Translation of the article: Архипов СВ. Новая техника проксимального крепления при реконструкции ligamentum capitis femoris: Дары волхвов ортопедическим хирургам. The text in Russian is available at the following link: 2026АрхиповСВ
CONTENT [i] Abstract [ii] Introduction [iii] Materials and Methods [iv] Technique [v] Discussion [vi] Conclusion [vii] Appendix [viii] References [ix] Structured Abstract [x] Additional material |
An experimental technique for reconstruction of
the ligamentum capitis femoris (ligamentum teres femoris) is described. The
proposed method involves creating two portions of the ligament analog: a pubic
portion and an ischial portion. Fixation of these portions is performed in
ischial and pubic tunnels drilled in the corresponding pelvic bones. The
technique was tested on a hip joint model. In arthroscopic reconstruction, it
is proposed to provide visualization through the inferior approach and the
femoral tunnel without distraction in the joint.
Approximately 3600 years ago, an anonymous
Egyptian physician recognized the role of the ligamentum capitis femoris (LCF;
ligamentum teres femoris) in the development of hip joint pathology (2025АрхиповСВ,e). He conveyed this insight to humanity in a manuscript that later
became the Book of Genesis, originally known as Bereshit (1922LeeserI; 1978БроерМ_ЙосифонД; 2025ArkhipovSV_ArkhipovaLN). In our view, this same physician authored
the oldest surgical textbook, now referred to as the Edwin Smith Papyrus
(1930BreastedJH). Evidence supporting this includes numerous medical
correspondences between the two texts (Appendix. Table). Such a high level of
medical knowledge was not documented anywhere in the world before or after
Egypt's Second Intermediate Period. The subsequent decline in medicine
persisted until the first millennium BCE, as evidenced by Mesopotamian
cuneiform texts and the Middle and New Kingdom papyri from the Nile Valley that
we have examined (Appendix. List).
The fact that a literary work from the Hyksos era became foundational to three major religions helped preserve critical information regarding of LCF injury. The first part of the biblical epic provides the earliest description of the injury mechanism, symptomatology, and differential diagnosis (Genesis 32:26,32-33; 33:3,14 according to 1922LeeserI; 1978БроерМ_ЙосифонД). This generous “gift of the Magi” proved extremely premature but was intended for the future. Contemporaries showed no interest in the identified problem of treating traumatic of LCF pathology. As often happens, the personal and the immediate were placed above the general and the future. The ancient physician was unable to devise a solution. Otherwise, the positive Old Testament hero who sustained a hip joint injury would have been healed upon in Egypt (2024АрхиповСВ). The objective reason was the primitive state of medical technology in the Bronze Age. An unknown intellectual delicately conveyed to posterity a call to find an answer to a complex clinical problem between the lines of a Book of Genesis.
In the first millennium BCE, the anatomical
structure mentioned in the Torah—that is, the Holy Scripture of Judaism—was
treated with religious reverence. It was sometimes interpreted as the femoral
tendon, muscle, blood vessel, or nerve. This is evident from discussions among
priests recorded in the Babylonian Talmud and from early translations of
Genesis from Hebrew. The material cause of the affliction did not fit their
theological doctrine. The priests interpreted the consequences of the mythical
incident allegorically and ignored the instruction to take care of LCF. In the
early first millennium CE, rabbis Eliezer, Rava, Yehuda, and Shmuel, understood
what structure was being referred (1916FriedlanderG; 1948EpsteinI). In the
second millennium, this view was confirmed by qualified physicians
(1851MaimonidesM; 1923,2004PreussJ). In the third millennium, it appears undisputed
among orthopedic and traumatologists, classical philologists, and translators
(2010СафроновД; 2019ArkhipovSV_SkvortsovDV; 2020ArkhipovSV_ProlyginaIV).
LCF injury is now widely recognized. At the end of the 20th century, pioneers of hip arthroscopy drew attention to it (1997GrayAJ_VillarRN; 1998ByrdJWT). In the early stages of development of this field of surgery, LCF damage was “treated” by resection or complete removal (1994VillarRN; 1997GrayAJ_VillarRN; 1999BaberYF_VillarRN; 2003ByrdJW_JonesKS). Later, it was established that arthroscopic debridement of isolated LCF tears yields short-term positive results (2011HavivB_O’DonnellJ). It should be noted that are still unclear about what exactly needs to be done in case of pathological changes of this structure.
Hippocrates of Kos, flourishing in the 5th–4th centuries BCE, believed that torn intra-articular structures do not heal. In §40 of his treatise Mochlicon, he stated: “Parts torn asunder, whether nerves [i.e. sinew, ligaments], or cartilages, or epiphyses, or parts separated at symphyses, cannot possibly be restored to their former state;” (1886AdamsF; 1941Гиппократ). It is unsurprising that the works of Asclepiades contain no recommendations for treating damaged hip joint structures. In the 3rd–2nd centuries BCE, the Greek physician Heraclides of Tarentum relied on spontaneous restoration of the LCF following dislocation (1829KühnCG; 2019АрхиповСВ_ПролыгинаИВ; 2020ArkhipovSV_ProlyginaIV). The Alexandrian surgeon Hegetor, in the 2nd century BCE, advised non-intervention and leaving the condition as is in such injuries (1965KolleschJ_KudlienF; 2020ArkhipovSV_ProlyginaIV). Suspecting excessive elasticity of the LCF, Galen of Pergamon in the 2nd century CE employed conservative therapy with “drying” applications, likely combined with prolonged immobilization (1829KühnCG; 2019АрхиповСВ_ПролыгинаИВ; 2020ArkhipovSV_ProlyginaIV).
For approximately 1700 years, no innovations emerged in the treatment of LCF pathology. In the 19th century, changes in the LCF were merely noted in association with hip trauma and disease (1839VrolikG; 1847DupuytrenG; 1879TillauxPJ). Only in the 1920s—exactly one hundred years ago—was the first open LCF reconstruction reported for congenital hip dislocation (1926,1927HeyGrovesEW). The technique was refined throughout the remainder of the 20th century and continues to evolve (1947ЗацепинТС; 1959,1962ФишкинВИ; 1960ШкольниковЛГ; 1964ЖуховицкийМС; 1964ЧаклинВД; 1980СегизбаевАУ; 1982ГинзбургЮБ_СущевичВГ; 1983МовшовичИА; 1986KorkusuzZ; 1986СтаматинСИ_МораруАТ; 1991ЗоряВИ_ПаршиковМВ; 1991КадыровМ_АхматовА; 1992МашковВМ_ТихоненковЕС; 1993ГафаровХЗ_АндреевПС; 1993КамоскоММ; 1993МашковВМ; 2008BacheCE_TorodeIP; 2008WengerDR_MiyanjiF; 2018YoussefAO; 2021PaezC_WengerDR; 2025EnglertG_KlingeleK; 2025SarassaC_HerreraAM).
We first considered applying arthroscopy and minimally invasive techniques for LCF reconstruction in 1996–1997 (1996,1997ArkhipovSV). A decade later, in 2006, success with arthroscopic reconstruction of this structure was first reported at conferences (2006PhilipponMJ,a,b). The initiative was enthusiastically adopted worldwide (2009BardakosNV_VillarRN; 2011BriggsKK_PhilipponMJ; 2011SimpsonJM_VillarRN; 2012AmenabarT_O’DonnellJ; 2012PhilipponMJ_GaskillTR; 2013LindnerD_DombBG; 2014Mei-DanO_McConkeyMO; 2014O'DonnellJM_SinghPJ; 2015HammarstedtJE_DombBG; 2016ChandrasekaranS_DombBG; 2016GarabekyanT_Mei-DanO; 2016KraeutlerMJ_Mei-DanO; 2016MengeTJ_PhilipponMJ; 2017ChaharbakhshiEO_DombBG; 2017DimitrakopoulouA_VillarRN; 2018BajwaAS_VillarRN; 2018BradyAW_Philippon MJ; 2018LocksR_PhilipponMJ; 2018NeumannJA_BanffyMB; 2018WhiteBJ_HerzogMM; 2019MaldonadoDR_DombBG; 2020O’DonnellJ_TaklaA; 2020RosinskyPJ_DombBG(a); 2020RosinskyPJ_DombBG(b); 2021AnkemHK_DombBG; 2021ShapiraJ_DombBG; 2024IsmailogluAV_KayaalpA). Gradually, the initial enthusiasm waned. A systematic review of outcomes following arthroscopic LCF reconstruction revealed reoperation rates varying up to 100% with anchor fixation and up to 22% with endobutton fixation (2021KnapikDM_ChahlaJ). Cases of semitendinosus graft resorption were noted (2012AmenabarT_O’DonnellJ). Although graft choice remains at the surgeon's discretion, the optimal option has not yet been determined (2025DombBG_Quesada-JimenezR).
Observing the declining trend in interest in surgical treatment of the LCF, we published the results of calculations showing that the load on the ligament during walking can be three times greater than body weight, that is, approximately 1750 N at normal weight (2019ArkhipovSV). By highlighting these intense pull-out forces, we aimed to direct colleagues toward exploring alternative graft fixation approaches. Coincidentally, an experimental study soon appeared that had a sobering effect on the arthroscopic community. A respected team demonstrated the insufficient reliability of popular fixation methods for reconstructed LCF: 438.1 ± 114.3 N with a button and even lower with an anchor (2021LallAC_DombBG). Subsequently, findings from an authoritative American-European collaboration undermined the technique further. By determining low LCF strength in pathological states, the investigators concluded that it has minimal significance for joint stability in normal conditions (2024StetzelbergerVM_TannastM).
In our opinion, LCF weakness in hip joint diseases is one of the primary causes of their development, alongside elongation and dysfunction (2012,2023АрхиповСВ). In healthy young joints, the mechanical properties of the LCF are comparable to those of the anterior cruciate ligament (2007WengerD_OkaR). The rationale for reconstructing the latter following injury has long been undisputed. The same will undoubtedly apply to the LCF once a reliable replacement method is established.
Today, altered LCF is rarely reconstructed during acetabular labral repair, despite this creating predispositions to osteoarthritis (2018WhiteBJ_HerzogMM; 2025ArkhipovSV,d; 2025АрхиповСВ,c). In femoroacetabular impingement syndrome, researchers see no substantial harm in partial LCF removal (2021BodendorferBM_NhoSJ). However, by focusing on LCF ruptures and those without it, the authors did not take into account the lengthening variant, in which the compressive force of the articular surfaces in the upper part of the joint increases. We observed this effect in experiments on mechanical models. Consequently, cartilage degeneration and osteophyte formation—i.e., the onset of osteoarthritis—are highly probable. The pathogenesis of femoroacetabular impingement syndrome remains incompletely understood, with a likely role for imbalances in biological, physical, and environmental factors (2025HeereyJ_AgricolaR). The impact of biomechanical disruptions due to LCF changes has not yet been fully evaluated, but we consider it the leading cause.
At the close of the first quarter of the 21st
century, research on the LCF has regained momentum. Experimental evidence has
emerged regarding its importance for musculoskeletal biomechanics
(2025ChenJH_AcklandD; 2025TengJ_RenL; 2025ZhangY_MartinRL). Even the use of an
LCF analog in a zoomorphic robot joint has been described (2025ItoH_SuzumoriK).
A
decade ago, A.S. Arkhipova suggested a more elaborate configuration of a
weight-bearing articulation featuring flexible elements and developed a working
prototypes of anthropomorphic and zoomorphic walking platforms (2016АрхиповаА; 2017,2018АрхиповаАС).
Moderate optimism persists among certain research groups regarding LCF reconstruction (2025DombBG_Quesada-JimenezR). As evident from the stream of publications we continuously monitor, a critical mass of consensus is accumulating on the significant role of the LCF (2025ArkhipovSV,a; 2025АрхиповСВ,a). This offers hope for reevaluating previously held negative views.
Why has no consensus yet emerged regarding the interpretation of surgical treatment failures for LCF? In our view, this stems from a lack of clear understanding of its function, physical, and topographic characteristics in the healthy joint. Galen of Pergamon was among the first to address this topic, outlining his position in the “Fourth Commentary on Hippocrates' Book On Joints” (1829KühnCG; 2019АрхиповСВ_ПролыгинаИВ; 2020ArkhipovSV_ProlyginaIV). The work indicates that the LCF should be short, flexible, extremely strong, elastic, and attached at appropriate sites. These characteristics evidently describe the norm in young subjects, whose anatomy Galen studied through dissections (1971ГаленК; 1959KevorkianJ; 2017ПролыгинаИВ). Systematic human anatomical studies in the 19th century noted extreme variability in LCF size, strength, and location (1848HarrisonR; 1868BeaunisH_BouchardA; 1893MoserE). Paraphrasing Virgil's words from the Aeneid (1979, IV:568-570) concerning the goddess Athena, J. Cruveilhier (1837) wrote: “nothing is more variable than the thickness and strength” of the LCF. We see in this the prerequisites for diverse dystrophic hip joint diseases (2004Архипов-БалтийскийСВ; 2012,2023АрхиповСВ).
The principles of Galen of Pergamon should be
followed when reconstructing the LCF. Failure to satisfy even one condition
dooms the procedure and subsequent rehabilitation to failure. Hip
osteoarthritis becomes inevitable. Hope for recovery, cherished by both
physician and patient in preparation for surgery, vanishes entirely. The future
holds only implantation of a prosthesis—essentially a simple ball-and-socket
joint—with its attendant limitations and complications (dislocation, loosening,
accumulation of wear debris). More advanced artificial hip joints incorporating
a full ligament complex exist only as models and experimental prototypes
(2008ArkhipovSV; 2008АрхиповСВ; 2019ArkhipovSV_SkvortsovDV;
2021ArkhipovSV_SkvortsovDV; 2025ArkhipovSV,b; 2025АрхиповСВ,d). When they will appear in operating rooms remains unknown.
Unfortunately, even companies anticipating innovations from unexpected sources
show no interest in endoprostheses with ligament analogs.
The situation appears deadlocked. The reconstructed element is deemed useless for stability, known fixation methods for artificial ligaments prove unreliable, and grafts are prone to damage and lysis (2011HavivB_O’DonnellJ; 2012AmenabarT_O’DonnellJ; 2021LallAC_DombBG; 2024StetzelbergerVM_TannastM). Since antiquity, skepticism in medicine has been countered by experimentation. Drawing on our own experiments with mechanical models, we present a project for LCF restoration in adults and children via arthroscopic, minimally invasive, or open surgical intervention. Our goal is to demonstrate the fundamental feasibility of creating an LCF analog: strong, non-elongating, flexible, with physiological attachment sites, and—most importantly—reliably connected to bone.
To demonstrate the proposed technique for the
LCF reconstruction, we fabricated hip joint models. These were based on
polyurethane bone analogs from Synbone (synbone.com): a pelvis and a proximal
femur. The varnished pelvis model had a realistic cast of the acetabulum
without articular cartilage (Figures 1 and 2).
 |
| Figure 1. Pelvic model, anterior view. |
 |
| Figure 2. Pelvic model, right lateral view. |
A through hole was made in the area of one of
the proximal attachment points of the LCF, and the floor of the acetabular
fossa was excised (Figure 3).
 |
| Figure 3. Pelvic model with excised acetabular fossa floor, lateral view. |
An analog of the acetabular articular cartilage
was created from self-curing plastic compound (Figures 4 and 5).
 |
| Figure 4. Lateral view of the formed lunate surface of the right acetabulum with articular surface analog. |
 |
| Figure 5. Anterior view of the formed lunate surface of the right acetabulum with articular surface analog. |
The contralateral acetabulum was not perforated. Its lunate surface was fabricated together with an analog of the transverse acetabular ligament, leaving an opening beneath it as present in normal anatomy (Figure 6).
 |
| Figure 6. Lateral view of the formed lunate surface of the left acetabulum, with a surgical instrument inserted through the opening beneath the transverse acetabular ligament analog. |
Femoral head articular surface models were created to match the size of each lunate surface, using self-curing plastic compound applied to the synthetic proximal femur analog (Figure 7).
 |
| Figure 7. Anterior view of the proximal femur model with femoral head articular surface analog. |
When aligned, the femoral head model and
acetabular surface analog formed a complete hip joint model (Figures 8 and 9).
 |
| Figure 8. Anteroinferior view of the left hip joint model. |
 |
| Figure 9. Anteroinferior view of the right hip joint model. |
To enable of the LCF analog fixation, a
through-tunnel was drilled along the axis of the femoral neck model. The entry
point was located in the subtrochanteric region, distal to the tuberculum
innominatum (Figures 10 and 11).
 |
| Figure 10. External view of the proximal femur model with a drill inserted toward the femoral head. |
 |
| Figure 11. External view of the proximal femur model with the completed tunnel toward the femoral head. |
The exit of the femoral tunnel was positioned
in a fovea created on the femoral head articular surface analog (Figure 12).
 |
| Figure 12. Medial view of the femoral head of model, with a surgical instrument inserted into the femoral tunnel. |
To replicate the LCF during technique demonstration, braided nylon cords of appropriate diameter were used.
Currently, both open and arthroscopic
reconstructions of the LCF utilize grafts with two fixation points: femoral and
acetabular. Variations in attachment site locations are minor. Occasionally,
multiple holes are drilled in the acetabulum to enhance proximal fixation
strength of the reconstructed LCF. We replicated this general principle on
fabricated hip joint model. The proximal end of the LCF analog, made from nylon
cord, was secured in a hole at the acetabular fossa floor and passed into a
hole in the femoral head model (Figure 13).
 |
| Figure 13. View of the LCF analog connecting the acetabular fossa floor of the pelvic model and the femoral head model. |
The opposite end was retrieved from the greater trochanter region, tensioned, and secured with an element simulating an interference screw (Figures 14 and 15).
 |
| Figure 14. View of the LCF analog through a window in the acetabular fossa floor of the pelvic model. |
 |
| Figure 15. Overall view of the pelvic model and right femur connected by the LCF analog. |
With appropriately selected length, the LCF
analog effectively limited adduction in the hip joint model (Figure 16).
 |
| Figure 16. View of the LCF analog through a window in the acetabular fossa floor of the pelvic model, demonstrating adduction in the hip joint. |
At extreme adduction, the femoral head model was clearly pressed against the analogue of the articular surface of the acetabulum of the pelvis model. A similar phenomenon occurred during maximum supination and pronation with slight adduction.
In the described case, proximal fixation of the
LCF analog used a hole in the acetabular fossa floor, positioned on the long
axis of the acetabular notch, midway between the equator and the projection of
the transverse acetabular ligament. Similar fixation is occasionally employed
in open LCF reconstruction in children (2025EnglertG_KlingeleK). Our experiments
on mechanical models demonstrated greatest femoral head stability within the
acetabulum while preserving adequate mobility with this fixation. However, bone
thickness at this acetabular site is minimal.
In adults, the acetabular fossa floor consists
of two cortical plates that often fuse into one 1–1.5 mm thick layer (1993МинеевКП). According to E.P. Podrushnyak (1972), mean acetabular fossa floor
thickness is 4.6 ± 0.7 mm in individuals aged 35–40 years and 4.3 ± 0.25 mm in
those aged 60–74 years. This indicates inability to achieve secure proximal
graft fixation. Moreover, obturator vessels and the obturator nerve course
intrapelvically in projection of the acetabular fossa floor. Their injury is
possible during bone perforation with a drill and placement of fixation
devices such as cortical buttons, dumbbell stoppers, or toggle rods. “The risk
of damage to the neurovascular bundle while drilling the acetabular tunnel is
probably the key reason for arthroscopic surgeons remaining rather reluctant to
carry out LT [LCF] reconstruction.” (2018BajwaAS_VillarRN).
Resolution of this dilemma requires alternative
techniques. In a porcine experiment, proximal LCF attachment was tested outside
the pelvis. Authors drilled an oblique tunnel from a point on the anteromedial
acetabular rim toward the acetabular notch (2011HosalkarHS_WengerDR). No
clinical reports describe use of such an isocentric pelvic tunnel position for
reconstructed LCF.
Three centuries ago, J.B. Winslow (1732) noted that the proximal LCF end appeared divided “into two flat parts, each attached to one of the angles of the acetabular notch.” A century later, G.B. Palletta (1820) described a third attachment area to the transverse acetabular ligament. Portions originating from these sites are now termed: posterior (ischial) bundle, anterior (pubic) bundle, and middle bundle attaching to the superior margin of the transverse acetabular ligament (2007DemangeMK_SakakiMH). Meticulous investigation by J.D. Mikula et al. (2017) identified six proximal LCF attachment points. Attaching a graft to all appears impractical. Reconstruction should involve fixation in at least two points, creating posterior (ischial) and anterior (pubic) bundles. Such natural LCF attachment is well illustrated in authoritative anatomical texts (Figures 17 and 18).
 |
Figure 17. Left hip joint opened by removing
the acetabular fossa floor from within the pelvis (from 1918GrayH, unchanged). |
 |
| Figure 18. Elevated LCF (transverse acetabular ligament removed), labels: 1 – acetabulum, 1’ – its floor, 1’’ – acetabular labrum; 2 – LCF; 3 – pubic portion of LCF; 4 – ischial portion of LCF; 5 – acetabular artery, 5’ – arterial branch to LCF; 6, 6’ – veins from the acetabular fossa floor (from 1904TestutL, unchanged). |
Current graft fixation involves two tunnels:
femoral and acetabular. The femoral tunnel, starting subtrochanterically below
the tuberculum innominatum and directed to the femoral head fovea, appears
optimal to us. Proposals to create a tunnel from the subcapital region on the
superior femoral neck surface (see 1947ЗацепинТС) risk damaging
numerous vessels entering and exiting the femoral head (Figure 19).
 |
| Figure 19. Macerated human femur, superior and lateral view, showing numerous vascular foramina communicating with cancellous bone of the head and neck (A preparation from the Department of Orthopedics and Traumatology of the Russian Peoples' Friendship University, Moscow). |
An acetabular tunnel in the fossa floor is
permissible but insufficient for secure graft fixation. We propose creating two
additional—or solely two—tunnels: pubic and ischial (Figure 20).
 |
| Figure 20. Schematic of tunnel locations in the ischium and pubis; red indicates external openings and direction of the ischial tunnel; blue indicates external openings and direction of the pubic tunnel (from 1918GrayH, with our additions). |
The presented method proposes
to create a patient position lying on his back with a forward rotation of 45°.
The pubic region, perineum, and buttock on the operative side must be
accessible. The ischial tunnel is optimally created from a point slightly
superior to the ischial tuberosity (tuber ischiadicum). It is directed toward
the base of the posterior horn of the lunate surface, traversing the
body of the ischial
bone (Figures 21–23).
 |
| Figure 21. Process of forming the ischial tunnel in the pelvic model. |
 |
| Figure 22. Pelvic model, inferior view, with entry hole for the ischial tunnel at the right ischial tuberosity. |
 |
| Figure 23. Pelvic model, lateral view, with surgical instrument inserted into the ischial tunnel, exiting into the acetabular notch. |
The pubic tunnel is created from a point at the
pubic tubercle (tuberculum pubicum). It is directed toward the base of the
anterior horn of the lunate surface, traversing the superior pubic ramus and
the body of the pubic bone (Figures 24–26).
 |
| Figure 24. Process of forming the pubic tunnel in the pelvic model. |
 |
| Figure 25. Pelvic model, anterior view, with trocar inserted into the pubic tunnel entry. |
 |
| Figure 26. Pelvic model, posterolateral view, with trocar inserted into the pubic tunnel exit from the acetabular notch. |
Penetrating the acetabular notch via these
tunnels eliminates risk to pelvic organs, major nerves, and main vessels. Tunnel
creation requires fluoroscopic and endoscopic control. An arthroscope is
introduced into the acetabular notch via the inferior portal (Figure 27), as
previously described by us (2025ArkhipovSV,c; 2025АрхиповСВ,b).
 |
| Figure 27. Anterior view of the left hip joint model, with optical system and surgical instrument inserted into the acetabular notch. |
Via the inferior portal, without distraction,
the following can be performed:
- inspection of the central compartment of the hip;
- inspection of the peripheral compartment of
the hip;
- removal of damaged LCF portions;
- preparation of anticipated tunnel exit sites;
- verification the accuracy of the guidewire and drill exit.
In some cases, certain manipulations may be
performed subsynovially without entering the joint cavity. After tunnel
creation, they are temporarily occluded to stop bone bleeding and fluid/gas
leakage.
The next step we propose is the creation of a
femoral tunnel using one of the known methods. Through it, without distraction,
the following can be performed:
- central compartment of the hip inspection;
- central compartment of the hip surgical
procedures;
- introduction of distal LCF endoprosthesis
fixation construct.
The femoral tunnel is temporarily occluded post-creation to stop bleeding and fluid/gas leakage before further steps. It can accommodate both optical system and instruments (Figure 28).
 |
| Figure 28. Demonstration of inserting optical system and surgical instrument into the femoral tunnel. |
Formed pubic and ischial tunnels can similarly
accommodate surgical instruments, akin to the femoral tunnel (Figure 29).
 |
| Figure 29. Demonstration of inserting surgical instruments into femoral and ischial tunnels. |
Visual support for these manipulations is provided by arthroscope insertion through the acetabular notch (Figures 30 and 31).
 |
| Figure 30. Demonstration of working with a surgical instrument inserted via the ischial tunnel, with optical system positioned in the acetabular notch. |
 |
| Figure 31. Demonstration of optical system in the acetabular notch and surgical instruments working in the joint via ischial and femoral tunnels. |
Concurrently, an assistant prepares two grafts
for LCF reconstruction or selects appropriately sized LCF endoprostheses. The
joint and LCF subsynovial space are irrigated, and the surgical team changes
gloves. Grafts or endoprostheses are sequentially introduced into the pubic and
ischial tunnels, advanced toward internal openings using wire passers and
ligatures (Figure 32).
 |
| Figure 32. Lateral view of the acetabulum of the pelvic model and portions of the LCF analogue inserted through the pubic and sciatic tunnels. |
The pubic and ischial LCF analog portions are
advanced toward the acetabular notch. Advancement assistance is possible with a
clamp inserted via the contralateral pelvic tunnel, plus additional support
from instruments via the femoral tunnel. Intra-articular length of pubic and
ischial portions can be adjusted later by tensioning distal ends (Figures 33
and 34).
 |
| Figure 33. Lateral view of the pelvic acetabulum model connected to the femoral model via pubic and ischial portions of the LCF analog. |
 |
| Figure 34. Overall view of the pelvic model connected to the femoral model via pubic and ischial portions of the LCF analog. |
Tensioning of each LCF analog portion follows
in adduction, extension, and external rotation (Figure 35).
 |
| Figure 35. Medial view of the acetabulum of the pelvic model and portions of the LCF analogue inserted through the pubic and sciatic tunnels. |
Finally, proximal and distal ends of pubic and
ischial LCF analog portions are secured in bone tunnels.
As noted, a third portion is possible, with proximal fixation at the acetabular fossa floor. Optimal point is at the acetabular notch–fossa boundary. The fossa floor hole can be created via the femoral tunnel (Figure 36).
 |
| Figure 36. Demonstration of creating a hole in the acetabular fossa floor via the femoral tunnel. |
A fourth portion attaching proximally to the transverse acetabular ligament is feasible but would lack mechanical function. In the experiment, proximal attachment displacement peripherally, promotes dislocation upon tensioning the LCF analog. The fourth portion could transmit tensile load to the transverse acetabular ligament. Its mechanoreceptors, with training, may partially compensate for lost native LCF sensory apparatus. R. Dee (1969) demonstrated close linkage between LCF and capsular sensory apparatus and hip muscle activity. We believe and electromyography reveals LCF– gluteus medius muscle interaction too. The gluteus medius muscle electromyographic curve shows a small plateau mid-single-support phase of gait (Figure 37).
 |
| Figure 37. Graph of gluteus medius muscle bioelectric activity during walking; vertical blue lines denote double-support phase, arrows indicate activity reduction segments in single-support phase, between which a plateau signals relative bioelectric signal increase. |
We attribute this gluteus medius muscle
activity increase to peak LCF tension episode. Both structures act
synergistically, with the muscle partially shunts load on the LCF.
For tendon's grafts, at least four months of protected weight-bearing during walking is required. Post-integration with tunnel walls, scar tissue maturation and strengthening training follows. This approach suits young patients. In middle and older age, LCF endoprosthesis use is optimal. Methods for fixing them in bone tunnels have been developed during the reconstruction of ligaments of other joints.
The areas of fixation of the LCF endoprosthesis in the femur can be elements of modified implants for osteosynthesis of the proximal femur, e.g., trifin nail with side plate, dynamic hip screw, or gamma nail in select cases (Figure 38).
 |
| Figure 38. Demonstration of LCF analog integration with implants; right – dynamic hip screw; left – trifin nail. |
After destruction of the LCF graft or
endoprosthesis, the possibility of repeated reconstruction must remain.
In aseptic femoral head necrosis or early osteoarthritis with pain, joint replacement is considered. With preserved acetabular cartilage, subtotal hip arthroplasty with LCF analog is appropriate (Figure 39).
 |
| Figure 39. Prototype subtotal hip prosthesis with LCF analog designed by us. |
Femoral component instability or lunate surface cartilage destruction
indicates total hip arthroplasty with LCF analog (2025ArkhipovSV,b; 2025АрхиповСВ,d). We have only a
demonstrational total hip prosthesis prototype with LCF analog (Figure 40).
 |
| Figure 40. Our prototype total hip endoprosthesis with LCF analog. |
Constructs of hip prosthesis with LCF and external ligaments are indicated in revision arthroplasty and oncologic procedures.
Implementation of our LCF reconstruction
technique involves arthroscopy, fluoroscopy, and small incisions. A key element
is the use of a novel access to the central compartment through the acetabular
notch (2025ArkhipovSV,c; 2025АрхиповСВ,b), which has not yet been clinically tested.
Ideally, most manipulations should be performed extra-articularly, specifically
within the subsynovial space of the LCF, which normally forms a tent-like
structure. Entry is possible beneath the transverse acetabular ligament, with
displacement and removal of adipose tissue. Hypothetically, penetration into
the synovial sheath through the femoral tunnel is possible, provided the LCF
synovial membrane is preserved and stromal damage occurs (subsynovial damage).
During surgery, every effort should be made to
preserve lymphatic, venous, and arterial vessels traversing the acetabular
notch. Particular attention must be paid to protecting terminal branches of the
acetabular and ligamentous portions of the ramus posterior nervi obturatorii.
This helps prevent complete loss of proprioception. Maintaining central nervous
system control is desirable to ensure comprehensive muscle-joint sensation for
upright posture maintenance and locomotion. Compensation for lost LCF
tensoreceptors may involve connecting one portion of the reconstructed LCF
analog to the transverse acetabular ligament.
Advantages of the proposed principle include
minimal trauma, reduced risk of compressive neuritis, and avoidance of
inadvertent damage to the acetabular labrum or external genitalia during joint
distraction. If there is no need to create an acetabular tunnel, the
possibility of injury to the obturator vascular-nerve bundle, pelvic organs, as
well as the injection of fluid or gas into the retroperitoneal space is
excluded. Skin incisions in the inferior gluteal fold, inguinal fold, and pubic
region—for creating ischial and pubic tunnels and the inferior portal—enhance
postoperative cosmesis.
This is our contribution to solving the tricky problem of treating LCF pathology, first identified by an ancient physician on the Nile's banks. We are not destined to implement the proposed reconstruction method. Orthopedic surgery is the work of the young. If not in its entirety, then perhaps someone will apply elements of the method in a different modification. The above is an as-yet-unclaimed gift for the coming generation of orthopedic surgeons.
The version of the Edwin Smith Papyrus that has
reached us—a copy of a much older original. It dates back to the 17th century
BC and was left unfinished. The scribe abruptly halted work, stopping “in the
middle of a line, in the middle of a sentence, in the middle of a word”
(1930BreastedJH). We can only speculate on the reasons: unfavorable
circumstances, declining health, or perhaps a realization of the lack of
interest among physicians.
Ultimately, the document was placed in an
unknown tomb, where it escaped destruction. Priests and magician-healers, alien
to scientific thought, could not destroy ideas that contradicted their
worldview. Having survived the ignorance of many eras, the manuscript
mysteriously returned from the afterlife. It feels as though, by the author's design,
this return occurred during a period of rapid advancement in surgical art and
morphology. The forgotten text materialized at the appointed time. As in a
fairy tale, in January 1862, a figure named Mustapha Aga—literally “the chosen
elder”—appeared to Edwin Smith and sold the priceless manuscript at an
accessible price (1930BreastedJH). Whether this was the mysterious dwarf
Rumpelstiltskin or the god Imhotep himself? A messenger pierced time to deliver
the work of a long-deceased polymath as a “gift of the Magi” to medical
innovators.
 |
Edwin Smith
(1822–1906) Artist Francisco
Anelli (1847) (CC0 – public domain, color correction, original in emuseum.nyhistory.org
collection). |
The scale of this “Medical Scripture” has been duly appreciated after 3500 years! Its first translator, J.H. Breasted (1930), noted that the Edwin Smith Papyrus is the earliest known scientific document, revealing an ancient Egyptian surgeon with a scientific mindset capable of observation and rational deduction from findings. Contemporary scholars confirm the authorship of a physician seeking the secrets of the human body, recognizing processes and states arising from physical factors (2005FisherRFG_ShawPLF). Essentially, a similar situation is described in the Book of Genesis: following a hip joint dislocation and LCF injury, lameness “upon his thigh” appears (Genesis 32:26,32-33 according to 1922LeeserI). In the vast majority of cases, this symptom is accompanied by pain. The author, evidently possessing medical training, describes in a text that became religious the onset of disease. Later, it would inevitably culminate in osteoarthritis. The primary link in the pathogenesis of this legendary pathology is unequivocally identified as an LCF defect. The plot's creator clearly understood this inexorable sequence but was powerless to prevent it. Whether he contemplated the possibility of suturing or plastic reconstruction of the LCF, it is a mystery.
It appears that the Edwin Smith Papyrus and the
Book of Genesis are the work of one author. The grandeur of his labor and
talent were realized only after thousands of years. Thus, despite obscurantism,
he lived and created not in vain. Digitized, these precious texts are now
hosted on numerous internet pages. There is hope they will endure eternally in
this form. Upon their initial publication, they underwent no peer review, nor
was their formatting, structure, or style coordinated. We proceed similarly.
Subjected only to self-censorship and capturing a personal perspective on LCF
reconstruction, this article will become public domain in the online space. Let
it be so, and for benefit – Sic fiat, et ad utilitatem.
S.A.
14 January 2026
Joensuu
P.S. The author is open to collaboration with implant and instrument manufacturers.
Table. Comparison of the level of medical knowledge in the Book of Genesis and ancient Egyptian papyri from the Middle to New Kingdom periods*
|
Concepts
in the fields of medicine, anatomy, and human physiology |
Historical periods |
|||
|
Middle Kingdom,
2040-1640 BCE**; sources are listed in the footnote |
Second Intermediate Period, 1640-1550 BCE** |
New Kingdom,
1550-1070 BCE**; sources are listed in the footnote |
||
|
Edwin Smith
Papyrus, 1640-1550 BCE*** (Before the Minoan
eruption?, 1610±14 BCE****) |
Book of Genesis,
circa 1600 BCE***** (After the Minoan
eruption, 1610±14 BCE****); |
|||
|
Surgical
manipulation of the chest |
- |
Case 44 |
2:21-22 |
- |
|
Ligament of the synovial joint and its pathology |
- |
Cases 7, 30 |
32:33 |
- |
|
Participation of a physician in dissection |
- |
Case 33 |
50:2 |
- |
|
Description of the L5-S1 nerve roots tension test |
- |
Case 48 |
33:3 |
- |
|
Description of walking after injury |
- |
Case 8 |
32:32; 33:14 |
- |
|
Cervical spine
injury |
- |
Cases 30-33 |
40:19 |
- |
|
Wound edge connection |
- |
Cases 2, 3, 10, 14, 23, 28, 47 |
2:21 |
- |
|
Bone dislocation in a joint |
- |
Cases 25, 31, 34 |
32:26 |
- |
|
Acute and chronic brain dysfunction |
- |
Cases 7, 8 |
12:1-3; 15:1-21; 17:1-22; 18:1 – 20:18;
22:1-18; 26:2-6,24; 28:12-15; 32:25-30; 35:1,9-12; 46:2-4 |
- |
|
Human hip joint |
- |
Case 48 |
32:26,33 |
- |
|
Multiple skin
ulcers |
- |
Case 39 |
12:17 |
- |
Note:
* A
total of 43 papyri related to the topic of “medicine” from the Middle Kingdom
to the New Kingdom of Ancient Egypt were examined, published on the website of
the project SCIENCE IN ANCIENT EGYPT
(sae.saw-leipzig.de). See the list below.
** The
Middle Kingdom period: 2040–1640 BCE; the Second Intermediate Period: 1640–1550
BCE; the New Kingdom: 1550–1070 BCE (2002BunsonMR).
***
Dating of the Edwin Smith Papyrus:
1640–1550 BCE (2007SanchezGM_BurridgeAL).
****
Dating of the Minoan eruption: 1610 ± 14 BCE, based on the consensus of the Global Volcanism Program (volcano.si.edu).
***** Dating of the Book of Genesis: after the Minoan eruption or around 1600 BCE (author’s opinion).
List of studied medico-magical papyri from the “Science in Ancient Egypt” project collection (Middle to New Kingdom periods)
Papyrus Athen Nationalbibliothek Nr. 1826
Papyrus British Museum EA 10085+10105
Papyrus Deir el-Medina 1 Verso
Papyrus Kahun London UC 32091A + UC 32095A + UC 32110D + UC 32137G(?)
Papyrus Kahun London UC 32106B
Papyrus Kahun London UC 32116A
Papyrus Kahun London UC 32117E
Papyrus Kahun London UC 32118A
Papyrus Kahun London UC 32271B
Papyrus Straßburg BNU hierat. 69
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Purpose:
To describe an experimental technique for
proximal fixation in ligamentum capitis femoris (ligamentum teres femoris; LCF)
reconstruction using pubic and ischial portions anchored in corresponding
pelvic bone tunnels, tested on synthetic hip joint models, and to propose it’s
for arthroscopic application with visualization via an inferior portal and
femoral tunnel.
Methods:
Synthetic polyurethane bone analogs (Synbone)
of the pelvis and proximal femur were used to fabricate hip joint models.
Acetabular cartilage analogs were created from self-curing plastic compound.
Femoral tunnels were drilled along the neck axis from the subtrochanteric
region below the tuberculum innominatum to the femoral head fovea. Novel pubic
and ischial tunnels were created from the pubic tubercle and superior to the
ischial tuberosity, respectively, directed toward the bases of the anterior and
posterior horns of the lunate surface, exiting at the acetabular notch. Braided
nylon cords served as LCF analogs. Fixation and tensioning were demonstrated,
with potential arthroscopic control through the acetabular notch via an
inferior portal and femoral tunnel, avoiding distraction where possible.
Mechanical stability was assessed qualitatively on models.
Results:
The proposed dual-bundle (pubic and ischial)
proximal fixation replicated natural LCF anatomy and provided satisfactory
limitation of adduction and rotational motions in the model. Femoral tunnel
placement preserved vascular anatomy. Pelvic tunnels avoided intrapelvic
neurovascular structures and organs. Visualization and instrumentation via the
inferior portal, femoral and pelvic tunnels allow for joint inspection,
debridement and graft insertion without distraction. Tensioning of LCF analog was
adjustable in adduction, extension, and external rotation. Integration with implants
for osteosynthesis or future endoprostheses was conceptually demonstrated.
Conclusions:
This experimental technique offers a novel,
potentially more reliable proximal fixation for LCF reconstruction by
distributing load across pubic and ischial tunnels, addressing limitations of
traditional acetabular fossa fixation (thin bone, neurovascular risk).
Arthroscopic feasibility relies on the inferior portal and femoral tunnel for
visualization and manipulation. While promising for stability and reduced
complications in models, clinical validation is required. The method may
represent an advancement in managing LCF pathology, particularly in
instability.
Level of Evidence:
Level V, technique description, model study.
Author of the article
Arkhipov S.V. – Independent Researcher, MD, PhD, Orthopedic Surgeon, Medical Writer, Joensuu, Finland.
Correspondence: Sergey Arkhipov, email: archipovsv @ gmail.com
Article history
January 14, 2026 - online version of the article published.
Suggested citation
Arkhipov SV. A Novel Technique for Proximal Fixation in Ligamentum Capitis Femoris Reconstruction: The Gifts of the Magi for Orthopedic Surgeons. About Round Ligament of Femur. January 14, 2026. https://roundligament.blogspot.com/2026/01/the-gifts-of-magi-for-orthopedic.html
Note
Translation of the article: Архипов СВ. Новая техника проксимального крепления при реконструкции ligamentum capitis femoris: Дары волхвов ортопедическим хирургам. О круглой связке бедра. 14.01.2026. https://kruglayasvyazka.blogspot.com/2026/01/blog-post.html
Keywords
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