Iliotibial band in ACL reconstruction offers a biomechanically sound, efficient approach to revision ACL surgery with added rotational control.
ACL reconstruction using the iliotibial band (ITB) is gaining attention as a biomechanically robust and versatile option, especially in revision cases. Recent insights from Outside-In Anterior Cruciate Ligament Revision and the systematic review Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction confirm its efficacy and functional value. These studies, led by Prof. Étienne Cavaignac and his team, offer evidence-based guidance on ITB use in ACL surgery.
ACL reconstruction, iliotibial band technique, was initially overshadowed by hamstring and patellar tendongrafts, despite strong mechanical properties. However, recent clinical findings demonstrate its value. In a study lead by Prof. Cavaignac and his pears and titled Iliotibial band autograft is a suitable alternative graft for anterior cruciate ligament reconstruction: a systematic review and meta-analysis of outcomes, the graft failure rate was just 4.2%,comparable to traditional options.
This technique uses the ITB as a pedicled graft, preserving its attachment to the Gerdy tubercle and supporting biological integration through maintained vascularisation. It also allows the combination of ACL reconstruction and lateral tenodesis in one procedure, improving rotational stability: a key challenge in revision cases.
ACL reconstruction with iliotibial band involves a 15-cm graft harvested through a lateral approach, tubularised using internal bracing (FiberTape®, Arthrex). An outside-in femoral tunnel is drilled at the Krackow F9 isometric point, reducing tunnel overlap risk and preserving the existing bone structure.
Tibial fixation is secured with an interference screw and an anteromedial cortical suspensory system. When needed, the gracilis tendon can be added to increase graft volume.
This approach enables single-stage revision surgery with both intra-articular and extra-articular control, combining mechanical efficacy with surgical efficiency.
The use of the iliotibial band in ACL surgery is supported by strong outcomes. Among the key results:
· Low failure rate: Only 4.2% of patients experienced a graft failure after surgery. In other words, the vast majority of reconstructed ligaments remained strong over time.
· Good knee stability: On average, the operated knee moved just 1.4 mm more than the other knee, a very small difference that suggests solid stability. 79% of patients had less than 3 mm of difference, which is considered an excellent result.
· Clinical tests were reassuring: After surgery, the Lachman and pivot-shift tests (both used to assess knee stability) were completely normal in 57% to 85% of patients, and close to normal in more than 95%.
· High functional scores: Patients reported excellent function in everyday life, with an average Lysholm score of 93 out of 100, indicating good knee comfort, strength and mobility.
· Return to sport: 89% of patients went back to sports activities and 61% returned to the same level they had before their injury, a strong result for such a serious knee issue.
· Comparable to other techniques: When compared to traditional grafts like the patellar tendon (BPTB), there were no significant differences in outcomes. Stability, graft strength and return to sport were very similar.
These results demonstrate that ITB is not only viable for revision procedures but may also become a strong candidate in primary reconstructions, especially where lateral control is critical.
Like all techniques, for an ACL reconstruction with iliotibial band, the cons are numerous. But there are also a few specific considerations to consider:
However, these risks are largely preventable with proper technique and preoperative planning. Moreover, no major differences were found between ITB and BPTB grafts regarding complication rates.
Combining the biological benefits of a pedicled graft with the mechanical advantages of lateral tenodesis, ACL reconstruction using the iliotibial band stands as an effective and versatile option. The data from Professor Cavaignac’s systematic review and his outside-in surgical technique confirm its suitability in both primary and revision ACL cases.
Professor Étienne Cavaignac offers expert care in complex ACL procedures: combining innovation, precision and a personalised approach to help you return to full function with confidence.
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