Proximal tibiofibular joint reconstruction with biceps femoris and iliotibial band autografts with suture tape augmentation

INTRODUCTION I nstability of the proximal tibiofibular joint (PTFJ) is a likely under-recognized condition. The true incidence is unknown, but it is likely under-reported in the literature due to spontaneous reductions in acute cases and misdiagnosis in chronic instability. Three types of instability exist: acute traumatic dislocations, chronic or recurrent dislocations, and atraumatic subluxations. Instability may be multidirectional, however most cases of PTFJ instability occur anterolaterally, owing to the weaker posterior stabilizing ligamentous complex. Chronic instability may be misdiagnosed as lateral meniscal pathology, and patients reporting lateral sided pain, instability with or without visible and audible popping sensations. Physical examination may reveal pain, apprehension, or translation of the fibula when the proximal fibula is translated or “shucked”, particularly anteriorly, with the knee flexed. Radiographs are unlikely to aid in diagnosis other than in cases of acute dislocations, although comparison radiographs to the contralateral knee may help detect subtle differences. Magnetic resonance imaging often demonstrates high T2 signal from fluid in the PTFJ or bone contusion of the fibular head or proximal tibia, but may also demonstrate subluxation of the PTFJ. Initial conservative management consists of activity modification, particularly avoiding knee hyperflexion, use of supportive straps, and undergoing physical therapy. If non-operative management fails, surgical intervention can be considered. A plethora of procedures have been described, which includes but is not limited to fibular head resection, fusion, stabilization with the use of suture buttons, and soft tissue reconstructions. Stabilization with autograft reconstruction may include biceps femoris tendon (BFT) and/or iliotibial band (ITB) rerouting. No “gold standard” has been recognized due to infrequency of the condition, and the literature on patient outcomes following stabilization being limited to case reports and small series. In an attempt to maximize patient outcomes, the authors elected to modify a previously described reconstruction technique which utilized ITB and BFT autografts for stabilizing the joint. The described modification is a hybrid technique which still utilizes the ITB and BFT but with added reinforcement of suture tape augmentation (Arthrex Internal Brace, Naples FL) for added stability. The authors feel this allows for a safer, less invasive procedure than previously described. The procedure was performed in an active 26-year-old female who sustained a left PTFJ dislocation which she manually reduced after a jumping injury. PTFJ pain and snapping persisted despite four months of nonoperative treatment. Physical examination in clinic revealed mild laxity at the PTFJ, andmagnetic resonance imaging demonstrated an effusion of the joint as well as edema of the fibular head. As such she was indicated for the procedure described below.