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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.
Surgical demonstration of the knee ITB Z-plasty lengthening and bursectomy technique. The case presented is a male patient with right knee refractory ITBS. After a diagnostic arthroscopy through an anterolateral portal, the patient is positioned supine, and the knee is flexed at 30°. Next, skin landmarks are marked. The surgical exposure is created by a lateral 4-cm incision along the axis of the ITB, beginning approximately 2 cm proximal to the joint line. Fibrous adhesions are released to allow anterior mobilization of the ITB, exposing the underlying inflammatory bursal tissue, which should be excised. Next, the LCL is identified and protected, and the “Z” is marked along the ITB’s central axis, with its center at the level of the lateral femoral epicondyle. The authors recommend making rein sutures on the “Z” arms to facilitate its mobilization. After completing the “Z” ITB section, both “Z” arms are attached in an end-to-end fashion by employing simple stitches with high resistance non-absorbable sutures, resulting in a 2-cm ITB lengthening. The Z-plasty lengthening is reinforced with marginal coronal absorbable sutures; overtensioning the band must be avoided. Once completed, stability is tested, and closure by layers is made. (ITB, iliotibial band; ITBS, iliotibial band syndrome; LCL, lateral collateral ligament.)
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.
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.
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.
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.
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
), and skin landmarks including Gerdy’s tubercle, the lateral femoral epicondyle, and the tibiofemoral joint line are marked (Fig 1).
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.
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.)
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.)
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.)
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
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,
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.
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.
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.
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.
Surgical demonstration of the knee ITB Z-plasty lengthening and bursectomy technique. The case presented is a male patient with right knee refractory ITBS. After a diagnostic arthroscopy through an anterolateral portal, the patient is positioned supine, and the knee is flexed at 30°. Next, skin landmarks are marked. The surgical exposure is created by a lateral 4-cm incision along the axis of the ITB, beginning approximately 2 cm proximal to the joint line. Fibrous adhesions are released to allow anterior mobilization of the ITB, exposing the underlying inflammatory bursal tissue, which should be excised. Next, the LCL is identified and protected, and the “Z” is marked along the ITB’s central axis, with its center at the level of the lateral femoral epicondyle. The authors recommend making rein sutures on the “Z” arms to facilitate its mobilization. After completing the “Z” ITB section, both “Z” arms are attached in an end-to-end fashion by employing simple stitches with high resistance non-absorbable sutures, resulting in a 2-cm ITB lengthening. The Z-plasty lengthening is reinforced with marginal coronal absorbable sutures; overtensioning the band must be avoided. Once completed, stability is tested, and closure by layers is made. (ITB, iliotibial band; ITBS, iliotibial band syndrome; LCL, lateral collateral ligament.)
References
Orava S.
Iliotibial tract friction syndrome in athletes—an uncommon exertion syndrome on the lateral side of the knee.
The authors report the following potential conflicts of interest or sources of funding: A.V. reports other from Arthrex, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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