Internal Brace Procedure: Understanding, Applications, and Recovery

What is an Internal Brace Procedure?

An internal brace procedure is a surgical technique designed to augment the primary repair or reconstruction of an injured ligament by reinforcing it with a strong, non-absorbable suture tape, providing immediate stability and protecting the healing tissue.

Understanding Ligamentous Injuries

Ligaments are strong, fibrous bands of connective tissue that connect bones to other bones, providing stability to joints and guiding their motion. When a ligament is subjected to excessive force, it can stretch or tear, leading to an injury known as a sprain. Severe sprains involve partial or complete tears, which can significantly compromise joint stability and function. Traditional surgical approaches for torn ligaments often involve direct repair (suturing the torn ends together) or reconstruction (replacing the torn ligament with a graft). While effective, these methods typically require a prolonged period of immobilization to protect the healing tissue, which can lead to muscle atrophy and joint stiffness.

What is an Internal Brace Procedure?

The internal brace procedure is a relatively newer surgical advancement in orthopedic sports medicine. It is not a standalone repair for a completely ruptured ligament, but rather an augmentation or reinforcement of a primary ligament repair or reconstruction. The core of the procedure involves the use of a high-strength, non-absorbable suture tape (commonly made from polyethylene, like Arthrex FiberTape®) that is strategically placed across the repaired ligament and anchored into the adjacent bones.

The fundamental purpose of the internal brace is to provide immediate, robust biomechanical support to the healing ligament, acting much like an "internal seatbelt." This added stability offloads stress from the native healing tissue or graft, allowing for a more protected and potentially accelerated rehabilitation process.

How Does an Internal Brace Work?

From a biomechanical perspective, the internal brace works by sharing the load placed on the injured or reconstructed ligament. When the joint moves or experiences stress, a portion of that force is absorbed by the strong suture tape, rather than solely by the delicate, healing ligament. This mechanism offers several critical advantages:

• Stress Shielding: The tape "shields" the healing ligament from excessive tensile forces, reducing the risk of re-rupture or stretching out during the early phases of recovery.
• Enhanced Stability: It provides immediate static and dynamic stability to the joint, which can be crucial for preventing unwanted motion that could disrupt the repair.
• Promotes Healing: By protecting the primary repair, the internal brace creates a more favorable environment for the body's natural healing processes, allowing for more robust collagen formation and maturation of the ligamentous tissue.

The tape is anchored into pre-drilled tunnels or directly onto the bone using small screws or specialized anchors, ensuring secure fixation on either side of the ligament tear or reconstruction site.

Common Applications of the Internal Brace

The internal brace has found increasing application across various joints, particularly in sports-related injuries:

• Ankle Ligament Repair: It is frequently used to augment repairs of the lateral ankle ligaments, such as the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL), often in conjunction with a Brostrom repair for chronic ankle instability. This allows for earlier weight-bearing and return to activity.
• Elbow Ulnar Collateral Ligament (UCL) Repair/Reconstruction: Commonly known as "Tommy John" surgery, the internal brace is a significant advancement in treating UCL injuries in throwing athletes. It can be used to directly repair a UCL tear (if the tear pattern is suitable) or, more commonly, to augment a UCL reconstruction, providing immediate strength and allowing for a much faster return to throwing compared to traditional methods.
• Shoulder Ligament Repair: Applications include augmentation of repairs for acromioclavicular (AC) joint separations, where it helps stabilize the clavicle to the coracoid process, and potentially for certain glenohumeral ligament repairs (e.g., Bankart repair augmentation for shoulder instability).
• Knee Ligament Repair: While not typically a substitute for ACL reconstruction, the internal brace can be used to augment primary repairs of other knee ligaments such as the medial collateral ligament (MCL) or lateral collateral ligament (LCL) in specific tear patterns, or as an additional stabilizing element in complex multi-ligament knee injuries.

Advantages of the Internal Brace

The adoption of the internal brace technique is driven by several compelling benefits:

• Accelerated Rehabilitation: The most significant advantage is the ability to initiate earlier and more aggressive rehabilitation protocols. The immediate stability provided by the brace reduces the need for prolonged immobilization, leading to faster restoration of range of motion and strength.
• Preservation of Native Tissue: In many cases, the internal brace allows for a direct repair of the torn ligament rather than a full reconstruction with a graft. Preserving native tissue can lead to better proprioception (the body's sense of joint position) and potentially more natural joint mechanics.
• Reduced Re-injury Risk: By protecting the primary repair during the critical early healing phase, the internal brace aims to reduce the risk of re-rupture or persistent instability.
• Improved Outcomes for Athletes: For competitive athletes, the accelerated recovery timeline can mean a significantly faster return to sport, often with a reduced risk of re-injury.
• Minimally Invasive Potential: The procedure can often be performed using arthroscopic or minimally invasive techniques, leading to smaller incisions, less pain, and quicker initial recovery.

Potential Disadvantages and Considerations

While highly beneficial, the internal brace procedure also has considerations:

• Cost: The specialized suture tape and instrumentation add to the overall cost of the surgical procedure.
• Surgical Skill: Precise placement and tensioning of the internal brace are crucial for its effectiveness, requiring a skilled and experienced surgeon.
• Not Universally Applicable: It is not suitable for all ligamentous injuries, especially those involving chronic degeneration, severe tissue loss, or complex avulsion fractures where a primary repair is not feasible.
• Potential for Irritation: Although the synthetic material is generally well-tolerated, there is a theoretical, albeit low, risk of irritation or discomfort from the implant in some individuals.
• Long-term Data: As a relatively newer technique, long-term outcomes data, particularly beyond 5-10 years, are still accumulating for all applications.

The Surgical Procedure

The internal brace procedure is typically performed under general anesthesia. The specific technique varies based on the joint and ligament involved. Generally, the surgeon will first perform the primary repair or reconstruction of the injured ligament. Following this, small tunnels are drilled into the bones on either side of the repaired ligament. The high-strength suture tape is then passed through these tunnels and secured with small anchors or screws, creating a taut bridge across the repair site. The tension of the tape is carefully adjusted to provide optimal stability without over-constraining the joint.

Recovery and Rehabilitation

Recovery following an internal brace procedure is often characterized by a more aggressive rehabilitation protocol compared to traditional methods. While initial immobilization (e.g., in a brace or cast) may still be necessary for a short period, the internal brace allows for earlier initiation of controlled range of motion and progressive strengthening exercises.

Physical therapy is paramount to success. It focuses on:

• Early Range of Motion: To prevent stiffness and restore joint mobility.
• Progressive Strengthening: To rebuild muscle strength around the joint.
• Neuromuscular Control and Proprioception: To re-educate the joint's stability and balance mechanisms.
• Sport-Specific Training: For athletes, a structured return-to-sport program is critical, gradually reintroducing high-impact and rotational movements.

The overall recovery timeline is often significantly reduced, allowing many patients, especially athletes, to return to their activities much sooner than with conventional approaches.

Who is a Candidate?

Candidacy for an internal brace procedure is determined by an orthopedic surgeon based on several factors, including:

• Type and Severity of Ligament Injury: Acute, repairable tears are often ideal candidates.
• Patient Activity Level and Goals: Athletes or individuals with high functional demands often benefit most from the accelerated recovery.
• Overall Joint Health: The procedure is most effective in joints free of significant arthritis or other major structural damage.

Conclusion

The internal brace procedure represents a significant advancement in orthopedic surgery, offering a robust and biomechanically sound method to augment ligament repairs and reconstructions. By providing immediate stability and protecting healing tissues, it facilitates accelerated rehabilitation, preserves native anatomy, and aims to improve long-term outcomes, particularly for athletes seeking a faster and more secure return to activity. As with any surgical intervention, a thorough discussion with an orthopedic specialist is essential to determine if an internal brace procedure is the most appropriate treatment option for a specific injury.