Internal Bracing Research Articles

Anterior cruciate ligament reconstruction: current concepts and latest thinking

Never has there been such focus on just one small ribbon-like ligament in the human body: the anterior cruciate ligament (ACL) is the most highly studied and highly written about ligament in the knee, and yet still, there seem to be many ongoing unknowns. Despite this, there seem to be even more so-called experts than papers, all with their own firm and didactic opinions. This review article provides a contemporary opinion on the subject of ACL tears and ACL reconstruction, with a focus on the diagnosis of ACL tears and the decision-making process, with respect to conservative versus surgical management. The review also discusses the topics of tunnel placement, graft options, internal bracing, the anterolateral ligament and, importantly, outcomes. This paper highlights that there are a number of different approaches and options, and emphasizes the importance of discussing the pros and cons of these options with your patients, thoroughly, with shared decision-making leading to fully informed consent.

Dynamic syndesmotic stabilisation and reinforcement of the antero-inferior tibiofibular ligament with internal brace

PurposeSyndesmotic injuries are associated with long recovery times and high morbidity. Systematic reviews show a trend toward better outcomes of suture buttons compared to screw fixation. The anteroinferior tibiofibular ligament (AITFL) confers the most significant component of translational and rotatory stability. Techniques have developed which reinforce the AITFL. This study aimed to assess results of syndesmotic stabilisation with dynamic stabilisation and reinforcement of the AITFL, with an early mobilisation program. Materials and methodsRetrospective case series of 30 patients (mean age 31 years). Syndesmotic instability was confirmed with clinical examination, MRI and weightbearing-CT. Dynamic syndesmotic stabilisation with a single suture button was performed followed by the placement of an Internal Brace over the AITFL. A standardised postoperative rehabilitation protocol was established. Foot and Ankle Ability Measure (FAAM) scores were collected postoperatively. ResultsThe average follow-up was 13 months. The total FAAM score for ADL was 95 ± 4.9 % (range, 83 – 100 %) and for sport activities 87 ± 13.6 % (range, 50 – 100 %). The rating of mean postoperative function for ADL was 94 ± 5.5 % (range, 80 – 100 %) and 90 ± 13 % (range, 35 – 100 %) for sportv. The difference between acute and chronic injuries was statistically higher (p < 0.05) for daily activities and sport, but the rating of current level of sport activites as well as for daily activites did not show a significant difference (p = 0.9296 and p = 0.1615, respectively). Twenty-seven patients (90 %) rated their overall current level of function as normal or nearly normal. ConclusionThis technique aims to directly stabilise the AITFL and the interosseous components of the syndesmosis, and allow early mobilisation and return to sport at 10 weeks. Early results show the procedure is safe, with comparable results to the literature. Acute injuries showed better results of the FAAM score than chronic injuries.

Biomechanical Stability of Lateral Ulnar Collateral Ligament Reconstruction and Repair of the Elbow: The Role of Ligament Bracing on Gap Formation and Stabilization

Background: Augmented (internal braced) lateral ulnar collateral ligament (LUCL) repair has been biomechanically compared with reconstruction techniques in the elbow. However, LUCL repair alone has not yet been compared with augmented repair and reconstruction techniques. Hypothesis: Internal bracing of LUCL repair would improve time-zero stabilization regarding gap formation, stiffness, and residual torque as compared with repair alone and reconstruction techniques to restore native elbow stability. Study Design: Controlled laboratory study. Methods: Overall, 24 cadaveric elbows were used for either internal braced LUCL repair (Repair-IB) or single- and double-strand ligament reconstruction with triceps (Recon-TR) and palmaris longus tendon graft (Recon-PL), respectively. Laxity testing in external rotation was consecutively performed at 90° of elbow flexion on the intact, dissected, and repaired conditions and with the previously assigned techniques. First, intact elbows were loaded to 7.0-N·m external torque to evaluate time-zero ligament rotations at 2.5, 4.0, 5.5, and 7.0 N·m. Rotation-controlled cycling was performed (total of 1000 cycles) for each surgical condition. Gapping, stiffness, and residual torque were analyzed. Finally, these and 8 additional intact elbows underwent torque-to-failure testing (30 deg/min). Results: The dissected state showed the highest gap formation and lowest peak torques (P < .001). While gap formation of Repair-IB (P < .021) was significantly lower than that of repair without internal bracing at all rotation levels, gaps of Recon-PL were similar to and Recon-TR were significantly higher than those of Repair-IB except for the highest torsion level. Residual peak torques at specific rotation angles between native state and Recon-TR (α2.5), Recon-PL (α4.0), and Repair-IB (α5.5) were similar; all other comparisons were significantly different (P < .027). Torsional stiffness of Repair-IB was significantly higher at all rotation angles measured. Analysis of covariance showed significantly less gap formation over residual peak torques for Repair-IB (P < .001) as compared with all other groups. The native state failure load was significantly higher than Recon-PL and Recon-TR failure loads, with similar stiffness to all other groups. Conclusion: Repair-IB and Recon-PL of the LUCL showed increased rotational stiffness relative to the intact elbow for restoring posterolateral stability to the native state in a cadaveric model. Recon-TR demonstrated lower residual peak torques but provided near-native rotational stiffness. Clinical Relevance: Internal bracing of LUCL repair may reduce suture-tearing effects through tissue and provide sufficient stabilization for healing throughout accelerated and reliable recovery without the need for a tendon graft.

Clinical Research Progress of Internal Brace Ligament Augmentation Technique in Knee Ligament Injury Repair and Reconstruction: A Narrative Review.

Knee ligament injuries are most common in sports injuries. In general, ligament repair or reconstruction is necessary to restore the stability of the knee joint and prevent secondary injuries. Despite advances in ligament repair and reconstruction techniques, a number of patients still experience re-rupture of the graft and suboptimal recovery of motor function. Since Dr. Mackay's introduction of the internal brace technique, there has been continuous research in recent years using the internal brace ligament augmentation technique for knee ligament repair or reconstruction, particularly in the repair or reconstruction of the anterior cruciate ligament. This technique focuses on increasing the strength of autologous or allograft tendon grafts through the use of braided ultra-high-molecular-weight polyethylene suture tapes to facilitate postoperative rehabilitation and avoid re-rupture or failure. The purpose of this review is to present detailed research progress in the internal brace ligament enhancement technique of knee ligament injury repair as well as the reconstruction from biomechanical and histological research and clinical studies and to comprehensively assess the value of the application of this technique.

Treatment of Calcific Insertional Achilles Tendinopathy: Knotless Internal Brace versus Knot-Tying Suture Bridge.

This study aimed to compare the knotless internal brace technique and the knot-tying suture bridge technique via the medial approach in the treatment of calcific Achilles tendinopathy. The clinical data of 25 cases of calcific Achilles tendinopathy in which nonoperative treatments had failed were retrospectively collected. All the patients received Achilles tendon debridement and Haglund deformity excision through a medial approach, followed by repair using the knotless internal brace technique or the knot-tying suture bridge technique. Pain was evaluated by using the visual analog scale (VAS). The American Orthopedic Foot and Ankle Score (AOFAS) questionnaire was administered preoperatively and postoperatively. The mean follow-up time was 2.6 (range 2-3.5) years. There were no wound complications and no Achilles tendon ruptures. At 1 year postoperatively, the internal brace group was superior to the suture bridge group in terms of the VAS scores (p = 0.003). However, no differences were noticed between the two groups in either the VAS or the AOFAS scores at 2 years postoperatively. The medial approach in combination with the suture bridge technique was effective in treating calcific Achilles tendinopathy. The knotless internal brace technique involved less pain compared to the knot-tying suture bridge technique only at the early postoperative stage.

Elbow Ulnar Collateral Ligament Tears: A Modified Consensus Statement

To establish consensus statements on the treatment of ulnar collateral ligament (UCL) injuries and to investigate whether consensus on these distinct topics could be reached. A modified consensus technique was conducted among 26 elbow surgeons and 3 physical therapists/athletic trainers. Strong consensus was defined as 90% to 99% agreement. Of the 19 total questions and consensus statements 4 achieved unanimous consensus, 13 achieved strong consensus, and 2 did not achieve consensus. There was unanimous agreement that the risk factors include overuse, high velocity, poor mechanics, and previous injury. There was unanimous agreement that advanced imaging in the form of either magnetic resonance imaging or magnetic resonance arthroscopy should be performed in a patient presenting with suspected/known UCL tear that plans to continue to play an overhead sport, or if the imaging study could change the management of the patient. There was unanimous agreement regarding lack of evidence for the use of orthobiologics in the treatment of UCL tears as well as the areas pitchers should focus on when attempting a course of nonoperative management. The statements that reached unanimous agreement for operative management were regarding operative indications and contraindications for UCL tears, prognostic factors that should be taken into consideration in when performing UCL surgery, how to deal with the flexor-pronator mass during UCL surgery, and use of an internal brace with UCL repairs. Statements that reached unanimous agreement for return to sport (RTS) were regarding portions of the physical examination should be considered when determining whether to allow a player to RTS; unclear how velocity, accuracy, and spin rate should be factored into the decision of when players can RTS and sports psychology testing should be used to determine whether a player is ready to RTS. V, expert opinion.

A combination interferometric and morphological image processing approach to rapid quality assessment of additively manufactured cellular truss core components

Advanced manufacturing (AM) processes such as laser powder bed fusion (LPBF) are increasingly capable of fabricating components with useful and unprecedented mechanical properties by incorporating complex internal bracing structures. From the standpoint of quality control and assessment, however, internally complex assemblies present significant build-verification challenges. Here we propose a hybrid approach to the inspection involving the application of computer-aided speckle interferometry (CASI) and morphological image processing as a rapid, inexpensive, and facile method for AM quality control. The described methodology has low capital equipment costs, is full-field and non-contact, can be used in an industrial setting, and has very low requirements in terms of operator training and expertise. Consisting primarily of the combination of image processing software with a simple optical system of variable sensitivity, the method is shown to be effective for inspection of a titanium honeycomb component subjected to differential pressure. Results are compared to those achieved with computed tomography (CT), immersion ultrasound testing (UT), and optical holographic interferometry. Lastly, we propose several possible processing strategies for automated quality assessment based on this powerful hybrid approach.

Surgical Site Infection Following the Correction of Adolescent Idiopathic Scoliosis With ApiFix: A Retrospective Study Analyzing Its Incidence and Recurrence.

Background and objective ApiFix (OrthoPediatrics, Warsaw, IN) is an internal brace used for the correction of adolescent idiopathic scoliosis (AIS) classified as Lenke 1 or 5 with a Cobb angle of 35-60 degrees that decreases to ≤30 degrees on lateral side-bending radiographs. Since the indications are very specific, it is not a common procedure. Our study aimed to evaluate the incidence of surgical site infection (SSI) and its recurrence following treatment with ApiFix. Materials and methods A retrospective study of 44 cases of AIS treated at our center from 2016 to 2022 with ApifiX was conducted. Two patients who presented with SSI were initially treated with irrigation and debridement (I&D) following antibiotic therapy. Results A total of 44 patients with a mean age of 15.1 years were evaluated. Two of our patients presented with early-onset infection while one of them presented after the end of treatment with a skin ulcer due to septic screw loosening. The removal of the ApiFix implant revealed a pedicle abscess during the screw removal. Conclusions In this study of 44 patients, we observed two cases of infection and one case of reinfection. Given the limited muscle detachment and short operating time needed for Apifix, statistics suggest that the risk of SSIis always present. Further randomized trials are needed to gather more evidence on this subject.

PROSPECTIVE CASE SERIES ON A NOVEL TECHNIQUE FOR COMBINED REPAIR AND RECONSTRUCTION IN ACUTE AND CHRONIC ACROMIOCLAVICULAR JOINT DISLOCATIONS

Acromioclavicular joint (ACJ) dislocations is a common disorder amongst our population for which numerous techniques have been described. It is thought that by using this novel technique combining a CC and AC repair with a reconstruction will result in high maintenance of anatomical reduction and functional results.12 consecutive patients ACJ dislocations were included. An open superior clavicular approach is used. Firstly, the CC ligaments are repaired after which a CC reconstruction is performed using a tendon allograft. Secondly, the AC ligaments are repaired using an internal brace construct combined with a tendon allograft reconstruction (Figure 1).The acute:chronic ratio was 6:6. Only IIIB, IV and V AC-joint dislocations were included. The Constant-Murley Score improved from 27.6 (8.0 – 56.5) up to 61.5 (42.0 – 92.0) at 12 months of follow up. Besides one frozen shoulder from which the patient recovered spontaneously no complications were observed with this technique. The CCD was reduced from 18.7 mm (13.0 – 24.0) to 10.0 mm (6.0 – 16.0) and 10.5 mm (8.0 – 14.0) respectively 12 weeks and 12 months postoperatively.There is some evidence, suggesting to address as well as the vertical (coracoclavicular (CC) ligaments) as the horizontal (acromioclavicular (AC) ligaments) direction of instability. This study supports addressing both entities however comparative studies discriminating chronic as acute cases should be conducted to further clarify this ongoing debate on treating ACJ instability.This study describes a novel technique to treat acute and chronic Rockwood stage IIIB – IV ACJ dislocations with promising short-term clinical and radiological results. This suggests that the combined repair and reconstruction of the AC and CC ligaments is a safe procedure with low complication risk in experienced hands. Addressing the vertical as well as horizontal stability in ACJ dislocation is considered key to accomplish optimal long-term results.

Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes

Ligament and tendon ruptures have historically been addressed with varying techniques involving either repair or reconstruction. More recently, the potential biomechanical benefits of suture augmentation (SA), also known as internal brace, have attracted substantial attention and helped renew interest in ligament repair surgery. We evaluated the biomechanical and clinical outcomes of SA-based techniques in the following sports medicine procedures: medial ulnar collateral ligament repair of the elbow, thumb collateral ligament repair, anterior cruciate ligament repair, Achilles’ tendon repair, and deltoid ligament repair. Published data on the use of SA to augment repairs of the ulnar collateral ligament, thumb collateral ligament, anterior cruciate ligament, Achilles’ tendon, and deltoid ligament repair demonstrate improved time-zero biomechanical and promising short- to mid-term clinical outcomes. However, surgeons must be wary of potential complications, including joint overconstraint, nerve paresthesia, and infection. Level of EvidenceLevel V, expert opinion.

Augmentation with Fibertape Leads to Biomechanically Superior but Similar Clinical Outcomes in ACL Surgeries: Systematic Review and Meta-analysis.

The current generation has witnessed significant progress in the field of knee arthroscopy. Suture tapes have gained immense popularity due to perceived improved biomechanical support to the graft while it heals. The purpose of the present systematic review is to analyze the biomechanical construct of suture tapes in ACL repairs and reconstructions along with clinical outcomes. Cochrane Library, PubMed, and Embase were searched until December 2021. All Biomechanical Studies on animal or cadaver knees that compared construct characteristics of suture tape in ACL repair or reconstruction and clinical studies in English focusing on outcomes following suture tape augmentation in ACL repair or reconstruction were included. The quality of clinical studies using the Modified Coleman Methodology Score (MCMS). A total of 16 studies biomechanical and 23 clinical studies were included in qualitative synthesis, leaving nine biomechanical studies for final quantitative analyses. Suture tape revealed biomechanical superiority in terms of ultimate strength, stiffness, cyclic displacement, and elongation of graft, while comparing ACLR with internal brace to standard ACLR. No significant difference in retear rates was seen in clinical studies. Clinical score(IKDC score) was found similar in both augmented and non-augmented construct. Similar results were obtained in biomechanical studies. The use of suture tape as a ligament augmentation in both ACL reconstruction and ACL repair offers more strength, less elongation or displacement, and is biomechanically stable and sound. There is a lack of data to comprehensively comment upon the clinical superiority of the use of internal augmentation. However, a meta-analysis of the retear rates and clinical outcome score revealed similar outcomes between suture tape augmented and nonaugmented groups.

Lachman Test on ACLR With Internal Bracing at Hasan Sadikin General Hospital Bandung

Introduction: The growing popularity of recreational and competitive sport activities has contributed to an increased number of anterior cruciate ligament (ACL) injuries in the past three decades. Because of its varying success rates, anterior cruciate ligament reconstruction (ACLR) is considered the gold standard surgical treatment for ACL rupture. ACLR in hyperlaxity patients has unpredictable outcomes because of its flexibility, therefore utilizing an internal brace aims to obtain a rigid fixation such as the enthesis structure. Methods: This prospective case series study was done from August 2021 to March 2022. Laxity was assessed using Beighton score, and patients were divided into three groups based on clinical laxity and surgical management that performed. Group 1 was no laxity patients performed ACLR without internal bracing, group 2 was laxity patients performed ACLR without internal bracing and group 3 was laxity patients performed ACLR with internal bracing. We conducted ACLR on 34 patients with a mean age of 35±6.71 years old. Twenty four patients had laxity with Beighton score 4–9. Ten patients had no laxity with Beighton score 0-3. ACLR were done with internal bracing augmentation for 15 patients with laxity. ACLR without internal bracing were done for 19 patients. Post-surgery follow up were scheduled at 1 and 3 months using Lachman test. Patients with no anterior displacement is considered as negative Lachman test , while patients with 0-5 mm, 5-10 mm, and &gt;10 mm of anterior displacement were considered as Lachman test grade 1, grade 2, and grade 3 respectively. Results: All patients completed 1 and 3 months post-operation follow-up using Lachman test. After 3 months follow-up, in group of patients with no laxity performed ACLR, negative Lachman test was found in 7 participants (70 %), and grade 1 was found in 3 participants (30 %). %) In group of laxity patients performed ACLR without internal bracing, negative Lachman test was found in 4 participants (44.4%), grade 1 in 2 participants (22.2%) and grade 2 in 3 participants (33.3%). Meanwhile in group of laxity patients performed ACLR with internal bracing, negative Lachman test was found in 12 participants (80%), grade 1 in 2 participants (13.3%) and grade 2 in 1 participant (6.7%). Negative Lachman test after 3 months follow up was found higher in patients performed ACLR with internal bracing. Discussion: Our results showed that patients who received ACLR with internal bracing recovered 80% of the time by the Lachman test after 3 months. Internal brace reduce graft failure and improve rehabilitation in ACLR. The limitation of this study was a subjective result performing Lachman test examination. A junior resident, senior resident and sport injury consultant may had different Lachman test valuation. Conclusion: The difference between preoperative and postoperative Lachman test results were statistically significant on laxity patients underwent anterior cruciate ligament reconstruction with internal bracing.

Anatomic Acromioclavicular Joint Reconstruction Using Semitendinosus Graft with Internal Bracing in Chronic Acromioclavicular Joint Dislocation: Case Series

Introduction: Acromioclavicular joint dislocations represent a frequent condition, affecting a very specific and generally active population and accounting for around 9% of all shoulder injuries. Case Presentation: We present a series of patients who underwent AC Joint reconstruction using Semitendinosus graft with internal bracing. The beach chair position is used for acromioclavicular reconstruction surgery. In this technique, we restore the anatomy, reconstruct the coracoclavicular ligament, and reinforced the acromioclavicular ligament. And it is reliable for chronic acromioclavicular joint injury. At final follow up we found excellent results with average pain score of 1.6, and average ROM of 160° of forward flexion and abduction, 70° of external rotation, and internal rotation level at T11. Postoperative function also showed great improvements with average ASES of 85 points, an average Constant Score of 89 points. This technique also achieved acceptable radiographic results, with an average coracoclavicular distance increase of 1.4 mm Discussion &amp; Conclusion: The loss of AC joint congruence with the Weaver Dunn procedure suggested that possibly the problem wasn’t only biological. This technique seems to be especially advantageous as it allows for an anatomic, biological, and minimally invasive procedure while avoiding some of the inconveniences described in other reports. Although demanding, it can be reproducibly performed arthroscopically, and good clinical outcomes should be expected.

Arthroscopic Fixation of Posterior Cruciate Ligament Avulsion Fracture with Combined Suture Tape and Internal Bracing by Suture-bridge Technique

Background: Tibial-sided avulsion fracture of the posterior cruciate ligament (PCL) almost always require surgical intervention. Multiple techniques of reduction and fixation have been described in the literature from open/mini-open conventional screw fixation to the all-arthroscopic fixation techniques. Recent evidence shows that the all-arthroscopic fixation techniques had higher subjective and objective knee outcome scores with the advantage of addressing concomitant intra-articular injuries such as osteochondral injuries or meniscal problems. Objectives: We propose an arthroscopic fixation technique using suture tapes placed in a suture-bridge technique and combined it with internal bracing to fix tibial-sided avulsion fracture of the PCL. Surgical Technique: After routine diagnostic knee arthroscopy in supine position via standard anterolateral and anteromedial portal, two standard posteromedial and posterolateral portal was created. A standard PCL aiming guide was used to create the tibial tunnel. PCL was secured using two single-looped suture tapes around it with both limbs brought to the posterior compartment through either side of the PCL (medial and lateral). Internal bracing was done with suture tape secured to the femoral side using fixed suspensory device and brought to the posterior compartment through the lateral side of the PCL. All tapes are then passed through the tibial tunnel in a suture-bridge manner and fixed to a button in 30° flexion while reduction quality was constantly checked under direct visualization. Results: The suture bridge configuration provides direct bone-to-bone healing and secure enough fixation for early range of motion and power exercises. All-arthroscopic approach avoids posterior element related complications such as fragment comminution and neurovascular injuries. Conclusions: This technique can be considered as a safe and effective method for fixation of tibial-sided PCL avulsion fracture, which allows active mobilization with lowered risk of complications.

Understanding Lateral Ankle Instability

Lateral ankle sprain is one of the most common sports injuries both in high level and recreational athletes. The frequency of injuries increases in recent years as more sports participations grow. Untreated ankle sprain can lead to deteriorated chronic ankle instability, thus understanding the management is of most important. Surgery for ankle instability can varied from a simple non augmented repair, augmented repair using autograft/allograft/or other choices of internal bracing, and revision cases of failed primary repair. The decision of what surgery is of the surgeon learning curves. However, with a proper diagnosis, a simple non augmented repair is acceptable with high success rate. In certain population and narrow indication, surgeon need other armamentarium such as augmented reconstruction using graft or other technique to avoid failure of primary case that leads to revision. At last, the success of lateral ankle instability surgery is highly dependent on proper phases of rehabilitation period. Understanding all matter that involves in the recovery of ankle ligament repair is of most important for the best outcome of the patients.

Internal Brace Ligament Augmentation versus Anatomical Repair with Hamstrings of the ACL – A Clinical Data Comparison Study

AIM: Investigation into the clinical results of internal brace ligament augmentation technique compared to the simple anatomical repair of the anterior cruciate ligament (ACL). METHODS: From May 2016 to November 2019, 128 patients underwent an operation using the internal brace technique. During the same time, 104 patients were operated on using the simple anatomical ACL repair. The mean age was 22.5-year-old for the first group and 26.8-year- old for the second one. The minimum follow-up was 24 months. All the patients performed an X-ray and magnetic resonance imaging. Two hypotheses were raised to assess the superiority of the internal brace technique versus the anatomical one in the early post-operative phase and the rehabilitation one. RESULTS: The mean operation time was 71 (65–75) min for the internal brace (IB) and 62 (55–65) for the anatomical. We had two post-operative infected knees in the first group (IB) and no infection in the second one. The clinical stability test results were much better in the IB group using the KT 1000. The rehabilitation phase showed a superior IB technique. The return to sport-time of the sportsmen was 6 months for the first group and 7–8 months for the anatomical. All the IB-operated patients found physiotherapy significantly easier than the anatomical ones. CONCLUSIONS: IB-technique performs better clinical outcomes than the anatomical repair. The presence of a foreign body (Ultrabraid) inside the knee may be a risk factor contributing toward the elevated infection rate. The IB technique costs are significantly more expensive compared to the anatomical but the low physiotherapy costs compensate for the final result.

Canadian Spine Society

# Abstract 57. Radiographic reporting in adolescent idiopathic scoliosis: Is there a discrepancy comparing radiologists’ reports and surgeons’ assessments? {#article-title-2} Cobb angle measurement is the standard method for quantification of scoliosis in adolescent idiopathic scoliosis (AIS),

Augmented primary sutures "internal bracing" following ligamentous elbow dislocation

Aim of surgical treatment is the primary stabilization of the unstable elbow following aligamentous elbow dislocation. Ligamentous elbow dislocations are typically accompanied by injuries to the surrounding musculature and collateral ligaments of the elbow joint. Surgical treatment is indicated in case of failure of nonoperative therapy, i.e., when adislocation can only be prevented in immobilization > 90° and pronation of the elbow or an active muscular centering of the elbow fails after 5-7days. Contraindications for asolely "internal bracing" augmented primary suture are generally in the case of accompanying bony injuries in elbow dislocations, extensive soft-tissue injuries, and septic arthritis of the elbow. The augmented primary suture of the elbow is performed using both alateral (Kocher or Kaplan) and medial (FCU split) approach to the elbow. After reduction of the elbow, the collateral ligaments are first augmented with high-strength polyethylene suture and fixed in the distal humerus together with another high-strength polyethylene augmentation suture. The extensors and flexors are then fixed to the medial and lateral epicondyle, respectively, using suture anchors. The aim of the postoperative management is early functional exercise of the elbow. The elbow is placed in an elbow brace to avoid varus and valgus load. Between August 2018 and January 2020, atotal of 12patients were treated with an augmented primary suture following unstable ligamentous elbow dislocation. After amean follow-up of 14 ± 12.7months, the mean Mayo Elbow Performance Score was 98.5points with amean functional arc of 115°. None of the patients reported arecurrent dislocation or persistent instability of the elbow.

The Use of the Internal Brace to Repair the UCL Injury of the Elbow in Athletes.

By Kevin E Wilk, Zachary M Thomas & 4 more. This month's Clinical Viewpoint is an invited clinical commentary that outlines the history, indications, and current protocol for the rehabilitation of the Internal Brace repair of the UCL at ASMI.

Three-dimensional correction of scoliosis by a double spring reduction system as a dynamic internal brace: a pre-clinical study in Göttingen minipigs

BACKGROUND CONTEXTAdolescent idiopathic scoliosis (AIS) is a major skeletal deformity that is characterized by a combination of apical rotation, lateral bending and apical lordosis. To provide full 3D correction, all these deformations should be addressed. We developed the Double Spring Reduction (DSR) system, a (growth-friendly) concept that continuously corrects the deformity through two different elements: A posterior convex Torsional Spring Implant (TSI) that provides a derotational torque at the apex, and a concave Spring Distraction System (SDS), which provides posterior, concave distraction to restore thoracic kyphosis. PURPOSETo determine whether the DSR components are able to correct an induced idiopathic-like scoliosis and to compare correction realized by the TSI alone to correction enforced by the complete DSR implant. STUDY DESIGN/SETTINGPreclinical randomized animal cohort study. PATIENT SAMPLETwelve growing Göttingen minipigs. OUTCOME MEASURESCoronal Cobb angle, T10-L3 lordosis/kyphosis, apical axial rotation, relative anterior lengthening. METHODSAll mini-pigs received the TSI with a contralateral tether to induce an idiopathic-like scoliosis with apical rotation (mean Cobb: 20.4°; mean axial apical rotation: 13.1°, mean lordosis: 4.9°). After induction, the animals were divided into two groups: One group (N=6) was corrected by TSI only (TSI only-group), another group (N=6) was corrected by a combination of TSI and SDS (DSR-group). 3D spinal morphology on CT was compared between groups over time. After 2 months of correction, animals were euthanized. RESULTSBoth intervention groups showed excellent apical derotation (TSI only-group: 15.0° to 5.4°; DSR-group: 11.2° to 3.5°). The TSI only-group showed coronal Cobb improvement from 22.5° to 6.0°, while the DSR-group overcorrected the 18.3° Cobb to -9.2°. Lordosis was converted to kyphosis in both groups (TSI only-group: -4.6° to 4.3°; DSR-group: -5.2° to 25.0°) which was significantly larger in the DSR-group (p<.001). CONCLUSIONSThe TSI alone realized strong apical derotation and moderate correction in the coronal and sagittal plane. The addition of distraction on the posterior concavity resulted in more coronal correction and reversal of induced lordosis into physiological kyphosis. CLINICAL SIGNIFICANCEThis study shows that dynamic spring forces could be a viable method to guide the spine towards healthy alignment, without fusing it or inhibiting its growth.