The first step in the management of chronic instability of the PTFJ is usually . Methods: Traumatic dislocations of the proximal tibiofibular joint are uncommon and are normally caused by high-energy injury or a fall on a twisted knee. official website and that any information you provide is encrypted 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. eCollection 2022 Sep. Pappa E, Kakridonis F, Trantos IA, Ioannidis K, Koundis G, Kokoroghiannis C. Cureus. 2017 Aug;33(8):1587-1593. doi: 10.1016/j.arthro.2017.03.012. 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. and transmitted securely. Proximal tibiofibular joint instability is a very unusual and uncommon condition. Early diagnosis of this injury can prevent further injuries to the joint that are harder to treat, such as chronic or fixed subluxation. Anavian J, Marchetti DC, Moatshe G, Slette EL, Chahla J, Brady AW, Civitarese DM, LaPrade RF. . Clinical History: 21-year-old male with lateral knee pain radiating into the calf status-post soccer injury. 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. A fibular bone bruise (asterisk) is present near the attachment of the posterior ligament. In both acute and chronic injuries, evaluation of the common peroneal nerve is also essential (Figure 11). Unable to load your collection due to an error, Unable to load your delegates due to an error. Dr. La Prade had just moved to Vail and I was his 2nd patient @ The Steadman Clinic. Proximal Tibiofibular Joint (PTFJ):Stabilizing Tape Technique for Posterior Instability Learn How We Can Help You Stay Active Request a Consultation About the Author: Robert LaPrade, MD Robert LaPrade, MD, PhD has specialized skills and expertise in diagnosing and treating complicated knee injuries. Treatment is prompt closed reduction with unstable injuries requiring surgical pinning versus soft tissue reconstruction. The fibular head lies in an angled groove behind the lateral tibial ridge, which helps to prevent anterior fibular movement with knee flexion [7]. 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. 62.4 Clinical Signs of Proximal Tibiofibular Joint Instability. MRIs ability to directly inspect the PTFJ supporting ligaments and relevant adjacent anatomy allows accurate characterization of the often unexpected injuries to the PTFJ. The PTFJ is also unstable on physical examination. Treatment of Instability of the Proximal Tibiofibular Joint by Dynamic Internal Fixation With a Suture Button. Instability of the proximal tibiofibular joint is a very rare condition that is often misdiagnosed when there is no suspicion of the injury. Typically, the proximal tibiofibular joint is injured in a fall when the ankle is plantar-flexed, with the stress being brought through the fibula, will cause the proximal fibula to sublux (partial dislocation) out of place over the lateral aspect of the knee joint. Proximal tibiofibular ligament reconstruction, specifically biceps rerouting and anatomic graft reconstruction, leads to improved outcomes with low complication rates. Imaging of Proximal Tibiofibular Joint Instability: A 10 year retrospective case series. Diagnosis requires careful assessment of radiographs of the knee and tibia (often missed injury). AJR Am J Roentgenol. 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. National Library of Medicine The systematic review identified 44 studies (96 patients) after inclusion and exclusion criteria application. Plain radiographs should be taken from anteroposterior, lateral, and oblique (45 to 60 degrees internal rotation of the knee) views, with comparison views from the contralateral knee, or from the preinjury knee if possible. 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). 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. Proximal tibiofibular dislocation is commonly missed initially when high-energy trauma results in other traumatic fractures as well, such as injury to the tibial plateau or shaft, injury to the ipsilateral femoral head or shaft, ankle fracture, or knee dislocation.1,2, 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. 2010 Sep;19(5):409-14. doi: 10.1097/BPB.0b013e3283395f6f. All other clinical possibilities should be ruled out before a diagnosis is made. The examination of patients with atraumatic subluxation or chronic instability should be performed with the knee flexed to 90 degrees. Arthroscopy. In other circumstances, significant trauma or a motor vehicle accident can cause a disruption of the proximal tibiofibular joint. [Progress on diagnosis and treatment of proximal tibiofibular joint dislocation]. 1998. Sequential axial (9A) and coronal (9B) fat-suppressed proton density-weighted images demonstrate a 20 mm avulsion fracture of the fibular head (red arrows) medial to the styloid at the posterior tibiofibular ligament insertion (blue arrows). For the case discussed in Figure 9 above, stabilization with an adjustable loop cortical fixation device was selected for multiple reasons. Burke CJ, Grimm LJ, Boyle MJ, Moorman CT 3rd, Hash TW 2nd. In addition, patients should avoid any deep squatting, or squatting and twisting, because this puts a significant amount of stress on this joint, for the first four months postoperatively. The most common traumatic dislocations are in an anterolateral direction, followed by posteromedial and superior dislocations. Epub 2020 Feb 13. 2000 Mar-Apr;28(2):191-9. doi: 10.1177/03635465000280020901. All nonsurgical therapies should be attempted before surgical intervention. 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 2023 Mar 13;18(1):196. doi: 10.1186/s13018-023-03684-x. 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. The drill sleeve is applied to the lateral aspect of the fibular head, avoiding the insertions of the FCL and the BFT. Early diagnosis of this injury can prevent further injuries to the joint that are harder to treat, such as chronic or fixed subluxation. Epub 2005 Dec 22. Warner B.T., Moulton S.G., Cram T.R., LaPrade R.F. Accessibility Clinical and Surgical Pearls Conclusions: Instability of the proximal tibiofibular joint is a very rare condition that is often misdiagnosed when there is no suspicion of the injury. After 6 weeks postoperatively, patients may start to use a stationary bike with low resistance. 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). Because the joint is relatively inherently stable because of its bony anatomy when the knee is out straight, most cases of proximal tibiofibular joint instability occur when the knee is bent. Rule out lateral meniscus tear. Most patient histories do not reveal any mechanism of injury to the proximal tibiofibular joint, and symptoms of lateral knee pain can be very misleading. 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. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Dislocation of the proximal tibiofibular joint is a very uncommon condition that is easily misdiagnosed without clinical suspicion of the injury. The anterior ligament should be identified in all three planes. Injection of steroid and anesthetic into the joint can relieve pain and confirm a positive diagnosis. However, this is a fairly common finding due to variable degrees of knee rotation. Are you sure you want to trigger topic in your Anconeus AI algorithm? Gross anatomy Articulation fibula: flat facet of the fibular head Orthop Rev. Concurrent with this, we will perform a Tinels test by percussing over the common peroneal nerve to confirm the presence of dysesthesias or zingers, which translate down the leg. The proximal tibiofibular joint ligaments both strengthen the joint and allow it to rotate and translate during ankle and knee motion. AJR Am J Roentgenol. 1997 Jul-Aug;25(4):439-43. doi: 10.1177/036354659702500404. 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. Patient History 2018 Feb 26;7(3):e271-e277. However, I will always be thankful to Dr. Shirzad for at least examining my proximal tib-fib joint and his supportive chart note acknowledging the pain upon palpation. 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. 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. Am J Sports Med. 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. 2014 Sep;472(9):2691-7. doi: 10.1007/s11999-014-3574-1. Surgical Management of Proximal Tibiofibular Joint Instability Using an Adjustable Loop, Cortical Fixation Device. I was told by one of the orthopedic surgeons that I worked with that I would never run again and would be lucky if I could ever hike again. The proximal tibiofibular joint ligaments both strengthen the joint and allow it to rotate and translate during ankle and knee motion. (Please keep reading below for more information on this condition.). 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. This is because there are no muscles that can control the joint for most activities of daily living. Tags: Surgical Techniques of the Shoulder Elbow and Knee in Sports Patients often report symptoms such as knee instability and giving way during these activities, as well as clicking and popping during daily activities.3 FOIA Management of Proximal Tibiofibular Instability Soft tissue edema is present in the anterior (green arrow) and posterior (blue arrows) PTFJ ligaments. (For a review of the posterolateral corner, please refer to https://radsource.us/posterolateral-corner-injury). Both the anterior and posterior ligaments may be torn however the posterior ligament is weaker and more often torn (Figures 6-8). Evaluation of the joint, the supporting ligaments, and the common peroneal nerve should be assessed alongside evaluation of the posterolateral corner. Epub 2017 May 10. Clinical and Surgical Pitfalls Dr LaPrade performed a deep root repair to my meniscus, which saved me from a knee replacement at this time. 1998 Feb;84(1):84-7. Numerous disorders of the proximal tibiofibular joint can present as lateral knee pain. 2023 Lineage Medical, Inc. All rights reserved, Knee & Sports | Proximal Tib-Fib Dislocation. doi: 10.7759/cureus.25849. A proximal tib-fib dislocation is a disruption of the proximal tibia-fibula joint associated with high energy open fractures of the tibia and peroneal nerve injury. MRI evaluation of chronic instability is more challenging given the lack of associated soft tissue edema (Figure 11). The anterior tibiofibular ligament lies just caudal to the anterior arm of the short head of the biceps femoris tendon (purple arrows) which courses anteromedial to the FCL to insert onto the tibia approximately 1 cm posterior to Gerdys tubercle. On MRI, the tibiofibular ligaments are obliquely oriented and extend cephalad from the fibula to the tibia and therefore multiplanar evaluation is essential.10 The anterior ligament is more readily identified given that it is thicker than the posterior ligament. Proximal tibiofibular joint instability is a very unusual and uncommon condition. 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. In this regard, it is recommended that the strengths of grafts chosen for proximal tibiofibular reconstructions meet or exceed these values. (including injections and arthroscopic surgery), I heard Dr. La Prade was going to practice in the Twin Cities - where I live, & waited for him, based on his renown reputation. Log In or Register to continue A prospective study of normal knees and knees with surgically verified grade III injuries. Published by Elsevier Inc. All rights reserved. Epub 2010 Feb 3. Atraumatic proximal tibiofibular joint subluxation is the more common presentation of proximal tibiofibular joint instability. I was life flighted to MCR in Loveland, CO. My orthopedic injuries were severe, but totally missesd by the orthopedic team at Poudre. Initial management of traumatic joint dislocation should involve closed reduction under local anesthesia, followed by surgical intervention if reduction fails. The anterior ligament is composed of three to four bundles and is further reinforced by the anterior aponeurosis arising from the long head of the biceps femoris tendon (BFT).3,4 The posterior ligament is generally composed of three bundles and significantly weaker than the anterior ligament (Figure 3).5 The inherent joint stability is also directly related to the inclination of the articular-surface which is classically defined as horizontal or oblique. History of Traumatic Injury Epub 2018 Jul 23. Eagan, MN 55121, I struggled with my knee for 18 months - having gone from 10,000 steps a day to only walking as needed. 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. Epub 2016 Jan 16. Instability of the joint can be a result of an injury to these ligaments. Before 2010 Nov;18(11):1452-5. doi: 10.1007/s00167-010-1049-9. HHS Vulnerability Disclosure, Help Arthroscopy. Epub 2017 Mar 20. While protecting the CPN, sharp dissection to the fibular head is performed. Proximal tibiofibular joint (PTFJ) instability is a rare knee injury, accounting for less than 1% of knee injuries. Surgical treatment discussion and videos courtesy of Jonathan A. Godin, MBA, MD, The Steadman Clinic and Steadman Philippon Research Institute. Medial Patellar Instability: A Systematic Review of the Literature of Outcomes After Surgical Treatment. The anterior-most sagittal image demonstrates the relationship between the anterior arm of the short head of the biceps femoris tendon (purple arrow), the fibular insertion of the FCL (yellow arrow), and the anterior tibiofibular ligament (green arrow). 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. PMC Clin Orthop Relat Res. PMID: 4837930. 2022;8:8. doi: 10.1051/sicotj/2022008. 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. Rev Chir Orthop Reparatrice Appar Mot. 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. Axial (5A), coronal (5B) and sagittal (5C) fat-suppressed proton density-weighted images demonstrate the anterior (green arrows) and posterior (blue arrows) PTFJ ligaments. 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. 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. 48 year-old female with an acute PLC sprain and ACL tear. Reconstruction using the biceps femoris tendon16 and iliotibial band17 autograft have been detailed, and LaPrade has also described a technique to reconstruct solely the posterior ligaments (Figure 12).18,19 Reconstruction of the anterior and posterior ligaments utilizing hamstring grafts has been described by Kobbe et al.20 and Morrison et al.21 More recently, multiple technique papers have described PTFJ stabilization without reconstruction.22,23.