Description
Objectives: The objective of this study was to evaluate the reliability of the cortical button as flexible fixation in the treatment of tibiofibular instability, describing the surgical technique used in the resolution of this case.
Methods: We present a 28-year-old female patient. She does multiple recreational sports (trekking, running, boxing, functional training) and refers to the onset of left knee pain in 2021 going down the hill while trekking without falling or trauma. Diagnosed in the first instance as patellofemoral dysfunction, she performed 22 sessions of kinesiotherapy and physiotherapy, and intra-articular corticosteroid injection was infiltrated in 2022. Pain persists without any change in the presentation of symptoms, which occur with physical activity. Over the months the intensity of the gonalgia increases, which when trotting generates claudication due to pain. She makes a new consultation where the radiographic study shows an increase in the proximal tibio fibular interosseous space compared to a healthy knee and in MRI evidence of anterolateral displacement of the fibula. Clinically, reducible articulation but with constant instability. Diagnosis of proximal fibular tibial instability was made. IKDC: 48 points, Lysholm: 63 points. Surgical management with cortical button was decided.
Results: The patient was positioned with a free leg at 90 degrees of flexion. Proximal tibiofibular instability is verified under intraoperative fluoroscopy. A 4cm approach is made on lateral border of fibular head from the proximal tip of the fibula to distal. In a blunt way, soft tissues are dissected, the common peroneal nerve is released and isolated. Subsequently, a 1.5mm guide wire is passed from the midpoint of the fibular head to the posteromedial area of the proximal tibia 1-2cm proximal to the hamstring insertion. Drilling with a 3.5mm drill and Tight Rope (Arthrex) passage for successful reduction of the proximal tibiofibular joint. No signs of neurological injury in the immediate postoperative period.
Patient 8 weeks after surgery with IKDC of 87 points and Lysholm of 92 points
Conclusions: The use of the cortical button as a means of flexible fixation is a technically reproducible tool, easy to perform and with acceptable clinical results, having the advantage that it can adapt to the micromovement that the proximal tibial fibular joint presents natively. We suggest in a preventive way to always identify the common peroneal nerve and carefully verify the orientation of the guide needle to ensure a good surgical result.
