What's In My Bag? With Thomas Clanton, MD, and Kent Ellington, MD
InternalBrace Ligament Augmentation RepairQ. Why have Brostroms been considered the gold standard when some of the literature indicates that patients have to step down in their activities?
Dr. Clanton: The Maffulli article in The American Journal of Sports Medicine (AJSM) is one of the only articles that includes a long-term outcomes analysis of the Brostrom procedure and suggests such a reduction in activity (42%). Most other studies, which look at shorter term results, generally have reported success rates ranging from 85-95% with the Brostrom procedure or with the Gould modification of this procedure.
Dr. Ellington: I would not call it a complication, but could be considered a failure. Patients want their instability corrected. The Brostom does this well; however, if patients have improved stability, yet cannot return to their previous level of activity/function, then the gold standard seems “tarnished.”
Q. What compelled you to use the InternalBrace construct to augment your Brostroms?
Dr. Clanton: After hearing Dr. Gordon Mackay’s presentation on the InternalBrace concept, we performed biomechanical testing that confirmed the improved strength of the augmentation. This was recently published in the February issue of The American Journal of Sports Medicine.
Dr. Ellington: I needed an augment (because of the stated failures above). I traditionally used the Evans procedure (split transfer of the brevis to the fibula). I never really liked this…it wasn’t anatomic, it sacrificed a tendon and you can make patients too tight. I decided to first use it in my work comp and revision Brostroms and when I experienced great success in these patients (more difficult patients) I was surprised actually. From there, I have now adopted to using InternalBrace in all my cases.
Q. We often hear “I never met a Brostrom that needed augmentation” OR “My Brostroms all do fine.” Knowing the clinical value, what would be your response to those conversations?
Dr. Clanton: The Brostrom procedure has been an excellent procedure over the short-term, but does not work in all situations. For example, it is not appropriate for patients who are reinjured and have instability following prior ankle reconstructions. I also do not favor the Brostrom technique in patients who are hyperflexible. In my opinion, we should always be vigilant for methods by which we can improve the results of what we do for our patients.
Dr. Ellington: The literature doesn't support such claims and once I thought the same. These patients rarely come back after initial follow-up. However, I strongly believe that although their instability has improved, some are not happy with their outcome because of inability to return to previous level. These patients likely choose not to return to see their doctor.
Q. It is understood that this procedure is relatively new with limited, long-term clinical follow-up. Can you comment on the outcomes and your experience with your patients you have treated? Please explain the difference between standard Brostrom repair and those that have InternalBrace?
Dr. Clanton: While the procedure is relatively new for the ankle, it has been used in other areas such as the shoulder and for the Achilles tendon with good results and few negative outcomes.
Dr. Ellington: I have used InternalBrace on around 25 patients, most with long-term follow-up. Without a doubt, they have increased stability.
Q. What have been the most positive effects of the InternalBrace for your patients?
Dr. Clanton: In my patients, the most positive aspect of the InternalBrace has been less worry (for the patient and me).
Dr. Ellington: Confidence in the ankle.
Q. Surgeons often speak of clinical studies before trying something new. Why try the InternalBrace now? What are the minimum expectations you have?
Dr. Clanton: Fortunately, there are now biomechanical studies that support the use of the InternalBrace and there are individuals such as Drs. Mackay, Coetzee, Gates, Vora, and Ellington who have extensive experience with the technique in the lateral ankle as well as other locations.
Dr. Ellington: It should be tried because the standard Brostrom has solid evidence that it is not as good as we think. The minimum expectations are no additional complications from using the InternalBrace, easy application of the system.
Q. What are the technique pearls you have learned and can pass along?
Dr. Clanton: It is important to follow the recommendations for exactly how to perform the technique, and to understand the anatomy and biomechanical function that one wishes to restore. It is certainly possible to place the augmentation in an incorrect position and over-constrain the joint. Dr. Mackay’s technique of keeping a hemostat under the FiberTape™ during the insertion of the second SwiveLock seems to help in avoiding this.
Dr. Ellington: The talus is a hard bone. When I tap the talus, I leave the tap in while I insert the system into the fibula. This allows the talus to “stretch” a little, making the placement of the talus implant a little easier.
Q. In simple terms, explain your surgical technique.
Dr. Clanton: I perform the Brostrom procedure and augment it with the InternalBrace placed over the top of the ATFL arm of the Brostrom.
Dr. Ellington: I repair my ATFL with 3.0 suture anchor. Then drill and tap (leave tap in) the talus. Next I drill and tap the fibula. I place the fibular side, line up the talus side (making mark a on FiberTape with surgical marker). I remove talus tap, place talus implant, with hemostat under and with the ankle in slight plantar flexion and inversion to prevent overtightening.
Q. Have you considered InternalBrace for other indications (Spring Ligament, Deltoid Ligament, and/or Lateral Ankle with Arthroplasty)?
Dr. Clanton: I have used the InternalBrace in all of those situations and it has been very effective.
Dr. Ellington: Yes, I have done three for spring ligament.
Intra-op: I place one limb plantar to dorsal with the FDL and the other dorsal to plantar. I hold the foot in slight plantar flexion/inv as I tension. Placing the calcaneus tunnel is verified first by finding the sustentaculum tali directly, then confirming by placing a small guide wire and checking a lateral and axial heel view. Then I remove the wire and drill.
Post-op: Awesome corrections. Fully weight-bearing — radiographic parameters much better than those without spring ligament repair. I now do on all flatfoot reconstruction. I’m starting to believe that this could replace the need for a lateral column lengthening (Evans) in some cases. It really improves talonavicular uncoverage.