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Landmarks for portal placement are identified. The anterolateral portal (AL) is first placed slightly anterior and approximately 1 cm distal to the tip of the greater trochanter (GT). The mid-anterior portal (MA) is then located 45 distal and anterior to the anterolateral portal, and 2-3 cm lateral to a line drawn from the anterior superior iliac spine (ASIS) to the center of the patella. There is typically a soft spot found in this location lateral to the border of the tensor fascia lata.
Source publication
There has been growing interest in recent years on the functional importance of the ligamentum teres and its role in hip stability. Partial or complete tearing has previously been treated with debridement or radiofrequency ablation with good results; however, a subset of patients will continue to experience persistent pain or instability with injur...
Context in source publication
Context 1
... routine preparation and draping of the hip, the procedure is begun by establishing standard anterolateral and mid-anterior portals to allow access to the central compartment (Fig 3). A standard diagnostic arthroscopy is performed using a 70 arthroscope to evaluate the LT and any other concomitant pathology (Video 1). ...
Similar publications
Once perceived to be a vestigial structure, the ligamentum teres (LT) is now increasingly understood to be critical to providing stability in the adult hip. Surgical treatment with arthroscopic debridement is usually the procedure of choice to treat LT tears. However, reconstruction is a possible alternative in select cases. The authors of a recent...
Citations
... In most of the patients, debridement or radiofrequency ablation of both partial and complete LT tears demonstrates satisfactory results [7]. However, in a relatively small subset of patients, who have persistent pain and instability following arthroscopic debridement of LT, an LT reconstruction (LTR) might be indicated to restore stability and increase function [8]. The LTR was first described by Simpson et al. [9] in 2011 as graft implantation that spans between the femoral head and cotyloid fossa through two tunnels, thereby restoring the function of the native LT. ...
The aim of the present study was to report the in vivo thickness of the cotyloid fossa at the acetabular ligamentum teres (LT) attachment and investigate the clearance of the obturator neurovascular bundle. Fifty-five consecutive patients undergoing a total hip arthroplasty for hip osteoarthritis were included. The thickness of the cotyloid fossa was measured at the acetabular LT attachment using a standard depth gauge. The minimal distance (clearance) of the obturator neurovascular bundle to the center of the acetabular LT attachment was measured in 7 patients (14 hips) who also underwent a computed tomography angiography. The average thickness of the cotyloid fossa at the acetabular LT attachment was 4.1 ± 2.3 (range: 1–10) mm. The obturator vein was closest to the acetabular LT attachment, but the clearance was more than the defined safe zone of 15 mm in all cases. Based on the current findings, it can be assumed that bone anchors might not be suitable for fixation of the graft in LT reconstruction (LTR) and an alternative implant such as a cortical button should be considered. Acetabular fixation of the graft with a 12-mm cortical button is relatively safe concerning injury to obturator neurovascular structures. The results of the present study provide a better understanding of the cotyloid fossa anatomy and might be relevant for surgeons who perform arthroscopic LTR.
... The guidewire should be placed in a retrograde fashion, starting from laterally over the greater trochanter through the femoral neck to exit the LT footprintfovea capitis for the ideal location of the femoral tunnel [11,23]. Past studies have suggested that the femoral neck should be drilled through its centre [10,24] as it may be important to avoid potential femoral neck fractures after the surgery. Targeting the LT footprint for the creation of the femoral tunnel is also necessary to avoid cartilage damage of the femoral head as well as to reconstruct the anatomical nature of LT. ...
The ideal femoral tunnel passing through the centre of the femoral neck targeted to the footprint of the ligamentum teres (LT) is established during the LT reconstruction surgery with the free-hand technique. We aimed to quantitatively determine the entry site and define the angular orientation of the ideal femoral tunnel with its relevance to the femoral valgus angle (FVA) and the femoral anteversion angle (FAA) to facilitate the creation of an ideal femoral tunnel during the LT reconstruction surgery. A total of 60 randomly selected CT images were obtained to reconstruct three-dimensional femur models. A virtual reamer representing the ideal femoral tunnel was placed in the femur models. The femur length, FVA, FAA, the femoral tunnel anterior angle, the femoral tunnel superior angle and the skin- and bony-entry sites were measured. The femoral tunnel angular orientation was strongly correlated with the FVA and the FAA. Mathematical formulas were defined by which entry site of the reamer and the anterior and superior angulation of the femoral tunnel could be estimated before the surgery. The mean skin-entry site was 67.3 mm distal and 0.1 mm anterior to the centre of the greater trochanter’s superior border. The angular orientation of the femoral tunnel using FVA and FAA can be easily estimated using mathematical formulas before LT reconstruction surgery. The entry site and angular orientation of the femoral tunnel described in this study can be used to reduce dependency on the usage of fluoroscopy and the workload on the surgeon during the LT reconstruction surgery.
... Once questioned to be a vestigial structure, there is now growing knowledge that the role the ligament teres is a stabilizing structure and pain generator in [56]. Accordingly, there is a commensurate interest in the detection [57,58] and treatment of ligamentum teres pathology [59][60][61]. The ligamentum teres is made up of two bundles of dense, well-organized collagen fibers with some adipose tissue [62]. ...
... 32 Moreover, the use of biocompatible anchors may be advantageous over buttons because of the potential for biological incorporation into the acetabulum, theoretically improving fixation strength. 36 Further investigations directly comparing the biomechanical properties and outcomes of acetabular fixation between anchors and buttons, as well as knotted and knotless anchors, are required to better understand differences in graft fixation to the acetabulum after LTR. ...
Purpose
To systematically review the literature to better understand the current indications for ligamentum teres reconstruction (LTR), current graft and acetabular fixation options used, patient-reported outcomes after LTR, and incidence of complications and reoperations after LTR.
Methods
A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. All literature related to LTR published prior to July 2020 was identified. The inclusion criteria consisted of investigations reporting on human patients with pathology of the ligamentum teres who underwent LTR, including mentions of the indications, graft type, acetabular fixation method, postoperative patient-reported outcome scores, and incidence of complications and reoperations.
Results
Seven studies comprising 26 patients (28 hips) were included. The most commonly reported indication for LTR was persistent pain and instability after failed prior hip arthroscopy (68%, 19 of 28 hips). The mean postoperative modified Harris Hip Score, Non-arthritic Hip Score, and visual analog scale score all showed improvement when compared with preoperative values. A total of 2 complications occurred. Complication rates ranged from 0% to 100% in included case reports and 0% to 11% in included case series. A total of 9 reoperations were performed. Reoperation rates ranged from 0% to 100% for case reports and 18% to 100% for case series. Reoperation rates ranged from 33% to 100% in studies with patients receiving acetabular fixation using anchors versus 0% to 22% in studies performing LTR with buttons. Reoperation rates in athletic patients and patients with Ehlers-Danlos syndrome ranged from 0% to 100% and 0% to 50%, respectively.
Conclusions
The main indication for LTR was persistent hip or groin pain and instability after a prior hip arthroscopy. The short-term postoperative modified Harris Hip Score, Non-arthritic Hip Score, and visual analog scale score after LTR showed favorable outcomes. However, reoperations after LTR were not uncommon.
Level of Evidence
Level V, systematic review of Level IV and V studies.
... The procedure for the arthroscopic treatment of BDDH varies slightly among surgeons; however, an in-depth description of the procedure was provided in the study by Menge et al. 31 In summary, labral repair involves suturing the torn labral fragments back to their approximated anatomic origin to restore the labral seal function. In addition, procedures such as osteoplasty for the correction of bony abnormalities can be performed, along with soft tissue release (ie, psoas or gluteus medius) and other accessory procedures. ...
... Moreover, ligamentum teres (LT) ruptures are associated with BDDH because of the hypermobile joints in patients with these ruptures, and the clinical diagnosis for this injury can be used to diagnose BDDH in patients and refer surgeons to the proper surgical method. 31 The axial traction apprehension test and the dial test can be used to confirm LT tears in conjunction with other methods to confirm BDDH diagnoses. 31 As many other injuries are associated with BDDH and require repair, the use of 1 criterion for diagnostic confirmation to determine which of the 2 surgical methods to use poses a challenge. ...
... 31 The axial traction apprehension test and the dial test can be used to confirm LT tears in conjunction with other methods to confirm BDDH diagnoses. 31 As many other injuries are associated with BDDH and require repair, the use of 1 criterion for diagnostic confirmation to determine which of the 2 surgical methods to use poses a challenge. In conclusion, the use of the LCEA as the main diagnostic criterion is not enough to direct the course of treatment in patients with BDDH. ...
Background
The treatment for borderline developmental dysplasia of the hip (BDDH) has historically been arthroscopic surgery or periacetabular osteotomy (PAO). As orthopaedic surgery is constantly evolving, a lack of comparison of outcomes for these 2 treatment methods could potentially be stalling the progression of treatment for patients with BDDH.
Purpose
To evaluate the existing literature on patient characteristics, procedures, clinical outcomes, and failure rates for patients with BDDH and to determine whether PAO or hip arthroscopic surgery is a better treatment method for patients with BDDH.
Study Design
Systematic review; Level of evidence, 4.
Methods
Studies included were found using the following search words: “hip” and “borderline dysplasia,” “osteotomy” or “arthroscopy,” and “outcome” or “procedure.” Articles were included if they detailed participants of all sexes and ages, reported on isolated hips, and had patients diagnosed with BDDH.
Results
A search was conducted across 3 databases, resulting in 469 articles for consideration, from which 12 total studies (10 on arthroscopic surgery and 2 on PAO) were chosen for a review. There were 6 studies that included patients with a lateral center-edge angle of 18° to 25°, while the remainder included patients with a lateral center-edge angle of 20° to 25°. All the studies reviewing arthroscopic surgery reported concomitant/accessory procedures, while the articles on the topic of PAO did not. It was determined that, whether treated using arthroscopic surgery or PAO, outcomes improved across all patient-reported outcome measures. Revision surgery was also common in both procedures.
Conclusion
There is a lack of consensus in the literature on the best treatment option for patients with BDDH. Preoperative patient characteristics and concomitant injuries should be considered when evaluating which surgical procedure will result in the most favorable outcomes.
... To date, most of the available literature on LT reconstruction consists of technical articles, cadaveric or biomechanical studies, and small case series with short-term follow-up. 10,21,53,54 Philippon et al 62 published results and early outcomes in 4 patients who underwent LT reconstruction. At a mean follow-up of 31 months, 3 (75%) patients demonstrated improvement on the mHHS, and 1 (25%) patient required subsequent hip resurfacing. ...
Background
Hip arthroscopic surgery in patients with borderline dysplasia continues to be controversial. In addition, it has been suggested that ligamentum teres (LT) tears may lead to inferior short-term patient-reported outcomes (PROs) when compared with a match-controlled group.
Purposes
(1) To report minimum 5-year PROs in patients with borderline dysplasia and LT tears who underwent hip arthroscopic surgery and (2) to compare these PROs to those of a matched-pair control group of patients with borderline dysplastic hips without LT tears.
Study Design
Cohort study; Level of evidence, 3.
Methods
Data were prospectively collected for patients who underwent hip arthroscopic surgery between September 2008 and August 2013. Patients were included if they had a preoperative diagnosis of borderline dysplasia (lateral center-edge angle [LCEA], 18°-25°) and had preoperative and minimum 5-year postoperative modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain scores. Exclusion criteria were osteoarthritis of Tönnis grade >1, previous hip conditions, any previous ipsilateral hip surgery, or workers’ compensation status. There were 2 borderline dysplastic groups created. An LT tear group was matched 1:1 to a control group (no LT tear) with similar age, sex, body mass index (BMI), and laterality via propensity score matching. Significance was set at P < .05.
Results
A total of 24 patients with an LT tear (24 hips) were matched to 24 patients without an LT tear (24 hips). There was no significant difference in age, sex, BMI, or laterality between groups. The mean age was 36.2 ± 17.2 and 34.9 ± 15.9 years for the control and LT tear groups, respectively ( P = .783). There were 17 (70.8%) and 16 (66.7%) female patients in the control and LT tear groups, respectively, and the mean preoperative LCEA was 23.3° and 22.2° in the control and LT tear groups, respectively. No differences were observed between groups in baseline PROs, intraoperative findings, or surgical procedures. LT debridement was performed in 17 (70.8%) patients in the LT tear group compared with 0 (0.0%) in the control group. Also, 5-year postoperative PROs were comparable in both groups, with the control group exhibiting superior Veterans RAND 12-Item Health Survey (VR-12) mental ( P = .041) and Short Form–12 (SF-12) mental ( P = .042) scores. Finally, hips with an intact LT were significantly more likely ( P = .022) to achieve the patient acceptable symptomatic state (PASS) for the mHHS (100.0% and 75.0%, respectively). No significant differences were present between the groups for the minimal clinically important difference (MCID) of the mHHS ( P = .140), MCID of the Hip Outcome Score–Sport-Specific Subscale (HOS-SSS) ( P = .550), or PASS of the HOS-SSS ( P = .390).
Conclusion
After hip arthroscopic surgery, patients with borderline dysplasia and LT tears demonstrated favorable PROs at a minimum 5-year follow-up. Outcomes were similar to a matched-pair control group without LT tears, with the group with intact LTs showing higher VR-12 mental and SF-12 mental scores. Furthermore, patients with borderline dysplasia and intact LTs were significantly more likely to achieve the PASS for the mHHS.
... Regarding alternative surgical management for complete LT tears, only technical notes with small samples and short-term follow-up have been published for LT reconstructions. [14][15][16][17][18]44 Furthermore, the usefulness of the addition of LT reconstruction, in an already steep hip arthroscopy learning curve, 45,46 needs further evaluation. According to our results, there is no justification for performing LT reconstruction during primary hip arthroscopies used to treat FAI, labral tears, and complete LT tears just yet. ...
... An anterior tibialis allograft ( Figure 8) is used to perform ligamentum teres reconstruction. 43 The length of the graft should be at least 120 mm and its diameter 7-8 mm. Under fluoroscopic guidance and direct arthroscopic visualization, a 2.4 mm guidewire is placed through the greater trochanter within the femoral neck in line with the fovea capitis. ...
Hip arthroscopy is an evolving procedure and its indications have expanded. The number of patients undergoing this procedure has increased significantly as well as the number of surgeons being trained. This has resulted in a notable increase in post-operative complication rates creating the need to develop advanced hip arthroscopic techniques. Revision hip arthroscopy is often complex and many factors should be considered to achieve a satisfactory clinical outcome. Careful pre-operative planning and agreement of expectations between the physician and patient regarding the procedure are important. This review describes several advanced treatment options that are used mainly in revision or complex primary hip arthroscopy cases. Labral reconstruction or augmentation technique is used in cases of severely deficient acetabular labral tissue to restore the fluid seal mechanism. In cases of symptomatic (often post-operative) adhesion formation, a spacer between the labrum and the joint capsule is useful for pain relief and prevention of future adhesions. Large defects of the capsule due to previous unrepaired capsulotomy or any other cause can be addressed with the capsular reconstruction technique. Ligamentum teres reconstruction using an anterior tibialis allograft is indicated in patients with hip instability and persistent pain after previous debridement or with complete tears of this structure. The senior author’s treatment of choice in cases of previous over-resection of CAM impingement is the remplissage technique to restore the bony defect of the femoral head-neck junction and preserve the joint seal.
... 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). ...
... 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)(21)(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. ...
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.
... 6 For these patients, reconstruction of the ligamentum teres is indicated to restore stability and increase function. 7 Given the thinness of the cotyloid fossa, extreme caution is required to avoid damaging arthroscopically unobservable pelvic structures, such as the obturator neurovascular bundle, when drilling the acetabular tunnel. Previous pelvic anatomy studies have focused on determining which structures are in danger during screw placement for cementless hip replacement 8,9 and arthroscopic acetabular labral repair. ...
... An axis was defined on the femur to simulate a reconstruction tunnel passing through the center of the femoral neck and exiting the ligamentum teres attachment on the fovea capitis (Fig 3). The diameter of the femoral tunnel was 7 mm, as previously described by Menge et al. 7 The distance from the resulting entry point of the tunnel on the lateral aspect of the femur to the center of the vastus ridge was measured. ...
... The femoral tunnel entry point on the lateral side of the femur was located at a mean distance of 7.0 mm distal and 5.8 mm anterior from the center of the vastus ridge. Previous studies described an entry point lateral to the greater trochanter 5,7,[12][13][14] and anterior to the proximal femoral neck, 15 aiming for the femoral head ligamentum teres attachment without defining a precise entry point. By using the center of the femoral neck along with the ligamentum teres attachment on the fovea capitis to define the tunnel orientation, our study adds a precise location of the femoral tunnel entry point distal and anterior to the center of the vastus ridge. ...
Purpose:
To provide a quantitative guide to tunnel placement concurrently through the femur and acetabulum during a ligamentum teres reconstruction, minimizing the risk of injury to the obturator neurovascular bundle.
Methods:
Nine human cadaveric pelvises, complete with femurs (mean age, 59.6 years; age range, 47-65 years), were studied. Before dissection, a 3-dimensional coordinate-measuring device was used to record the neutral orientation of the femur in the acetabulum. The specimens were then dissected free of all extra-articular soft tissue, except for the ligamentum teres and the obturator neurovascular bundle, and digitized. An anatomic femoral reconstruction tunnel through the femoral neck was simulated and extended along its axis into the acetabulum. The femur was digitally rotated internally from 0° to 30° and externally from 0° to 40°, as well as abducted from 0° to 30° and adducted from 0° to 20°, in increments of 1°. At each position, the location of the simulated acetabular reconstruction tunnel was measured with respect to the obturator bundle and the edge of the acetabular fossa.
Results:
The anatomic reconstruction tunnel entered the lateral side of the femur at a mean distance of 7.0 mm distal and 5.8 mm anterior to the center of the vastus ridge. By angling the femur at 15° of internal rotation and 15° of abduction, the obturator neurovascular bundle was avoided in 100% of specimens.
Conclusions:
The most important finding of this study was that a ligamentum teres reconstruction tunnel could be reamed through the femoral neck and safely positioned in the acetabulum by angling the femur at 15° of internal rotation and 15° of abduction.
Clinical relevance:
These quantitative descriptions of the ligamentum teres reconstruction tunnels can be used to guide arthroscopic surgical interventions designed to address ligamentum teres pathology.
