What is Iliotibial Band Tenodesis (Modified Lemaire Tenodesis with Iliotibial Band Graft)?
Iliotibial band (ITB) tenodesis or modified Lemaire tenodesis with iliotibial band graft is a type of minimally invasive surgical technique that is employed in conjunction with anterior cruciate ligament (ACL) reconstruction to improve anterolateral rotational stability in a knee with a high degree of rotational instability or as a supplement during ACL revision surgery. ACL reconstruction surgery is usually performed by replacing the torn or damaged anterior cruciate ligament in your knee with a tendon graft obtained from another section of the patient’s own body (autograft) or from a donor (allograft). Revision ACL (anterior cruciate ligament) reconstruction is a second surgery performed to correct a failed primary ACL reconstruction surgery.
An iliotibial band is a tough group of fibers that begins at the iliac crest of the hip and runs along the outside of the thigh, attaching to the outer side of the shinbone just below the knee joint. Its function is to coordinate with the thigh muscles and provide stability to the knee joint.
ITB tenodesis or anterolateral iliotibial band tenodesis technique (modified Lemaire technique) supplements the ACL reconstruction and involves taking a strip or part of the ITB leaving it secured to its natural origin on the shinbone. The harvested ITB graft is passed underneath the lateral collateral ligament (LCL) and is finally attached to the lateral thigh bone on the outer side of the knee. Modified Lemaire tenodesis with iliotibial band graft can be an appropriate treatment choice in ACL surgery to increase the stability of the knee and make a more stable ACL construct for patients hoping to return to high levels of activity and rigorous sports.
Anatomy of the Knee
The knee joint is one of the most complex joints of the body. The lower end of the thighbone (femur) meets the upper end of the shinbone (tibia) at the knee joint. A small bone called the patella (kneecap) rests on a groove on the front of the femoral end. Another bone of the lower leg (fibula) forms a joint with the shinbone. Bands of tissue, including the cruciate and collateral ligaments, keep the different bones of the knee joint together and provide stabilization to the joint. Surrounding muscles are connected to the knee bones by tendons. The bones work together with the muscles and tendons to provide mobility to the knee joint.
Indications for Iliotibial Band Tenodesis (Modified Lemaire Tenodesis with Iliotibial Band Graft)
Iliotibial band tenodesis is indicated while undergoing ACL reconstruction or revision ACL reconstruction to reinforce the ACL repair and enhance knee instability to prevent failure of ACL reconstruction as a result of re-injury or re-rupture of the ACL tendon graft in highly active patients or athletes.
An ACL tear or injury is a sports-related injury that occurs when the knee is forcefully twisted or hyper-extended. It usually occurs with an abrupt directional change with the foot fixed on the ground or when the deceleration force crosses the knee. Changing direction rapidly, stopping suddenly, slowing down suddenly while running, landing from a jump incorrectly, and direct contact or collision, such as a football tackle can also result in injury to the ACL.
ACL is one of the four major ligaments of the knee that connects the femur to the tibia and helps stabilize your knee joint. It prevents excessive forward movement of the tibia in relation to the femur as well as limits rotational movements of the knee. When this ligament tears, unfortunately, it does not heal on its own and often leads to the feeling of instability in the knee, requiring reconstruction to correct the abnormality.
Preparation for Iliotibial Band Tenodesis (Modified Lemaire Tenodesis with Iliotibial Band Graft)
In general, preparation for iliotibial band tenodesis surgery will involve the following steps:
- A review of your medical history and a physical examination to check for any medical issues that need to be addressed prior to surgery.
- Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to help detect any abnormalities that could compromise the safety of the procedure.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should inform your doctor of any medications or supplements you are taking or any conditions you have such as heart or lung disease.
- You may be asked to stop taking certain medications, such as blood thinners, anti-inflammatories, aspirin, or other supplements for a week or two.
- You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.
Procedure for Iliotibial Band Tenodesis (Modified Lemaire Tenodesis with Iliotibial Band Graft)
Iliotibial band tenodesis surgery is usually performed in conjunction with ACL reconstruction surgery under general anesthesia in a minimally invasive arthroscopic technique. In general, the procedure involves the following steps:
- Your surgeon will make two to three small cuts, about 1/4-inch-long, around your knee.
- An arthroscope is inserted into the knee joint through one of the incisions.
- An arthroscope is a thin tubular instrument with a camera, light, and a magnifying lens attached at the end that is connected to an external monitor and enables your surgeon to view the inside of the knee joint.
- Along with the arthroscope, a sterile solution is pumped into the joint to expand it, enabling your surgeon to have a clear view and space to work inside the joint.
- Miniature surgical instruments are passed through the other incisions and the torn ACL is removed and a new tendon graft is used to reconstruct the ACL. Usually, the tendon graft is taken from the patient’s own hamstring or patellar tendons (autograft). During reconstruction, your surgeon secures the autograft in the femur and tibia with screws. This first step occurs in all ACL reconstruction/revision cases.
- The second step offers additional reinforcement of the ACL for patients at high risk of re-rupture or injury. In this stage of surgery, your surgeon tightens the iliotibial band (a section of tissue on the lateral side of the knee). A large incision is made on the lateral side of the knee, and a small segment of the iliotibial band is detached. Your surgeon then slides this segment underneath the lateral collateral ligament and anchors it to the femur to add extra support to the ACL. The lateral collateral ligament is a ligament found on the outer (lateral) side of the knee.
- After confirming satisfactory reconstruction and iliotibial band tenodesis, the scope and the instruments are withdrawn, and the incisions are sutured and bandaged.
Postoperative Care and Instructions
In general, postoperative care instructions and recovery after iliotibial band tenodesis will involve the following:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic or anesthetic reactions and monitor your vital signs as you recover.
- You may notice pain, swelling, and discomfort in the knee area. Pain and anti-inflammatory medications are provided as needed to keep you comfortable.
- You are advised to keep your leg elevated while resting to prevent swelling and pain.
- You will be given assistive devices such as crutches with instructions on restricted weight-bearing for a specified period of time. You are encouraged to walk with assistance as frequently as possible to prevent blood clots.
- Instructions on surgical site care and bathing will be provided to keep the wound clean and dry.
- Refrain from strenuous activities for the first few months and lifting heavy weights for at least 6 months as it can stress the knee. A gradual increase in activities is recommended.
- An individualized physical therapy protocol will be designed to help strengthen the knee muscles and optimize knee function.
- You will be able to resume your normal daily activities in a couple of months, but with certain activity restrictions. Full recovery and return to sports usually take about 9 to 12 months.
- You may return to your work in about 6 weeks if your job is not too physically demanding. Those with physically demanding jobs will require a longer recovery period.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Iliotibial band tenodesis surgery is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Knee stiffness
- Pain and weakness in the knee
- Adverse reactions to anesthesia
- Blood clot or deep vein thrombosis
- Damage to adjacent soft tissue structures
- Limited range of motion
- Risk of graft failure
- Risk of lateral compartment osteoarthritis