For more than 30 years the accepted orthopaedic approach to joint instability, secondary to ligament injury, has been reconstruction with allograft or autograft in both the acute and chronic situation
The quest for anatomical repair and restoration of function has been superseded by reconstruction with bone tunnels forged under the weight of historical research. With new internal bracing principles and the evolution of technology surgeons are now able to successfully return to acute ligament repair.
The InternalBrace principle supports early mobilisation of the repaired ligament and allows the natural tissues to progressively strengthen. It is important to recognise the distinction between internally bracing a repaired ligament and replacing a ligament with a synthetic. This principle, established in lateral ligament reconstruction of the ankle (Figure 1), has resulted in its successful application to other extremity ligaments including the deltoid, spring, and syndesmosis. The InternalBrace has since been successfully applied to all knee ligaments including ACL, PCL, MCL (Figure 2, MCL direct repair with InternalBrace), LCL, ALL, and PFL. Upper limb experience in the hand, elbow and shoulder is now rapidly expanding.
The InternalBrace was conceived by Professor Gordon Mackay. The construct is comprised of a FiberTape (Arthrex, Naples, FL) and two Biocomposite SwiveLock anchors (Arthrex, Naples, FL), which act as a seatbelt to protect the native ligament repair. Returning to the first clinical indication, the anatomy and biomechanical properties of the lateral ligament complex and various associated surgical procedures to restore stability have been comprehensively reviewed and published in a series of papers by the Steadman Phillipon Research Laboratory in Vail, Colorado [1,2,3,4]. These papers concluded that direct soft tissue fixation to anatomical sutures or bone anchors was not of sufficient strength to support early mobilisation. This essential appreciation has helped to determine the biomechanical advantages derived from using an internally bracing technique to support early mobilisation.
The principle of internal bracing to facilitate early mobilisation, ligament healing, and restoration of optimal function can be applied to all ligaments. The FiberTape “seatbelt” has an impressive safety record. It has excellent biocompatibility with more than one million implanted over 10 years with 0.0008 per cent reported synovial reactions (Arthrex Data, Naples, FL). Experience with rotator cuff repair using FiberTape confirms collagen ingrowth and incorporation, negating the need for removal (Figure 3). The InternalBrace has allowed a refocus on the restoration of normal anatomy and, in turn, function. It supports early mobilisation of the repaired ligament and allows the natural tissues to progressively strengthen and heal with minimal surgical morbidity.
We are now witnessing a sea change in orthopaedic practice for the management of acute ligament ruptures, which may in the future relegate ligament reconstruction to a salvage procedure. During the past six years alone more than 50,000 InternalBrace procedures have been performed worldwide with indications, acceptance and adoption rapidly expanding.
1. Waldrop NE 3rd, Wijdicks CA, Jansson KS, et al. Anatomic suture anchor versus the Broström technique for anterior talofibular ligament repair: a biomechanical comparison. Am J Sports Med 2012;40(11):2590–6.
2. Clanton TO, Viens NA, Campbell KJ, et al. Anterior talofibular ligament ruptures, part 2: biomechanical comparison of anterior talofibular ligament reconstruction using semitendinosus allografts with the intact ligament. Am J Sports Med 2014;42(2):412–6.
3. Clanton TO, Campbell KJ, Wilson KJ, et al. Qualitative and quantitative anatomical investigation of the lateral ankle ligaments for surgical reconstruction procedures. J Bone Joint Surg Am 2014;96(12):e98.
4. Viens NA, Wijdicks CA, Campbell KJ, et al. Anterior talofibular ligament ruptures, Part 1: Biomechanical comparison of the augmented Broström repair techniques with the intact anterior talofibular ligament. Am J Sports Med 2014;42(2):405–11.