Name: InternalBrace™ Ligament Augmentation Procedure: Experience in a Military Population
Uploaded: 2019-06-14T00:00:00Z
Channel: Arthrex

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.

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VID1-000369-en-US | B | InternalBrace™ Ligament Augmentation Procedure: Experience in a Military Population

Kevin D. Martin

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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.

InternalBrace™ Ligament Augmentation Procedure: Experience in a Military Population

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