Published papers

As evidence grows about the success of the Internal Brace in accelerating injury recovery time leading to greater functionality and significantly less long – and short-term health implications, we are delighted to bring you published papers documenting this evidence

Evaluation of a New Knotless Suture Anchor Repair in Acute Achilles Tendon Ruptures: A Biomechanical Comparison of Three Techniques

Posted on June 12, 2017

Acute ruptures of the Achilles tendon are a common injury, and debate has continued in published studies on how best to treat these injuries. Specifically, controversy exists regarding the surgical approaches for Achilles tendon repair when one considers percutaneous versus open repair. The present study investigated the biomechanical strength of 3 different techniques for Achilles tendon repair in a cadaveric model. A total of 36 specimens were divided into 3 groups, each of which received a different construct.

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Comparison of Broström technique, suture anchor repair, and tape augmentation for reconstruction of the anterior talofibular ligament

Posted on January 6, 2017

Abstract: Purpose Recently, tape augmentation for Broström repair has been introduced in order to improve the primary stability of the reconstructed anterior talofibular ligament
(ATFL). The biomechanical effect of tape augmentation suture anchor (SA) repair is not known yet. The aim of the present study was to compare construct stability of the traditional Broström (TB) repair compared with a stand alone SA repair (SutureTak®, Arthrex) and SA repair combined with tape augmentation (InternalBrace®, Arthrex) internal brace (IB) of the ATFL.

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Biomechanical Analysis of Internal Bracing for Treatment of Medial Knee Injuries

Posted on January 6, 2017

Abstract: The internal brace technique uses a high-strength suture tie to augment injured tissues or a primary repair, allowing early rehabilitation. Anatomic repair with internal bracing is a novel and promising treatment for femoral-sided medial knee avulsion injuries of the medial collateral ligament and posterior oblique ligament. Unfortunately, biomechanical and clinical data are lacking. To evaluate this technique compared with other treatment options, 3 assays of 9 cadaveric matched pairs (54 knees) were tested to failure at 30° under valgus load in a biomechanical testing apparatus. The primary outcome measure was moment at failure (Nm), with secondary outcome measures of stiffness (Nm/°), valgus angulation at 10 Nm (°), and valgus angulation at failure (°). Repair with internal bracing was compared with the intact state, repair alone, and allograft reconstruction. The mean moment to failure (62.5±24.9 Nm) for internal bracing was significantly lower than that for intact specimens (107.2±39.7 Nm) (P=.009). Mean moment to failure and valgus angle at failure were significantly greater for internal bracing (95±31.9 Nm) than for repair (73.4±27.6 Nm) (P=.05). Internal bracing was similar to reconstruction for the primary outcome measure (53.5±26.3 Nm vs 66.9±28.8 Nm) (P=.227) and for all secondary outcome measures. These findings indicate that posteromedial knee repair with internal bracing for femoral-sided avulsions is superior to repair alone and is similar to allograft reconstruction for all parameters measured; however, this technique did not re-create biomechanical properties equivalent to the intact state. [Orthopedics. 2016; 39(3):e532-e537.]

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Biomechanical Comparison of Ulnar Collateral Ligament Repair With Internal Bracing Versus Modified Jobe Reconstruction

Posted on January 6, 2017

Background: The number of throwing athletes with ulnar collateral ligament (UCL) injuries has increased recently, with a seemingly exponential increase of such injuries in adolescents. In cases of acute proximal or distal UCL insertion injuries or in partial thickness injuries that do not respond to nonoperative management, UCL repair and augmentation rather than reconstruction may be a viable option.
Purpose/Hypothesis: The purpose of this study was to biomechanically compare a new technique of augmented UCL repair versus a typical modified Jobe UCL reconstruction technique. The hypotheses were that (1) the repaired specimens would have less gap formation and a higher maximal torque to failure compared with the reconstruction group, and (2) while both groups would show an increase in gap formation after the simulated tear, the repair group would return closer to the native values compared with the reconstruction group.
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Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

Posted on January 6, 2017

Abstract – Background: There is renewed interest in ACL repair following rupture with the development of new repair techniques. The aim of the audit was to assess outcomes and complications of ACL repair with Internal Brace Ligament Augmentation (IBLA) at minimum one year follow-up.

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Anatomical Reconstruction of the Spring Ligament Complex “Internal Brace” Augmentation

Posted on January 6, 2017

Abstract: The calcaneonavicular(spring) ligament complex is a critical static support of the medial arch of the foot. Compromise of this structure has been implicated as a primary causative factor of talar derotation leading to the clinical deformity of peritalar subluxation. Few procedures have been described to address this deficiency. The technique we describe here is a simple yet effective method to reconstruct the spring ligament complex that can easily be used in conjunction with other more commonly used procedures for extra-articular reconstructions of this deformity. We believe this procedure allows for a more powerful deformity correction and may decrease dependency on other nonanatomic reconstructive procedures.

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Achilles Tendon Repair Using the InternalBrace™ Principle

Posted on January 4, 2017

Despite extensive research, the management of acute ruptures of the Achilles tendon remains an area of controversy and there is no consensus regarding the optimal treatment. An InternalBrace™ (Arthrex, Inc., Naples, Florida) is a ligament augmentation repair using high strength sutures/tape and knotless bone anchors which encourages healing and allows early mobilization. This article describes, with video illustration, a knotless Achilles tendon repair technique using the InternalBrace™ principle.

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Anterior Cruciate Ligament repair revisited – Preliminary results of primary repair with internal brace ligament augmentation, a case series

Posted on December 20, 2016

Abstract – Objectives: The aim of the audit was to assess outcomes and complications of ACL repair with Internal Brace Ligament Augmentation (IBLA) at minimum one year follow-up

Methods: 68 consecutive patients who underwent ACL repair with IBLA were followed for a minimum of one year following surgery. KOOS and WOMAC scores were collected at set time points via an online outcomes system. Improvements in scores from baseline were recorded and effect sizes for the five KOOS and three WOMAC domains were calculated. Patients suffering from re-rupture or undergoing re-interventions were identified and Kaplan-Meier survivorship calculated.

Results: Improvement was seen over the study period in all KOOS and WOMAC domains with the majority of improvement seen in the first three months. The results were comparable to the literature on ACL reconstruction. In the KOOS score, the greatest effect size at one year was seen in the Quality of Life (QoL) (2.82, 95% CI 2.25 to 3.39) and Sport domains (2.60, 95% CI 2.09 to 2.12). The lowest KOOS effect size was seen in the Activities of Daily Living (ADL) domain (1.1, 95% CI 0.68 to 1.51), with similar smaller improvements seen in the WOMAC domains. There were four re-interventions including one for re-rupture, and one each for surgery for arthrofibrosis, meniscal tear and chondral parthology.

Conclusions: This audit provides early functional outcome and failure data that demonstrates the technique of ACL repair with IBLA is comparable with early results from ACL reconstruction, with the greatest improvements seen in return to sporting activity.

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Paediatric ACL repair reinforced with temporary internal bracing

Posted on December 20, 2016

Abstract: Purpose Instability following non-operative treatment of anterior cruciate ligament (ACL) rupture in young children frequently results in secondary chondral and/or meniscal injuries. Therefore, many contemporary surgeons advocate ACL reconstruction in these patients, despite the challenges posed by peri-articular physes and the high early failure rate. We report a novel management approach, comprising direct ACL repair reinforced by a temporary internal brace in three children.

Methods Two patients (aged 5 and 6 years) with complete proximal ACL ruptures and a third (aged seven) with an associated tibial spine avulsion underwent direct surgical repair, supplemented with an internal brace that was removed after 3 months.

Results Second-look arthroscopy, examination and imaging at 3 months confirmed knee stability and complete ACL healing in all cases. Normal activities were resumed at 4 months, and excellent objective measures of function, without limb growth disturbance, were noted beyond 2 years.

Conclusion ACL repair in young children using this technique negates the requirement and potential morbidity of graft harvest and demonstrates the potential for excellent outcome as an attractive alternative to ACL reconstruction, where an adequate ACL remnant permits direct repair.

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Anterior Cruciate Ligament Repair with Internal Brace Ligament Augmentation

Posted on December 2, 2016

Abstract – Background: Anterior cruciate ligament (ACL) reconstruction using tendon or ligament autograft is the gold standard surgical treatment for acute ruptures; however, this is still associated with subsequent problems and variable outcomes. Renewed interest in healing of injured ACL tissue has led to new surgical repair techniques. Case description: We report the case of one of the first patients to undergo this novel procedure of ACL repair with internal bracing. An internal brace is a bridging concept using braided suture tape and knotless bone anchors to reinforce ligament strength. We followed the case of one of the first patients to undergo this technique over two years post-operatively. Outcomes: In this case, we present a good functional outcome along with radiographic and arthroscopic evidence of a healed ACL with normal appearance. The successful application of this technique has been demonstrated. Discussion: ACL repair techniques are re-emerging as a promising treatment option for acute proximal ruptures. Repair of the ACL can be performed successfully and has the advantage of retaining the natural proprioceptive fibres of the ligament. The internal brace acts as a secondary stabiliser after repair, which may allow accelerated rehabilitation and return to sports, whilst resisting injury recurrence when this is possible. Conclusions: Repair with internal bracing of the ACL provides an unobtrusive support which allows accelerated recovery. In this case, we demonstrate with radiographic and arthroscopic evidence, a robustly healed ACL after repair with internal bracing. Functional outcomes are excellent over two years following surgery and long term; retained proprioception may prevent re-injury and development of post-traumatic osteoarthritis.

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Anterior Cruciate Ligament Repair Revisited. Preliminary Results of Primary Repair with Internal Brace Ligament Augmentation: A Case Series

Posted on December 2, 2016

Background: There is renewed interest in ACL repair following rupture with the development of new repair techniques. The aim of the audit was to assess outcomes and complications of ACL repair with Internal Brace Ligament Augmentation (IBLA) at minimum one year follow-up.

Materials and methods: 68 consecutive patients who underwent Anterior Cruciate Ligament (ACL) repair with IBLA were followed for a minimum of one year following surgery. Knee Injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster osteoarthritis index (WOMAC) scores were collected at set time points via an online outcomes system. Improvements in scores from baseline were recorded and effect sizes for the five KOOS and three WOMAC domains were calculated. Patients suffering from re-rupture or undergoing re-interventions were identified and Kaplan-Meier survivorship calculated.

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A review of ligament augmentation with the InternalBrace: The surgical prinicple is described for the lateral ankle ligament and ACL repair in particular and a comprehensive review of other surgical applications and techniques is presented

Posted on November 6, 2015

Abstract: This article reviews the surgical decision-making considerations when preparing to undertake an anatomic ligament repair with augmentation using the InternalBrace™. Lateral ankle ligament stabilization of the Broström variety and ACL repair in particular are used to illustrate its application. The InternalBrace ™ supports early mobilization of the repaired ligament and allows the natural tissues to progressively strengthen. The principle established by this experience has resulted in its successful application to other distal extremity ligaments including the deltoid, spring, and syndesmosis complex. Knee ligament augmentation with the InternalBrace™ has been successfully applied to all knee ligaments including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), anterolateral ligament (ALL), and patellofemoral ligament (PFL). The surgical technique and early results will be reviewed including multi-ligament presentations. Upper limb experience with acromioclavicular (AC) joint augmentation and ulnar collateral ligament (UCL) repair of the elbow with the InternalBrace™ will also be discussed. This article points to a change in orthopaedic practice positioning reconstruction as a salvage procedure that has additional surgical morbidity and should be indicated only if the tissues fail to heal adequately after augmentation and repair.

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