Iliotibial band syndrome is a common cause of lateral knee pain in athletes, and can have a significant impact upon their physical performance. Despite the good outcomes obtained with open surgery in ITBS, we consider it essential to be able to offer minimally invasive surgery to our patients, with a view to allowing them a rapid and optimum return to their previous sports level. According to the results of our study, the AIAR procedure appears to achieve this objective, with excellent results in 79–93% of the cases and a high satisfaction rate (86%).
The diagnosis of ITBS is eminently clinical, based on a detailed history and physical examination. Ultrasound and MRI may be useful tools for differential diagnosis and postsurgical monitoring(5, 7, 16, 17). However, the use of MRI to confirm the diagnosis is more controversial, and in our study we detected two problems with this test. Firstly, according to our data, MRI yielded a false negative rate of 29%, despite the fact that its sensitivity was tried to be increased by performing physical exercise in the 72 hours prior to the scan. Secondly, we observed differential misclassification bias with the use of MRI, since the radiologist tended to report the test as suggestive of ITBS despite the mere presence of nonspecific changes such as an increased thickness of the ITB or increased fluid in the external recess, when a clinical suspicion of ITBS was stated in the request for the MRI study. In this regard, we consider ultrasound-guided local anaesthetic infiltration before a running test to be particularly important in the diagnostic algorithm.
The conservative management of ITBS should include training modification, increasing the muscle training sessions to the detriment of continuous running, a common error in runners. The temporary clinical improvement afforded by corticosteroid and anaesthetic infiltration is quite constant in ITBS, for although the underlying aetiology is multifactorial, in most cases a local inflammatory process is found at LFC level(18). Likewise, focal shock waves have been shown to be useful in chronic cases in which other physiotherapy techniques have failed(19). However, conservative management has been shown to effectively reduce the symptoms during a maximum follow-up time of 6 months(6). In patients refractory to such conservative measures, orthopaedic surgeons should be able to offer an alternative, particularly for those individuals whose professional activity depends directly on their running capacity. This is the case of the patients reported in our study, which included individuals pending a university scholarship in relation to their athletic performance, and others preparing physical tests for access to different national security forces.
There are multiple surgical options, with a return to sports rate of 81–100%(6). Despite the good results reported with open surgery(8, 9, 11–13), we consider that arthroscopy allows the same procedures to be performed with the evident advantages afforded by minimally invasive surgery: less soft tissue aggression, less pain, less blood loss and shorter hospital stay. Furthermore, it offers possibility of performing a diagnostic examination allowing any concomitant lesions to be treated simultaneously.
Our study showed statistically significant improvement in the ARS and IKDC functional scores, with a mean difference between the final follow-up and the preoperative visits of 12.1/16 and 34.2/100 points, respectively. Excellent outcomes were also obtained in 79% of the cases with the ARS scale, and in 93% with the IKDC scale. All other patients had good outcomes. In addition, 86% of the patients claimed to be completely satisfied after surgery, and 14% were mostly satisfied.
The rate of return to previous sports activity was 100%, and no local or systemic complications were recorded. Results consistent with those of our own study have been previously reported in the literature. Michels et al.(14) presented the results of a series of 33 patients subjected to debridement of the lateral synovial recess using a totally intraarticular arthroscopic technique. All patients were able to perform slow running three months after the operation, 80% reported excellent outcomes, and 17% good outcomes, based on the functional scale of Drogset et al.(10) Cowden and Barber(4) described a similar procedure in a single 41-year-old male who ran marathons and was able to return to athletic activity without discomfort after the pain disappeared four weeks following surgery. However, none of the previous studies used a combined arthroscopic technique for sub-iliotibial release and elongation of the ITB, representing global management of ITBS. Pierce et al.(20) described a combined technique adding arthroscopic lengthening of the ITP through incisions with Metzenbaum scissors at proximal, distal, anterior and posterior level of the ITB, from its point of insertion in Gerdy's tubercle. However, to our knowledge, no previous studies have evaluated the results of arthroscopic management combining both techniques in a prospective series of patients.
Regarding the surgical procedure, in the first cases we used intraoperative ultrasound support to check the position of the needle scalpel and confirm total release of the ITB. However, this measure was subsequently removed from our protocol, as it added surgery time and offered no technical advantage over direct intraarticular visualization, which allows us to check the mechanical properties of the ITB through direct palpation, and confirm its increased elasticity after the micro-tenotomy-induced release.
This study has several limitations, including its small sample size. This, and the fact that all patients were distance runners, could limit extrapolation of the results to the general population. However, ITBS is practically exclusive to athletes. We therefore considered that it would be more significant to conduct a specific analysis of the results of our technique in this population subgroup. On the other hand, the minimum follow-up time of 12 months could also be considered a limitation. Nevertheless, the choice of this time period was based on sports performance recovery criteria after consulting coaches with experience in rehabilitation. The mentioned follow-up time was thus considered suitable for assessing recovery of the previous sports level in the absence of complications. Lastly, it could be considered that there are more complete knee functional assessment scales than those used in our study. However, we decided to use the ARS and IKDC scales because there was little clinical impact upon the daily activities of the patients included in the study. We thus considered that we needed more specific scales to adequately assess the sports performance impact of ITBS and improvement after the operation.