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The first live hamstring transplant in Europe – in which a mother donated her tendon to repair her injured daughter’s knee – has been performed by British surgeons. The success of the operation paves the way for a new approach to treating the common problem of damaged knees.Erin Howett, 11, injured her knee during a skiing session on a dream family holiday to Lapland in 2011.
‘At first we weren’t too worried,’ says her mother Penny, 37. ‘Erin has a high pain threshold and was happy to ski again straight away once the medics had checked her over. She was limping a bit, but not in distress.’
A mother's gift: Erin Howett, 11, from Basingstoke, Hampshire, can ski again thanks to her mother Penny, 37
It was only a couple of weeks later and back at home in Basingstoke, Hampshire, that Penny asked her doctor to take a look at Erin’s knee, which was still swollen and painful.
They were immediately referred to consultant orthopaedic surgeon Adrian Wilson at Hampshire Hospitals NHS Foundation Trust, who diagnosed her with a torn anterior cruciate ligament (ACL) – a very common knee injury. The ligament runs diagonally from the front of the shin to the back of the thigh and helps control the knee’s rotation.
Injuring the ACL seriously affects limb stability. It is thought to happen to one in every 600 people each year.
‘An increasing number of young people are suffering this injury,’ says consultant knee surgeon and ACL specialist Paul Trikha, a colleague of Mr Wilson at Ashford and St Peter’s NHS Hospital in Surrey. ‘They are increasingly taking to contact sports or skiing, which are high-risk activities for such injuries.’
The most popular option for ACL reconstruction is using the patient’s own hamstrings, taking tendons from the back of their thighs to create a new ligament. The largest one is left behind to maintain hamstring function.
How the operation was done
The other option is an allograft, in which ligaments are transplanted from a deceased donor. Using living parental (or other family member) tissue, first attempted in Australia 20 years ago, means there is no risk of rejection.
In August Erin and Penny were admitted to North Hampshire Hospital where they were operated on in separate theatres under general anaesthetic.
An inch-long incision was made a little less than an inch below Penny’s inside knee, and the hamstring – like a ribbon of smoked salmon – was removed from where it anchors to the bone. This procedure took between six and eight minutes.
The hamstring was then folded into four and stitched together to form a new ACL using a technique introduced to the UK by Mr Wilson. It was packaged up and immediately transferred to the adjacent theatre to be transplanted into Erin.
Using minute keyhole incisions, Erin’s damaged ACL was removed. Holes were drilled in the femur and tibia (bones in the leg) and the donated graft was then threaded through her knee cavity. The graft was fixed to the bones with tiny metal buttons which sit in the drilled holes. The whole procedure took about an hour.
ACL reconstruction is rarely performed on children because of the risk of growth abnormalities and deformity, as well as the increased challenges of surgery due to their smaller anatomy. The condition is traditionally managed with a leg brace and physiotherapy.
But with increasing numbers of ACL injuries, doctors are keen to find an effective treatment. The two surgeons say better education of GPs and A&E doctors is also needed, as the diagnosis is often missed in the early stages.
‘Such injuries are generally not seen by a specialist until three to 12 months after they occur,’ says Mr Wilson. ‘By this time the patient is likely to have suffered a secondary injury.’
It took 18 months after the accident for Erin to have the operation as a special licence was required for the live tissue donation. But the results have been remarkable.
‘Erin wasn’t in pain, but the first couple of days were a struggle as she didn’t believe that she could straighten the leg again after 18 months of pain and being unable to,’ says Penny.
Now, less than three months after surgery, Erin’s leg is almost back to normal.
‘She wasn’t lucky at all to have a knee injury,’ says Penny, ‘but she was very lucky to have those two doctors working on her.’
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