Histological analysis of ACL reconstruction failures due to synthetic-ACL (LARS) ruptures

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Paolo Di Benedetto
Piero Giardini
Alessandro Beltrame
Francesco Mancuso
Renato Gisonni
Araldo Causero


anterior cruciate ligament, synthetic ligament, reconstruction, histology, failure


Introduction: Anterior Cruciate Ligament (ACL) reconstruction is an established surgical procedure. Synthetic ligaments represent an option for ACL reconstruction. Their popularity declined for the raising concerns due to re-ruptures, knee synovitis and early arthritis related to I and II generation artificial ligaments. The introduction of a III generation synthetic ligament (Ligament Advanced Reinforcement System-LARS) permitted renewed interest in the adoption of this kind of graft. Main purpose of our study was to describe the histological findings on samples obtained from a consecutive series of ACL revision surgeries due to LARS ACL reconstruction failures. Secondary aim was to determine the reason for LARS rupture. Methods: In a period between 2016 and 2018 eleven patients underwent ACL revision surgery due to LARS ACL reconstruction failure. At the time of the arthroscopic procedure, samples of synovial membrane and remnants of the torn LARS were sent to the Pathological-Anatomy Institute of our Hospital for a histological analysis. Results: Histological analysis of the synovial tissues confirmed the arthroscopic evidence of synovitis mainly characterized by chronic inflammation with predominance of multinucleated giant cells. The adoption of polarized light microscopy revealed the presence of brightly bi-refractive material (LARS wear particles) in the synovial tissue; at higher magnification wear debris were detected inside the cytoplasma of multi nucleated cells. The histological analysis of the removed LARS revealed a surrounding typical foreign body reaction with poor signs of fibrovascular ingrowth of the synthetic ligament. Conclusions: Our findings could not clearly advocate a unique mechanism of LARS-ACL reconstruction failure: biologic issues (poor tissue ingrowth) and mechanical issues (fibers properties and tunnel position) probably concur in a multi factorial manner. ACL reconstruction using artificial ligaments can not be considered a simple surgery. Artificial augments require some expertise and could therefore achieve better results if used by skilled sport surgeons other than trainees or low volume surgeons. The Authors believe that ACL reconstruction with synthetic devices still have restricted indications for selected patients (e.g. elderly patients who require a fast recovery, professional athlete, autologous tendons not available and/or refusing donor tendons). Our study arises additional suspicion on the unresponsiveness of synthetic fibers and claim some concern in the implantation of synthetic devices. 


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1.Cameron J Norsworthy, MB.BS., FRACS (Australia) My experience with the LARS ACL device at minimum 5 year follow up 2017 ISAKOS Congress
2.Ventura A, Terzaghi C, Legnani C, Borgo E, Albisetti W. Synthetic grafts for anterior cruciate ligament rupture: 19-year outcome study. The Knee 2010;17-2:108-13.
3.Newman SD, Atkinson HD, Willis-Owen CA.Anterior cruciate ligament reconstruction with the ligament augmentation and reconstruction system: a systematic review. Int Orthop. 2013 Feb;37(2):321-6. doi: 10.1007/s00264-012-1654-y. Epub 2012 Sep 14. Review.
4. Roe J, Pincewski L, Russell V et al.A 7-Year Follow-up of Patellar Tendon and Hamstring Tendon Grafts for Arthroscopic Anterior Cruciate Ligament Reconstruction. AJSM 2005; 33 (9): 1337-1345
5.Yasen S, Borton Z, Eyre-Brook A et al. Clinical outcomes of anatomic, all inside, anterior cruciate ligament (ACL) reconstruction. The Knee 2017; (24): 55-62
6.Glezos CM1, Waller A, Bourke HE, Salmon LJ, Pinczewski LA.Disabling synovitis associated with LARS artificial ligament use in anterior cruciate ligament reconstruction: a case report.Am J Sports Med. 2012 May;40(5):1167-71. doi: 10.1177/0363546512438510. Epub 2012 Mar 9.
7.Li H, Yao Z, Jiang J, Hua Y, Chen J, Li Y, Gao K, Chen S.Biologic failure of a ligament advanced reinforcement system artificial ligament in anterior cruciate ligament reconstruction: a report of serious knee synovitis.Arthroscopy. 2012 Apr;28(4):583-6. doi: 10.1016/j.arthro.2011.12.008. Epub 2012 Feb 22.
8. Guidoin MF1, Marois Y, Bejui J, Poddevin N, King MW, Analysis of retrieved polymer fiber based replacements for the ACL.Biomaterials. 2000 Dec;21(23):2461-74.
9.Bugelli et al, LARS in ACL reconstruction: evaluation of 60 cases with 5-year minimum follow-up (2017) Musculoskeletal Surg DOI 10.1007//s12306-017-0499-3
10. Viateau V1, Manassero M, Anagnostou F, Guérard S, Mitton D, Migonney V.Biological and biomechanical evaluation of the ligament advanced reinforcement system (LARS AC) in a sheep model of anterior cruciate ligament replacement: a 3-month and 12-month study.
11. Zhenyu J, Chenchen X, Wei W et al. Clinical outcomes of anterior cruciate ligament reconstruction using LARS artificial graft with an at least 7-year follow-up. Medicine Open (2017) 96:14 (e6568)
12.Parchi P.D et al, Anteriori Cruciate Ligament reconstruction with LARS Artificial Ligament-Clinical results after long-term follow-up Joints 2018;6:75-79
13. Jia et al, Comparison of artificial graft versus autograft in anterior cruciate ligament reconstruction: a meta-analysis, BMC Musculoskeletal Disorders (2017) 18:309
14. Bianchi et al, LARS versus hamstring tendon autograft in anterior cruciate ligament reconstruction: a single-centre, single surgeon retrospective study with 8 years of follow-up European Journal of Orthopaedic Surgery & Traumatology https://doi.org/10.1007/s00590-018-2304-x
15. Jia et al, Clinical outcomes aof anterior cruciate ligament reconstruction using LARS artificial graft with at least 7-year follow-up Medicine 2017 96:14 (e6568) http://dx.doi.org/10.1097/MD.0000000000006568
16. Bugelli et al, LARS in ACL reconstruction: evaluation of 60 cases with 5-year minimum follw-up Musculoskeletal Surg 2017 DOI 10.1007/s12306-017-0499-3
17. Tiefenboeck et al, Clinical and functional outcome after anterior cruciate ligament reconstruction using the LARS system at a minimum follow-up of 10 years Knee 2015 22(6):565-568
18. Li et al, Biologic failure of a ligament advanced reinforcement system artificial ligament in anterior cruciate ligament reconstruction: a report of serious knee synovitis Arthroscopy 2012;28:583-6
19. Tulloch et al, Synovitis following anterior cruciate ligament reconstruction using the LARS device Knee Surg Sports Traumatol Arthrosc 27 (8), 2592-2598 Aug 2019
20. Tulloch et al, Primary ACL reconstruction using the LARS device is associated with a high failure rate at minimum of 6-year follow-up European Society of Sports Traumatology, Knee Surgery, Arthroscopy https://doi.org/10.1007/s00167-019-05478-3
21. Satora et al, Synthetic grafts in the treatment of ruptured anterior cruciate ligament of the knee joint, Polym Med. 2017;47(1):55-59
22. Filbay et al, Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture Best Pract Res Clin Rheumatol. 2019 Feb; 33(1): 33–47.
23. Mall et al, Results After Anterior Cruciate Ligament Reconstruction in Patients Older Than 40 Years: How Do They Compare With Younger Patients? A Systematic Review and Comparison With Younger Populations. Sports Health. 2016 Mar-Apr;8(2):177-81. doi: 10.1177/1941738115622138.
24. Kan et al, Autograft Versus Allograft in Anterior Cruciate Ligament Reconstruction: A Meta-Analysis With Trial Sequential Analysis, Medicine (Baltimore) , 95 (38), e4936 Sep 2016
25. De SA et al, The REVision using imaging to guide staging and evaluation (REVISE) in ACL reconstruction classification, J Knee Surg. 2019 Sep 30. doi: 10.1055/s-0039-1697902.
26. Wilde et al, Revision anterior cruciate ligament reconstruction, Sports Health: a multidisciplinary approach 2014 6:504
27. Di Benedetto P. et al, Causes of failure of anterior cruciate ligament reconstruction and revision surgical strategies, Knee Surg Relat Res 2016;28(4):319-324
28. Di Benedetto P. et al, New System for femoral fixation (TTS) in anterior cruciate ligament reconstruction with hamstring tendons-5 year follow-up, Orthopaedic Proceedings 2009 91-B:SUPP_I, 86-86
29. Dini et al, Multiple ACL revision: failure analysis and clinical outcome, The Journal of Knee Surgery DOI https://doi.org/10.1055/s-0039-3400741
30. Samitier et al, Failure of anterior cruciate ligament reconstruction Arch Bone Jt Surg 2015; 3(4):220-240

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