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Abstract of the article: Hosalkar HS et al. Isocentric
reattachment of ligamentum teres: a porcine study (2011). The article describes
a method of isocentric fixation of the proximal end of the ligamentum capitis
femoris (LCF) during plastic surgery in an experiment on pigs. The text in
Russian is available at the following link: 2011HosalkarHS_WengerDR.
Abstract
Background: Recent reports reveal interest in the mechanical
importance of ligamentum teres (LT) in hip dislocation. In the previously established procedure of
anteroinferior acetabular LT reattachment in developmental dysplasia of the
hip, the LT functions as a check-rein, showing promising results. However, this
position of reattachment could potentially limit motion. The purpose of this
study was to evaluate the feasibility of an isocentric point for reattachment
of the LT and to study its impact on hip function using a young porcine model.
Methods: Pelvic specimens with intact anatomy were obtained
from 6 skeletally immature pigs (12 hips). Through
a careful anteromedial capsulotomy, the LT was detached from its acetabular
insertion then reattached to 1 of 2 positions: (1) anteroinferior lip of the
acetabulum; (2) proposed isocentric position. Intra-articular stress
distribution was measured through a complete range of motion with a prescale
Fuji pressure film. Tension was then applied to the LT and the stresses were
recorded again. In addition, radioopaque solution was injected into the
substance of the LT, then floroscopy tracked the LT location initially and
after the 2 reattachment positions through a full hip range of motion.
Results: Reattachment of the LT at an isocentric point is
feasible in a pig model. With careful
physiologic tensioning of this reattachment, hip can maintain full motion with
no excessive pressure areas created within the joint. On the contrary, the
initial technique of anteroinferior extra-articular attachment limits external
rotation and extremes of abduction. We found this LT tracking technique (with
radioopaque dye injection) to be reliable and reproducible.
Conclusions: The isocentric reattachment of the LT is feasible in
this pig model and serves as a natural check-rein to dislocation without
limiting joint motion or causing abnormal cartilage pressures.
Clinical relevance: Isocentric LT reattachment may provide a method
for improving stability of open reductions when treating children with such
conditions.
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Hosalkar HS, Varley ES, Glaser D, Farnsworth CL, Bomar JD, Wenger DR. Isocentric reattachment of ligamentum teres: a porcine study. Journal of Pediatric Orthopaedics. 2011;31(8)847-52. DOI: 10.1097/BPO.0b013e31822e0276 journals.lww.com , pubmed.ncbi.nlm.nih.gov
Surgical Technique
Once the baseline measurements had
been recorded, the musculature was gently retracted with the LT then released
from its origin at the cotyloid fossa and transverse ligament of the acetabulum
using a number 12 scalpel blade. A number 1-0 polydioxanone suture (Ethicon,
Somerville, NJ) was woven Bunnell style into the medial end of the LT (Fig. 2).
The LT was then transferred to 1 of 2 reattachment positions: anteroinferior
acetabulum (group A.I.) and the new proposed isocentric position (group I.C.)
(Fig. 3). The transfer technique for the A.I. group was performed as follows.
In brief, by an extrapelvic approach, a 4 mm drill was used to create a shallow
groove within the cortical bone at the anteroinferior edge of the acetabulum
just anterior to the labrum. The sutured ligamentum was then pulled into this
groove and sutured to the adjacent bone and periosteum using a standard amount
of operative tension (standardized at 20 N in this case) recorded by a load
cell (Honeywell, NJ). The transfer technique for the I.C. reattachment group
was also by an extrapelvic approach. To assess the feasibility of this approach,
a physiologic isocentric reattachment point was identified at the base of the cotyloid
fossa. A 4 mm diameter drill was then placed at the anteromedial edge of the
acetabulum well anterior to the triradiate growth plate taking care not to
damage this critical zone (Fig. 4A). An oblique tunnel was created (Fig.
3) and the LT was detached, which reproducibly exited at the desired location
at the base of the cotyloid fossa within the acetabulum. Using a suture woven through
the ligament, the LT was pulled through the newly developed isocentric channel
(Fig. 4B) and fixed with an endobutton (Fig. 4C) using an operative tension of
20 N.
Harish S Hosalkar – Department of
Orthopedics, Rady Children's Hospital, University of California, San Diego, CA,
USA. hhosalkar@rchsd.org
Eric S Varley
Diana Glaser
Christine L Farnsworth
James D Bomar
Dennis R Wenger
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, plastic surgery, reconstruction, open plastic surgery, transposition, pigs, animals, experiment
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