title: Is stability of the proximal tibiofibular joint important in the multiligament-injured knee?
abstract: BACKGROUND
  The incidence of proximal tibiofibular joint instability in the setting of the multiligament-injured knee has not been previously reported. The integrity of the proximal tibiofibular joint is required to perform a fibular-based, lateral-sided knee reconstruction.
  
  
  OBJECTIVE
  We report (1) the frequency of proximal tibiofibular joint instability in patients presenting with multiligament knee injuries and evaluate (2) our ability to restore stability to this joint, (3) patient-reported outcome scores, and (4) complications in patients surgically treated for proximal tibiofibular joint instability at the time of treatment of multiligament knee instability.
  
  
  METHODS
  From 2005 to 2013, 124 patients (129 knees) sustaining multiligament knee injuries with Grade 3 instability to at least two ligaments were treated at our institution. We defined proximal tibiofibular joint instability as a dislocated or dislocatable proximal tibiofibular joint at the time of surgery. These patients underwent surgery to restore proximal tibiofibular joint stability and ligament reconstruction or repair and were followed with routine clinical examination, radiographs, and subjective outcome measures, including Lysholm and IKDC scores. Minimum followup was 12 months (mean, 32 months; range, 12-61 months).
  
  
  RESULTS
  Twelve knees (12 patients, 9% of 129 knees) showed proximal tibiofibular joint instability. Knee stability in 10 patients was restored to Grade 1 or less in all surgically treated ligaments. No proximal tibiofibular joint instability has recurred. No patients have complained of ankle stiffness or pain. In the ten patients with subjective scores, mean Lysholm score was 75 (range, 54-95) and mean IKDC score was 58 (range, 22-78). There were four complications: one failed posterolateral corner reconstruction, one proximal tibiofibular joint screw removal secondary to pain over the screw head, one deep infection treated with serial irrigation and débridements with graft retention, and one closed manipulation secondary to arthrofibrosis and loss of ROM.
  
  
  CONCLUSIONS
  In the setting of multiligament-injured knees, our series demonstrated a 9% incidence of proximal tibiofibular joint instability. The technique we describe successfully restored stability to the proximal tibiofibular joint and resulted in satisfactory patient-reported outcomes with low complication rates.
  
  
  METHODS
  Level IV, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.
authors.affiliation: Orthopaedic Associates of Michigan, 230 Michigan, Suite 300, Grand Rapids, MI, 49503, USA, Michael.Jabara@oamichigan.com.
authors.forename: Michael
authors.initials: M
authors.lastname: Jabara
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Bradley
authors.forename: Michael
authors.initials: M
authors.lastname: Merrick
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005360:Fibula / Q000601:surgery*; D005500:Follow-Up Studies; D006801:Humans; D007593:Joint Instability / Q000209:etiology / Q000503:physiopathology / Q000601:surgery*; D007718:Knee Injuries / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D007719:Knee Joint / Q000503:physiopathology / Q000601:surgery*; D008023:Ligaments, Articular / Q000293:injuries / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016059:Range of Motion, Articular; D019651:Plastic Surgery Procedures / Q000379:methods*; D013977:Tibia / Q000601:surgery*; D055815:Young Adult