The article by Chen JH, Al’Khafaji I, Ernstbrunner L, O’Donnell J, Ackland D. Joint contact behavior in the native, ligamentum teres deficient and surgically reconstructed hip: A biomechanics study on the anatomically normal hip (2025). The authors experimentally demonstrated the role of the ligamentum capitis femoris (LCF) in unloading the upper sector of the acetabulum and the femoral head. The text in Russian is available at the following link: 2025ChenJH_AcklandD
Joint contact behavior in the native, ligamentum teres deficient and surgically reconstructed hip: A biomechanics study on the anatomically normal hip
CONTENT [i] Abstract [ii] Introduction [iii] Materials and methods [iv] Results [v] Discussion and Conclusion [vi] References [vii] Application |
Background
The ligamentum teres is known to
contribute to hip joint stability; however, the effect of surgical
reconstruction of ligamentum teres tears on hip joint function is poorly
understood. This study aimed to employ a cadaver model to quantify peak pressure,
average pressure, contact force, and contact area between the femoral head and
acetabulum in native, ligamentum teres deficient and reconstructed hips.
Nine fresh-frozen human cadaveric
hips were dissected and mounted to a multi-axis Materials Test System. Digital
pressure sensors were placed on anterior, posterior, and superior regions of
the acetabulum. Joint loading was simulated in 20deg flexion, neutral position,
and 10deg extension. Peak pressure, average pressure, contact force, and
contact area were measured.
Ligamentum teres deficiency
caused a significant increase in average pressure (mean difference:
161.6 kPa, p = 0.002)
in the superior acetabulum of the neutral hip relative to the ligament intact
hip and in peak pressure (mean difference: 1462.5 kPa, p = 0.023) in the anterior
acetabulum of the extended hip compared to the intact hip. Ligamentum teres
reconstruction subsequently restored average and peak pressure to levels not
significantly different from those in the intact state (p > 0.05).
Reconstruction also led to a significant decrease in average pressure (mean
difference 241.0 kPa, p = 0.047)
and contact force (mean difference: 124.5 N, p = 0.039)
in the posterior acetabulum of the flexed hip relative to the intact hip.
Ligamentum teres reconstruction
may help to prevent excessive contact that occurs in the ligamentum teres
deficient hip and may mitigate or slow the onset of degenerative changes
associated with ligamentum teres deficiency.
Keywords
Acetabulum, Ligament reconstruction, Suction seal, Hip arthroscopy, Joint loading, Biomechanical model
1 Introduction
The ligamentum teres is a pyramidal-shaped
intra-articular, extra-synovial ligament (Rosinsky et al., 2020) that attaches
to the rim of the acetabular fossa, near the traverse acetabular ligament, and
the fovea capitis of the femoral head (Mikula et al., 2017). The ligamentum
teres not only serves as a conduit for the vascular supply to the femoral head
epiphysis in the skeletally immature hip (Perumal et al., 2019; Wertheimer and
Lopes Sde, 1971), but it also plays an important role in stabilizing the hip
joint during movements involving both hip flexion and external rotation, as
well as involving both hip extension and internal rotation (Al'Khafaji et al.,
2024; Kraeutler et al., 2016). Furthermore, the ligamentum teres is known to
maintain hip joint congruency, negative intra-articular pressure and the hip
joint suctional seal, with its effect being the most prominent in the neutral
hip position or during hip extension (Al'Khafaji et al., 2024).
Tears of the ligamentum teres are being increasingly
diagnosed in hip arthroscopy and recognized as a common cause of debilitating
hip pain (Pergaminelis et al., 2017). Tearing of the ligamentum teres is the
third most common cause of hip pain in athletes (Byrd and Jones, 2004;
O'Donnell and Arora, 2018), and is known to occur due to hip dislocation or
traumatic twisting of the hip (Lindner et al., 2013). Ligamentum teres tearing
often co-exists along other acetabular or intra-articular hip lesions and is
often diagnosed and managed arthroscopically with other co-existing pathology,
such as acetabular dysplasia, hip microinstability, and femoroacetabular impingement
(FAI) (Pergaminelis et al., 2017). Partial or complete tearing of the
ligamentum teres can compromise hip function and affect activities of daily
living (Gray and Villar, 1997; Kraeutler et al., 2016; O'Donnell and Arora,
2018).
Arthroscopic ligamentum teres reconstruction is a
surgical procedure for patients with complete ligamentum teres tears as well as
hip instability and excessive external hip rotation (Lindner et al., 2013).
Ligament reconstruction can be achieved using a synthetic graft, allograft, a
double-stranded semitendinosus autograft, or an iliotibial band tendon
autograft (Kraeutler et al., 2016). While reconstruction surgery has been shown
to lead to significant improvements in pain and instability symptoms at 12
months (O'Donnell et al., 2020) and 17.7 months after surgery (Pergaminelis et
al., 2017), long-term outcomes have been variable. Complication rates range
from 0 % to 100 % (Knapik et al., 2016), which includes reoperation due to
component failure, lysis of adhesions, pain and conversion to total hip
arthroplasty. At present, the relationship between immediate changes in hip
joint biomechanics and long-term degenerative changes to the hip following
ligamentum teres reconstruction remain poorly understood, as is the extent to which
reconstruction may mitigate load-related degenerative changes at the hip.
The aim of this study was to quantify hip joint
contact pressure, area and force in the native, ligamentum teres deficient, and
surgically reconstructed hips. We hypothesize that ligamentum teres deficiency
increases the contact pressure and contact force while decreases the contact
area compared to the intact cadaveric hip, and ligamentum teres reconstruction
restores these alterations to levels similar to that of the intact hip.
2 Materials and methods
2.1 Specimen preparation
Nine hip specimens were harvested from fresh-frozen cadavers (mean age: 66.6 ± 1.9 yrs., range 59 to 71 yrs.; mean weight: 63.3 ± 13.2 kg). This sample size was sufficient for a study power (>0.8) in detecting statistically significant between-group differences in joint distraction force and stiffness between the intact and ligamentum teres deficient hip (Al'Khafaji et al., 2024). All specimens were radiographically screened for fracture, osteoarthritis, femoroacetabular impingement, previous ligamentum teres or labrum injuries, acetabular dysplasia, and any signs of previous surgery. The femur was transected approximately 160 mm from the greater trochanter and the distal femur removed. The semitendinosus tendon harvested for grafting. The capsule and all extracapsular musculotendinous tissue surrounding the hip joint were removed by sharp dissection to investigate the isolated effect of the ligamentum teres in maintaining hip joint contact. Each hip was dislocated to visualize and confirm the presence an intact and pathology-free ligamentum teres. The ligamentum teres was protected initially, and the labrum left intact. The ligamentum teres was then sharply released from its femoral and acetabular attachments and completely removed from the joint to simulate a complete ligamentum teres tear. The cotyloid soft tissues were left in place. Ethical approval for this study was obtained through the University of Melbourne Human Ethics Advisory Group.
2.2 Ligamentum teres reconstruction surgery
The ligamentum teres was reconstructed in each
specimen using a modification of an established protocol (Amenabar and
O'Donnell, 2012). A double-stranded semitendinosus tendon graft was harvested
and fixed on the posteroinferior and anteroinferior region of the acetabular
fossa and transverse acetabular ligament using suture. Anchors were deferred
given the ease of use of sutures while providing sufficient fixation strength.
With the hip in 30° of external rotation and neutral flexion, the tendon graft
was then pulled through the 6 mm femoral tunnel, and the graft tensioned
manually to 20 Lbf, which was confirmed using a tensiometer. This standardized
ligament tension was modeled on the approximate load applied clinically on the basis
of previous research (Amenabar and O'Donnell, 2012). The graft was then secured
with an interference screw in the femur (Fig. 1). All the procedures were
performed by one qualified orthopaedic surgeon.
 |
| Fig. 1 Radiograph illustrating ligamentum teres reconstruction, including graft, suture, interference screw and tunnel. |
2.3 Biomechanical testing
Hip joint specimens were first tested in the native state, followed by testing in the ligamentum teres deficient state and then after ligamentum teres reconstruction. Digital pressure sensors (Tekscan 4000 thin-film pressure sensors, Tekscan, Inc., USA) were placed into the acetabulum in the anterior, posterior, and superior regions to measure peak pressure, average pressure, contact force and contact area (Fig. 2A-C). Each digital pressure sensor was inserted laterally into the spherical joint space to minimize uneven contact between the articulating surfaces, while also avoiding contact with the ligamentum teres in its intact state. Each sensor measured 33.0 mm height x 27.9 width × 0.1 mm thickness. Separate tests were performed for each of the three sensor positions, and for each of the three hip joint positions i.e., only one sensor was placed in the joint cavity at a time to evaluate hip joint contact behavior for a given hip joint position. The edges of the sensor were carefully trimmed without damage to any of the sensels. This set up ensures the proper fitting of the sensor with the natural congruency of the hip joint cavity to minimize the risk of wrinkling. To minimize the effects of repeated shear and compressive loading on sensor wear and damage, new Tekscan sensors comprising two independent sensing arrays were used for each specimen, and tests alternated between the two sensor arrays. Specimens were then mounted to a two-axis materials test system (Instron, Model 3521, Parker Hydraulics, USA) using a set of customized fixtures. The proximal femur was potted in a hollow block using dental cement and mounted to the upper crosshead of the Instron while the hemipelvis was potted using dental cement and mounted to the lower crosshead of the Instron. Each joint was initially placed in the neutral position and centered prior to testing. Passive translation of the hemipelvis fixture was performed in the transverse plane using adjustable fixtures to ensure that each joint was centered and congruent based on visual inspection and palpation, after which the position of the hemipelvis was locked for subsequent testing (Fig. 2). Specimens were regularly irrigated throughout testing to simulate physiological fluid conditions. This was achieved using a spray-based immersion of the joint articulation approximately once every thirty seconds both before and during joint loading.
 |
| Fig. 2 Experimental setup of the hip joint specimens. A Tekscan 4000 thin-film sensor was placed in the posterior (A), anterior (B) and superior (C) regions of the acetabulum, and loading was undertaken on an Instron machine with the hip in the neutral position (D), as well as in 20° flexion (E) and 10° extension (F). During testing, the femur (Fem) was mounted to the upper cross-head (UCH) of the Instron Materials Test System by embedding it in an upper potting block (UPB) filled with dental cement. The hemipelvis (HP) was embedded in a lower potting block (LPB) filled with dental cement and mounted to a custom fixture (CF). This fixture facilitated positional adjustment in the transverse plane to achieve joint congruency and centering via a series of slots and adjustable locking nuts in the Instron Support Table (IST). The fixture also facilitating locking of the hip at specific joint angles in the flexion-extension plane. |
The upper crosshead of the materials test system, which was instrumented with a 10kN load cell with a precision of 0.2 % of the rated output, was used to apply a concentric compressive load of 100 N between the femoral head and acetabulum. This load was held for 20 s to ensure joint reduction and congruency, stabilization of the soft tissues, and re-establishment of the suction seal. The compressive force was then increased at a rate of 20 N/s until a load of 600 N was reached, which was held for 30 s. The peak pressure, average pressure, contact force and contact area were recorded and averaged across the last 10 s of this period to minimize viscoelastic behavior. The testing protocol was repeated with the hip in neutral internal-external rotation as well as when the hip aligned with the sagittal plane and positioned in 20° flexion and 10° extension (Fig. 2D-F). A minimum 5 min between tests was permitted to reposition the specimen and allowed the cartilage and soft tissue to return to equilibrium. These hip joint angles were selected since because they represent the joint configurations during walking at the point of maximum hip joint loading and maximum hip extension respectively.
2.4 Data analysis
3 Results
3.1 Effect of ligamentum teres deficiency
Ligamentum teres deficiency resulted in a significant increase in the
average pressure (mean difference: 161.6 kPa, 95 %CI [87.6, 235.6], p = 0.002)
(Fig. 3) (Table 1) in the superior region of the acetabulum in the neutrally
positioned hip compared to that in the intact hip. In the anterior region of
the acetabulum in the extended hip, the peak pressure of the ligamentum teres
deficiency hip was significantly higher than that in the intact hip (mean
difference: 1462.5 kPa, 95 %CI [449.8, 2475.2], p = 0.023) (Fig. 4).
 |
| Fig. 3 Average pressure measurements of hip joint specimens in the neutral (A), Flexed (B), and extended (C) hip joint positions. Data are given for the ligamentum teres intact, deficient, and reconstructed hips. Whiskers indicate one standard deviation about the mean. One asterisk represents p < 0.05, two asterisks represent p < 0.01 while three asterisks represent p < 0.001. |
 |
| Fig. 4 Mean peak pressure measurements of hip joint specimens in the neutral (A), flexed (B), and extended hip joint positions (C). Data are given for the ligamentum teres intact, deficient, and reconstructed hips. Whiskers indicate one standard deviation about the mean. One asterisk represents p < 0.05, two asterisks represent p < 0.01 while three asterisks represent p < 0.001. |
Table 1 Summary of the mean, standard deviation and p-values of the peak pressure, average pressure, contact force, and contact area of hip joints in 20° flexion, neutral position, and 10° extension. Data are given for the intact, ligamentum teres deficient and reconstructed states.
Ligamentum teres deficiency caused a significant decrease in peak pressure
(mean difference: 500.3 kPa, 95 %CI [168.8, 831.8], p = 0.014) (Fig. 4) (Table
1) in the superior region of the acetabulum in the neutrally positioned hip
compared with that in the intact hip. In addition, ligamentum teres deficient
hip showed a significant decrease in the contact force (mean difference: 146.3
N, 95 %CI [27.9, 264.6], p = 0.030) (Fig. 5) in the anterior region of the
acetabulum in the flexed hip compared to that in the native hip. A similar
trend was observed in the posterior region of a flexed hip, where contact area
of the ligamentum teres deficient hip (mean difference: 127.4mm2, 95 %CI
[58.8196.1], p = 0.001) (Fig. 6) was significantly lower compared with that in
the intact hip.
 |
| Fig. 5 Contact force measurements of hip joint specimens in the neutral (A), Flexed (B), and extended (C) hip joint positions. Data are given for the ligamentum teres intact, deficient, and reconstructed hips. Whiskers indicate one standard deviation about the mean. One asterisk represents p < 0.05, two asterisks represent p < 0.01 while three asterisks represent p < 0.001. |
 |
| Fig. 6 Contact area measurements of hip joint specimens in the neutral (A), Flexed (B), and extended (C) hip joint positions. Data are given for the ligamentum teres intact, deficient, and reconstructed hips. Whiskers indicate one standard deviation about the mean. One asterisk represents p < 0.05, two asterisks represent p < 0.01 while three asterisks represent p < 0.001. |
3.2 Effect of ligamentum teres reconstruction
Ligamentum teres reconstruction caused a significant reduction in the
average pressure (mean difference: 227.6 kPa, 95 %CI [142.4, 312.8], p <
0.001) (Fig. 3) (Table 1) in the superior region of the acetabulum in the
neutrally positioned hip relative to that in the ligamentum teres deficient hip
and the average pressure of the ligamentum teres reconstructed hip was not
significantly different from the intact hip (p > 0.05). A similar trend was
observed in the anterior region of the acetabulum in the extended hip, where
ligamentum teres reconstruction caused a significant reduction in the peak
pressure relative to that in the ligament deficient hip (mean difference:
1326.3 kPa, 95 %CI [321.9, 2330.6], p = 0.041) (Fig. 4). There was no
significant difference between the peak pressure of the reconstructed hip and
the hip with an intact ligamentum teres (p > 0.05).
Ligamentum teres reconstruction resulted in a significantly lower
average pressure (mean difference: 241.0 kPa, 95 %CI [77.6, 404.4], p = 0.007)
(Fig. 3) (Table 1) in the posterior region of the acetabulum in the flexed hip
relative to that in the native hip. Similarly, ligamentum teres reconstruction
was associated with a significantly lower contact force (mean difference: 124.5
N, 95 %CI [4.0, 245.0], p = 0.039) (Fig. 5) in the posterior region of the
acetabulum in the flexed hip relative to that in the intact hip. Ligamentum
teres reconstruction led to a significantly lower peak pressure (mean
difference: 954.9 kPa, 95 %CI [648.6, 1261.2], p < 0.001) (Fig. 4) in the
superior region of the acetabulum of the neutrally positioned hip relative to
the intact hip. Further, the peak contact pressure in the ligamentum teres
reconstructed hip was also significantly lower than that in the ligament
deficient hip (mean difference: 454.625 kPa, 95 %CI [137.2, 772.1], p = 0.031).
In the present study, ligamentum teres deficiency resulted in a
significant increase in peak pressure and average pressure, with its effect
being the most prominent in the anterior or superior regions of the acetabulum
of the neutral or extended hip. Ligamentum teres reconstruction restored these
alterations to levels that were equivalent to those in the intact hip. However,
the peak pressure of the ligamentum teres reconstructed hip in the superior region
of the acetabulum of the neutral positioned hip was significantly lower than
both the intact hip and the ligamentum teres deficient hip. Ligamentum teres
reconstruction resulted in significant reductions in the average pressure and
contact force in the posterior region of the acetabulum in the flexed hip
compared to the intact hip. These findings partially support our hypothesis
that the ligamentum teres deficiency increases the peak pressure and average
pressure at the hip, while ligamentum teres reconstruction restores these
alterations.
The present study showed that ligamentum teres deficiency resulted in a
significant increase in the average pressure in the superior region of the
acetabulum in the neutrally positioned hip and the peak pressure in the anterior
region of the acetabulum (in the extended hip) relative to that in the native
hip. This is likely due to the loss of the stability provided by the ligamentum
teres in hip flexion and extension. After reconstruction, the average pressure
was restored to a level that was equivalent to that in the native hip. This may
be explained by the restoration of the biomechanical restraint of the
ligamentum teres in the hip. The native ligamentum teres features two main
attachments in the anteroinferior and posteroinferior cotyloid fossa with
separate bundles that attach to the fovea capitis of the femoral head (Mikula
et al., 2017). The anteroinferior and posteroinferior attachments may help to
prevent superior displacement of the femoral head. In the ligamentum teres
deficient state, these attachments are lost, and consequently, the femoral head
may be displaced superiorly and anteriorly, resulting in a significant increase
in the peak pressure and average pressure. In the ligamentum teres
reconstruction adopted in this study, a double-stranded semitendinosus tendon
graft was employed as this replicates the ligament path, as described
previously (Amenabar and O'Donnell, 2012). In addition, restoration of joint
contact pressure and area following ligament reconstruction is likely to be
conductive to a more effective suction seal, which may further contribute to
improved joint stability.
When the joint was neutrally positioned, ligamentum teres reconstruction
led to a significant reduction in the peak pressure in the superior region of
the acetabulum. Furthermore, ligamentum teres reconstruction led to a
significant decrease in the average pressure and contact force in the posterior
region of the acetabulum in the flexed hip. These findings suggest that there
may be some limitations associated with the current ligamentum teres
reconstruction technique. In the reconstruction model, when a compression load
is applied, the graft tension may limit superior displacement of the femoral
head, thereby leading to a reduction in the peak pressure. Additionally, the
graft tension generated during compression may also pull the femoral head away
from the posterior region of the acetabulum when the hip is flexed. As a
result, the average pressure and contact force may not be restored to a level
comparable to that of the intact hip. Lastly, repeated testing of the repaired
hip specimens may have resulted in some loss of tension in the repaired
ligament, and this behavior may be clinically relevant in the context of joint
stability in the reconstructed hip.
Ligamentum teres deficiency caused a significant reduction in the
contact area in the posterior region of a flexed hip. This reduction could be
attributed to the effect of the posterior attachment of the ligamentum teres in
aligning the femoral head to the acetabular fossa. In the case of a complete
ligamentum teres tear, loss of the posterior ligamentum teres attachment allows
the femoral head to be displaced, resulting in a decrease in the contact area
in the posterior region. Reduced contact area could also be attributed to the
role of the ligamentum teres in maintaining the fluid seal of the hip joint.
The ligamentum teres occupies the cotyloid fossa to create greater congruency
in the hip joint to improve the fluid seal (Al'Khafaji et al., 2024). In
ligamentum teres deficiency, the cotyloid fossa is vacant, thereby leading to
poor joint articulation and a decrease in the contact area between the femoral
head and the acetabulum.
There are some limitations that ought to be considered. Firstly, human tissue acquired for this study was from aged cadavers. While radiographic screening was performed to exclude macroscopic degenerative changes, the results may not be representative of hips in young adults. Secondly, hip joint contact behavior was tested in three hip positions, as these represent the joint configurations during walking. Future studies ought to consider joint positions and loads during other activities of daily living, including stair ambulation, as well as walking at faster speeds. Third, our model does not account for structural changes in the graft that occur over time due to experienced internal forces and biological graft healing. Fourth, this study did not define the ideal or optimum position of the hip during graft fixation, and this may affect the results. We fixed the graft with the hip in a neutral sagittal and externally rotated position as this appears to be most commonly executed position in current clinical practice. Fifth, the ligamentum teres was completely removed from the joint in the ligament deficient state in order to isolate the effect of the ligamentum teres, and the resultant joint contact patterns may not necessarily be representative of a partially torn ligamentum teres, nor a complete tear in which residual ligament remains within the joint and contributes to joint contact. Sixth, the Tekscan pressure sensor was a thin, flat and highly flexible instrumented array, and its insertion and contact with the curved joint articular surface may have resulted in crinkling, and subsequent errors in the overall pressure distribution. To mitigate this, non-instrumented edges of the sensor were carefully trimmed away to reduce the overall sensor size and achieve a better fit and more joint congruency. Removal of capsular and extracapsular musculotendinous tissue surrounding the hip joint facilitated greater exposure and access to the hip joint cavity, which was needed to position and remove wrinkles from the sensing array. Nonetheless, some wrinkling may have occurred, impacting the pressure data, and increasing overall data variance. Finally, while all tissue samples were regularly irrigated, the suction seal of the hip joint may have been compromised during repeated testing. The specific effect of ligamentum teres reconstruction on the fluid seal was not directly assessed in the present study and as such remains hypothetical.
5 Conclusion
Ligamentum teres deficiency not only increases the average pressure in
the superior region of the acetabulum in the neutral hip and the peak pressure
in the anterior region of the acetabulum in the extended hip relative to that
in the intact hip, but it also causes a reduction in the average pressure,
contact force, and contact area in the posterior region of the acetabulum in
the flexed hip. Although reconstruction surgery is effective in restoring the
average pressure and contact force in the superior region of the acetabulum in
the neutrally positioned hip, as well as the peak, average pressure, and
contact force in the anterior region of the acetabulum in the extended hip, it
does not restore the peak pressure in the superior region of the acetabulum in
the neutrally positioned hip, as well as the average pressure and contact force
in the posterior region of a flexed hip. These limitations may present a risk
factor for hip instability and potential degenerative changes. Further studies
ought to investigate how to appropriately tension the ligamentum teres graft to
recreate normal hip joint biomechanics.
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Source & links
Chen JH, Al’Khafaji I, Ernstbrunner L, O’Donnell J, Ackland D. Joint contact behavior in the native, ligamentum teres deficient and surgically reconstructed hip: A biomechanics study on the anatomically normal hip. Clinical Biomechanics. 2025;130:106666. DOI: 10.1016/j.clinbiomech.2025.106666 clinbiomech.com/pdf , clinbiomech.com/fulltext , sciencedirect.com
Authors & Affiliations
Jacob H. Chen - Department of
Biomedical Engineering, University of Melbourne, Australia
Ian Al'Khafaji -∙ Orthosport
Victoria Institute, Richmond, Victoria, Australia
Lukas Ernstbrunner - Department
of Biomedical Engineering, University of Melbourne, Australia; Department of
Orthopaedic Surgery, Eastern Health, Box Hill Hospital, Box Hill, Australia
John O’Donnell - Hip Arthroscopy
Australia, Richmond, Victoria, Australia
David Ackland - Department of Biomedical Engineering, University of Melbourne, Australia; dackland @ unimelb.edu.au
Notes
Open Access: This item is Open Access
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, experiment, biomechanics, role, significance, reconstruction
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