Distal iliotibial band lengthening for refractory greater trochanteric pain syndrome

The National Institute for Health and Clinical Excellence (NICE) has issued full guidance to the NHS in England, Wales, Scotland and Northern Ireland on Distal iliotibial band lengthening for refractory greater trochanteric pain syndrome.

# Guidance
Current evidence on the efficacy and safety of distal iliotibial band lengthening for refractory greater trochanteric pain syndrome is inadequate in quantity and quality. Therefore this procedure should only be used in the context of research. Research studies should clearly define patient selection, and outcomes should include measures of function and quality of life.# The procedure

# Indications and current treatments
Greater trochanteric pain syndrome is a disorder that affects the (lateral) side of the hip or hips. Greater trochanteric pain may be associated with inflammation of the trochanteric bursa (also known as trochanteric bursitis). The trochanteric bursa is a small fluid-filled sac that separates the greater trochanter of the femur and the overlying fascia lata to allow smooth movement. Greater trochanteric pain may also be associated with direct injury, tendon damage, infection, differences in leg length or hip-replacement surgery.
Greater trochanteric pain syndrome is usually managed conservatively with rest, physiotherapy, anti-inflammatory medication and corticosteroid injections. In patients refractory to conservative treatment, surgical options such as bursectomy or supratrochanteric fasciotomy may be used.

# Outline of the procedure
The aim of distal iliotibial band lengthening for refractory greater trochanteric pain syndromeis to relieve the pressure between the greater trochanter and the fascia lata by lengthening the iliotibial band (a thickened and reinforced part of the fascia lata which runs longitudinally throughout its length).
Distal iliotibial band lengthening for greater trochanteric pain syndrome is carried out with the patient under local or general anaesthesia. Through a short lateral incision above the knee a 'Z' lengthening of the iliotibial band of approximately 1.52 cm is performed. The fascia is repaired with sutures.
Sections 2.3 and 2.4 describe efficacy and safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the overview.

# Efficacy
A case series of 11 patients reported a mean Harris hip score of 61 before the procedure and 91 at a mean 43-month follow-up (the Harris hip score measures functional ability, hip dynamics and range of movement on a scale from 0 to 100, in which a higher score indicates a better health outcome).
The case series of 11 patients reported a mean pain score (measured on a scale from 0 to 100; a higher score indicates worse pain) of 83 before the procedure and 13 at a mean follow-up of 43 months.
A case series of 12 patients reported a significant increase in mean EQ-5D score (a standardised assessment of mobility, self care, usual activities, pain and/or discomfort and anxiety and/or depression; a higher score indicates a better health outcome) from 0.26 before the procedure to 0.67 at a mean 28-month follow-up (p < 0.005).
The Specialist Advisers expressed doubt about the conceptual mechanism of action of this procedure. They listed key efficacy outcomes as pain relief, patient satisfaction, hip function (measured using the isokinetic strength Harris hip score) and quality of life (measured using SF-36 or Euroqol scores).

# Safety
Seroma was reported in 1 patient in the case series of 11 patients (timing of event not stated): this was successfully treated by surgical drainage.
The Specialist Advisers considered that loss of strength in the lower limb was a theoretical adverse event.# Further information
For related NICE guidance see our website.

# Information for patients
NICE has produced information on this procedure for patients and carers ('Understanding NICE guidance'). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedure guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS. It is for healthcare professionals and people using the NHS in England, Wales, Scotland and Northern Ireland, and is endorsed by Healthcare Improvement Scotland for implementation by NHSScotland.
This guidance was developed using the NICE interventional procedure guidance process.
We have produced a summary of this guidance for patients and carers. Information about the evidence it is based on is also available.
Changes since publication
January 2012: minor maintenance.
Your responsibility
This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
Copyright
 National Institute for Health and Clinical Excellence 2011.  All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
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