Review of Common Clinical Conditions of the Proximal Tibiofibular Joint

CHRONIC INSTABILITY

Chronic instability is commonly the result of untreated or misdiagnosed subluxation of the PTFJ. Ogden¹⁰ 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. The first step in the management of chronic instability of the PTFJ is usually a nonoperative approach. Immobilization, activity level modification, utilization of a supportive strap placed 1 centimeter below the fibular head for pain relief, and participation in a strength-training program of the lower leg are initial treatment recommendations.^10,11,13 Many patients with chronic PTFJ instability do not respond to conservative treatment and may pursue surgical intervention. Surgical treatment options include permanent arthrodesis, resection of the fibular head, soft tissue reconstruction, and temporary fixation.^10,13,26,31 Given the rare nature of the injury and lack of data on varying treatments, there is no clear consensus on the optimal surgical procedure.

Arthrodesis and fibular head resection are 2 traditional methods of surgically addressing the PTFJ, but both have limitations that need to be recognized. Arthrodesis involves clearing the PTFJ of all articular cartilage, bone grafting, and then reducing the joint using screw fixation.¹¹ Rigid fixation prevents rotation of the fibula which puts additional stress on the ankle, frequently causing pain and instability of the ankle joint.^10,11 The other traditional surgical option, fibular head resection, involves excision of the head and neck of the fibula while preserving the fibular styloid and LCL.⁴ Fibular head resection is indicated when peroneal nerve symptoms or palsy occur in PTFJ injuries.^4,10 Unfortunately, resection may disrupt the posterolateral corner structures of the knee and result in pain and instability.^3,13 As a general rule, it is advisable to avoid arthrodesis and fibular head resection in children and athletes because of the length of time during which complications can develop.¹¹

Van den Bekerom and colleagues²⁶ suggest that their technique of temporary fixation of the PTFJ using a cancellous screw yields satisfactory outcomes in treating chronic PTFJ instability. The method entails having the ankle dorsiflexed and the head of the fibula slightly externally rotated and reduced into the most stable position. A hole is drilled in the anteromedial direction from posterior fibula head into the tibia. A non-tapped cortical screw is used to fix the fibula head in the reduced position.²⁶ The screw is removed after 3 to 6 months. Seven of 8 patients treated with this technique by Van den Bekerom and colleagues²⁶ have had alleviation of symptoms, although the screws broke in 2 cases before their planned removal.

Soft tissue reconstruction of the PTFJ has been an evolving area of treatment. Several techniques using a variety of tissue grafts and fixation methods have been described. Giachino³² proposed a reconstruction in which the fibular head is stabilized with a strip of ipsilateral biceps femoris tendon still attached distally to the fibular head and deep fascia of the leg. Drill holes are made in the tibia, and the tissue is secured anteriorly to the fascia with a suture. Shapiro and colleagues³³ performed a stabilization using a strip of the iliotibial band still connected to its insertion on Gerdy’s tubercle. The graft was tunneled through a tibial drill hole from anterior to posterior and through the fibular head from posterior to anterior before suturing back onto itself. Another technique described by Mena and colleagues³⁴ uses a split biceps tendon autograft, harnessing the strong attachments of the tendon to the fibular head to stabilize the reduced PTFJ.

More recently, Miller³⁵ employed elements of the techniques described by Gianchino,³² Shapiro and colleagues,³³ and Mena and colleagues³⁴ to develop a method involving the biceps femoris tendon and iliotibial band in a soft tissue reconstruction. The technique involves harvesting the biceps femoris tendon while preserving the distal insertion and harvesting the iliotibial band while leaving the distal insertion at the Gerdy’s tubercle intact.³⁵ The biceps tendon is passed from posterior to anterior through a tibial bone tunnel, and the iliotibial band graft is passed through the same tunnel but in the anterior to posterior direction. A bioabsorbable interference screw is placed into the tibial tunnel from anterior to posterior. The remaining biceps tendon graft is sewn into the soft tissue of the anterior tibia. The tail of the iliotibial band graft is passed through the fibular bone tunnel in the posterior to anterior direction and looped around the fibular head and under the LCL before being sewn back onto itself.³⁵ Kobbe and colleagues³⁶ described a surgical technique using the ipsilateral semitendinosis tendon while Maffulli and colleagues³⁷ and Morrison and colleagues³⁸ presented techniques using the ipsilateral gracilis tendon. These techniques do not jeopardize lateral knee or fibular head stability by avoiding the use of the biceps femoris and iliotibial band, as well as local knee stabilizers. Warner and colleagues³¹ proposed a similar technique to the aforementioned using a semitendinosus tendon; however, they do not reconstruct the anterior ligamentous structures, as seen in Figures 4A and 4B.³⁹ The authors have concerns that a 2-limb reconstruction as described by Kobbe and colleagues³⁶ and Morrison and colleagues³⁸ may be prone to overconstraint or other errors in tensioning because it does not allow for differential tension to be applied to each limb.³¹ According to Warner and colleagues,³¹ the anterior structures of their patients with chronic PTFJ instability have appeared normal, and isolated posterior ligamentous reconstruction has been adequate for the restoration of stability. Camarda and colleagues²⁸ proposed a technique very similar to that of Warner and colleagues;³¹ however, the tibial tunnel is reamed from posterolateral to the anteromedial aspect of the tibia, exploiting the skin incision previously used for tendon harvest.

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