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Category: Hindfoot; Arthroscopy; Sports; Trauma Introduction/Purpose: Flatfoot deformities are chronic debilitations that involve multiple ligament complexes that stabilize the hindfoot. No study has clearly evaluated the efficacy of utilizing the spring ligament internal-brace fibertape device as an adjunct through clinical and radiographic measures. The purpose of this study is to explore the diagnostic efficacy of 3T MRI to evaluate the spring ligament, and to compare operative failures, complications, and radiographic outcomes of patients who underwent procedures for posterior tibial tendon dysfunction (PTTD) that employed the internal-brace fibertape (IB) and those that did not in the non-internal-brace (NIB) group. Methods: Following IRB approval, patients that underwent flatfoot reconstruction by four surgeons at a single institution between 2015 and 2018 were queried from an institutional radiology database. A total of 44 cases were identified with procedures that utilized the IB, and those that underwent MRI preoperatively had spring ligament integrity compared to intraoperative findings. These 44 cases that utilized the IB were subsequently match paired 1:2 with an NIB group. Data was collected retrospectively for both clinical and radiographic outcomes. Clinical outcomes included failures leading to reoperation, complications, and additional procedures. Radiographic parameters involved pre- and post-operative comparisons. Inadvertent reoperations that implicated malunion or the need for a triple arthrodesis within 13 months of the initial procedure were compared. Patient complications were compared. Statistical analysis was performed to evaluate the relationship between the clinical outcomes of these patients and use of the IB as an additional source of stabilization. Results: A total of 132 cases were analyzed with 44 that employed the IB and 88 NIB. The average ages for each group were 46.7 and 46.5 years for the IB and NIB group respectively. Of the 44 IB patients, 0 out of the 10 (0.0%) who had received a preoperative MRI were correctly identified as having an attenuated or frankly torn spring ligament as determined intraoperatively. There were significant differences in failure rates between groups with 0.0% of IB procedures and 4.5% of NIB procedures resulting in failure (p=0.022). There were no significant differences among complications between groups. There were significant improvements between all pre- and post-operative radiographic measurements within each group. However, the improvements were not found to be significant between groups. Conclusion: The results of this systematic retrospective chart review demonstrate that the spring ligament internal-brace device may serve as an effective adjunct in PTTD procedures and suggest considering it when planning irrespective of preoperative MRI findings. The data suggest that failure rates may be reduced without increasing complications. Both methods of fixation can provide significant improvements in reconstructing the arch. However, the internal-brace may reduce the prevalence of post- operative malunion or the need for a triple arthrodesis.