Content
Article
by Gill HS. CORR
Insights: How Strong Is the Ligamentum Teres of the Hip? A Biomechanical Analysis (2024). To clarify the role of ligamentum capitis
femoris (LCF), the author recommends a combination of experimental studies with
computer modeling. The text in Russian is available at the following link: 2024GillHS
Where
Are We Now?
Hip
preservation surgery has seen a rapid increase in usage over the last 15 years
[10], in large part driven by the groundbreaking work of Ganz et al. [5], who
described the association between femoroacetabular impingement and hip
osteoarthritis and who also developed effective methods of surgical dislocation
that maintain the blood supply to the femoral head [4]. Arthroscopic methods
have now become established and are seeing wider use. The evidence base for hip
preservation has grown as well, with minmum 10-year follow-up showing decreased
pain and improved function for most patients, and research has identified a
number of risk factors for early reoperation [12]. However, the contribution of
various anatomical structures to overall hip stability is not fully understood.
The ligamentum teres in particular has not been well studied, with most
research on it involving populations who are not representative of those who
undergo hip preservation surgery. This structure is of clinical interest as
lesions in the ligamentum teres are common in patients undergoing hip
preservation surgery, and these lesions have been proposed to be a source of
pain [2].
In the
current issue of Clinical Orthopaedic and Related Research”, Stetzelberger et
al. [11] investigated basic biomechanical properties of the ligamentum teres
from a relevant cohort (mean age 27 + 8 years, 61% [19 of 31] of whom were
male), and they also examined the relationship between these properties and
patientspecific factors. Of the original 74 patients from whom specimens were harvested
intraoperatively, 31 samples were available for biomechanical testing to
establish ultimate load to failure, tensile strength, stiffness, and elastic
modulus. These mechanical properties were found to have rather low values in
comparison with other ligamentous structures, particularly those from the lower
limb. Tensile strength, stiffness, and elastic modulus were also found to be
higher for female patients, and excessive femoral version was associated with
stronger and stiffer ligaments. The findings suggest that the ligamentum teres
is not an important mechanical contributor to overall hip stability. This is
intriguing, as the biomechanical function of the ligament remains elusive, but
there is a relationship between ligament properties and patient sex as well as
with excessive femoral version. It has been suggested that the ligamentum teres
plays a role in neuromuscular control.
Given that it is a relatively weak structure, well within the range of available surgical materials, and lesions in the ligament are possibly a source of pain, surgical reconstruction of the ligament may be a useful adjunct to hip-preserving procedures (see the “Read This Next” section). It is important to balance increased surgical complexity against improvements in outcomes.
Where Do We Need To Go?
The current study [8] has shown that the basic mechanical properties have relatively low values, and some associations with donor factors have been revealed. However, the biomechanical and indeed, the neurological sensing roles, remain unknown. The mechanical property values are in similar ranges to previous cadaveric studies but the tensile strength is lower, and the very limited description of the toe region of the load extension has been given. If proprioception is an important role for the ligament, it would be useful to understand the toe region behavior in greater detail. The current (and previous studies) have applied tensile loads to the structure. Considering the ways in which the mechanical behavior of the ACL has been better understood and with the acceptance of the concept of distinct structural bundles [5], with successive fiber recruitment [10], which is consistent with the theorized proprioceptive function, testing the ligamentum teres under physiological loading scenarios would be important. A limitation of the current paper is the low number of samples tested, and this can be addressed simply.
Where Do We Need To Go?
The current study [8] has shown that the basic mechanical properties have relatively low values, and some associations with donor factors have been revealed. However, the biomechanical and indeed, the neurological sensing roles, remain unknown. The mechanical property values are in similar ranges to previous cadaveric studies but the tensile strength is lower, and the very limited description of the toe region of the load extension has been given. If proprioception is an important role for the ligament, it would be useful to understand the toe region behavior in greater detail. The current (and previous studies) have applied tensile loads to the structure. Considering the ways in which the mechanical behavior of the ACL has been better understood and with the acceptance of the concept of distinct structural bundles [5], with successive fiber recruitment [10], which is consistent with the theorized proprioceptive function, testing the ligamentum teres under physiological loading scenarios would be important. A limitation of the current paper is the low number of samples tested, and this can be addressed simply.
How Do We Get There?
Increasing the sample size and repeating the experiments described by Stetzelberger et al. [8] is needed, and this will enable more nuanced assessments of the patient factors that need to be explored. A limitation of Stetzelberger et al. [8] was the way in which cross-sectional area was estimated; while elegant, this method assumed a cylindrical cross-section. Imaging using lightsheet microscopy [6], or similar technology, will enable the ligamentum teres structure to be resolved in 3D and the cross-sectional area to be directly measured. Obtaining specimens that preserve the connection to the host bones would facilitate experiments to explore the fiber behavior under physiological loading; however, there are considerable challenges in obtaining these types of specimens from living donors. It is important to combine experimental studies with computer modelling similar to the approach taken by Gardiner and Weiss [4] for the MCL, as it is difficult to envisage experiments that can fully replicate physiological loading.
Read This Next
Useful information regarding the distribution of nociceptors in the various structures of hip including the ligament teres is given in Haversath et al.
Brady et al.
provided some guidance regarding tunnel placement for reconstruction of the ligament
teres.
Bajwa and Villar provided a useful editorial
commentary regarding reconstruction.
I recommend reading Gardiner and Weiss [4],
whilst they studied the MCL which can be directly
imaged during loading, their overall approach combined modelling and experimentation to
understand function and loading patterns of a ligament. They found that
representing specimen specific
characteristics was important, and this may well be the case for the hip joint
and the ligament teres.
Bajwa AS, Villar RN. Editorial Commentary:
Arthroscopic Hip Ligamentum Teres Reconstruction-Reality or Mythology?
Arthroscopy. 2018;34:152-154.
Brady AW, Chahla J, Locks R, Mikula JD, Slette EL, LaPrade RF, Philippon MJ. Arthroscopic Reconstruction of the Ligamentum Teres:
A Guide to Safe Tunnel Placement. Arthroscopy. 2018;34:144-151.
Haversath M, Hanke J, Landgraeber S, Herten M, Zilkens C, Krauspe R, Jager M. The distribution of
nociceptive innervation in the painful hip: a histological investigation. Bone
Joint J. 2013;95-B:770-776.
1. Bardakos NV, Villar RN. The ligamentum teres of the adult hip. J Bone Joint Surg Br. 2009;91:8-15.
2. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119-1124.
3. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res. 2003:112-120.
4. Gardiner JC, Weiss JA. Subject-specific finite element analysis of the human medial collateral ligament during valgus knee loading. J Orthop Res. 2003;21:1098-1106.
5. Otsubo H, Shino K, Suzuki D, Kamiya T, Suzuki T, Watanabe K, Fujimiya M, Iwahashi T, Yamashita T. The arrangement and the attachment areas of three ACL bundles. Knee Surg Sports Traumatol Arthrosc. 2012;20:127-134.
6. Poola PK, Afzal MI, Yoo Y, Kim KH, Chung E. Light sheet microscopy for histopathology applications. Biomed Eng Lett. 2019;9:279-291.
7. Sienko A, Ekhtiari S, Khanduja V. The growth of hip preservation as a speciality. Knee Surg Sports Traumatol Arthrosc. 2023;31:2540-2543.
8. Stetzelberger VM, Nishimura H, Hollenbeck JFM, Garcia AR, Brown JR, Schwab JM, Philippon MJ, Tannast M. How Strong Is the Ligamentum Teres of the Hip? A Biomechanical. Clinical Orthopaedics and Related Research. 2024.
9. Vahedi H, Yacovelli S, Diaz C, Parvizi J. Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure. JB JS Open Access. 2021;6.
10. Zavatsky AB, Wright HJ. Injury initiation and progression in the anterior cruciate ligament. Clin Biomech (Bristol, Avon). 2001;16:47-53.
Gill HS. CORR Insights: How Strong Is the Ligamentum Teres of the Hip? A Biomechanical Analysis. Clinical Orthopaedics and Related Research, 2024;482(9)1696-7. DOI: 10.1097/CORR.0000000000003206 ovid.com , purehost.bath.ac.uk
Gill, Harinderjit S. DPhil, DSc - Professor, Department of Mechanical
Engineering, Claverton Down Campus: University of Bath, Claverton Down, Bath,
BANES BA2 7AY, UK, Email: R.Gill @ ath.ac.uk
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, role, strength, mechanical strength, biomechanics
NB! Fair practice / use: copied for the purposes of criticism, review, comment, research and private study in accordance with Copyright Laws of the US: 17 U.S.C. §107; Copyright Law of the EU: Dir. 2001/29/EC, art.5/3a,d; Copyright Law of the RU: ГК РФ ст.1274/1.1-2,7
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