The iliotibial band revisited: surgical anatomy and imaging-based guidelines for lateral tenodesis in ACL reconstruction

To provide an updated, clinically oriented review of the iliotibial band (ITB), emphasizing its surgical anatomy, biomechanical relevance, imaging correlates, and role in knee ligament reconstruction, with a focus on lateral extra-articular tenodesis (LET) and anterior cruciate ligament (ACL) augmentation.

A structured narrative review was conducted, summarizing anatomical, biomechanical, radiological, clinical, and surgical literature. Key elements included gross and histological anatomy of the ITB, its relationship with Kaplan fibers and anterolateral capsulo-fascial structures, imaging assessment using MRI and ultrasound, and evidence supporting ITB-based procedures in selected ACL reconstruction settings.

The ITB functions as both a passive and dynamic stabilizer of the lateral knee and contributes to control of internal tibial rotation, particularly in ACL-deficient or high-risk knees. Its deep capsulo-osseous component, including the Kaplan fibers, forms part of the broader anterolateral restraint system. MRI and ultrasound may support anatomical correlation and evaluation of associated lesions, but imaging findings should be interpreted as complementary to clinical assessment rather than as independent determinants of LET indication. In selected high-risk populations, including young pivoting-sport athletes, revision ACL patients, and patients with generalized laxity, ITB-based LET has been associated with improved rotatory control and reduced graft failure risk when appropriate tensioning principles are respected.

The ITB is a clinically relevant anatomical and biomechanical structure in contemporary ACL reconstruction. Its layered architecture and relationship with Kaplan fibers help explain the rationale for selective LET augmentation. Current evidence supports ITB-based LET as an adjunct in appropriately risk-stratified patients, while imaging should be viewed as supportive for anatomical correlation and associated pathology rather than as a stand-alone basis for surgical decision-making.

V (Narrative review).