this ppt provides a comprehensive review & exam oriented details compiled from journals & old edition textbooks. because ITB contracture has become a rare presentation. & new edition books doesnt speak about it much...

1. PRESENTER : DR VENKATESH V
MODERATOR : DR SAGAR B G
1

2.  A Fibrous Thickening Of The Fascia Lata That
Extends From The Iliac Crest Down The
Lateral Part Of The Thigh To The Lateral
Condyle Of The Tibia And That Provides
Stability To The Knee And Assists With
Flexion And Extension Of The Knee
2

3.  Origin : It originates at the
anterolateral portion of the
external lip of the iliac crest due to
condensation of the fascia lata.
 Fibers converging from TFL & gluteus
maximus forms the ITB
 Insertion : inserts at the lateral condyle of
the tibia at Gerdy's tubercle.
3

4.  The action of the ITB and its associated
muscles is to extend, abduct,
and laterally rotate the hip. In addition, the
ITB contributes to lateral knee stabilization.
 During knee extension the ITB moves anterior
to the lateral condyle of the femur,
 while 30 degrees knee flexion, the ITB moves
posterior to the lateral condyle.
4

5.  The IT band stabilizes the knee both in
extension and in partial flexion, and is
therefore used constantly during walking and
running.
 static standing position : due to the normal
tension in ITB , the proximally it lies over or
post to GT keeps hip in extension,
And at knee it lies anterior to knee joint and
keeps knee extension.
5

6.  During locomotion : Swing phase : the ITB
and pull of the TFL are anterior to the greater
trochanter and axis of hip flexion/extension;
this maintains the hip in flexion.
 During stance phase and pushoff phase of
walking or running, the band is pulled
posteriorly over the greater trochanter as the
hip extends.
6

7.  knee joint = As the knee is flexed past 30°, the
band or tract is pulled posteriorly over the
lateral femoral epicondyle.
 weightbearing increases the
compressive/frictional forces on the GT and
lateral femoral condyle.
 Increases the lateral distractive forces on the
patella (encouraging subluxation) and to the
proximal tibia (encouraging tibial external
rotation)
7

8.  ITB contracture causes bony changes during
period of growth.
 Deformity can reduce the effectiveness of a
muscle. Ex – hip flexion contracture the
action other group of Mm like gluteii is also
affected
8

9.  Involvement of the attached muscles is
responsible for increased tension.
 The taut band is perceived by deep palpation
while adducting & extending the thigh.
 Hence pt assumes position of ease = flexion
+ abd + ext rotn + knee flexn.
9

10.  Genu valgum & flexion of knee : compressive
forces acting on the outer half of epiphysis
plate probably retard the lateral growth plate.
 also the band due to
contracture moves posteriorly
causing knee flexion and abduction
force producing valgus
10

11.  External rotation of tibia : lowest fibers are
obliquely downwards & forwards to insert on
tibia (antero laterally).
 Shortening due to compression forces on
distal femur & upper tibia.
11

12.  Flexion+abduction + external rotation of hip
 Genu valgum & flexion contracture of knee
 Limb length discrepancy
 External tibial torsion+ with or without knee joint
subluxation
 pelvic obliquity
 Increased lumbar lordosis
 Equino-varus deformity.
12

13. Pelvic obliquity :
A, In abduction contracture
of hip, spine remains
straight and pelvis level as long
as hip is in abduction. B, When
hip with abduction contracture is
brought into weight bearing position,
pelvis must assume oblique
position, causing scoliosis of
lumbar spine.
13

14.  Affected limb in abd + app lengthened
 Normal limb in add + app shortening
 During walking pt has to widely abduct the
shortened limb to take a step ahead.
14

15. 15

16.  Equino varus deformity :: due to the external
tibial torsion = ankle & knee are not in axis =
which during correction if not corrected/ if
the compensation not corrected by the
orthoses = torsion force results in equino-
varus position.
16

17.  Hip dislocation secondary to contracture
Imbalance between abd + ext rotator & flexor
+ int rotator.
Due to the abductor weakness GT growth
contributes minimally. Head keeps growing
vertically = which pressurizes acetabulum ,
stretches capsule leads to dislocation.
17

18.  Diagnostic tests :
 Noble Compression Test :
18

19.  OBER’S TEST :
19

20.  Renne test :
20

21. 21

22.  Prevention of contracture in early stages :
 HIP : in neutral rotation + slight abduction +
No flexion
 To prevent rotation a bar lllr to DB splint can
be used with slight internal rotation.
22

23.  If early contracture recognized = do a simple
release with release of lateral intermuscular
septa
 In recurrence =To do soutter’s release.
 Knee roll to prevent genu recurvatum
deformity.
23

24.  WELL LEG TRACTION :
24

25. 25

26. 26

27.  Complete Hip Release of a Flexion,
Abduction, and External Rotation Contracture
 By yount’s procedure :
 lateral position, make a transverse incision
medial and distal to the anterior superior iliac
spine, extending it laterally above the greater
trochanter
27

28.  Divide the iliopsoas tendon distally
 Detach the sartorius from ASIS
 Detach the rectus from AIIS
 Divide the tensor fasciae latae from its
anterior border
 Detach the gluteus medius and minimus and
the short external rotators from their
insertions
 Retract the sciatic nerve posteriorly, then
open the hip capsule from anterior to
posterior
28

29.  For the Yount procedure, expose the fascia
lata through a lateral longitudinal incision
just proximal to the femoral condyle.
 Divide the iliotibial band and fascia lata
posteriorly to the biceps tendon and at a level
2.5 cm proximal to the patella.
 At this level, excise a segment of the iliotibial
band and lateral intermuscular septum 5 to 8
cm long.
29

30. 30

31.  Cut the origin of TFL, G medius and minimus
muscles subperiosteally from the wing of the
ilium
 Free the proximal part of the sartorius
 Free subperiosteally the attachments of the
abdominal muscles from the iliac crest
 Strip the iliacus muscle subperiosteally from
the inner table
31

32.  Free the straight and reflected tendon of
rectus femoris
 Releasing these contracted structures often
allows the hip to be hyperextended without
increasing the lumbar lordosis; this is an
important point because in this situation
correction may be more apparent than real.
32

33.  After the deformity has been completely
corrected, resect the redundant part of the
denuded ilium with an osteotome
 Suture the abdominal muscles to the edge of
the gluteal muscles and tensor fasciae latae
over the remaining rim of the ilium with
interrupted sutures.
33

34.  Redundant part of ilium is resected.
34

35.  SHARRARD PROCEDURE :
 Releasing the IP tendon from
LT
 Release the sartorius,
Rectus femoris from insertion
 Make a hole through the
iliac wing just lateral to the
sacroiliac joint.
35

36.  Release IP tendon & iliacus
Muscle from the origin
 Pass the iliopsoas
tendon and
the entire iliacus muscle
through the hole
36

37.  With awls and burs and from anteriorly to
posteriorly, make a hole through the greater
trochanter until it is big enough to receive the
tendon.
 pass the end of the tendon from posteriorto
anterior through the tunnel in the greater
trochanter
37

38.  Create a gutter or notch
In the iliac wing lateral to
SI joint.
And transfer only the IP tendon
By retaining the iliacus inside the
Pelvis
38

39. 39

40.  Sartorius, rectus Femoris is released.
 A notch is created between ASIS & AIIS
 Iliopsoas tendon is passed in this notch &
secured in the greater trochanter.
40

41.  Management of dislocated hip :
 Early – Closed reduction
 Late – contracture is severe = tenotomy +
skeletal traction in 300= wait till head comes
down till Acetabulum.
- correct muscle imbalance by tendon
transfer.
Acetabuloplasty – salters, pemberton & chiari.
41

42.  Subtrochanteric osteotomy on the normal
limb
 Heavy steinmann pin placed just below GT
 Below this a wedge of bone is removed with
the base on the lateral cortex – spica for 4
weeks.
 After that a wedge is cut on lateral side then
abducted & immobilized for 4 weeks.
42

43.  Gmax is the major extensor of hip
 Paralysis leads to pelvis inclination forward &
causes flexion contracture.
 Rx: ITB is approached by 2 incisions through
first incision near supracondylar region ITB is
cut T/S & a strip is separated which is passed
subcutaneously proximally to the 2nd incision
on lateral proximal thigh .
43

44.  Gutter is created in the V lateralis muscle
plane . & transferred ITB is sutured including
V Lat.
 3rd incision put on lateral to the spinus
process of lumbar 4th 5th & sacrum medial to
PSIS.
 Erector spinae is freed from medial 1/3rd
from lateral 2/3rd
44

45.  The lateral 2/3rd is mobilized and sutured to
subcutaneously passed ITB.
 Suturing has to be done in hip extension &
tension.
45

46.  Soutters release = according to soutter “1926
 He wrote when long standing cases are not
amenable to tenotomies then myotomies are
considered.
 Structures released = FL from anterior to post
 Muscles & fascia attached to ASIS is
subperiosteally released and pushed downwards.
 Here the muscles are not cut across its just
moved downwards.
46

47.  Hamstring lengthening & hamstring transfer
to the distal femur condyle (posteromedially
& posterolaterally )
 Medial & lateral patellar retinacular release
 Disadvantages of the procedure : loss of
active knee flexion
Development of genu recurvatum
47

48.  Thank u !!!!
48