Orthopedics

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Case Reports 

Bilateral, Atraumatic, Proximal Tibiofibular Joint Instability

Troy D. Morrison, DO; James A. Shaer, MD; Jill E. Little, BA

Abstract

Dislocation of the tibiofibular joint is rare and usually results from a traumatic event. Only 1 case of atraumatic proximal tibiofibular joint instability in a 14-year-old girl has been reported in the literature, however this condition might occur more frequently than once thought. A wide range of treatment options exist for tibiofibular dislocations. Currently, the first choice is a conservative approach, and when this fails, surgical means such as resection of the fibula head, arthrodesis, and reconstruction are considered. However, no consensus exists on the most effective treatment.

This article reports a unique case of bilateral, atraumatic, proximal tibia and fibular joint instability involving a 30-year-old man with a 20-year history of pain and laxity in the right knee. The patient had no trauma to his knees; he reported 2 immediate family members with similar complaints, which suggests that this case is likely congenital. After conservative approaches proved to be ineffective, the patient underwent capsular reconstruction using free autologous gracilis tendon. At 6-month postoperative follow-up, the patient was pain free with no locking and instability. He then underwent surgery on the left knee. At 1-year follow-up after the second surgery, the patient had no symptoms or restrictions in mobility. We provide an alternative surgical approach to arthrodesis and resection for the treatment of chronic proximal tibiofibular instability. In the treatment of chronic tibiofibular instability, we believe that reconstruction of the tibiofibular joint is a safe and effective choice.

First reported by Nelaton in 1874, dislocation of the tibiofibular joint is an uncommon problem in orthopedics,1-4 occurring in <1% of knee injury cases.1 Some believe that this condition is more common than previously thought, and, as such, this diagnosis is infrequently made on first evaluation, particularly in a chronic setting.4,5 Many of these dislocations are the result of athletic injury,1,4-7 with causes including twisting, hyperextension (contact and non-contact), an anterior blow to a flexed knee, and a valgus force on a flexed knee.8 A review of the literature yielded 1 reported case of atraumatic proximal tibiofibular joint instability. Klaunick9 reported a single case of recurrent idiopathic proximal tibiofibular dislocation in a 14-year-old girl.

The proximal tibiofibular joint is stabilized by a fibrous capsule, which is reinforced by 2 or 3 broad bands. The stronger anterior bands make up the anterior proximal tibiofibular ligament, and the weaker posterior band comprises the posterior proximal tibiofibular ligament.10 Additional stability is provided by the fibular collateral ligament, popliteofibular ligament, popliteus tendon, and the biceps femoris tendon.10

Treating instability of the tibiofibular joint is difficult. Cazeneuve et al11 maintain that, because there are many varieties of treatment for tibiofibular dislocations, no uniformly satisfactory treatment exists. The current treatment of choice is a conservative approach.7,12 When this does not provide adequate treatment, various surgical approaches may be considered: resection of the fibula head, arthrodesis, and reconstruction.1-3,5,7,12,13

This article reports a case of bilateral, atraumatic, proximal tibia and fibular joint instability.

A 30-year-old man presented with a history of pain and laxity in the right knee of 20 years’ duration. The patient had no recollection of a traumatic event that would provide the etiology for this condition. He was never involved in organized sports as a child or young adult. He had no history of a seizure disorder. Consultation with an orthopedist during childhood and again as an adult for similar complaints did not result in a correct diagnosis being made. He also reported multiple visits to the emergency department for which he was treated with a knee immobilizer. Previous examinations, followed by nonsteroidal pain medication and physical therapy, yielded little to no relief. He also reported that…

Abstract

Dislocation of the tibiofibular joint is rare and usually results from a traumatic event. Only 1 case of atraumatic proximal tibiofibular joint instability in a 14-year-old girl has been reported in the literature, however this condition might occur more frequently than once thought. A wide range of treatment options exist for tibiofibular dislocations. Currently, the first choice is a conservative approach, and when this fails, surgical means such as resection of the fibula head, arthrodesis, and reconstruction are considered. However, no consensus exists on the most effective treatment.

This article reports a unique case of bilateral, atraumatic, proximal tibia and fibular joint instability involving a 30-year-old man with a 20-year history of pain and laxity in the right knee. The patient had no trauma to his knees; he reported 2 immediate family members with similar complaints, which suggests that this case is likely congenital. After conservative approaches proved to be ineffective, the patient underwent capsular reconstruction using free autologous gracilis tendon. At 6-month postoperative follow-up, the patient was pain free with no locking and instability. He then underwent surgery on the left knee. At 1-year follow-up after the second surgery, the patient had no symptoms or restrictions in mobility. We provide an alternative surgical approach to arthrodesis and resection for the treatment of chronic proximal tibiofibular instability. In the treatment of chronic tibiofibular instability, we believe that reconstruction of the tibiofibular joint is a safe and effective choice.

First reported by Nelaton in 1874, dislocation of the tibiofibular joint is an uncommon problem in orthopedics,1-4 occurring in <1% of knee injury cases.1 Some believe that this condition is more common than previously thought, and, as such, this diagnosis is infrequently made on first evaluation, particularly in a chronic setting.4,5 Many of these dislocations are the result of athletic injury,1,4-7 with causes including twisting, hyperextension (contact and non-contact), an anterior blow to a flexed knee, and a valgus force on a flexed knee.8 A review of the literature yielded 1 reported case of atraumatic proximal tibiofibular joint instability. Klaunick9 reported a single case of recurrent idiopathic proximal tibiofibular dislocation in a 14-year-old girl.

The proximal tibiofibular joint is stabilized by a fibrous capsule, which is reinforced by 2 or 3 broad bands. The stronger anterior bands make up the anterior proximal tibiofibular ligament, and the weaker posterior band comprises the posterior proximal tibiofibular ligament.10 Additional stability is provided by the fibular collateral ligament, popliteofibular ligament, popliteus tendon, and the biceps femoris tendon.10

Treating instability of the tibiofibular joint is difficult. Cazeneuve et al11 maintain that, because there are many varieties of treatment for tibiofibular dislocations, no uniformly satisfactory treatment exists. The current treatment of choice is a conservative approach.7,12 When this does not provide adequate treatment, various surgical approaches may be considered: resection of the fibula head, arthrodesis, and reconstruction.1-3,5,7,12,13

This article reports a case of bilateral, atraumatic, proximal tibia and fibular joint instability.

Case Report

A 30-year-old man presented with a history of pain and laxity in the right knee of 20 years’ duration. The patient had no recollection of a traumatic event that would provide the etiology for this condition. He was never involved in organized sports as a child or young adult. He had no history of a seizure disorder. Consultation with an orthopedist during childhood and again as an adult for similar complaints did not result in a correct diagnosis being made. He also reported multiple visits to the emergency department for which he was treated with a knee immobilizer. Previous examinations, followed by nonsteroidal pain medication and physical therapy, yielded little to no relief. He also reported that 2 immediate family members had similar symptoms.

Upon examination the patient had gross instability at the proximal tibia and fibular joint (marked anterior and posterior instability). Motor and sensory examination of bilateral lower extremities was unremarkable. There was no ligamentous instability of the cruciates, collaterals, or the posterior lateral corner in either knee. Bilateral knee range of motion (ROM) was 0° to 135°. There was no hypermobility of the thumb, digits, elbow, or shoulders. There was no hyperextension of the knee.

Plain radiographs of the knee revealed no osseous abnormalities. The morphology of the fibular head was normal. The patient was diagnosed with atraumatic bilateral proximal tibia and fibular instability. Chopart strap and physical therapy was recommended, but it produced no effective results. Additionally, the patient reported similar symptoms in the left knee as well.

Due to a lack of improvement from conservative approaches, due to the lack of consensus in the literature on a “gold standard” method for treatment, the senior author (T.D.M.) developed an alternative surgical approach to treat this patient. The patient underwent capsular reconstruction of the right proximal tibiofibular joint using free autologous gracilis tendon. The patient was informed that this technique has not been described and that we would wait at least 1 year before considering it for the other knee.

With the patient supine and the aid of a tourniquet, the gracilis tendon was harvested through an oblique incision over the pes anserine. The knee was maintained in a flexed position. A linear incision was then made over the fibular head. The fascia was opened in line with the incision. The common peroneal nerve was identified and protected. The anterior aspect of the tibiofibular joint was opened to evaluate for any arthritic changes. After exposing the anterior and posterior aspects of the fibular head, a 3.5-mm drill was used to make a tunnel from anterior to posterior through the fibular head.

On the back table, the gracilis graft was stripped of its soft tissue, sized, and fixed with a Fiberwire Loop (Arthrex, Naples, Florida) suture using a whipstitch on both ends. Next, a guidewire was placed posterior to the fibular head and driven through the tibia exiting anteromedially in the area of the hamstring harvest site. A second guidewire was placed just anterior to the fibular head and parallel to the first. The guidewires were brought out of the harvest site incision. The fibula was held in a reduced position. A cannulated reamer that matched the diameter of the graft was used to create tunnels through the tibia over the guidewires at a depth to allow complete seating of the graft in both the anterior and posterior tunnel. The fibular head tunnel was opened up to match the graft size. The graft was passed from anterior to posterior through the fibular head. Next, using beath pins, Fiberwire sutures in the graft were passed through the bone tunnels. Holding the graft secure in a tightened position, stability of the fibular head was assessed. The Fiberwire suture was tied together over a bone bridge. Stability of the fibular head was again evaluated (Figure 1). The anterior capsule of the tibiofibular joint was repaired.

Figure 1A: The diagram demonstrates the position of the graft Figure 1B: The diagram demonstrates the posterior portion of the graft
Figure 1: The diagram demonstrates the position of the graft. The drill holes are illustrated by dotted lines (A). The diagram demonstrates the posterior portion of the graft as it exits the posterior fibula. The tibial drill holes are illustrated by the dotted lines (B).

At 5-week follow-up, the patient reported he felt he was improving; however, he still had episodes of pain but no instability was present. He had an active ROM from 0° to 120° of flexion and his gait was normal. By three and a half months postoperatively, the patient had returned to working full time (up to 11 hours), which often required him to be on his feet for 7 to 8 hours. He was still experiencing some pain but reported that he was progressively more functional. There was no effusion or crepitation in the knee, and there was no instability on anterior and posterior stress to the fibular head. At 6-month follow-up, the patient reported being pain free with no incidences of locking or instability. He had active ROM from 0° to 135° of flexion.

One year after his initial surgery, the patient underwent capsular reconstruction of the left proximal tibia and fibular joint using the same surgical technique. At 2-month follow-up, the patient reported soreness in the knee but no motion. There was no instability on palpation; active ROM was 0° to 110° of flexion. One year after the second surgery and 2 years after the initial surgery, the patient reported feeling better than he did preoperatively in both knees. He had active ROM from 0° to 135° in both knees. He was able to work a full day without symptoms. He had no restrictions in his activities of daily living. He occasionally felt a sense of the joint moving in the late evenings. Clinically there was physiological motion of both proximal tibia and fibular joint; however, this motion was considerably less than what was there preoperatively. Magnetic resonance imaging showed that the grafts were still intact and there was no evidence of degenerative changes within the proximal tibiofibular joint (Figure 2).

Figure 2A: MRI 12 months postoperatively Figure 2B: A well-reduced proximal tibiofibular joint
Figure 2: MRI 12 months postoperatively demonstrates a well-reduced proximal tibiofibular joint with good graft position (red arrows) (A) and good graft incorporation (red arrow) (B).

Discussion

Instability of the proximal tibiofibular joint is rarely reported. The etiology of this condition is usually traumatic caused by a twisting athletic injury, or slipping injury resulting in a flexed knee under the body of the patient.4 Ogden4 also reported predisposing pathologic conditions including ligamentous hyperlaxity, muscular dystrophy, amputations and Ehlers-Danlos syndrome. To our knowledge, there are no reported cases of congenital proximal tibiofibular instability. As mentioned earlier, Klaunick9 recently reported a single case of idiopathic proximal tibiofibular dislocation in a 14-year-old girl. This supports our notion that proximal tibiofibular instability can be congenital.

The fact that this patient had bilateral involvement, no traumatic events involving his knees, and symptoms since age 10 years supports, but does not prove, the conclusion that this case is likely congenital. Further confirmation is found in the history that 2 immediate family members had the same symptoms.

The first treatment option is usually conservative management.10 Unsatisfactory conservative treatment has led to a diversity of surgical intervention options. Surgical treatment for chronic instability include: fibular head resection, arthrodesis, and reconstruction with a biceps femoris tendon graft.1-3,5,7,12,13

Resection of the fibular head requires preserving the fibular styloid and lateral collateral ligament while excising the fibular head and neck.6 Fibular head resection has been associated with chronic ankle pain and the development of knee instability, making it contraindicated in athletes.6,14 Arthrodesis has also been linked with pain and instability.4

A reconstruction technique has been described by Weinert and Raczka3 in 1986 and Mena et al15 in 2001. In both techniques, the posterior one-half of the biceps tendon is used to reconstruct the superior posterior tibiofibular ligament.3 The report by Weinert and Raczka3 shares the same limitations as ours: the technique was performed on a single patient with limited follow-up. Mena’s technique was repeated by Tanner and Brinks16 on a single patient with success over a 3-year follow-up. More recently, Horst and LaPrade17 published an anatomic reconstruction similar to the technique presented here. Using the semitendinosus tendon, they recreated the posterior ligamentous structures in 2 patients. Their autogenous hamstring graft was passed through a fibular head tunnel from anterior to posterior and then through a tunnel in the tibia from posterior to anterior. Bioabsorbable screws secured at each end of the graft.

Similar to the technique presented here, Horst and LaPrade’s method is based on reconstructing the normal anatomic static stabilizers of the proximal tibiofibular joint. Like our technique, they also preserve the biceps femoris tendon, which adds stability to the joint.4,16,17 The technique developed by the senior author recreates the anterior and posterior ligamentous structures ensuring adequate stability on both sides of the joint. Additionally, this allows a symmetric reduction when tensioning both the anterior and posterior sides of the graft.

We present the above approach as an alternative to arthrodesis and resection for the treatment of chronic proximal tibiofibular instability. Although no evidence of a biomechanical advantage exists for our reconstruction technique, we believe restoring an anatomic ligamentous anterior and posterior restraint is advantageous. Because we obtain our graft from the medial side of the knee, we do not disrupt the tendons and ligaments that provide stability to the lateral side of the knee. A better understanding of the anatomy and biomechanics of the proximal tibiofibular joint will greatly improve the treatment of this condition.

References

  1. Harvey GP, Woods GW. Anterolateral dislocation of the proximal tibiofibular joint: case report and literature review. Today’s OR Nurse. 1992; 14(3):23-27.
  2. Giachino AA. Recurrent dislocations of the proximal tibiofibular joint. Report of two cases. J Bone Joint Surg Am. 1986; 68(7):1104-1106.
  3. Weinert CR, Raczka R. Recurrent dislocation of the superior tibiofibular joint. Surgical stabilization by ligament reconstruction. J Bone Joint Surg Am. 1986; 68(1):126-128.
  4. Ogden JA. Subluxation and dislocation of the proximal tibiofibular joint. J Bone Joint Surg Am. 1974; 56(1):145-154.
  5. Turco VJ, Spinella AJ. Anterolateral dislocation of the head of the fibula in sports. Am J Sports Med. 1985; 13(4):209-215.
  6. Sekiya JK, Kuhn JE. Instability of the proximal tibiofibular joint. J Am Acad Orthop Surg. 2003; 11(2):120-128.
  7. Veth RPH, Klasen HJ, Kingma LM. Traumatic instability of the proximal tibiofibular joint. Injury. 1981; 13(2):159-164.
  8. LaPrade RF, Terry GC. Injuries to the posteriolateral aspect of the knee. Association of anatomic injury patterns with clinical instability. Am J Sports Med. 1997; 25(4):433-438.
  9. Klaunick G. Recurrent idiopathic anterolateral dislocation of the proximal tibiofibular joint: case report and literature review. J Pediatric Orthopaedics B. 2010; 19(5):409-414.
  10. Espregueira-Mendes JD, Vieira de Silva M. Anatomy of the proximal tibiofibular joint [published online ahead of print December 22, 2005]. Knee Surg Sports Traumatol Arthrosc. 2006; 14(3):241-249.
  11. Cazeneuve JF, Bracq H, Meeseman M. Weinert and Giachino ligament arthroplasty for the surgical treatment of chronic superior tibiofibular joint instability. Knee Surg, Sports Traumatol, Arthroscopy. 1997; 5(1):36-37.
  12. van den Bekerom MPJ, Weir A, van der Flier RE. Surgical stabilisation of the proximal tibiofibular joint using temporary fixation: a technical note. Acta Orthop Belg. 2004; 70(6):604-608.
  13. Semonian RH, Denlinger PM, Duggan RJ. Proximal tibiofibular subluxation relationship to lateral knee pain: a review of proximal tibiofibular joint pathologies. J Orthop Sports Phys Ther. 1995; 21(5):248-257.
  14. Draganich LE, Nicholas RW, Shuster JK, Sathy MR, Chang AF, Simon MA. The effects of resection of the proximal part of the fibula on stability of the knee and on gait. J Bone Joint Surg Am. 1991; 73(4):575-583.
  15. Mena H, Brautigan B, Johnson DL. Split biceps femoris tendon reconstruction for proximal tibiofibular joint instability. Arthroscopy. 2001; 17(6):668-671.
  16. Tanner SM, Brinks KF. Reconstruction of the proximal tibiofibular joint: a case report. Clin J Sport Med. 2007; 17(1):75-77.
  17. Horst PK, LaPrade RF. Anatomic reconstruction of the chronic symptomatic anterolateral proximal tibiofibular joint instability [Published online ahead of print February 3, 2010]. Knee Surg Sports Traumatol Arthrosc. 2010; 18(11):1452-1455.

Authors

Drs Morrison and Shaer and Ms Little are from St Elizabeth Health Center, Youngstown, Ohio.

Drs Morrison and Shaer and Ms Little have no relevant financial relationships to disclose.

Correspondence should be addressed to: Troy D. Morrison, DO, Department of Orthopedic Trauma, St Elizabeth Health Center, 1044 Belmont Ave, Youngstown, OH 44501 (tmorrison007@yahoo.com).

doi: 10.3928/01477447-20101221-28

10.3928/01477447-20101221-28

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