Journal of Orthopaedics, Trauma and Rehabilitation 25 (2018) 54e57

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Journal of Orthopaedics, Trauma and Rehabilitation

Journal homepages: www.e-jotr.com & www.ejotr.org

Case Report

Iliotibial band impingement by overhanging tibial tray: A pain

generator after total knee replacement treatable without revision
Ka-Bon Kwok*, Jason Chi-Ho Fan, Yuk-Wah Hung, Alexander Pak-Hin Chan,
Tsz-Wan Chow Bernard, Lawrence Chun-Man Lau
Department of Orthopaedics and Traumatology, Alice Ho Miu Ling Nethersole Hospital, Hong Kong

a r t i c l e i n f o a b s t r a c t

Article history: Soft-tissue impingement can cause disabling pain after total knee arthroplasty. We report a case of
Received 13 August 2017 painful crepitus over Gerdy's tubercle after total knee replacement. Iliotibial band impingement by
Received in revised form overhanging tibial tray was diagnosed. The symptom persisted despite physiotherapy and local corti-
23 October 2017
costeroid injection. A combined arthroscopic and open approach was used to excise intraarticular
Accepted 6 December 2017
scarring and release the impinged iliotibial band. The painful crepitus was resolved instantaneously
without recurrence at 3 year follow-up. Morbidity associated with component revision has been avoided.
Keywords:
iliotibial band
impingement
knee arthroscopy
中 文 摘 要
pain
total knee arthroplasty 全膝關節置換術後軟組織夾擠可導致疼痛。 我們報告了一宗全膝關節置換後捷耳弟氏(Gerdy's)結節疼痛的病
例，其後診斷為脛骨部件突出所致的髂脛帶夾擠 。症狀於物理治療和局部皮質類固醇注射後持續。我們使用
了聯合關節鏡和開放方法來消除關節內瘢痕並釋放鬆了髂脛帶。疼痛於術後即刻解獲舒緩，並在3年隨訪覆
查時無復發。這技術避免了關節翻換及其相關問題。

Introduction over lateral aspect of knee since 1 month after the operation
(Figure 1). Physical examination showed tenderness at Gerdy's
Despite the clinical success of total knee replacement, there tubercle. The range of motion was 5e110 with crepitus felt at
remain 20% of patients not satisfied with the operation.1 Persistent around Gerdy's tubercle upon flexion and extension. Noble's test
pain after total knee replacement remains a challenging condition was performed to verify the clinical suspicion of iliotibial band
because of difficulty in identifying the underlying cause. Soft-tissue syndrome. It began with supine position with the knee flexed at
impingement is a category of causes that is amenable to non- 90 . Direct pressure was applied to the Gerdy's tubercle, and the
revision procedures.2e4 We report a case of iliotibial band knee was gradually extended. Pain was reproduced at 30 flexion. It
impingement due to overhanging tibial tray which has not been confirmed the pain origin was iliotibial band.
reported in the literature. Combined open iliotibial band release White cell count, C-reactive protein and erythrocyte sedimen-
and arthroscopic excision of scar was performed. The component tation rate were all normal. Scannogram revealed the mechanical
was retained with complete symptom resolution. tibiofemoral angle was 4 valgus (Figure 2A). X-ray showed over-
hang of tibial tray over lateral tibial plateau (Figures 2B and 2C).
Case report Computer tomography scan confirmed the tibial tray was over-
hanged at the direction of Gerdy's tubercle for 3 mm beyond the
Left total knee replacement (Genesis II®, Smith and Nephew, cortex (Figure 2D). It was flushed with medial cortex. The rotation
Memphis, TN, USA) was performed for a 73-year-old woman with was neutral with reference to Akagi's line, which was the line
osteoarthritis of knee. The mechanical tibiofemoral angle was 3 connecting middle of posterior cruciate ligament insertion to
valgus preoperatively. During operation the lateral soft tissue was medial border of patellar tendon insertion (Figure 2E). Operative
not tight without the need for release. She had complained of pain record was retrieved. The femoral and tibial components used were
size 4 and 3, respectively.
Injection of local anaesthesia and steroid at Gerdy's tubercle was
* Corresponding author. Alice Ho Miu Ling Nethersole Hospital, 11 Chuen On done to confirm the diagnosis of iliotibial band impingement and as
Road, Tai Po, Hong Kong. E-mail: [email protected].

https://doi.org/10.1016/j.jotr.2017.12.001
2210-4917/Copyright © 2017, Hong Kong Orthopaedic Association and the Hong Kong College of Orthopaedic Surgeons. Published by Elsevier (Singapore) Pte Ltd. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 K. Ka-Bon et al. / Journal of Orthopaedics, Trauma and Rehabilitation 25 (2018) 54e57 55

first performed to prevent leakage of irrigation fluid after open

surgery. Anterolateral and superolateral portals were established.
Dense fibrous overgrowth at the lateral femoral gutter close to the
prosthetic edge was found. It was debrided with 4.5 mm shaver.
Care was taken not to abrade the component or breach the capsule.
The anterolateral and superolateral portals were alternated as
working and viewing portals to ensure complete debridement. The
rim of tibial tray was revealed at the end of the procedure
(Figure 3).
Open iliotibial band release was then performed. A 3 cm oblique
incision was made over Gerdy's tubercle. A 7 cm skin bridge should
be present from the previous incision to avoid skin bridge necrosis.
After incising subcutaneous fat, iliotibial band was identified. The
impingement was confirmed by noting crepitus upon passive
flexion and extension of knee.
Complete excision of the impinging part of iliotibial band
throughout the whole range of motion is essential for complete
symptomatic relief. A triangular flap of iliotibial band excision
was fashioned. Anterior and posterior borders were labelled with
marker pen with the knee at end extension and flexion, respec-
tively. The flap was then excised without breaching the capsule.
Complete excision was double checked by moving the knee
through complete range to note any residual crepitus. Any re-
Figure 1. Preoperative film of left knee. (A)The mechanical tibiofemoral angle was 3 sidual impinged fascia was further excised. The fascial defect was
valgus; (B and C) there was osteoarthritis mainly involving medial compartment and not closed to allow remodelling upon healing. The subcutaneous
patellofemoral compartment. fat and skin were closed with Vicryl 2O and Nylon 3O, respec-
tively (Figure 4).
a trial of conservative treatment. She was referred to physiothera- Postoperative rehabilitation began immediately after operation.
pist for iliotibial band stretching exercise. There was transient Patient was allowed to walk with full-weight bearing on the
improvement with symptom recurrence 1 month after the injec- operated limb. Immediate active and passive range of motion was
tion test. Combined arthroscopic excision of scar and open iliotibial initiated. Gradual stretching of iliotibial band was started after
band release was decided. stitch removal at second week.

Surgical technique Outcome

The patient was positioned supine with tourniquet applied. Side The painful crepitus resolved immediately after operation. The
bump was placed proximal enough to avoid interference with patient was last seen at 3 years after operation. There was no
instrumentation through superolateral portal. Arthroscopy was recurrence of pain or crepitus. The range of motion was 0e120 . The

Figure 2. X-ray at 1 month after operation. (A) The mechanical tibiofemoral angle was 4 valgus; (B) X-ray showed overhang of tibial tray at lateral; (C) the implant was well
positioned at lateral view; (D) computer tomography confirmed overhang of tibial tray was over Gerdy's tubercle for 3 mm beyond lateral cortex. It was flush with medial cortex; (E)
the rotation of tibial tray was neutral with respect to Akagi's line.
56 K. Ka-Bon et al. / Journal of Orthopaedics, Trauma and Rehabilitation 25 (2018) 54e57

be the pain origin after total knee replacement but through a

different mechanism. Luyckx et al. reported a series of iliotibial
band traction syndrome with the use of a cruciate retaining, guided
motion prosthesis (Journey®, Smith and Nephew, Memphis, TN,
USA)6. The asymmetric cam and post mechanism caused excessive
anterior translation and internal rotation of the tibia. The iliotibial
band was repetitively stretched and caused pain. In this case, the
prosthesis used (Genesis II®, Smith and Nephew, Memphis, TN,
USA) has a posterior stabilising design without such abnormal
Figure 3. Knee arthroscopy was first performed. (A) Dense fibrous overgrowth was biomechanics. The iliotibial band was impinged directly by the
found over lateral compartment; (B) debridement was done using 4.5 mm shaver; (C) overhanging tibial tray.
after thorough debridement tibial tray was revealed.
Tibial tray overhang is associated with increased pain and
inferior outcome after total knee replacement.7 Reported causes
include use of symmetrical tibial tray, excessive component
external rotation and oversizing. In this case, a tibial tray with
asymmetrical design has been used to optimise the coverage. It was
one size smaller than the femoral component. It has been maxi-
mally medialized with neutral rotational alignment. Despite these
efforts, component overhang still occurred. Diagnosis of lateral
overhang of tibial tray intraoperatively can be difficult as it is
obscured by soft tissue when medial parapatellar approach is used.
The lateral cortical rim of proximal tibial should be thoroughly
palpated to confirm it is flushed with edge of tibial tray. If it was
diagnosed intraoperatively in this case, a tibial tray of further
smaller size could have been used.
Iliotibial band release was first described for the management of
iliotibial band syndrome, which is an overuse injury in long dis-
tance runner and cyclist.8,9 Proposed pathophysiology of iliotibial
band syndrome includes friction of iliotibial band over lateral
femoral condyle, compression of connective tissue underneath and
bursal inflammation. Its therapeutic strategy has been adopted for
management of iliotibial band impingement by implant in this case.
We have used a combined open and arthroscopic approach for two
reasons: First, it ensures thorough debridement for complete
symptom relief. The intraoperative finding of dense fibrous over-
growth at arthroscopy and iliotibial band scarring on open explo-
ration confirmed the necessity of both approaches; second, it
maintains integrity of joint capsule to reduce the risk of peri-
prosthetic infection, which would be a devastating complication.
Figure 4. Open iliotibial band release was followed. (A) The incision is planned such Complete symptomatic relief was finally achieved with revision
that a 7 cm skin bridge is present from the previous midline incision; (B) the triangular arthroplasty avoided.
flap was marked after moving the knee through range of motion; (C) after excision the
knee capsule was preserved to prevent exposure of prosthesis.
In conclusion, we reported a case of lateral knee pain after total
knee replacement caused by iliotibial band impingement by over-
hanging tibial tray. Combined open release and arthroscopic
knee society function score and knee score were 65 and 99, debridement was performed. Symptom was relieved with retention
respectively. of the component. It is an important reversible entity to be iden-
tified among the wide array of causes for pain after total knee
replacement.
Discussion

Soft-tissue impingement can cause disabling pain after total Conflict of interest statement
knee replacement but is amenable to simple operative procedure.
In the literature, reported impinged structures included fabella2, The authors have no conflict of interest to declare.
fat-pad3 and popliteal tendon4. They were all treatable with release
of the impinged structures without the need of revision arthro-
plasty. This case is the first in the literature to have iliotibial band as References
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