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[i] Summary

Abstract of the article Stetzelberger VM, Nishimura H, Hollenbeck JF, Garcia A, Brown JR, Schwab JM, Philippon JM, Tannast M (2024). The authors found low ligamentum capitis femoris (LCF) strength in patients with femoroacetabular impingement. A Russian translation is available at this link: 2024StetzelbergerVM_TannastM.

Background: Intraarticular hip pain represents a substantial clinical challenge, with recent studies implicating lesions in the ligamentum teres as potential contributors. Even more so, damage to the ligamentum teres is particularly prevalent among young patients undergoing joint-preserving interventions. Although several studies have investigated the biomechanical attributes of the ligamentum teres, inconsistencies in reported findings and reliance on cadaveric or animal models have raised concerns regarding the extrapolation of results to clinical practice. Furthermore, there is a lack of research examining ligamentum teres biomechanics specifically within the relevant patient cohort-individuals who benefit from joint-preserving surgical interventions.

Questions/purposes: We sought (1) to determine the biomechanical properties (ultimate load to failure, tensile strength, stiffness, and elastic modulus) of fresh-frozen ligaments from patients undergoing surgical hip dislocation, and (2) to identify patient-specific factors that are associated with them.

Methods: This was an institutional review board-approved study on intraoperatively harvested ligamentum teres from 74 consecutive patients undergoing surgical hip dislocation for joint preservation (August 2021 to September 2022). After the exclusion of patients with previous surgery, posttraumatic deformities, avascular necrosis, slipped capital femoral epiphysis, and Perthes disease, 31 ligaments from 31 patients were analyzed. The mean age of the study group was 27 ± 8 years, and 61% (19) of participants were male. The main indication for surgery was femoroacetabular impingement. Standardized AP pelvic and axial radiographs and CT scans were performed in all patients for better radiological description of the population and to identify associated radiological factors. The ligament was thoroughly transected at its origin on the fossa acetabuli and at the insertion area on the fovea capitis and stored at -20°C until utilization. Specimens were mounted to a materials testing machine via custom clamps that minimized slippage and the likelihood of failure at the clamp. Force-displacement and stress-strain curves were generated. Ultimate failure load (N), tensile strength (MPa), stiffness (N/mm), and elastic modulus (MPa) were determined. Using a multivariate regression analysis and a subgroup analysis, we tested demographic, degenerative, and radiographic factors as potential associated factors.

Results: The ligamentum teres demonstrated an ultimate load to failure of 126 ± 92 N, and the tensile strength was 1 ± 1 MPa. The ligaments exhibited a stiffness of 24 ± 15 N/mm and an elastic modulus of 7 ± 5 MPa. After controlling for potential confounding variables like age, fossa/fovea degeneration, and acetabular/femoral morphologies, we found that female sex was an independent factor for higher tensile strength, stiffness, and elastic modulus. Excessive femoral version was independently associated with lower load to failure (HR 122 [95% CI 47 to 197]) and stiffness (HR 15 [95% CI 2 to 27]). Damage to the acetabular fossa was associated with reduced load to failure (HR -93 [95% CI -159 to -27]).

Conclusion: Overall, the ligamentum teres is a relatively weak ligament. Sex, degeneration, and excessive femoral version are influencing factors on strength of the ligamentum teres. The ligamentum teres exhibits lower strength compared with other joint-stabilizing ligaments, which calls into question its overall contribution to hip stability.

Clinical relevance: Young patients undergoing hip-preserving surgery are the population at risk for ligamentum teres lesions. Baseline values for load to failure, tensile strength, elastic modulus, and stiffness are needed to better understand those lesions in this cohort of interest.


Illustrations

 

 Fig. 1 Patient selection is shown using a flowchart diagram.


Fig. 2 This figure demonstrates the intraoperative ligament harvesting. (A) The ligament is resected at its origin on the transverse ligament and (B) at its origin on the fovea capitis of the femur.

 

Fig. 3 The graph displays the typical load-displacement curve of the ligamentum teres. 


 Fig. 4.1 The forest plot shows load-to-failure values in the present study compared with other ligaments from the evidence. (A) Isolated ligament [1, 3, 4, 7, 8-10, 12, 17, 22, 24, 27, 29, 31, 32, 35-37, 47, 48]. (B) The forest plot shows tensile strength values in the present study compared with other ligaments from the evidence [3, 8, 17, 27, 29, 30, 32, 33, 36, 37, 52]. 


Fig. 4.2 The forest plot shows load-to-failure values in the present study compared with other ligaments from the evidence. (C) The forest plot shows stiffness values in the present study compared with other ligaments from the evidence [4, 7, 8-10, 12, 17, 22, 24, 27, 29, 30, 32, 35, 36, 47, 48]. (D) The forest plot shows elastic modulus values in the present study compared with other ligaments from the evidence [1, 7, 8, 9, 22, 27, 29, 31, 33, 36, 37, 52].

 

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Stetzelberger VM, Nishimura H, Hollenbeck JF, Garcia A, Brown JR, Schwab JM, Philippon JM, Tannast M. How strong is the ligamentum teres of the hip? A biomechanical analysis. Clinical Orthopaedics and Related Research. 2024;482(9)1685-95. pubmed.ncbi.nlm.nih.gov , journals.lww.com , ovid.com ;  

PMID: 39158387 ; PMCID: PMC11343551 ; DOI: 10.1097/CORR.0000000000003124

Copyright © 2024 by the Association of Bone and Joint Surgeons.


The work is cited in the following publications: К вопросу о прочности LCF.


Vera M Stetzelberger  – Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO, USA ; Department of Orthopaedic Surgery and Traumatology, HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland

Haruki Nishimura – Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO, USA. 

Justin F M Hollenbeck – Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO, USA. 

Alexander Garcia – Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO, USA. 

Justin R Brown – Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO, USA. 

Joseph M Schwab – Department of Orthopaedic Surgery and Traumatology, HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland.

Marc J Philippon – Steadman Philippon Research Institute, The Steadman Clinic, Vail, CO, USA. 

Moritz Tannast – Department of Orthopaedic Surgery and Traumatology, HFR Cantonal Hospital, University of Fribourg, Fribourg, Switzerland.


ligamentum capitis femoris, ligamentum teres, ligament of head of femur, role, pathology, impingement, properties, strength, mechanical properties


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1176-1178(a)Rambam

  Fragments from the book Rambam. Mishneh Torah. Sefer Shofetim, Negative Mitzvot (1176-1178). The treatise Mishneh Torah – legal code, work of Jewish law, its parts Sefer Shofetim (Kings and Wars) and Negative Mitzvot ( Negative Commandments ) was written between about 1176-1178 years in Egypt ( 1sefaria.org , 2sefaria.org ). The author mentions the pathology of ligamentum capitis femoris (LCF, גיד) in humans and points out the presence of this structure in animals.  See our commentary at the link:   1176-1178(a)Rambam [Rus]. Quote 1. [Heb] Mishneh Torah. Sefer Shofetim, 9.1 (original source:  sefaria.org ) Quote 2. [Heb] Mishneh Torah. Negative Mitzvot, 183 (original source:  sefaria.org ) Translation Quote 1. [Eng] Mishneh Torah. Laws of Kings and Wars (The Book of Judges ) , 9.1-3 9.1 Adam, the first man, was commanded with six commandments: 1) idolatry, 2) “blessing” (euphemistically) the Name (of G-d), 3) murder, 4) illicit sexual relations, 5) thievery...
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