Instability of the proximal tibiofibular joint

Injury to the proximal tibiofibular joint is typically seen in athletes whose sports require violent twisting motions of the flexed knee. Instability of this joint may be in the anterolateral, posteromedial, or superior directions. With acute injury, patients usually complain of pain and a prominence in the lateral aspect of the knee. A closed reduction should be attempted in patients with acute dislocation. If this is unsuccessful, open reduction and stabilization of the joint with repair of the injured capsule and ligaments can be done. Patients with chronic dislocation or subluxation report lateral knee pain and instability with popping and catching, which may be confused with lateral meniscal injury. Symptoms of subluxation may be treated nonsurgically with physical therapies such as activity modification, supportive straps, and knee strengthening. For patients with chronic pain or instability, surgical options include arthrodesis, fibular head resection, and proximal tibiofibular joint capsule reconstruction.     

Proximal tibiofibular joint: Rendezvous with a forgotten articulation

The proximal tibiofibular joint (PTFJ) is a plane type synovial joint. The primary function of the PTFJ is dissipation of torsional stresses applied at the ankle and the lateral tibial bending moments besides a very significant tensile, rather than compressive weight bearing. Though rare, early diagnosis and treatment of the PTFJ dislocation are essential to prevent chronic joint instability and extensive surgical intervention to restore normal PTFJ biomechanics, ankle and knee function, especially in athletes prone to such injuries. PTFJ dislocations often remain undiagnosed in polytrauma scenario with ipsilateral tibial fracture due to the absence of specific signs and symptoms of PTFJ injury. Standard orthopedic textbooks generally describe no specific tests or radiological signs for assessment of the integrity of this joint. The aim of this paper was to review the relevant clinical anatomy, biomechanics and traumatic pathology of PTFJ with its effect on the knee emphasizing the importance of early diagnosis through a high index of suspicion. Dislocation of the joint may have serious implications for the knee joint stability since fibular collateral ligament and posterolateral ligament complex is attached to the upper end of the fibula. Any high energy knee injury with peroneal nerve palsy should immediately raise the suspicion of PTFJ dislocation especially if the mechanism of injury involved knee twisting in flexion beyond 80° and in such cases a comparative radiograph of the contralateral side should be performed. Wider clinical awareness can avoid both embarrassingly extensive surgeries due to diagnostic delays or unnecessary overtreatment due to misinformation on the part of the treating surgeon.     

Proximal Tibiofibular Joint: A Forgotten Entity in Multi-Ligament Injuries of the Knee

PurposeThe proximal tibiofibular joint (PTJF) can be injured with the structures in the lateral aspect of the knee in a multi-ligament knee injury (MLKI) patient. Such injuries are scarce but require attention in the management of the complex MLKIs. The assessment and management of such injuries are not well described in the English literature. This study describes the frequency of PTFJ injuries, clinical assessment and functional outcomes of such injuries in MLKI patients.MethodologyThe data were collected retrospectively from the cohort from 2013 to 2018. The 84 MLKI were included in the study, out of which 9 patients had associated PTFJ injury. All the PTFJ injuries were operated by one single surgeon (D.S) which involves stabilization with K-wires (Kirschner wire) and fixation with 4 mm cancellous cannulated screw along with reconstruction surgery for MLKI in single stage.ResultsThe frequency of PTFJ injury in our patient cohort is 10.71%. Three patients out of the nine patients received Larson procedure apart from the fixation of PTFJ. At a mean follow-up of 13 months, the Lysholm score was 77.4 (range: 69–86) and mean modified Cincinnati score was 62 (range: 52–72). There was grade I posterior laxity present in one patient with PCL and PLC injury, one patient with ACL, PCL and PLC injury, and one patient with ACL, PCL, MCL and PLC injury at final follow-up. Terminal flexion of 15° or more restriction was noted in six patients. All patients were satisfied with the outcome.ConclusionEvaluation of PTFJ should be an integral part of preoperative as well as an intraoperative examination of MLKI patients. The fixation of this joint is of utmost importance for the reconstructive ligament procedures on the lateral aspect of the knee. The dial test used for the assessment of the integrity of PLC injury should have a prerequisite of proximal tibiofibular joint stability, otherwise, it can lead to erroneous assessment.Level of evidenceIV.     

Double Dislocation of Interphalangeal Joints Accompanied with Contralateral Shoulder Dislocation: A Case Report

Dislocation of any joint is an orthopaedic emergency and needs immediate attention by the attending physician. A delay in reducing a dislocated joint can lead to disastrous complications both immediately as well as in the long run. Although anterior dislocation of a shoulder joint is by far the commonest dislocation encountered by any emergency care physician, other joints may also get dislocated. In certain cases two joints may get dislocated simultaneously. Such dislocation is known as a double dislocation. Double dislocation of the proximal interphalangeal joint and the distal interphalangeal joint in the same finger is a rare injury. High impact loading at the fingertip is the primary cause in most cases and it is often associated with younger individuals playing contact sports. The right little finger is the digit commonly involved and this injury is evident in football players more often than not. Although closed reduction is a preferred treatment, it may not be always successful. Time of presentation, tendon interposition, associated swelling and co‐existent phalangeal fractures are certain key impediments to a successful closed reduction manoeuvre. In patients with an open injury, a thorough wash out and appropriate antibiotic cover is mandatory. We report a rare case of double dislocation of the interphalangeal joints accompanied with contralateral shoulder dislocation in an elderly man sustained after a fall which was treated successfully with closed reduction and early mobilization.     

Maisonneuve Equivalent Injury With Proximal Tibiofibular Joint Dislocation: Case Report and Literature Review

We report the case of a 31-year-old male who presented with traumatic dislocation of both proximal and distal tibiofibular joints without fibular fracture. The patient underwent closed reduction of the proximal tibiofibular joint and surgical stabilization of the distal tibiofibular joint. An 18-month postoperative evaluation confirmed a very good clinical outcome after anatomic reduction. This type of trauma is very rare and, to our knowledge, has only been described 3 times previously. Furthermore, our surgical management was different from that used for the previous cases and proved to be satisfactory.     

Elbow Dislocation with Irretrievable Rotating‐Rope Injury of the Forearm: Case Report and Literature Review

BackgroundSimultaneous dislocation of the elbow, radioulnar joint and proximal radius fracture with rotary noose injury to the medial ulna tubercle is extremely rare. An emergency surgery was performed to reduce it. The radial head with the backbone was reset after two hammers were fixed, then the radial capitulum safety was fixed with a locking plate. After the ulnar instability was examined, two Kirschner wires were drilled percutaneously to fix the elbow flexion at 100° under closed reduction, and two Kirschner wires were drilled percutaneously to fix the ulnar joint. Good follow‐up results were achieved. To the best of our knowledge, this is the first report on this particular type of injury and on this approach to treating this type of injury.Case presentationWe report the case of a 36‐year‐old male, who extended and landed on his left hand to protect his child in right arm before felling, resulting in severe pain and deformity of his left elbow and wrist and loss of movement in these joints. X‐ray examination found proximal distal radioulnar joints, a proximal radial fracture and a dislocation bowstring in the ulna nodule. For a timely diagnosis in an emergency open reduction situation, accurate judgment of this injury is highly important. After 12 months of postoperative follow‐up, the patient was symptom‐free, and radiographs showed fracture healing.ConclusionWe performed emergency reduction and internal fixation of the elbow and successfully saved elbow function, no stability decrease and movement restriction. This case also provides a new reference for the treatment of this type of elbow fracture dislocation.     

上胫腓关节三维有限元模型的建立及对两型关节脱位的生物力学分析

背景：上胫腓关节是一个容易让人忽视的关节,临床上许多膝部的顽疾是由上胫腓关节的外伤或病变引起,研究其生物力学很重要。目前,新型高效的有限元研究方法尚未应用于上胫腓关节脱位的生物力学研究中。 目的：通过正常人的上胫腓关节CT扫描图像,建立两型（水平型和倾斜型）上胫腓关节的三维有限元模型,分析躯体受到由远端向近端的纵向作用力下,上胫腓关节处的应力分布,提供对活体上胫腓关节评估的新方法。 方法：选择2名（水平型和倾斜型各1名）均无上胫腓关节及膝关节外伤史的正常健康志愿者,进行64排CT扫描其上胫腓关节,运用逆向工程原理,通过三维有限元建模软件建立两型三维有限元模型。以上胫腓关节最常受力--沿纵轴受力,分别在两型三维有限元模型上进行力学加载,研究上胫腓关节处的应力分布,记录胫骨和腓骨出现明显相对位移（脱位）的作用力大小。 结果：成功建立了两型上胫腓关节的三维有限元模型,其加载后的应力主要分布于两型上胫腓关节的腓骨内侧部分及腓骨头中部偏外上的区域,沿纵轴作用力引起两型关节脱位的作用力为：倾斜型关节1250 N,水平型关节1850 N。 结论：倾斜型上胫腓关节较水平型上胫腓关节更易发生脱位,与文献的结果相一致。研究所用的两型上胫腓关节的三维有限元模型具有有效性,可作为力学分析的基础模型。     

Superior dislocation of the fibular head associated with a tibial shaft fracture.

Superior dislocation of the proximal tibiofibular joint occurred in a 34-year-old woman who sustained a Grade 3B open left tibial fracture. An external fixator was applied to the tibia, and the tibiofibular joint was treated by closed reduction. Two bone graftings were performed, and the patient ultimately required a fibular osteotomy to allow tibial impaction. At 10 months posttrauma, the patient is fully weight-bearing and has no pain either at the tibia or the tibiofibular joint.     

上胫腓关节脱位的诊断和治疗进展

上胫腓关节脱位在临床相对少见,可以是单纯的脱位,也合并胫骨骨折、腓骨骨折、踝关节等损伤,慢性不稳的患者易被误诊为半月板损伤。由于其临床症状较轻,影像学改变细微,容易被误诊或漏诊,及时的诊断和治疗对于预防膝关节慢性疼痛和不稳至关重要。本文总结了上胫腓关节脱位的解剖基础、损伤分型、诊断要点、手法复位、手术治疗、临床效果及不足等各方面进展,以指导临床工作中对上胫腓关节脱位的诊断和治疗。     

Dorsal fracture-dislocations of the proximal interphalangeal joint: evaluation of closed reduction and percutaneous Kirschner wire pinning

Background

The purpose of this study is to evaluate the outcome of closed reduction and percutaneous Kirschner wire pinning in acute dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint.

Methods

Eight men and one woman were treated with closed reduction and percutaneous Kirschner wire pinning by one orthopaedic surgeon. The ring finger was injured in six patients, the small finger in two patients and the middle finger in one patient. The mean joint surface involvement was 36 % (range, 26–49 %). The Kirschner wires were removed after an average of 28 days (range, 24–37 days).

Results

All patients demonstrated a painless, but fusiform, swollen PIP joint after a mean follow-up of 6.5 months. The average flexion of the PIP joint was 106° (range, 80–110), and the average extension of the PIP joint was 4° short of full extension (range, 10 hyperextension–15 flexion contracture). All patients had a concentrically reduced PIP joint with a healed fracture on radiographs. Two patients had radiographic evidence of degenerative changes, but were asymptomatic. One patient developed a superficial pin track infection, which quickly resolved with a short course of antibiotics, and avascular necrosis affecting one of the condyles of the proximal phalanx.

Conclusions

In agreement with previous studies, closed reduction and percutaneous Kirschner wire pinning in dorsal fracture-dislocations of the PIP joint is a minimally invasive and simple technique which appears to give satisfactory outcomes in the short to intermediate term.     

Isolated dislocation of the proximal tibiofibular joint

We have reported the case of an anterolateral dislocation of the proximal tibiofibular joint in a soccer player, apparently the second case in the literature. As in that reported by O'Rourke and McManus, this patient was attempting to gain his balance and this may indeed be an important contributing factor. Ogden's classification is now well accepted and has been reviewed along with a discussion of the mechanisms of injury. The diagnosis can generally be made by clinical examination and confirmed by roentgenographs. Treatment usually consists of closed reduction with 3 weeks of casting. In complicated cases, however, resection of the fibular head may be required.     

Inferior dislocation of the proximal tibiofibular joint: a new type of dislocation with poor prognosis

Dislocation of the proximal tibiofibular joint is an unusual injury. We report a patient, who developed inferior proximal tibiofibular dislocation after a severe motorcycle accident. The dislocation was associated with avulsion of the leg, fractures of the fibula and the ankle and neurovascular lesions. The patient was surgically treated and had a good final outcome. Classifications of proximal tibiofibular dislocations did not include inferior dislocation. This type is always associated with avulsion mechanism and has the poorest prognosis.     

Inferior dislocation of the proximal tibiofibular joint: a report on four cases

The authors report four cases of inferior dislocation of the proximal tibiofibular joint. A literature search disclosed reports on superior, anterolateral and posterolateral dislocation, but none on inferior dislocation of the proximal tibiofibular joint. The latter was associated in these four cases with fracture of the tibia, as also noted in cases of superior dislocation, and with severe neurovascular lesions.     

Traumatic proximal tibiofibular dislocation with neurovascular injury

23 years old male presented with inferolateral dislocation of proximal tibiofibular joint associated with popliteal artery and common peroneal nerve injury. The extension of the injury to involve the interosseus membrane up to the distal tibiofibular joint. The association of popliteal artery injury is not reported before to the best of our knowledge.     

分期治疗外伤性膝关节脱位合并多韧带损伤的疗效观察

目的观察分期治疗外性伤膝关节脱位合并多韧带损伤的临床疗效。方法 2005年6月-2008年11月,收治13例外伤性膝关节脱位合并多韧带损伤患者。男9例,女4例;年龄18～54岁,平均30.7岁。致伤原因:运动伤8例,交通事故伤2例,高处坠落伤2例,扭伤1例。左侧3例,右侧10例。受伤至入院时间6 h～2 d,平均9 h。8例前交叉韧带(anterior cruciate ligament,ACL)、后交叉韧带(posterior cruciate ligament,PCL)及内侧副韧带(medial collateral ligament,MCL)损伤,3例ACL、PCL及外侧副韧带(lateral collateral ligament,LCL)损伤,2例ACL、PCL、MCL及LCL损伤。10例外翻应力试验为++～+++,5例内翻应力试验为++～+++;13例前、后抽屉试验均为阳性,Lachman试验为++～+++。一期手术修复PCL、MCL、LCL及半月板,术后固定3～4周后开始功能锻炼,4～6个月后膝关节活动范围良好且存在前方不稳时二期于关节镜下重建ACL。结果两次手术后切口均Ⅰ期愈合,无感染及骨筋膜室综合征等并发症发生。患者均获随访,随访时间12～60个月,平均36个月。一期术后4周2例出现关节腔积液,经穿刺抽吸后缓解,其余患者均未出现膝关节不适。二期术后3个月1例外翻应力试验++,1例为+;1例内翻应力试验为+;1例Lachman试验++,1例为+;其余患者各试验均为阴性。二期术后12个月患膝关节屈曲达100～135°,平均123.4°;伸直达0～4°,平均2.3°。根据Lysholm膝关节功能评分标准评定:获优9例,良2例,可2例,优良率84.6%。结论分期治疗外伤性膝关节脱位合并多韧带损伤可获得较好的临床效果。     

An Approach to Intraoperatively Identify the Coronal Plane Deformities of the Distal Tibia When Treating Tibial Fractures with Intramedullary Nail Fixation: a Retrospective Study

ObjectiveTo develop a new approach to intraoperatively identify the presence of coronal plane deformities (both valgus and varus) when treating tibial fractures with closed reduction and intramedullary nail fixation.MethodsA retrospective analysis was conducted by enrolling 33 consecutive patients with tibial fractures who received closed reduction and intramedullary nail fixation from January 2018 to January 2019 at our trauma center. Out of the 33 patients, 23 were males and 10 were females and the average age was 41 years (ranging 22 to 69 years of age). Standard anteroposterior and lateral preoperative radiographs were routinely performed. After intraoperatively inserting the tibial intramedullary nail through the standard entry point, the parallel relationship between the distal horizontal interlocking screw and the tibiotalar joint surface on the anteroposterior fluoroscopy was used to determine the occurrence of valgus or varus deformities of the distal tibial fragment. Radiographic and clinical outcomes were analyzed using the average interval from injury to surgery, the lateral distal tibial angle (LDTA) of the unaffected and affected sides, complications and the Olerud–Molander ankle score.ResultsAll 33 patients were postoperatively followed for 13 to 25 months (mean 18.7 months). The fractures achieved bone union at an average of 4.3 months (ranging from 3 to 6 months). The total complication rate was 60.6% (20 cases), including four cases that showed deep vein thrombosis, one case showing an infection and delayed union and 15 cases showing slight to moderate anterior knee pain. The postoperative LDTA of the unaffected side measured 87.3° to 89.6 ° (average 88.7° ± 0.8°), and the LDTA of the affected side was 87.5° to 90.4° (average 88.9° ± 1.1°). There was no significant difference between the unaffected and affected sides (t = −1.865, P = 0.068). The intraoperative measurement indicated six cases of valgus angulation and three cases of varus angulation deformities, and all deformities were corrected during surgery. According to the Olerud–Molander ankle score, clinical outcomes demonstrated 22 excellent cases, eight good cases, two fair cases, and one poor case 12 months after surgery.ConclusionThe parallel relationship between the distal horizontal interlocking screw and tibiotalar joint surface on intraoperative anteroposterior films were able to determine the onset of valgus or varus angulations of the distal tibial fragment in the fracture zone after the tibial intramedullary nail was inserted through the standard entry point.     

Neglected surgically intervened bilateral congenital dislocation of knee in an adolescent

Neglected bilateral congenital dislocation of knee is unusual. A 12 year old boy presented with inability to walk due to buckling of the knee. The symptoms were present since the child learnt walking. He preferred not to walk. Bilateral supracondylar femoral osteotomy was done at the age of 6 years. Patient had a fixed flexion deformity of both knees, 30° in the right (range of flexion from 30° to 45°) and 45° fixed flexion deformity in left knee respectively (range of flexion from 45° to 65°) when presented to us. The radiological examination revealed bilateral congenital dislocation of knee (CDK). No syndromic association was observed. He was planned for staged treatment. In stage I, the knee joints were distracted by Ilizarov ring fixators and this was followed by open reduction of both the knee joints in stage II. A bilateral supracondylar extension osteotomy was done 18 months after the previous surgery (stage III). The final followup visit at 4 years the patient presented with range of motion 5-100° and 5-80° on the right and left knee respectively with good functional outcome. The case is reported in view of lack of treatment guidelines for long standing neglected CDK in an adolescent child.