Chapter

Dislocation of the Proximal

60 Tibiofibular Joint
Nathan Kopydlowski, Eric Tannenbaum, and Jon K. Sekiya

Dislocation of the proximal tibiofibular joint is a very rare The posterior joint capsule is supported by the posterior
condition that is easily misdiagnosed without suspicion of proximal tibiofibular ligament, which consists of two thick
the injury. Proximal tibiofibular dislocation can be an idio- bands that pass obliquely upward from the fibular head and
pathic subluxation of the joint, more commonly seen in con- connect to the posterior aspect of the lateral tibial condyle.
junction with high-energy tibia and ankle fractures. It is most The popliteus tendon covers and reinforces the posterior
common in sports that involve violent twisting of the knee proximal tibiofibular ligament8,28,32,35 (see Fig. 60-2).
such as wrestling, parachute jumping, mixed martial arts, Some physicians also believe that the posterolateral struc-
gymnastics, skiing, rugby, football, soccer, snowboarding, long tures of the knee, including the arcuate ligament, the fabel-
jumping, and baseball.* The pathology of the tibiofibular lofibular ligament, the popliteofibular ligament, the popliteus
joint is a result of anatomic variations of the proximal muscle, the interosseous membrane, and the lateral collateral
joint, the biomechanical axis of the ankle, and training ligament, stabilize the joint.36,37,44 The lateral collateral liga-
program errors.39 Injury to this structure can be caused by ment arises from the lateral femoral condyle in the midcoro-
ligaments that strengthen and support the proximal tibiofibu- nal plane and runs distally and posteriorly to the posterolateral
lar joint, as well as allow the functional structure and the aspect of the fibular head25,27,28 (see Fig. 60-2).
biomechanics of the lower kinetic chain to influence move- Ogden’s historic 1974 article described two different
ments at the joint, all of which increase the chance of anatomic variants based on the arbitrary determinant of a
instability.29,30 Some physicians question the frequency of tib- 20-degree angle with the horizontal plane.27 The inclination
iofibular joint injury due to common misdiagnosis.30,39 Diag- angle for the proximal tibiofibular joint with respect to the
nosis of this rare injury will be improved by a better horizontal plane is important when the anatomic stability of
understanding of the anatomy and biomechanics of the joint, the joint is determined. The greater the slope that the joint
the mechanisms leading to instability, and the symptoms that makes with the horizontal plane, the more vulnerable it is to
result from this injury. rotational forces.48 Ogden described a horizontal variant as
<20 degrees of joint inclination (Fig. 60-3A). It has been
observed to have greater resistance to rotational forces
ANATOMY because of its position behind the prominent ridge of the
The chief function of the proximal tibiofibular joint is to proximal tibia and its large planar, circular articular surface
dissipate some of the forces on the lower leg such as torsional with an average surface area of 26 mm2. The horizontal
stresses on the ankle, lateral tibial bending movements, and variant was also observed to have greater external rotation
tensile weight bearing.27 The proximal tibiofibular joint is a compared with the oblique variant.27-29 Ogden described an
synovial membrane–lined, hyaline cartilage articulation that inclination of >20 degrees as an oblique variant (Fig. 60-3B).
communicates with the knee joint in 10% of adults† and must This increased angle of inclination can reach as high as 76
be considered as the fourth compartment of the knee (Fig. degrees and causes a highly variable surface area, averaging
60-1A and B). The joint capsule is strengthened by ligamen- 17 mm2, and configuration. The angle of inclination shows
tous attachments that increase in strength and thickness from an inverse correlation with the surface area of the joint.27,29,35
anterior to posterior.‡ Responsibility for stabilization of the The oblique variant was found in 70% of the joint injuries
proximal tibiofibular joint falls on the anterosuperior and described by Ogden and instability is thought to stem from
posterosuperior tibiofibular ligaments.48 The joint capsule the decreased surface area and increased angle of inclination
consists of the tibial facet and the fibular facet, located on found in oblique joints.29,45
the posterolateral aspect of the tibial condyle The normal orientation of the proximal tibiofibular joint
and the medial proximal surface of the head of the fibula, does not sit in a sagittal plane; as a result, it encounters
respectively.39 normal movement in the anterolateral and posteromedial
The anterior capsule of the joint is stabilized by the ante- direction.39 Anterior-posterior motion during flexion and
rior tibiofibular ligament, which consists of three broad bands extension, respectively, is increased in children and gradually
that pass obliquely distal from the fibular head and connect decreases with age.27 During anterior movement of the fibular
to the anterior aspect of the lateral tibial condyle. An exten- head, the biceps femoris tendon, which inserts on the styloid
sion of the deep layer of the biceps femoris tendon located process and the upper surface of the head of the fibula, adds
anterior to the anterior proximal tibiofibular ligaments con- support and stability.
nects on Gerdy’s tubercle and helps to stabilize the anterior When the knee is flexed between 0 degrees and 30 degrees,
joint capsule8,25,28,32,35 (Fig. 60-2). the lateral collateral ligament is tight and supports the joint.
When the knee is flexed beyond 30 degrees, the lateral col-
*References 8, 13, 15, 19, 21, 24, 28, 29, 38, 40, and 45-46. lateral ligament and the biceps femoris tendon relax, causing
†
References 7, 17, 27, 32, 35, and 38. the proximal fibula to migrate anteriorly. Laxity in the joint
capsule caused by the orientation of the knee in the flexed
582
 CHAPTER 60 Dislocation of the Proximal Tibiofibular Joint 583

A B
Figure 60-1. Arthrogram of diagnostic and therapeutic injections. A, Needle positioned in the proximal tibiofibular joint. B, Radiographic
dye is used to verify that the needle is in the correct position. Note the communication of the proximal tibiofibular joint with the knee
joint.

Lateral collateral Arcuate ligament Popliteus

ligament tendon
Popliteus
Lateral
tendon
collateral
Biceps femoris ligament Popliteal
tendon tendon
Biceps
Arcuate ligament
Popliteofibular femoris
ligament tendon

Anterior Posterior
proximal Popliteus proximal
tibiofibular muscle tibiofibular
ligament ligament

Anterior
proximal
tibiofibular
ligament

Posterior Lateral

Anterior

Figure 60-2. Anatomy of the proximal tibiofibular joint. (© Whiddon DR, Parker TA, Kuhn JE, Sekiya JK: Disorders of the proximal tibiofibular
joint. In Scott NW [ed]: Surgery of the knee, ed 4, Philadelphia, 2006, Elsevier, pp 797–803.)

position increases the vulnerability of the proximal tibiofibu-

lar joint to injury.27
When the knee is extended, the same structures become
tightened, causing the fibular head to return to its posterior
position.1,27 Because of the arrangement and tightening of
the ligaments around the joint, the proximal tibiofibular joint
34! is most stable when the knee is extended.16,48
The proximal tibiofibular joint is very important in the
external rotation of the fibula with ankle dorsiflexion. It has
10! been observed that during movement of the ankle, rotational
movement can be observed in the proximal tibiofibular
joint.38 The oblique variant causes greater constraint in rota-
A B tional mobility and is thought to increase torsional loads
Figure 60-3. Lateral radiographs show the anatomic variations in during forced ankle dorsiflexion, increasing the probability of
the joint described by Ogden. An increased slope of the articula- fibular dislocation or fracture.27
tion causes instability in the joint by minimizing the surface area Semonian et al reported that it is important to recognize
of the joint. A, Horizontal orientation (<20 degrees). B, Oblique the neurologic aspect of the lateral region of the knee owing
orientation (>20 degrees) is more likely to develop instability. (©
2003 American Academy of Orthopaedic Surgeons. Reprinted from
to the fact that many diagnoses of joint instability go unno-
the Journal of the American Academy of Orthopaedic Surgeons, ticed until patients develop footdrop. The common peroneal
vol 11[2], pp 120–128, Figure 45-2, with permission.) nerve passes posteriorly over the head of the fibula and comes
584 SECTION 5 Sports Medicine: Ligament Injuries

in close contact with the proximal tibiofibular joint. The

peroneal nerve is palpable along the lateral aspect of the knee
because of its path as it wraps around the fibular neck before
the peroneus longus muscle overlaps it laterally.39 Physicians
diagnosing a patient with anterolateral, posteromedial, or
superior dislocation must be aware of peroneal nerve injury.48

CLASSIFICATION OF INSTABILITY
Ogden described the four commonly used types of dislocation
based on the direction of instability of the joint: atraumatic
subluxation, anterolateral dislocation, posteromedial disloca-
tion, and the rare superior dislocation.29,35 In Ogden’s study
of 43 patients, 10 had subluxation, 29 anterolateral disloca-
tion, 3 posteromedial dislocation, and 1 superior disloca-
tion.29 The literature also describes five cases of inferior A
dislocation.11,26 Physicians diagnosing this type of injury
should be aware of its association with a common peroneal
nerve injury that most commonly occurs in patients diag-
nosed with anterolateral or posteromedial dislocation.5,8
Injury to the anterior and posterior capsular ligaments, and
commonly the lateral collateral ligament, can lead to common
anterolateral dislocation29,30,35 (Fig. 60-4A). The main cause
of this injury is a fall on a hyperflexed knee with the foot
inverted and plantarflexed.* Flexion of the knee results in
relaxation of the lateral collateral ligament and the biceps
femoris tendon, and twisting of the body creates a torque that
forces the fibular head laterally to the edge of the bone but-
tress of the lateral tibial metaphysis.13,29 A reflex contracture
of the peroneal, extensor hallucis longus, and extensor
digitorum longus muscles, caused by forced plantar flexion
and ankle inversion, forces the laterally displaced fibular head B
anteriorly.4,28,29,32
Posteromedial dislocation typically stems from direct
trauma to the knee or from a twisting injury that puts
torsional strain on supporting ligaments, causing them to
tear27,29,32,35 (Fig. 60-4B). The resulting loss of support causes
tension in the biceps femoris tendon to displace the fibular
head posteriorly and medially along the posterolateral tibial
metaphysis.29
Subluxation typically occurs in patients who have no
history of inciting trauma but may have generalized ligamen-
tous laxity; it is not commonly bilateral.29,30,35 The anterior *
capsule and the anterior ligament of the joint are thought to
*
be involved in proximal tibiofibular joint subluxation.39 C *
Symptoms of subluxation include excessive anterior-posterior *
motion without actual dislocation of the joint. Figure 60-4. A, Anteroposterior and lateral radiographs of an
Superior dislocations are caused by tearing of the tibiofibu- anterolateral dislocation of the proximal tibiofibular joint. B, Pos-
lar interosseous membrane and result in dislocation of the teromedial dislocation of the proximal tibiofibular joint. C, Supe-
entire fibula29 (Fig. 60-4C). The superior migration of the rior dislocation. Note the tibia fracture (asterisks) associated with
entire fibula commonly results from high-energy ankle inju- this high-energy injury. (© 2003 American Academy of Orthopaedic
Surgeons. Reprinted from the Journal of the American Academy of
ries.35 They are commonly found in conjunction with lateral Orthopaedic Surgeons, vol 11[2], pp 120–128, with permission.)
malleolar and tibial fractures.29,32 Atraumatic superior dislo-
cation of the proximal tibiofibular joint has been seen in
conjunction with congenital dislocation of the knee.29 shaft.11,26 In all cases, the common peroneal and tibial nerves
Five cases of inferior proximal tibiofibular dislocation were affected; all were high-energy motorcycle injuries.11
have been described in the literature, and all were associated
with severe neurovascular injury and fracture of the tibial CLINICAL PRESENTATION
Early recognition of injury to the proximal tibiofibular joint is
important to optimize management and avoid potential mis-
*References 9, 12, 22, 23, 27-29, 32, 33, 35, 38, 40, 45, and 46. diagnosis.36 Early treatment of these injuries may prevent this
 CHAPTER 60 Dislocation of the Proximal Tibiofibular Joint 585

condition from developing into chronic or fixed subluxation, associated tibial and ankle fractures and often require surgery
which is more difficult to treat.39 Before a diagnosis of proxi- for correction.29 Inferior dislocations have been described in
mal tibiofibular joint instability is made, the integrity of sur- the literature as having a very poor prognosis; four of five
rounding ligamentous structures must be checked because of cases result in above-knee or below-knee amputation.26 Pos-
the common injuries that can present with the same symp- terolateral dislocation was described in the literature in one
toms.48 When a patient presents with high-energy trauma, the case and is not mentioned as one of the four types of disloca-
proximal tibiofibular dislocation may be missed initially tion by Ogden.43 It is not uncommon for patients with chronic
because of other traumatic injuries such as fracture of the instability of the proximal tibiofibular joint to be diagnosed
tibial plateau or shaft, ipsilateral femoral head or shaft, distal with Charcot-Marie-Tooth (CMT) disease or to undergo
femoral epiphysis, ankle fracture, or knee dislocation.10,29 diagnostic knee arthroscopy for this problem, so this condi-
Anterolateral injury usually occurs after a fall on a flexed tion should be considered in the differential diagnosis in
knee or a violent twisting motion during an athletic activity, patients with lateral knee pain.
and prominent pain is common over the lateral aspect of the
knee, along with a prominent fibular head.* Pain commonly PHYSICAL EXAMINATION
causes the patient to be unable to bear weight on the affected
leg; range of motion in the knee is limited, especially knee Physical examination of a suspected injury to the proximal
extension, and motion of the ankle may cause more pain.46,51 tibiofibular joint is very important as most patient histories
Patients often present with pain along the biceps femoris do not reveal any specific mechanism of injury, and symptoms
tendon, which appears as a tense, curved cord. Pain that is of lateral knee pain can be very misleading. Many patients
increased by extending the flexed knee and by dorsiflexing present with pain along the lateral aspect of the knee that
and everting the foot is also seen.29 radiates proximally into the region of the iliotibial band and
Posteromedial dislocations are common after direct trauma medially into the patellofemoral joint.20 Side-to-side com-
to the knee with pain secondary to that trauma. Common parison is necessary in adolescents because of the mobility of
peroneal nerve injury can be seen with these injuries, even the fibular head before skeletal maturity is reached.30 The
though symptoms are usually transient.5 relative avascularity of tissues surrounding the joint reduces
Subluxation is seen most commonly in adolescents, can the likelihood that swelling may be present with an isolated
be bilateral, and usually presents with pain on the lateral proximal tibiofibular joint injury.27,29,33,48 A prominent lateral
side of the knee that is increased by direct pressure over the mass with tenderness to palpation over this mass will be
fibular head.29,30 Instability of the knee can be demonstrated observed with any dislocation, along with a mobile fibular
by moving the fibular head anteriorly and laterally by relaxing head with knee flexion. Also, locking and popping of the
the lateral collateral ligament and the biceps femoris tendon knee when mobilized can occur and can be confused with a
with the knee flexed 90 degrees.14 Muscular dystrophy, Ehlers- lateral meniscal tear.16 Some patients feel more intense pain
Danlos syndrome, and generalized ligamentous laxity can be when walking down a decline.8 Patients have also been
associated with subluxation.29,30,39,41 Prepubescent females reported to have loss of sensation and a tingling feeling in
commonly exhibit laxity and usually experience a decrease the region of the fibular head after heavy activity.15 It is neces-
in symptoms as they reach skeletal maturity.29-31,41,42 Other sary to examine the strength and functionality of the ankle
associated events include osteomyelitis, rheumatoid arthritis, and peroneal nerves because of the association of peroneal
septic arthritis, previous below-the-knee amputations, osteo- nerve damage with this injury. Examination of the ankle joint
chondroma, and growth disturbances around the knee, as well is important in determining functionality of syndesmotic
as runners who have recently increased their mileage.3,23,29,35,39 ligaments and the interosseous membrane.48
Recurrence of chronic dislocation of the proximal tibio- Physical examination for chronic instability or atraumatic
fibular joint is often missed because its symptoms mirror a subluxation, in the absence of acute trauma, should first
wide range of other knee conditions. Most patients usually consist of assessment of the fibular head for tenderness while
live their daily lives without symptoms until they become the knee is flexed to 90 degrees. Grasping the fibular head
involved in activities that require sudden changes in direc- between the thumb and index finger should allow evaluation
tion, such as athletic movement.12 It is common for patients of anterior-posterior mobility; the patient should be asked if
to complain of sensations of knee instability or giving way, this motion reproduces the symptoms or causes any appre-
especially while climbing stairs.42 The nature and location of hension.42 The Radulescu sign may be helpful; this is per-
this injury often mimic those of other knee pathologies, such formed by having the patient lie prone with the knee flexed
as injury to the lateral collateral ligament or biceps femoris to 90 degrees. One hand stabilizes the thigh, while the other
tendon, posterolateral rotatory instability, iliotibial band internally rotates the lower leg to see if the fibular head can
syndrome, or tendinitis of the popliteus tendon or biceps be subluxated or dislocated anteriorly.3
femoris tendon.39 Associated symptoms of instability with
clicking or popping also mimic a lateral meniscus injury, IMAGING STUDIES
exostosis, or intra-articular loose bodies in the popliteus
tendon sheath.† Plain radiographs should be taken of the injured knee in true
Superior dislocations are rare and usually present after anteroposterior and lateral views, and comparison views
high-energy trauma with lateral knee pain and the displaced should be obtained from the uninjured knee or from preinjury
fibular head as a lateral mass.29,35 They commonly occur with radiographs if possible.35,49 The anteroposterior view should
show the medial aspect of the fibular head crossing the lateral
*References 9, 23, 28, 45, 46, and 51. border of the tibia. Using the lateral view, Resnick et al
†
References 3, 9, 31, 38, 40, 42, 45, 46, and 51. described a line that follows the lateral tibial spine distally
586 SECTION 5 Sports Medicine: Ligament Injuries

edema of the joint, as well as edema of the soleus at its fibular

origin of the popliteus muscle.2 Other uses that can be very
helpful are diagnostic and include therapeutic injection into
the proximal tibiofibular joint using palpation or injection
under fluoroscopic guidance; this topic will be discussed later
under Treatment.

TREATMENT OF INSTABILITY
Symptomatic atraumatic subluxation of the proximal tibio-
fibular joint can commonly be treated successfully with
nonsurgical treatment. Patients who present with generalized
ligamentous laxity usually have self-limiting symptoms that
resolve with skeletal maturity. Activity modification is impor-
tant with avoidance of knee hyperflexion.13,39 Placement in a
cylinder cast for 2 to 3 weeks may help to reduce the substan-
tial pain that some patients feel.29,30
An acute anterolaterally dislocated proximal tibiofibular
joint should be treated by first trying a closed reduction under
local anesthesia or intravenous sedation.8,19 Closed reduction
is most successful when the knee is in 80 to 110 degrees of
flexion and pressure to the fibular head is applied in the
posteromedial direction. Flexion of the knee relaxes the
lateral collateral ligament and the biceps femoris
tendon.8,29,32,33,46 Closed reduction of the fibular head may fail
if it is perched on the lateral tibial ridge by the lateral col-
lateral ligament.48 Controversy surrounds the orientation of
the foot, although an externally rotated, everted, and dorsi-
Figure 60-5. Resnick’s line (solid line) depicted on the lateral flexed foot relaxes the peroneal, extensor hallucis longus, and
radiograph of a normal knee is used to identify instability of the
proximal tibiofibular joint. Resnick’s line should intersect near the extensor digitorium longus muscles, theoretically aiding in
midpoint of the fibular head and defines the posterior border of the reduction.29,32,45 As the fibula is reduced, an audible pop
the tibia. (© Whiddon DR, Parker TA, Kuhn JE, Sekiya JK: Disorders may be heard, after which the posterolateral structures and
of the proximal tibiofibular joint. In Scott NW [ed]: Surgery of the knee, the lateral collateral ligament should be assessed for strength
ed 4, Philadelphia, 2006, Elsevier, pp 797–803.)
and stability. Barring concomitant ligamentous injury, reduc-
tions are normally stable. Posteromedial dislocations can also
be reduced using this method; however, the literature reports
that long-term results may be poor.29
along the posterior aspect of the tibia (Fig. 60-5). This impor- Postreduction management is controversial; some authors
tant bony landmark for determining dislocation of the joint advocate a soft dressing without immobilization and crutch-
defines the most posteromedial portion of the lateral tibial assisted weight bearing progressing to full weight bearing
condyle. In an uninjured knee, this line is observed over the over 6 weeks.9,32,46 Some authors recommend immobilization
midpoint of the fibular head because the fibular head extends for 3 weeks, with the knee in the neutral to slightly
over the posterior border of the tibia. The fibular head will flexed position.29,45,51 Other recommendations are that after
be viewed as anterior to this line on the lateral view in closed reduction, patients are allowed to mobilize with a
radiographs of anterolateral dislocations. In a posteromedial support bandage for 6 weeks, with sporting activities restricted
dislocation, all or most of the fibular head is posterior to this for another 6 weeks, and can return to competitive athletics
line on the lateral radiograph.35 within 6 months of injury.19 Ogden’s study showed that
Resnick recommends an oblique view with the knee in 45 immobilization following closed reduction later required
to 60 degrees of internal rotation for best visualization of surgical intervention for continuing symptoms in 57% of
the joint space, although much controversy surrounds this patients.29
view. Internal rotation shows the proximal tibiofibular joint When instability is not associated with self-limiting condi-
in profile and allows a view of the width of the articular space tions, recurrent symptoms of proximal tibiofibular joint
and appearance of the subchondral bone.35 Veth et al instability corrected by nonsurgical management may cause
described a view that demonstrated a change in the distance degenerative changes in the joint and necessitate surgical
of the medial aspect of the fibular head from the lateral aspect intervention. The most common symptoms of recurrent
of the tibia plateau, achieved by arranging the lower leg in a instability, such as pain that is felt within the joint,29,30 can
position of 30 to 90 degrees of internal rotation.50 be corrected by several described procedures, such as arthrod-
If diagnosis is suspected but cannot be clearly established esis, fibular head resection, and ligamentous reconstructions.
on a plain radiograph, axial computed tomography is a more Before any surgical intervention is attempted, an injection
accurate imaging modality in detecting injury to the joint.18 into the proximal tibiofibular joint in the office or under fluo-
Magnetic resonance imaging (MRI) has also confirmed the roscopic guidance with local anesthetic and steroid can help
diagnosis of recent dislocation by the presence of pericapsular to confirm the diagnosis and can potentially give some relief
 CHAPTER 60 Dislocation of the Proximal Tibiofibular Joint 587

A B
Figure 60-6. Isolation of the peroneal nerve during surgical reduction of the proximal tibiofibular joint.

of symptoms for even a long while (see Fig. 60-1). Recurrent

symptoms of instability can be corrected by a supportive strap
placed 1 cm below the fibular head, as well as by hamstring
and gastrocnemius muscle strengthening. When the strap is
placed too tightly, it can cause peroneal nerve palsy; thus, the
strap should be worn only during activities that produce
symptoms.13,39,42,46
In cases of irreducible dislocation in which closed reduc-
tion fails, surgical intervention, commonly open reduction,
is advised.1,4,32,46 Closed reduction can fail if the proximal
fibula is caught anteriorly on the lateral tibial ridge and the
lateral collateral ligament remains intact and taut.4 Following
open reduction, the joint should be stabilized using temporary
cannulated screw fixation,20 tricortical screw fixation,36
Kirschner wires,1,24,32,46 or a Steinmann pin,29 combined with
primary repair of the torn capsule and injured ligaments. Figure 60-7. Identification of the proximal tibiofibular joint
Rajkumar described open reduction and internal fixation anteriorly.
using bioabsorbable pins in a professional soccer player with
good results.34 In the presence of acute injury to the postero-
lateral structures, primary repair of these structures is associ- subluxation or dislocations are present.5,29,30 The head and
ated with favorable outcomes.50 Regardless of the surgical neck of the fibula should be excised while the styloid process
intervention, careful attention to avoidance of injury to the and the lateral collateral ligament are left intact. The lateral
common peroneal nerve is important5,9,18 (Fig. 60-6A and B). collateral ligament is then secured to the underlying tibia.30,46
MacGiobain et al described a surgical procedure performed Scar tissue observed around the peroneal nerve should be
to reduce an anterolateral dislocation after closed reduction treated with neurolysis.30 This procedure successfully reduces
failed. A short incision was made anterior to the joint, and pain symptoms but may cause chronic ankle pain and knee
the biceps femoris tendon was partly dissected off the fibular instability.6,13 Fibular head resection is not recommended for
head. The reduction was maintained with a K wire that was children, whose physes are at risk for injury, or athletes, for
removed electively 6 weeks following surgery, and the patient whom instability can cause damage to the posterolateral
was found to have full function 12 weeks after surgery.24 structures of the knee. Both fibular head resection and
Although arthrodesis is successful at reducing pain symp- arthrodesis could have negative effects on the epiphyseal
toms,10 it predisposes the ankle joint to increased pain and plate of the proximal fibula, leading to unequal growth of the
instability by preventing rotation of the fibula, consequently tibia and fibia.48
transferring rotational forces to the ankle.29,30 Arthrodesis is Patients experiencing recurrent instability have seen
performed by isolating and protecting the peroneal nerve, success in reconstruction of the ligamentous structures sup-
after which the articular surfaces of the joint are denuded to porting the proximal tibiofibular joint in limited studies.
bleeding subchondral bone (Fig. 60-7). The joint is reduced Giachino12 reported two cases of ligamentous reconstruction
and fixed with cancellous lag screws (Fig. 60-8A through C). with good results, no recurrent pain or instability, and a
It is immobilized for 5 weeks; full weight bearing can be return to previous activity levels. He described using one half
started after 8 weeks.42 The authors recommend resecting of a posterior strip of biceps femoris tendon still attached
1.5 cm of the fibula at the junction of the proximal and distally to the fibular head and a 10-cm rolled strip of deep
middle thirds to reduce stress applied to the fibula and trans- fascia of the anterolateral compartment of the leg still
ferred to the ankle, which decreases the probability of further attached proximally to the fibular head. The common pero-
injury3,12,29 (Fig. 60-9A through C). neal nerve is isolated, the lateral head of the gastrocnemius
Fibular head resection may be used when peroneal nerve muscle is retracted, and the soleal attachment to the posterior
symptoms or palsy associated with proximal tibiofibular part of the proximal tibiofibular joint is dissected to expose
588 SECTION 5 Sports Medicine: Ligament Injuries

Rkb
Rkb

A B C
Figure 60-8. Radiographs taken during follow-up show fixation of the proximal tibiofibular joint using cancellous lag screws. A, Lateral.
B, Anteroposterior. C, Merchant views.

Rkb

A B C
Figure 60-9. Surgical dissection during proximal tibiofibular joint stabilization. A and B, Before and after osteotomy. C, Anteroposterior
radiograph depicting resection of the middle third of the fibula following arthrodesis.

the posterior surface of the proximal tibia. A hole is drilled fixation, and fractures in the ankle and fibular head were fixed
from anterior to posterior in the tibia, and the two new liga- with K wires. After 12 months, the patient was able to walk
ments are wrapped around the head of the fibula with the without crutches using a knee brace.26
proximal tibiofibular joint held reduced. The grafts are passed Postsurgical management usually includes immobilization
through the tibial drill hole from posterior to anterior and of the ankle and knee joints for 6 weeks in a non–weight-
are anchored to the fascia anteriorly. The knee is immobilized bearing status, with temporary fixation devices removed
for 6 weeks with subsequent progressive weight bearing. between 6 and 12 weeks. Gradual return to full weight-
Alternatively, Shapiro40 reported using a 20 × 2-cm strip bearing status and initiation of muscle-strengthening and
of iliotibial band, still connected to its insertion on Gerdy’s range-of-motion exercise can begin after fixation devices are
tubercle, that is tubularized and then passed through a drill removed.32,46 Accurate diagnoses are very important, as
hole in the tibia at a level just proximal to Gerdy’s tubercle. strengthening of the lower leg muscles of a patient with
The graft is passed through the posterior capsule and the anterolateral dislocation would enhance joint instability and
arcuate complex, then through a drill hole from posterior to increase symptoms.
anterior in the reduced fibula at the fibular head/neck junc-
tion. The graft is placed deep to the lateral collateral ligament CONCLUSION
from anterior to posterior and tightened, then is secured to
itself and the posterior capsule. We believe it is important to have a suspicion of a proxi-
Van den Bekerom et al reviewed eight surgical stabiliza- mal tibiofibular dislocation/subluxation when a patient
tion procedures that produced highly successful results. The presents with lateral knee pain as part of the differential.
technique involved an open approach to the proximal tibio- Correct diagnosis of chronic subluxation of the joint
fibular joint, mobilization of the common peroneal nerve, versus acute injury is important to avoid long-term complica-
fixation with one cancellous screw, and subsequent screw tions. Treatment of a proximal tibiofibular injury should be
removal after 3 to 6 months.47 conservative when appropriate. When closed reduction fails,
Nikolaides et al reported successful reduction of an infe- open reduction should be performed with capsular and
rior dislocation by open reduction and internal fixation with ligamentous repairs ± surgical reconstruction versus surgical
K wires. Fractures in the fibular shaft were fixed with plate arthrodesis.
 CHAPTER 60 Dislocation of the Proximal Tibiofibular Joint 589

Parkes JC, 2nd, Zelko RR: Isolated acute dislocation of the proximal tibio-
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