Abstract
Instability of the proximal tibiofibular joint (PTFJ) is a rare injury pattern than can affect high-demand athletes involved in twisting or pivoting movements on a flexed knee. Instability may produce painful subluxations during provocative activity and occasional neuritic symptoms from tethering of the common peroneal nerve at the fibular neck. There are several reports of reconstruction for symptomatic PTFJ instability; however, no optimal treatment has been elucidated in the literature. Use of a cortical button suspensory device for fixation of the PTFJ offers the advantage of stabilizing the joint without need for free graft harvest or rigid screw fixation. The present technical report illustrates the operative technique and the advantages, disadvantages, pearls, and pitfalls associated with this operation.
Instability of the proximal tibiofibular joint (PTFJ) is a rare pathology that predominantly affects athletes participating in sports involving twisting motions in knee flexion.1 PTFJ instability can cause significant morbidity and functional impairment during sporting activity because of continuous irritation of the common peroneal nerve.1 Furthermore, due to the subtlety of its presentation, this injury may often go undiagnosed particularly as symptoms resolve with spontaneous reduction, particularly with atraumatic onset.
Static stabilizers of the PTFJ include anterior and posterior ligaments that connect the fibular head to the lateral tibial condyle.1 Additional stabilizers include the knee joint capsule, popliteus tendon, and the biceps femoris tendon.1 Anterolateral instability is the most commonly reported pattern.1 A myriad of operative treatment options exists to treat PTFJ instability with low complication rates, relief of symptoms, and improved outcomes; however, there is no established optimal treatment modality.2
Cortical button suspensory devices fixation has increasingly been used for the stabilization of tibiofibular instability, both distally and to a lesser extent proximally, given their strong biomechanical properties and limited bulk.3,4 The present technical report presents a cross country athlete with atraumatic, subacute onset of PTFJ instability with common peroneal nerve symptoms. The purpose of this report is to describe successful use of suture button fixation of symptomatic PTFJ instability to facilitate an expeditious return to sport without morbidity.
Surgical Technique
Indications and Preoperative Imaging
Tenderness to palpation of the PTFJ will be present in those with disruption. The patient must be assessed for existence of foot drop or aberrant sensation in the peroneal nerve distribution over the anterolateral leg with and without activity. Physical examination of the knee is used to determine whether alternative ligamentous instability exists or patellar maltracking that may be responsible for patient symptoms. Shuck testing is then performed to determine anterior-posterior translation of the fibula with respect to the tibia. Guarding and apprehension may be present on shuck testing.
Plain film radiographs are first obtained to determine any osseous abnormalities. Magnetic resonance imaging is then obtained to further evaluate the PTFJ ligaments (Fig 1). On magnetic resonance imaging, the PTFJ is in anatomic position, with convex tibial articulation, and congruent reduction when in full extension and without focal edema or evidence of acute ligamentous disruption. Patients are first trialed with nonoperative management through physical therapy and activity modification. The decision to pursue operative intervention is made with persistence of pain and dysfunction that precludes return to daily activities.
Fig 1.
Magnetic resonance imaging of the left knee in (A) coronal, (B) sagittal, and (C) axillary slices that reveal no focal edema surrounding the proximal tibio-fibular joint. Red arrows: anterior and posterior superior tibiofibular ligaments.
Patient Positioning
The patient is positioned supine on a standard operating room table. Tourniquet is placed over the left lower extremity. A lateral post is positioned at the mid-thigh and a foot bolster is placed to allow the knee to rest at 70 to 90° of flexion. The patient is prepped and draped in a standard sterile fashion. Examination under anesthesia is performed to confirm anterolateral instability of the PTFJ. A tourniquet is used for the duration of the case.
Operative Technique
Diagnostic Arthroscopy
Diagnostic arthroscopy is performed using standard medial and lateral parapatellar portals to exclude intra-articular pathology, particularly at the lateral joint line. Synovitis in the compartments of the knee may be debrided at this time. The structures of the knee, including the medial and lateral menisci, popliteus tendon, ligamentum mucosum, and anterior and posterior cruciate ligaments are examined to ensure integrity.
Arthroscopic equipment is removed, and portal sites are closed primarily. The knee is then brought to 90° of flexion. A posterior-based incision is made approximately 5 to 7 cm in length and centered over the fibular head (Fig 2).
Fig 2.
Posterior-based 5- to 7-cm incision centered over top the fibular head.
Surgical Approach
Dissection is carried down to fascia developing full thickness skin flaps. The peroneal nerve is identified 2 cm distal from the proximal tip of the fibula using manual palpation and careful dissection with Metzenbaum scissors. Care is taken to preserve surrounding vasculature throughout the course of the nerve as it is mobilized both proximally and distally. After mobilization, the nerve is safely retracted inferiorly to gain exposure to the PTFJ (Fig 3).
Fig 3.
Patient left knee positioned supine and in 90° flexion with (A) identification of the common peroneal nerve and (B) retraction inferiorly. Red arrow: common peroneal nerve.
Implant Fixation
The drill site is identified at the area of metaphyseal thickening on the fibula (Fig 4). At approximately 30° angled anteriorly in the coronal plane toward the tibia, a 3.7-mm trocar-shaped drill is advanced perpendicular to the PTFJ across all 4 cortices under fluoroscopic guidance (Fig 5).
Fig 4.
Drill site for insertion of button fixation of the proximal tibia-fibular joint in left knee, positioned supine and in 90° flexion.
Fig 5.
Establishment of drill site of proximal tibiofibular fixation using fluoroscopic guidance.
With the knee in 70 to 90° of flexion, a suspensory cortical fixation device (TightRope, Arthrex, Naples, FL, USA) is deployed in standard fashion. The implant is passed through the proximal fibula and tibia cortices from the lateral side using a shuttle wire. Each suture tail is wrapped around tensioning handles. The tensioning handles are pulled, 1 at a time, until the button lay flush on the medial tibial cortex (Fig 6). Fluoroscopy is used to confirm adequate deployment of the suture button so that it is seated flat along the medial tibia. A blunt hemostat is placed underneath the lateral button, whereas the alternating suture is passed so that the lateral button is seated flat on the proximal fibula (Fig 7). The pull-through sutures are cut and removed, whereas the lateral sutures are cut flush. Fluoroscopy is used to confirm accurate placement of the device (Fig 8).
Fig 6.
Insertion of suspensory ligament device into the predrilled proximal fibula and tibia to reconstitute the proximal tibiofibular joint in left knee, positioned supine and in 90° flexion.
Fig 7.
Final tensioning of the suspensory ligament device using tensioning handles wrapped around device's suture tails in left knee, positioned supine and in 90° flexion.
Fig 8.
Fluoroscopy anteroposterior view of the left knee demonstrating suspensory cortical fixation device traversing the proximal tibia fibular joint.
Repeat examination of the PTFJ is performed with anterior and posterior shuck testing; this is comparable to the contralateral side. The wound is irrigated and closed in layers, with a subcuticular closure and application of an adhesive skin glue. Final postoperative films are acquired (Fig 9).
Fig 9.
Final postoperative radiographs at 4 months following surgery demonstrating (A) anteroposterior and (B) lateral views of the left knee.
Rehabilitation
The patient is limited to toe touch weightbearing from 0 to 2 weeks after surgery, with the knee locked in full extension, and passive range of motion is allowed from 0 to 90°. From 2 to 4 weeks, the patient is advanced to partial weightbearing with crutches with the knee locked in full extension. From 4 to 6 weeks, the patient is advanced to full weightbearing as tolerated with the brace unlocked. The patient is weaned from crutches as tolerated and progressive strengthening and conditioning training is initated at 6 weeks. A running program, or alternative sport specific programs, may be used to advance the patient's return to sport. Jogging is advanced first to 0.5 to 1 mile. If able to be performed asymptomatic, the patient is advanced to half-speed sprints. This is advanced to full speed as tolerated depending on the level of pain. Next, the patient is advanced to performing 6 80-yard sprints with cutting and advanced speed as tolerated. This program is performed each day until the patient was able to tolerate the program without pain. Upon completion of the running program, the patient is able to return to competition (Table 1).
Table 1.
Rehabilitation Protocol Following Proximal Tibiofibular Joint Reconstruction
| Time Interval | Rehabilitation |
|---|---|
| 0-2 weeks | Weightbearing: Toe touch weightbearing Range of motion: Knee locked in full extension in hinged knee brace |
| 2-4 weeks | Weightbearing: Partial weightbearing with crutches Range of motion: Knee locked in full extension in hinged knee brace |
| 4-6 weeks | Weightbearing: Full weightbearing as tolerated Range of motion: Knee remain in hinged knee brace, unlocked Strengthening: Advance as tolerated; begin sports-specific exercise |
Discussion
The present technique article presents the operative management of PTFJ instability using the popular suspensory cortical button fixation device (Video 1). The presented patient had a successful outcome with surgery and was able to return to sport in less than 6 months. Outcomes regarding PTFJ instability are limited; however, continued investigations should be aimed at using cortical suspensory devices to fix the joint.
The PTFJ is stabilized predominantly by the ligamentous complex anteriorly and posteriorly and the popliteus tendon posteriorly.1 Anterolateral dislocation is most reported in the literature, and coincides with injury to the anterior and posterior capsular ligaments.1 Nonoperative treatment through immobilization has been reported in 35 patients, which resulted in improvement without persistent symptoms in 59% of patients.2 Various fixation methods have been reported in the literature, including internal fixation with screw, free graft reconstruction, and cortical button suspensory fixation.2 Kruckeberg et al.2 performed a systematic review wherein 16 patients were treated with screw alone and 62.5% of patients reported no instability with fixation. Fibular head resection was performed in 8 patients, and resulted in no instability symptoms; however, 1 patient had persistent temporal peroneal nerve palsy.2 Alternative reconstructive options include free graft and a suture bridge construct.5 In patients receiving free graft reconstruction, none had instability symptoms; however, 2 patients were reported to have sustained a fracture perioperatively.2 Tafazal et al.6 used a cortical button suspensory construct in a single case report in an 8-year-old child for management of isolated, chronic PTFJ instability. The patient developed peroneal nerve neuropraxia which resolved by 5 months, and successfully returned to sport. The patient had persistent pain in the anteromedial aspect of the leg and the implant was removed thereafter, which resolved all symptoms.6 A recent Technical Note discussed treatment of symptomatic PTFJ instability with a 2-device cortical suspensory device.7 The present case found adequate fixation with use of 1 device and an earlier progression of rehabilitation to prevent stiffness.
Cortical suspensory fixation devices have become increasingly used in the repair of ligamentous structures, particularly the distal syndesmosis.8,9 Biomechanically, suture button devices have demonstrated superiority in comparison to screws and plate-screw constructs in restoring the distal syndesmosis.3,4 Clinically, suture button constructs have shown either equivalent or superior outcomes in comparison to syndesmotic screws alone.10,11 Additionally, cortical suspensory devices are less likely to cause fracture during drilling when compared to free graft constructs.2 Use of such devices to reconstruct the PTFJ have had successful reports in recent case reports.12 Additionally, fixation with suspensory device provides less rigid fixation in comparison to screw only to allow for earlier range of motion (Table 2, Table 3). The primary risk associated with this technique is persisten peroneal nerve symptoms. However, fixation through alternate modes of fixation such as a screw, pin, or bone graft are reported to have a higher incidence of such symptoms.2 Careful dissection and retraction prevents this injury. Alternatively, wound infection, dehiscence, and heterotopic ossification have also been reported.
Table 2.
Advantages and Disadvantages of Cortical Suspensory Device Fixation of the Proximal Tibiofibular Joint
| Advantages | Disadvantages |
|---|---|
| Small unilateral incision centered over fibula | Reliance on synthetic implant for syndesmotic instability |
| Allows for range of motion and partial weight bearing within 2-4 weeks and return to sport within 6 months | Free graft reconstruction required in event of failure |
| Smaller drill size compared to free graft constructs limits secondary fracture | |
| Lack of donor site morbidity from graft harvest |
Table 3.
Pearls and Pitfalls of Cortical Suspensory Device Fixation of the Proximal Tibiofibular Joint
| Pearls | Pitfalls |
|---|---|
| Careful dissection required to preserve common peroneal nerve, distal branches, and surrounding vasculature | Cognizant of anatomic variants with more proximal bifurcated common peroneal nerve Avoidance of the pes anserinus complex and saphenous nerve during far-cortex drilling and deployment of the far cortex button |
| Mobilization of nerve to allow for ease of retraction without excessive pressure | Failure to retract the common peroneal nerve or use a drill guide can result in damage adjacent structures |
| Drill must be angled anteriorly (approximately 30°) to reconstitute the proximal tibiofibular joint | Confirm button implant is flipped correctly through fluoroscopy |
| Central pin positioning in the proximodistal and anteroposterior planes of the proximal fibular metaphysis is critical to ensure anatomic and stable fixation | Eccentric drilling can result in iatrogenic failure or loss of fixation during final construct tensioning |
Continued reports may be used to validate the efficacy of fixation through cortical suspensory devices and compare constructs with that of free graft reconstruction or rigid screw fixation. The present technical report demonstrates the pearls and pitfalls of treating PTFJ instability with a single suspensory device and found no morbidity, resolution of instability symptoms, and swift return to sport in this single case.
Conclusion
The present technical report demonstrates use of cortical button suspensory device for fixation of the PTFJ. This technique offered early rehabilitation and return to sport without morbidity. Further research may be performed to compare efficacy with alternative constructs.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: B.R.W. reports serving as a board/committee member for the American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, and Society of Military Orthopaedic Surgeons and on the editorial/governing board of the American Journal of Orthopaedics and Arthroscopy; receiving publishing royalties, financial of material support from Elsevier; being a paid presenter/speaker for Genzyme; being a consultant for Encore Medical; being a consultant and receiving hospitality payments from Vericel Corporation; receiving research support and education payments from Arthrex, Southtech Orthopedics, and Midwest Associates; receiving education grants and hospitality payments from Smith & Nephew; receiving education and hospitality payments from Desert Mountain Medical; and receiving hospitality payments from Wright Medical Technologies and DePuy Synthes. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
The patient is positioned supine and the left knee is draped sterilly for arthroscopic examination of the knee. Following diagnostic arthroscopy, the left knee is brought into flexion and a 5- to 7-cm incision is made over the proximal fibula. Careful dissection is made to identify and mobilize the common peroneal nerve while preserving nearby vasculature. Once mobilized proximally and distally, the common peroneal nerve is retracted inferiorly. The drill site was marked at the area of metaphyseal thickening of the fibula and a 3-mm drill was advanced at an angle of 30° to reconstitute the proximal tibiofibular joint. The cortical suspensory device was advanced through the joint and appropriately tensioned. Fluoroscopy was used to ensure successful deployment of the implant.
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Associated Data
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Supplementary Materials
The patient is positioned supine and the left knee is draped sterilly for arthroscopic examination of the knee. Following diagnostic arthroscopy, the left knee is brought into flexion and a 5- to 7-cm incision is made over the proximal fibula. Careful dissection is made to identify and mobilize the common peroneal nerve while preserving nearby vasculature. Once mobilized proximally and distally, the common peroneal nerve is retracted inferiorly. The drill site was marked at the area of metaphyseal thickening of the fibula and a 3-mm drill was advanced at an angle of 30° to reconstitute the proximal tibiofibular joint. The cortical suspensory device was advanced through the joint and appropriately tensioned. Fluoroscopy was used to ensure successful deployment of the implant.