Internal bracing for lateral ligament of the ankle (ankle)
Ankle ligament injury is recognised as one of the most frequent sports-related injuries, often resulting in long-standing instability and secondary degenerative change within the ankle joint itself.
Direct surgical repair was traditionally reported as unsuccessful as the soft tissue repair to bone was too weak and non-anatomical repairs came in to fashion. This often involved drilling holes through bone and weaving donor tendon, often resulting in a stable ankle but a loss of function, pain and an increased risk of arthritis. Recovery also required an extended period of immobilisation as the dead tissue became revascularised.
An advance on this approach was the restoration of normal anatomy using the Brostrom approach, but this still required abnormal tensioning of the tissues with tightening of the retinaculum the prolonged period of immobilisation. It was anticipated that these tissues would stretch with time although most recent studies following with a nine-year follow up of patients following Brostrom repair found that only 58% were still performing at pre-injury levels of sport.
The internal brace is a five minute addition to a standard Brostrom procedure allowing augmentation principally of the anterior talofibular ligament although the calcaneal fibular ligament can also be augmented in situations of chronic deficiency, grossly obese patients or those returning to contact sport.
The Internal brace restores immediate stability, providing equivalent strength to the uninjured anterior talofibular ligament. This transforms the patient’s experience by diminishing pain and swelling, restoring function rapidly and can reduce recovery times by 50%. We have had a weak level sportsman returning eight weeks after ligament reconstruction, although the average recovery period would be ten to twelve weeks.
The successful principals of Internal Brace technology can also be applied to the medial aspect of the ankle to reinforce the spring ligament in patients who have developed flat feet. This can be used to augment partial trend and transfer, simplifying surgical repair of the spring ligament but also providing additional confidence for early mobilisation and an accelerative recovery.
In a similar fashion, the deltoid ligament medially can also be repaired without the morbidity of donor site harvest minimising the risks of soft tissue and wound breakdown.
Above: This video charts the progress of International netball player Claire Brownie who underwent a reconstruction of her ankle with Internal Bracing. Her injury was so severe it was thought she would not be fit to play for Scotland at the 2014 Commonwealth Games – watch her remarkable recovery story here.
Achilles Tendon Internal Bracing (ankle)
The Achilles tendon remains an area of some controversy as traditional outcomes following surgical management have shown modest improvement over conservative treatment with some well-recognised risks, including wound infection, although the risk of re-rupture was noted to be considerably lower.
The internal brace for Achilles repair has transformed surgical outcomes, ensuring the restoration of musculo-tendinous length and providing a repair which is at least three times as strong as a conventional repair. This allows early weight bearing and mobilisation which in turn accelerates healing, minimises wasting and pain and restores function.
It is a knotless technique which avoids the difficulties of tensioning several knots simultaneously and also removes the strangulation and ischemia from the rupture site. The technique involves fixation of the healthy soft tissues proximally and the transfer of the bridging cabling through the damaged tissue before being fixed to the calcaneus using swivel locks in a neutral position. The soft tissues can then be gently tacked around the scaffold.
The results have been dramatic, not only ensuring minimal muscle wasting in optimal outcome but achieving this in less than half of the conventional time period if it was ever to be restored.