Anterior cruciate ligament reconstruction: a systematic review of polyethylene terephthalate grafts Jonathan Seymour Mulford* and Dong Chen† *Prince of Wales Hospital, Randwick, New South Wales and †Orthopaedic Department, Bendigo Hospital, Bendigo, Victoria, Australia Key words anterior cruciate ligament, knee, LARS ligament, polyethylene terephthalate, systematic review. Correspondence Dr Jonathan Mulford, Prince of Wales Hospital, Suite 21, Level 7 Prince of Wales Private Hospital, Baker Street, Randwick 2031, NSW, Australia. Email: jonathanmulford1971@gmail.com J. S. Mulford MBBS, FRACS; D. Chen MB, MS, PhD. Accepted for publication 10 March 2011. doi: 10.1111/j.1445-2197.2011.05884.x Abstract Background: The ligament advanced reinforcement system (LARS) ligament is an artificial polyester ligament made from polyethylene terephthalate (PET) that is used for primary anterior cruciate ligament (ACL) reconstructive surgery. Recent media attention has resulted in a high awareness of this reconstructive option among patients; however, the outcomes compared with autograft are controversial. Objectives: A systematic review of the literature was undertaken to examine the outcomes following LARS and long-term PET artificial grafts in ACL reconstructive surgery. The ultimate objective was to determine whether the LARS ligament should be incorporated into routine practice. Methods: A systematic search strategy from 1970 to June 2010 was used to retrieve relevant studies. Inclusion of articles was established through application of a prede- termined protocol, independent assessment by two reviewers and a final consensus decision. Results: Twelve articles met the inclusion criteria for the LARS ligament. The meth- odology of the identified articles was poor. Only short-term outcomes were available. These results were good with low complication rates. Eleven articles reported on other PET grafts and recorded long-term follow-up of more than 4 years. These grafts had poor outcomes and a high rate of complications. No meta-analysis was possible. Conclusions: There are surprisingly few studies reporting on LARS ligament out- comes. The literature has poor methodological quality. Short-term results for the LARS ligament appear good, with faster recovery times compared with autografts. Final short-term results are not significantly different from autograft. There is real concern that late failure and iatrogenic osteoarthritis may occur based on the results of other PET grafts. Introduction The ligament advanced reinforcement system (LARS) ligament is a polyester made of polyethylene terephthalate (PET). There has been much recent interest in the LARS ligament for primary anterior cruciate ligament (ACL) reconstruction despite the graft being avail- able for 15 years. There has been intense media interest generated in Australia, after high profile sportsmen and women have received the artificial graft. This has resulted in a heightened awareness among the general public, regarding this graft option for primary ACL reconstruction. The ligament is certainly attractive to surgeons and patients. The operating time is shorter, there is no morbidity associated with an autograft and the rehabilitation can be aggressive, thus resulting in quick recovery. However, although the short-term results are encour- aging, the absence of published longer-term outcomes for LARS ligaments should be acknowledged. Previous experience with other artificial ACL grafts since the 1970s has shown poor long-term results. A systemic review process was undertaken to determine if knee surgeons should incorporate this graft into routine practice. REVIEW ARTICLE ANZJSurg.com © 2011 The Authors ANZ Journal of Surgery © 2011 Royal Australasian College of Surgeons ANZ J Surg 81 (2011) 785–789