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Iliotibial band lengthening (for ITB friction syndrome)

    Overview

    Learn the Iliotibial band lengthening (for ITB friction syndrome) surgical technique with step by step instructions on OrthOracle. Our e-learning platform contains high resolution images and a certified CME of the Iliotibial band lengthening (for ITB friction syndrome) surgical procedure.

    This is a description of the surgical technique for iliotibial band (ITB) lengthening and bursa excision for recalcitrant ITB friction syndrome. The technique shown is in a young and very physically active man . Iliotibial band friction syndrome is an overuse injury often experienced by runners and presents with lateral sided knee pain. Surgery is reserved for recalcitrant cases that do not improve with rest, physiotherapy, alignment correction and anti-inflammatory medication.
    Well over 90% of cases of iliotibial band friction pain will settle with conservative treatment over 6 months. All patients should have a trial of specific physiotherapy, anti-inflammatory medication and a diagnostic local anaesthetic / steroid injection.
    Failure of the above measures after 6 months may strengthen the argument for surgery. The patient however must accept that the success of surgery is only around 75%. Although it is low risk there have been reports of weak abduction with overlengthening of the ITB.
    Iliotibial band friction syndrome is often a diagnosis of exclusion with investigations being normal.

    Author :Mr Andrew Pearse FRCS (Tr & Orth)
    Institution: The Worcestershire Acute Hospitals NHS Trust, UK.
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    Indications

    INDICATIONS
    Recalcitrant iliotibial band friction syndrome
    Well over 90% of cases of iliotibial band friction pain will settle with conservative treatment over 6 months. All patients should have a trial of specific physiotherapy, anti-inflammatory medication and a diagnostic local anaesthetic / steroid injection.
    Failure of the above measures after 6 months may strengthen the argument for surgery. The patient however must accept that the success of surgery is only around 75%. Although it is low risk there have been reports of weak abduction with overlengthening of the ITB.
    It is often a diagnosis of exclusion. In this case the patient had been suffering symptoms for 6 years. He had been investigated in the past with MRI and even gone on to an arthroscopy which demonstrated no post-operative improvement. When he presented to my knee clinic he had increasing pain at work and when running. His work involved heavy lifting during which he experienced bilateral lateral knee clicking and pain. He had the same procedure on the opposite leg 6 months earlier with complete alleviation of pain and clicking.
    SYMPTOMS & EXAMINATION
    Lateral sided knee pain over the lateral femoral epicondyle – increases with activity (running, repetitive lifting). Although not severe the pain can be debilitating enough for patients to avoid activity. It is a crescendoing burning, aching pain, that slowly subsides with rest over a number of hours. Unlike a neural pattern, the pain does not radiate significantly.
    Clicking associated with pain
    Examination is largely normal other than point tenderness on compression whilst bringing the knee from 90 degrees flexion into extension (Noble compression test). Some patients also demonstrate a tight ITB on Ober’s Test – restricted adduction of the hip in the lateral position.
    Diagnosis is often clinical and by exclusion of other lateral sided knee conditions. Therefore a thorough history and reproduction of pain and examination is critical.
    IMAGING
    MRI – however this can be negative. It can be advantageous for the patient to evoke the pain by running immediately prior to the scan. A positive scan will show inflammation of the bursa and thickening of the ITB at the level of the lateral epicondyle. This investigation can also aid ruling out any concurrent / alternative diagnosis such as lateral meniscal tear.
    Long-leg alignment films – to exclude malalignment
    Ultrasound +/- injection
    ALTERNATIVE OPERATIVE TREATMENT
    Isolated ITB bursectomy
    ITB “windowing” by removing a small triangle over the epicondyle
    Percutaneous lengthening
    NON-OPERATIVE MANAGEMENT
    Rest
    Analgesia – oral anti-inflammatories are especially indicated
    Injections – steroid and local anaesthetic injections can be both therapeutic and diagnostic. The injection is directly over the point of pain and aimed to the deep surface of the ITB, within the bursa. Ultrasound guided injections can be considered, which would also serve to observe any increased fluid in the bursa or ITB thickening.
    Physiotherapy – this is vital. The aim is to lengthen the ITB by stretching. Gluteal control.
    Orthotic realignment / off-loading
    CONTRAINDICATIONS
    Diagnostic uncertainty
    Active infection

    Setup

    Patient supine
    High thigh tourniquet
    Sandbag under the buttock on the operating side to externally rotate the leg
    Diathermy

    Operation

    The leg was prepped with alcoholic betadine. The sandbag under the left buttock rotates the leg into an ideal position.

    The lateral joint line (solid line) and the lateral epicondyle are marked out. The knee is flexed to make the ITB easier to palpate. The dotted lines represent the anterior and posterior edges of the tendon. The knee is then brought back into extension. The position of the ITB at this level remains the same in flexion and extension. The illusion of the shift at 30 degrees of flexion relative to the lateral femoral condyle is due to the changing tension with the anterior and posterior fibres.
    As can be seen from the image the midpoint of the ITB, and therefore the incision, is a safe distance anterior to the biceps tendon and hence the common peroneal nerve.

    The knee is rested back in extension and the initial incision is made directly over the lateral epicondyle in line with the ITB. The incision is no more than 5 cm.

    Sharp dissection is continued down through the subcutaneous fat layer onto the paratenon.

    The paratenon is incised in line with the underlying tendon fibres and reflected. The anterior and posterior edges of the ITB are clearly identified, as it is fairly distinct from the adjacent muscle fascia. The band itself is around 3 cm wide (AP) and 3-5mm thick.

    A pair of dissecting scissors are passed behind the tendon to elevate it off the underlying bursa. This will often be quite scarred in chronic cases.
    The lateral femoral epicondyle lies deep to the ITB. The lateral collateral ligament (LCL) attaches closely behind the epidondyle. To avoid inadvertent damage the curve of the dissecting scissors should face forward and dissection should be achieved by OPENING rather than closing the scissors. Alternatively an artery clip can be used.

    The horizontal line of the Z-plasty is measured at 3cm in the centre of the ITB, in line with the fibres, centred over the epicondyle.

    The horizontal line of the Z-plasty is measured at 3cm in the centre of the ITB, in line with the fibres, centred over the epicondyle.
    Note the larger dot marking the epicondyle.

    The distal end of the incision commences 1.5cm distal to the epicondyle and continues 1.5cm proximal in the line of the fibres. Caution must be taken to cut only the ITB fibres and not cut too deeply, risking damage to the LCL.

    Distally a perpendicular vertical incision extends to the posterior edge.

    Proximally a perpendicular vertical incision extends to the anterior edge.

    The two limbs are elevated off the underlying bursa. The image shows the planned lengthening by sliding the limbs half of their length in opposite directions, thereby increasing the length of the tendon by 1.5cm at the level of the lateral epicondyle.

    A thickened scarred portion of the underlying bursa is excised. This tissue is less than 1cm in lengthen and directly over the epicondyle. Caution must be taken to avoid inadvertent damage to the lateral collateral ligament origin or the lateral superior genicular bundle, although this should be more anterior.
    Damage to the LCL should be identified and direct repair must be performed, followed by a period of immobilisation. Damage to the nerve and the adjacent artery, albeit rare could lead to aneurysm formation. However the risk of osteonecrosis of the patella is minimal due to the compressive supply from the medial superior and inferior branches. Indeed ablation of the nerve is occaionally used to control anterior knee pain.

    The lengthened limbs are then sutured side-by-side, which is my preference, as it avoids tapering the tendon at this level. Overlapping and suturing one limb on top of the other has been described also.

    A combition of single fixing sutures followed by continuous sutures with absorbable suture, in this case 0 vicryl, is used to repair the Z-plasty.
    The literature advised avoiding lengthening the ITB by 1 to 1.5cm to avoid weakening hip abduction.

    The paratenon is then closed with 2/0 vicryl.

    The subcutaneous layer is closed with 3/0 undyed vicryl and clips to skin.

    Local anaesthetic is infiltrated around the wound as a field block. Adhesive dressing adn wool and crepe bandage is applied.

    Post Operative

    Post operative weightbearing – 2 weeks protected weightbearing on crutches for pain relief purposes. After this full weightbearing is commenced.
    Swelling control and analgesia.
    No specific programme is routinely required.
    Compressive stockings are advised during the period of altered weightbearing status.
    Skin clips are removed at 14 days.
    Return to sport is expected at 3-4 months post-surgery after a period of building up from light jogging (6 weeks) to sprinting, cutting and pivoting. Sports specific activity advice is advisable from a physiotherapist.

    Recommended Reading

    Significant controversy exists about the effectiveness of surgery for this condition. Indeed the diagnosis is somewhat contentious, as to whether it is a bursitis secondary to friction or inflammation/degeneration within the tendon itself. Many techniques have been described to for the surgical management of recalcitrant cases. These include – release of the tendon with a partial fasciotomy (posterior edge); excision of a window / triangle over the epicondyle; percutaneous release; mesh insertion; isolated bursectomy; epicondyle excision.
    The literature contains case series rather than a true level one study. For this technique a reference paper is:
    Iliotibial band Z-lengthening. Richards DP, Alan Barber F, Troop RL. Arthroscopy. 2003 Mar;19(3):326-9.
    Technical description of the Z-plasty technique.
    Z-plasty lengthening for iliotibial band friction syndrome. Barber FA1, Boothby MH, Troop RL. J Knee Surg. 2007 Oct;20(4):281-4.
    Longterm results are described in a case series of 8 patients maintain complete resolution of symptoms out to 8 years.
    Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: indications, technique, and clinical outcomes. Hariri S1, Savidge ET, Reinold MM, Zachazewski J, Gill TJ. Am J Sports Med. 2009 Jul;37(7):1417-24.
    This article summaries a number of case series and their results as well as their technique for bursectomy. In essence satisfaction rate of surgery is around 75%.
    It is as always imperative to select the correct patients and allow for a thorough period of non-operative measure to be undertaken to prove a truly recalcitrant case of ITB friction syndrome.
    In this particular case the patient presented with identical symptoms in the opposite knee having had an excellent response to his original surgery.

    Reference

    • orthoracle.com

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