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
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 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
|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 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)
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
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
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. Menas 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
Similar to the technique presented here, Horst and LaPrades 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.
- Harvey GP, Woods GW. Anterolateral dislocation of the proximal
tibiofibular joint: case report and literature review. Todays OR
Nurse. 1992; 14(3):23-27.
- Giachino AA. Recurrent dislocations of the proximal tibiofibular
joint. Report of two cases. J Bone Joint Surg Am. 1986;
- 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.
- Ogden JA. Subluxation and dislocation of the proximal tibiofibular
joint. J Bone Joint Surg Am. 1974; 56(1):145-154.
- Turco VJ, Spinella AJ. Anterolateral dislocation of the head of the
fibula in sports. Am J Sports Med. 1985; 13(4):209-215.
- Sekiya JK, Kuhn JE. Instability of the proximal tibiofibular joint.
J Am Acad Orthop Surg. 2003; 11(2):120-128.
- Veth RPH, Klasen HJ, Kingma LM. Traumatic instability of the proximal
tibiofibular joint. Injury. 1981; 13(2):159-164.
- 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.
- 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.
- 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.
- 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;
- 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.
- 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;
- 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.
- Mena H, Brautigan B, Johnson DL. Split biceps femoris tendon
reconstruction for proximal tibiofibular joint instability.
Arthroscopy. 2001; 17(6):668-671.
- Tanner SM, Brinks KF. Reconstruction of the proximal tibiofibular
joint: a case report. Clin J Sport Med. 2007; 17(1):75-77.
- 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.
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 (email@example.com).