Tibiofibular Instability Research Articles

Comparative Study for Surgical Treatment of Acute Distal Tibiofibular Syndesmotic Lesions Using the Modified Suture-Button Fixation Versus Static Syndesmotic Screw Fixation.

Several techniques to treat acute distal tibiofibular instability are described consisting in static and dynamic fixation procedures. The aim of our work is to compare the outcomes of acute syndesmotic injury fixation between the modified technique of dynamic fixation using the suture-button principle as an efficient and low-cost method and the classic static fixation. It is a prospective study including patients presenting with acute syndesmotic injury. After fracture fixation, residual syndesmotic instability was managed using syndesmotic screw in group A and dynamic fixation with a double Ethibond suture in group B. Functional results were assessed using the American Orthopaedic Foot and Ankle Society score (AOFAS) score. Radiological evaluation was done by a postoperative computed tomography (CT) scan of both ankles and plain X-rays of the ankle after surgery and at 18 months. Group A included 20 patients meanwhile 35 patients were in group B. The reduction was satisfactory in the 2 groups according to the postoperative CT scan measurements. The mean healing time in group A was 49.65 days and 51.49 days in group B (P = .45). We did not find any significant difference in terms of loss of reduction in the 2 groups. The return to work was faster in group B (P = .04). Patients in group B had better AOFAS score (P = .03) and ankle range of motion than those in group A. The difference was statistically significant (P = .02 for dorsal flexion and P = .001 for plantar flexion). For group A, we did not note any early complications. Meanwhile, 7 patients developed skin complications in group B (P = .03). However, no significant difference was found in terms of late complications. The modified dynamic suture-button fixation remains a therapeutic alternative in low-income countries that could achieve better outcomes than static fixation, with easy postoperative follow-up. Level II.

Modified Reconstruction of The Proximal Tibiofibular Joint Using Iliotibial Band: A Case Report

Introduction: Instability of the proximal tibiofibular joint is a rare condition and may present with an atypical presentation due to its location and symptoms. Recent techniques and graft has allowed to repair tibiofibular joint. Iliotibial band autograft might be used as a choice for this case as its characteristic, cost effectiveness, minimal invasive graft harvesting procedure, and long term outcome bring consideration to use as choice for the treatment. Objective: To introduce the new technique for PTFJ instability by using ITB graft Case report: A 21-year-old office worker male came to our clinic with discomfort on lateral aspect of right knee. He injured his right knee after he externally twist his right knee when he was going to wake up (stand up) from bed. He experienced immediate lateral pain and swelling lateral knee pain persisted until 1 week before admitted to the hospital. Discussion: In our case, patient is a office worker without an adequate energy cause the joint becoming sublux. For the surgical technique , we took the graft form the center side of ITB with the intentional purpose of preventing Kaplan Fiber. For the reaming procedure we took place directly behind the fibula and keep the posterior capsule intact to prevent further damage and infection on surgical site. We choose to use biomaterial implant for this study because the use of biomaterial screw itself has a low complication rate compare to metallic screw with no significant different in outcome (6). This technique overall has a satisfaction result with improvement of Lyshom score Conclusion: Iliotibial band is an alternative graft that can be used for reconstruction in tibiofibular joint. For its minimal invasive technique and cost effectiveness and satisfy long term outcome coud be a consideration for the treatment in tibiofibular instability.

Proximal Tibiofibular Joint Reconstruction With a Semitendinosus Allograft for Chronic Instability

Whereas acute proximal tibiofibular joint (PTFJ) dislocation may require urgent reduction, chronic or recurrent instability may initially be approached with conservative treatment. Indications for PTFJ reconstruction include persistent lateral knee pain and/or tibiofibular instability for which conservative treatment has failed. Owing to the low incidence of diagnosed isolated PTFJ instability, there is still no consensus regarding the optimal surgical treatment, with an array of options having been previously described. We describe the treatment of isolated PTFJ instability using an anatomic reconstruction with semitendinosus allograft for chronic instability.

Proximal tibiofibular stabilization by anatomical ligamentoplasty and diaphyseal osteotomy of the fibula

Proximal tibiofibular instability is a rare condition for which treatment is poorly codified. A 21-year-old patient, a leisure sportswoman, presented a post-traumatic anterolateral instability of the proximal tibiofibular articulation without cartilage lesion. We propose an original surgical technique based on a review of the literature that combines an anatomical ligamentoplasty of the proximal tibiofibular joint and a proximal fibular diaphyseal osteotomy to reduce the distal tibiofibular mechanical stresses. This original technique allows a favorable evolution with recovery of professional and sports activities at 6 months.

Can treatment of posterior malleolus fractures with tibio-fibular instability be usefully addressed by Bartonicek classification?

IntroductionAnkle fractures account for 4% of all fractures and treatment of those involving the Posterior Malleolus remains controversial. Clinical and radiological outcomes in a cohort of patients with Posterior Malleolus fractures conservatively treated were retrospectively evaluated; furthermore, a treatment algorithm was suggested. MethodsPatients were divided according to Bartoníček classification. The clinical evaluation was made with OMAS/AOFAS scores; the radiological evaluation with Van Dijk classification for post-traumatic arthritis. ResultsClinical outcome worsened with the severity of Bartoníček classification, but early degenerative changes were not correlated neither to the clinical outcome nor to the injury pattern. Clinical and radiological outcomes depended on the damage of the syndesmosis as articular step-offs and tibio-fibular notch involvement. DiscussionWe recommend conservative treatment for Bartoníček type I, type II and type III fractures, the latter when undisplaced and without tibial plafond depression. We suggest surgical treatment for type IV and displaced type III fractures.

Cortical Button Fixation for Proximal Tibiofibular Instability: A Technical Report

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.

Clinical Characteristics and Outcomes After Anatomic Reconstruction of the Proximal Tibiofibular Joint

To assess the most common presenting symptoms, clinical outcomes, and satisfaction after anatomic reconstruction of the proximal tibiofibular joint (PTFJ) with a free semitendinosus autograft. Consecutive patients with minimum 2-year follow-up after isolated anatomic PTFJ reconstruction were retrospectively reviewed. Patients were evaluated with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and Lysholm Knee Survey score along with a simple numeric patient satisfaction score (0-10, with 10 rated as perfect). Statistical analysis was performed with paired t tests, with P < .05 considered significant. The study included 16 PTFJ reconstruction surgical procedures in 15 patients with isolated proximal tibiofibular instability verified by an examination under anesthesia (4 reconstructions in male patients vs 12 in female patients); the average age was 37.9 ± 14.6 years, with an average follow-up period of 43.2 months (range, 22-72 months). Of the 13 patients with complete follow-up, 11 (84.6%) were able to return to full desired activities and previous level of sport. Fourteen patients presented with concomitant common peroneal nerve pathology. Two patients had a subsequent complication. No patients needed an additional procedure. Significant (P < .05) improvement occurred across all WOMAC domains and in the WOMAC total score, from 31.4 (±14.9) preoperatively to 15.2 (±15.5) postoperatively. Lysholm Knee Survey scores significantly (P < .05) improved from 51.2 (±17.2) to 75.0 (±18.0). Patients' overall satisfaction was rated 7.6 (± 2.7) of10. At an average follow-up of 43.2 months, anatomic PTFJ reconstruction for isolated PTFJ instability provided improvement in clinical outcomes, a return to activities, and a low risk of complications or need for additional procedures. PTFJ reconstruction with hamstring tendon graft is a promising surgical treatment that improves patient satisfaction when conservative treatment of PTFJ instability fails. Level IV, case series.

Computed Tomography With Stress Maneuvers for Evaluation of Distal Tibiofibular Syndesmosis Instability (CTMETS)

Computed Tomography With Stress Maneuvers for Evaluation of Distal Tibiofibular Syndesmosis Instability (CTMETS)

A Biomechanical Comparison of the Arciero and LaPrade Reconstruction for Posterolateral Corner Knee Injuries.

Background:Injury to the posterolateral corner (PLC) of the knee requires reconstruction to restore coronal and rotary stability. Two commonly used procedures are the Arciero reconstruction technique (ART) and the LaPrade reconstruction technique (LRT). To the authors’ knowledge, these techniques have not been biomechanically compared against one another.Purpose:To identify if one of these reconstruction techniques better restores stability to a PLC-deficient knee and if concomitant injury to the proximal tibiofibular joint or anterior cruciate ligament affects these results.Study Design:Controlled laboratory study.Methods:Eight matched-paired cadaveric specimens from the midfemur to toes were used. Each specimen was tested in 4 phases: intact PLC (phase 1), PLC sectioned (phase 2), PLC reconstructed (ART or LRT) (phase 3), and tibiofibular (phase 4A) or anterior cruciate ligament (phase 4B) sectioning with PLC reconstructed. Varus angulation and external rotation at 0º, 20º, 30º, 60º, and 90º of knee flexion were quantified at each phase.Results:In phase 3, both reconstructions were effective at restoring laxity back to the intact state. However, in phase 4A, both reconstructions were ineffective at stabilizing the joint owing to tibiofibular instability. In phase 4B, both reconstructions had the potential to restrict varus angulation motion. There were no statistically significant differences found between reconstruction techniques for varus angulation or external rotation at any degree of flexion in phase 3 or 4.Conclusion:The LRT and ART are equally effective at restoring stability to knees with PLC injuries. Neither reconstruction technique fully restores stability to knees with combined PLC and proximal tibiofibular joint injuries.Clinical Relevance:Given these findings, surgeons may select their reconstruction technique based on their experience and training and the specific needs of their patients.

The Proximal Tibiofibular Joint: A Biomechanical Analysis of the Anterior and Posterior Ligamentous Complexes

Background: Dislocation of the proximal tibiofibular joint is a complex injury that is often overlooked or misdiagnosed. Surgical management is recommended for severe acute or for chronic symptomatic instability of the proximal tibiofibular joint. Although the anterior ligamentous complex has been reported to be stronger than the posterior complex, biomechanical data are lacking. Purpose: To determine the ultimate load of the anterior and posterior ligamentous complexes of the proximal tibiofibular joint to determine optimal graft selection. Study Design: Controlled laboratory study. Methods: Ten nonpaired, fresh-frozen knee specimens were dissected to expose the anterior and posterior proximal tibiofibular ligamentous complexes. The tibia was split in the coronal plane to separate the anterior and posterior ligamentous complexes, and the fibula was left intact. Specimens were secured in a dynamic testing machine and preconditioned for 10 cycles between 2 and 10 N at 0.1 Hz followed by loading to failure at a rate of 25 mm/min. Results: The mean (±SD) ultimate load of the anterior complex (517 ± 144 N) was significantly greater than the mean ultimate load of the posterior complex (322 ± 160 N) (P = .012). The mean surface areas of the anterior and posterior complexes were 761 ± 174 mm2 and 565 ± 103 mm2, respectively (P = .008). The mean values for stiffness of the anterior (133 N/mm) and posterior (109 N/mm) complexes were similar (P = .250). Conclusion: The ligaments of the human proximal tibiofibular joint were able to withstand a mean ultimate failure load of 517 ± 144 N for the anterior complex and 322 ± 160 N for the posterior complex. In this regard, it is recommended that the strengths of grafts chosen for proximal tibiofibular reconstructions meet or exceed these values. Clinical Relevance: The optimal surgical treatment for addressing residual proximal tibiofibular instability is not well defined. Before an anatomic reconstruction of the proximal tibiofibular ligament is developed, the individual biomechanical properties of the anterior and posterior ligamentous structures of the proximal tibiofibular joint need to be considered to facilitate an optimal reconstruction design.

Lateral instability of the upper ankle joint

Because of their frequency, ankle sprains are of major clinical and economic importance. The simple sprain with uneventful healing has to be distinguished from the potentially complicated sprain which is at risk of transition to chronic ankle instability. Conservative treatment is indicated for the acute, simple ankle sprain without accompanying injuries and also in cases of chronic instability. If conservative treatment fails, good results can be achieved by anatomic ligament reconstruction of the lateral ankle ligaments. Arthroscopic techniques offer the advantage of joint inspection and addressing intra-articular pathologies in combination with ligament repair. Accompanying pathologies must be adequately addressed during ligament repair to avoid persistent ankle discomfort. If syndesmotic insufficiency and tibiofibular instability are suspected, the objective should be early diagnosis with MRI and surgical repair.

Imaging of Proximal Tibiofibular Joint Instability: A 10 year retrospective case series

ObjectiveDetail the imaging findings in patients with proximal tibiofibular instability treated with surgical stabilization. MethodsRetrospective analysis of preoperative imaging in patients with clinically confirmed tibiofibular instability. ResultsOperative fixation of the 16 patients was as follows: 11 using a fiberwire suture construct and 5 using screw fixation. Proximal tibiofibular ligamentous abnormalities were present in 100% of acute (< 6 months) and 85.7% of chronic (>6 months) instability cases who underwent MRI. ConclusionMRI is sensitive in the evaluation of tibiofibular ligamentous integrity in proximal tibiofibular instability. Chronic instability should be considered in younger adults with isolated tibiofibular osteoarthritis.

The Utilization of a Suture Bridge Construct for Tibiofibular Instability During Transtibial Amputation Without Distal Bridge Synostosis Creation

Symptomatic distal tibiofibular instability is a known complication of trauma-related transtibial amputations. Overt proximal tibiofibular dislocations, which are easily recognized on routine radiographs, may occur concurrently with the traumatic injury or amputation. More commonly, however, the proximal tibiofibular joint remains structurally intact in the presence of distal instability due to the loss of the distal syndesmotic structures and damage to the interosseous membrane, resulting in fibular angulation and distal tibiofibular diastasis. Some authors have espoused treating this instability with the creation of a distal tibiofibular bridge synostosis (the so-called Ertl procedure or modifications there of) to prevent potentially painful discordant motion and to minimize the prominence of the residual distal fibula. Recent studies, however, have suggested an increase in complication and reoperation rates in transtibial amputations that received a bridge synostosis compared with standard transtibial amputations. Additionally, although there are several described techniques for bridge synostosis creation, most are dependent on having sufficient remaining fibula to construct the bone bridge without unnecessary shortening of the tibia; however, sufficient residual fibula is not always available after traumatic and trauma-related amputations. We propose a technique utilizing a suture bridge to restore tibiofibular stability when performing transtibial amputations in patients with proximal tibiofibular dislocations or distal diastasis, avoiding the potential need for a distal bridge synostosis.

Proximal tibiofibular joint instability in a child

Proximal tibiofibular instability is a rarely reported clinical entity in children. In this case report, we describe such a case in an 8-year-old boy successfully stabilized using a minimally invasive technique with a Tightrope device. The child remained pain free and asymptomatic at 2 years of follow-up. The surgical technique is described as well as potential complications and a review of the literature.

Bilateral, Atraumatic, Proximal Tibiofibular Joint Instability

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.

50 YO Male with 4 Months History of Right Proximal Fibular Pain

HISTORY: A 50 yo white male referred from the ER with 2 months history of insidious onset localized sharp pain over the proximal lateral lower right leg. He first felt the pain after working with a shovel for about 4 hours in his garden. No direct trauma. Pain is present during rest and walking. Prevents him from sleep at night. No complaint of back pain. No radiation distally. Aggravated by weight bearing, and direct pressure over the painful area. He visited the ER twice, one month apart. Had negative X-rays, and minimal improvement with NSAIDS. Recently had increasesd numbness on the dorsum of foot. Denied any fever, chills, nausea, or weight loss. PMH of back surgery 1990, multiple oral and dental abscesses, and a recent abscess behind the ear that drained extensively. EXAMINATION: FROM of knee, hip and ankle. No effusion of knee or ankle, no soft tissue swelling. 5/5 strength testing bilaterally and no pain with isometric testing of knee flexion or extension; Ankle plantar flex ion, dorsiflexion, eversion or inversion. Sensation to fine touch was intact and equal bilaterally on leg, foot, first and second web spaces. (-) Tinel's over the peroneal nerve. +2 pulses. He was apprehensive when an attempt we examined the painful area. (+) Tenderness over an area about 1 cm on the fibula starting about 2 inches distally from the proximal end. (-) Tenderness on medial and lateral joint lines. No palpable mass or deformity. Negative straight leg raise test, lachman, McMurray, varus and valgus laxity. Fibular subluxation with knee flexion, and with walking which reproduces discomfort. Manually subluxing the fibula causes the pain shooting distally. Left fibula exam was normal. DIFFERENTIAL DIAGNOSIS: Fibular fracture. Proximal tibiofibular instability. Peroneal nerve entrapment. Osteomyleitis of proximal fibula. TESTS & RESULTS: CBC, ESR WNL. Xrays revealed no fracture or periosteal changes to suggest osteomyletis or tumor. MRI of the knee was negative. (-) Venous Doppler study for DVT. Normal velocity of peroneal nerve on conduction study above and below the fibular head, and (-) EMG. FINAL WORKING DIAGNOSIS: Right Proximal tibiofibular instability with Chronic Subluxing Fibular head. TREATMENTS: Ace wrap & crutches was given in ER with inadequate relief. Patient received a custom made brace to help hold the fibular head in place which initially relieved his discomfort almost completely. A week later it stopped working and patient was back to pain medications. Cylinder cast with strapping was tried aiming at 3 weeks application, however, the patient developed peroneal nerve dysesthesias and the cast was discontinued. The patient was referred for a ligament reconstructive procedure.

Chronic symptomatic proximal tibiofibular instability in a 3-year-old girl

A 3-year-old girl was presented with recurrent pain at the right knee and a “snapping” when walking. A free range of motion of both knee joints, stable cruciate and collateral ligaments and a ventrally subluxating and snapping fibula when flexing the knee were found. Due to a longer course of recurrent subluxation and pain, an operation was performed and the tibiofibular ligaments and joint capsule were tightened by sutures. Other operative techniques proposed in the literature are discussed; most of them could lead to deformities or growth disturbances. The reports of tibiofibular instability in the literature are presented. The girl is the youngest patient with idiopathic proximal tibiofibular instability reported in the literature at least in the last 75 years.

Instability of the tibio-fibular syndesmosis: have we been pulling in the wrong direction?

Syndesmotic stability in ankle fractures is usually assessed intraoperatively by pulling on the fibula with a bone hook in the coronal plane (“Hook Test”). Our clinical observations have suggested that instability may be more marked in the sagittal plane. Our aim was to compare movement at the tibio-fibular syndesmosis in the sagittal and coronal planes after sequential ligament division in a cadaver model. Seven specimens were used. The Hook Test was performed in both the sagittal and coronal planes. Movement was assessed by measuring the displacement of parallel k-wires. In all specimens, the anterior tibio-fibular, interosseous and posterior tibio-fibular ligaments were sequentially divided. In three specimens the deltoid ligament was then divided and the interosseous membrane in another three. After division of all three syndesmosis ligaments the mean displacement was 8.8 mm (±3.9) in the sagittal plane and 1.5 mm (±0.4) in the coronal plane. When the deltoid ligament was then divided, the displacement increased to 11.7 mm (±2.4) and 3.2 mm (±0.5), respectively. When the interosseous membrane was divided the measurements were 12.7 mm (±4) and 3.1 mm (±1.5). Movements were consistently greater in the sagittal plane than the coronal plane and we conclude that distal tibio-fibular instability should be assessed in the sagittal plane.

Ankle fractures resulting from rotational injuries.

Ankle fractures are among the most common skeletal injuries; selection of an optimal management method depends on ankle stability. Stable fractures (eg, isolated lateral malleolar) generally are managed nonsurgically; unstable fractures (eg, bimalleolar, bimalleolar equivalent) usually are managed with open reduction and internal fixation. Stress radiographs may aid in the management of incomplete deltoid injury in which there is medial swelling and tenderness without radiographic talar shift. A posterior malleolar fracture should be reduced and stabilized if it comprises >30% of the articular surface and remains displaced after fibular stabilization. Ankle fractures with syndesmotic injury have additional tibiofibular instability that can be controlled by screw fixation. However, the choice between metal and bioabsorbable screws, screw size, number of cortices fixed, and indications for screw removal remain controversial. Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations.

Congenital longitudinal deficiency of the tibia.

We performed a clinical and radiographic review of 15 patients (19 limbs) with longitudinal deficiency of the tibia treated between 1981 and 2001. Ten limbs with Kalamchi type I deficiencies were managed by through-knee amputation. Five type II deficiencies were treated by foot ablation and tibiofibular synostosis, either at the same time or staged, but prosthetic problems may arise from varus alignment and prominence of the proximal fibula. Patients with type III deficiencies (four cases) were treated by foot ablation. Prosthetic problems relating to proximal or distal tibiofibular instability may necessitate additional surgical intervention.