Internal Brace for Ligament Repairs:

As Good As It Sounds?

Internal Brace for Ligament Repairs: As Good As It Sounds?

By Alan Zhang, M.D., FAANA

Member, AANA Communications and Technology Committee


Augmentation of ligament repairs by adding suture (or tape-type suture) and anchor constructs has grown in popularity with applications in many orthopaedic procedures. Many refer to this technique as adding an “Internal Brace.” It should be noted that the name InternalBrace™ refers to a trademarked product utilizing a specific orthopaedic device company’s suture and anchor products. Sometimes a trademarked name sounds so good and becomes so synonymous with a product that it is used in common language even when referring to other brands. Other examples of this phenomenon include referring to the brand name BAND-AID® by Johnson and Johnson (New Brunswick NJ) instead of “adhesive bandage” or the brand name Kleenex® by Kimberly-Clark (Neenah, WI) instead of “tissue paper.” You can credit outstanding marketing and branding or strong market presence for these cases but with respect to InternalBrace™, as multiple orthopaedic companies produce sutures, tapes and anchors that can be used for augmentation, a more generic term of “suture augmentation” may be appropriate.


Suture augmentation has gained national attention in recent news as high-profile athletes have undergone surgical procedures utilizing this technique with the hopes of achieving a faster return to play. While some of these cases have been anecdotally successful, it is important to better understand the biomechanical and clinical evidence behind the many applications of suture augmentation.


One of the most high-profile cases reporting the use of suture augmentation occurred when NFL quarterback Aaron Rodgers suffered an Achilles tendon rupture during his first game of the 2023 season. He subsequently underwent an Achilles tendon repair with tape-type suture augmentation. The classic Achilles tendon repair involves open or percutaneous repair in a direct tendon to tendon fashion at the site of rupture. Suture augmentation can be applied to this construct by passing tape-type suture through the torn tendon and fixing the tape directly to the calcaneus with anchors. This technique has shown improved strength compared to traditional repair under biomechanical testing and has been reported to possibly allow return to play within four months of the surgery (at the time of writing this newsletter Rodgers has not yet completed his rehabilitation). Despite the recent publicity for augmentation of Achilles tendon repairs, there remains a lack of clinical research on outcomes with only reports of small case series currently available1.


Another headline grabbing case occurred when Brock Purdy, quarterback for the San Francisco 49er’s, suffered an acute tear of his elbow Ulnar Collateral Ligament (UCL) on his throwing arm during the NFL playoffs. He underwent primary repair of the UCL with tape-type suture augmentation in March 2023 and was able to return to play six months later at the start of the following season. Return to high-level throwing was significantly faster in this case compared to the classic treatment for these injuries utilizing UCL reconstruction or Tommy John surgery. For UCL reconstruction, return to play would be at least one year with some baseball pitchers out for two years. UCL repair with augmentation has been favorably supported by recent literature as systematic reviews have reported this technique to have biomechanically equivalent findings compared to UCL reconstruction but with a faster return-to-play timeline and a high return to pre-injury level of play2,3.


Repair of thumb ulnar collateral ligament (UCL) injuries has also employed use of suture augmentation. NFL quarterback Drew Brees returned to play five weeks after repair and suture augmentation of a tear in his thumb UCL on his throwing hand in 2019. For this procedure, while biomechanical testing has demonstrated increased strength using suture augmentation compared to repair alone, further clinical research is needed. Currently only a series of 18 players with successful return to play after undergoing thumb UCL repair with augmentation has been reported4.


With a renewed interest in repair of anterior cruciate ligament tears as opposed to reconstruction, suture augmentation of primary ACL repairs has also garnered interest. Biomechanical analysis of suture augmentation for ACL repair revealed higher load to failure and stiffness of the construct5. A recent systematic review revealed the procedure to have a 10.4% failure rate from 347 patients in nine studies and concluded the procedure to be safe for acute proximal ACL tears6. Augmentation has been used in other aspects of knee surgery such as to treat MCL, PCL and LCL injuries, but further research is also needed to assess clinical outcomes for augmentation of these procedures.


Finally, one of the first procedures in which suture augmentation was utilized was for Brostrom repair for ankle instability. This application of suture augmentation has obtained higher level clinical evidence as in a multi-center, randomized trial of 119 patients. Patients who underwent Brostrom repair with augmentation were able to return to play sooner (13 weeks) than those who underwent a tradition modified Brostrom procedure (17.5 weeks)7. Patients who underwent augmentation were also more likely to return to play by 26 weeks (96%) compared to patients who underwent the traditional procedure (87%). Clinical studies such as this are needed for many of the other applications of suture augmentation.

Despite anecdotal evidence from high-profile athletes that may drive demand for these procedures, it is important to note that there may be drawbacks with routine use of suture augmentation. For one, adding implants and materials needed for augmentation can incur significant additional OR costs. Further, tape augmentation constructs may over-constrain joints if not properly tensioned and long-term risks for degenerative change are unknown.


In conclusion, whether you call it “suture augmentation” or “internal brace,” although biomechanical analyses have typically demonstrated improved construct strength, higher quality clinical studies are still needed to support routine use of suture augmentation in many orthopaedic procedures.



  1. Jackson, G.R., Opara, O., Tuthill, T., Khan, Z.A., Hevesi, M., Mameri, E., Jawanda, H., Batra, A.K., Schundler, S., McCormick, J., Knapik, D.M., Verma, N., Chahla, J. Suture Augmentation in Orthopaedic Surgery Offers Improved Time-Zero Biomechanics and Promising Short-Term Clinical Outcomes. Arthroscopy. 2023 May;39(5):1357-1365. doi: 10.1016/j.arthro.2023.01.012. Epub 2023 Jan 18. PMID: 36681361.
  2. Spears, T.M., Parikh, B., Chalmers, P.N., Smith, M.V., Freehill, M.T., Bowman, E.N. Elbow Ulnar Collateral Ligament Repair With Suture Augmentation Is Biomechanically Equivalent to Reconstruction and Clinically Demonstrates Excellent Outcomes: A Systematic Review. Arthroscopy. 2023 Oct 11:S0749-8063(23)00808-3. doi: 10.1016/j.arthro.2023.09.030. Epub ahead of print. PMID: 37832744.
  3. Boksh, K., Mishra, P., Akram, N., Abdolrazaghi, S., Singh, H. Medial Ulnar Collateral Ligament Repair With Augmentation: A Systematic Review and Meta-analysis of Preclinical Studies. Orthop J Sports Med. 2023 May 2;11(5):23259671231158373. doi: 10.1177/23259671231158373. PMID: 37152548; PMCID: PMC10159257.
  4. Gibbs, D.B., Shin, S.S. Return to Play in Athletes After Thumb Ulnar Collateral Ligament Repair With Suture Tape Augmentation. Orthop J Sports Med. 2020 Jul 29;8(7):2325967120935063. doi: 10.1177/2325967120935063. PMID: 32775473; PMCID: PMC7391447.
  5. Massey, P., Parker, D., McClary, K., Robinson, J., Barton, R.S., Solitro, G.F. Biomechanical Comparison of Anterior Cruciate Ligament Repair With Internal Brace Augmentation vs. Anterior Cruciate Ligament Repair Without Augmentation. Clin Biomech (Bristol, Avon) 2020;77:105065.
  6. Wilson, W.T., Hopper, G.P., Banger, M.S., Blyth, M.J.G., Riches, P.E., MacKay, G.M. Anterior Cruciate Ligament Repair With Internal Brace Augmentation: A Systematic Review. Knee. 2022 Mar;35:192-200. Doi: 10.1016/j.knee.2022.03.009. Epub 2022 Mar 30. PMID: 35366618.
  7. Kulwin, R., Watson, T.S., Rigby, R., Coetzee, J.C., Vora, A. Traditional Modified Broström vs. Suture Tape Ligament Augmentation [published online ahead of print, 2021 Jan 23]. Foot Ankle Int. 2021;1071100720976071. doi:10.1177/1071100720976071.
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