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Ismailoglu AV, Ismailoglu P, Zeynalov SI, Ozdogmus O, Yildizhan SE, Bayramoglu A, Kayaalp A. A guide to facilitate the creation of a femoral tunnel for arthroscopic ligamentum teres reconstruction: a three-dimensional computed tomography study. J Hip Preserv Surg 2024; 11:13-19. [PMID: 38606335 PMCID: PMC11005763 DOI: 10.1093/jhps/hnad027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/25/2023] [Accepted: 08/02/2023] [Indexed: 04/13/2024] Open
Abstract
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.
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Affiliation(s)
- Abdul Veli Ismailoglu
- Department of Anatomy, School of Medicine, Marmara University, Maltepe Basibuyuk Yolu, No: 9, Maltepe, Istanbul 34854, Turkey
- Department of Anatomy, School of Medicine, Acibadem University, Kayisdagi cad., Kerem Aydinlar Kampusu, No: 32, Atasehir, Istanbul 34752, Turkey
| | - Pelin Ismailoglu
- Department of Physiotherapy and Rehabilitation, Faculty of Health Sciences, Fenerbahce University, Metropol İstanbul, Ataşehir Blv, Atasehir, Istanbul 34758, Turkey
| | - Samir I Zeynalov
- Department of Orthopaedics & Traumatology, Ardahan State Hospital, Inonu Mah., Sugoze, Ardahan Merkez, Ardahan 75000, Turkey
| | - Omer Ozdogmus
- Department of Anatomy, School of Medicine, Marmara University, Maltepe Basibuyuk Yolu, No: 9, Maltepe, Istanbul 34854, Turkey
| | - Saliha Elif Yildizhan
- Department of Biostatistics and Medical Informatics, School of Medicine, Acibadem University, Kayisdagi cad., Kerem Aydinlar Kampusu, No: 32, Atasehir, Istanbul 34752, Turkey
| | - Alp Bayramoglu
- Department of Anatomy, School of Medicine, Acibadem University, Kayisdagi cad., Kerem Aydinlar Kampusu, No: 32, Atasehir, Istanbul 34752, Turkey
| | - Asim Kayaalp
- Department of Orthopedic Surgery, Ankara Cankaya Hospital, Barbaros Sk. No: 44, Cankaya, Ankara 06700, Turkey
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Particularities on Anatomy and Normal Postsurgical Appearances of the Hip. Radiol Clin North Am 2023; 61:167-190. [PMID: 36739140 DOI: 10.1016/j.rcl.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Detailed knowledge of anatomy helps to understand pathologic processes. This article focuses on the anatomy and functionality of the hip, with emphasis on recently studied concepts and anatomic features that have an association with the development of symptoms. The most common anatomic variants posing a challenge for diagnosis and other common findings in asymptomatic patients are reviewed. Good understanding of the different surgical procedures helps in providing as much information as possible to guarantee a favorable outcome, improving prognosis. We review what are the commonly expected postsurgical appearances and the most common postsurgical complications.
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Cohen D, Jean PO, Patel M, Aravinthan N, Simunovic N, Duong A, Safran MR, Khanduja V, Ayeni OR. Hip microinstability diagnosis and management: a systematic review. Knee Surg Sports Traumatol Arthrosc 2023; 31:16-32. [PMID: 35441843 DOI: 10.1007/s00167-022-06976-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/29/2022] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this systematic review is to present the most common causes, diagnostic features, treatment options and outcomes of patients with hip micro-instability. METHODS Three online databases (MEDLINE, Embase, and PubMed) were searched from database inception March 2022, for literature addressing the diagnosis and management of patients with hip micro-instability. Given the lack of consistent reporting of patient outcomes across studies, the results are presented in a descriptive summary fashion. RESULTS Overall, there were a total of 9 studies including 189 patients (193 hips) included in this review of which 89% were female. All studies were level IV evidence with a mean MINORS score of 12 (range: 10-13). The most commonly used features for diagnosis of micro-instability on history were anterior pain in 146 (78%) patients and a subjective feeling of instability with gait in 143 (81%) patients, while the most common feature on physical examination was the presence of anterior apprehension with combined hip extension and external rotation in 123 (65%) patients. The most common causes of micro-instability were iatrogenic instability secondary to either capsular insufficiency or cam over-resection in 76 (62%) patients and soft tissue laxity in 38 (31%) patients. CONCLUSION The most common symptom of micro-instability on history was anterior hip pain and on physical exam was pain with hip extension and external rotation. There are many treatment options and when managed appropriately based on the precise cause of micro-instability, patients may demonstrate improved outcomes. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dan Cohen
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Pierre-Olivier Jean
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Milin Patel
- Faculty of Science, McMaster University, Hamilton, ON, Canada
| | | | - Nicole Simunovic
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Andrew Duong
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada
| | - Marc R Safran
- Department of Orthopedic Surgery, Stanford University, Redwood City, CA, USA
| | - Vikas Khanduja
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, 1200 Main St West, 4E15, Hamilton, ON, L8N 3Z5, Canada. .,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, L8N 3Z5, Canada.
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Abibe RB, Rahal SC, dos Reis Mesquita L, Doiche D, da Silva JP, Mamprim MJ, Pinho RH, Battazza A, Alves CEF, Saunders WB. Ligamentum teres reconstruction using autogenous semitendinosus tendon with toggle technique in rabbits. PeerJ 2023; 11:e14777. [PMID: 36987457 PMCID: PMC10040178 DOI: 10.7717/peerj.14777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/03/2023] [Indexed: 03/30/2023] Open
Abstract
Background Ligamentum teres (LT) has traditionally been considered a vestigial or redundant structure in humans; however, based on new studies and the evolution of hip arthroscopy, the LT injury has been viewed as a source of hip pain. Therefore, LT reconstruction can be beneficial in some cases. Rabbits have been frequently used as a model for cranial cruciate ligament reconstruction but few studies are available for ligamentum teres reconstruction. Objective To evaluate the semitendinosus tendon to replace ligamentum teres with the toggle technique, using rabbits as an experimental model. Methods Twenty-six female Norfolk rabbits with approximately 3 months of age were divided into two equal groups after excision of ligamentum teres (LT) from the right hip joint: G1-no reconstruction of LT and capsulorrhaphy; G2-double-bundle reconstruction of the LT using semitendinosus tendon autograft. In both groups, the LT was removed from the right hip joint. In G2 the autograft was harvested from the left hind limb of the same rabbit. The rabbits were evaluated clinically at different time intervals; before surgery (M1), 48 h (M2), 15 days (M3), 30 days (M4) and 90 days (M5) after surgery. Results The rabbits supported their limbs on the ground in both the groups. As complications of the procedure, four hip joints showed subluxations in the radiographic evaluation of G1; three at M4 and one at M5. In G2; two luxations of hip joints at M3 and one subluxation at M4 were seen. On ultrasound, irregular articular surface was seen in 30.8% of the rabbits that had subluxation of hip joints. Gross evaluation identified tendon graft integrity in 76.92% of the rabbits. Histological analysis revealed graft adhesion to the bone in the early phase comprised of sharpey-like collagen fibers. Conclusion The double-bundle reconstruction of the LT using autologous semitendinosus tendon associated with the toggle rod shows an early phase of tendon graft ligamentization at 90 days post-operatively in young rabbits, but biomechanical bias suffered by the tendon during gait must be considered.
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Affiliation(s)
- Rebeca Bastos Abibe
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Sheila Canevese Rahal
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Luciane dos Reis Mesquita
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Danuta Doiche
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Jeana Pereira da Silva
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Maria Jaqueline Mamprim
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Renata Haddad Pinho
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Alexandre Battazza
- Department of Veterinary Clinic, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - Carlos Eduardo Fonseca Alves
- Department of Veterinary Surgery and Animal Reproduction, School of Veterinary Medicine and Animal Science, Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | - W. Brian Saunders
- Department of Small Animal Clinical Sciences, Texas A&M University, College Station, Texas, United States
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Matthewson G, Williams A, Macciacchera M, Shahabinezhad A, Duong A, Ayeni OR. Effective Management Options for Treatment of Microinstability of the Hip: a Scoping Review. Curr Rev Musculoskelet Med 2022; 16:9-18. [PMID: 36472785 PMCID: PMC9839911 DOI: 10.1007/s12178-022-09808-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To review the recent literature identifying and summarizing the research involving management of microinstability of the hip and highlight new and evolving techniques in its treatment. RECENT FINDINGS Recent updates in the understanding of capsular management hip arthroscopy will likely lead to less revision surgery and a decreased incidence of persistent post-operative pain. Repair of residual capsular defects has shown good outcomes with high patient satisfaction. Capsular plication remains the gold standard for hips with increased pain that show signs of capsular laxity/deficiency on exam or imaging. Capsular reconstruction has shown equivalent results to other revision hip arthroscopy procedures with low rates of complications. Ligamentum teres pathology, although rare, should be considered a source of pain, particularly in patients with laxity on exam. In cases where CAM over-resection has occurred, remplissage using allograft is an effective option for restoring the capsular suction seal and stability. Microinstability is increasingly being recognized as a source of post-operative hip pain. Patients with collagen disorders remain a challenging clinical entity with increased rates of complications and post-operative pain. CAM resection should be performed carefully and not disrupt the suction seal but be sufficient to not cause further impingement. Improved evidence including well-designed prospective studies with large sample sizes will determine the future management of this complex problem.
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Affiliation(s)
- Graeme Matthewson
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Allison Williams
- grid.28046.380000 0001 2182 2255Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | - Matthew Macciacchera
- grid.4912.e0000 0004 0488 7120Faculty of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ali Shahabinezhad
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Andrew Duong
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
| | - Olufemi R. Ayeni
- grid.25073.330000 0004 1936 8227Division of Orthopaedic Surgery, Department of Surgery, McMaster University, 1200 Main St West, 4E15, Hamilton, Ontario L8N 3Z5 Canada
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6
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Criteria for the Operating Room Confirmation of the Diagnosis of Hip Instability: The Results of an International Expert Consensus Conference. Arthroscopy 2022; 38:2837-2849.e2. [PMID: 35378192 DOI: 10.1016/j.arthro.2022.03.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/20/2022] [Accepted: 03/02/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to establish an international expert consensus on operating room findings that aid in the diagnosis of hip instability. METHODS An expert panel was convened to build an international consensus on the operating room diagnosis/confirmation of hip instability. Seventeen surgeons who have published or lectured nationally or internationally on the topic of hip instability were invited to participate. Fifteen panel members completed a pre-meeting questionnaire and agreed to participate in a 1-day consensus meeting on May 15, 2021. A review of the literature was performed to identify published intraoperative reference criteria used in the diagnosis of hip instability. Studies were included for discussion if they reported and intraoperative findings associated with hip instability. The evidence for and against each criteria was discussed, followed by an anonymous voting process. For consensus, defined a priori, items were included in the final criteria set if at least 80% of experts agreed. RESULTS A review of the published literature identified 11 operating room criteria that have been used to facilitate the diagnosis of hip instability. Six additional criteria were proposed by panel members as part of the pre-meeting questionnaire. Consensus agreement was achieved for 8 criteria, namely ease of hip distraction under anesthesia (100.0% agreement), inside-out pattern of chondral damage (100.0% agreement), location of chondral damage on the acetabulum (93.3% agreement), pattern of labral damage (93.3% agreement), anteroinferior labrum chondral damage (86.7% agreement), perifoveal cartilage damage (97.6% agreement), a capsular defect (86.7% agreement), and capsular status (80.0% agreement). Consensus was not achieved for 9 items, namely ligamentum teres tear (66.7% agreement), arthroscopic stability tests (46.7% agreement), persistent distraction after removal of traction (46.7% agreement), findings of examination under anesthesia (46.7% agreement), the femoral head divot sign (40.0% agreement), inferomedial synovitis (26.7% agreement), drive-through sign (26.7% agreement), iliopsoas irritation (26.7% agreement) and ligamentum teres-labral kissing lesion (13.3% agreement). All experts agreed on the final list of 8 criteria items reaching consensus. CONCLUSION This expert panel identified 8 criteria that can be used in the operating room to help confirm the diagnosis of hip instability. LEVEL OF EVIDENCE Level V expert opinion.
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7
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Lall AC, Ankem HK, Ryan MK, Beason DP, Diulus SC, Roach RP, Rosinsky PJ, Maldonado DR, Emblom BA, Domb BG. In-line Pullout Strength of 2 Acetabular Fixation Methods for Ligamentum Teres Reconstruction of the Hip: A Cadaveric Study. Orthop J Sports Med 2021; 9:23259671211052533. [PMID: 34881346 PMCID: PMC8646775 DOI: 10.1177/23259671211052533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/02/2021] [Indexed: 01/23/2023] Open
Abstract
Background: Ligamentum teres (LT) reconstruction is an appropriate alternative in select cases of LT full-thickness tears, resulting in hip micro- or macroinstability. Graft fixation at the acetabular fossa is critical to achieving the best functional results. Purpose: The purpose of this study is to compare the pullout strength of 2 graft fixation methods used for LT reconstruction of the hip. Study Design: Controlled laboratory study. Methods: In 7 cadaveric specimens, the acetabular socket was prepared after the native LT was transected and the femoral head was removed. Seven separate tibialis anterior grafts were then prepared by suturing a running-locking No. 2 suture on each tail of the graft. Three specimens had fixation of the graft to the acetabulum using an adjustable cortical suspension suture button; the remaining 4 were fixed to the acetabulum using a knotless suture anchor. Specimens were then mounted onto a custom jig within a mechanical test frame to allow for the in-line pull of the graft fixation construct. After a preload of 5 N, each specimen was loaded to failure at 0.5 mm/s. Stiffness and load to failure were measured for each specimen construct. Results: Suture button fixation had a higher mean load to failure when compared with the knotless anchor fixation method (mean ± SD, 438.1 ± 114.3 vs 195.9 ± 50.0 N; P = .01). There was no significant difference in mean stiffness between the methods of fixation (24.5 ± 1.4 vs 26.5 ± 5.8 N/mm; P = .6). Conclusion: In this cadaveric study, the suture button fixation demonstrated greater load to failure than the knotless anchor fixation. Clinical Relevance: Results of this study can guide surgical decision making when selecting an acetabular fixation method for LT reconstruction.
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Affiliation(s)
- Ajay C Lall
- American Hip Institute, Des Plaines, Illinois, USA.,American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | - Hari K Ankem
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | - Michael K Ryan
- Andrews Sport Medicine and Orthopaedic Center, Birmingham, Alabama, USA
| | - David P Beason
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Samantha C Diulus
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | - Ryan P Roach
- American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Philip J Rosinsky
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | - David R Maldonado
- American Hip Institute Research Foundation, Des Plaines, Illinois, USA
| | - Benton A Emblom
- Andrews Sport Medicine and Orthopaedic Center, Birmingham, Alabama, USA.,American Sports Medicine Institute, Birmingham, Alabama, USA
| | - Benjamin G Domb
- American Hip Institute, Des Plaines, Illinois, USA.,American Hip Institute Research Foundation, Des Plaines, Illinois, USA.,AMITA Health St Alexius Medical Center, Hoffman Estates, Illinois, USA
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8
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Mazek J, Gnatowski M, Salas AP, Domżalski M, Wójcicki R, Skowronek J, Skowronek P. Ligamentum teres reconstruction with labrum and capsule repair after posterior acetabular wall fracture: a case report. J Hip Preserv Surg 2021; 8:i41-i45. [PMID: 34178370 PMCID: PMC8221382 DOI: 10.1093/jhps/hnab029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/16/2021] [Indexed: 01/12/2023] Open
Abstract
The aim of this case study is to present arthroscopic treatment of recurrent hip instability after acute post-traumatic posterior hip dislocation with a fracture of the posterior acetabular wall. A male patient aged 35 suffered a dislocation of the right hip joint with a fracture of the posterior acetabular wall due to an accident. The fracture was stabilized during emergency surgery with a locking compression plate, and the patient was released home in a hip brace. Multiple dislocations of the hip joint followed with the implant being confirmed as stable. Decision was made to qualify the patient for a right hip arthroscopy. During the surgery, ligamentum teres was reconstructed using gracilis and semitendinous muscle grafts, followed by the labrum and joint capsule repair, where the surgery that stabilized the acetabular wall fracture had damaged them. There were no complications following the procedure. Short-term follow-up of 3 months demonstrates the patient has a stable hip, reduced pain and has returned to pre-injury activities.
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Affiliation(s)
- Jacek Mazek
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland.,Center for Specialized Surgery Ortopedika, 03-152 Warsaw, Poland
| | - Maciej Gnatowski
- Center for Specialized Surgery Ortopedika, 03-152 Warsaw, Poland
| | | | - Marcin Domżalski
- Orthopaedic and Trauma Department, Medical University of Lodz, Lodz, Poland
| | - Rafał Wójcicki
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland
| | - Jacek Skowronek
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland
| | - Paweł Skowronek
- Jan Kochanowski University in Kielce, Orthopaedic and Traumatology Clinic, Kielce, Poland
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Morattel B, Bonin N. Unusual apical femoral head deformity treated by hip arthroscopy and tunnel drilling through femoral head: a case report. J Hip Preserv Surg 2021; 8:i25-i33. [PMID: 34178368 PMCID: PMC8221387 DOI: 10.1093/jhps/hnab026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 03/11/2021] [Indexed: 11/23/2022] Open
Abstract
Femoro-acetabular impingement (FAI), is the result of an abnormal morphology of the hip joint. On the femoral side, asphericity of the head can be highlighted by an alpha angle measurement >50° on computed tomography or MRI. However, some particular cephalic asphericities can make it difficult to measure the alpha angle, leading to a diagnostic pitfall. While in the classic cam effect, the deformity is peripheral and can be treated by arthroscopic femoroplasty, an apical head deformity remains a therapeutic challenge. We present the case of a 17-year-old male patient with a femoral head deformity, corresponding to an ISHA zone 6 overhang, significantly improved in everyday and sports life by arthroscopic trapdoor technique to resect the focal central deformity while enabling concomitant treatment of central compartment pathology, in this case, a hypertrophic ligamentum teres and femoral head chondral flap. Etiology of this femoral head deformity remains uncertain but could be a particular cam deformity, sequelae to pediatric disease or instability with repeated traction of the ligament teres on the femoral head apical insertion during cephalic growth.
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Affiliation(s)
- Boris Morattel
- Orthopaedic Surgeon, Lyon Ortho Clinic, 29B Avenue des sources, Lyon 69009, France
| | - Nicolas Bonin
- Orthopaedic Surgeon, Lyon Ortho Clinic, 29B Avenue des sources, Lyon 69009, France
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10
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Hartigan DE, Hegedus CE. Editorial Commentary: Ligamentum Teres Reconstruction May Improve Hip Stability But Has High Revision Rates: Fad or Restoration of Function? Arthroscopy 2021; 37:1820-1821. [PMID: 34090567 DOI: 10.1016/j.arthro.2021.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 02/02/2023]
Abstract
Ligamentum teres (LT) tears are correlated with hip instability, and biomechanical research suggests there is a stabilizing function of the intact native LT. With regard to LT reconstruction, currently, there are imaging studies demonstrating that the ligament goes on to heal and properly function. There are also no long-term clinical studies on the success rates of LT reconstruction. The clinical studies that have been done are done with a fairly high number of concomitant procedures, which makes it difficult to discern whether improvement can be attributed to the LT reconstruction. A recent review shows that after LT reconstruction, these very difficult patients can respond favorably to surgery two-thirds of the time. However, in the remaining one-third of patients, an additional surgery was required. In my own practice, patients with instability patterns on examination who have failed primary arthroscopy and have any degree of even minor bony dysplasia with signs of ligamentous laxity and LT tear are a population that I personally would recommend a periacetabular osteotomy to optimize bony stability. For those not a candidate for periacetabular osteotomy , the patient should be educated on the risks of failure of LT reconstruction and have reasonable expectations, and the operation should be performed by an experienced hip arthroscopist with LT reconstruction experience.
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11
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Shapira J, Yelton MJ, Rosinsky PJ, Maldonado DR, Meghpara MB, Ankem HK, Lall AC, Domb BG. Ligamentum Teres Reconstruction May Lead to Improvement in Outcomes Following a Secondary Hip Arthroscopy for Symptomatic Microinstability: A Systematic Review. Arthroscopy 2021; 37:1811-1819.e1. [PMID: 33515734 DOI: 10.1016/j.arthro.2021.01.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To present the indications, surgical technique, outcomes, and complications for patients undergoing arthroscopic reconstruction of the ligamentum teres (LT). METHODS Articles were included if they had postoperative patient-reported outcomes (PROs) for arthroscopic LT reconstruction. Studies were analyzed for patient demographics, clinical assessment and indications, radiographic and magnetic resonance imaging data, concomitant procedures performed, PROs, surgical techniques, intra-articular classifications, complications, and need for follow-up surgeries. For PROs, the standard mean difference was calculated. The proportion of patients achieving patient acceptable symptomatic state for postoperative modified Harris Hip Score (≥74) was recorded. The number of patients achieving minimal clinically important difference for modified Harris Hip Score (Δ ≥8) was calculated. RESULTS The majority of the cases were revision arthroscopies. Of the 3 studies reporting on patients undergoing LT reconstruction due to microinstability, 4, 9, and 11 patients demonstrated a mean improvement of 25.7, 35.2, and 27.7 in modified Harris Hip, respectively. In addition, one of the studies reported a mean improvement of 31.1 and 4.2 in Nonarthritic Hip Score and visual analog scale, respectively. Of the 3 studies, the percentile of patients surpassing minimal clinically important difference and patient acceptable symptomatic state ranged between 50% and 100% and 33.3% and 88.8%, respectively. Overall, 5 patients underwent revision hip arthroscopy due to adhesions, iliopsoas impingement, and persistent microinstability, and 3 patients underwent a secondary hip arthroplasty due to refractory pain and radiographic evidence of hip osteoarthritis. CONCLUSION Reconstruction of the LT may be considered in surgical management for patients with symptomatic hip instability due to soft-tissue causes. Current evidence supports for LT reconstruction predominantly for patients experiencing refractory instability following previous hip preservation procedures. Patients' expectations as well as the relatively high reoperation rate (i.e., 33%) should be discussed before the procedure. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.
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Affiliation(s)
- Jacob Shapira
- American Hip Institute Research Foundation, Chicago, U.S.A
| | | | | | | | - Mitchell B Meghpara
- American Hip Institute Research Foundation, Chicago, U.S.A.; AMITA Health St. Alexius Medical Center, Hoffman Estates, U.S.A
| | - Hari K Ankem
- American Hip Institute Research Foundation, Chicago, U.S.A
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, U.S.A.; AMITA Health St. Alexius Medical Center, Hoffman Estates, U.S.A.; American Hip Institute, Chicago, Illinois, U.S.A
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, U.S.A.; AMITA Health St. Alexius Medical Center, Hoffman Estates, U.S.A.; American Hip Institute, Chicago, Illinois, U.S.A..
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13
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Knapik DM, Farivar D, Kunze KN, Gilat R, Nho SJ, Chahla J. Indications and Outcomes After Ligamentum Teres Reconstruction: A Systematic Review. Arthrosc Sports Med Rehabil 2021; 3:e939-e949. [PMID: 34195664 PMCID: PMC8220633 DOI: 10.1016/j.asmr.2021.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Accepted: 01/27/2021] [Indexed: 10/30/2022] Open
Abstract
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.
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Affiliation(s)
- Derrick M Knapik
- Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A
| | - Daniel Farivar
- Rush University School of Medicine, Chicago, Illinois, U.S.A
| | - Kyle N Kunze
- Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A.,Rush University School of Medicine, Chicago, Illinois, U.S.A
| | - Ron Gilat
- Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A
| | - Shane J Nho
- Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A.,Rush University School of Medicine, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Midwest Orthopaedics at Rush University, Chicago, Illinois, U.S.A.,Rush University School of Medicine, Chicago, Illinois, U.S.A
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Arthroscopic Triple Reconstruction in the Hip Joint: Restoration of Soft-Tissue Stabilizers in Revision Surgery for Gross Instability. Arthrosc Tech 2021; 10:e1239-e1248. [PMID: 34141538 PMCID: PMC8185569 DOI: 10.1016/j.eats.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/11/2021] [Indexed: 02/03/2023] Open
Abstract
Gross hip instability in an active adult with previous normal hip anatomy is usually due to disruption of the static stabilizers of the hip joint. Although such a disruption can result from a high-grade injury, it can be iatrogenic after previous hip arthroscopy. The patient may present with a painful limp and recurrent subluxation sensation in the affected hip joint. Revision hip arthroscopy in this scenario is generally complicated, and it is not uncommon for all the soft-tissue stabilizers to be compromised. The labrum, ligamentum teres (LT), and capsule of the hip joint are often so damaged that reparation is not an option. Reconstruction of the torn LT is an established method to add secondary stability while addressing the labral pathology in the hip joint with microinstability. Concomitant reconstruction of all the static restraints has yet to be described addressing triple instability. This Technical Note presents a stepwise approach, including tips and pearls, for arthroscopic triple reconstruction of the labrum, LT, and capsule. We believe this method is a safe and reproducible way to effectively treat gross hip instability in young patients.
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Hunt SA. Editorial Commentary: "Loose Lips Sink Ships"-But What About "Loose Hips"? Arthroscopy 2020; 36:2183-2185. [PMID: 32747062 DOI: 10.1016/j.arthro.2020.05.045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 02/02/2023]
Abstract
Hip instability continues to be a challenge in hip preservation. Our understanding of the role of osseous anatomy, labral integrity and soft-tissue stabilizers has increased dramatically over the past several decades. Connective-tissue disorders such as Ehlers-Danlos syndrome pose a significant challenge to the management of instability in all joints but particularly in the hip. Ligamentum teres tears have been found to be more common than previously thought, although their significance is still not well understood. In patients with both Ehlers-Danlos syndrome and ligamentum teres tears, reconstruction and capsular plication result in moderate success, but not in all cases.
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