Suture anchors provide the highest attachment strength possible, making technically demanding procedures simpler, safer, and more reproducible. The bioabsorbable anchors are made of PLDLA (poly(L-lactide-co-D, L-lactide)), PLLA ((poly)L-lactide) or BioComposite (PLDLA/Beta tricalcium phosphate). They maintain strength during the critical 12-week soft tissue healing phase and then undergo resorption.

Foot and Ankle

Product

The Arthrex Brostrom Repair System allows surgeons to perform a modified Broström-Gould procedure through a single, 1.5 cm incision. The convenient all-in-one system includes 2 BioComposite™ SutureTak® anchors, all the necessary drill guides, the Micro SutureLasso retrievers to help facilitate percutaneous shuttling of the #1 FiberWire® suture through the ATFL and extensor retinaculum.
During simultaneous arthroscopy, surgeons have the option to perform the all-arthroscopic ArthroBrostrom® repair technique using the same instruments from the Arthrex Brostrom Repair System. These techniques offer surgeons 2 truly minimally invasive options to treat patients presenting with lateral ankle instability.

With the InternalBrace™ ligament augmentation 2.0 system, surgeons can now drill, tap, and implant through the talus offset guide. The system provides surgical versatility with added size and material options as well as a laser-line window to determine the SwiveLock® implant location. Cannulated drills and taps allow surgeons to adopt a percutaneous or minimally invasive approach. The biologic advantages of the collagen‐coated FiberTape® suture and JumpStart® antimicrobial dressing complete this comprehensive ligament augmentation system.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

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Human

InternalBrace™ 2.0 Ligament Augmentation Repair

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InternalBrace™ Procedure for Brostrom Repair

James McWilliam, MD (New York, NY), provides a cadaveric demonstration of the InternalBrace™ 2.0 ligament augmentation procedure with DX FiberTak® anchors with SutureTape following a Brostrom repair. The InternalBrace procedure results in a biomechanically superior repair versus Brostrom alone1 and allows for accelerated rehabilitation2 in patients with ankle instability.
References
<ol>
 <li>Veins NA, Wijdicks CA, Campbell KJ, LaPrade RF, Clanton TO. Anterior talofibular ligament ruptures, part 1: biomechanical comparison of augmented Brostrom repair techniques with the intact anterior talofibular ligament. Am J Sports Med. 2014;42(2):405- 411. doi:10.1177/0363546513510141</li>
 <li>Coetzee JC, Ellington JK, Ronan JA, Stone RM. Functional results of open Broström ankle ligament repair augmented with a suture tape. Foot Ankle Int. 2018;39(3):304-310. doi:10.1177/1071100717742363</li>
</ol>
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

Brostrom Repair With InternalBrace™ 2.0 Ligament Augmentation Procedure

We're going to make an incision off the tip of the fibula from about the CFL anteriorly and a little bit proximally to include the atfl and a lot of the anterolateral capsule of the ankle. The initial dissection is through skin. Then we're going to mobilize the inferior extensor retinaculum, which is pretty robust in this specimen. Next we're going to incise the capsule and ligaments off of the distal fibula. This is surprisingly proximal. And we're actually taking it off a little bit proximal to the tip of the fibula to get enough ligament and capsule to pass our sutures. This is the Taylor drill guide. It has an extension which provides a seven millimeter offset from the sinus tarsi. This seven millimeter offset is going to allow drilling of the anchor for the atfl. Insertion into the talus in a reliable fashion. If we put the handle of the Taylor Offset Guide in about the 730. Position, this is going to reliably reproduce the insertion site of the ATF fell into the talus. Now that's 730 position on a left foot. You can check the position you can see here on the AP. You have great position on the lateral. You have great position approximately 20mm proximal and anterior to the lateral process of the talus. Next we will over drill and tap the guidewire to prepare a tunnel for insertion of a 4.75mm Bio-SwiveLock anchor that's preloaded with FiberTape SwiveLock. Anchor has an insertion guide that will tell you when your anchor is countersunk. Now you can see the insertion side of the anchor is approximately 20mm proximal and anterior to the lateral process of the talus and almost anatomic position. Next we will drill for our FiberTak anchors that are going to provide our actual lateral ligament and capsule repair. The FiberTak is a soft tissue anchor whose pull out strength is greater than the traditional Bio-SutureTak anchor. So we put one just proximal to the tip of the fibula. The second one is approximately 1 to 2cm proximal to the first. So we have a good SutureBridge to perform our capsule and ligament repair. When inserting the FiberTak anchor, it's important that you keep the drill guide in the same position as you drill. The anchor is fully inserted and then initially tensioned by pulling back on the drill guide against the handle. After tying down the capsule ligament, we're ready to drill for the fibular insertion site of the internal brace. I do this between my FiberTak anchors and a anchors and a little bit proximal up on the fibula. Drove the appropriate drill bit tap and then we're ready to insert. I will anchor the fibular insertion with the ankle inflection. Next I'll take a proximal flap of periosteum off of the fibula and repair it to the inferior extensor retinaculum. Typical wound closure and then application of JumpStart dressing. The JumpStart dressing is unique in that in an aqueous medium, it provides a galvanic current that both promotes wound healing and provides an antimicrobial environment.

This animation demonstrates an all-knotless Brostrom repair using the DX Knotless FiberTak® anchor and InternalBrace™ ligament augmentation technique, highlighting the steps necessary for insertion and fixation.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

InternalBrace™ Repair With DX Knotless FiberTak® Anchors

When using the DD Nautilus FiberTak for ArthroBrostrom repair. The incision is made on the outside of the ankle over the torn ligament. Place the slotted guide on the bone and drill using the 1.8mm K-wires. Drill and cycle the drill. Keeping the guide in place and stable, insert the knotless FiberTak with gentle mallet until the inserter is flush with the guide. Undo the rubber O ring and remove the suture and needles from the inserter handle, and then remove the inserter and guide. Separate out the shuttle stitches from the blue working stitch, ensuring there are not any tangles or knots. Gently pull back on the blue working stitch, but only to make sure it is engaged in the bone. Do not fully set the anchor. Repeat the steps for the second anchor location. Introduce the seven millimeters talus offset guide into the sinus tarsi and flush against the talus. Drill with a 3.4mm drill bit It and then tap with the 4.75mm tap. Leaving the guide in place. Insert the 4.75mm SwiveLock into the talus. Remove the inserter and the guide. Pass the needle from the blue working stitch from the knotless FiberTak through the ligament in a mattress fashion. Once the suture is passed, cut the needle off at the purple marking on the suture closest to the needle. Double over the blue working stitch through the loop end of the shuttling. Stitch at the purple marking and pinch and hold the sutures. Pull axially on the tape end of the shuttling. Stitch in line with the anchor, using short jigs until the blue working suture and shuttle loop are converted through the anchor. Place the foot in the desired position and continue to pull gently in an axial motion until the desired tension is met. Cut the suture and repeat for the second anchor. Place the drill guide for the 3.4mm. Drill on the fibula between the dx knotless FiberTaks and drill. Then tap using the 3.5mm. Tap. Remove the tap and guide. Load the FiberTape for the internal brace in the 3.5mm. Swivel lock and place the eyelet at the fibular hole. Pulling the FiberTape taut. Use a marking pen to mark the FiberTape tail even with the laser marking on the inserter. Then pull the eyelet back on the FiberTape to the mark. Insert the 3.5mm swivel lock and then cut the FiberTape flush to bone and the all knotless ligament repair is complete.

Anish R. Kadakia, MD (Chicago, IL), presents the benefits of and clinical success using the InternalBrace™ ligament augmentation procedure and refutes competitive information.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

InternalBrace™ Ligament Augmentation Procedure: Clinical Success

Hello, my name is Anish Kadakia from Northwestern University and today we're going to discuss the internal brace ligament augmentation repair. My experience, some of the biomechanical and clinical data and discussion of some of the quote unquote, competition or competitors that are out there that are trying to mimic the excellent results that we're able to achieve. Let's look at some of the data about standard Atfl Brostrom reconstruction. What we know is that unprotected motion causes lengthening and failure of the reconstruction. So although we feel a taking the ligament, putting it back together and tightening it is okay. Unfortunately it is not. When you look at using suture anchors which are superior with regards to initial stability, they still do not provide enough rigidity for the repair for the long term. And this is just a biomechanical study showing how rigid and stable the internal brace is to stress. Why do I use the augmentation with the internal brace? Because it is better for the patient. Based on the data we have, early motion is critical. It's better for collagen. And the and the InternalBrace allows me to achieve that without lengthening. It's not just about the faster rehab that's kind of a short term goal. It's very important for our athletes, but for our non-athletes, the goal is that after a year, they're still stable. They don't have to come back and see you, and they're not getting that instability and that risk for arthritis. The InternalBrace allows reproducibility of the positive outcome. I've done over 200 procedures and I want to emphasize this not just for the lateral ankle. That's clearly where I started, but I use it all over the foot and ankle. And it's allowed me to do things I was unable to do without the internal brace. When you look at efficacy and safety, 1.5 million FiberTape bridging constructs have been used with really the best safety compatibility records in orthopedics, which is not the case for the competition. Collagen ingrowth is a very unique aspect of the internal brace because of the collagen coated FiberTape that we use. This is a case from a colleague of mine that had a large cavus deformity that underwent a reconstruction and unfortunately needed to be revised because of Subtalar instability, not because of the ankle joint and during his revision he noted peroneal tendon scarring, but also that the internal brace was completely coated with collagen. You can't even see the blue. So during his revision to do a non anatomical instability, he had to remove the collagen. Internalbrace is actually very hard for him to find. So you can see here as opposed to a synovitis reaction or a foreign body reaction, you actually have positive collagen ingrowth on the FiberTape. This is a white paper that we did kind of backing up the clinical data that we have the collagen coated FiberTape and a green identifies live tenocytes viability of Tenocytes. You can see the collagen coated FiberTape is superior to any of the competition. And red. If you look at the bottom two slides, red is actually tenocytes death. You look at live cell density on a graphical manner. You can see, statistically speaking, the collagen FiberTape is superior to all other products out there, and this is the only one that has collagen coating. What would be ideal for ligament augmentation? A native ligament is not a rubber band. And that seatbelt analogy actually is probably the best one. It is static. It's supposed to hold you in place while the native atfl doesn't really move. It's 0.4mm of excursion in a normal population with this particular ultrasonography study. And if you're symptomatic, you're unstable. 1.2mm of excursion causes you to have ankle instability. So we know AugMend should not have laxity or elasticity because that would make no sense. When you look at another study the data is reproducible for how much ligament has excursion. And the answer is it does not. The mean change in this ultrasound study was 0.1mm, and a symptomatic patient had 1.9mm, or almost two centimeters of laxity. We have a lot of studies to support the clinical efficacy of the internal brace. Multiple studies show that they have superior outcomes. Return to exercise is fast. And one thing that you'll notice is that there's not a lot of complications. If you look these studies up, they do not have product related complications. No studies without surgical complications, but it is not is not related to the product. So the internal brace ligament augmentation is safe. It's effective. It's better for the patients. This is a retrospective study that was done by Doctor Coetzee and his team. And you can see the mean return to sport was superior with the internal brace. This is a prospective randomized study by Doctor Colin Watson, Doctor Rigby Coetzee and Vora. This is the type of study that we want in orthopedics. It's very rare when you look at level one studies, 59 patients, standard brostrom with a suture anchor so appropriately done brostrom and those that had the primary repair augmented with the internal brace. When you look at early follow up return to sport, it was superior in patients that had the augmentation patients who were in the standard group. Some of them did not return to activity. And it's clearly more patients were unable to return to sport that did not have an augmentation. So in this prospective randomized study, the internal brace did better. Patients without the internal brace had to quit from the accelerated rehab. And there's just no question that the internal brace was superior. When you look at the at the competition per se, when you look at Ardalan. The argument that they use to promote their product is that it is elastic. It absorbs and rebounds. That's not my slide. That's their slide. Absorb and rebound would be the absolute opposite of what you would want in a ligament. Remember a ligament does not move it. Elasticity is only 0.1mm in the normal population. When you look at theirs at 125 newtons, which is about average for the amount of strain you would put on the atfl. They have 2.4cm of excursion. And that is clearly above and beyond someone who is symptomatic. So not only does it have elasticity, it is so elastic. It's actually worse than a patient that has ankle instability. This actually doesn't make any sense whatsoever when you talk about ligament reconstruction. When you look at the data in PubMed there's 121 articles when you type in the internal brace and you isolate that. And there's actually 153 for Ardalan. Well you may say, well look they have more studies. But it's not quantity. It's always about quality. So if you look at what they are published on you can see there's foreign body reactions, poor outcomes. With Ardalan. It's actually mostly quote unquote not ideal or bad data. This is a failed Achilles tendon rupture that was augmented with Ardalan. It's a standard Achilles rupture where we know that the mid substance SpeedBridge is phenomenal, does great minimal reaction. Patients have minimal scarring. And you can see here this patient has the opposite pain weakness. The Ardalan did not get absorbed. It was still present. And Doctor Ali is a very well respected surgeon who is a master of the Achilles tendon. This is another article looking at a systematic review of Ardalan. 11 articles for CMC arthritis where it was actually used initially. And so what were the areas of agreement? Now typically when you look at a systematic review, areas of agreement are positive things. There is nothing positive that they could possibly come up with. Ardalan is not recommended. High revision rate was noted in every article. Worse outcomes. Why would you use this type of a device? And we should just be aware that it's not helpful to the patient. There's another study prospective randomized study. And you may argue, well, they have a randomized study too. But what's the conclusion. Well swelling and pain was more common in Ardalan six required removal. And they had significantly better pain. But those that did not receive the Ardalan. Now they're trying to promote this for the foot and ankle. But when you look at the data, none of those are procedure specific. Those complications are body specific. The rejection rate, inflammation, worsening pain, that's not particular to the hand. That's just from the product itself. So they stayed here. Soft tissue reconstruction with Ardalan for multiple foot and ankle applications. And you may assume this is going to be 2030 50 procedures. Well let's look at the summary. Three cases. That's it. So they're using the word multiple in the most minimal way you can. It gets even better. So it causes foreign body reaction. This is a multiple published complication with Ardalan. Three cases of foreign body reaction specifically related to the implant itself. So physiologic body specific, not procedure specific. No surgeon would want this and no patient would want this if they knew the data anywhere near their ankle joint or anywhere in their body. If you're going to get a foreign body reaction, why would you put this in? The InternalBrace is superior for ligament augmentation, and is superior to any other product that tries to mimic the efficacy and the mechanics of the internal brace augmentation. We have multiple clinical articles showing both safety and efficacy, which nobody else does. Arthrex is the only company to have collagen coating to promote Tenocytes growth. Ardalan has proven foreign body reaction and is too elastic for ligament repair. The internal brace is biomechanically stable, promotes collagen growth, improves clinical outcomes and should be used in I use for all my ligament reconstruction. Thank you very much.

Kevin D. Martin, DO (Colorado Springs, CO), describes his experience with the InternalBrace™ ligament augmentation procedure for ankle and syndesmotic instability in an active military population.
The InternalBrace surgical technique is intended only to augment the primary repair/reconstruction by expanding the area of tissue approximation during the healing period and is not intended as a replacement for the native ligament. The InternalBrace technique is for use during soft tissue-to-bone fixation procedures and is not cleared for bone-to-bone fixation.

InternalBrace™ Ligament Augmentation Procedure: Experience in a Military Population

Hi, I'm Kevin Martin. I'm an orthopedic foot and ankle surgeon from Colorado Springs, Colorado. Over the past five years, I've had the distinct privilege of caring for active duty military service members. During that time, this patient population is very unique and challenging. This population also has a very high rate of chronic ankle instability. When I began my career, I was using a standard two ankle modified brostrom technique. But this technique requires prolonged therapy and oftentimes revision is difficult. If they roll their ankle again. So in my practice, I initially heard the internal brace allowed for much quicker rehabilitation. So I began using it for my revisions and up tempo service members. But after the paper presented giving us good evidence, I began using it more and more throughout my clinic because oftentimes my patients also have very poor compliance. These guys push the limits trying to get to duty very quickly. Not all about you, but noncompliance is always an issue for me. So let me tell you about Sergeant TI. Sergeant TI is the epitome of noncompliance. He was injured his ankle while out on a mission approximately two months before seeing me. During that time, he had pain, swelling and the inability to walk, squat or pivot and has had difficulty with all daily activities. Upon presenting to me, not only did he have lateral ankle instability, he also had very significant syndesmosis findings. You can see with a positive translation test as well. His x rays demonstrate medial clear space widening and decreased tib fib overlap. The gravity stress view, which I like to use, also demonstrated significant medial clear space widening with no tib fib overlap, again indicating Syndesmosis was also involved in this injury. His MRI demonstrates a complete rupture of the TfL with a positive lambda sign. Deltoid involvement and just overall very angry MRI as you appreciate here with the edema throughout the talus as well. Preoperatively I asked Sergeant T if he would perform a single leg heel rise to me, and he just flat out said no, sir. And this guy is tough as nails. So if this guy refuses to do it, you know that it hurts. I then performed an ankle stabilization test, stabilizing his ankle, as Amendola describes, and he was able to now do a single leg heel raise and walk pretty comfortably in my preoperative holding area, indicating that the that the Syndesmosis was obviously involved Intraoperatively he had a very significant fibular translation test. He also demonstrated a partial undersurface tear of the deltoid. So with this combination of injury, not only having the lateral ligaments and the proximal syndesmosis injury, you have to ask yourself what kind of construct am I going to use? So to reduce the fibula into incisura, a TightRope is placed first. Then I work myself distally performing a standard broström with a two anchor technique and repair the deep capsule and the remnants of the TfL and the TfL to the fibula. I then augment with the internal brace. I place a 4.75 SwiveLock into the talus. A second limb goes into Wagstaff's tubercle. Wagstaff tubercle in the fibula is very important because that's the key anatomic structure to make sure this is both anatomic. And then from wagstaff's I take the second limb of the internal brace up and place it in the anterior lateral process of the tibia. This gives us what I call in my clinic a flying V technique. Following this, I use the periosteum and the inferior extensor retinaculum as a repair to ensure that the internal brace is placed between two layers of tissue, making sure it will not become prominent or irritate the irritate the patient. Post-operatively, following the repair of his syndesmosis was stabilized very nicely. Little did I know that at two weeks Sergeant T was going to be performing Military Freefall School, better known as Halo. He already had this scheduled. So these jumps right here demonstrate him jumping out of a plane at approximately 15,000ft, two and a half weeks after surgery. And I absolutely do not recommend this for any of your patients. But this is what this patient decided and felt good enough that he could do after surgery. The problem with falling out of a plane 40 times at two weeks after surgery is that whatever goes up must come down. So I don't know about you, but I don't want any of my patients performing this 40 times two weeks after surgery. But he felt comfortable enough to do so. Little did I know that when he returned, I was given my standard rehab talk. I was asking him to do a single leg hop, which he did with no problem. I analyzed his gait as seen here, and he walked with a completely non-intelligent gait. At this point, I was explaining to him, you're ready to go on to the next phase of rehab. And then he described to me what he had just done completing 40 high altitude freefall jumps, which was incredible. Letting me know that the internal brace act as a check ring and ring and protected him throughout the rehab period. Typically, what I recommend to my patients is that post-operatively we use the two cubed technique. Two weeks non-weight bearing in a splint, two weeks weight bearing as tolerated in a boot, and two weeks into an ankle lace up brace. And some people will advance very quickly through this. Others take a little bit longer, but I typically use the single leg hop examination in my clinic to allow them to advance to the next level. It's very routine for my patients to be able to perform a single leg hop at six weeks, and this is what allows me to advance them. And this is what the indication to me is that they're making it, that they can go on to the next level. And so far, what I've given you is all level five evidence. My team and I are working on a multicenter, randomized, controlled, prospective study that's going to allow us to base our judgments not only on level five, but also high level evidence looking at a two anchor technique versus the two anchor technique augmented with the internal brace. And I look forward to sharing those results with you. Thank you.

Arthrex® Brostrom Repair

Child (D)

The Nano, Micro, Mini and 3.5 mm Corkscrew FT Suture anchors are designed with a fully threaded length to create maximum cortical purchase in smaller bones.
The Small Joint Corkscrew anchor offers a small inner diameter and large cancellous thread design for maximum holding power in cancellous bone.
Finally, the 3.7 mm Small Joint Bio-Corkscrew® Suture anchor features a unique suture eyelet molded into the body that virtually eliminates suture abrasion during knot tying.

Modified Brostrom-Gould Technique for Lateral Ankle Ligament Reconstruction

Achilles SutureBridge™

The Achilles SutureBridge is a technique designed to cure insertional Achilles tendinitis, or to repair Achilles tendons, which have detached from the heel bone. The surgeon begins by exposing the attachment site of the Achilles tendon to the heel bone. The tendon is then split down the middle, and both ends are detached from the bone. If present, a posterior bone spur is removed with the saw. Otherwise, the heel bone is freshened to bleeding bone to enhance healing. A bone socket is created in the heel bone with the punch and tap. An anchor is screwed into the socket. One suture from the anchor is discarded, while the other is used to suture the Achilles tendon. A second anchor is placed in the heel bone. And the other side of the tendon is sutured. The sutures are tied, bringing the Achilles tightly to the bone. The surgeon then creates two additional sockets lower in the heel bone. Sutures are crossed and secured to the bone using PushLock anchors. The repair is complete when both sutures are securely fixed to the bone in all four sockets.

Corkscrew® Anchors

The DX FiberTak® all-suture anchors are ideal for any soft-tissue repair about the foot and ankle and maintain a very high pull-out strength considering the small profile of the anchor.1-3 These anchors offer the benefits, clinical experience, and product support surgeons have come to appreciate from Arthrex.
<ul>
 <li>Single- and Double-Loaded</li>
 <li>1.3 mm SutureTape, 0.9 mm SutureTape, FiberWire® Suture</li>
 <li>1.35 mm K-Wire Drill Recommended</li>
 <li>1.6 mm K-Wire Drill (Hard Bone)</li>
</ul>
References
1. Arthrex, Inc. Data on file (APT-05068). Naples, FL; 2021.
2. Arthrex, Inc. Data on file (APT-03508). Naples, FL; 2018.
3. Arthrex, Inc. Data on file (APT-03296). Naples, FL; 2017.

Robert B. Anderson, MD (Green Bay, WI), demonstrates using the DX FiberTak® anchor with SutureTape to repair the superficial deltoid complex, highlighting the surgical tips and technique.

Deltoid Repair Using DX FiberTak® Anchor With SutureTape

I'd like to demonstrate our approach to the medial instability pattern, perhaps those with acute superficial deltoid ligament injuries. Now, again, this is something we've been identifying much more commonly over the past ten years and in association with external rotation injuries to the ankle. Those external rotation injuries result in high ankle sprains syndesmotic injuries. Weber. See fibular fractures or Maisonneuve fractures. And what we found through our research with the NFL. My own clinical experience dealing with NFL players who sustain these types of injuries is that, more often than not, the superficial deltoid complex is a vault off of the anterior aspect of the medial malleolus. And I think it's very, very important to repair that superficial deltoid when it is avulsed attenuated or ruptured, and particularly in the acute setting, to give yourself hopefully, a better outcome and a better rehabilitation program. Now, for the purpose of this demonstration, I made the incision a little bit larger than I than I normally would. So this is basically we're creating an Anteromedial Arthrotomy. So I'm going to come in here. Now. If this was an acute rupture, I'd have a big flap right here and a chronic situation. I'm going to have an attenuated complex. I'm going to actually come along now the anterior margin of the medium list. And I'm going to incise into this complex. I'm going to develop a flap, basically a flap of the superficial deltoid here on the other side. I do typically lift this up. Create a little bit of a cuff of tissue. I can openly visualize the ankle joint through this arthrotomy. I can remove any impingement lesions I might find or have recognized preoperatively. So I can take a small osteotomy and remove any impingement lesions off of the anterior aspect, the distal tibia, or even off the Taylor neck. And then what's very important to do is to go ahead and denude soft tissue over this aspect of the medial malleolus, where you're going to place your anchor. Again, you want to develop a nice bleeding surface for re adherence of your Reconstructed superficial deltoid complex. So this is your FiberTak guide. And we're going to place it there on that portion of the anterior median malleolus. And again I'm below the level of the joint line. But I'm well seated in the anterior aspect the medial malleolus. And I'll go ahead and then take the guidewire drill and harder bone. It's good to cycle this back and forth a couple times. Make sure you've opened it up adequately. And again this is an all suture anchor the FiberTaks and all suture anchor. And we place it to the hole at that location. And then we go ahead and we'll tap it into position. So we'll tap that down. Goes nicely into the bone of the medium list. Once you seed it at this level then you're just going to basically pull back. And that's going to engage your sutures in the bone. With that done, you then take off your black restraining loop on top. You then have sutures already in place that can then be removed from the top of the device as shown here. And then again our slots upwards. Now we can see very nicely. This can just basically come right off. Come out. And here's our sutures. I'll get my hand out of the way. Here's our sutures. We're just going to slide them right out of the guide sleeve. This device has two attached suture tapes that will then use to create a horizontal mattress in our attenuated superficial deltoid ligament complex. Or again, if it's an acute setting, it would be the avulsed complex itself. So again, the beauty of the SutureTape is it has great pull through strength, particularly for these soft tissue applications. So we'll place these far into the attenuated complex. And again you'll recognize this because it's very similar to what's done on the lateral side when you do a broström procedure. Thus we call this a medial broström type of repair. So there's one seated SutureTape. Here's another one. I'm grabbing a large portion of that thick attenuated superficial deltoid complex, and then I'll go basically test it. So I'm going to go in I'm going to suture these down. And you put your several knots in to secure it. So at this point in time now I'll go ahead. And I will actually then take one of my needles from the SutureTape. And I'll then grab this material posteriorly. With the two needles there's one. And I just find this gives almost like a pants over vest type of effect, and seems to provide a little bit more stability to the whole construct. So now with that, I can then go ahead and almost create like a pants or vest type effect, just more security for that complex. Allows me a little more freedom with my post op. As far as when to range, when to walk them. So once that's completed, remove that close up your soft tissues nylon to skin. And then again I usually will splint them in a dorsiflex position. Slight inversion if it's an isolated deltoid injury. If it's in combination with lateral based injuries then I'll just dorsiflex. But in neutral they'll stay in the splint for two weeks. I oftentimes will then put them into a cast at that two week mark. If it's again isolated deltoid, I'll let them wait for that cast for an additional two weeks. Then they'll go into a boot and start their rehab at four weeks. But I ask them to avoid any rotational maneuvers for approximately 12 weeks after the surgery has been performed.

DX FiberTak®  Anchor Double-Loaded With 0.9 mm SutureTape

DX FiberTak® All-Suture Anchors

Threaded anchors provide greater opportunity for bone contact than barbed anchors and also provide a path for removal. Providing excellent strength in a smaller size, this non-absorbable, braided polyblend suture is preloaded for convenience. A short inserter and self-drilling design create a reliable and quick procedure with no additional instrumentation needed. The Small Bone FASTak suture anchor is a fully threaded, 2.4 mm x 7.5 mm titanium suture anchor that is preloaded with 2-0 FiberWire. It comes on a handled inserter with two 17.9 mm 3/8 circle swedged-on tapered needles. It alleviates the need for pre-drilling, while creating an excellent point of fixation. Designed for use in the hand, wrist, and elbow for soft tissue reattachment procedures such as UCL repair of the thumb, ligament repair for scapholunate disassociation in the wrist, as well as ECRB repair in tennis elbow debridement, this device can also be used to repair lateral ankle ligaments for a modified Brostrom procedure. Benefits:
<ul>
 <li>Threaded for Pull-out Strength - Threaded anchors provide greater opportunity for bone contact than barbed anchors, and also provide a path for removal if needed.</li>
 <li>Preloaded with Two Needles and FiberWire - Providing excellent strength in a smaller size, this nonabsorbable, braided polyblend suture is preloaded for convenience.</li>
 <li>Straightforward Technique - A short inserter and self-drilling design create a reliable and quick procedure with no additional instrumentation needed.</li>
</ul>

FASTak® Anchor

BioComposite SutureTak® Anchors
The BioComposite SutureTak anchors are unique “push-in” anchors that are ideal for soft-tissue repair in the foot and ankle.
These anchors offer the benefits, clinical experience, and product support surgeons have come to appreciate from Arthrex.
<ul>
 <li>Sizes — 2.4 mm and 3.0 mm</li>
 <li>Single- and Double-Loaded</li>
 <li>FiberWire® suture, 1.3 mm SutureTape, and 0.9 mm SutureTape</li>
 <li>Ergonomic drivers for extremity usage</li>
 <li>Extremity-specific needles attached</li>
</ul>

2.4 mm BioComposite SutureTak® Anchor With 0.9 mm SutureTape

3.0 mm BioComposite SutureTak® Anchor With SutureTape

Jorge Acevedo, MD, (Royal Palm Beach, FL) presents the Arthroscopic Brostrom Technique utilizing the BioComposite SutureTak® and Curved Micro SutureLasso™. It allows the surgeon to treat intra-articular pathology and repair the lateral ankle instability simultaneously with minimal incisions.

ArthroBrostrom®

I'm Doctor Jorge Acevedo and I will be presenting the ArthroBrostrom technique. Initially, the landmarks are outlined, including the superficial peroneal nerve, inferior extensor retinaculum. A standard anteromedial portal is performed, and the joint is visualized with a standard 21 point inspection. The standard anterolateral portal is then performed using an inside out technique. This is performed with care to avoid injury to the superficial peroneal nerve. It is important to make the portal in a location where the lateral gutter is easily accessed. Initially, the arthroscopic shaver is used to carefully debride the lateral gutter. This is a crucial step in order to gain appropriate visualization, and usually requires a minimum of five minutes. The drill guide is first inserted and placed just above the inferior tip of the fibula, approximately one centimeter above the distal tip. It is important to hold this cannula perpendicular to the fibula. The guidewire is then placed typically through the cannulated, obturator and drill guide. It is helpful to palpate the posterior fibula while drilling the guidewire in order to determine correct trajectory. Once the wire is inserted, the cannulated drill is placed over the guidewire in order to achieve drilling to the hard stop. The drill is then removed while holding the cannula in place. The anchor is placed through the cannula. And impacted to the laser line on the proximal handle. This can also be visualized arthroscopically to assure that the laser line is seated up to the bone. The anchor driver is removed with a twisting motion. At this stage, it is important to determine which suture is in the more proximal and or superior end versus the more distal end or inferior end, and assure that they are not crossed. When using the inside out technique, the SutureLasso is visualized entering the joint between the sutures and the lateral ridge of the talus. The surgeon's thumb is maintained on the gentle curve of the lasso, so that the lasso can be oriented to easily pierce the inferior extensor retinaculum and capsule. The lasso is felt just above the perineal tendons and allowed to penetrate the skin. The wire loop is left in place while pulling the SutureLasso out of the portal. The inferior suture is passed first using the wire loop. The sutures are clearly visualized and the SutureLasso is again passed through the anterolateral portal. And pierced a centimeter anterior to the first pass. The wire loop is again passed through the SutureLasso and the SutureLasso is then removed. The second limb is subsequently shuttled using the wire loop. While this is occurring, your assistant can hold the more inferior limb so that it that it is not accidentally pulled through. Alternatively, the outside end technique can be used. It is useful, however, to have both techniques in your repertoire in order to better access different anatomy. The second anchor cannula is then placed approximately one centimeter proximal to. The first anchor location is approximately right below the level of the articular surface of the joint. In a similar fashion as was done previously, the guidewire is drilled through the cannula during the drilling process. You want to make sure that the cannula is angled out or laterally and not medially into the joint. The guidewire is then over drilled to the hard stop as shown previously. The anchor is then placed through the cannula up to the laser line. The second suture is labeled as a TigerWire suture. To differentiate from the first set of sutures, it is important not to pass the SutureLasso horizontally, because this will engage only the subcutaneous Cutaneous tissue, but instead enter the skin perpendicularly to grab the inferior extensor retinaculum and the atfl and enter the joint as shown. The next step is to have your assistant pass the wire loop so that he can then grab the wire with the suture grasper. Prior to pulling the sutures through, an incision is then made approximately 3 to 4mm in length along Langer's lines. This prevents cutting the suture while making the incision. The inferior limb of the second anchor can then be passed using the wire loop. Once again. This is visualized arthroscopically to make sure that the limbs are not crossed. The second pass is made again perpendicular to the skin and away from the nerve. Again, the wire is pass and grasped within the joint and pulled out of the portal site. The second suture is then passed with the wire loop. At this point one can simulate the suture tying in order to gauge the amount of tissue imbrication, the sutures are passed through the small incision subcutaneously. The ankle is held in neutral and slight eversion, either a slight or not as used in the most inferior set of sutures, or a regular surgeon's knot can be used to tie the sutures. Sometimes it will have a puckering effect of the skin, which can be easily released with a hemostat. The repair can be visualized arthroscopically if the surgeon desires to augment the procedure. The sutures can be tunneled subcutaneously over the lateral border of the fibula. A separate secondary incision can be made in order to pass both sets of sutures proximally. A PushLock anchor can then be placed into the lateral fibula, creating a second row and a SutureBridge situation.

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SutureTak^®