Internal Bracing Reinforcement

Internal Bracing Augmentation (or 'Reinforcement') with Fibre Tape has really transformed PCL surgery worldwide. It is also used to strengthen up ACL or extra articular grafts. Where we have really seen a difference is in the multiligaments and the PCLs because we always used to have slackness in the PCL (or 90% of the time we would). We just don't see that any more.

Gordon Mackay introduced the concept of the 'internal brace' which he used to repair ligaments particularly around the ankle, for example in ruptured Achilles tendon or anterior talofibular ligament. He would then just oppose the tissue and get the patients going very quickly. Having done that successfully in the ankle, he moved up to the knee and we’ve been working together on this concept - it is Gordon’s technique, but we have been refining it.

Besides using it in adults, I have been particularly successful in using it in children. The current concept of repairing the ACL, as opposed to reconstructing it, has become so popular that in Austria Jürgen Barthofer - who does 70 acute ACLs a year and looks after elite skiers - does it as a routine, and has had a very low failure rate. Gordon Mackay has 2- and 5-year data. We have our own series which we are following up. The technique is fairly straightforward to do and to teach, and is one of the highlights of teaching in Freiham - the big Arthrex lab or cadaveric facility in Germany. They have 50 cadaveric workstations there, and twice a year surgeons come in and get trained up on this technique. I also have visitors in my operating theatre most weeks - two on a Friday and most weeks during the week as well - to come and see this technique.

The technique involves putting stitches around the existing ACL tissue - and this can be done chronically (I have done one at 5 months and Gordon Mackay has done one at a year) - as long as the tissue is good quality it does not really matter how long the patient is from the injury. Of course the longer you go from an injury the less likely it is that there will be good tissue, so we do prefer to do them ‘fresh’. We use a special device to pass the stitches into the top of the ACL where it has come away from the side of the femur - a so-called proximal tear - which 90% of them are, and we pass sutures up a tunnel in the femur. We only need to make that 2.4 mm wide. So we drill a 2.4 mm tunnel in the femur and a 2.4 mm tunnel in the tibia, and we pass the so-called ‘internal brace’ up from the bottom to the top, ie FibreTape folded over a ‘tight-rope-button' (which is the fixation device). Then alongside it in the femur we pull up the repair sutures, and they get tied onto the button. So the ACL is re-opposed to the side wall by pulling the ACL back onto the sidewall through that tunnel by using the sutures, and then tying those onto the button, and the button is also suspending the FibreTape which goes all the way down through the existing ACL, through the tibia and is then fixed onto the tibia with some form of fixation device (we use a little bio-degradable screw).

Now I have done a 5-year old - who is just coming up to a year and is doing brilliantly. I had a second look at three months because I took the hardware out, and it looked amazing. I have done a 6 year old too - same story. I have done a nine year old, a twelve year old and a series of teenagers - and I have got a 15 year old who got back to playing lacrosse ‘for England!’ at 5 months - which is just unheard of!

It is a great technique, and doesn’t burn any bridges. This 15 year old girl (or 16 year old), who played Elite-level lacrosse, is back playing now and she says her knee feels 100% normal which is quite unusual after her ACL surgery - but many of these patients do report that. And the nice thing is that, if anything does go wrong (and I have had no failures in the paediatric group and only one in the adult group) you’ve only made these tiny little pilot holes, these tunnels, so it is like going back and doing a fresh ACL. It is very very new and exciting, and more parents need to know about it.

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Adrian Wilson
- knee surgeon

I am really proud of the concept, which I got really from Peter Meyers in Australia. Peter always used nylon tape inside his grafts if they were small in size (say less than 7mm in diameter). He was doing it for 30 years (20 years when I joined him as a Fellow, and he had had no side effects. So when I was shown the FibreTape I thought “that’s a great alternative to the nylon tape because it is so much finer, and stronger and smaller". So we started doing that five years ago and we have got over 300 cases now. No-one has had any issues with synovitis, or with it causing destruction to the bone - it has been incredibly successful. And that has taken off all over the world.To date one million FibreTapes have been sold.

Video from Wiemi Douoguih, MD - orthopaedic surgeon with MedStar Orthopaedic Institute at MedStar Washington Hospital - about his patient with a similar procedure.

For those of you who sign into MedScape, here is an interesting article entitled 'A Novel Arthroscopic Technique for ACL Preservation' by colleague, Gregory S. DiFelice, MD.

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