alot of people are on here and other sites looking for answers to there knee problems caused by surgery. I dont want to fix one problem and cause another.

I know never can promise it will be perfect and last for ever and be problem free, I just thought that if the Lars was to fail which I think it will sooner or later that he still has all this tendons to do the other surgery later. If we can give hime 5 or so good ears then he can do what he wants to do.

i can understand if everyone does not like the lars but it seems like the petella one has just as many bad stories.

I have read about soccer players in the last few months getting the Lars done and coming back in 4 months, problem is I dont know how they will be in 4 years?

so to ramble on, but I know have information overload and truly no idea which way to go

any constructive opinions would be a big help

Thanks

Kneedad

Offline clarky_vl

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Re: LARS question
« Reply #1 on: August 31, 2008, 05:09:57 PM »
hi,
first, sorry your son tore his ACL, and also that your health care system means you have to make this decision, i am from the uk, and so it took a while with me too!

i can see why the LAR's option seems good for you, but i really think that you should use a tendon graft for this surgery. you said yourself that you think it would fail sooner or later, meaning he would have to have it redone. if you do it with a tendon graft, and you do it right, then there is a good chance he will never have to have ACL surgery again, and be as good as he was before. and you DEFINITELY dont want ACL surgery again  :-\ (it may seem like they fail alot if you read some stories here, but they usually give very good results)

it seems to me like the only attraction for the LARS is the quick return, but if you go with the patellar tendon surgery, you have a year to get back. the 9-12 month recovery is just a rough guide, with the 12 months being the far end. assuming everything goes to plan, i am SURE he will be back and ready before next september, many people manage it (read some of the stories on the cruciates board etc) and dont forget that your son is already in good shape, which will help him! 

i am 16 now, and still in school, and i had my first reconstruction when i was 15, right at the beginning of an important and very busy year with school, but i managed to fit in time to do the rehab with everything else. its hard work, but not 6 hours at a clinic a day!!

also, i would like to say that i have just had a revision done of my original hamstring reconstruction (failure was just bad luck, it really doesnt happen THAT often) and the graft for the revision was  half LARS, half my own hamstring tendons. the reason the LARS was used was just to give the graft extra strength, i would never have considered the LARS as an option if it was on its own.

please dont just settle for the LARS because of time!! also, what does you son think about his options?

i hope i have helped you a bit, and feel free to ask any questions!
11/10/07 ACLr-hamstring, lat meniscectomy, microfracture
29/7/08 ACL revision-hamstring/LARS
7/7/09 ACL revision-quad/LARS
20/2/10 Screws out, bone grafts, arthroscopy.
6/7/10 ACL revision-BPTB allograft
14/3/11 Screws out, bone grafts, arthroscopy.
Then: ACL revision + extra-articular repair

Offline kneedad

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Re: LARS question
« Reply #2 on: August 31, 2008, 05:35:49 PM »
thank you for your reply.
My son like most kids his age just wants to play ball, he trusts us to make the right choice for him. I hate having to make this choice as I feel either way there are complications we will regret.
As you are haveing the second surgery with the LARS as a brace, this is similar to the one in montreal. he repairs the acl and puts the lars in as support. Not sure how well an acl heals after repair?
I know he will do his best in either way as far as putting in the effort for recovery. It just seams that the LArs has less work involved. I dont say that as looking for the easy way, just as the reality of less time to recover and more time to get back to game shape.
what scares me is hearing about the other knee problems on here caused by normal surgery. I am sure that there are thousands of good one who have no reason to come on here and post.

As you are the same age, I am sure you understand his only focus is to play,
How was your recovery after your first one? (sorry to hear you needed it again)

does anyone know the success rate of the old way. as lars is a small group the numbers are easy to find, it is depending on which study between 70- 85%. What are the % of old way with no complications to the knee?

Thanks for your help

Kneedad

Offline clarky_vl

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Re: LARS question
« Reply #3 on: August 31, 2008, 06:25:58 PM »
hi,
my recovery the first time around went pretty well, i was on time in achieving all the goals like ROM etc, and my surgeon and physio were always pleased with how things were going. only problem is that the laxity had returned after only a few weeks, and got worse and worse and 9 months later needed redoing. i havent really had a reason for what happened, just that it might be because my knees are hypermobile, and therefore it wasnt really the fault of the surgery. they hoped that having the LARS there along with a normal autograft would give it extra strength so that it would not stretch out again. from what i can understand, the hamstrings heal like a normal graft, and heal to the bone, but the LARS remains there with it. i'm hoping it works  ;D

i think i have read about what you are talking about, although i didnt think it was that successful usually? certainly not long term. and i dont really know about how well this heals, there doesnt seem to be much information about it around, although maybe the LARS website has some information about it?

i read that the normal tendon method was around 90-95% successful, with hamstring and patellar tendon methods giving pretty much the same results. also, i think that most need redoing due to reinjury, not as a complication of the surgery, so its usually quite good. there is quite alot of info about it around...

have you done much research about both?  have you got a favourite yet? good luck!
11/10/07 ACLr-hamstring, lat meniscectomy, microfracture
29/7/08 ACL revision-hamstring/LARS
7/7/09 ACL revision-quad/LARS
20/2/10 Screws out, bone grafts, arthroscopy.
6/7/10 ACL revision-BPTB allograft
14/3/11 Screws out, bone grafts, arthroscopy.
Then: ACL revision + extra-articular repair

Offline kneedad

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Re: LARS question
« Reply #4 on: August 31, 2008, 06:52:17 PM »
Hi
Thank you again.
sorry you need to do this again for any reason.

I try to stay away from the Lars website as I would only expect positive results are posted. I am trying to google the hell out of it with different combinations of words.

from what I see anything prior to early 90's was a failure. but after that they changed the design, which I would assume is the one your getting. to a more ACL like material. they report a 80% success rate at 5 years.
we are leaning toward the LARs just to remove all the other complications of the normal surgery.
I look at it this way. if they say he will be ready to go in 4 months then it gives him an extra 6 months to strngthen the leg. we have also decided that when ever he is on the field he will wear his brace no matter how good he feels. I am guessing that would reduce the chance of reinjury.
I also need to disregard reinjury in both cases as if it happens, it happens.

I hope more people jump in here to comment, good or bad. Problem I have is in Europe most of the blogs are not in english, so I am missing alot of info, that may be useful good or bad.

please stay in touch and I will keep this updated on what we finally choose and how it goes.

Thanks and good luck with yours.

knedad

Offline Kaputt_Knee

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Re: LARS question
« Reply #5 on: August 31, 2008, 08:05:41 PM »
kneedad,

PLEASE do a search here in the bulletin board for the threads about LARS. There was a saleswoman on this site trying to promote the procedure under the guise of being a "caring mother". The arguments for and against this type of replacement are more than amply aired in the threads with lots of references to papers for and against. The lady who went under the name of "Norcalgirl" or something similar was claiming, as the web site does, miraculous recoveries which are not really realistic.

The procedure is largely ignored because of a lot of the inherent dangers, proved over many years experience, of artificial fibre ligament replacements poisoning the body. Yes they are a quick fix, but a few years down the road they have ended up causing people no end of trouble as the auto-immune system basically destroys them over time. I believe that LARS ligaments are used in PCL when both ACL and PCL are blown. As Vicky states, she has a LARS ligament as a support to her autograft.

Most elite athletes are given either allograft or patella tendon autografts as these make a far safer and stronger graft, using bone plugs to attach the graft in the correct site. Think of international sportsmen and women who have had ACL grafts - they are invariably patella tendon grafts. More important to the long term success of a replacement is the quality of the rehab and the effort the individual puts in to recovery. If you can intensively rehab then return to top level is usually less than a year.

Most important to the long-term future of your son is having the right surgeon do the job. You say you are in Canada, but do not say how old your son is. You need someone experienced in doing this procedure in young people and elite athletes. Depending on your son's age, a paediatric orthopaedic surgeon is probably the best place to start looking.

I have had 2 artificial fibre ligaments replacing the ACL in my right knee - both failed within a year of being put in place, for the third and final revision I insisted on a patella tendon graft. Thankfully that has been happily doing what it is supposed to do for nearly 20 years now. I was a national level volleyball player at the time as well as a Phys Ed instructor in High School, so the graft took some punishment. I am now more "retired" but continue to teach skiing  ;), as well as paragliding and mountain hiking (I live in the German Alps)

Please take an informed and very long look at all the options - personally I do not think LARS is one of your options.

Try looking at the information on the Stedman-Hawkins clinic web site to start with.

Good luck

Sue in Germany
1989 big trauma R. knee - sorted
1990-2004 3ACL recons and 20+ arthroscopies -RK
3/06 LK ACL torn!
4/06 ACL recon, kneecap broken
09 &10/06- 2x meniscus trims
3/07 - Notch Plastic & Lateral Release
14/8/08 complete revision ACL plus LCL/PLC recon
6/2/09 returned to skiing! Whoopee

Offline kneedad

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Re: LARS question
« Reply #6 on: August 31, 2008, 09:36:02 PM »
Hi
Thank you for your opinion.
My son is 16. He is in great shape and couuld handle the recovery of either.

It all boils down to the time thing. Doing it the oldschool way, just seems to be cutting it close.
The Lars way seems to give him the next few years to do his football, then I feel he will most likely need it again. Well 30% chance of it.

It is hard to weigh taking away his dream vs giving him a chance knowing there is a good chance he will need it again. He wants to play, that is what is important to him ( right now)

The new Lars sounds promising, just hate the lack of info.

wish all the studies where on 16 year old football player, would make life easier

kneedad

Offline clarky_vl

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Re: LARS question
« Reply #7 on: August 31, 2008, 10:15:39 PM »
hello again,
yeah, the LARS website is all abit one sided, but it taught me alot about the structure etc. and as Sue says, there is quite abit on this site about it too.

have you read some of the stories of people on here? they show that people do get back to full activities in much less than the 12 months that you need using their own tendons, it is definietly possible, therefore if time isnt an issue, why use the 'dodgy' option that isnt really proven to be successful when you could have the graft that has been shown to be successful and last without complications most of the time? having to have it all done again is really horrible, surgery and rehab is difficult, it is worth 'cutting it close' to avoid doing this again.

i know it wont be nice for him having to sit out for his recovery, but you wont be taking away his dream, he will be able to get back to it all, and even with the LARS he will have some recovery time, a couple of months extra for the autograft one may well ensure he never has to do it again.

obviously i agree with Sue that LARS isnt the best option for your son. and honestly, complications are rare with the autograft surgery  :)  i think the best thing you can do is just research everything alot and then decide together with your son what is best for him

and good luck again
11/10/07 ACLr-hamstring, lat meniscectomy, microfracture
29/7/08 ACL revision-hamstring/LARS
7/7/09 ACL revision-quad/LARS
20/2/10 Screws out, bone grafts, arthroscopy.
6/7/10 ACL revision-BPTB allograft
14/3/11 Screws out, bone grafts, arthroscopy.
Then: ACL revision + extra-articular repair

Offline kneedad

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Re: LARS question
« Reply #8 on: August 31, 2008, 10:20:29 PM »
Thank you again for your opinion and good wishes.
I will let you know which way we go and how it turns out.
I have changed my mind about twenty times today... time to give the head a rest.
sometimes too much information is a bad thing.

Thank you again

Kneedad

Offline miss_sporty

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Re: LARS question
« Reply #9 on: August 31, 2008, 10:46:27 PM »
Hi,
I don't know much about LARS ligaments but you asked about the recovery rate for natural ligaments, which i have read from multiple sources to be around 80-90% for both patellar and hamstring grafts.

I am 17 and had a hamstring ACL reconstrcution 6 weeks ago and hope to return to high level sports again, and I do think that a natural ligament offers the best chance of this and also the best for the long term health of the knee. Hope this has helped and hope your son is doing ok :)
Torn ACL
Hamstring graft reconstruction
Patellar tendon graft reconstruction

Offline digginit

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Re: LARS question
« Reply #10 on: August 31, 2008, 10:52:20 PM »
The other thing you probably should consider is that wherever he wants to play after high school will likely consider the type of surgery he's had and the probable durability of the knee.  If he's had a surgery that's tried and true, they're gonna look on that more favorably, I'd imagine, than a procedure that's gonna leave him needing more knee surgery.  The lesser procedure is likely to catch up with him at the most inopportune time.  Doesn't sound like his playing schedule is gonna get easier over the next few years if your hopes come to fruition.

~dig

Offline Kaputt_Knee

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Re: LARS question
« Reply #11 on: August 31, 2008, 10:59:37 PM »
Kneedad,

I'm warning you that I am going to be brutally blunt in this post. Please do not take this personally, but I have worked with young sportsmen and women all my working life, so I understand the pressures you and your son are under.

Sorry to disagree but at 16 he still has open growth plates in the long bones - you need to talk with someone who is experienced in orthopaedic surgery on adolescents. No matter how skilled a surgeon is, working on developing bodies requires a special training, hence there are paediatric specialists in all fields. Many very experienced surgeons are reluctant to operate on adolescents until it is established that the growth plates have closed.

If LARS was as good as it claims to be don't you think that all the major sportsmen and women who have had this problem would be using it? Who has actually used it and is really world class - Ernie Els, Tiger Woods, Bodie Miller, Alan Shearer, Michael Owen all have had major ACL replacement surgery in the past couple of years using what you call "old school methods". The careers of each of these proven elite sportsmen are dependant on having a successful long term outcome. They were mostly operated on by either Steadman or one of the elite group of surgeons trained at the Steadman-Hawkins Clinic. None of them had a LARS ligament. Top-flight European sportsmen and women fly to the States to be operated on by sports injury specialists because their livelihood is completely dependant on the outcome of this surgery. None of them have had a LARS ligament, despite the time that it has been available (well over 15 years) and approved by the various regulatory bodies, such as the FDA in the States.

Stop thinking in terms of time and start thinking about this realistically - your son is going to have to undergo a major traumatic surgery in a key joint in the body - whether it is an autograft, allograft or LARS is actually irrelevant. You say there is a meniscus tear as well - repairs or trims to this cannot be short cut on the recovery time. If this treatment is any where near as good as the claims, why is it not being widely used in the country where it was developed (France, Austria and I believe Hungary)? It is permitted in Canada, yet the leading surgeons do not use it - ask yourself why.

For the sake of a few months you could be condemning your son to further and far more complex surgery when the knee joint fails again. Yes, if the claims are accurate, he could possibly return to sport in 4 months, maybe even less. However the lack of proprioception in the joint will cause him problems. Studies have already proved that the laxity at 24 months in LARS ACL replacements is significantly greater than with autografts. They seem to have overcome some of the early onset synovitis problems that other artificial ligaments caused, but again long term studies are not there to back up their claims.

He is 16, he will be evaluated for his possible scholarship in the next 2 seasons - if you go private now and have an autograft or an allograft of some kind of another he could be in full training for the season by next summer, if not earlier. Many who have had ACL replacements here have returned to their sports feeling stronger and fitter than before the accident that caused the injury. I have just undergone a multiple ligament reconstruction in my left knee using my own tissue and have been told by my surgeon that it is not unrealistic to hope that I can return to skiing before the end of this coming season. I will not be having intensive rehab by the way as my job does not allow me the time off.

What seems like an age at 16 can become a lifetime of arthritis and crippling pain by his late 20s or 30s if you get it wrong. What are your real priorities here - your son's long term health or a quick fix so he can go to college on a possible scholarship?

Using just the Bulletin Boards here and similar sites is somewhat depressing - there is a natural skewing towards repeated and unsuccessful surgery. In reality there are literally thousands of successful reconstructions which never come anywhere near any boards such as these as there are no complications. Use the information in the Information Hub and then use the web to research studies on adolescent surgery. Find an experienced paediatric surgeon and ask them what is their recommendation.

I'm sorry but an ill-considered short-cut, just to save time, usually ends up in a very long and tedious detour.

Again, my apologies for being blunt but my intention is really to make you concentrate on the long term best option for your son. I have experience of artificial ligaments. I am just grateful mine failed before they rotted in my knee.

Sue in Germany
1989 big trauma R. knee - sorted
1990-2004 3ACL recons and 20+ arthroscopies -RK
3/06 LK ACL torn!
4/06 ACL recon, kneecap broken
09 &10/06- 2x meniscus trims
3/07 - Notch Plastic & Lateral Release
14/8/08 complete revision ACL plus LCL/PLC recon
6/2/09 returned to skiing! Whoopee

Offline kneedad

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Re: LARS question
« Reply #12 on: August 31, 2008, 11:33:14 PM »
Thank you again, and blunt is what I want.
This In my opinion is not a decision a parent should be making as we do not have the background to make the right choice, so we start to make it with emotion and heart.
Thank you all again

Kneedad

Offline ATsoccergirl

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Re: LARS question
« Reply #13 on: September 03, 2008, 08:01:15 PM »
Hey KneeDad,

Sue brought your post to my attention.  Stay away from the LARS ligament.  It is not designed for use in adolescent athletes, and further more not designed for those who are skeletally immature. 

In terms of recovery time, you are getting a rather high time frame.  I am an athletic trainer in the US, but I work along side an orthopedic surgeon as a physician extender.  I have also played high level soccer (including professionally overseas) for many years.  The time frame we typically instruct athletes to expect if they are dedicated to rehab (this does not mean 6 hours a day) is 4-6 months with the majority of athletes (without complications) returning around 4.5 months.  We have developed a very aggressive post-op protocol and have an incredibly low failure rate.  In terms of a graft we use a contalateral patellar tendon autograft.   I have had two ACL reconstructions, with the first one I also had a posterolateral complex repair, but I returned in 15 months (the absolute minimum).  After the second, I was kicking a ball within two months, and returned to soccer in exactly 4 months. 

Your first step before making any decisions is for your son's doctor to determine if his tibial growth plates are closed.  This can be done with a simple X-ray.  He is at the age where they should start to close, but I don't think that they would be fully closed.  This is going to guide his treatment.  An ACL reconstruction is performed differently if the growth plates are opened.  You cannot use a graft with boneplugs on it, so either a hamstring graft or an allograft will be used.  There are also very careful how the tunnels are drilled.  The growth plate cannot be disrupted by the surgery or he will stop growing in that leg which would lead to a whole host of problems.

I have also worked as a collegiate athletic trainer.  Most people don't know that if an athlete has had a part injury or surgery we are often consulted by coaches before a scholarship was offered.  I don't have a problem with most things, but a LARS ligament would be a huge red flag for me.  If I was handed a file on an athlete and was asked if they would be able to handle the demands of collegiate soccer.  I would say no, and tell them to offer the scholarship to someone else.  The outcomes are extremely unpredictable, it is also not as strong as natural ligaments, they also do not last as long.

For comparison here is tested failure point of different graft options  (in newtons)
Autografts
i. Patellar autograft- 2375 N
c. patellar autograft- 2950 N
Quad bundle Hamsting- 4550 N
Quad tendon w/o bone plug- 2353 N
                    w/ bone plug-  3360 N
Allografts
Anterior Tibialis- 4122 N
Posterior Tibialis- 3594 N
Patellar tendon - 2090 N
Quad Bundle hamstring- 3900 N
Achilles- 5670 N

LARs ligaments are around 1000 N, but this number reduces over time

The natural ACL will fail with a force around 2160 N

Most daily activities forces max out around 400 N

A newton is roughly equal to 0.25lbs of force. 

Joint reaction forces (the amount of weight going through the joint at a particular time) can vary with the activity, here are some examples.
(1=normal body weight)

Sitting (knee flexed to 90)- 0
Walking- 1.5
Stairclimbing- 4.0
Deep knee bends- 8
SLR- 0.5
SAQ- 2.0
Running-3

If you son has a LARs ligament that has a failure point of 250lbs of force.  Just as an example I'm going to say he weighs 120lbs.  When he is running he is putting enough force on the LARs for failure (360 lbs).  Now imagine how much force would occur when he is playing. 

I would highly suggest that you seek out someone in the US as you said you have the ability to.  Three good choices would be the Steadman-Hawkins clinic in Colorado, University of Iowa in Iowa City, Iowa, or the Cinncinnatti Sports Medicine center in Ohio. 
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.

Offline ATsoccergirl

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Re: LARS question
« Reply #14 on: September 03, 2008, 08:03:31 PM »
Sorry, most of my references were to soccer.  As a football player he would have no chance of scholarship with a LARs ligament.  It will not hold up to the sport. 
1999 LR, 2002 ACL/PLC recon, reversal of LR, 2004 ACL revision, 2006 Car accident torn PCL and small fractures resulting in bone chips in my knee.  Torn MCL 3 times.  Wicked screws under IT band and Pes Anserine.  June 2008-Hip Arthroscopy.