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Study design
A prospective case series study was performed between 01/01/2018 and 31/06/2020. All patients gave informed consent to participation in the study, which was conducted in accordance with institutional standards.
Patient population
The patients were enrolled consecutively. The inclusion criteria were all adult distance runners diagnosed with iliotibial band syndrome and with negative response to nonoperative treatment after six months. Distance runner was defined as professional or amateur patient running medium (1500 m) and long (marathon and ultra-trail runners) distances.
The exclusion criteria were: (i) incomplete clinical reports; (ii) non-distance runners; (iii) concomitant injuries interfering with running; (iv) bilateral involvement, (v) negative local anaesthetic infiltration test; and (vi) revision surgeries after previous ITB procedures.
Patient should meet all the inclusion criteria and none of the exclusion criteria. Before being included in the study, all patients performed a preoperative protocol, regardless of the complementary tests performed up to that time.
Preoperative protocol
Complete medical history and physical examination were recorded in all patients. A local anaesthetic infiltration test was performed, which consisted in an ultrasound-guided sub-iliotibial bursa infiltration with 2ml of 2% mepivacaine, followed immediately by a 5 km race. If the patient´s symptoms were relieved temporarily during the race, the test was regarded positive.
High-field MRI (≥ 1.5 T) was performed in all cases after sports had been performed by the patient in the 72 h before the scan, thereby increasing the sensitivity of the imaging technique when oedema appeared at the level of the LFC or ITB (Fig. 1).
Preoperative MRI: coronal (right) and axial (left) views showing edema at the level of the ITB.
Prior to the surgical indication, a specific rehabilitation program was conducted to optimize conservative management with those techniques that had not been yet applied in the patient, including stretches of the fascia lata, proximal eccentric muscle training, intratissue percutaneous electrolysis and at least three focal shockwave sessions.
Independent and outcome variables
Demographic data (age, gender, and body mass index -BMI-), comorbidities, athletic discipline, time to surgery, and postoperative follow-up time were collected in all patients.
The intraoperative characteristics (time of ischemia, confirmation of ITBS, identification of concomitant lesions, and need for drainage) and intra- and post-operative complications were also recorded.
The main variables of the study were the rate and timing of return to previous sporting level, which were reported by patients at follow-up visits. Return to previous sport level was treated as a dichotomous outcome, and was defined as competing after undergoing the PLAR technique in at least one race of the same distance as pre-injury at or above the pre-injury level of competition. The return to sport rate was calculated from the number of athletes who returned to sport, out of the number of athletes who underwent the PLAR technique, and expressed as a percentage.
The secondary variables were the clinical evaluation of the patients based on the Activity Rating Scale (ARS), the International Knee Documentation Committee (IKDC) questionnaire, and the degree of satisfaction. The results of the ARS and IKDC scales were interpreted as follows: excellent = 95–100 for IKDC and 15–16 for ARS; good = 84–94 for IKDC and 13–14 for ARS; and fair = 65–83 for IKDC and 10–12 for ARS. The degree of satisfaction was evaluated in all patients with a poll based on the question: does the surgery meet your expectations?. The possible answers were: completely satisfied, mostly satisfied, somewhat satisfied, dissatisfied.
Surgical procedure
All procedures were performed by the same surgeon. The ITBS diagnosis was confirmed intraoperatively by observing a collapse of the space between the LFC and the ITB due to a mixture of bursitis and hard fibrotic adhesions preventing passage of the arthroscopy optics (Fig. 2).
Intraoperative image. Fibrotic adhesions between the LFC and the ITB.
The patients were placed supine on a conventional table with arthroscopy support, fitting an ischemia cuff to the thigh and performing standard aseptic preparation. The LFC, fibular head, Gerdy’s tubercle, and the anteromedial (AM) and anterolateral (AL) standards portals were identified and marked.
The procedure started with routine diagnostic arthroscopy through the AL portal. If there were doubts about concomitant lesions, an additional AM portal was used in order to be able to perform tactile examination of the knee structures. Under direct intraarticular vision, the superolateral (SL) portal was prepared using a 16G Abbocath spinal needle (Hospira, Lake Forest, IL, USA) as a guide, always through the tendinous portion of the vastus lateralis muscle or the capsule, making sure not to perforate the quadriceps muscle tissue (Fig. 3). All the portals were prepared with a No. 11 scalpel blade.
Intraoperative image. Superolateral portal (SLP) using a 16G Abbocath spinal needle as a guide
With the knee in 30º flexion we initially performed a debridement and resection of the lateral synovial recess, using a motorized shaver (Fig. 4) and a vaporizer (90-degree, model 405Q3, Bonss Medical Tech, Taizhou, Jiangsu, China) (Fig. 5). In patients with ITBS we can observe an abnormal anatomy with increased fibrosis in the lateral synovial recess, so we consider paramount to perform a wide resection in this area until we reach a complete view of the iliotibial band externally and the LFC medially, even seeing the external meniscal wall in its anterior half, and being able to advance the optics through from anterior to the popliteal tendon in the posterior zone, always preserving the meniscus-tibial and meniscus-femoral ligaments. This procedure was performed mainly from the SL portal under visual control from the AL portal, with inversion of the two portals to complete the release.
Intraoperative image. Release of the fibrous adhesions in the space between the LFC and ITB using a motorized shaver
Intraoperative image. Release of the fibrous adhesions in the space between the LFC and ITB using a vaporizer
The second part of the procedure involved percutaneous lengthening of the ITB under direct vision by arthroscopy. This was done with controlled knee varus at 30° of flexion, seeking a balance between lengthening and the preservation of muscle function. An 18G 3-mm needle scalpel (Nokor needle; Becton Dickinson and Co., Franklin Lakes, NJ, USA) was used to perform controlled micro-tenotomies as a micro-pie-crusting technique on the ITB. In all cases they were made longitudinal and parallel to the fibers, and in those cases with greater fibrosis of the ITB, the tenotomies were also made transversely in the posterior third (Fig. 6).
Intraoperative image. Micro-tenotomies on the ITB by an 18G 3-mm needle scalpel
After completing the procedure, skin closure was performed with Prolene (Ethicon, Inc.) 2/0, and a compressive elastic bandage was placed, with a semirigid support in the external zone, where a bulge characteristically forms due to fluid extravasation through the micro-tenotomies. Redon drainage (Fresenius Kabi AG, Bad Homburg, Germany) was used for 12 h in patients with intraoperative identification of a sub-iliotibial bursa associated to significant vascular infiltration, and in all cases, we infiltrated a mixture of corticosteroids and local anesthetic (2 ml of Celestone Cronodose + 4 ml of 2% mepivacaine).
Post-operative protocol
All patients were discharged with full weight-bearing assisted by two crutches according to tolerance.
Rehabilitation started from the first postoperative day. During the first two weeks, full joint range recovery exercises, isometric exercises and even post-supported squats were allowed in order to minimize muscle atrophy. Between weeks 2 and 4, eccentric muscle training (free, weight-bearing and single-foot squats, as well as frontal and lateral lunge exercises) combined with proprioception exercises using a BOSU (both-sides-up) ball or unstable platform were allowed. From weeks 4 to 8, plyometric exercises, elliptical tape, and static bicycle exercises were enhanced, and gentle skipping exercises were allowed, according to tolerance. From the 8th week, and depending on the muscle and proprioceptive condition of the patient, we allowed running a distance of 1 km every other day, combining walking and running stretches, and added distance or speed increments of 10% every two days if tolerance proved good. From the 12th week after surgery, recovery was authorized to continue at the athletics club under the control of the coach or physiotherapist.
Follow-up protocol
A minimum follow-up of 12 months was performed. Postoperative data were collected in all patients at 15 days, 1, 3, 6 and 12 months, and at the end of follow-up (medical discharge). Complications and clinical course were assessed at all visits, while the sporting performance and the ARS and IKDC questionnaires were assessed at 3, 6 and 12 months, without access to a copy of the scales during the interim period, in order to prevent patient self-monitoring of recovery and influencing the final outcome. The degree of satisfaction was recorded at the last follow-up visit.
Statistical analysis
The statistical analysis was performed using SPSS® version 22.0 package for Mac (IBM, NY, USA). Statistical significance was considered for p ≤ 0.05 and a statistical power of 90%.
Standard descriptive statistics including measures of central tendency (mean/median) and variance (standard deviation [SD]/interquartile range [IQR]) were calculated, as well as frequencies and proportions.
The preoperative and final follow-up functional scores were compared using the Wilcoxon signed-rank test.
A multiple non-parametric analysis comparing the IKDCS and ACS scales preoperatively and at 6 and 12 months was performed using the Friedman’s statistical test.
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