Distal Iliotibial Band Z-lengthening for Iliotibial Band Syndrome

Abstract

Background:

This technique video reviews an iliotibial band Z-lengthening procedure for iliotibial band (ITB) syndrome using a patient case example.

Indications:

Indications for considering surgical intervention include a diagnosis of iliotibial band syndrome, ruling out other possible etiologies of knee pain, and a minimum of 6 months of failed conservative treatment.

Technique Description:

There are several surgical techniques described in the literature, although the ITB Z-lengthening procedure is preferred at our institution. This technique uses a “Z”-type incision through the distal ITB to allow lengthening of the ITB and to allow access for surgical debridement of the underlying inflamed bursa. Nonabsorbable suture is then used for a side-to-side repair of the ITB in the elongated position.

Results:

Complications from this technique are uncommon, and the few published outcomes from this procedure show good clinical results and return to preactivity levels.

Discussion/Conclusion:

Preoperative planning should include analysis of lower extremity alignment and can include advanced imaging to rule out intra-articular pathology. Diagnostic arthroscopy is typically used at the start of the case for completeness. Distal iliotibial band Z-lenghtening can be a successful surgical option for patients who have failed extensive conservative treatment for iliotibial band syndrome.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This is a technique video for a distal iliotibial band (IB) Z-lengthening procedure as treatment for iliotibial band (ITB) syndrome. This procedure was done as a part of the University of Virginia Department of Orthopedics.

We will review the following items in this video:

• Background: patient presentation, physical examination, and surgical recommendation

• Preoperative planning

• Patient positioning

• Surgical technique

• Postoperative management and return to sport recommendations

• Potential complications

• Patient outcomes

• List of references

This case example is of a 21-year-old female, collegiate distance runner, who has experienced recurrent and persistent lateral-sided right knee pain for 1 year at presentation. Her initial symptoms would present on longer distance runs. She has had increasing severity and regularity of her symptoms over time and now has pain with daily activities, including routine walking and stairs. She had received targeted therapy for ITB syndrome from her athletic trainer, trialed rest, and had failed improvement with bracing and taping. Topical and oral anti-inflammatory medication have become less effective over time. Her examination demonstrated normal alignment, full range of motion, no effusion, and negative meniscal testing. She was positive for tenderness over the distal IB and lateral femoral epicondyle. Crepitus was noticed over the lateral epicondyle with a knee extension to flexion transition, and she was positive on the Ober test.

Initial evaluation radiographs showed normal alignment, well-maintained joint spaces, and no acute abnormalities. Advanced imaging by magnetic resonance imaging (MRI) was obtained before our evaluation to rule out any intra-articular pathology.

MRI initially seen here with T2-weighted coronal cuts displays edema and thickening of the distal IB and increased signal and size of the IB bursa. With the T2-weighted axial cuts, significant edema and inflammation at the distal IB can again be seen. No significant additional intra-articular pathology was present.

Her diagnosis of ITB syndrome was confirmed based on her clinical evaluation and imaging. Our initial recommendation included continued conservative treatment to include formal physical therapy and rest from sport, and a corticosteroid injection was provided in the office. After refractory symptoms, the patient underwent a platelet-rich plasma injection 3 months after our initial evaluation. Despite this extended course of nonoperative treatment, the patient continued to have persistent symptoms and was unable to return to a competitive level of activity at which point we recommended surgical invention in the form of diagnostic arthroscopy and IB Z-lengthening.

Multiple surgical treatments have been proposed for this condition, although we have had good success with the Z-lengthening procedure which will be seen here. Indications for the procedure include a diagnosis of ITB syndrome and at least 6 months of failed conservative treatment.

Pearls to the preoperative planning process involve ruling out additional potential sources of pain through advanced imaging. Ensure there are no lower extremity malalignment issues that can be contributing and may need to be addressed, and plan on performing a diagnostic arthroscopy at the time of the procedure.

Patient positioning for this procedure is supine with a slight bump placed under the ipsilateral hip for better exposure to the lateral knee. We use a lateral stress post for the arthroscopic portion of the procedure, and a nonsterile thigh tourniquet is placed and used throughout the procedure.

The procedure is started with a diagnostic arthroscopy. This patient showed well-preserved cartilage and meniscus in the medial compartment, an intact anterior cruciate ligament, well-preserved cartilage and meniscus in the lateral compartment, and well-preserved patellofemoral articulation. The arthroscopy equipment is then removed from the table, and the lateral femoral epicondyle, Gerdy’s tubercle, and proximal fibular head are marked out on the skin. A 5- to 6-cm incision is marked out in line with the distal IB, just anterior to the epicondyle and extending to the joint line. Surgical dissection is carried out through the subcutaneous layers to the IB. The adherent soft tissue layers are dissected from the IB to allow clear visualization. The division between the biceps femoris and IT band is delineated, and the eventual incisions are planned. The average lengthening was 1.5 cm according to the technique paper by Troop et al, and therefore a 3-cm longitudinal limb is planned to allow adequate tissue for a side-to-side repair in the lengthened state. No. 15 blade is used to make the planned Z cut. Underlying inflamed bursa is removed sharply with care to avoid iatrogenic damage to the underlying lateral collateral ligament (LCL). After dissection of underlying adhesions and taking the knee through simple range of motion, the resting tension of the IB was assessed and the amount of lengthening determined. Nonabsorbable suture is then used to secure the 2 limbs of the IT band in a side-to-side fashion with a horizontal mattress or figure-of-8 configuration. Once the repair is complete, the knee is taken through a full range of motion to ensure a secure construct and appropriate tensioning. The tourniquet was then deflated, hemostasis achieved, and then a routine layered closure was performed.

Postoperative management for our institution consists of 50% weight bearing to the operative extremity with limited motion, 0° to 90°, in a hinged knee brace for the first 6 weeks. The patient should undergo physical therapy during this time, ensuring no loss of range of motion, and focus on quadriceps activation and recovery. After 6 weeks, the patient is progressed to weight bearing as tolerated and allowed to remove the hinged knee brace and work on full range of motion. We recommend continued physical therapy with a graduated rehabilitation with return to running at the 4- to 5-month time frame.

Complications after this procedure are rare but could include seroma formation, postoperative infection, iatrogenic LCL injury, and potentially even iatrogenic peroneal nerve injury. Listed are a few pearls to help avoid these potential problems.

Published outcomes after IB Z-lengthening are rare. Barber et al published the results from their retrospective review of 8 patients with a mean follow-up of 76 months. They report that all patients undergoing the procedure had complete resolution of their symptoms and full return to preoperative activity levels. No complications were reported.

Our patient had complete resolution of her symptoms with a full return to preoperative activity levels and no complications.

From the Department of Orthopedics at the University of Virginia, we thank you.

Our references are listed.