Name: Common Questions Regarding InternalBrace™ Ligament Augmentation
Uploaded: 2017-06-29T00:00:00Z
Channel: Arthrex

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VPT1-00777-EN | A | Common Questions Regarding InternalBrace™ Ligament Augmentation

Gordon Mackay

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Common Questions Regarding InternalBrace™ Ligament Augmentation

Surgeons want to know how much tension should be on the internal brace. And really, when we think about the principle of internal bracing, what we're actually doing is restoring and protecting the natural length of the ligament. So it's more about measuring rather than tensioning. So contrary to your normal intuition in terms of ArthroBrostrom repair of everting the ankle and gathering those soft tissues, expecting them to stretch out as we carry out the ArthroBrostrom repair, you can tension the soft tissues a little, but with the ankle and neutral we can then position the internal brace. And if we measure either end of it for the depth of the anchor, you can put it in a traumatically at that fixed length. If you need to use a little force when you're inserting it, then hemostat just underneath it is enough to ensure there's a bit of physiological laxity, so it will protect your repair, but it won't constrain the joint excessively. No, I think that's a very good point in terms of what happens to the FiberTape. We've been following this very carefully because initially we were concerned that there might be some rare characteristics or any sign of itis that folk have seen with synthetic ligaments, but the difference with InternalBrace is it acts as a seatbelt. It's only there to protect when the tissues are stretched an injurious length, and otherwise they're not excessively loaded. So when we biopsied the internal base, we've seen excellent collagen in growth and a degree of synovial ization, but we've not seen any sign of itis or local reaction. So it's very reassuring. And sometimes actually, if for any reason there's been a re-injury in a revision case, it can be difficult to identify the FiberTape itself within the healed ligament, so we can reassure surgeons that this is a safe product that will not interfere in the longer term with the joint. Initially, we thought the internal brace was appropriate for maybe for our most athletic patients or younger patients who wanted to return to sport. But really, we found that that it transforms your recovery and your rehabilitation. It seems to give you better function and protects your repair. And the and the patients are comfortable. So why would you immobilize them if you didn't need to? For something that only adds an extra ten minutes to your procedure? You can sleep easy, know that your repair is protected, and that patient can mobilize. So there are distinct advantages. Now, I will InternalBrace all my ligament repairs so they don't have to be young athletes if they have diabetes or if they are cardiac cripples. And they might not want to use crutches or be immobilized inefficiently in a boot. It's a tremendous advantage to be able to internally brace and encourage immediate mobilization. So my answer is why wouldn't you internally brace? You certainly would if it was your ankle. In terms of which anchor you insert first, it's really down to the surgeon's preference to an extent. Often it's good to define the anatomy before the ankle or soft tissues are swollen, and you can position your drillholes confidently. So I generally find that preparing the talus first and then inserting my 4.75 with my FiberTape it acts as a bit of a retractor Factor. Well, I then do a standard brostrom repair. Once I've completed the brostrom repair, I can roll the FiberTape out like a carpet over the top of it, and then fix in the fibula itself and cut flush. It doesn't seem to cause any irritation and it balances the ankle perfectly. So I would suggest that that would be adequate. In terms of your question about whether or not we should do both the calcaneofibular ligament and anterior talofibular ligament. I have to say I would an exception that I would do the the calcaneofibular ligament. I would add a little bit of soft tissue tensioning to the retinaculum on top if I felt there was some looseness within the subtalar joint. But I try to gather the calcaneofibular ligament in my soft tissue repair. I think the internal brace still gives adequate protection to the whole ligament complex, if it's positioned at the midpoint of the atfl. There are surgeons, however, who feel better using it as a two single strands, and that is surgeon's preference. And as long as you're confident about the about the anatomy. You can do that without any any concerns at all. It's just that if you're not a surgeon that routinely does that, it a bit like double bundle ACL. It complicates what is otherwise a very simple procedure. In terms of rehabilitation. It is quite different and I try not to be too rigid about it. The idea of the soft walker boot initially I allow patients to weight bear, and really it's to protect the soft tissue repair and allow the swelling to settle in the wound to heal. But as soon as the patient is comfortable enough, they can mobilize and they can come out of the boot with some confidence because at time zero, this restores the normal native strength of the atfl. So we know the ankle is stable, and as long as they're comfortable, there's no reason why they can't mobilize at a pace that they're comfortable with. Some patients want to stay a little longer in the boot, and I can fully understand that. So I allow them to take the lead in terms of their rehabilitation. But as a surgeon, I'm certainly not anxious about early mobilization and loading. In fact, patients respond very positively to it. It's a very good point about where we should place the place the internal brace because surgeons have their own own preferences. Certainly, it's been my experience over the last six years that we've had no concerns in terms of any joint reaction or irritation when it's been placed, as we designed it, to lie over the atfl. When we do that, it seems to incorporate very nicely into the healing ligament complex, and we get collagen in growth and it becomes embedded within it, and it also remains as a form of internal armor. When we put it within the joint, it can potentially cause abrasion or irritation within the joint, and it is much less likely to embed within the healing ligament itself. So although some surgeons can get away with it, there's also been reports of some irritation within the joint by taking that approach. So we certainly recommend that it should be applied on top of the atfl. In terms of who the InternalBrace would be suited to, I agree the our indications widen. We often discourage or discouraged from doing certain procedures as surgeons because of the complications involved see using allograft or autograft and protracted recoveries, we've found with InternalBrace that it can we can simplify the procedure. We can restore normal anatomy. So it does allow us to deal with a different population group. And certainly in my practice, I've now been able to do it in acute situations where someone has had recurrent episodes of instability and had had a severe inversion injury. I would rather standardize their outcome and make it predictable, rather than waiting for another three months and assessing the ankle to see whether or not we can restore normal function, because we can do it simply and effectively. I think there is a responsibility to be more aggressive. Also, we want to give a consistent and predictable outcome because there are lots of people that are managing with unstable ankles that we know will result in secondary disability, even arthritis or fusion and joint replacement in the future. So why, now that we've got the technology, why don't we take this, the challenge on board and offer them better care?

Common Questions Regarding InternalBrace™ Ligament Augmentation

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