Internal Bracing Research Articles

Intersurgeon Consistency of Ulnar Collateral Ligament Repair With Internal Brace: A Biomechanical Analysis.

Injury to the ulnar collateral ligament (UCL) of the medial elbow has been treated successfully with ligament repair augmented with internal brace. Previous work has shown that this procedure does not overconstrain the ulnohumeral joint; however, the procedures were conducted by a single surgeon, which controlled for anchor placement and graft tensioning. Our purpose was to evaluate the reproducibility of contact mechanics and joint torque after UCL repair with internal brace as performed by different surgeons compared with repair by a single surgeon. It was hypothesized that there would be no significant difference in elbow contact mechanics, valgus torque, or torsional stiffness between the 2 groups. Controlled laboratory study. Nine pairs of fresh-frozen cadaveric elbows were tested biomechanically under 3 conditions: UCL-intact (UCL-I), UCL-deficient (UCL-D), and UCL-repaired with internal brace augmentation (UCLR-IB). For each pair, 1 elbow was repaired by a single surgeon, and the contralateral elbow was repaired by 1 of 9 other surgeons. Testing consisted of valgus torsion between 0° and 5° with the elbow positioned at 90° of flexion. Ulnohumeral contact mechanics and overall joint torque and stiffness were measured and compared between surgeon groups. There were no statistically significant differences between the single-surgeon and multiple-surgeon groups regarding contact area (P = .83), contact force (P = .27), peak pressure (P = .26), or peak force (P = .30); however, contact pressure was significantly affected (P = .02) by surgeon group. Compared with UCL-I, both UCL-D and UCLR-IB conditions had a significant overall effect on contact area (P = .004) and contact force (P = .05); however, contact pressure (P = .56), peak pressure (P = .27), and peak force (P = .24) were not affected by injury condition. Measurements of elbow torque (P = .28) and stiffness (P = .98) were not significantly different between surgeon groups. UCL repair with internal brace provided consistent results among several surgeons when compared with a single surgeon. The procedure did not lead to joint overconstraint while also returning the ligament to near-intact levels of resisting valgus stress. UCL repair with internal brace augmentation is a reproducible surgical technique that has good clinical outcomes in the literature.

Biomechanical comparison of novel ulnar collateral ligament reconstruction with internal brace augmentation vs. modified docking technique.

Ulnar collateral ligament (UCL) reconstruction (UCLR) is a common surgery among baseball pitchers. UCL repair combined with augmentation using high-strength tape, referred to as an internal brace, was developed as an alternative to UCLR in select patients with the benefit of allowing these athletes to return to sport (RTS) faster. A combined UCLR with an internal brace may allow players indicated for a UCLR to RTS more expeditiously. Twenty-four cadaveric elbows were divided into 3 groups: 12 specimens into the modified docking (MD) group, 6 into the double-docking (DD) group, and 6 into the double docking with internal brace augmentation (DDA) group. This allowed a 1:1 comparison of the MD to the DD and the MD to the DDA. Valgus cyclic testing of native and reconstructed specimens was executed at 90° elbow flexion. After preconditioning, all specimens were cycled between 2 and 10 Nm for 250 cycles. Reconstructed specimens continued to a torque test to catastrophic failure step. Outcome data included intracyclic stiffness, maximum cyclic rotational displacement, gap formation, and failure torque. Cyclic stiffness of the constructs remained constant throughout the entirety of the torque-controlled cycling phase. The DDA group resulted in a 38% increase in cyclic stiffness from native testing (not statistically significant) and a statistically significant 54% increase from the MD (P=.002). The DDA mean cyclic stiffness was significantly greater than the Native (P<.001), DD (P=.025), and MD (P<.001) groups. Between reconstruction groups, mean gap formation was greatest among the MD group (2.51°±1.59°) and least for the DDA group (1.01°±0.57°) but did not reach statistical significance. Tape augmentation to the modified UCLR (DDA group) improved cyclic stiffness and reduced gap formation compared with the MD group.

Trends in Anterior Cruciate Ligament Repair: A Bibliometric and Visualized Analysis.

Bibliometrics is a methodology that measures the scientific output of an author, institution, or country. Visualized analysis is the transformation of data into visible form by software, highlighting important features, including commonalities and anomalies, allowing users to easily and quickly perceive significant aspects of their data. To conduct a bibliometric analysis of the literature on anterior cruciate ligament (ACL) repair, with visualization of trends, in order to identify the areas of interest and the primary researchers involved in ACL repair. Cross-sectional study. The PubMed database was queried on April 14, 2022, for publications that reported on ACL repair from 1960 onward. The initial search resulted in 1392 publications. Filter settings were applied to remove publications with weak correlation, such as those on meniscal repair and ACL reconstruction. Publication information, citations, authors, commonly used terms, and affiliated institutions and countries were analyzed by VOSviewer and Python. A total of 553 articles were included for analysis. Three techniques were visualized: bridge-enhanced ACL repair, internal brace, and dynamic intraligamentary stabilization. The most published authors were Martha Murray (51 articles), Gregory Difelice (35 articles), and Braden Fleming (31 articles). The most cited article was "Collagen-Platelet Rich Plasma Hydrogel Enhances Primary Repair of the Porcine Anterior Cruciate Ligament" by Murray et al. The journals with the most publications on ACL repair were the American Journal of Sports Medicine (n = 49); Knee Surgery, Sports Traumatology, Arthroscopy (n = 49); and Arthroscopy (n = 48). The top 3 institutions by publication number were the Hospital for Special Surgery (n = 51), Boston Children's Hospital (n = 49), and Brown University (n = 31), with the most publications coming from the United States (n = 242), Germany (n = 83), and the United Kingdom (n = 47). The results demonstrate that the research on ACL repair comes from a small number of authors and corresponding institutions; the top sports medicine journals and the developed countries have an interest in this topic.

Traumatic Great Toe MCL Avulsion in Professional Athlete Treated Surgically with MCL Repair with Suture Tape Augmentation Allowing Rapid Return to Sport

Category: Sports; Midfoot/Forefoot; Trauma Introduction/Purpose: Acute medial collateral ligament (MCL) tears of the great toe metatarsophalangeal joint (MTPJ) are a rare occurrence. There is minimal literature existing regarding both operative and non-operative management of this pathology, also known as 'traumatic bunion' due to its low incidence. The closest analog is a traumatic ulnar collateral ligament (UCL) rupture in the hand (Skier's thumb). Suture anchor repair with an internal brace has proven to be an effective treatment for thumb UCL tears with rapid rehabilitation and early range of motion. This method has not yet been reported in literature for a weightbearing joint such as the hallux MTPJ. We present a case report for a professional surfer with traumatic great toe MCL avulsion with surgical technique allowing rapid return to sport. Methods: We present a case report of a novel technique for this rare traumatic MCL avulsion. Surgical management of the great toe MCL was performed utilizing a pre-loaded interference screw to fixate suture at the MCL origin with suture tape augmentation. A mid-axial medial approach was used with L-shaped capsular flap to expose the MCL. 3-0 braided suture was passed through the proximal avulsed MCL. A drill tunnel was prepared at the MCL origin, and the MCL was repaired to its anatomic origin with an interference screw technique for knotless technique. The interference screw was preloaded with suture tape. The suture tape from the interference screw was passed extra articular and the capsule was repaired. The sutuer tape was then inserted into the MCL insertion on the distal phalanx using a small interference screw and drill tunnel for a suture tape augmentation while the toe was held in neutral MTPJ position. Results: He was made weightbearing as tolerated in a CAM boot post-operatively. Immediate active great toe MTPJ motion was permitted. At 2 weeks post-op, sutures were removed, and he was allowed self-directed passive range of motion of the toe, with continued weightbearing as tolerated in the boot. All restrictions were lifted at 4 weeks for a return to play protocol and the patient resumed surfing immediately at that time. His last follow up appointment was at 3 months post-op, at which time he had resumed full activity, had no deformity recurrence, no pain, and his range of motion was symmetric to the contralateral foot. The patient was able to compete at full activity in a national tournament to continue the professional tour at 3 months post- operatively. Conclusion: This report demonstrates a novel surgical technique for the treatment of a rare traumatic MCL avulsion of the great toe (the 'traumatic bunion'). In this case of great toe MCL repair in a professional surfer, we utilized a knotless technique to repair the MCL to it's anatomic origin and also provide suture tape augmentation to allow rapid rehabilitation. This report demonstrates rapid return to sport, an excellent outcome, easy rehabilitation, and straightforward surgical technique. More research will be needed to demonstrate the success of this technique in a broader population.

Effect of Internal Bracing on Broström Operation Clinical Outcomes

Category: Ankle; Other Introduction/Purpose: When patients fail conservative management for chronic lateral ankle instability, a Broström procedure is often recommended. The purpose of this study was to investigate the postoperative trends between Broström recipients who were and were not augmented with suture tape, while secondarily assessing the relationship between demographics and medical history with postoperative outcomes for those patients. Methods: We conducted a retrospective review of 125 patients treated with a modified Broström by a single fellowship-trained foot and ankle surgeon at an academic medical center between 2016 and 2020. Overall, 39 patients received suture tape augmentation, 95 underwent a primary Broström and 30 a revision, and 24 were operated on with a nanoscope. Various demographics, medical history, patient-reported outcome measures (PROMs) (e.g., Foot and Ankle Outcome Score [FAOS], Foot and Ankle Ability Measure [FAAM]), and postoperative outcomes were collected. Average follow-up was 1.0 years (0.25-4.58). Results: There were no differences in any postoperative PROMs (i.e., FAOS, FAAM) between suture tape augmentation cohorts. Similarly, no difference existed in follow-up duration or complication rate. The only significant difference between cohorts pertained to the proportion of patients who underwent a reoperation specifically for incision and debridement (suture tape=71.4%, no suture tape=0.0%; p=.013). Furthermore, when analyzing the primary and revision Broström operation cohorts, there were no differences in any postoperative PROM, follow-up duration, or complication. Finally, when analyzing cohorts whose procedures did and did not use a nanoscope, there was no difference in any PROMs, complications, or reoperation rate, but follow-up duration was significantly longer for those whose procedures did not use a nanoscope (nanoscope=0.71 years, no nanoscope=1.13 years; p=.003). (Table 1) Conclusion: Neither suture tape augmentation or revision status was found to affect postoperative outcomes or PROMs for the Broström operation. However, unlike the control group, no patients who did not received suture tape augmentation underwent reoperation for deep infection, and these patients had a lower complication rate. The only variable that showed a difference in postoperative outcomes was whether a patient was concomitantly operated on with a nanoscope, in which their follow-up duration was reduced. Based on their overall predictiveness, preoperative PROMs may provide insight into clinical success following a Broström operation.

The Effect of an External Ankle Brace on Return to Play Following Ankle Sprains in Elite Collegiate Athletes

Category: Sports; Ankle Introduction/Purpose: Ankle sprains are some of the most common injuries experienced by collegiate athletes. The goal of treatment is to restore function to the ankle allowing the athlete to return to full activity while minimizing lost playing time. There is a paucity of literature on return to play (RTP) for Grade I-IV sprains. There is also no literature regarding the role of external ankle bracing in elite collegiate athletes. The purpose of this study was to determine the return to play in Division I collegiate athletes after being treated in an external ankle brace following Grade I-IV ankle sprain. Methods: All athletes at an NCAA Division I Institution who sustained ankle sprains (Grade I-IV) between August 2020 and November 2021 and were treated with an external ankle brace were included. Athletes were allowed to gradually RTP using the external ankle brace. Athletes were Graded I-IV by the team's ATC and physician (Malliaropoulos et. al 2009). Grade I sprains were characterized by full weight-bearing capacity (WBC), minimal swelling, isolated tenderness to one ankle ligament, and no instability. Grade II sprains were characterized by partial-to-full WBC, moderate swelling, tenderness to two ankle ligaments, and mild-moderate instability. Grade III sprains were defined by no-to-partial WBC, severe swelling, tenderness to two or more ankle ligaments, and moderate-severe instability. Grade IV sprains were defined as syndesmotic sprains. Athlete RTP was defined as full participation in sports-specific activities with full WBC and clearance for competition. RTP between sprain grades was compared using the Mann-Whitney U test. Results: Thirteen elite collegiate athletes participating in cleated sports were treated: football (n=10), lacrosse, baseball, and track and field (all n=1). Grade I sprains (n=4) averaged RTP of 5.8 +- 1.4 days. Grade II sprains (n=8) averaged RTP of 14.4 +- 2.2 days. No Grade III sprains were observed. The athlete sustaining a Grade IV sprain (n=1) had a RTP of 17 days. A significant difference was found for time for RTP between Grade I and Grade II ankle sprains (p=0.02). Athletes with Grade I and II sprains wore the external brace during sport for 10.8 +- 3.9 days and 10.4 +- 4.7 days, respectively. There were no Grade III sprains observed. The athlete sustaining a Grade IV sprain wore the external brace for 24 days for RTP. There were no secondary complications using the external ankle brace during this study. Conclusion: Our results suggest an external ankle brace is a viable alternative to taping and internal bracing for rapid RTP for elite collegiate athletes. There was a significant difference in RTP of 8.6 days for athletes sustaining Grade I and II sprains that were treated with the external ankle brace. There is a lack of literature documenting the time for RTP for ankle sprains. Further investigation is needed to compare external ankle bracing with other ankle sprain treatment modalities regarding RTP.

Optimal Position of the Bone Anchor for the Internal Brace Suspensionplasty Technique for Thumb Basal Joint Arthroplasty

Ligament reconstruction and tendon interposition is a common technique for thumb basal joint arthroplasty. Recently, a variation of this technique, a suture suspensionplasty, has been introduced. The goal of our study was to assess the optimal position of the bone anchor in the thumb metacarpal. We hypothesized that an anchor placed in the radial aspect of the thumb metacarpal base would provide improved stability and resist subsidence more effectively than an ulnar-based thumb anchor. Eight fresh-frozen cadaver arms were imaged fluoroscopically in anteroposterior and lateral views centered over the thumb carpometacarpal joint before and after trapeziectomy and after the placement of radial-based and ulnar-based bone anchors. The intermetacarpal angle between the thumb and index metacarpals was measured on all images after the application of a standard force. Radial abduction, opposition, subsidence, palmar abduction, and adduction were measured. Subsidence was calculated as the percentage loss of the trapezial space. Both radially and ulnarly placed internal brace constructs allowed more radial abduction, opposition, and palmar abduction than the pretrapeziectomy constructs. They both also reduced subsidence by approximately 20% to 29% compared with the posttrapeziectomy constructs. Comparing radial to ulnar constructs, motion and subsidence were similar. There was immediate stability of the thumb with respect to axial load and subsidence after anchor placement, and this was independent of the anchor position. The position of the bone anchor in the thumb metacarpal base did not affect the range of motion. Although the device can limit subsidence, it does not appear to restrict any range of motion of the thumb, irrespective of anchor position. This cadaver study can help hand surgeons understand the effect of positioning of bone anchors when performing a specific suture suspensionplasty technique.

Arthroscopic anterior talofibular ligament repair with Internal Brace and lasso-loop technique for chronic ankle lateral instability.

To introduce the surgical technique and clinical outcomes of arthroscopic anterior talofibular ligament (ATFL) repair using the Internal Brace and lasso-loop technique for chronic ankle lateral instability. A retrospective study was performed on 29 patients who underwent all-arthroscopic ATFL repair with the Internal Brace and lasso-loop technique from January to August 2020. The patients included 24 males and five females, with a mean age of 30.17years. Through the accessory anterolateral (AAL) portal, we drilled the bone tunnels and fixed the tape with 4.75mm and 3.5mm "SwiveLock" anchors and reattached the torn ligament by the lasso-loop technique. All 29 patients underwent all-arthroscopic procedures smoothly without serious complications, such as infection and important nerve or vessel injuries. There were eight cases of lateral malleolar avulsion fractures and ten cases of talus cartilage injury. The visual analog scale (VAS), Karlsson-Peterson, Tegner, and American Orthopedic Foot and Ankle Society (AOFAS) scores were used to evaluate the clinical consequences. All the patients were followed up for 18.66 ± 4.85months on average. The average pre-operative VAS score was 4.69 ± 1.04, which was significantly higher than the average post-operative VAS score of 1.14 ± 1.56. At the final follow-up appointments, the averages of Karlsson-Peterson, AOFAS, and Tenger scores were 75.83 ± 9.44, 88.31 ± 6.81, and 6.93 ± 1.79, respectively, which was significantly higher than that before the operation. This arthroscopic anterior talofibular ligament repair with the Internal Brace and lasso-loop technique achieves satisfactory clinical outcomes with the benefits of high safety and reliability for chronic ankle lateral instability.

Hybrid Knot and Knotless Suture Anchor Repair for Patellar Tendon Rupture

Background: Patellar tendon ruptures are the third-most common injury involving the knee extensor mechanism. They typically occur in men under 40 years old as a result of eccentric quadriceps contraction while the knee is flexed and the foot is planted.1 The optimal treatment is surgical repair within 2 weeks of injury to prevent scar formation, degeneration, and loss of tendon excursion. Indications: Operative management is generally indicated for patellar tendon ruptures. In this case, a physically active, healthy 24-year-old man presented with acute pain, extensor lag, and patella alta related to a basketball injury. He was diagnosed with acute patellar tendon rupture/extensor mechanism disruption and indicated for surgery. Technique description: We describe a technique for primary patellar tendon repair which uses both knot-based and knotless suture anchor fixation. Using a pulley effect, sutures in the inferior patellar anchors are used to reduce and repair the patellar tendon back to its bony origin. Patellar anchor-based tapes and a suprapatellar traction suture are affixed with knotless anchors to the proximal tibia to reinforce the repair. Anchor-based suture limbs are used to repair the medial and lateral retinacula. Results: The senior authors’ experience with this technique has been excellent restoration of extensor mechanism function, with rehabilitation permitting early range of motion and no major complications or failures. This patient returned to unassisted activities of daily living between 8 and 12 weeks and had returned to gym workouts and recreational sports at 12 months. Discussion/conclusion: Biomechanical studies have demonstrated that compared with transosseous repair, suture anchor repair decreases gap formation and improves ultimate load to failure. Advantages of suture anchor repair include smaller incision, less tissue dissection, shorter operative time, and improved repair biomechanics. Our technique follows a principle of tendon repair using a high number of suture and tape limbs to span the repair. In addition, this technique incorporates a “double row” of suture anchors and spans the primary repair with a suture and tape “internal brace.” The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Rehabilitation and functional outcomes in internally braced and standard ACL reconstructions

PurposeThe purpose of this study was to compare surgical outcomes in patients who underwent ACL reconstruction, with and without internal bracing, at 1–3, 4–7, and 8–12 months of postoperative physical therapy. Previous studies show that ACL reconstruction with internal bracing allows earlier and more aggressive rehabilitation. Therefore, it was hypothesized that patients with internal bracing would display superior surgical recovery compared to ACL reconstruction alone after adjusting for length of physical therapy.1–3 MethodsPatients who underwent ACL reconstruction and had a minimum two-year follow-up were included. Demographics including age, gender, use of internal bracing, and pre-operative level of activity were collected. Patient-reported outcomes were assessed using KOOS scores. Results46 patients underwent ACL reconstruction between January 2013 and December 2015. The mean age was 31.53 ± 8.37 years. Patients who received ACL reconstruction with internal bracing reported similar improvement in KOOS scores (mean = 42.82 ± 15.44; median = 46.39 [34.52–51.80]) compared to ACL reconstruction alone (mean = 38.18 ± 19.91; median = 40.17 [29.49–53.90]) (p = 0.475). Patients who received ACL reconstruction with internal bracing reported comparable improvement to ACL reconstruction alone at 0–3 months (Internal bracing: mean = 35.39 ± 15.26, median = 40.45 [26.49–47.73]; No internal bracing: mean = 42.51 ± 12.33, median = 39.32 [35.69–52.94], p = 0.4113), 4–7 months (Internal bracing: 41.96 ± 14.49, 45.55 [33.94–52.68]; No internal bracing: 30.64 ± 32.29, 41.65 [26.17–46.12], p = 0.7491) and 8+ months groups (Internal bracing: 63.36 ± 13.06, 63.36 [58.74–67.98]; No internal bracing: 47.05 ± 10.14, 47.05 [43.46–50.63]) (p = 0.6985). ConclusionThis study demonstrates no statistical difference in functional outcome scores when comparing patients with internally braced ACL reconstruction compared to standard reconstruction. Therefore, the increased structural support provided by use of internal bracing in ACL reconstruction does not afford to quicker improvement in patient-reported recovery.

Paper 96: The Biomechanical Role of the Deltoid Ligament on Ankle Stability: Injury, Repair and Augmentation

Objectives:The deltoid ligament is frequently ruptured in association with ankle fractures and syndesmotic injuries. Despite the frequency of this ligamentous injury, surgical repair is not the current practice due to the belief that non-weightbearing during fracture recovery allows for adequate healing. However, conservative management has shown poor outcomes both acutely and over time with the development of arthritis. The contribution of the anterior and posterior bundles of the deltoid ligament to the stability of the ankle remains unknown, as does the effect of deltoid repair versus repair with augmentation.To determine the biomechanical role of the native anterior and posterior deltoid ligament in ankle stability and to determine the efficacy of simple suture vs augmented repair of each bundle. It was hypothesized that sectioning of the anterior and posterior deltoid ligaments would significantly increase ankle laxity in eversion, external rotation and anterior translation, repairing the anterior and posterior deltoid ligaments using suture anchors would significantly reduce ankle laxity compared to the sectioned states, and augmenting the repairs with an Internal Brace would further reduce ankle laxity compared to the suture anchor repair.Methods:Ten cadaveric ankles (50.9 mean age, male) were dissected free of soft tissue superficial to the medial ligamentous structures and mounted on a six-degrees-of-freedom robotic arm. The specimens underwent biomechanical testing in eight sequential states: 1) intact, 2) anterior deltoid cut, 3) anterior repair, 4) internal brace tibio-spring augmentation 5) internal brace tibio-calcaneal augmentation, 6) posterior deltoid cut, 7) posterior repair, 8) complete deltoid cut). Biomechanical testing consisted of three tests: 1) Anterior drawer 88 N, 2) Eversion 5 Nm, 3) External rotation 5 Nm, each run at 0° and 25° of plantarflexion under 100 N of joint compression. Anterior translation (mm) eversion (deg), external rotation (deg), were measured for each associated motion. A 1-factor random-intercepts linear mixed effect model was created for each test, and all pairwise comparisons were made between testing states, adjusting for multiple comparisons using Tukey’s method.Results:The complete deltoid cut state had significantly higher anterior translation, eversion, and external rotation at 0⁰ and 25⁰ of plantar flexion compared to all other states (+8.6mm ATT p=0.01-9, +34.1⁰ Eversion p=0.01-9, +14.7⁰ p=0.01-9 ER compared to native at 0⁰ plantar flexion, respectively). The anterior Deltoid cut showed a significant increase in eversion at 25⁰ of plantarflexion compared to the native state (+6.65⁰ P=0.0007). The anterior deltoid repair alone showed no significant decrease from the anterior deltoid cut, however both augmented anterior repairs showed significant decreases in eversion (-5.1⁰, p=0.023; -5.0, p=0.026, respectively). No other significant differences were observed between any states.Conclusions:The most important finding of this study was that the complete deltoid tear caused major ankle instability in anterior translation, external rotation and eversion. Therefore, deltoid repair is strongly recommended in the clinical setting of a complete tear. The anterior deltoid tear alone caused significant eversion instability at 25⁰ of plantarflexion, which was significantly reduced by the first augmented repair, the addition of a second augmentation showed no additional benefit over a single augmentation. Cutting the posterior deltoid in the setting of an augmented anterior repair showed no effect on ankle kinematics, therefore an augmented anterior repair can be seen a sufficient to stabilize a complete deltoid tear. Our findings suggest that surgeons may need to reconsider non-operative treatment on complete anterior deltoid injuries and that repair with augmentation offers superior stability.Figure 1.* is significantly different from all cut, # is significantly different from negative, $ is significantly different from anterior deltoid cutFigure 2.Location of augmented repairs.Figure 3.Setup.

Anatomic Repair of a Lateral Collateral Ligament and Anterolateral Capsular Complex Injury With Internal Brace Augmentation

Background: Lateral collateral ligament (LCL) injuries are implicated in varus instability of the knee. Often, these accompany other ligamentous injuries including anterior cruciate ligament (ACL), posterior cruciate ligament (PCL) tears, and injury to the anterolateral capsular complex (ALCC). Use of internal brace augmentation with anatomic repair is an alternative to reconstruction to improve patient outcomes and facilitate early range of motion and weight bearing. Indications: We present a case of an anatomic repair of a LCL and an ALCC injury with internal brace augmentation. Technique Description: A curvilinear incision centered over the lateral epicondyle is used. The avulsed LCL and biceps tendon was exposed and a placed #5 FiberWire was placed into the distal LCL, biceps tendon, and the popliteofibular ligament. A split was made in the iliotibial (IT) band and a second #5 FiberWire was placed proximally in the LCL/biceps tendon for additional fixation. A tunnel was made in the fibular head and tibia using a 2.4-mm beath pin and the two #5 FiberWires were passed to the anteromedial tibia. The FiberWires were fixed to the tibia using a 14-mm attachable button system (ABS) manhole cover for suspensory fixation. Repair and internal bracing of the anterolateral capsular complex was accomplished with 2 interlocked TightRopes and a #2 FiberTape. This fixation method achieved repair by compressing the anterolateral capsular complex onto its tibial origin. The suture devices also served to augment the repair and were fixed proximally to the femur using another 14-mm ABS manhole cover. The FiberTape was fixed to the anterolateral tibia distally with a 4.5 mm SwiveLock. The TightRopes were passed through a tunnel to the anterolateral tibia and secured using an ABS Dog Bone. The construct was tensioned in near full extension and gapping was matched fluoroscopically to the contralateral knee. Results: Patient was cleared for full return to sports 9 months postoperatively. At the final follow up visit, the patient had excellent strength, stability, and 135° range of motion on the operative knee. Patient had returned to exercise at home but was unable to return to sports due to COVID-19 restrictions. Conclusion: Anatomic repair of the LCL and the ALCC with internal brace augmentation can serve as an effective alternative to reconstruction and demonstrates excellent patient outcomes regarding restoring stability, ROM, and return to preoperative sports.

All-inside arthroscopic anterior cruciate ligament reconstruction with internal brace Ligament Augmentation using semitendinosus tendon autograft: A case series

Introduction and importanceAnterior Cruciate Ligament (ACL) reconstruction surgery has been proven to be closely related to the graft healing process, which can last up to 12 months after surgery. In recent years, through various biomechanical and clinical studies, Internal Brace Ligament Augmentation (IBLA) has been shown to protect the graft during these early postoperative stages and improve the outcome of ACL reconstruction. We present this case series of all-inside arthroscopic anterior cruciate ligament reconstruction with IBLA using semitendinosus tendon autografts, with the goal of evaluating postoperative clinical and patient-reported outcomes. Case presentationA total of 37 patients who underwent all-inside arthroscopic anterior cruciate ligament reconstruction with IBLA using only semitendinosus tendon autografts, were evaluated, in terms of patient reported outcome and clinical assessment, during the 3, 6 and 12 months post-operative follow-up. Results: The mean Lysholm Knee score at the final follow-up was 94,03 +- 3,65 with a difference of 34,59 +- 5,52 to the baseline level. International Knee Documentation Committee (IKDC) classification rated 30 cases of grade A and 7 cases of grade B. In terms of clinical tests and knee's range of motion, all patients have returned to normal, and no cases of re-rupture or other severe complications were found. Clinical discussionEarly follow-up patient reported outcomes have provided good to great results for the 37 patients who underwent all-inside arthroscopic anterior cruciate ligament reconstruction with IBLA using semitendinosus tendon autografts and no cases of graft failure or other notable complication has been discovered. Clinical findings suggest improved knee's integrity and range of movement during the early stages, which may promote early rehabilitation, however future long-term comparative studies are needed. ConclusionIBLA with all-inside ACL reconstructions using only semitendinosus autograft has provided good to great results however, future long-term comparative studies are needed.

Scapholunate Ligament Reconstruction without Immobilization Is Safe and Leads to Better Functional Results.

Background Reconstruction of the scapholunate ligament (SL) is associated with a reduction in range of motion. In this study, we compared SL reconstruction and early mobilization with SL reconstruction and Kirschner wires (K-wire) fixation for 6 weeks. Methods We performed a nonrandomized trial involving patients with an arthroscopically confirmed SL ligament injury. In total, 11 patients were assigned to SL reconstruction with internal brace augmentation and early mobilization and 10 were assigned to standard SL reconstruction and K-wire fixation for 6 weeks before mobilization started. We assessed the range of motion, grip strength, functional status, intensity of pain, global perceived effect, and duration until return to work. Results In both groups, there was one traumatic breakout of the reconstructed ligament and two patients in the control group were lost to follow-up. The 10 patients in the internal brace group had a mean increase in wrist flexion of 1.8 degrees at 1 year compared with a decrease in wrist flexion of 13.4 degrees in the seven patients of the control group. Wrist extension increased by 4.5 degrees in the internal brace group and decreased by 4.5 degrees in the control group. In addition, the internal brace group scored 6.1 (much improved) for the global perceived effect and the control group 4.7 (slightly improved), and treatment without immobilization resulted in an earlier return to work (35.1 vs. 73.6 days). Conclusions In SL reconstruction, internal brace augmentation and early mobilization result in improved wrist flexion and extension, higher satisfaction, and earlier return to work.

Posterior cruciate ligament reconstruction with independent internal brace reinforcement: surgical technique and clinical outcomes with a minimum two year follow-up

PurposeWe developed an augmentation technique for PCL reconstruction with independent internal brace reinforcement and evaluated the functional outcome after PCL reconstruction employing autologous hamstrings augmented with an internal brace system for patients with isolated or combined grade 3 posterior instability who were treated with this technique.MethodsFrom January 2016 to January 2018, patients with isolated or combined grade 3 PCL tears who underwent single-bundle PCL reconstruction using autologous hamstrings augmented with independent internal braces were studied. The function of the operated knee was evaluated according to the International Knee Documentation Committee (IKDC) score, Lysholm score, and Tegner activity score. The patients were asked the level of returned to their previous sport. Posterior knee laxity was examined with a KT-1000 arthrometer, and data on range of motion (ROM), re-operation, and other complications were collected.ResultsA total of 33 consecutive patients who received single-bundle PCL reconstruction using autologous hamstrings augmented with independent internal braces with a minimum two years follow-up were included in this study. Two patients had undergone this procedure during the study period and were not included in this study (one had combined bone fractures, and one patient had previous meniscus surgery). Thirty-one patients were available for final analysis. The mean follow-up was 45.35 ± 10.88 months (range 29–66 months). The average IKDC subjective knee evaluation scores from 51.65 ± 12.35 to 84.52 ± 6.42, the Lysholm score from 53.90 ± 11.86 to 85.68 ± 4.99, and the Tegner score from 2.81 ± 0.79 to 6.71 ± 1.83 (P < 0.05 for all). The mean total posterior side-to-side difference in knee laxity, assessed using a KT-1000 arthrometer, decreased from 12.13 ± 2.66 mm pre-operatively to 1.87 ± 0.56 mm post-operatively at 70° (P < 0.05). Most patients (29/31) had normal or near normal knee ROM post-operatively; two patients revealed a 6–15° loss of knee flexion compared with the contralateral knee. Twenty-nine patients (93.55%) returned to a normal daily exercise level. Twenty-three patients (74.19%) returned to competitive sports with high-level sports (Tegner score of 6 or above; eleven patients (35.48%) reported to be on the same level as well as the Tegner level); six patients (19.35%) returned to recreational sports (Tegner score of 4 or 5). Two patients had Tegner scores of 2 and 3, indicating poor function level. No patient needed PCL revision surgery during the follow-up period.ConclusionSingle-bundle PCL reconstruction with internal brace augmentation for PCL injury exhibited satisfactory posterior stability and clinical outcomes in patients with isolated or combined grade 3 PCL injuries at a minimum two year follow-up.

Elbow Ulnar Collateral Ligament Injuries in Overhead Athletes: An Infographic Summary.

Ulnar collateral ligament (UCL) injuries of the elbow are common in throwing athletes. Given that the UCL's primary function is to provide valgus stability during the deceleration phase of throwing, injury to the UCL will render throwing difficult to nearly impossible.15 Injuries will occur more so in the sports of baseball, softball, and javlineers participating in track and field.5,10,14 Data has indicated that valgus torque reaches 64 N-m and proximal forces as high as 1000 N to prevent elbow distraction. Further, angular velocity across elbow may reach 1900-2480 degrees/second.6,8 Imaging modalities that have the greatest accuracy for diagnosis include magnetic resonance imaging (MRI), MRI-arthrogram, and stress ultrasonography.2,3,11,12 Treatment of UCL injury depends on multiple factors. These include if the injury is a partial tear or complete tear and the location (distal versus proximal) of the partial tear.7 Further, complete tears, as well as partial distal tears, are more likely to undergo surgical intervention.1,13 Treatment decision-making is primarily dependent on following factors: location, severity, if the patient is a throwing athlete, and if the patient is in his or her last year of his/her throwing career due to the length of the rehabilitation process if surgery is pursued.15 Return-to-play success rates when treated conservatively vary from anywhere from 42% to 100%. Conservative treatment includes rest, rehabilitation, platelet-rich plasma injections, and a throwing program.4 Surgical treatment has evolved significantly with various reconstructive techniques and (when indicated) surgical repair with internal bracing. Return-to-play rates are high, ranging from 80% to 95% with low complication rates, but rehabilitation for reconstruction can range from 12-18 months or longer. Therefore, patients must be made aware of the commitment to the rehabilitation process if electing to undergo surgical reconstruction.9.

Biomechanical Evaluation of Suture Tape Internal Brace Reinforcement of Soft Tissue Allografts for ACL Reconstruction Using a Porcine Model.

Background:Internal bracing of anterior cruciate ligament (ACL) surgery is a newer concept gaining popularity.Purpose/Hypothesis:To assess the biomechanical performance of soft tissue ACL reconstruction allografts reinforced with suture tape. It was hypothesized that load to failure would increase and cyclic displacement would decrease at time zero in the constructs reinforced with internal brace suture tape compared with those without suture tape augmentation.Study Design:Controlled laboratory study.Methods:We performed ACL reconstruction on porcine knees using bovine extensor tendon soft tissue allografts: 10 knees without (control) and 10 knees with (reinforced) suture tape reinforcement. An all-inside reconstruction technique was utilized with retrograde tunnel creation. An adjustable-loop device was used for femoral and tibial fixation of all grafts. The suture tape was placed through the tension loop in the femoral fixation construct and independently fixed in the tibia with an interference screw anchor. For each specimen, the authors recorded ultimate load, yield load, stiffness, cyclic displacement, and mode of failure. Outcomes between groups were compared using the Student t test.Results:There was a 33% decrease in mean cyclic displacement in the specimens with reinforced grafts (reinforced vs control: 3.9 ± 0.7 vs 5.8 ± 1.5 mm; P = .001). The reinforced grafts also had a 22% higher mean ultimate load (921 ± 180 vs 717 ± 122 N; P = .008) and a 25% higher mean yield load (808 ± 201 vs 602 ± 155 N; P = .020). There was no significant difference in stiffness between the reinforced versus nonreinforced grafts (136 ± 16 vs 132 ± 18 N/mm; P = .617). Three of the 10 control specimens failed at the graft, compared with 1 of 10 reinforced grafts. All other constructs in both groups failed at the tibial fixation site.Conclusion:Suture tape reinforcement of soft tissue grafts significantly decreased cyclic displacement while significantly increasing ultimate and yield loads without increasing graft construct stiffness during biomechanical testing at time zero in a porcine animal model.Clinical Relevance:The improved biomechanical performance of suture tape–reinforced graft constructs could allow patients to participate in earlier advancement of aggressive rehabilitation and potentially reduce failure rates as graft remodeling progresses.

Lunotriquetral Ligament Repair Using Augmented Internal Brace.

Lunotriquetral (LT) ligament tear, usually in combination with an adjacent carpal ligament injury, can result in complete LT dissociation and VISI (Volarflexed Intercalated Segment Instability). Operative techniques for the management of instability are highly variable with many described in literature, although there is little evidence to demonstrate the superiority of one definitive therapeutic technique of repair and reconstruction. In this paper, we discuss our proposed technique for performing LT ligament repair using an augmented internal brace, which addresses triquetral extension and lunate flexion. The internal brace construct also provides biomechanical superiority as it includes the augmentation of the ligament and capsule repair. We use figures and references from our case example to demonstrate this technique.

Treatment of Medial Collateral Ligament Injury During Total Knee Arthroplasty With Internal Suture Brace Augmentation: A Cadaveric and Biomechanical Study

Intraoperative medial collateral ligament (MCL) injury during total knee arthroplasty (TKA) is a serious complication. External bracing and/or conversion to a constrained implant has previously been studied. The technique of using an internal high-strength suture brace to augment an MCL repair has been evaluated in the nonarthroplasty patient and could provide an alternate solution. The goal of this study was to determine whether MCL repair with internal suture bracing restores stability of the implanted knee joint. A robotic simulator completed laxity testing on 5 cadaveric knee specimens in 4 sequential phases: (1) intact knee, (2) after implantation with TKA, (3) after sectioning of the MCL, and (4) after MCL repair with suture brace augmentation. Laxity was compared between the different test phases throughout range of motion. Subsequently, the internal brace was tested to failure under valgus load. The MCL repair with internal bracing was effective at restoring laxity in varus-valgus, internal-external, and me-dial-lateral degrees of freedom through midflexion, with limited support at deeper flexion angles and in anterior-posterior laxity. Rotational laxity was not significantly different than intact knee laxity. Generally, medial-lateral translations were less and anterior-posterior translations were greater and were significantly different at 30° to 45° and 90°, respectively. The mean failure moment was 46.4±9.1 Nm, with the primary mode of failure being MCL repair. Primary MCL repair with internal bracing using a high-strength suture augment showed the potential to provide adequate stability and strength to correct MCL incompetence in TKA without the use of an external knee brace or constrained implants. [Orthopedics. 202x;4x(x):xx-xx.].

Jigless Knotless Internal Brace Versus Other Minimal Invasive Achilles Tendon Repair Techniques in Biomechanical Testing Simulating the Progressive Rehabilitation Protocol

The jigless knotless internal brace surgery (JKIB), an alternative method for minimal invasive surgery (MIS) repair of acute Achilles tendon rupture, has advantages of preventing sural-nerve injury in MIS and superficial wound infection in open surgery, as previous clinical research demonstrates. However, no comparative study on the biomechanical performance between JKIB and other MIS techniques has been reported until now. In this study, 50 fresh porcine Achilles tendons were used to compare the JKIB with open surgery (two-stranded Krachow suture) with other MIS techniques, including Percutaneus Achilles Repair System (PARS), Speedbridge (SB), and Achillon Achilles Tendon Suture System (ACH), using a biomechanical testing with cyclic loading at 1 Hz. This test was used to simulate a progressive rehabilitation protocol where 20 to 100 N was applied in the first 250 cycles, followed by 20 to 190 N in the second 250 cycles, and then 20 to 369 N in the third 250 cycles. The cyclic displacement after 10, 100 and 250 cycles were recorded. The survived cycles were defined as a sudden drop in measured load. In survived cycles, the JKIB group (552.3 ± 72.8) had significantly higher cycles than the open, PARS, and ACH groups (204.3 ± 33.3, 395.9 ± 96.0, and 397.1 ± 80.9, respectively, p < .01) as analyzed by post hoc analysis, but no significant difference as compared with the SB group (641.6 ± 48.7). In cyclic displacement after 250 cyclic loadings, the JKIB group (11.29 ± 1.29) showed no significant difference as compared with PARS, SB, and ACH groups (12.21 ± 1.18, 9.80 ± 0.80, and 11.57 ± 1.10 mm, respectively) and significant less displacement than the open group (14.50 ± 1.85, p < .01). These findings suggest that JKIB could be an option for acute Achilles tendon repair in the MIS fashion due to no larger cyclic elongation compared with other MIS techniques.