The article
by Srinivasan S, Verma S, Sakthivel S. Macromorphological Profile of Ligamentum
Teres Femoris in Human Cadavers–A Descriptive Study (2025) is devoted to the
morphology of ligamentum capitis femoris (LCF) in the Indian population. The
text in Russian is available at the following link: 2025SrinivasanS_SakthivelS.
Macromorphological Profile of Ligamentum Teres Femoris in Human Cadavers–A Descriptive Study
CONTENT [i] Abstract [ii] Introduction [iii] Materials and Methods [iv] Results and Discussion [v] Conclusion [vi] References [vii] Application |
Introduction:
The ligamentum teres femoris (LTF) is an intra-articular ligament extending from fossa of acetabulum to the head of femur and is triangular or pyramidal in shape. Recent literature supports its role as a secondary stabilizer of hip and increasing evidence supports reconstructive surgery following tear. This study aims to provide detailed morphology of human LTF to aid reparative procedures.
Materials and Methods:
A total of 44 hip joints (34 male and 10 female) were dissected and those with gross deformity or signs of previous surgery were excluded. LTF was examined for shape, bundles, synovium, attachments, blood vessels, bundles, length, breadth, and thickness. The imageJ software was used for measuring the area of attachment. The data were recorded and analyzed using the SPSS software.
Results:
The average age of cadavers was 70.1 ± 8.2 years (range: 50–81 years). LTF was absent in 2.3%. The shape was triangular in 64% and rectangular in 36%. The acetabular attachment was mostly circular (50%) and that of femoral was oval (69.1%). The blood vessel openings at the acetabular end were seen in 78.6% and at femoral end in 16.7%. Most LTF had three bundles (45.2%) and in 14.3% no bundles were seen. Around 62.9% of fovea gave attachment to LTF. The average length of LTF was 3.1 ± 0.5 cm. The difference between the thickness at the acetabular end of two sides was statistically significant (P = 0.04).
Conclusion:
The study findings would supplement existing literature for arthroscopic reconstruction of LTF to determine appropriate graft dimensions and sites of fixation..
The ligamentum teres femoris (LTF) is one of the ligaments
supporting the acetabular-femoral articulation or hip joint. It is intra-articular
as well as extra-synovial and extends from the fossa of acetabulum to the head
of femur.[1,2] It is traditionally described as a triangular or pyramidal
in shape.[2] The apex attaches to the fovea capitis femoris (FCF), a focal
depression on the head of femur. The fovea has separate zones for the ligament
attachment and reception during movement. Due to its round or ovoid appearance
near FCF, the ligament is also called as the round ligament of the head of
femur.[3] The proximal end or base blends with the transverse ligament of
acetabulum, and is attached to ischial and pubic sides of the acetabular notch.[3] The
body of ligament, between two ends, consists of distinct bundles, namely
anterior, posterior, and medial.[4]
LTF was considered to be a vestigial structure in the past
and was neglected and resected during procedures for reduction of dislocation
in conditions such as developmental dysplasia of hip. However, recent
literature indicates that it is essential for conveying proprioception and
nociception to the hip joint, thus acting as a secondary stabilizer of the
joint. The ligament also aids in vascularization of the developing femoral
head. A slight increase in mean adduction of hip following arthroscopic sectioning
of LTF alludes to a role in joint stability and its absence will make joint
unstable.[5,6] The other function of LTF is to act as a suspensory
ligament to diminish the pressure between head of femur and roof of acetabulum.
It forms a sling-like structure during squatting and acts as a windscreen wiper
in spreading the synovial fluid during movements.[7,8] Some authors have
advocated that it is a strong intrinsic stabilizer of hip with definitive
significance in joint movements.[7,9]
The first line of treatment in LTF injuries is primarily
based on the conservative methods such as activity modification, targeted
muscle exercises for core strengthening, hip stabilization, and pain medication.[10] In
case of failed conservative therapy, debridement of LTF tear along with
surrounding synovium using radiofrequency ablation is used.[10] Simpson et
al. have described the need for LTF reconstruction in the patients with
microinstability following debridement.[11] Philippon et al. found a
notable improvement in hip stability of patients following arthroscopic
reconstructive surgery on LTF.[12] Majority of studies on LTF are from the
clinical settings,[11,12] and further data are needed on the description of
its gross features in the general population. Furthermore, the prevailing
literature on the macrostructure of LTF is scant in the Indian population. The
present study was thus designed to supplement the existing literature which
would be valuable during arthroscopic reconstruction of LTF to determine
appropriate graft dimensions and ideal sites for fixation.
The hip joints from 22 formalin-embalmed cadavers (17 male
and 5 female) available in the department of anatomy were utilized. The hips
with any gross deformity or signs of previous surgery were excluded. The
research protocol was approved by the Institutional Ethics Committee
(JIP/IEC/2018/0183 dated May 22, 2018).
Dissection of hip joint: After clearing of skin and fascia
around the hip, the femoral vessels and nerve were divided a short distance
below the inguinal ligament. The rectus femoris and sartorius muscles were
reflected downward after cutting two inches below the proximal attachments. The
joint capsule was exposed by cutting iliopsoas tendon close to lesser
trochanter and reflecting upward. The adductor muscles were separated from
origin and turned downward. Posteriorly, the gluteus maximus was cut by a
vertical incision one inch medial to insertion on femur, and sciatic nerve was
divided. The piriformis, obturator internus, glutei medius, and minimus muscles
were freed from the attachment on femur and reflected. The quadratus femoris
and gemelli muscles were removed. The capsule was divided just beyond the
acetabular margin to see the head of femur. With cadaver in supine position,
the femur was gently extricated from the joint to expose LTF.
Gross examination: The LTF was examined in situ for
shape, number of bundles, and features of synovium. The two ends of ligament were
excised at the attachments. The ligament was then examined under a stereo
microscope (Olympus SZ61, Tokyo, Japan) for blood vessels and bundles. The
length, breadth, and thickness were measured using digital Vernier calipers
(Mitutoyo make, Kawasaki, Japan) with a sensitivity of 0.1 mm. For measurement
of area, the bone sites were photographed, and the images were transferred to
imageJ software (version 2.0) Developed by National Institute of Health and
laboratory for Optical and Computational Instrumentation, University of
Wisconsin, US. The observations were recorded by a single observer and the mean
of three readings was taken as final. All the data were recorded and analyzed
using IBM_ PASW Statistics version 20.0 (SPSS software version 20.0 Chicago;
Illinois; US). The statistical difference between the left and right sides was
analyzed by paired t-test. The relation of fovea capitis area with that of
femoral and acetabular attachments was determined using Pearson correlation
test. The Fischer’s exact test was used for comparing the categorical variables
on the right and left sides. The statistical analysis was carried out with 5%
level of significance and P < 0.05 was considered statistically
significant.
The following morphometric parameters were taken: Length (cm), breadth and thickness (cm) – acetabular end, middle, femoral end, area of attachment (cm2)-acetabular end, femoral end, and area of FCF (cm2).
RESULTS
A total of 44 hip specimens (34 male and 10 female) were
dissected. The average age of cadavers was 70.1 ± 8.2 years (range: 50–81
years). LTF was absent [Figure 1] in left hip of a male cadaver (2.3%; 1/44).
The ligament was thin and rudimentary in right hip joint of the same cadaver.
In 21 cadavers, LTF was placed in the lower part of joint cavity extending
upward and laterally from acetabulum to FCF. The body of ligament was band-like
with upper aspect toward the acetabulum, lower surface close to the head of
femur (below FCF), and anterior and posterior margins separating the two. The
synovial membrane was seen as a glossy cover all over the ligament. A synovial fold
[Figure 2] on the ligament was seen in 71.4% (right-66.7% and left-76.1%)
extending from the acetabular floor. The LTF was mostly triangular [Figure 3]
with broad base at acetabulum [Table 1]. The triangular was also the most
common shape in males (62.5%) and females (70%).
 |
| Figure 1 Left hip joint cavity (open) with completely absent ligamentum teres femoris |
 |
| Figure 2 Specimen showing a synovial fold (arrow) on the superior surface of ligamentum teres femoris |
 |
| Figure 3 Left hip joints showing rectangular (a) and triangular (b) ligamentum teres femoris |
 |
| Table 1 Morphological features of ligamentum teres femoris |
The profile at acetabular end was mainly “broad and flat”
(BFL) but it was “broad and funnel-like” (BFU) in 21.4%. BFL was more common on
the left than the right [Table 1]. The incidence of BFL was 81.2% in males, and
70% in females. The profile at femoral end was “narrow and round” in 28.6% and
“narrow and flat” in 71.4%. LTF took origin from pubis and ischial edge of
acetabular notch, floor of acetabular fossa, and transverse acetabular ligament
(TAL) in all the specimens. The shape of acetabular attachment was mostly
circular followed by oval [Table 1]. The circular was most common shape in
males (43.7%) as well as females (70%). Distally, LTF was attached to the upper
half of fovea in all the cases and its shape of attachment was mainly oval
followed by triangular [Table 1]. LTF was oval in 75% in males and in 50% in
females. The difference between right and left sides was significant for
triangular and rectangular shapes (P < 0.001), BFL profile at
acetabular end (P = 0.015), oval and circular acetabular attachments, and
oval femoral end attachment (P < 0.001). LTF was frayed at insertion in
19%, on the right in 4.8% and in 33.3% on the left. The small, firm nodules
were palpable closer to femoral end in 19%, more on the left (28.6%) than the
right (9.5%).
The branching vessels were visible below the synovial
membrane near the acetabular end in all specimens and in 30.9% near the femoral
end. Small blood vessels were visible on the superior surface in 69% and
inferior surface in 21.4%. In the middle part of ligament [Figure 4], a network
of vessels was noted on the superior surface in 19%, but none on the inferior
aspect. The blood vessel openings at the cut acetabular end [Figure 4] were
seen in 78.5%, on the right in 85.7%, and on the left in 71.4% [Table 2]. It
was noted in 71.9% males and 47.6% females. At the cut acetabular end, a single
vessel opening was more common on both sides and in two sexes. At the femoral
end, only one vessel opening was observed that more common on the left side.
Two to three collagen bundles [Figure 5] were seen at the acetabular end of
ligament that joined into a single band at the femoral end. In 14.3%, LTF
appeared as a single band-like structure as distinct bundles were not apparent.
Most LTF had three bundles that were named anterior, posterior, and medial. The
medial bundle was not seen in specimens with only two bundles. Three bundles
were more common on the right and two bundles on the left [Table 2]. In males,
50% had three bundles, 43.7% had two bundles, and 6.3% had none.
 |
| Figure 4 Specimens showing cut end of a blood vessel (a) at the acetabular end and sub-synovial blood vessels; (b) in the middle part of the of ligamentum teres femoris |
 |
| Table 2 Blood vessels and collagen bundles in ligamentum teres femoris |
 |
| Figure 5 Left hip joint showing the anterior (1) and posterior (2) collagen bundles visible in a specimen of ligamentum teres femoris. (a) Femoral attachment intact. (b) Femoral end cut |
The difference in the mean length and width of LTF on the right and left sides was not statistically significant. However, the difference between the thickness at the acetabular end on the two sides was statistically significant [Table 3]. Table 4 shows the morphometric measurements in males and females. Around 62.9% of fovea gave attachment to LTF, 63% on the right and 65.3% on the left. Figure 6 shows the sites of attachment on femur and acetabulum. There was a positive correlation between the area of FCF and the femoral attachment (correlation coefficient: R = 0.731; L = 0.332) reaching significance on the right (P = 0.01). Furthermore, there was a positive correlation between the area of FCF and the acetabular attachment (correlation coefficient: R = 0.626; L = 0.394) reaching significance on the right (P = 0.01) and left (P = 0.03).
 |
| Table 3 Morphometric measurements of ligamentum teres femoris |
 |
| Table 4 Morphometric measurements of ligamentum teres femoris in males and females |
 |
| Figure 6 The sites of ligamentum teres femoris attachment (marked red). (a) Femoral attachment on the fovea capitis femoris. (b) Acetabular attachment |
DISCUSSION
The present study identified the LTF as a 3.1 ± 0.5 cm long
band-like structure extending from acetabular notch and fossa to occupy 65.3%
of bony FCF. The body of ligament had two surfaces and two margins.
Perumal et al. described the LTF as a triangular-shaped ligament with base
attached to TAL and apex to FCF of the femur.[2] It has been described as
pyramidal in shape with base towards TAL and apex to the FCF by Keene and
Villar[13] and Perez-Carro et al. as well.[14] Gray and Villar
described it as a flattened, triangular structure with base at TAL and apex
toward FCF of the femur.[15] The observations from the above-mentioned
studies as well as the current study imply that LTF is mainly a broad
triangular or pyramidal-shaped structure at the acetabular end and narrow
rounded or flat profile at FCF [Table 5]. Conversely, Kirci et al.
described LTF as rectangular in 65.4% and triangular in 34.6%.[16] Perumal et
al. noted the absence of LTF in 2.8% Thai cadavers and Tan and Wong reported it
in 10% compared to 2.3% in the present study.[2,17]
Fu et al. described the synovial folds as plicae mainly
distributed over the external surface of acetabular labrum and base of the LTF;
and also along the reflections of synovial membrane on the base of the neck of
femur. The synovial folds help in lubricating the synovial fluid over the
articular surfaces of the joint, assist in joint stability and act as a
radiator.[18] The presence of synovial fold in the present study
correlates with the previous study done by Perumal et al. which reported
the presence of synovial fold as frenulum in 86.7% of specimens.[2] Bardakos
and Villar, and Perez-Carro et al. described the presence of prominent
synovial fold on the superior surface which was responsible for the pyramidal
shape profile of LTF.[1,14] Grey and Villar described a compressed
synovial fold responsible for flattened triangular profile of LTF.[15] BFL
was more common profile than the BFU in the present study. The profile of the
LTF is important in understanding the footprints of the attachment at the ends
of ligament and can be utilized for use of LTF as a graft in reconstructive
surgeries of anterior cruciate ligament.[19]
 |
| Table 5 Shape of ligamentum teres femoris in various studies |
The oval shape of distal attachment was more common in this
study which was similar to previous studies by Cerezal et al. who
documented that the shape of distal end of the ligament was round or oval.[20] Another
study by Perumal et al. showed the similar findings regarding the shape of
distal end of LTF which was oval in majority of the cases.[21] Mikula et
al. identified an oval-shaped femoral attachment in all the cases in their
study.[8] In a previous study by Perumal et al., the frayed end of
LTF was reported as an interrupted synovial reflection in form of perforation
or cleft on the superior aspect of acetabular end of LTF unlike the current
study where the fraying was present on the distal end of LTF. The changes such
as fraying and nodules are associated with the degenerative hip joint
pathology.[2] In the current study, fraying was observed in 19% of cases
and mostly on the left side.
Tucker described the foveolar artery arising either
independently from obturator and medial circumflex femoral arteries, or from
both. It passed into acetabulum under the TAL and gave off a branch to
Haversian pad of fat and then ran along the LTF.[22] The artery of LTF
takes origin from the obturator artery in 80% individuals and in 20% from the
acetabular branch of medial circumflex femoral artery. The acetabular branch of
medial circumflex femoral artery gives off the foveal artery which runs within
the LTF and enters into the fovea capitis of the femoral head.[23] Among
114 anatomic specimens studied by Chandler and Kreuscher, the LTF was
relatively avascular in four, large number of small vessels were present in
eight, the arteries showed partially or complete sclerosis in 16, and the
arteries with mean diameter of 0.2–1.5 mm were seen in 86 specimens.[9] Chung
found that the artery within the LTF did not reach the femoral head in 63% of
specimens and in 31% of specimens, the LTF provided one or two deep vessels to
the center of femoral head.[24] We have noted fewer vessel openings on
femoral than acetabular end possibly due to reduced number of vessels reaching
head of femur.
 |
| Table 6 Length of ligamentum teres femoris in various studies |
The collagen bundles are responsible for the strength of LTF
and thus maintaining the stability of hip joint.[4] The recognition of the
collagen bundles and the profile of the ligament attachment would be
particularly significant for the appropriate repair technique and preservation
of ligament function.[8] Perez-Carro et al. described that the
proximal attachment of LTF comprised of anterior and posterior bundles.[14] Demange et
al. described that the LTF consisted of three collagen bundles, namely
anterior, posterior, and medial.[5] The central or medial bundles were
described by Kapandji et al.[25] In the present study, the proximal
end of the LTF contained three anterior, posterior, and medial bundles in
45.2%, two bundles in 40.5%, and no bundles in 14.3%.
The LTF length has a major impact on stability of the hip
joint during movements. The length of LTF gets altered and plays a pathological
role in subluxation of hip in early cases of Perthe’s disease. In hip joints
with congenital dislocation, the length of the ligament is increased.[26] The
length of LTF is also believed to play an important role in the range of
rotatory movements of hip joint. It has been noticed that the LTF is shorter in
length in the other mammals as compared to that in humans. This is believed to
limit the range of hip joint rotation in quadrupeds in contrast to man that has
assumed the bipedal gait.[27] Salter and Dunn described an abnormally long
LTF with a shallow acetabular cavity associated with capsular laxity in
congenital disease of hip joint.[26,28] Knowledge about the LTF length
would be helpful in preparing appropriate graft size for ligament
reconstruction.[29] Many authors studied the LTF length by using different
tools and subjects.[14,30] The length of the LTF measured from the current
study using Vernier calipers was 3.1 ± 0.5 cm (ranging between 19.7–3.7 cm).
The length of the LTF was calculated from its most proximal attachment to the
most distal attachment. The present study results coincide with the findings
from Perez-Carro et al. and Kapandji et al.[14,25] However, the
ligament length in a study by Harrison et al. was higher than the average
in other studies [Table 6].
The width at the proximal end of LTF was found to be more
than the width at the centre and at distal end of LTF. The findings of the
present study coincide with the study by Perumal et al. which showed that
the width at the base was more than the femoral end.[2] The present study
also correlates with the data published by Chandler and Kreuscher et al.;
Kaplan et al.; and Blankenbaker et al.[7,9,30] The thickness of
the LTF is another parameter of importance next to the length of the LTF in
maintaining the stability of the hip joint. Jonsator suggested that the
possible cause for hip joint subluxation in Perthe’s disease was the swelling
of soft tissue contents of acetabular fossa, especially LTF.[33] A thick
LTF along with degenerating changes is also seen in osteoarthritic hips from
patients in the elderly age group.[34] In a previous study by
Perumal et al., thickness of apex (distal end) was more compared to center
(mid-zone) and base (proximal end).[2] In the present study, the thickness
at the femoral end was more when compared to acetabular end thickness possibly
due to mostly oval profile distally. Furthermore, the thickness at acetabular
end was significantly more on the left when compared to the right.
The knowledge of area of attachment provides an
understanding of the ideal site for graft placement and is essential for graft
fixation in LTF reconstruction surgeries.[21] In study by Mikula et al.,
the area of attachment of acetabular and femoral ends was 4.3 cm2 (95% CI,
3.2–5.5 cm2) and 0.9 cm2 (95% CI, 0.6–1.0 cm2), respectively.[8] In the
current study, the area of attachment at the acetabular end was 8.4 ± 1.3 cm2 and
at femoral end, the area of attachment was 1.7 ± 0.3 cm2. The mean area of
fovea capitis was 2.7 ± 0.3 cm2 which was greater when compared to the
study by Perumal et al. in which the surface area of fovea capitis was 1.8
± 0.7 cm.[21]
LTF injuries are typically associated with hip dislocation.
Partial or complete tears may occur in the flexion-adduction stress in a sudden
twisting injury.[1] The complete tears of LTF are one of the etiological
factors for hip instability.[20] The patients with damaged or degenerated
LTF commonly present with persistent hip pain, hip joint stiffness, and
restricted movements.[15] Lately, many authors have reported that the
reconstructive procedures of LTF improve the patient outcome, especially in
cases with hip instability and chronic pain.[35] Furthermore, the
conservation of normal anatomic architecture of ligament is essential to
achieve the optimal functional status. The knowledge on the morphometric
parameters of the ligament and their precise attachments could help surgical
decision-making in choosing the appropriate graft dimensions during LTF
reconstruction surgeries. This is likely to decrease the need of arthroscopic
debridement of the LTF tear in athletes involved in sports and to minimize the
variations in the ligament length that could potentially cause movement
restriction and joint instability postoperatively. One of the limitations of
the study is the small sample size due to constraints in procuring cadaveric
material for dissection. Furthermore, due to large difference between the
number of male and female cadavers, the data from the two could not be
statistically compared. Future studies on LTF may focus on acquiring data from
larger sample from a specific population to facilitate in generalization of
research outcomes. Data from imaging studies of hip joint would also be useful
to surgeons for preoperative planning.
The LTF is absent in 2.3% hip joints from the Indian population. The average length of LTF is 3.1 ± 0.5 cm and the acetabular end is significantly thicker on the left side than the right in study population. The ligament has mostly three bundles that merge distally but it appeared as a single band in 14.3%. The oval-shaped femoral end attaches on the upper part of fovea occupying 62.9% area. The area of FCF is positively correlated with both the femoral and acetabular attachments. The blood vessels are more likely to be seen at the acetabular than femoral end. The present study findings would supplement existing literature and would be valuable for arthroscopic reconstruction of ligament to determine appropriate graft dimensions and sites of fixation.
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Source
& links
Srinivasan S, Verma S, Sakthivel S. Macromorphological Profile of Ligamentum Teres Femoris in Human Cadavers–A Descriptive Study. National Journal of the Society of Medical Anatomists. 2025;2(1)16-22. ovid.com
DOI : 10.4103 /NJSOMA.NJSOMA_3_25
Authors
& Affiliations
Srinivasan, S. - Department
of Anatomy, Saveetha Medical College, Chennai, Tamil Nadu, India
Verma, Suman - Department of Anatomy, JIPMER, Puducherry, India
Sakthivel, Sulochana - Department of Anatomy, JIPMER, Puducherry, India
Note
The work is cited in the following publications: К вопросу о прочности LCF.
Open Access: This item is Open Access
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, anatomy, topography, attachment, properties, blood supply, absence
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