Article: White BJ et al. Simultaneous acetabular labrum and ligamentum
teres reconstruction: a case report (2018). A case of ligamentum capitis
femoris (LCF) reconstruction using a tendon graft is described. The text in Russian
is available at the following link: 2018WhiteBJ_HerzogMM.
Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report
White BJ, Scoles AM, Herzog MM
CONTENT [i] Abstract [ii] Introduction [iii] Materials and Methods [iv] Results [v] Discussion & Conclusion [vi] References [vii] Application |
This study aims to present the surgical technique for reconstructing both the acetabular labrum and the ligamentum teres and to describe the early outcomes of this procedure in a 15-year-old male with recurrent hip instability. A 15-year-old patient with recurrent left hip dislocation, hip joint instability and failed non-operative intervention presented following two left hip dislocations. A labral reconstruction was performed utilizing an iliotibial band allograft tissue with a concomitant ligamentum teres reconstruction using a tibialis anterior allograft. The patient was assessed pre- and postoperatively using modified Harris Hip Score, Lower Extremity Functional Scale and Visual Analogue Scale for pain and satisfaction. The patient reported improvement on all measures, including hip stability 14 months following surgery. The patient has not reported any episodes or subjective feelings of instability, has not required further surgical procedures in the hip and has returned to full sports participation. This case report demonstrates a technique for and early outcomes of simultaneous arthroscopic ligamentum teres and acetabular labrum reconstruction in a patient with recurrent hip instability. Short-term outcomes suggest improved hip stability, reduced pain, high patient satisfaction and return to pre-injury activities at 14 months postoperative in this single case report.
The acetabular labrum has been demonstrated to play a key role in the
hip [1–4]. The labrum’s main function is to create a tight seal with the
femoral head to prevent fluid flow outside of the joint space, enhance
acetabular volume and stability of the joint [2–5]. Degeneration or sudden
tearing of the labrum can cause microinstability and pain [2, 3], and treatment
options that restore the fluid seal surrounding the hip joint have shown
promise for improving joint stability and alleviating pain among patients with
labral pathology [6–8]. In particular, complete arthroscopic allograft labral
reconstruction is an emerging technique that allows the surgeon to directly
influence the size, quality and length of a labral graft, which consistently
restores functional labral tissue [8, 9].
While the biomechanical role and importance of the labrum have been recently
established in the literature, other intra-articular structures of the hip have
been studied less frequently, including the ligamentum teres. The ligamentum
teres arises from the acetabular ligament along the inferior margin of the
acetabulum and inserts into the fovea capitis of the femur [10, 11]. The
ligamentum teres tightens in positions of flexion and external rotation, as
well as extension and internal rotation [12]. This finding suggests that the
ligamentum teres may be particularly important for stabilization in the setting
of osseous hip instability. While individuals with normal hip anatomy have
osseous constraints protecting against instability, the ligamentum teres
tension in positions where the hip is most vulnerable to instability may be
critical for those with acetabular insufficiency [12].
Historically, the ligamentum teres in the immature hip has been shown to
provide a source of vascularity, while in the adult hip it has long been
regarded as a vestigial remnant without any biomechanical or biological
function [10, 13]. However, recent studies have determined the histological
presence of both nociceptors and mechanoreceptors in the ligamentum teres,
indicating that the ligamentum teres is part of the reflex pathway of the hip
that is responsible for proprioception, pain sensation and overall stability of
the joint [10, 14–16].
The increased understanding of the role of the ligamentum teres has led to the belief that degeneration or tearing of this structure may contribute to significant pain and general hip dysfunction in the pre-arthritic hip. In certain instances, reconstruction of this ligament may be recommended to mitigate pain and enhance stability of the hip [16, 17]. The importance of this case report stems from the novelty of performing a complete allograft ligamentum teres reconstruction in combination with a complete allograft labral reconstruction to treat severe hip instability. The purpose of this article is to present the surgical technique and early outcomes for a case in a 15-year-old male with recurrent hip instability who underwent reconstruction of both the acetabular labrum and ligamentum teres.
Patient presentation
This case involves a 15-year-old male patient with no pertinent
orthopaedic past medical or surgical history. He sustained an initial injury to
his left hip six weeks prior to presentation following a direct lateral impact
during a lacrosse match. The patient felt pain but was able to return to play.
Two weeks later, he was running in a lacrosse match and sustained a non-contact
left hip injury. He was unable to ambulate and was taken by ambulance to the
emergency room, where he was diagnosed with a posterior hip dislocation. He
underwent uncomplicated closed reduction within two hours of the injury and was
referred for follow-up to the senior author’s practice. Upon examination, his
left hip had good range of motion, demonstrated no joint laxity and had a
negative dial test. There was no laxity in his elbows, wrist, hands or knees.
His hip range of motion was symmetric to his contralateral side with internal
rotation to 10 degrees and external rotation to 65 degrees. His radiographs
showed a concentric reduction with no fracture (Fig. 1). He was instructed to
limit weight bearing to 30% for 4 weeks, and to start a physical therapy
program focusing primarily on hip stabilization and gluteus medius activation.
He was also given standard instructions for posterior hip precautions to limit
flexion to 90 degrees, adduction to neutral and to limit internal rotation. He
was not braced, and the risks of avascular necrosis were discussed. He was
instructed to follow-up with our clinic in 6–8 weeks.
 |
| Fig. 1. Preoperative AP pelvis radiograph showing a left hip that is concentrically reduced with a lateral center edge angle of 32 degrees. |
Approximately 4 weeks after his clinical evaluation, he dislocated his
hip in his sleep. He was evaluated in the Emergency Room where a magnetic
resonance imaging (MRI) scan was ordered due to the lack of clinical suspicion
for hip dislocation. It showed the left hip to be dislocated posteriorly with
the ligamentum teres absent (Fig. 2). The hip was reduced with closed reduction
techniques, and he was instructed to follow-up with our clinic. Radiographic
evaluation in our clinic showed a non-arthritic joint with reasonable lateral
coverage and a lateral centre edge angle of 32 degrees with no crossover sign.
His overall acetabular volume was low with small anterior and posterior walls
and neutral acetabular version. A CT scan was ordered to assess the volume of
the cup and, specifically, integrity of the posterior acetabular wall (Fig.
3a). Distal cuts were not made through the knee so femoral version was not
analysed. Both the anterior and posterior walls were small and there was a mild
flattening to the posterior wall, on a cephalad cut on the CT scan there was
small ossification (Fig. 3b). It was not felt to be a fragment of the
acetabular wall, but rather possibly some early heterotopic ossification. He
was sent to an Orthopaedic Traumatologist for confirmation, and he was sent
back to our clinic for definitive treatment.
 |
| Fig. 2. Preoperative MRI of the left hip indicating posterior hip dislocation. |
 |
| Fig. 3. Preoperative CT scan of the left hip evaluating integrity of the posterior acetabular wall (a) and indicating mild flattening and small ossification of the posterior wall (b), which were determined to be negative for posterior wall fracture by an Orthopaedic Traumatologist. |
Both he and his family were
very concerned about the stability of his hip and requested a surgical
procedure to correct the problem and prevent it from happening again. A
periacetabular osteotomy to increase acetabular coverage and bony stability was
ruled out as it was felt that his acetabulum was in an optimal position for a low
volume cup. His lateral X-ray showed mild CAM-type femoroacetabular impingement
with an alpha angle exceeding 60 degrees (Fig. 4).
His MRI showed a labral tear and no evidence of avascular necrosis. He and his
family were offered hip arthroscopy to address both the labral tear and the
ligamentum teres deficiency, understanding the possibility of reconstruction of
both.
 |
| Fig. 4. Preoperative cross table lateral radiograph showing mild CAM-type FAI. |
Data collection
The patient completed a pre- and postoperative subjective questionnaire that included a Visual Analogue Scale (VAS) for average pain at rest, average pain with activities of daily living (ADL) and average pain with athletic activities in addition to the Lower Extremity Functional Scale (LEFS) [18] and the modified Harris Hip Score (MHHS) [19]. At follow-up the patient also completed a satisfaction scale, where 1 was very dissatisfied and 10 was very satisfied. Failure was defined as subsequent intra-articular hip surgery or recurrent hip instability.
Arthroscopic findings
Hip arthroscopy was performed with a standard supine approach. His hip
capsule was grossly intact and was opened roughly 3 cm with a linear
capsulotomy between the 10:30 and 2:30 position on the acetabulum for exposure
and a 1 cm medial sleeve of capsular tissue was preserved for later repair. His
labrum was extensively torn, shredded, degenerative and severely bruised from
the 7:0–4:30 position of the acetabulum. It also appeared very small, measuring
2 mm in diameter throughout (Fig. 5). Additionally, it did not form a seal with
a femoral head, so it was non-functional and did not contribute to the
stability or volume of the acetabulum (Fig. 6). The labrum was deemed not
suitable for repair as it was grossly insufficient in size, inflamed and
chronically torn. In the posterior compartment the labrum and capsule complex
was torn off of the posterior aspect of the acetabular wall (Fig. 7). The
posterior wall of the acetabulum was shallow, but there was no evidence of a
fracture from the previous instability episodes. In the peripheral compartment
there was reactive wear over the neck from the underlying cam type impingement.
There was also an indentation medial to the head/neck junction on the anterior femoral
head in a crescent shape that likely resulted from the previous posterior
dislocations (Fig. 8). A grade 2 area of chondromalacia measuring 5 × 15 mm was
noted on the posterior inferior aspect of the acetabulum, and diffuse grade 1
chondromalacia and softening of the cartilage on the posterior femoral head was
also noted. Otherwise the cartilage was normal. As expected, the ligamentum
teres was completely absent and a large amount of inflammatory tissue was
present in the fovea (Fig. 9). Additionally, in the peripheral compartment any
adduction in a flexed position caused the femur to violently dislocate
posteriorly. This indicated substantial joint instability and reinforced the
need for combined labral and ligamentum teres reconstruction.
 |
| Fig. 5. Arthroscopic view from the anterolateral portal showing an extensively torn, shredded and bruised labrum measuring 2 mm in diameter. |
 |
| Fig. 6. Arthroscopic view from the anteromedial portal of the anterior aspect of the reduced hip showing a severely torn and bruised labrum with no seal between the femoral head and acetabulum. |
 |
| Fig. 7. Arthroscopic view from the anteromedial portal of the posterior aspect of the hip joint showing a severely torn and inflamed labrum and capsule. |
 |
| Fig. 8. Arthroscopic view from the anteromedial portal with the hip flexed showing an indentation in the femoral head, suggestive of previous hip dislocation. |
 |
| Fig. 9. Arthroscopic view from the anterolateral portal showing a severely inflamed fovea and deficient ligamentum teres. |
Surgical technique
Arthroscopically, femoral osteoplasty was performed, removing 4–7 mm of excess bone over a 3.5 mm width to create a more anatomic concavity, reducing the alpha angle to approximately 45 degrees and removing the cam deformity. The labrum was resected and the acetabular rim was excoriated, which, in addition to the femoral osteoplasty, provided a nice bleeding environment for incorporation of the labral graft. The goal was to prepare the acetabular edge without reducing the acetabular volume, so less than 1 mm was removed to achieve this.
The torn, damaged labrum was removed from the origin of the transverse
acetabulum (7:30) to approximately 2/3 down the back of the acetabulum (4:00).
The labral reconstruction was performed using a front-to-back fixation
technique described previously [20]. The extent of the labral deficiency was
first measured to estimate graft length and anchors were placed in the
acetabular rim in preparation of securing the labral graft. Frozen iliotibial
band allograft was used for this technique. The graft was rolled and sutured
using an accordion-type suturing technique to create a final tubularized graft measuring
approximately 5.5 mm in diameter and 12.5 cm in length. After the graft was
secured to the acetabular rim utilizing the nine previously placed suture
anchors, the hip was reduced and a perfect seal was noted between the
reconstructed labrum and the femoral head (Figs 10 and 11). The hip was also
more stable in the peripheral compartment.
 |
| Fig. 10. Arthroscopic view from the anteromedial portal of the posterior aspect of the joint showing the 12.5 cm labral reconstruction with allograft from approximately the 1: 00–4: 00 position. |
 |
| Fig. 11. Arthroscopic view from the anteromedial portal showing a perfect seal between the allograft labral reconstruction and a concentrically reduced femoral head. |
Following the labral reconstruction, the ligamentum teres reconstruction began using a similar technique as described previously [21, 22]. The joint remained in a reduced position while a guide wire was placed over the lateral aspect of the femur to establish an acceptable guide to the inferocentral aspect of the femoral head over the fovea (2:00 position). Once the guide wire was in an acceptable position, the hip was distracted to view entry of the guide wire through the femoral head. Parallel guides were used to make small adjustments and a 10 mm drill was used to create a tunnel from the lateral aspect of the femur to the femoral head. Once this was completed, the synovium and the remnant of the ligamentum teres over the posterior aspect of the fovea down to the bone were then debrided working either down the tunnel in the femoral neck or through the arthroscopic portals. A 4.5 mm drill was inserted down the femoral neck tunnel and angled posteriorly into the fovea. This was used to drill through the fovea and fluoroscopic assistance was used to avoid plunging through the medial wall of the pelvis.
Once the tunnel was created, a Zimmer Biomet ToggleLoc (Zimmer Biomet,
Warsaw, Indiana) was passed to the medial aspect of the pelvis and flipped
under fluoroscopic guidance. The ligamentum teres graft was created from a
tibialis anterior allograft measuring approximately 5 mm in diameter and 18 cm
in length (Allosource, Centennial, Colorado). The graft was then looped through
the suture construct on the end of the ToggleLoc and doubled over to create a
final graft diameter of 10 mm. The suture was then used to pull the graft down the
femoral tunnel to the base of the fovea. This zip loop construct locked the
medial aspect of the graft to the fovea of the acetabulum. With the graft
fixed, the hip joint was reduced and a perfect seal was noted between the
labral reconstruction and the femoral head. The anterior portion of the
capsulotomy was then closed with #1 vicryl to preserve the stability gained
with an intact hip capsule. With the hip extended and externally rotated
slightly, the ligamentum teres graft was tightened and a 9 × 30 mm PEEK
interference screw (Arthrex, Naples, Florida) was inserted in the femoral
tunnel to secure the graft (Fig. 12).
 |
| Fig. 12. Arthroscopic view from the anteromedial portal showing the ligamentum teres reconstruction with allograft. |
Postoperative management
The rehabilitation program following the labral and ligamentum teres reconstruction was similar to that following labral reconstruction [8]. The patient was cautioned regarding the aneural properties of the grafts and began a supervised physical therapy program within 1 week of surgery. Limited weight bearing at 30% for 6 weeks and posterior hip precautions were maintained, including no flexion more than 90 degrees, no adduction across midline or internal rotation and an abduction pillow for 4 weeks. The focus of physical therapy was to regain motion, strengthen the gluteus medius muscle and establish a normal gait pattern. The long-term goal was to return to the full pre-injury level of physical activity approximately after 6 months.
Subjective follow-up questionnaires were obtained from the patient at 14 months postoperative. At the time of follow-up his MHHS improved from 58 preoperatively to 100 postoperatively and his LEFS improved from 56 to 79. Similarly, his VAS pain scores decreased; at rest he improved from 3 to 1, with activity he improved from 3 to 1, and with athletics he improved from 5 to 1. Patient satisfaction was 10 out of 10. The only subjective complaint was ‘a little bit of difficulty’ with ‘making sharp turns while running fast’ on the LEFS. The patient has not reported any episodes or subjective feelings of instability and has not required further surgical procedures in the hip.
Imaging, including anteroposterior and lateral radiographs, was obtained
at 3 months posteroperatively. The radiographs showed a non-arthritic joint
that is well reduced and hardware for the ligmentum teres reconstruction in the
appropriate position (Fig. 13).
 |
| Fig. 13. Final AP pelvis radiograph showing anatomic tunnel placement and medial fixation of the ligamentum teres reconstruction and a concentric, stable reduction of the left hip. |
At 14 months postoperative, simultaneous arthroscopic labral reconstruction and ligamentum teres reconstruction in a young patient with recurrent, severe hip instability resulted in excellent patient-reported outcomes. While arthroscopic labral reconstruction and ligamentum teres reconstruction techniques have been reported separately in the literature [(20–22], to our knowledge, simultaneous reconstructions have been rarely reported. Consistent with the results identified in a previous systematic review on ligamentum teres injuries [16, 17] and published outcomes following arthroscopic labral reconstruction of the hip [8, 23, 24], the postoperative results in this case suggest benefits of surgical reconstruction in the presence of recurrent hip instability.
While the acetabular labrum’s role in hip stability is increasingly recognized [2, 3], the ligamentum teres has recently emerged as a key stabilizer of the hip that may also contribute to hip symptomology [10, 16, 17, 25–27]. Nociceptive and proprioceptive nerve endings have been identified in the ligamentum teres, indicating that damage to this structure may produce pain [10, 16, 27, 28]. Additionally, although the published data regarding mechanical and biological properties of the ligamentum teres are still limited, increasing evidence suggests that it may be critical for hip stability [16, 17]. Data from animal models demonstrated a significant increase in the number of hip dislocations when the ligamentum teres was resected compared with the control group with intact ligamentum teres [16, 25]. The ligamentum teres is believed to contribute to the stability of the hip most substantially when externally rotated and flexed or internally rotated and extended, and when other stabilizers of the hip such as the acetabular labrum are deficient [12, 16].
As our understanding of hip anatomy evolves and improves, arthroscopic treatment options for both labral and ligamentum teres pathology have also advanced. Historically, surgical options for both labral and ligamentum teres pathology included predominantly debridement and resection [17, 29, 30]. In recent years, arthroscopic techniques for labral pathology have progressed to primarily labral preserving procedures. Complete labral reconstruction, in particular, has recently emerged as a first-line treatment option in the setting of insufficient or poor-quality labral tissue [8]. Several advantages for labral reconstruction over labral repair include the recreation of a normal labral size and quality and recreate a tight seal between the femoral head and the labrum, which results in improved stabilization of the hip and reduced pain [8, 13, 21, 31]. Similarly, while short-term successes in reducing pain following ligamentum teres debridement have been appreciated, complete reconstruction may provide further benefits for pain reduction and improved hip stability, especially in positions of extension or external rotation while squatting [13, 16].
Due to the important stabilization role of both the acetabular labrum and the ligamentum teres, arthroscopic ligamentum teres reconstruction coupled with labrum reconstruction represents a novel way of approaching severe hip instability. In this case, the patient had severe recurrent hip instability with appropriate acetabular coverage following a lacrosse injury. Subsequently, the preferred treatment choice was soft tissue reconstruction as opposed to osteotomy. The potential for continued pain and instability with debridement, coupled with the evidence for stability provided by both the ligamentum teres and labrum, provided the basis for performing both a labrum and a ligamentum teres reconstruction on the patient. In reconstructing the patient’s acetabular labrum and ligamentum teres using allografts the patient was able to retain physiological integrity in the hip joint, and short-term outcomes have been excellent.
Limitations
Early outcomes recorded for this patient appear promising, but further
long-term assessment is necessary to continue to monitor hip stability, ADL and
future joint health. In addition, this procedure was performed on a young,
otherwise healthy adolescent. This population can represent a particularly
challenging group and may not be representative of other age groups. As a case
report, this study also does not include a comparative group; therefore, it is
not possible to determine if labral reconstruction or ligamentum teres
reconstruction alone would have resulted in the same outcome. Given the limited
reports of ligamentum teres reconstructions in the literature, we believe this
case report is an important addition that highlights success of a novel
procedure for a complex presentation. Finally, it is important to note that
this procedure is technically demanding, requires advanced hip arthroscopy
training, and has a steep learning curve. As such, these results may not be
generalizable to all patients or surgeons.
Conclusions
This case report demonstrates a technique for and early outcomes of simultaneous arthroscopic ligamentum teres and acetabular labrum reconstruction in a patient with recurrent hip instability. Short-term outcomes suggest improved hip stability, reduced pain, high patient satisfaction and return to pre-injury activities at 14 months postoperative in this single case report.
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Source & links
White BJ, Scoles AM, Herzog MM. Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report. Journal of Hip Preservation Surgery. 2018;5(2)166-73. doi: 10.1093/jhps/hny001 pmc.ncbi.nlm.nih.gov
Authors & Affiliations
Brian J White – Western
Orthopaedics, 1830 Franklin Street, Suite 450, Denver, CO 80218-1217, USA
E-mail:
prismresearchconsulting@gmail.com
Alexandra M Scoles – Western
Orthopaedics, 1830 Franklin Street, Suite 450, Denver, CO 80218-1217, USA
Mackenzie M Herzog – Professional
Research Institute for Sports Medicine, LLC, Chapel Hill, NC 97515, USA
Notes
Licence
This is an open access article.
FUNDING
None.
CONFLICT OF INTEREST STATEMENT
Brian J. White is a consultant for Smith & Nephew, Biomet, and
Conmed Linvatec, where he holds a role in surgeon education and product
development for hip arthroscopy.
Keywords
ligamentum capitis femoris, ligamentum teres, ligament of head of femur, experiment, animals, rabbit, plastic surgery, reconstruction, open plastic surgery, experiment
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