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Proximal Tibiofibular Joint Reconstruction With Autogenous

Semitendinosus Tendon Graft
Lawrence Camarda, MD, PhD, Andrea Abruzzese, MD, and Michele DArienzo, MD

Summary: Isolated and chronic anterolateral instability of the proximal tibiofibular joint (TFJ) is an uncommon condition, generally
linked to an unrecognized or unhealed dislocation of the TFJ. Clinically, abnormal anterior movement of the head of the fibula is
detected. In acute injuries conservative management should be preferred, whereas surgical treatment have been advocated in patients with
chronic TFJ instability. Authors describe a new surgical reconstruction
technique for chronic instability of the proximal TFJ using an autogenous semitendinosus tendon. The graft is passed through fibular and
tibia tunnels and fixed with 2 interference screws. The tibial tunnel is
reamed from the posterolateral side of the tibia to the anteromedial
aspect of the tibia, exploiting the previously skin incision used for
tendon harvest. The technique proved to be safe and effective to stabilize the proximal TFJ.
Key Words: tibiofibular joint reconstructionknee injuriesknee
ligamentTFJposterolateral corner.
(Tech Orthop 2013;28: 269272)

solated injuries of the proximal tibiofibular joint (TFJ) are an

uncommon injury, frequently associated to violent twisting
motions on a flexed knee. The most common of proximal
tibiofibular instability is anterolateral dislocation caused by
disruption of the proximal capsular ligaments.1 These conditions are frequently misdiagnosed than other knee ligament
injuries. Patients with proximal TFJ instability may feel pain
and clunking as the joint dislocates with pain along the lateral
aspect of their knee. The management is controversial with
conservative management preferred for acute injuries. However, if pain and instability persist, surgical treatment should
be recommended.
We present a case of a woman with a chronic instability
of the proximal TFJ treated with a new anatomic posterior
tibiofibular ligament reconstruction.

ILLUSTRATIVE CASE
A 23-year-old woman was admitted to our department with pain
on the lateral side of her right knee after a domestic injury sustained 4
months earlier. The patient reported that she fell on a flexed knee with
her ankle inverted. Clinically, knee examination showed no effusion
and no meniscal tear sign was present. However, during the McMurray
test the patient showed lateral knee discomfort, especially when the
knee was flexed and the leg internally rotated. In addition, on anterior
drawer test, grasping the patients tibia and fibula and pulling it
From the Department of Orthopaedic Surgery, University of Palermo,
Palermo, Italy.
The authors declare that they have nothing to disclose.
Address correspondence and reprint requests to Lawrence Camarda,
MD, PhD, Department of Orthopaedic Surgery, University of Palermo,
Via del Vespro, Palermo 90100, Italy. E-mail: lawrence.camarda@
unipa.it.
Copyright r 2013 by Lippincott Williams & Wilkins
ISSN: 0148-703/13/2803-0269

forward, an anterolateral dislocation of the fibular head was evident

with a visible and audible clunk. This dislocation was accompanied by
pain and sensitive anomalies along peroneal nerve distribution. In full
extension, the instability of the TFJ was not detected. Standard anteroposterior and lateral x-ray were normal. The magnetic resonance
imaging of the affected knee showed a complete integrity of the
menisci and of the main knee ligaments. Abnormal hyperintensity was
located posteriorly around the proximal TFJ.
An anatomic ligament reconstruction of the posterior proximal
TFJ was performed using an autologous semitendinosus tendon.

Surgical Technique
A medial skin incision was performed over the pes anserinus and
the semitendinosus was harvest. The tendon graft was sized to pass
through a 6-mm tunnel and then tubularized using a no. 2 nonabsorbable suture (Fiberwire; Arthrex, Naples, FL). With the patient
placed supine on the operating table, the knee flexed at 90 degrees and
a tourniquet placed high up on the thigh, a lateral exposure was made
through a skin incision over the lateral aspect of the knee. A straight
line incision was performed just 2 cm from the posterior aspect of the
lateral epicondyle to the distal part of the fibular head. A 4-cm horizontal fascial incision was performed posterior to the fibular head, 3 cm
anterior to the biceps tendon. The fibers of the lateral gastrocnemius
muscle were elevated from the fibula, exposing the posterior aspect of
the fibular head. At this point, a small vertical incision was made over
the anterolateral aspect of the fibula head to expose the origin of the
fibular collateral ligament (FCL). Care was taken to avoid FCL
insertion site damage during subsequent surgical steps. A 2-mm pin
guide was passed just medially and distally from the insertion of the
FCL and directed posteromedially to exit the posterior aspect of the
fibula. Then, a 6-mm tunnel was reamed through the fibula over this
guidewire. A second guidewire was then drilled from the posterolateral
aspect of the tibia to the previous incision site used for the hamstring
tendon harvest. During this step, the fibular head was subluxed anteriorly and an anterior cruciate ligament tibial guide was placed so that
the guidewire was direct from the posterolateral side of the tibia to the
anteromedial aspect of the tibia (Fig. 1). At this point, a 6-mm full
tunnel was then reamed over the Kirschner-wire from posterior to
anterior. The free end of the semitendinosus graft was first passed
through the fibular tunnel and then through the tibial tunnel
using sutures previously placed into the eyelet-tipped guide pins.
A 7 23 mm bioabsorbable screw (Stryker) was used first to fix the
graft into the fibular tunnel. The fibula was then reduced posteriorly
applying a gentle pushing force to the fibular head and tying the graft
from the tibial side. At this point, a 7 28 mm bioabsorbable screw
was used for the tibial side fixation with the knee flexed at 90 degrees
(Figs. 24). Graft excess was then trimmed from both fibular and
tibial side.
The knee was immobilized in a postoperative hinged knee brace
locked at 0 degrees for 2 weeks. Passive range of motion (ROM) began
at the third week postoperatively, and at the fourth week the brace was
unlocked to achieve a ROM of 0 to 110 degrees. Partial weight bearing
with crutches started at 2 weeks and full weight bearing was allowed
from the fourth week postoperatively. At 2 months, physical therapy
was intensified to maximize both knee and ankle ranges of motion.
During the complete rehabilitation period, the patient was instructed to
avoid excessive plantar and dorsal ankle flexion, especially at 60 to 100
degrees of knee flexion.
At 2-year follow-up, the patient showed a good stability of the
proximal TFJ. No pain and instability were reported on the lateral side

Volume 28, Number 3, 2013

FIGURE 3. Lateral view of the knee showing the inclination of the

tibial tunnel.
FIGURE 1. Front view of 3-dimensional computed tomography
scan of the knee showing fibular and tibia tunnels.
of the knee during sport and daily activities. In addition, function of the
peroneal nerve was totally recovered.

DISCUSSION
We present a new surgical reconstruction technique for
chronic anterolateral instability of the proximal TFJ using an
autogenous semitendinosus tendon. The main advantage of this

FIGURE 2. Posterior view of the knee.

technique is the creation of the tibial tunnel directed through

the previously medial skin incision used for tendon graft harvest. Using an autogenous graft, this could prevent another
skin incision, decreasing postoperative pain. Moreover, the
anteromedial tibial tunnel could improve the tibial graft fixation using interference screws, because of a higher bone
density of the anteromedial area of proximal tibia compared
with the anterolateral area.2 To avoid pin guide slippage during
drilling due to the curvature of the posterolateral border of the
tibia, the guidewire was passed from the back of the tibia to the
anteromedial side. During this step, anterior cruciate ligament
tibial guide was placed on the contrary subluxing anteriorly the
fibular head and reaching the correct tibial anatomic footprint
of the posterior TFJ ligaments.
Isolated traumatic instability of the proximal TFJ is an
uncommon and underrecognized injury.1 The TFJ is stabilized
by 3 broad ligaments forming a fibrous capsule,3 2 posterior
proximal tibiofibular ligament and 1 stronger anterior

FIGURE 4. For tibial tunnel creation, a guidewire was drilled

from the posterolateral aspect of the tibia to the previously
incision site used for the hamstring tendon harvest.

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tibiofibular ligament. A disruption of these ligaments is generally traumatic and could produce an abnormal fibular head
movement that can lead to fibular head dislocation. Proximal
TFJ injuries were classified by Ogden1 in 4 types according to
the position of the fibular head in relation to its anatomic
position: subluxation, anterolateral dislocation, posteromedial
dislocation, or superior dislocation. Generally, TFJ instability
occurs in early age and affects young athletic patients such as
soccer players, dancers, skiers, horse riders, parachute jumpers,
and patients with generalized ligamentous laxity.46 A common mechanism of injury is a fall on a flexed knee with the
ankle plantar flexed and inverted and a leg adducted.1,3 In this
situation, the proximal fibula loose the stabilizing forces
offered by the FCL and the biceps femoris tendon in full
extension. In addition, as the ankle is flexed and inverted,
the proximal fibula moves anteriorly predisposing the rupture
of the posterior ligament of the TFJ and consequently its
dislocation.
In acute setting, patient could report an unexpected pain
along the lateral aspect of the knee, after a reported twisting
motion of the knee in a flexed position. However, the dislocation could spontaneously be reduced before the examiner
reaches the patient, making difficult the diagnosis and confusing the injury with a meniscal tear.7 For this reason, a high
index of suspicion should be maintained in patients with lateral
knee pain among the fibular head and difficulty in weight
bearing.8,9 Chronic instability of the proximal TFJ is often a
result of a misdiagnosed and untreated subluxation. Patient
could report painful audible and palpable clunk or snap located
on the lateral side on the knee, usually evoked by the patient
during knee flexion and extension. Involvement of the common peroneal nerve could be observed with light superficial
sensory deficit. For both acute and chronic instability, on
physical examination a free movement of the knee joint and no
effusion could be noted. In cases of acute anterior dislocation,
an abnormal prominence of the fibula head could be observed.
In cases of chronic instability, on anterior drawer test an
abnormal anterior movement of the fibular head could be
detected.1,5,10 Furthermore in cases of suspected cases of TFJ
injury, a specific anterior drawer test applied to the fibular head
should be performed. With the knee flexed at 80 to 90 degrees
and keeping the fibular head with the first and second finger, a
gentle anteroposterior translation could generate an anterior or
posterior fibular head subluxation.
In acute stable injuries, the treatment consists of prompt
closed reduction of the dislocation performed under general
anesthesia by applying a direct pressure over the fibular head
with the knee flexed at 90 to 100 degrees and the ankle dorsiflexed and externally rotated.8,1113 Casting for 3 to 4 weeks
is suggested followed by mobilization of the knee with progressive ROM exercises.11 Open reduction with percutaneous
wire fixation is necessary in cases of failed closed reduction.
Kirschner-wire, bioabsorbable pins, or a cortical screw could
be alternatively used to stabilize the proximal TFJ.1416 Surgical treatment options such as resection of the fibular head
and permanent arthrodesis of the proximal TFJ have been
previously advocated in patients with chronic TFJ instability.1
However, early and late complications were described such
as posterolateral instability of the knee, peroneal nerve injury,
and postoperative ankle pain and instability, due to the
increased rotational forces on the ankle joint after a TFJ
arthrodesis.12 For this reason, soft-tissue reconstructions were
described and recommended for adolescent patients and athletes. At first, Giachino17 described a posterior TFJ reconstruction using the posterior half of the biceps femoris tendon

Proximal Tibiofibular Joint Reconstruction

leaving the attachment on the head of the fibula intact. The

tendon is passed through a tibial tunnel previously reamed and
secured anteriorly to the fascia with a suture. Shapiro et al18
described a similar procedure using a strip of the iliotibial band
preserving the distal attachment to Gerdy tubercle. The graft is
passed through tibial and fibular tunnels previously reamed and
then fixed suturing itself to the posterior capsule, with the joint
in a reduced position. Miettinen et al19 described a technique in
which the biceps femoris tendon graft left attached on the head
of the fibula is pulled through an anterolateral tibial tunnel
previously reamed. Dawson and Bear recreated both anterior
and posterior proximal tibiofibular ligaments reaming 3 bone
tunnels, respectively, 1 in the fibular head and 2 in the tibial
side. The gracilis autograft was then pulled through the tunnels
and fixed using 3 biotenodesis screws.7 Luscombe and Maffulli20 described a technique in which an autograft gracilis
tendon is passed through 2 tunnels that go through the proximal TFJ and then fixed with an interference screw placed in
the medial side of the proximal tibia. Finally, Horst and
LaPrade9 described an anatomic reconstruction technique utilizing an autogenous hamstring tendon graft passed through a
fibular and tibia tunnel and fixed with 2 interference screws. In
the case described here, the tibial tunnel is reamed from the
posterolateral side of the tibia to the anteromedial aspect of the
tibia, exploiting the previously skin incision used for tendon
harvest. Up to date, our cohort of patients treated with this new
technique is very small because of the rarity of the injury. Two
patients have been treated with this surgical technique. The
case we presented herein is a case with a longer follow-up
(24 mo). The other patient has a shorter follow-up (5 mo);
however, good functional recovery was observed at the last
clinical evaluation. For all patients treated, the surgical
technique described proved to be safe and effective to
stabilize the fibular head allowing a functional reconstruction
of the TFJ.

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