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.
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.
The purpose of this study was to assess if the use of sterile stockings in lower limb surgery results in the contamination of the operative site with skin commensals from unprepared skin. Twenty-five consecutive patients under going elective single knee arthroscopy were included in our study. All patients were operated on in the same laminar airflow theatre, by the same surgeon using the same method of skin preparation and operative technique. Skin swabs were taken from each patient’s foot prior to the commencement of surgery. The limb was then prepared as follows;
An unscrubbed assistant holds up the leg, the leg is then prepared with betadine, by the surgeon from ankle to thigh, sparing the foot. The surgeon then towels off the thigh. The surgeon with the stocking in his hand, then takes hold of the foot using the stocking and unrolls it over the foot and up the leg. The stocking is bandaged in place and surgery commences. Two samples were also cut from the cuff of the stocking, one prior to its use to act as a control and the other once it had been unrolled up the leg. The three samples were then sent to microbiology. The swabs were plated out on blood (x2), chocolate and Maconkey agar. One blood plate was incubated anaerobically at 37°c and the others in air at the same temperature. The stocking sample was cultured in nutrient broth. After 48 hours isolates were identified using standard techniques. The results showed that none of the stocking samples yielded positive microbiology, however all of the foot swab samples did. They all grew coagulase negative Staphylococcus (CNS), five also grew conforms and one grew Pseudomonas, as well. We can conclude from this, that this method of skin preparation using the sterile stocking is safe. It appears in this study, that the action of unrolling the stocking over the unprepared foot and then up the prepared leg does not contaminate the prepared operative site with commensals from the foot. However concern is raised by the high incidence of CNS on the foot, and may be a source of potential infection.
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.
