The proximal tibiofibular joint ligaments both strengthen the joint and allow it to rotate and translate during ankle and knee motion. Arthroscopy. Rule out lateral meniscus tear. The PTFJ is also unstable on physical examination. Epub 2005 Dec 22. A prospective study of normal knees and knees with surgically verified grade III injuries. 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. 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. In general, reaming a tunnel from front to back (anterior to posterior) through the fibular head and having it exit where the proximal tibiofibular joint posterior ligaments attach, and then drilling another tunnel from front to back on the tibia and which exits posteriorly at the attachment site of the proximal posterior tibiofibular joint ligaments, is the desired location for an anatomic-based reconstruction graft. A fibular bone bruise (asterisk) is present near the attachment of the posterior ligament. The most common traumatic dislocations are in an anterolateral direction, followed by posteromedial and superior dislocations. The fibular head lies in an angled groove behind the lateral tibial ridge, which helps to prevent anterior fibular movement with knee flexion [7]. My right knee was totally destroyed; ACL, MCL, PCL all severely torn; the patella was the only thing intact in my right knee. PMID: 1749660. Marchetti DC, Moatshe G, Phelps BM, Dahl KD, Ferrari MB, Chahla J, Turnbull TL, LaPrade RF. Injuries to the joint are more commonly atraumatic and should be treated with surgery only after all other therapies have been exhausted. 2017 Aug;33(8):1587-1593. doi: 10.1016/j.arthro.2017.03.012. Dirim B, Wangwinyuvirat M, Frank A, Cink V, Pretterklieber ML, Pastore D, Resnick D. Communication between the proximal tibiofibular joint and knee via the subpopliteal recess: MR arthrography with histologic correlation and stratigraphic dissection. The proximal tibiofibular joint is located between the lateral tibial plateau of the tibia, and the head of the fibula. 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. 55 year-old female status-post fibular head dislocation with stable reduction but lateral-sided laxity. 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). A Primer and Practical Guide to the Diagnosis of Joint Pain and Inflammation. A slightly curved lateral incision over the fibular head is made. NCI CPTC Antibody Characterization Program. Injection of steroid and anesthetic into the joint can relieve pain and confirm a positive diagnosis. 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. (Please keep reading below for more information on this condition.). Important Points Instability of this joint may be in the anterolateral, posteromedial, or superior directions. Although many patients do not note symptoms during daily activities, symptoms may develop during activities that require sudden changes in direction. To provide the highest quality clinical and technology services to customers and patients, in the spirit of continuous improvement and innovation. Conclusion: MRI is sensitive in the evaluation of tibiofibular ligamentous integrity in proximal tibiofibular instability. The vast majority of the time, the torn ligaments are the posterior proximal tibiofibular joint ligaments, so a graft which is placed in the anatomic position to restore these ligaments has been proven to be successful. All other clinical possibilities should be ruled out before a diagnosis is made. 8600 Rockville Pike 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. 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 ]. Epub 2022 Apr 1. Anavian J, Marchetti DC, Moatshe G, Slette EL, Chahla J, Brady AW, Civitarese DM, LaPrade RF. Axial fat-suppressed proton density weighted image at the PTFJ demonstrates marked soft tissue edema surrounding the joint with intact anterior (green arrow) and posterior (blue arrow) PTFJ ligaments. McNamara WJ, Matson AP, Mickelson DT, Moorman CT 3rd. The forgotten joint: quantifying the anatomy of the proximal tibiofibular joint. R. F. (2010). It is common for patients to also have transient peroneal nerve injuries, especially with posteromedial dislocation.1,2 The TightRope is subsequently tightened by pulling and spreading the sutures until the lateral button reaches the fibular head. Taping of the proximal tibiofibular joint, in a reverse direction to pull it away from the tendency to anterolateral subluxation, can be very effective at obtaining a validated clinical response in a patient who has injuries to this joint. Nonoperative treatment is associated with persistent symptoms, whereas both fixation and fibular head resection are associated with high complication rates. There are two ways to initiate a consultation with Dr. LaPrade: You can providecurrentX-rays and/or MRIs for a clinical case review 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. In general, we prefer an autograft (using ones own tissues) because it will heal in faster than an allograft (cadaver graft). 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. PMID: 27133689. We have found it to be very effective at restoring stability to this joint and not resulting in joint overconstraint. PMID: 29881700; PMCID: PMC5989917. Clinical History: 21-year-old male with lateral knee pain radiating into the calf status-post soccer injury. Epub 2017 Mar 20. ABSTRACT Protection of the peroneal nerve during surgery helps to prevent injury and relieves symptoms common to this injury. 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. Most patients are cleared to begin full activities between four to six months postoperatively, assuming they have adequate restoration of proximal tibiofibular joint stability, pain relief, and return of strength, agility and endurance. On the lateral radiograph the fibular head barely intersects the radio-dense line (dotted line) representing the posteromedial margin of the lateral tibial condyle. Imaging Techniques You can schedule an office consultation with Dr. LaPrade. In cases where the symptoms of proximal tibiofibular joint instability are difficult to discern, especially for chronic cases, we have found that taping of the proximal tibiofibular joint is helpful to confirm the diagnosis. With the knee flexed 90 the fibular head may be subluxed/dislocated by gentle pressure in an anterior or posterior direction. 2018 Apr;26(4):1104-1109. doi: 10.1007/s00167-017-4511-0. It causes significant lateral sided knee pain and functional deficits and can be associated with up to 9% of multiligament knee injuries. 43 year-old male with lateral knee pain status-post snowboarding injury. 48 year-old female with an acute PLC sprain and ACL tear. Rev Chir Orthop Reparatrice Appar Mot. Recent traumatic anterolateral proximal tibiofibular joint dislocation. The implant is pulled back laterally to ensure that the medial button is engaged against the cortex. PMID: 97965. 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. History and physical examination are very important for diagnosis. The treatment of proximal tibiofibular joint instability usually depends upon whether it is an acute or chronic injury. Thank you for choosing Dr. LaPrade as your healthcare provider. The reconstructive procedure is recommended for patients whose pain is a result of joint instability. 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. Proximal Tibiofibular Joint Reconstruction With a Semitendinosus Allograft for Chronic Instability. I had wanted to do the Proximal Tibiofibular Surgery locally instead of flying out of state. Orthop Rev. Axial and coronal fat-suppressed proton density-weighted images demonstrate soft tissue edema surrounding the PTFJ with subtle irregularity of the posterior ligament (blue arrow) near the fibular attachment and an underlying bone contusion (arrowhead). History of Traumatic Injury The early recognition of instability in the proximal tibiofibular joint is necessary to optimize management of the injury and to avoid potential misdiagnosis. 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. 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. Burke CJ, Grimm LJ, Boyle MJ, Moorman CT 3rd, Hash TW 2nd. 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 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. Improved outcomes can be expected after surgical treatment of PTFJ instability. The surgical treatment for proximal tibiofibular joint instability most often consists of an anatomic reconstruction of the torn ligaments. Knee Surgery, Sports Traumatology, Arthroscopy, 18(11), 1452-1455 . Traumatic dislocations of the proximal tibiofibular joint are uncommon and are normally caused by high-energy injury or a fall on a twisted knee. The implant is pulled through, flipping the medial button on the outside of the anteromedial cortex. Dislocation of the proximal tibiofibular joint is a very uncommon condition that is easily misdiagnosed without clinical suspicion of the injury. 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. Instability of the proximal tibiofibular joint . MRI evaluation of chronic instability is more challenging given the lack of associated soft tissue edema (Figure 11). Nonoperative treatment is associated with persistent symptoms, whereas both fixation and fibular head resection are associated with high complication rates. Protection of the peroneal nerve during surgery helps to prevent injury and relieves symptoms common to this injury. The integrity of the proximal tibiofibular joint is best visualized through plain radiographs. Diagnosis requires careful assessment of radiographs of the knee and tibia (often missed injury). Epub 2010 Feb 3. Morrison T.D., Shaer J.A., Little J.E. 2010 Sep;19(5):409-14. doi: 10.1097/BPB.0b013e3283395f6f. Reconstructive procedures are recommended for patients whose source of pain is instability in the joint as opposed to arthritis. 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. These two bones of the leg are connected via three junctions; The superior (proximal) tibiofibular joint - between the superior ends of tibia and fibula The inferior (distal) tibiofibular joint - between their inferior ends The examination of patients with atraumatic subluxation or chronic instability should be performed with the knee flexed to 90 degrees. Injuries to the joint are more commonly atraumatic and should be treated with surgery only after all other therapies have been exhausted. Fibular resection during an arthrodesis procedure can decrease ankle pain and instability after surgery. This site needs JavaScript to work properly. Clinical and Surgical Pearls 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