Technique for Reconstruction of the Proximal Tibiofibular Joint Using Biceps Femoris and Iliotibial Band Autograft With Suture Tape Augmentation

Abstract

Background:

Proximal tibiofibular joint instability is an uncommon condition that can occur in acute traumatic dislocations, chronic or recurrent dislocations, and atraumatic dislocations. A variety of procedures have been described for treatment of this condition including fibular head resection, arthrodesis, suture button stabilization, and soft tissue reconstruction.

Indications:

The initial management consists of conservative measures such as activity modification, use of a supportive strap, and physical therapy. When nonoperative management fails, surgical management is indicated.

Technique Description:

To optimize surgical technique and patient outcomes, a previously described reconstruction technique was modified with reinforcement of suture tape augmentation and decreased invasiveness.

Results:

This technique has several advantages including a smaller incision with shorter iliotibial band (ITB) and biceps femoris tendon (BFT) grafts and safer posterior to anterior drilling as opposed to anterior to posterior directed drilling.

Discussion/Conclusion:

The authors believe there is increased stability with this reconstruction technique due to the added suture tape augmentation in addition to the biologic healing potential provided by the ITB and BFT autografts.

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is the technique for reconstruction of the proximal tibiofibular joint (PTFJ) using biceps femoris and iliotibial (IT) band autograft with suture tape augmentation. This is by Dr Nikolas Sarac, Joseph Burger, and Dr Timothy Miller at the Jameson Crane Sports Medicine Institute at The Ohio State University Wexner Medical Center in Columbus Ohio.

Shown here are our authorship disclosures. We have no disclosures to make regarding this topic.

Proximal tibiofibular joint instability is initially treated conservatively, but surgical management is indicated when nonoperative management fails. A variety of procedures have been described, but no standard of care has been established due to low incidence of this condition and the lack of long-term results following operative intervention. This video will provide an overview of the condition and present our modified technique for soft tissue reconstruction with a case presentation included.

The anatomy of the PTFJ has been described in the past. The center of the joint is located approximately 45° inferior and 30° posterior to the center of the tibial plateau where it is stabilized using the anterior and posterior proximal tibiofibular ligament complexes.

The anterior ligamentous complex has 4 bands that are variably present. This includes a superior band which is most consistently present, in addition to 2 middle bands and an inferior band. The posterior complex has typically 3 bands, most commonly, a superior and middle band, and occasionally an inferior band is present as well.

Proximal tibiofibular joint instability is an uncommon, yet likely under-recognized condition. This can occur in an acute traumatic dislocation, or as a chronic and recurrent dislocation. The mechanism is often secondary to landing on a flexed knee with the foot inverted and plantar flexed, with most cases occurring anterolaterally due to the weaker posterior ligamentous complex. The presentation can mimic lateral meniscus pathology with lateral knee pain, instability, catching, or popping. The physical examination shows pain, laxity, or apprehension with the knee flexed to 90°, the tibia stabilized, and the fibula is manually translated anteriorly or posteriorly, or shucked. Radiographs are frequently unremarkable other than cases of acute dislocation, and magnetic resonance imaging (MRI) may reveal subluxation of the joint or bone contusion of the fibular head or proximal tibia. Initial management is conservative consisting of activity modification, supportive straps, and physical therapy. When this fails however, surgical management is indicated. Although long-term surgical management of PTFJ results are lacking, restored function and reduction in symptoms have been reported in the literature.

Our patient was a 26-year-old woman with a left knee injury after she jumped into a hole and felt a pop at the lateral aspect of her knee. She presented to our office 2 months after the initial injury with recurrent shifting and popping in the lateral joint. On physical examination, she had no effusion, near full range of motion, negative McMurray test, and no lateral joint line tenderness; she was ligamentously stable, reproducible pain at the PTFJ was present with external rotation of the ankle.

Our patient was able to demonstrate to us a maneuver in which she could voluntarily dislocate and then reduce the PTFJ shown here.

Shown here are her anteroposterior (AP) and lateral radiographs without evidence of fracture or degenerative changes and stable positioning of the PTFJ.

Her subsequent MRI showed a mild amount of edema at the medial aspect of fibular head as shown by the red arrow, along with effusion of PTFJ as shown by yellow arrow. There was no evidence of meniscal, cartilage, or ligamentous pathology otherwise.

In assessing this case, this is a 26-year-old woman with persistent instability of the PTFJ now 2 months after her initial injury. She was treated conservatively with physical therapy, but continued to have persistent pain and subluxation events despite 4 months of nonoperative management. She was indicated for reconstruction of the PTFJ using IT band and biceps femoris autograft with suture tape augmentation for added stability.

Multiple technique options have been described in the management of PTFJ instability, and a number of case studies have been published describing short-term results. Long-term outcomes data, however, is lacking. Kruckeberg et al performed a systematic review to evaluate the various described surgical options including internal fixation, fibular head resection, direct ligament repair, ligament reconstruction with free graft, or rerouting of biceps femoris tendon. They reported restored function and reduction in symptoms after surgical treatment of PTFJ instability but they did not compare between groups given the heterogeneity of reported outcomes and number of patients.

Our technique is based on the modification of a previous technique published in 2014 in Techniques in Orthopaedics using both the biceps femoris and IT band left attached distally and routed through the proximal tibia and the proximal fibula.

With our current technique, the patient is positioned supine on the operating room table with a large C-arm fluoroscopy unit on the contralateral side. A side post and foot positioning device were used to flex the knee to 90°. General anesthesia is used, intravenous (IV) antibiotics are administered, and 1% lidocaine with epinephrine was injected subcutaneously to minimize bleeding and the need for use of a tourniquet.

An approximately 12 cm curved incision is made along the lateral aspect of the proximal tibia just over the PTFJ. This was centered between the Gerdy tubercle, the fibular head, and the lateral epicondyle of the femur.

Careful dissection is made through soft tissue to expose the PTFJ, as well as the IT band and biceps femoris tendon.

The common peroneal nerve is identified in its usual position, just posterior to the biceps femoris tendon. It can be seen here being traced during the video. A vessel loop is placed around the nerve to retract it gently during the remainder of the procedure.

A 5-cm graft is harvested from the posterior half of the biceps femoris tendon as seen here with the tendon still attached to the fibula.

The biceps femoris graft tendon is then truncated from its superior attachment, leaving the distal portion attached to its insertion on the fibular head.

A nonabsorbable suture is then woven through the tail of the tendon graft, in preparation for later docking into the proximal tibia.

Shown here is the biceps femoris tendon graft fully stitched in preparation for docking.

Next, the IT band is identified at its insertion point on the Gerdy tubercle where it is then harvested, maintaining its insertion onto the Gerdy tubercle during this procedure.

Shown here, we measure our graft to be approximately 5 cm from the insertion point onto the Gerdy tubercle prior to truncation of the graft.

The IT band graft is shown here isolated still attached to the Gerdy tubercle. Deleted “at the tip of the Allis clamp at the center of the screen.”

Similar preparation steps were followed with nonabsorbable suture passing through the graft, as seen here, in preparation for docking of the IT band graft into the fibular head.

The safe spot for the proximal tibial pilot hole is just distal to the inferior lateral geniculate artery and just proximal to the fibular circumflex artery at the proximal lateral tibial metaphysis.

The common peroneal nerve and the lateral aspect of the gastrocnemius complex are then retracted to expose the proximal posterior tibial metaphysis. Avoiding the lateral inferior geniculate artery, the tibial nerve, and popliteal vessels, the safe spot for docking in the proximal tibia is identified and confirmed on fluoroscopic x-ray. Then, a 5.5-mm drill is used in the posterior to anterior direction to create our tunnel socket in the proximal tibia as seen here.

A 5.8-mm tap is used to enlarge the entry point of the socket as shown here at the proximal tibia.

The suture from the biceps femoris tendon graft is then inserted into a 5.5-mm absorbable anchor along with the FiberTape suture placed at the eyelet of the anchor and then docked in the pilot hole at the proximal tibia. The graft is then tensioned appropriately, and excess sutures are removed.

After confirming the appropriate location under fluoroscopy, a 5.5-mm drill is then used to create a socket at the fibular head as seen here. A 5.8-mm tap is then used to enlarge the opening prior to insertion of the anchor.

The second 5.5-mm absorbable anchor is then inserted into the fibular head with appropriate tension to dock the IT band graft and to ring into place the internal brace for the posterior limb of the reconstruction.

Shown here is the final reconstruction. Appropriate positioning of both anchors was confirmed using fluoroscopy, and the knee was taken through range of motion. A knot was then tied between the stay suture and the preparation suture on the IT band graft to secure additional fixation of the fibula. The common peroneal nerve is then inspected and confirmed to be completely intact.

The wound is then thoroughly irrigated and closed in a layered fashion with absorbable suture including a fatty tissue closure.

Postoperatively, the patient is placed on oral aspirin daily for 6 weeks. In addition, the patient remains non-weightbearing in a hinged knee brace for 4 weeks with active and passive range of motion from 0° to 90° at postoperative day 1. The patient then begins formal physical therapy between 10 and 14 days post surgery focusing on quadriceps, hamstring, and hip abductor strength. They begin return to sports typically between 5 and 6 months postoperatively with isokinetic testing and video running gait analysis commonly used for determining athletes’ readiness to return to sport.

Shown here is a patient who is 5 months post surgery from bilateral PTFJ reconstructions. Her range of motion is full with no pain with isometry maintained at the PTFJ.

Shown here is the same patient, a pole vaulter, 5 months status post PTFJ reconstruction on the left side, 1.5 year post reconstruction on the right side with normal gait.

Potential complications of this procedure include injury to the surrounding structures including the biceps femoris tendon, the common peroneal nerve, the lateral inferior genicular artery, the tibial nerve, and the popliteal vessels. Therefore, meticulous surgical dissection and technique must be maintained in performing this procedure as well as use of intra-operative fluoroscopy to confirm optimal positioning of the bony tunnels. Other potential complications include recurrent instability, graft laxity or failure, fixation failure, or deep vein thrombosis.

Long-term studies on surgical treatment of the PTFJ instability are lacking, restored function and reduction in symptoms have been reported in the literature. Several advantages of this hybrid technique include smaller incision with shorter IT band and biceps femoris tendon grafts, safer posterior to anterior drilling as opposed to anterior to posterior directed drilling, and the authors believe there is added stability of the reconstruction as a result of the use of the internal brace as well as biologic healing potential from the grafts.

Thank you to Dr Nikolas Sarac and Joseph Burger and entire staff at the Jameson Crane Sports Medicine Institute for their assistance in creating this video.