55 year-old female status-post fibular head dislocation with stable reduction but lateral-sided laxity. Preoperative Considerations 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. However, this is a fairly common finding due to variable degrees of knee rotation. Proximal tibiofibular joint dislocation - Radiopaedia I was life flighted to MCR in Loveland, CO. My orthopedic injuries were severe, but totally missesd by the orthopedic team at Poudre. Injuries to the joint are more commonly atraumatic and should be treated with surgery only after all other therapies have been exhausted. 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. It can be associated with subtle instability and subluxation or frank dislocation of both the PTFJ and the native knee joint. The TightRope is subsequently tightened by pulling and spreading the sutures until the lateral button reaches the fibular head. The integrity of the proximal tibiofibular joint is best visualized through plain radiographs. History and physical examination are very important for diagnosis. Proximal tibiofibular joint instability is a very unusual and uncommon condition. Axial images from superior to inferior demonstrate soft tissue edema surrounding the proximal tibiofibular joint. Resecting and protecting the peroneal nerve during surgery can prevent peroneal nerve palsy. All nonsurgical therapies should be attempted before surgical intervention. Proximal Tibiofibular Joint Reconstruction With a Semitendinosus Allograft for Chronic Instability. Clin Orthop Relat Res. Diagnosis requires careful assessment of radiographs of the knee and tibia (often missed injury). 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. 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. Level IV, systematic review of level IV studies. The drill sleeve is applied to the lateral aspect of the fibular head, avoiding the insertions of the FCL and the BFT. With the knee flexed 90 the fibular head may be subluxed/dislocated by gentle pressure in an anterior or posterior direction. Improved outcomes can be expected after surgical treatment of PTFJ instability. Tightening is gradually tested by manipulation of the proximal fibula, until appropriate stability is achieved. The surgical treatment for proximal tibiofibular joint instability most often consists of an anatomic reconstruction of the torn ligaments. The treatment of proximal tibiofibular joint instability usually depends upon whether it is an acute or chronic injury. 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. Once a diagnosis of PTFJ instability is confirmed, a standard diagnostic arthroscopy is performed through 2 portals. The clinical presentation of joint injury can range from common idiopathic subluxation with no history of trauma, to less common high-energy traumatic dislocations that may be associated with long bone fracture. Dr LaPrade performed a deep root repair to my meniscus, which saved me from a knee replacement at this time. Am J Sports Med. 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. 2018 Apr;26(4):1096-1103. doi: 10.1007/s00167-017-4508-8. Injury to the proximal tibiofibular joint can lead to lateral knee pain and instability owing to chronic rupture of the posterior tibiofibular ligament. Klaunick G. Recurrent idiopathic anterolateral dislocation of the proximal tibiofibular joint: case report and literature review. I was hit by a car on my bicycle near Horsetooth Reservoir in CO. Careful dissection to the posterior aspect of the joint is carried out after a peroneal nerve neurolysis is performed. 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. Anavian J, Marchetti DC, Moatshe G, Slette EL, Chahla J, Brady AW, Civitarese DM, LaPrade RF. 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. McNamara WJ, Matson AP, Mickelson DT, Moorman CT 3rd. The examination of patients with atraumatic subluxation or chronic instability should be performed with the knee flexed to 90 degrees. Okubo A, Kajikawa Y, Nakajima S, Watanabe N, Yotsumoto T, Oshima Y, Iizawa N, Majima T. SICOT J. If one obtains the diagnosis soon after injury (acutely), immobilization of the knee in extension for a few weeks to try to get the posterior injured ligaments to heal is reasonable. The Proximal Tibiofibular Joint: A Biomechanical Analysis of the ABSTRACT Imaging of Proximal Tibiofibular Joint Instability: A 10 year - PubMed The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). I had wanted to do the Proximal Tibiofibular Surgery locally instead of flying out of state. Anatomic reconstruction of the proximal tibiofibular joint. government site. Atraumatic instability is more common and often misdiagnosed. 1974 Jun;(101):186-91. Both the anterior and posterior ligaments may be torn however the posterior ligament is weaker and more often torn (Figures 6-8). Apropos of 3 cases]. It is common for patients to also have transient peroneal nerve injuries, especially with posteromedial dislocation.1,2 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. When fractures are present, they are more often associated with the posterior ligament and it is important to distinguish these fractures from a posterolateral corner injury. 2000 Mar-Apr;28(2):191-9. doi: 10.1177/03635465000280020901. 2018 Apr;26(4):1104-1109. doi: 10.1007/s00167-017-4511-0. MRI evaluation of chronic instability is more challenging given the lack of associated soft tissue edema (Figure 11). Knee Surg Sports Traumatol Arthrosc. Treatment is prompt closed reduction with unstable injuries requiring surgical pinning versus soft tissue reconstruction. Lateral Collateral Ligament and Proximal Tibiofibular Joint Clinical Characteristics and Outcomes After Anatomic Reconstruction of the Proximal Tibiofibular Joint. An anatomic study. 2017 Oct 25;30(10):972-975. doi: 10.3969/j.issn.1003-0034.2017.10.019. It is our goal to provide the highest level of care and service to our patients. Clin Imaging. Anterolateral dislocation commonly stems from injury to the anterior and posterior capsular ligaments, and commonly the lateral collateral ligament.1,2 The common cause of traumatic anterolateral dislocation is a fall on a flexed knee, or a violent twisting motion during an athletic activity.3 The hyperflexed knee results in relaxation of the biceps femoris tendon and the lateral collateral ligament, and the violent twisting of the body creates a torque that pushes the fibular head laterally to the edge of the lateral tibial metaphysis.1,2 The forced plantar flexion and ankle inversion forces the laterally displaced fibular head anteriorly.1 A slightly curved lateral incision over the fibular head is made. A fat-suppressed proton density-weighted axial image (12B) demonstrates post-surgical appearance after open PTFJ ligament reconstruction with hamstring autograft (arrows) in a 30 year-old competitive weightlifter with chronic PTFJ instability. Am J Sports Med. and transmitted securely. The examination of patients with atraumatic subluxation or chronic instability should be performed with the knee flexed to 90 degrees. 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. Surgical treatment discussion and videos courtesy of Jonathan A. Godin, MBA, MD, The Steadman Clinic and Steadman Philippon Research Institute. I am 5-months post surgery, and am doing great, stationary biking and exercising every day, no pain.You know you are seeing the best when you find out he has written over 500 medical journal articles - among many other accomplishments. Orthop Rev. PMID: 10750995. Medial Patellar Instability: A Systematic Review of the Literature of Outcomes After Surgical Treatment. Epub 2005 Dec 22. Proximal Tibiofibular Joint Instability and Treatment Approaches: A Systematic Review of the Literature Authors: Bradley M. Kruckeberg Mayo Clinic - Rochester Mark Cinque Stanford Medicine. 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. Focal edema is seen in the proximal soleus muscle (asterisks) adjacent to the fracture, and edema surrounds the common peroneal nerve (arrowhead). During significant trauma, traumatic dislocations of the tibiofibular joint are commonly missed, so the physical examination of this joint is a significant part of the comprehensive knee examination. Instability of the Proximal Tibiofibular Joint : JAAOS - Journal of the Previous attempts to make it better provided only temporary relief. A variety of surgical treatments have been proposed over the last decades. 27 The proximal tibiofibular joint is a synovial membrane-lined, hyaline cartilage articulation that communicates with the knee joint in A new technique. 38 year-old with chronic posterolateral corner instability status-post failed FCL reconstruction with partially visualized fixation screw. Patient History In the setting of acute injury and subsequent stabilization, the posterior PTFJ ligaments have been shown to scar, thereby precluding the need for a full reconstruction.22 Moreover, the avulsion fracture portends bone-to-bone healing and any reconstruction technique requiring drilling through the posteromedial aspect of the fibular head risks comminuting and further displacing the fracture fragment. 48 year-old female with an acute PLC sprain and ACL tear. Level of evidence: In fact 2 years ago I finished climbing the top 100 peaks in CO. All other clinical possibilities should be ruled out before a diagnosis is made. HHS Vulnerability Disclosure, Help Epub 2017 Mar 20. Methods: Ogden 10 reported that 57% of patients with acute proximal tibiofibular dislocations required surgery for ongoing symptoms after treatment failure with closed reduction and 3 weeks of immobilization. Proximal tibiofibular ligament reconstruction, specifically biceps rerouting and anatomic graft reconstruction, leads to improved outcomes with low complication rates. This helps us to confirm that the patient does have instability of the proximal tibiofibular joint which may require surgery. The Proximal Tibiofibular Joint: A Biomechanical Analysis of the Anterior and Posterior Ligamentous Complexes. Suspicion of atraumatic injury to the proximal tibiofibular joint warrants extensive inspection during the physical examination of the knee. The implant is pulled through, flipping the medial button on the outside of the anteromedial cortex. Proximal Tibiofibular Joint Instability | Knee Specialist | Minnesota The diagnosis of joint instability can be confirmed by steroid and local anesthetic injection into the joint under fluoroscopic guidance, if pain is relieved. Robert LaPrade, MD, PhD 2022 Jun 11;14(6):e25849. 43 year-old male with lateral knee pain status-post snowboarding injury. Early diagnosis of this injury can prevent further injuries to the joint that are harder to treat, such as chronic or fixed subluxation. The proximal tibiofibular joint is a synovial sliding joint which dissipates torsional forces applied at the ankle and tensile forces generated during lateral tibial bending moments.2 The joint is stabilized by multiple ligaments including the anterior and posterior tibiofibular ligaments as well as the fibular collateral ligament (FCL). While protecting the CPN, sharp dissection to the fibular head is performed. An injury to the proximal tibiofibular joint is rather rare, but can be debilitating in patients who have symptoms.