Interventional procedure consultation document

Distal iliotibial band lengthening for refractory greater trochanteric pain syndrome

Treating greater trochanteric pain syndrome by lengthening the iliotibial band

The greater trochanter is the bony bump on the outer side of the hip. This area may become painful following hip surgery or as a result of inflammation of the fluid-filled sac (bursa) that allows smooth motion between bones and tendons or muscles. Such inflammation (bursitis) is often caused by minor repetitive trauma or a direct injury.

This procedure aims to relieve the pressure on the bursa by lengthening the fibrous band that runs along the outside of the thigh from the hip to the knee (iliotibial band).

The National Institute for Health and Clinical Excellence (NICE) is examining distal iliotibial band lengthening for refractory greater trochanteric pain syndrome and will publish guidance on its safety and efficacy to the NHS in England, Wales, Scotland and Northern Ireland. NICE’s Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisers, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about distal iliotibial band lengthening for refractory greater trochanteric pain syndrome.

This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

• comments on the provisional recommendations
• the identification of factual inaccuracies
• additional relevant evidence, with bibliographic references where possible.

Note that this document is not NICE’s formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that NICE will follow after the consultation period ends is as follows.

• The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
• The Advisory Committee will then prepare draft guidance which will be the basis for NICE’s guidance on the use of the procedure in the NHS in England, Wales, Scotland and Northern Ireland.

For further details, see the Interventional Procedures Programme manual, which is available from the NICE website (www.nice.org.uk/ipprogrammemanual).

NICE is committed to promoting through its guidance race and disability equality and equality between men and women, and to eliminating all forms of discrimination. One of the ways we do this is by trying to involve as wide a range of people and interest groups as possible in the development of our guidance on interventional procedures. In particular, we aim to encourage people and organisations from groups in the population who might not normally comment on our guidance to do so. We also ask consultees to highlight any ways in which draft guidance fails to promote equality or tackle discrimination and give suggestions for how it might be improved. NICE reserves the right to summarise and edit comments received during consultations, or not to publish them at all, where in the reasonable opinion of NICE, the comments are voluminous, publication would be unlawful or publication would otherwise be inappropriate.

Closing date for comments: 28 September

Target date for publication of guidance: January 2010

1 Provisional recommendations

1.1 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.

2 The procedure

2.1 Indications and current treatments

2.1.1 Greater trochanteric pain syndrome is a disorder that affects the (lateral) side of the hip or hips. Greater trochanteric pain may be associated with overuse and with inflammation of the trochanteric bursa, a small fluid sac that separates the greater trochanter of the femur and the overlying fascia lata to allow smooth movement (also known as trochanteric bursitis). Greater trochanteric pain may also be associated with direct injury, tendon damage, infection, differences in leg length or hip-replacement surgery.

2.1.2 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.

2.2 Outline of the procedure

2.2.1 The aim of distal iliotibial band lengthening for refractory greater trochanteric pain syndrome is 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).

2.2.2 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 1.5–2 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, available at www.nice.org.uk/IP826overview

2.3 Efficacy

2.3.1 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 of 0–100, in which a higher score indicates a better health outcome).

2.3.2 The case series of 11 patients reported a mean pain score (measured on scale from 0–100; higher score indicates worse pain) of 83 before the procedure to 13 at a mean follow-up of 43-months.

2.3.3 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 mean 28-month follow-up (p < 0.005).

2.3.4 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).

2.4 Safety

2.4.1 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.

2.4.2 The Specialist Advisers considered that loss of strength in the lower limb was a theoretical adverse event.

3 Further information

3.1 For related NICE guidance see www.nice.org.uk

Bruce Campbell

Chairman, Interventional Procedures Advisory Committee

August 2010

_{Personal data will not be posted on the NICE website. In accordance with the Data Protection Act names will be anonymised, other than in circumstances where explicit permission has been given.}

_{It is the responsibility of consultees to accurately cite academic work in order that they can be validated.}