Proximal Tibiofibular Joint: An Often-Forgotten Cause of Lateral Knee Pain
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1 Forster et al. Tibiofibular Joint Disorders Musculoskeletal Imaging Pictorial Essay Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved ruce. Forster 1 Jimmy S. Lee Sarah Kelly Mariana O Dowd Peter L. Munk Gordon ndrews Lorie Marchinkow Forster, Lee JS, Kelly S, et al. Keywords: joint, knee, musculoskeletal imaging, pain DOI: /JR Received May 10, 2006; accepted after revision ugust 1, ll authors: Department of Radiology, University of ritish olumbia and University of ritish olumbia Hospital, 2211 Wesbrook Mall, Vancouver, V6T 25, anada. ddress correspondence to.. Forster (ruce.forster@vch.ca). WE This is a Web exclusive article. JR 2007; 188:W359 W X/07/1884 W359 merican Roentgen Ray Society Proximal Tibiofibular Joint: n Often-Forgotten ause of Lateral Knee Pain OJETIVE. This article presents the imaging findings of proximal tibiofibular joint disorders that can cause lateral knee pain. ONLUSION. The proximal tibiofibular joint is often neglected in the evaluation of lateral knee pain. The images presented in this article highlight the diverse disorders of this area. ecause this joint is usually in the field of view in radiography, T, and MRI of the knee, evaluation of it should be a part of all knee imaging assessments. he proximal tibiofibular joint is a T source of lateral knee pain that is often overlooked as a result of its lack of emphasis in the literature and textbooks [1, 2] and the few reports devoted to its disorders [2]. This point is particularly significant in that the proximal tibiofibular joint is usually in the field of view of most knee imaging studies. The proximal tibiofibular joint is a synovial joint that functions in dissipating lower leg torsional stresses and lateral tibial bending moments and in transmitting axial loads in weight-bearing [1]. Numerous disorders of the proximal tibiofibular joint can present as lateral knee pain. In this article, normal proximal tibiofibular joint anatomy and imaging characteristics of disease entities that occur at this site are discussed. In addition, many diseases that are not technically in the proximal tibiofibular joint but are adjacent or related to it are also included, because lesions in these adjacent structures can affect the proximal tibiofibular joint. This article will emphasize osteoarthritis, neoplasms, ganglion cysts, pigmented villonodular synovitis, and trauma. Other disorders that can affect the proximal tibiofibular joint but are not specifically discussed include osteoid osteoma, Maisonneuve fracture of the fibular neck, and infections. Taken together, these examples of proximal tibiofibular joint disorders underscore the importance of evaluation of this joint in routine knee imaging assessments. Normal natomy of the Proximal Tibiofibular Joint The proximal tibiofibular joint is located between the lateral tibial condyle and the fibular head. It communicates with the knee joint in approximately 10% of adults, although communication in up to 64% has been reported with MR arthrography [1]. ecause the proximal tibiofibular joint can be contiguous with the knee joint, either joint may be affected when the joint pressure is elevated, and thus the proximal tibiofibular joint has been construed as the fourth compartment of the knee joint [1]. fibrous capsule surrounds the proximal tibiofibular joint articulation, and this is strengthened by anterosuperior and posterosuperior tibiofibular ligaments (Figs. 1 and 2). The common peroneal nerve descends along the lateral aspect of the popliteal fossa and curves around the anterolateral aspects of the fibular head and neck (Fig. 1). It passes lateral to the anterior compartment musculature and deep in relation to the peroneus longus musculature, where it divides into superficial and deep branches. Normal MRI natomy The anterosuperior and posterosuperior ligaments have low signal intensity on all imaging sequences (Fig. 2). small amount of fluid (high T2 signal) may normally be present in the proximal tibiofibular joint. Nerves are low to intermediate signal intensity on T1-weighted images (Fig. 2) and become slightly higher in signal intensity on T2-weighted images. Disorders Osteoarthritis Degenerative arthritis of the proximal tibiofibular joint may accompany osteoarthritis JR:188, pril 2007 W359
2 Forster et al. Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved of the knee or occur in isolation. In patients scheduled to undergo total knee replacement arthroplasty, an unrecognized proximal tibiofibular joint disorder may be a source of progressive lateral knee pain and may influence clinical outcome. s with other joints, osteophytes (Fig. 3), subchondral cysts, subchondral sclerosis, and joint space narrowing are typical imaging findings. Neoplasms Various neoplasms can affect the proximal tibiofibular joint, including osteochondroma, osteoblastoma, osteosarcoma, and nerve sheath tumors. n osteochondroma is a benign lesion that rarely undergoes malignant transformation [3]. It is usually asymptomatic and is usually discovered incidentally (Fig. 4). In superficial regions such as the proximal tibiofibular joint, osteochondroma can present as a painless palpable mass or with symptoms related to nerve irritation. Osteoblastoma is an uncommon benign neoplasm occurring predominantly in the axial skeleton (Fig. 5). pproximately 35% occur in long tubular bones, and 75% of these are in the diaphysis. Only a few cases involving the epiphysis have been reported [3]. Osteosarcoma is the second most common primary bone malignancy [3], with a peak incidence in the second to third decades of life. lthough the distal femur and the proximal tibia are most often involved, any bone can be affected. ggressive, boneforming features are usually noted on imaging (Figs. 6 and 6). Schwannomas and neurofibromas make up most of the peripheral nerve sheath tumors. Most of these are solitary, slowly growing masses; when they are large, they can cause pain and neuropathy. Schwannomas and neurofibromas typically show homogeneously low signal intensity on T1-weighted imaging, high signal intensity on T2-weighted imaging (Fig. 7), and intense enhancement with administration of gadolinium. target appearance may be seen when central fibrous tissue causes T2 shortening. Trauma The proximal tibiofibular joint is often injured by direct trauma. However, indirect forces causing varus strain, hyperflexion, or hyperextension can also lead to significant injuries, including fracture, dislocation, ligament strains (Fig. 8) and tears, and injury to the neurovascular bundle. The popliteus tendon, lying in close proximity to the proximal tibiofibular joint, should be carefully assessed for either an isolated tear (Fig. 9) or involvement in a more complex posterolateral corner injury. Posterolateral orner Injury The posterolateral corner of the knee is anatomically complex and is made up of the lateral collateral ligament, the popliteus muscle and tendon, and the arcuate complex (arcuate, fabellofibular, and popliteofibular ligaments) (see [4] for a detailed review). The diagnosis of posterolateral corner injury should be suspected when disruption of more than one of these structures is encountered [4]. n avulsion fracture of the styloid process of the fibular head (Fig. 10), which is the site of insertion of the arcuate complex, has been termed the arcuate sign and is an indicator of posterolateral instability [5]. Most often, the mechanism of injury is direct force to the anteromedial tibia with the knee in extension. It is important to recognize a posterolateral corner injury because the knee is unstable in extension and there is usually an accompanying anterior or posterior cruciate ligament (PL) tear (Fig. 10). Unrecognized or untreated posterolateral instability can lead to failures of the anterior cruciate ligament (L) or PL repairs and chronic knee instability [5, 6]. Ganglion ganglion is a tumorlike, cystic lesion that arises from the joint, tendon sheath, or muscle [7]. Those arising near the proximal tibiofibular joint articulation are rare entities that can be associated with compression of the common peroneal nerve (Fig. 11). Pigmented Villonodular Synovitis (PVNS) disease of unknown cause, PVNS is characterized by synovial hypertrophy with diffuse or focal hemosiderin deposition in the joint [8]. It is monoarticular, affecting the knee most frequently, and it usually occurs in adults in the third or fourth decade. Imaging reveals large, globular areas of low T1 and T2 signal outlining the hypertrophied synovium (Fig. 12). onclusion The examples of proximal tibiofibular joint disorders presented in this article highlight the diverse disease entities that can occur at this joint. ecause the proximal tibiofibular joint is usually included in the field of view in radiography, T, and MRI of the knee, evaluation of it should be a part of all imaging assessments of the knee region. References 1. ozkurt M, Yilmaz E, tlihan D, et al. The proximal tibiofibular joint: an anatomic study. lin Orthop Relat Res 2003; 406: ozkurt M, Yilmaz E, kseki D, et al. The evaluation of proximal tibiofibular joint for patients with lateral knee pain. Knee 2004; 11: Resnick D, Kransdorf M. one and joint imaging, 3rd ed. Philadelphia, P: Elsevier Saunders, 2004: Recondo J, Salvador E, Villanua J, et al. Lateral stabilizing structures of the knee: functional anatomy and injuries assessed with MR imaging. RadioGraphics. 2000; 20[spec no]:s91 S Huang GS, Yu JS, Munshi M, et al. vulsion fracture of the head of the fibula ( arcuate sign): MR imaging findings predictive of injuries to the posterolateral ligaments and posterior cruciate ligament. JR 2003; 180: Hughston J, Jacobson KE. hronic posterolateral rotatory instability of the knee. J one Joint Surg m 1985; 67: Miskovsky S, Kaeding, Weis L. Proximal tibiofibular joint ganglion cysts: excision, recurrence, and joint arthrodesis. m J Sports Med 2004; 32: Ryan RS, Louis L, O onnell JX, et al. Pigmented villonodular synovitis of the proximal tibiofibular joint. ustralas Radiol 2004; 48: W360 JR:188, pril 2007
3 Tibiofibular Joint Disorders Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved Fig. 1 Normal anatomy of proximal tibiofibular joint as shown on coronal and transverse cross-sectional drawings., ommon peroneal nerve (arrow) curves around fibular head and divides into superficial and deep components., nterosuperior and posterosuperior tibiofibular ligaments are shown (arrows), which strengthen fibrous capsule of proximal tibiofibular joint. Fig. 2 Normal MRI anatomy of proximal tibiofibular joint in 31-year-old woman., xial fast spin-echo proton density weighted fat-saturated image shows anterior and posterior proximal tibiofibular ligaments as low-signal-intensity bands (arrows)., xial fast spin-echo T1-weighted image shows intermediate-signal-intensity common peroneal nerve as it courses around fibular head (arrow). Fig. 3 Osteoarthritis in 56-year-old man with recent knee trauma. Transverse T images of knee show osteophytosis (arrow). cute lateral tibial plateau fracture is present. JR:188, pril 2007 W361
4 Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved Forster et al. Fig. 4 Fibular head osteochondroma in 27-year-old woman with lateral knee swelling for 5 months., nteroposterior radiograph of knee shows welldefined bone protuberance arising from medial aspect of fibular head (arrow)., xial T image shows exostosis arising from posteromedial fibular head (arrow) and protruding into proximal tibiofibular joint. This was subsequently resected and diagnosis was pathologically determined. Fig. 5 Osteoblastoma in 19-year-old man who presented with 4-month history of lateral knee pain., Transverse T image shows expansile, osteolytic lesion (arrow) with minimal osteoid matrix in fibular head. Lesion protrudes toward posterior tibia., nterior and posterior whole-body bone scintigraphy image shows solitary lesion in fibular head and prominent radionuclide uptake., nteroposterior radiograph after resection of tumor and bone grafting. W362 JR:188, pril 2007
5 Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved Tibiofibular Joint Disorders Fig. 6 Osteosarcoma in 19-year-old woman presenting with lateral knee pain and palpable mass., nteroposterior radiograph shows mixed lytic and sclerotic lesion of right fibular head and periosteal reaction on medial fibular neck and shaft., oronal STIR MR image shows irregular, high-signal-intensity, lobulated mass involving proximal fibula. ortex is breached and mass extends into proximal tibiofibular joint. ssociated soft-tissue mass is present., Sagittal T1-weighted MR image shows mass is primarily isointense to muscle. Patient underwent resection of proximal fibula. Fig. 7 ommon peroneal nerve schwannoma in 45-year-old man with drop foot., Transverse T1-weighted MR image with gadolinium and fat saturation shows well-delineated, homogeneously enhancing mass centered on common peroneal nerve and adjacent to fibular neck, where it branches into its superficial and deep components. and, oronal () and sagittal () T2-weighted STIR MR images show mass is hyperintense and well defined. JR:188, pril 2007 W363
6 Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved Forster et al. Fig. 8 nterior tibiofibular ligament strain in 23-year-old woman with acute hyperflexion injury. and, ontiguous transverse fast spin-echo T2-weighted fat-suppressed MR images show high signal intensity surrounding anterior tibiofibular ligament (arrow, ) consistent with partial tear, fibular head bone marrow edema (arrow, ), and small amount of fluid (high signal) in proximal tibiofibular joint., oronal STIR MR image shows bone marrow edema in fibular head. Fig. 9 Popliteus tendon rupture in 55-year-old man after hyperextension injury., Transverse fast spin-echo proton density weighted fat-saturated MR image shows popliteus tendon is ruptured and retracted from its femoral attachment. High-signalintensity fluid surrounds torn tendon (arrow). and, Sagittal T2*-weighted gradient echo () and coronal fast spin-echo T2-weighted fat-saturated () images show same findings (arrows) as in. W364 JR:188, pril 2007
7 Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved Tibiofibular Joint Disorders Fig. 10 Posterolateral corner injury in 32-year-old man after motor vehicle accident., oronal fast spin-echo T2-weighted fat-saturated MR image shows bone marrow edema in fibular head (arrow) secondary to avulsion of arcuate complex., Sagittal fast spin-echo T2-weighted MR image shows accompanying tear of mid portion of anterior cruciate ligament (L). high-signal-intensity mass (arrow), representing focal hemorrhage, disrupts normally low-signal-intensity L fibers. Fig. 11 Popliteus tendon ganglion in 32-year-old man., Oblique sagittal fast spin-echo T2-weighted MR image shows well-defined, lobulated, elongated, high-signal-intensity mass (arrow). Mass is associated with popliteus tendon just posterior to tibia. and, Transverse fast spin-echo proton density weighted fat-saturated () and coronal fast spin-echo T2-weighted fat-saturated () MR images show markedly hyperintense mass related to popliteus tendon. JR:188, pril 2007 W365
8 Downloaded from by on 01/17/18 from IP address opyright RRS. For personal use only; all rights reserved Forster et al. Fig. 12 Pigmented villonodular synovitis in 36-year-old woman with progressive knee swelling and discomfort. (Figures 12 and 12 reprinted with permission from Ryan RS, Louis L, O onnell JX, et al. Pigmented villonodular synovitis of proximal tibiofibular joint. ustralas Radiol 2004; 48: [8].), Transverse T1-weighted MR image of knee shows lobulated foci of low signal intensity in and around proximal tibiofibular joint and in fibular head. and, oronal fast spin-echo T2-weighted with fat saturation () and gradient-recalled echo () MR images of knee show that, because of magnetic susceptibility properties of hemosiderin, blooming artifacts can occur on gradient sequences, and globular low-signal lesions become more conspicuous. W366 JR:188, pril 2007
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