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Knee Iliotibial Band Z-Plasty Lengthening and Bursectomy Technique

Open AccessPublished:July 13, 2022DOI:https://doi.org/10.1016/j.eats.2022.03.026

      Abstract

      Multiple surgical techniques have been described to treat refractory iliotibial band syndrome. However, there is lacking evidence demonstrating superiority of one technique over the other and limited audiovisual resources. Most surgical procedures aim to release the iliotibial band; nevertheless, few focus on reducing concomitant inflammation. The present article illustrates a Z-plasty lengthening technique associated with local bursectomy for treating iliotibial band syndrome refractory to conservative treatment.

      Technique Video

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      Technique Video

      See video under supplementary data.

      Iliotibial band syndrome (ITBS) is characterized by pain in the lateral aspect of the knee that increases with physical activity and decreases with rest.
      • Orava S.
      Iliotibial tract friction syndrome in athletes—an uncommon exertion syndrome on the lateral side of the knee.
      It is considered a sports-related overuse injury, presenting more frequently in athletes such as runners, cyclists, and hikers.
      • Orava S.
      Iliotibial tract friction syndrome in athletes—an uncommon exertion syndrome on the lateral side of the knee.
      • Bolia I.K.
      • Gammons P.
      • Scholten D.J.
      • Weber A.E.
      • Waterman B.R.
      Operative versus nonoperative management of distal iliotibial band syndrome—where do we stand? A systematic review.
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      • Noble C.A.
      The treatment of iliotibial band friction syndrome.
      • Martens M.
      • Libbrecht P.
      • Burssens A.
      Surgical treatment of the iliotibial band friction syndrome.
      • Holmes J.C.
      • Pruitt A.L.
      • Whalen N.J.
      Iliotibial band syndrome in cyclists.
      • Drogset J.O.
      • Rossvoll I.
      • Grøntvedt T.
      Surgical treatment of iliotibial band friction syndrome: A retrospective study of 45 patients.
      • Richards D.P.
      • Barber F.A.
      • Troop R.L.
      Iliotibial band Z-lengthening.
      • Walbron P.
      • Jacquot A.
      • Geoffroy J.M.
      • Sirveaux F.
      • Molé D.
      Iliotibial band friction syndrome: An original technique of digastric release of the iliotibial band from Gerdy’s tubercle.
      The pathophysiologic mechanism that originates the ITBS is not entirely elucidated.
      • Bolia I.K.
      • Gammons P.
      • Scholten D.J.
      • Weber A.E.
      • Waterman B.R.
      Operative versus nonoperative management of distal iliotibial band syndrome—where do we stand? A systematic review.
      Two main theories have been reported: one focuses on the mechanical friction between the iliotibial band (ITB) and the lateral femoral epicondyle; the other centers on the inflammation of the underlying bursal tissue.
      • Drogset J.O.
      • Rossvoll I.
      • Grøntvedt T.
      Surgical treatment of iliotibial band friction syndrome: A retrospective study of 45 patients.
      ,
      • Richards D.P.
      • Barber F.A.
      • Troop R.L.
      Iliotibial band Z-lengthening.
      ,
      • Baker R.L.
      • Fredericson M.
      Iliotibial band syndrome in runners. Biomechanical implications and exercise interventions.
      ,
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      Both concepts should be addressed to achieve proper management of this pathology.
      ITBS is mainly treated conservatively, and is based on rest, ice, and nonsteroidal anti-inflammatory drugs associated with physical therapy focusing on stretching the ITB and thigh lateral structures, strengthening hip abductors, neuromuscular control, and improving function.
      • Orava S.
      Iliotibial tract friction syndrome in athletes—an uncommon exertion syndrome on the lateral side of the knee.
      ,
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      ,
      • Martens M.
      • Libbrecht P.
      • Burssens A.
      Surgical treatment of the iliotibial band friction syndrome.
      ,
      • Drogset J.O.
      • Rossvoll I.
      • Grøntvedt T.
      Surgical treatment of iliotibial band friction syndrome: A retrospective study of 45 patients.
      ,
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      • Michels F.
      • Jambou S.
      • Allard M.
      • Bousquet V.
      • Colombet P.
      • De Lavigne C.
      An arthroscopic technique to treat the iliotibial band syndrome.
      • McKay J.
      • Maffulli N.
      • Aicale R.
      • Taunton J.
      Iliotibial band syndrome rehabilitation in female runners: A pilot randomized study.
      Local steroids injections can be used when other conservative measures have failed to confer clinical improvement.
      • Orava S.
      Iliotibial tract friction syndrome in athletes—an uncommon exertion syndrome on the lateral side of the knee.
      ,
      • Noble C.A.
      The treatment of iliotibial band friction syndrome.
      ,
      • Holmes J.C.
      • Pruitt A.L.
      • Whalen N.J.
      Iliotibial band syndrome in cyclists.
      ,
      • Baker R.L.
      • Fredericson M.
      Iliotibial band syndrome in runners. Biomechanical implications and exercise interventions.
      ,
      • McKay J.
      • Maffulli N.
      • Aicale R.
      • Taunton J.
      Iliotibial band syndrome rehabilitation in female runners: A pilot randomized study.
      More than 90% of the patients respond favorably to these nonoperative measures
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      ,
      • Aronen J.G.
      • Chronister R.
      • Regan K.
      • Hensien M.A.
      Practical, conservative management of iliotibial band syndrome.
      and return to sports after 3 to 4 months.
      • Walbron P.
      • Jacquot A.
      • Geoffroy J.M.
      • Sirveaux F.
      • Molé D.
      Iliotibial band friction syndrome: An original technique of digastric release of the iliotibial band from Gerdy’s tubercle.
      ,
      • Michels F.
      • Jambou S.
      • Allard M.
      • Bousquet V.
      • Colombet P.
      • De Lavigne C.
      An arthroscopic technique to treat the iliotibial band syndrome.
      ,
      • Pierce T.P.
      • Mease S.J.
      • Issa K.
      • Festa A.
      • McInerney V.K.
      • Scillia A.J.
      Iliotibial band lengthening: An arthroscopic surgical technique.
      In those cases refractory to conservative treatment (usually after 3-6 months), surgical intervention is advocated.
      • Orava S.
      Iliotibial tract friction syndrome in athletes—an uncommon exertion syndrome on the lateral side of the knee.
      • Bolia I.K.
      • Gammons P.
      • Scholten D.J.
      • Weber A.E.
      • Waterman B.R.
      Operative versus nonoperative management of distal iliotibial band syndrome—where do we stand? A systematic review.
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      • Noble C.A.
      The treatment of iliotibial band friction syndrome.
      • Martens M.
      • Libbrecht P.
      • Burssens A.
      Surgical treatment of the iliotibial band friction syndrome.
      Multiple surgical options to treat ITBS have been described, including open and arthroscopic techniques (Table 1).
      • Bolia I.K.
      • Gammons P.
      • Scholten D.J.
      • Weber A.E.
      • Waterman B.R.
      Operative versus nonoperative management of distal iliotibial band syndrome—where do we stand? A systematic review.
      However, these techniques aim either to release the ITB or to reduce inflammation by excision of underlying bursal tissue without considering a multifactorial etiology. The present article presents a technique that combines ITB Z-plasty lengthening associated with local bursectomy, adapted from Barber et al.
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      ,
      • Richards D.P.
      • Barber F.A.
      • Troop R.L.
      Iliotibial band Z-lengthening.
      and Hariri et al.
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      The objective of the present study is to illustrate this technique.
      Table 1Surgical Options to Treat Refractory ITBS
      AuthorYearType of StudynSurgical Technique(s)Return to SportsClinical Postoperative ResultsComplication(s)
      Noble
      • Noble C.A.
      The treatment of iliotibial band friction syndrome.
      1979Case series9Posterior ITB triangle resection88.8% (running) at 2-16 monthsRecurrent pain (1)
      Martenset al.
      • Martens M.
      • Libbrecht P.
      • Burssens A.
      Surgical treatment of the iliotibial band friction syndrome.
      1989Case series19Posterior ITB triangle resection100% same level (football, running, and cycling) at 7 weeks100% satisfiedHematoma with surgical revision (1)
      Holmes et al.
      • Holmes J.C.
      • Pruitt A.L.
      • Whalen N.J.
      Iliotibial band syndrome in cyclists.
      1993Case series4Percutaneous release25% same level (cycling)

      71.4% pain-free activity
      Open surgical revision (3)
      21Ellipse resection81% same level (cycling) at 6-8 weeksHematoma (2), seromas (9), and surgical ellipse revision (1)
      Drogsetet al.
      • Drogset J.O.
      • Rossvoll I.
      • Grøntvedt T.
      Surgical treatment of iliotibial band friction syndrome: A retrospective study of 45 patients.
      1999Case series45Posterior ITB hemisection ± bursectomy84.5% good-excellent subjective resultsWound infection (1), residual pain (20), knee weakness (2), and local effusion (1)
      Richards et al.
      • Richards D.P.
      • Barber F.A.
      • Troop R.L.
      Iliotibial band Z-lengthening.
      2003Technical note1Arthroscopic exploration + Z-plasty lengthening
      Sangkaew
      • Sangkaew C.
      Surgical treatment of iliotibial band friction syndrome with the mesh technique.
      2006Technical note1Mesh: multiple punctures adjacent to the epicondylePain-free, return to occupational activity
      Boothby et al.
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      2007Case series8Z-plasty lengthening100% same level at 59-97 months100% resolution of original lateral knee pain. Cincinnati: 82.9, Tegner: 4.4, Lysholm: 88.6, and IKDC
      Might have used different scoring systems.
      : 2.6
      None
      Hariri et al.
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      2009Case series11Arthroscopic exploration + open bursectomy72.3% same or higher level at 2 years54.5% completely satisfied, 27.3% mostly satisfied. Tegner: 5, Lysholm: 94.1, and IKDC
      Might have used different scoring systems.
      : 87.5
      Michelset al.
      • Michels F.
      • Jambou S.
      • Allard M.
      • Bousquet V.
      • Colombet P.
      • De Lavigne C.
      An arthroscopic technique to treat the iliotibial band syndrome.
      2009Case series35Arthroscopic lateral gutter synovial recess resection100% (running) at 3 months97.1% good-excellent subjective resultsHematoma with surgical revision (1)
      Cowden and Barber
      • Cowden C.H.
      • Barber F.A.
      Arthroscopic treatment of iliotibial band syndrome.
      2014Case report1Arthroscopic Kaplan fiber and lateral synovial recess resectionSame level at 4 weeksSatisfied, pain-free at 4 weeksNone
      Inoue et al.
      • Inoue H.
      • Hara K.
      • Arai Y.
      • et al.
      Outcome of low-invasive local split-thickness lengthening for iliotibial band friction syndrome.
      2017Case series31Split-thickness lengthening100% (competition) at 5.8 weeksNo extensor and flexor muscle strengths differences between affected and healthy sides at 2 monthsNone
      Walbron et al.
      • Walbron P.
      • Jacquot A.
      • Geoffroy J.M.
      • Sirveaux F.
      • Molé D.
      Iliotibial band friction syndrome: An original technique of digastric release of the iliotibial band from Gerdy’s tubercle.
      2018Technical note14Release from Gerdy’s tubercleSame level at 4 months85.7% satisfaction rate. Tegner: 6 and Lysholm: 93Deep venous thromboses (2)
      Dart et al.
      • Dart S.E.
      • Hyde Z.
      • Gwathmey W.
      • Werner B.C.
      Distal iliotibial band z-lengthening for iliotibial band syndrome.
      2021Technical note1Z-plasty lengtheningSame level (time not described)None
      NOTE. Postoperative clinical scores are given in mean values. “–” indicates not clearly described.
      IKDC, International Knee Documentation Committee; ITBS, iliotibial band syndrome.
      Might have used different scoring systems.

      Surgical Technique (With Video Illustration)

      A narrated step-by-step demonstration of the knee ITB Z-plasty lengthening and bursectomy technique may be reviewed in Video 1. The patient is positioned supine, and a knee diagnostic arthroscopy is performed through an anterolateral portal to rule out other possible concomitant pathology. The authors routinely use a tourniquet during the whole procedure.
      After the arthroscopy, the knee is flexed at 30° (where the greatest tension between the ITB and the lateral epicondyle occurs
      • Cowden C.H.
      • Barber F.A.
      Arthroscopic treatment of iliotibial band syndrome.
      ), and skin landmarks including Gerdy’s tubercle, the lateral femoral epicondyle, and the tibiofemoral joint line are marked (Fig 1).
      Figure thumbnail gr1
      Fig 1Surface anatomy landmarks. In a right 30° flexed knee, with the patient in a supine position, the surface anatomy landmarks are recognized, such as Gerdy’s tubercle (1), which corresponds to the distal insertion of the ITB and can be located by direct palpation. It is necessary to establish the joint line (2) and the lateral femoral epicondyle (3) location to trace the path of the ITB (4) proximally along the lateral face of the thigh. The surgical approach is created by a 4-cm lateral incision (5) along the ITB’s axis. (ITB, iliotibial band.)
      The surgical exposure is created by a 4-cm incision along the axis of the ITB, beginning approximately 2 cm proximal to the joint line. Dissection of the subcutaneous tissue should allow complete visualization of the ITB to perform a proper release of its anterior and posterior edges. Local fibrous adhesions should be released proximally and distally to isolate the band from deeper tissues. This allows an anterior mobilization of the ITB, exposing the underlying inflammatory bursal tissue, which should be excised. The authors recommend sending a bursal sample for pathology evaluation to confirm bursal inflammation. The knee lateral collateral ligament must be identified and protected before proceeding with the Z-plasty to avoid potential iatrogenic residual knee instability (Fig 2). Next, a 2-cm longitudinal line is drawn along the ITB’s central axis, with its center at the level of the lateral femoral epicondyle. A perpendicular line is drawn toward the ITB’s posterior edge at its proximal end. Another perpendicular line is marked at its distal end, this time toward the ITB’s anterior edge, which completes the “Z” figure. Before incising the band, the authors recommend making rein sutures on the “Z” arms to facilitate its mobilization (Fig 3). The “Z” figure is carefully cut using a number 23 scalpel, preventing any potential damage to the deeper structures. After a complete ITB section, both “Z” arms are attached in an end-to-end fashion by employing simple stitches with a number 2 high resistance nonabsorbable suture, resulting in a 2-cm ITB lengthening. The authors advocate for the use of nonabsorbable sutures, as absorbable sutures could lose tension before the ITB has healed, causing premature repair failure. The Z-plasty lengthening is reinforced with marginal coronal absorbable sutures; over-tensioning the band must be avoided (Fig 4). Once completed, stability must be tested by performing passive and full range of knee motion. Finally, a closure by layers is made. The authors recommend intradermal stitches for better aesthetic results. Table 2 summarizes the pearls and pitfalls of this procedure.
      Figure thumbnail gr2
      Fig 2Lateral collateral ligament identification. In a right knee, via a lateral incision in the supine position with the knee flexed at 30°, the lateral collateral ligament (arrow), which lies underneath the ITB (which has been anteriorly reflected with a retractor, and not visible in this picture), must be identified and protected as it is the main structure at risk due to its proximity to the lateral epicondyle (asterisk). (ITB, iliotibial band.)
      Figure thumbnail gr3
      Fig 3Preparing the ITB Z-plasty. Schematic representation of the ITB in a right knee. A 2-cm longitudinal line is drawn along the ITB’s central axis (1), with its center at the level of the lateral femoral epicondyle. At its proximal end, a perpendicular line is drawn towards the ITB’s posterior edge (2). Another perpendicular line is marked at its distal end towards the ITB’s anterior edge (3), completing the “Z” figure. The authors recommend making rein sutures on the “Z” arms to facilitate its mobilization. (ITB, iliotibial band.)
      Figure thumbnail gr4
      Fig 4End-to-end ITB repair. Schematic representation of the ITB Z-plasty in a right knee. After a complete ITB section, both “Z” arms are attached in an end-to-end fashion by employing simple stitches with a #2 nonabsorbable suture (black), resulting in a 2-cm ITB lengthening. The Z-plasty lengthening is reinforced with marginal coronal absorbable sutures (light blue), considering not overtensioning the band. (ITB, iliotibial band.)
      Table 2Pearls and Pitfalls
      Pearls
      • Removal of adhesions below the band allows its correct manipulation
      • Bursectomy: removing the inflamed bursal tissue may aid in alleviating symptoms
      • Rein sutures before incising the band facilitate the manipulation of its ends
      Pitfalls
      • Failure to identify and protect the LCL: if injured, iatrogenic varus instability may be produced
      • Overtensioning ITB end-to-end sutures: enough tension to close the band and secure its stability in a full range of motion should be applied, being careful not to overtighten it. Otherwise, ITBS symptoms may persist
      • Absorbable sutures could lessen their tension before the ITB has healed, causing premature plasty failure: high resistance, non-absorbable sutures should be used to fix the Z-plasty to avoid this complication
      ITB, iliotibial band; ITBS, iliotibial band syndrome; LCL, lateral collateral ligament.

      Postoperative Rehabilitation Protocol

      The postoperative rehabilitation protocol includes immediate weight-bearing assisted by 2 crutches, range of motion as tolerated, and quadriceps isometric–strengthening exercises. Patients will usually no longer need crutches between 1 and 2 weeks after surgery. At 4 weeks, a nonimpact workout is started, with stationary biking and swimming, including balance recovery and close chain strengthening exercises. At 8 weeks, plyometric exercises are started, including jumps and pivoting drills. A progressive return to sports program begins once the patient has achieved appropriate lower extremity strength, range of motion, and proprioception. Patients are allowed to return to sports 12 weeks after surgery.

      Discussion

      Multiple surgical techniques have been described to treat refractory ITBS, such as a posterior triangular resection of the ITB,
      • Noble C.A.
      The treatment of iliotibial band friction syndrome.
      ,
      • Martens M.
      • Libbrecht P.
      • Burssens A.
      Surgical treatment of the iliotibial band friction syndrome.
      elliptical resection,
      • Holmes J.C.
      • Pruitt A.L.
      • Whalen N.J.
      Iliotibial band syndrome in cyclists.
      transverse sectioning of the posterior half,
      • Drogset J.O.
      • Rossvoll I.
      • Grøntvedt T.
      Surgical treatment of iliotibial band friction syndrome: A retrospective study of 45 patients.
      multiple punctures of the band, or the mesh technique,
      • Sangkaew C.
      Surgical treatment of iliotibial band friction syndrome with the mesh technique.
      isolated bursectomy,
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      digastric release from Gerdy’s tubercle,
      • Walbron P.
      • Jacquot A.
      • Geoffroy J.M.
      • Sirveaux F.
      • Molé D.
      Iliotibial band friction syndrome: An original technique of digastric release of the iliotibial band from Gerdy’s tubercle.
      and the Z-plasty lengthening technique.
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      ,
      • Richards D.P.
      • Barber F.A.
      • Troop R.L.
      Iliotibial band Z-lengthening.
      Despite the broad range of surgical procedures, the Z-plasty lengthening and bursectomy technique appears as an attractive procedure that combines the treatment of 2 of the most accepted pathophysiologic mechanisms. On the one hand, it lengthens the ITB, decreasing the friction between the band and the lateral epicondyle. On the other hand, removing the inflammatory tissue, especially the bursae, reduces pain and inflammation. Due to its broader approach, this merging surgical technique should be a more appropriate method to treat refractory ITBS.
      There are limited clinical data and audiovisual material demonstrating the Z-plasty technique. Recently, Dart et al.
      • Dart S.E.
      • Hyde Z.
      • Gwathmey W.
      • Werner B.C.
      Distal iliotibial band z-lengthening for iliotibial band syndrome.
      published a video on the Z-plasty lengthening technique. However, they only described one case with a more conservative rehabilitation protocol (knee brace and 50% weight-bearing for 6 weeks). Their video shows a side-to-side suture of the ITB, which may cause greater shear stress forces on the plasty and condition an early failure of the repair, as opposed to the end-to-end technique shown in the present article. This might be the reason for their need of a more conservative rehabilitation protocol. The present technique was adapted from the Z-plasty lengthening technique described by Barber et al.
      • Boothby M.H.
      • Troop R.L.
      • Alan Barber F.
      Z-plasty lengthening for iliotibial band friction syndrome.
      They showed a case series with full return to the previous activities. However, their validated patient-reported outcomes measurements (Tegner and Lysholm) were slightly lower than those reported by Hariri et al.
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      This difference between functional results might be explained due to the open bursectomy performed by Hariri et al.,
      • Hariri S.
      • Savidge E.T.
      • Reinold M.M.
      • Zachazewski J.
      • Gill T.J.
      Treatment of recalcitrant iliotibial band friction syndrome with open iliotibial band bursectomy: Indications, technique, and clinical outcomes.
      which was not performed in Barber’s case series, yet included in the present Technical Note.
      In conclusion, this study describes the ITB Z-plasty lengthening technique with associated bursectomy for treating ITBS refractory to conservative treatment.

      Supplementary Data

      • Loading ...

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