The remaining graft was held taut, and the knee was cycled through flexion and extension. The knee was then placed in approximately 30° of flexion, and the fibular head was noted to be well reduced within the tibiofibular joint. This was confirmed visually and fluoroscopically. A 4.75-mm biotenodesis interference screw was then placed from anterior-to-posterior in the fibular tunnel. The remaining tendon exiting posteriorly from the tunnel was then over-sewn onto the remaining native biceps femoris tendon attached to the fibular head. The knee was stable through flexion and extension, and gentle pressure on the fibular head demonstrated no subluxation motion (Video 2). The wound was copiously irrigated with normal saline. The tourniquet was then taken down, and following the reapproximation of the deep fascia, the wound was closed in standard subcutaneous fashion.
POSTOPERATIVE COURSE
The patient was initially kept in a knee immobilizer following surgery and instructed to use touch-down weight-bearing for 3 weeks. She was switched to a hinged brace at 1 week postoperatively. Physical therapy began with range of motion exercises, and an active flexion was withheld until 6 weeks postoperatively. After 6 weeks, the patient was allowed to progress to an active ROM and increase to weight-bearing as tolerated. Strengthening was started at 12 weeks.
MRI was performed at 4 months postoperatively because the patient reported pain with running. The MRI demonstrated no evidence of stress reaction or fracture in the area of reconstruction. She was advised to continue with physical therapy and stop running. At 5-month post-reconstruction, the patient reported that her pain had resolved and that she had no complaints of any peroneal nerve neuropraxia. At 6 months she had returned to normal activity without complaints. At this point, she was instructed to follow-up as needed.
The patient was seen in office 5.5 years after the initial surgery for an unrelated orthopedic issue. At this time, follow-up data were obtained for her PTFJ reconstruction. She stated that she was very satisfied with the results of her surgery. She claimed to be pain free and had been performing normal activities without any difficulty. Upon physical examination, she achieved full range of motion. She had no extension lag or flexion contracture. She achieved functional and clinical Knee Society Scores of 94 and 90 points, respectively.
DISCUSSION
This article details a soft tissue PTFJ reconstruction using a split biceps femoris graft with over 5 years of clinical follow-up. Chronic PTFJ instability is a rare clinical entity, and unless gross instability is evident upon physical examination, its diagnosis may be confused with the diagnosis of more common complaints, such as meniscal tears or iliotibial band syndrome.
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