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Medical News & Perspectives
March 8, 2000

New Twist in Knee Repair

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JAMA. 2000;283(10):1278. doi:10.1001/jama.283.10.1278-JMN0308-2-1

Cardiff, Wales—A senior orthopedic surgeon at the University Hospital of Wales has pioneered a new technique—inspired by hair plaiting—for reconstruction of the anterior cruciate knee ligament.

John Fairclough, MD, was looking for a solution to the difficulty of repairing damaged knee ligaments and strengthening the tendons between the femur and the tibia. Inspiration came from an unexpected source: while watching his wife plait the hair of his 12-year-old daughter, Fairclough recognized the advantages of plaiting four strands of tendons together. However, creating a four-strand plait seemed beyond the skill of his wife or others he consulted.

The breakthrough came when Fairclough's local hairdresser, who uses the plaiting technique at his salon, visited him with a knee injury and agreed to teach him how to do the plait.

"I was doing some experimental work in the lab. I had these four strands [of the gracilis and semitendinosus tendons], and I wanted to make them into a plait. Errol Willy came in with a torn cartilage and I jokingly said to him, ‘Can you plait four?' He said, ‘Well, you sort my knee out and I'll sort your tendons out.'"

Willy drew a diagram and gave Fairclough lessons, but it was not until the surgeon had practiced for a week on his daughter's hair that he felt he had got it right.

"The advantage of plaiting is that it has allowed us to anchor the tendon easily and firmly in the bone. By weaving the four strands together to make one strong tendon, the knee gains greater strength," said Fairclough.

Act "like a rope"

He explained that current techniques for replacing the anterior cruciate ligament use four separate strands of two tendons lying parallel—"like four pieces of spaghetti"—so that when tension is applied, the effect is variable along each strand. Also, most techniques use tendons of different diameter and thus of different strength and stiffness, so they act as individual and potentially variable transmitters of load. "The simple act of braiding the tendons," he said, "allows the hamstrings to behave as a single unit, like a rope, rather than like individual strands."

He developed the new technique during the past 2 years working with Surgicraft Limited, a United Kingdom–based medical device manufacturer and distributor. The technique requires that two tendons be made into four strands by being looped at their midpoint through a strong simple anchor point (the Surgicraft device), so they can be plaited together into one "rope."

Fairclough is careful to point out that he is not claiming the new approach, called the Surgicraft Soffix Welsh Braid Technique, is "revolutionary." "We do need to be cautious about the new technique," he said. "Surgeons should be skeptical of being overzealous about what the long-term claims are for this technique."

Model hard, surgery easy

Fairclough said he will not be publishing for another 3 years. He has data for 2 years, but most knee surgeons in the United Kingdom do not publish articles about new techniques until after 5 years of work, he explained. "Besides that," he said, "the problem is that the basic bioengineering model is very difficult to publish, because the behavior of the plait is very difficult to model. Trying to model a braid in computer terms has proved to be extremely difficult. However, the surgery is relatively easy, we are able to rehabilitate patients very rapidly, and at present the 2 year results appear very encouraging."

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