The study was established to assess the long-term results and differences between autogenous and synthetic anterior cruciate ligament (ACL) reconstruction.

We randomised 50 patients into 2 groups: 26 (52%) underwent reconstruction with middle third patellar tendon graft (PTG) harvested using the ‘Graftologer’ (Neoligaments) and 24 (48%) underwent reconstruction with the Leeds-Keio ligament (LK).

Subjective knee function was assessed using the Lysholm score, Tegner activity score, IKDC grading, and clinical assessment of anterior knee pain. Laxity was tested clinically, including anterior draw at 20° (Lachman), pivot shift, and arthrometric measurements using the Stryker laxometer.

At five years we have noted no significant difference in Lysholm scoring and Pivot shift between the LK group and patellar tendon group. But there was a significant difference in Tegner activity level and IKDC activity scores with PTG faring better at five years. There is no significance difference in anterior knee symptoms between the groups.

Conclusion: Due to the success of PTG/Hamstring in routine primary ACL reconstruction there does not seem to be a role for artificial ligaments. However, if we just look at functional outcome and patient satisfaction, LK patients seem to be doing as well as PTG at five years. So, there may be a place for the Leeds Keio graft where autologous tissue is unavailable.

The study was established to assess the long-term results and differences between autogenous and synthetic anterior cruciate ligament (ACL) reconstruction.

We randomised 50 patients into 2 groups: 26 (52%) underwent reconstruction with middle third patellar tendon graft (PTG) harvested using the ‘ Graftologer ‘ (Neoligaments), and 24 (48%) underwent reconstruction with the Leeds-Keio ligament (LK).

Subjective knee function was assessed using the Lysholm score, Tegner activity score, IKDC grading, and clinical assessment of anterior knee pain. Laxity was tested clinically, including anterior draw at 20° (Lachman), pivot shift, and arthrometric measurements using the Stryker laxometer.

At five years we have noted a slight reduction in Lysholm scoring in the LK group, as well as reduced Tegner activity level. Pivot shift and laxity were significantly greater in the LK group.

Compared with earlier results, which showed little subjective difference between the groups, the autogenous PTG group show more sustainable long-term results than the synthetic (LK) group. There is no significant difference in anterior knee symptoms between the groups.

We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees, 41 hips) and found that 66% (58% of knees, 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1.3 units per patient (1.1 for knees, 0 to 6; 1.5 for hips, 0 to 4).

We then established a new protocol for postoperative blood transfusion. This requires the calculation of the maximum allowable blood loss (MABL) that each individual patient can safely lose based upon their weight and preoperative haematocrit. The total blood loss up to this volume is replaced with colloid. When a patient’s total blood loss reaches their MABL their haematocrit is measured at the bedside using the Microspin system (Bayer plc, Newbury, UK). If their haematocrit is low (< 0.30 for men, < 0.27 for women), blood is transfused. As a safety net all patients have their haemoglobin formally checked on days 1, 2, and 3 after surgery and have a transfusion if the haemoglobin levels are less than 8.5 g/dl.

We conducted a further audit of 82 patients (35 knees, 47 hips) after the introduction of this protocol. Under the new protocol only 24% of patients required blood (11% of knees, 34% of hips) with a mean transfusion requirement of 0.56 units per patient (0.26 for knees, 0 to 4; 0.79 for hips, 0 to 4).

The use of clinical audit and the introduction of strict guidelines for transfusion can change transfusion practice and result in improved patient care. Our transfusion protocol is a simple and effective method of keeping transfusion to a minimum and is particularly useful in departments which do not have the facility to use autologous blood or reinfusion drains for elective orthopaedic surgery.

Blood is a costly commodity with side-effects that can be avoided by eliminating unnecessary transfusion. The purpose of this study was to prospectively audit the amount of blood we were transfusing in elective joint surgery and to then institute a new, more scientifically based post-operative protocol to see if we could reduce our transfusion requirements.

We prospectively audited 79 patients undergoing primary knee or hip arthroplasty (38 knees and 41 hips) in our unit and found that 66% (58% of knees and 73% of hips) had at least one unit of blood transfused postoperatively, with a mean transfusion requirement of 1. 3 units per patient (1. 1 for knees, range 0–6; 1. 5 for hips, range 0–4).

We then devised a new protocol for post-operative blood transfusion. This new protocol requires the calculation of the volume of blood that each individual patient can safely lose (maximum allowable blood loss – MABL) based upon their weight and pre-operative haematological indices. Total blood loss up to this volume is replaced with colloid. In the first 24 hours, if a patient’s total blood loss reaches their MABL they have their haematocrit measured at the bedside using the Microspin™ system. If their haematocrit is low (< 0. 30 for males, < 0. 27 for females) they are transfused blood. We set our ‘transfusion trigger’ after the first 24 hours at 8. 5 g/dl. Blood is transfused if the formal haemoglobin check on days 1, 2 or 3 is less than this.

We conducted a further audit of 82 patients (35 knees, 47 hips) following the institution of this protocol. Under the new protocol only 24% of patients required blood (11 % of knees, 34% of hips) with a mean transfusion requirement of 0. 56 units per patient (0. 26 for knees, range 0–4; 0. 79 for hips, range 0–4).

The use of clinical audit and the institution of strict guidelines for transfusion can effectively change transfusion practice and result in the delivery of improved patient care. Our transfusion protocol is a simple and effective method of keeping blood transfusion to a minimum and is particularly useful in a unit that does not have the facility to use autologous blood or re-infusion drains for elective orthopaedic surgery.

Aim: We conducted a prospective, randomised study of 50 patients, 40 (80%) male and 10 (20%) female, with anterior cruciate ligament (ACL) rupture to compare the results of ligament reconstruction by middle third patellar tendon graft (M) or synthetic Leeds-Keio (LK) ligament.

Method: The patients were randomised into two groups. 26 (52%) underwent PTG repair and 24 (48%) LK repair. Subjective knee function was classified using the Lysholm score, Tegner activity score and IKDC grading. Laxity was tested by clinical examination including anterior draw, pivot shift and arthrometric measurements using the Stryker Laxometer (Stryker Corporation, Kalamazoo, Michigan, USA).

Results: We present the early (two to five-year follow-up) results of this on-going trial. There was no statistical difference between the two groups in activity levels, both pre-injury and current. However, both pivot shift and anterior laxity were significantly greater in the LK group at two years and greater.

Discussion: While the LK group did develop significantly greater laxity, it is demonstrated that the functional outcome is not affected. We conclude therefore that if the results of surgery were to be based on a functional outcome rather than objective measurements of laxity, it would seem logical that the LK is an acceptable alternative to autogenous PTG.

However whilst function appears to be as good the less successful objective criteria do suggest reservations for the long term results of the Leeds-keio graft.