Patients who undergo this reconstruction are kept on crutches for 6 weeks with no to minimal weight-bearing movement, but are allowed full range of motion. Am J Sports Med. Arthritic conditions of the PTFJ are treated similar to those of any diarthrodial joint, with additional option of surgical arthrodesis or resection arthroplasty. According to the Ogden classification, proximal tibiofibular joint injuries can be classified into the following subgroups 1-6: type 1: subluxation (more often in children and adolescents ) type 2: anterior dislocation (most common ~85%) type 3: posteromedial dislocation type 4: superior dislocation Radiographic features Plain radiograph The coronal images demonstrate the normal anterior ligament located just caudal to the anterior arm of the short head of the biceps femoris tendon (purple arrow). In the past, while others have often treated this instability of this joint by fusing it, we have reported through research that a proximal posterior tibiofibular joint ligament reconstruction is easily performed, does not overconstrain the joint and has decreased the chance of leading to ankle pathology further down the line. Knee Surg Sports Traumatol Arthrosc. Dr. La Prade had just moved to Vail and I was his 2nd patient @ The Steadman Clinic. Related (Please keep reading below for more information on this condition.). Purpose: Internal bracing is performed with a knotless suture button (TightRope syndesmosis implant; Arthrex). In addition, we frequently perform a common peroneal nerve neurolysis concurrent with the ligament reconstruction to release the scar tissue around the common peroneal nerve so that any further nerve irritation will not occur after surgery due to postoperative swelling or scar tissue entrapment. Proximal tibiofibular ligamentous abnormalities were present in 100% of acute (< 6 months) and 85.7% of chronic (>6 months) instability cases who underwent MRI. While it is often difficult to identify a complete tear, in the absence of a history of dislocation or instability, edema in the ligaments associated with a fibular bone bruise along the posterior ligament attachment should raise awareness of recent traumatic injury. We recommend joint reconstruction to repair the proximal tibiofibular joint, which will retain the functional anatomy and rotation of the joint, over arthrodesis, especially in children and athletes. We advise that patients initiate a program of weaning off the crutches at the six week point and starting the use of a stationary bike to regain the strength of their quadriceps mechanism. My right knee was totally destroyed; ACL, MCL, PCL all severely torn; the patella was the only thing intact in my right knee. Protection of the peroneal nerve during surgery helps to prevent injury and relieves symptoms common to this injury. Reconstructive procedures are recommended for patients whose source of pain is instability in the joint as opposed to arthritis. The TightRope needle is then passed through to the anteromedial aspect of the tibia until it exits the skin medially. A closed reduction should be attempted in patients with acute dislocation. 1974 Jun;(101):192-7. The relative avascularity of the area of the proximal tibiofibular joint prevents the presentation of knee effusion with an isolated injury, but there may be a prominent lateral mass. Medial Patellar Instability: A Systematic Review of the Literature of Outcomes After Surgical Treatment. Evaluation of the joint, the supporting ligaments, and the common peroneal nerve should be assessed alongside evaluation of the posterolateral corner. Resecting and protecting the peroneal nerve during surgery can prevent peroneal nerve palsy. The proximal tibiofibular joint is a synovial joint that functions in dissipating lower leg torsional stresses and lateral tibial bending moments and in transmitting axial loads in weight-bearing [ 1 ]. 55 year-old female status-post fibular head dislocation with stable reduction but lateral-sided laxity. Joint subluxation is common in adolescents, typically girls, and results from hypermobility of the joint, in which symptoms can decrease with skeletal maturity.2 Some studies have shown that congenital dislocation of the knee can also be associated with atraumatic superior dislocation of the proximal tibiofibular joint.1, Traumatic dislocations of the proximal tibiofibular joint are uncommon and are normally caused by high-energy injury or a fall on a twisted knee. Reconstructive procedures are recommended for patients whose source of pain is instability in the joint as opposed to arthritis. The anterior sagittal image demonstrates the normal anterior ligament (green arrow) and the relationship between the anterior ligament, the FCL (yellow arrow), the anterior arm of the short head of the BF tendon (purple arrow), and the anterior arm of the long head of the BF tendon (orange arrow). A fibular bone bruise (asterisk) is present near the attachment of the posterior ligament. The condition is often missed, and the true incidence is unknown. The reconstructive procedure is recommended for patients whose pain is a result of joint instability. The arthrodesis procedure is recommended for patients in whom the correction of joint instability would not relieve pain, such as patients with proximal tibiofibular joint arthritis. Important Points Proximal tibiofibular (PTF) joint instability is a rare condition: only 96 cases have been reported in the published literature. History and physical examination are very important for diagnosis. Atraumatic instability is more common and often misdiagnosed. Preoperative Considerations I can run, bike, & climb mountains. Anatomic reconstruction of chronic symptomatic anterolateral proximal tibiofibular joint instability. Proximal Tibiofibular Joint Injuries - Discussion: - function of the PTFJ - accept 1/6 the axial load of the leg - resist torsional stresses originating from the ankle - resist tensile forces created with weight bearing - resists lateral bending forces - subluxation is common in preadolescent females and resolves with skeletal maturity 3D renders demonstrate posterior proximal tibiofibular reconstruction using LaPrades technique (12A). doi: 10.2214/AJR.07.3406. and transmitted securely. MRI evaluation of chronic instability is more challenging given the lack of associated soft tissue edema (Figure 11). Atraumatic proximal tibiofibular joint subluxation is the more common presentation of proximal tibiofibular joint instability. Patients often report symptoms such as knee instability and giving way during these activities, as well as clicking and popping during daily activities.3, Traumatic dislocations commonly cause pain along the lateral knee that radiates into the region of the iliotibial band and the patellofemoral joint and is increased with palpation of the prominent fibular head and ankle motion.4 The patients pain commonly limits the range of motion, especially knee extension, and motion of the ankle; the patients ability to bear weight on the affected leg is also limited by pain. PMID: 20127312. LaPrade RF, Gilbert TJ, Bollom TS, Wentorf F, Chaljub G. The magnetic resonance imaging appearance of individual structures of the posterolateral knee. It is common for patients to also have transient peroneal nerve injuries, especially with posteromedial dislocation.1,2. Physical Examination Techniques FOIA Recurrent dislocation of the proximal tibiofibular joint. Moatshe G, Cinque ME, Kruckeberg BM, Chahla J, LaPrade RF. In acute cases, it may be difficult to make the patient relax sufficiently to be able to examine for proximal tibiofibular joint instability, but usually having the knee flexed to 90 degrees and trying to perform an anterolateral subluxation maneuver of the proximal tibiofibular joint is sufficient to confirm this diagnosis. The chief function of the proximal tibiofibular joint is to dissipate some of the forces on the lower leg such as torsional stresses on the ankle, lateral tibial bending movements, and tensile weight bearing. All nonsurgical therapies should be attempted before surgical intervention. CHRONIC INSTABILITY. The examination of patients with atraumatic subluxation or chronic instability should be performed with the knee flexed to 90 degrees. 3. Once a diagnosis of PTFJ instability is confirmed, a standard diagnostic arthroscopy is performed through 2 portals. Pessoa P, Alves-da-Silva T, Guerra-Pinto F. Knee Surg Sports Traumatol Arthrosc. Improved outcomes after all forms of PTFJ instability treatment were reported; however, high complication rates were associated with both PTFJ fixation (28%) and fibular head resection (20%). Subluxation of the proximal tibiofibular joint. Knee Surg Sports Traumatol Arthrosc. The diagnosis of proximal tibiofibular joint instability is almost always based on a thorough clinical exam. Numerous disorders of the proximal tibiofibular joint can present as lateral knee pain. The anatomy and function of the proximal tibiofibular joint. Successful diagnosis of the injury can be improved by a better understanding of the biomechanics of the joint and a clinical suspicion of the injury when symptoms are present. Although many patients do not note symptoms during daily activities, symptoms may develop during activities that require sudden changes in direction. Clin Imaging. 1998. Knee Surg Sports Traumatol Arthrosc. We anticipate that our patients will return back to full activities about 4-5 months after surgery, following the rehabilitation program. 1991 Nov;20(11):957-60. PMID: 28339288. The proximal tibiofibular joint ligaments both strengthen the joint and allow it to rotate and translate during ankle and knee motion. Reconstruction is recommended to maintain correct anatomic function and rotation of the joint. Flexing the knee to 90 degrees to relax the lateral collateral ligament and biceps femoris tendon, then moving the fibular head anteriorly and posteriorly, can test instability of the joint. However, on a true lateral radiograph, the fibular head should intersect a line created by the posteromedial portion of the lateral tibial condyle and anterior or posterior displacement of the fibular head will disrupt this relationship.9 In cases of transient traumatic dislocation, anatomic alignment may be within normal limits and therefore normal radiographic alignment does not exclude the possibility of recent dislocation or instability. Dislocation of the Proximal Tibiofibular Joint - Musculoskeletal Key When the knee is flexed beyond 30 degrees, relaxation of the FCL and biceps femoris tendons allows the fibula to shift anteriorly which reduces joint stability and allows the fibular head to move approximately 7-10 mm in the anteroposterior plane.6,7 In the event of an added twisting element, external rotation of the tibia pulls the fibula laterally and tension in the anterolateral compartment musculature then further draws the fibula anteriorly.8. eCollection 2022 Sep. Pappa E, Kakridonis F, Trantos IA, Ioannidis K, Koundis G, Kokoroghiannis C. Cureus. . Axial (8A), coronal (8B), and sagittal (8C) fat-suppressed proton density-weighted images. Injuries to the joint are more commonly atraumatic and should be treated with surgery only after all other therapies have been exhausted. Optimal radiographic evaluation of the PTFJ is performed in 45-60 degrees internal rotation. Instability of the proximal tibiofibular joint - PubMed In general, we prefer an autograft (using ones own tissues) because it will heal in faster than an allograft (cadaver graft). In this regard, it is recommended that the strengths of grafts chosen for proximal tibiofibular reconstructions meet or exceed these values. The posterior ligament is disrupted near the fibular attachment on the axial image with subtle irregularity on the sagittal image. Warner B.T., Moulton S.G., Cram T.R., LaPrade R.F. Lateral Collateral Ligament and Proximal Tibiofibular Joint The integrity of the proximal tibiofibular joint is best visualized through plain radiographs. Am J Sports Med. I am so glad I did! Chapter 92 R. F. (2010). Improved outcomes can be expected after surgical treatment of PTFJ instability. Furthermore, we excluded studies that did not report patient follow-up time and studies without any patient-reported, clinical or radiographic outcomes at the final follow-up. 2022 Sep 30;33(3):291-304. doi: 10.31138/mjr.33.3.291. Proximal tibiofibular stabilization by anatomical ligamentoplasty and Diagnosis requires careful assessment of radiographs of the knee and tibia (often missed injury). Ogden JA. You can schedule an office consultation with Dr. LaPrade. Instability of the proximal tibiofibular joint is a very rare condition that is often misdiagnosed when there is no suspicion of the injury. Are you sure you want to trigger topic in your Anconeus AI algorithm? All nonsurgical therapies should be attempted before surgical intervention. On the AP radiographs the right knee demonstrates decreased overlap between the fibular head and the lateral tibial condyle compared with the left indicating that the fibular head is displaced laterally. In order to best treat this pathology. 2008 Aug;191(2):W44-51. Reconstruction is recommended to maintain correct anatomic function and rotation of the joint. Ogden JA. While the role of the fibula and the posterolateral corner (PLC) in maintaining knee stability has received widespread attention, the contribution of the proximal tibiofibular joint to knee stability is often overlooked and injuries may easily go unnoticed. Oksum M, Randsborg PH. Knee Surg Sports Traumatol Arthrosc. In order to ensure that the ligament heals without having it stretch out, it is recommended that the patients be non-weight or toe-touch weight bearing for the first six weeks to ensure that the joint is not overloaded to allow the reconstruction graft to start to heal in the tunnels. The site is secure. In acute cases, we have found that immobilization in a brace in full extension for 3 weeks is often very effective to allow the posterior proximal tibiofibular joint ligament tear to scar in sufficiently such that there is no instability. Atraumatic subluxation is thought to result from injury to the anterior ligament and to the anterior capsule of the joint, and it can be associated with Ehlers-Danlos syndrome, muscular dystrophy, and generalized laxity.1 Subluxation typically occurs in patients who have no history of inciting trauma but may have generalized ligamentous laxity; the condition is not commonly bilateral. Instability of the proximal tibiofibular joint (PTFJ) may be acute or chronic in etiology and four types of instability initially described by Ogden include anterolateral dislocation, posteromedial dislocation, superior dislocation, and atraumatic subluxation.1Anterolateral dislocation is by far the most common form of instability and the focus of this discussion. For the treatment of PTFJ instability, there were 18 studies (35 patients) describing nonoperative management, 3 studies (4 patients) reported on open reduction, 11 studies (25 patients) reported on fixation, 4 studies (10 patients) that described proximal fibula resection, 3 studies (11 patients) reported on adjustable cortical button repair, 2 studies (3 patients) reported on ligament reconstructions, and 5 (8 patients) studies reported on biceps femoris tendon rerouting. History and physical examination are very important for diagnosis. Patients with subluxation of the proximal tibiofibular joint commonly report pain over the joint that is aggravated by direct pressure over the fibular head. The proximal tibiofibular joint (PTJF) can be injured with the structures in the lateral aspect of the knee in a multi-ligament knee injury (MLKI) patient. Instability of the proximal tibiofibular joint is a very rare condition that is often misdiagnosed when there is no suspicion of the injury. doi: 10.1016/j.eats.2017.09.003. Fibular resection during an arthrodesis procedure can decrease ankle pain and instability after surgery. There are no specific exercises for proximal tibiofibular joint instability. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Same patient as radiographs in Figure 4. I had wanted to do the Proximal Tibiofibular Surgery locally instead of flying out of state. The implant is pulled through, flipping the medial button on the outside of the anteromedial cortex. Patient History A slightly curved lateral incision over the fibular head is made. Proximal Tibiofibular Joint Reconstruction With a Semitendinosus Allograft for Chronic Instability. Chapter Synopsis Instability of the proximal tibiofibular joint is a very rare condition that is often misdiagnosed when there is no suspicion of the injury. A variety of surgical treatments have been proposed over the last decades. Proximal Tibiofibular Joint Reconstruction With Autogenous - LWW Imaging of Proximal Tibiofibular Joint Instability: A 10 year - PubMed The fibular head lies in an angled groove behind the lateral tibial ridge, which helps to prevent anterior fibular movement with knee flexion [7]. Epub 2005 Dec 22. Initial management of traumatic joint dislocation should involve closed reduction under local anesthesia, followed by surgical intervention if reduction fails. Patients often report symptoms such as knee instability and giving way during these activities, as well as clicking and popping during daily activities. Instability of the proximal tibiofibular joint (PTFJ) can be post-traumatic or due to accumulative injuries and may also be underdiagnosed pathology that can present with symptoms of lateral and/or medial knee pain. Proximal Tibiofibular Joint (PTFJ): Stabilizing Tape Technique for Posterior Instability Twin Cities Orthopedics -Complex Knee Injury Clinic Jill Monson, PT, OCS Physical Therapy Team -Complex Knee Injury Clinic Twin Cities Orthopedics | Training HAUS Warnings Atraumatic subluxation is thought to result from injury to the anterior ligament and to the anterior capsule of the joint, and it can be associated with Ehlers-Danlos syndrome, muscular dystrophy, and generalized laxity.1 Subluxation typically occurs in patients who have no history of inciting trauma but may have generalized ligamentous laxity; the condition is not commonly bilateral. Instability of this joint may be in the anterolateral, posteromedial, or superior directions. Traumatic dislocations commonly cause pain along the lateral knee that radiates into the region of the iliotibial band and the patellofemoral joint and is increased with palpation of the prominent fibular head and ankle motion. 2019 Feb;27(2):412-418. doi: 10.1007/s00167-018-5061-9. Hey - if he is good enough for Olympic and professional athletes..he's good enough for me! EDINA- CROSSTOWN OFFICE The surgical treatment for proximal tibiofibular joint instability most often consists of an anatomic reconstruction of the torn ligaments. The examination of patients with atraumatic subluxation or chronic instability should be performed with the knee flexed to 90 degrees. I was hit by a car on my bicycle near Horsetooth Reservoir in CO. PMID: 32061975. The proximal tibiofibular joint should be palpated for tenderness, and laxity should be evaluated by translating the fibular head anteriorly and posteriorly with the thumb and index finger and asking the patient if the symptoms are reproduced or if there is any apprehension. The anterior tibiofibular ligament (green arrow) is edematous but in continuity. Successful diagnosis of the injury can be improved by a better understanding of the biomechanics of the joint and a clinical suspicion of the injury when symptoms are present. This was devastating news after being a top triathlete (3rd in the world in my age group in 1989 & 1st nationally in my age group) and a big marathon runner. Kobbe P., Flohe S., Wellmann M., Russe K. Stabilization of chronic proximal tibiofibular joint instability with a semitendinosus graft. Level IV, systematic review of level IV studies. Atraumatic subluxation is thought to result from injury to the anterior ligament and to the anterior capsule of the joint, and it can be associated with Ehlers-Danlos syndrome, muscular dystrophy, and generalized laxity. The posterior ligament attaches to the fibula medial to the styloid and inferomedial to the insertion of the popliteofibular ligament.11 The integrity of the FCL and biceps femoris tendons should also be evaluated as posterolateral corner injuries will often demonstrate soft tissue edema surrounding the joint without disruption of the proximal tibiofibular ligaments. Atraumatic proximal tibiofibular joint subluxation is the more common presentation of proximal tibiofibular joint instability. Injury to the proximal tibiofibular joint can lead to lateral knee pain and instability owing to chronic rupture of the posterior tibiofibular ligament. Clinical and Surgical Pitfalls MRIs ability to directly inspect the PTFJ supporting ligaments and relevant adjacent anatomy allows accurate characterization of the often unexpected injuries to the PTFJ. All other clinical possibilities should be ruled out before a diagnosis is made. Gross anatomy Articulation fibula: flat facet of the fibular head government site. Robert LaPrade, MD, PhD The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). 2016 May-Jun;40(3):470-6. doi: 10.1016/j.clinimag.2015.12.011. Rule out lateral meniscus tear. However, in chronic cases, immobilization would not be sufficient to achieve this goal. Proximal Tibiofibular Joint Stabilization With Concurrent Quantitative radiographic assessment of the anatomic attachment sites of the anterior and posterior complexes of the proximal tibiofibular joint. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Proximal Tib-Fib Dislocation. It can be associated with subtle instability and subluxation or frank dislocation of both the PTFJ and the native knee joint. Treatment of Instability of the Proximal Tibiofibular Joint by Dynamic The drill guide is directed in a posteroanterior direction toward the anteromedial aspect of the proximal tibia, making sure to avoid the MCL and pes anserinus. The treatment of proximal tibiofibular joint instability usually depends upon whether it is an acute or chronic injury. Accessibility The forgotten joint: quantifying the anatomy of the proximal tibiofibular joint. A more definitive way to validate a diagnosis of proximal tibiofibular joint instability is with a taping program of the joint. Treatment for proximal tibiofibular joint stability requires that nonsurgical management be attempted first for patients with atraumatic subluxation of the proximal tibiofibular joint. The proximal (or superior) tibiofibular joint is a synovial joint between the superior aspects of the tibia and fibula and is one of the multiple sites of cartilaginous and fibrous articulation carrying the name of the tibiofibular joint. Most proximal tibiofibular joint instabilities can be treated with closed reduction and conservative care, but some require internal fixation or soft-tissue reconstruction. It is common for patients to also have transient peroneal nerve injuries, especially with posteromedial dislocation.1,2 Limit patients to passive flexion until 6 weeks to reduce the stress that is applied to the reconstructed ligaments (prevent biceps femoris from pulling on the fibular head). Is stability of the proximal tibiofibular joint important in the multiligament-injured knee? This site needs JavaScript to work properly. Proximal Tibiofibular Joint: An Often-Forgotten Cause of Lateral Knee Bookshelf Level of evidence: In the past, chronic instability was treated with arthrodesis or fibular head resection; however, complications related to altered knee and ankle biomechanics rendered these options less desirable.13,14,15, As knee ligament reconstruction surgery has developed, various techniques to reconstruct the ligaments have been described. Many common injuries can cause the same symptoms as proximal tibiofibular dislocation; therefore the integrity of the surrounding ligamentous structures should be investigated before a diagnosis is made. Patients with subluxation of the proximal tibiofibular joint commonly report pain over the joint that is aggravated by direct pressure over the fibular head. Atraumatic dislocation of the proximal tibiofibular joint is easily misdiagnosed when there is no clinical suspicion of the injury, owing to its association with a wide range of symptoms that mirror many common knee injuries. It is our goal to provide the highest level of care and service to our patients. 2017 Aug;33(8):1587-1593. doi: 10.1016/j.arthro.2017.03.012. The arthrodesis procedure is recommended for patients in whom the correction of joint instability would not relieve pain, such as patients with proximal tibiofibular joint arthritis. Early diagnosis of this injury can prevent further injuries to the joint that are harder to treat, such as chronic or fixed subluxation. 2022;8:8. doi: 10.1051/sicotj/2022008. Conclusion: MRI is sensitive in the evaluation of tibiofibular ligamentous integrity in proximal tibiofibular instability. The relative avascularity of the area of the proximal tibiofibular joint prevents the presentation of knee effusion with an isolated injury, but there may be a prominent lateral mass.1 Anterolateral dislocations often manifest with severe pain near the proximal tibiofibular joint and along the stretched biceps femoris tendon, which may appear to be a tense, curved cord.1 Dorsiflexing and everting the foot, as well as extending the knee, emphasize pain at the proximal tibiofibular joint. PMID: 10750995. If one has a chronic proximal tibiofibular joint injury, we prefer to trial taping to validate that the symptoms of the proximal tibiofibular joint injury are improved with the taping program. Sequential axial (1A), coronal (1B), and sagittal (1C) fat-suppressed proton density-weighted images are provided through the proximal tibiofibular joint. A new technique. The integrity of the ankle and functional status of the peroneal nerve should also be assessed during the physical examination, because of the association of nerve, syndesmotic ligament, and interosseous membrane damage with this injury. I was life flighted to MCR in Loveland, CO. My orthopedic injuries were severe, but totally missesd by the orthopedic team at Poudre. Proximal Tibiofibular Joint Instability and Treatment - PubMed 2010 Nov;18(11):1452-5. doi: 10.1007/s00167-010-1049-9. 48 year-old female with an acute PLC sprain and ACL tear. The proximal tibiofibular joint should be palpated for tenderness, and laxity should be evaluated by translating the fibular head anteriorly and posteriorly with the thumb and index finger and asking the patient if the symptoms are reproduced or if there is any apprehension.4 The stability of the proximal tibiofibular joint is typically increased by full extension of the knee; if it is not, the lateral collateral ligament and posterolateral structures may also be injured. Instability of the proximal tibiofibular joint occurs when the ligaments which provide stability to this joint are injured. Clinical History: 21-year-old male with lateral knee pain radiating into the calf status-post soccer injury. It causes significant lateral sided knee pain and functional deficits and can be associated with up to 9% of multiligament knee injuries. At the time of clinical evaluation, patients report lateral knee pain or instability which invokes a broad differential diagnosis. The proximal tibiofibular joint should be palpated for tenderness, and laxity should be evaluated by translating the fibular head anteriorly and posteriorly with the thumb and index finger and asking the patient if the symptoms are reproduced or if there is any apprehension.4 The stability of the proximal tibiofibular joint is typically increased by full extension of the knee; if it is not, the lateral collateral ligament and posterolateral structures may also be injured. 2700 Vikings Circle On the lateral radiograph the fibular head barely intersects the radio-dense line (dotted line) representing the posteromedial margin of the lateral tibial condyle. The TightRope is subsequently tightened by pulling and spreading the sutures until the lateral button reaches the fibular head. Treatment for proximal tibiofibular joint stability requires that nonsurgical management be attempted first for patients with atraumatic subluxation of the proximal tibiofibular joint. eCollection 2023 Jan. Mediterr J Rheumatol. Management of Proximal Tibiofibular Instability Proximal Tibiofibular Taping Example