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Case Report With Video Illustration

Arthroscopic Reconstruction of the Ligamentum Teres

James M. Simpson, F.R.C.S.Ed.(Tr&Orth), Richard E. Field, F.R.C.S.(Orth), andRichard N. Villar, F.R.C.S.

Abstract: We describe a case of arthroscopic reconstruction of the ligamentum teres using a noveltechnique. This technique is both simple and reproducible. We believe it to be a useful addition tothe procedures available to the arthroscopic hip surgeon.

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This article describes the arthroscopic reconstruc-tion of the ligamentum teres in a 20-year-old

dancer performed by the 2 senior authors. The conceptand methods were tested over a 2-year period by useof 12 cadaveric hips before the first patient underwentsurgery (Table 1). The ligamentum teres is a powerfultatic restraint between the acetabulum and femoralead with a tensile strength, in a porcine model, sim-lar to the anterior cruciate ligament (ACL) of thenee.1 Furthermore, the position in which the hip iseast stable corresponds to that in which the ligamen-um teres is most taught: adduction, flexion, and ex-ernal rotation.2 Evidence exists that rupture of this

ligament can be a potent source of hip pain,3-6 whichmay be successfully treated by debridement. How-ever, in some patients with persistent hip pain, it is ourbelief that this relates to the loss of stability normallyprovided by an intact ligamentum. On occasion, there-

From The Richard Villar Practice, Cambridge Lea HospitalJ.M.S., R.N.V.), Cambridge, England; and South West Londonlective Orthopaedic Centre (R.E.F.), Surrey, England.Received August 9, 2010; accepted September 22, 2010.Address correspondence and reprint requests to James M. Simp-

on, F.R.C.S.Ed.(Tr&Orth), The Richard Villar Practice, Cam-ridge Lea Hospital, 30 New Road, Cambridge CB4 9EL, Eng-and; E-mail: jm.simpson@rcsed.ac.uk

© 2011 by the Arthroscopy Association of North America0749-8063/10472/$36.00doi:10.1016/j.arthro.2010.09.016

Note: To access the video accompanying this report, visit the

i[Month] issue of Arthroscopy at www.arthroscopyjournal.org.

Arthroscopy: The Journal of Arthroscopic and Related

fore, reconstruction of the ligamentum teres may beindicated.

POSITIONING AND SETUP

A lateral decubitus hip arthroscopic position wasused; our detailed technique for hip arthroscopy hasalready been described.7 The patient was under gen-ral anesthesia, and a specialist hip distracter was usedSmith & Nephew, Andover, MA). Intravenous cefu-oxime (1.5 g) was used as prophylactic antibioticover, followed by a 5-day course of oral erythromy-in (500 mg four times daily). Lateral, anterolateral,nd posterolateral portals were used throughout therocedure, together with a 70° arthroscope. Normalaline solution (0.9% sodium chloride) containing epi-ephrine, 1 mg per 3 L, was used for irrigation.The patient had undergone an arthroscopy of the same

ip (right) 6 months earlier, and the current operationas performed because of ongoing symptoms. A com-lete avulsion of the ligamentum teres from the fovea ofhe femur was confirmed (Fig 1, Video 1 [available atww.arthroscopyjournal.org]). The remainder of the

entral compartment was systematically assessed. Amall anteroinferior acetabular osteochondral defect wasoted; this had failed to heal despite a microfractureeing performed at the first arthroscopy.The posteroinferior portion of the cotyloid fossa was

horoughly debrided with a 90° radiofrequency probeVideo 1). The arthroscope and instruments were freely

nterchanged between the 3 portals, although the postero-

1Surgery, Vol xx, No x (Month), 2011: pp xxx

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2 J. SIMPSON ET AL.

lateral portal was generally easier for accessing the foveaand the posteroinferior aspect of the cotyloid fossa.

GRAFT PREPARATION

To eliminate the risk of donor-site morbidity, an arti-ficial graft made of polyethylene terephthalate (LigamentAugmentation & Reconstruction System [LARS], Arc-sur-Tille, France) was used. Good results have beenreported for this material in ACL reconstruction.8,9 Aynthetic knee medial collateral ligament graft (MCL 32,ARS) was used because this best suited the proposedrocedure. The graft was looped over a 6-mm EndoBut-on (Smith & Nephew). The final construct comprisingARS ligament and EndoButton was sized at a diameterf 8 mm. Control sutures were applied to the EndoBut-on, which was then attached to a reversed ACL passingin (Beath pin), which acted as an introducer (Fig 2).

FEMORAL AND ACETABULAR TUNNELS

The fovea of the femoral head was clearly visual-zed by use of a combination of hip flexion and inter-

TABLE 1. Key Points

● Cadavers used to trial techniques● Careful patient selection● Acetabular safe zones to safeguard against vascular injury● Synthetic graft to eliminate donor-site morbidity● Ongoing audit of outcomes

FIGURE 1. View of right femoral head (FH) showing bare foveaas a result of complete rupture of ligamentum teres (posterolateral

viewing portal). (CF, cotyloid fossa.)

al rotation. A femoral tunnel aimer arm was devel-ped by modifying an existing hip arthroscopy guideCrosstrac hip guidance system; Smith & Nephew),he tip of the curved aimer being placed in the centerf the fovea (Fig 3, Video 1) and then being attachedo the hip guidance system. A 3.2-mm guidewire wasassed through the greater trochanter and along theemoral neck, under image intensifier control, until itsip was seen arthroscopically to exit precisely from theenter of the fovea. The guidewire was then used to

FIGURE 2. The graft, here portrayed by a shoelace (G), passedhrough the EndoButton (EB). The white suture (white arrow) keepshe EndoButton against the side of the ACL passing pin (PP) until thendoButton “flip” is performed later in the procedure by pulling on

he apical suture (black arrow) and releasing the white suture.

FIGURE 3. Intra-articular view of femoral aimer arm (AA) inposition in fovea of right femoral head (FH) (posterolateral view-

ing portal). (CF, cotyloid fossa.)

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3LIGAMENTUM TERES RECONSTRUCTION

develop a femoral tunnel, 9 mm in diameter, by use of acannulated drill. Bleeding from the foveal end of thetunnel was controlled by passing a flexible radiofre-quency probe (Dyonics Eflex ligament chisel; Smith &Nephew) down the tunnel and ablating the hemorrhagingtissue.

The femoral head was then rotated within the ace-tabulum so that when a guidewire was passed up thefemoral tunnel, it precisely struck the optimum pointof graft insertion in the acetabulum. This position wasat the posteroinferior portion of the cotyloid fossa,leaving a bridge of bone measuring approximately 5mm inferiorly so as not to break into the obturatorforamen. The posteroinferior portion of the acetabu-lum is also known to be a safe point for acetabularpenetration at hip arthroplasty surgery.10 The guide-wire was not allowed to penetrate the medial wall ofthe acetabulum. However, once the precise locationfor the acetabular hole had been identified, the guide-wire was removed from the femoral tunnel and an8-mm drill was passed down the tunnel to fashion theacetabular tunnel under direct arthroscopic vision andwith great care.

GRAFT POSITIONING

The femoral and acetabular tunnels were then com-plete and suitably aligned. The EndoButton/ligament/reversed ACL passing pin complex was passed down

FIGURE 4. EndoButton/ligament/reversed ACL passing pin com-lex entering acetabular tunnel (AT) (posterolateral viewing por-al). (G, graft; EB, EndoButton.)

the femoral tunnel under image intensifier control.

Direct vision was used to guide the EndoButton intothe acetabular tunnel (Fig 4, Video 1). Image intensi-

er views (Fig 5) were used to confirm exit from thecetabular tunnel on the inner lamina of the pelvisefore the EndoButton was flipped (Fig 6). The intro-

ducer and all sutures were then removed, althoughtension was maintained on the LARS ligamentthroughout (Fig 7) to ensure that the EndoButtonremained securely apposed to the inner lamina of thepelvis.

The limb was then rotated into 60° of externalrotation, and traction on the right lower limb wasslowly released. The ligament, which remained undertension throughout, was then fixed securely within thefemoral tunnel by a graft fixation screw (9 � 30–mmSoftsilk 1.5 screw; Smith & Nephew). The excessligament was cut flush with the greater trochanter.

Twenty milliliters of 0.25% bupivacaine was placedinto the hip joint before skin closure, with all theincisions being closed with interrupted No. 3/0 nylonsutures. Formal check radiographs (anteroposteriorand lateral views) were performed before the patientreturned to the ward (Fig 8).

REHABILITATION AND RECOVERY

The patient was discharged home the day afterurgery and was restricted to touch weight bearing for

weeks. She was also asked to avoid any activexternal rotation of the hip but was permitted active

FIGURE 5. Image intensifier view of EndoButton (EB) withinacetabular tunnel but before it penetrates medial wall of acetabu-

lum. (A, 70° arthroscope; PP, passing pin.)

4 J. SIMPSON ET AL.

hip flexion to a maximum of 60° for the same period.An intensive physiotherapy rehabilitation programwas commenced a week postoperatively.

Ten weeks after her operation, the patient reportedthat she was no longer aware of the “knocking” feel-ing that had been present before surgery. She had

FIGURE 6. The EndoButton (EB) has now been flipped against themedial wall of the pelvis; the inferior guidewire (GW) is lyingexternally on top of the patient’s proximal thigh. (A, 70° arthro-scope.)

FIGURE 7. Ligamentum teres graft (G) before final tensioning andscrew placement (posterolateral viewing portal). (FH, femoral

chead; CF, cotyloid fossa.)

regained normal hip flexion, but external rotation re-mained restricted to 50% of the contralateral hip. HerNon-Arthritic Hip Score on the day of surgery was 42.These same scores at 6 weeks and 6 months aftersurgery were 72 and 86, respectively.

The patient’s latest clinical review, 8 months afterreconstruction, showed continued improvement inboth her confidence and muscle control around thehip. Her Non-Arthritic Hip Score was 89. The reha-bilitation program is now focused on returning hermuscular control, strength, and stamina to the extremelevels required in professional dance.

DISCUSSION

The breadth of procedures available to the arthros-

FIGURE 8. Postoperative radiographs to show interference screw(IS) and EndoButton (EB) position on (A) anteroposterior view and(B) lateral view.

opic hip surgeon continues to grow,7 although clearly,

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5LIGAMENTUM TERES RECONSTRUCTION

arthroscopic reconstruction of the ligamentum teres isin its infancy. However, it has been established that arupture of the ligamentum teres can be a source ofpain4 and that the ligamentum does impart sometability to the hip joint.1 We believe that to arthros-

copically reconstruct this structure is a reasoned andjustifiable response in carefully selected individuals.The technique we describe is based on similar liga-ment reconstruction procedures elsewhere in the mus-culoskeletal system, in addition to being simple andreproducible.

Transacetabular holes have been used by hip ar-throplasty surgeons successfully for many years.11

The concept of safe zones for transacetabular drillholes was developed by Wasielewski et al.10 for useby hip arthroplasty surgeons seeking to use screwsto provide initial stability for uncemented acetabu-lar components. The recommended acetabular entrypoint was selected with reference to these zones(Fig 9). The posteroinferior and posterosuperior

uadrants are considered safe, whereas the anterioruadrants are to be avoided because of the closelypposed major vascular structures.12,13 The exit

point lies safely inferior with reference to the neigh-boring vascular structures in the female pelvis (Fig10). In the male pelvis the obturator vein more

FIGURE 9. Model showing entry point for acetabular tunnel (AT)with reference to ASIS, femoral vessels (FA&V), and obturator

vessels (OA&V).

closely follows the artery and is therefore evenfurther away from the acetabular entry point than inthe female pelvis.

The indications for ligamentum teres reconstructionremain to be fully defined. Currently, this is onlyoffered to patients in whom arthroscopic surgery hasfailed and where the symptoms are consistent withinstability of the hip. As clinical experience with thisprocedure grows, the selection criteria will change. Itis important that these initial patients undergo detailedfollow-up and have their outcomes recorded withinthe orthopaedic literature.

Acknowledgment: The authors wish to record the sig-ificant contribution made to the development of this tech-ique during the cadaveric phase by Aslam Mohammed,.R.C.S., F.R.C.S.(Orth), Wrightington Hospital, Wigan,ngland.

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2. Bardakos NV, Villar RN. The ligamentum teres of the hip.

FIGURE 10. Model showing exit point of acetabular tunnel (AT)ith reference to neighboring vascular structures in female pelvis.

CIA&V, common iliac vessels; EIA&V, external iliac vessels;IA&V, internal iliac vessels; OA&V, obturator artery and vein;V, branch of obturator vein.)

J Bone Joint Surg Br 2009;91:8-15.

6 J. SIMPSON ET AL.

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