Outcomes of arthroscopic debridement of isolated Ligamentum Teres tears using the iHOT-33

Ligamentum Teres Lesions Are Associated With Poorer Patient Outcomes in a Large Primary Hip Arthroscopy Cohort of 1,935 Patients

Purpose

To retrospectively evaluate the prevalence and characteristics of ligamentum teres (LT) lesions identified in a single-surgeon hip arthroscopy cohort and to compare surgical outcomes of those with, and without, identified LT lesions.

Methods

Patients who underwent primary hip arthroscopy between 2005 and 2018 in one surgeon’s clinic were identified. Those with a history involving extra-articular scoping or any previous surgery on the ipsilateral hip were excluded. Patient-reported outcome measures completed before and after surgery included the Hip Disability and Osteoarthritis Outcome Score, Nonarthritic Hip Score, and 12-item International Hip Outcome Tool. Conversion to hip joint replacement was ascertained through a national register.

Results

A total of 1,935 primary hip arthroscopies (from 1,607 different patients) were included in this study. In total, 323 LT lesions were identified. Those with LT lesions were older than those without (40.3 ± 11.3 years compared with 33.9 ± 12.1 years; P < .001), and more frequently female (58.2% vs 41.8%; P = .001). Hips with lesions had a smaller lateral center-edge angle than other hips (33.0 ± 6.8° vs 34.1 ± 6.0°; P = .004). All patient-reported outcome measures improved significantly (P < .001) from pre- to post-surgery for patients with and without LT lesions. However, patients with LT lesions reported less improvement in the 12-item International Hip Outcome Tool (difference –5.60; P = .004) and in Hip Disability and Osteoarthritis Outcome Score symptoms (–4.41; P = .004), sports (–7.81; P < .001), and quality of life subscales (–8.85; P < .001) than those without lesions. Hips with LT lesions also had a 6.2% 2-year rate of subsequent hip replacement (20/323 hips) compared with those without lesions (0.9%; 14/1612 hips; P < .001).

Conclusions

In this single-surgeon hip arthroscopy cohort, identification of LT lesions was associated with poorer patient-reported outcomes and increased likelihood of conversion to arthroplasty within 2 years. These findings suggest a poorer prognosis for patients with LT injury compared with those without.

Level of Evidence

Level III, retrospective cohort study.

Multicenter Outcomes After Hip Arthroscopy: Comparative Analysis of Patients Undergoing Concomitant Labral Repair and Ligamentum Teres Debridement Versus Isolated Labral Repair

Background:

Increased attention has been directed toward the ligamentum teres (LT) and its association with acetabular coverage, labral pathology, and hip microinstability; however, few studies have evaluated whether LT pathology influences the rate of clinically significant outcome improvement after hip arthroscopy.

Purpose:

To determine if patients with femoroacetabular impingement syndrome (FAIS) undergoing labral repair and concomitant LT debridement achieve outcomes similar to patients without LT pathology undergoing labral repair.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

We conducted a retrospective review of a prospectively maintained multicenter database for hip arthroscopy. Included were patients with FAIS who underwent primary labral repair and who had preoperative and minimum 2-year postoperative outcome scores. Patients diagnosed with concomitant partial LT tear were identified and matched 1:3 according to age, sex, and body mass index (BMI) to patients without LT pathology. The following clinical outcomes were compared between groups: modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sport Subscale, International Hip Outcome Tool, and visual analog scale for pain and satisfaction. Achievement of the minimal clinically important difference and patient acceptable symptomatic state was also compared between groups.

Results:

This study included 124 patients with FAIS with labral tear and concomitant partial LT tear and 372 patients with labral tear and no LT pathology. The age, BMI, and sex of the matched cohort were 38.0 ± 12.0 years (mean ± SD), 24.3 ± 3.6 kg/m2, and 62.0% female, respectively. No significant difference in age, BMI, sex, workers’ compensation status, or duration of pain was observed at baseline. Analysis of radiographic parameters indicated that patients who underwent isolated labral repair had a lower preoperative Tönnis angle (4.8° ± 4.4° vs 6.3° ± 5.4°; P = .006). There were no significant differences between groups on any pre- or postoperative outcome measure, and there were no significant differences in the proportion of patients who achieved the minimal clinically important difference or patient acceptable symptomatic state on any outcome measure.

Conclusion:

Patients with labral tear and concomitant partial LT tear experienced similar preoperative scores and achieved similar outcomes as patients with isolated labral tears after hip arthroscopy.

Arthroscopic Ligamentum Teres Reconstruction: Minimum 2-Year Patient-Reported Outcomes With Subanalysis of Patients With Ehlers-Danlos Syndrome

PURPOSE

To report on minimum 2-year outcomes of patients undergoing arthroscopic ligamentum teres reconstruction (LTR).

METHODS

Our institutional registry was retrospectively reviewed for all patients undergoing LTR between December 2012 and February 2016. LTR was indicated for a fully torn or dysfunctional ligamentum teres with symptomatic multidirectional instability not treatable by osteotomy or capsular plication alone. Demographic data, preoperative clinical and radiographic measures, and intraoperative data were recorded. Patient-reported outcome measures including the modified Harris Hip Score, the Non-Arthritic Hip Score, a visual analog scale score for pain, and patient satisfaction were recorded preoperatively and annually postoperatively. Revision arthroscopies and conversions to total hip arthroplasty were recorded.

RESULTS

Twelve reconstruction procedures were performed in 10 patients during the study period. Minimum 2-year follow-up was available for 9 patients (11 hips). The mean follow-up time was 44.27 months (range, 24-72 months). There were 7 female and 2 male patients, and the mean age was 30.34 years (range, 17.23-43.68 years). Two hips underwent conversion to total hip arthroplasty at a mean of 21.12 months. For the remaining patients, significant improvements were observed in the modified Harris Hip Score (from 44.1 to 71.8), Non-Arthritic Hip Score (from 47.5 to 78.6), and visual analog scale score (from 7.8 to 3.6) (P < .05). The average patient satisfaction rating was 7.88 (range, 4-10). Subanalysis of 5 patients (7 hips) with a diagnosis of Ehlers-Danlos syndrome showed a higher failure rate in this group.

CONCLUSIONS

Although LTRs are indicated and performed only in a select group of patients, the procedure can provide meaningful improvement in patient-reported outcomes, pain reduction, and patient satisfaction. However, most patients undergoing LTR at present have underlying factors that significantly mitigate their prognosis, such as Ehlers-Danlos syndrome or failed previous surgery. Because these patients represent a subset of patients with complex hip pathologies in whom treatment is difficult, the expectations of surgery should be set accordingly.

LEVEL OF EVIDENCE

Level IV, therapeutic study, case series.

Ultrasonography-guided intra-articular steroid injection in the hip for symptomatic round ligament partial tear or degeneration

Purpose

The objectives of this study were to demonstrate the benefits of ultrasonography-guided intra-articular steroid injection in the hip (UISIH) for the treatment of partial tear or degeneration of the round ligament of the femur and to determine the prognostic factors for this treatment.

Methods

We retrospectively analyzed the records of 40 patients who were diagnosed with a partial tear or degeneration of the round ligament of the femur and who underwent UISIH between August 2014 and November 2018. The inclusion criteria were a lack of history of UISIH or other interventional procedure and the presence of follow-up records after the hip injection. The short-term clinical outcome was evaluated at the first follow-up appointment after UISIH. Possible prognostic factors for UISIH such as age, sex, injection side, and average follow-up time were analyzed using the chi-square test, the Fisher exact test, and the t test.

Results

UISIH was found to have been effective in 35 of the 40 patients (87.5%) at the first follow-up visit. The average follow-up time was 43 days. No significant differences were observed in the clinical outcome of UISIH with respect to age, sex, injection side, or follow-up time.

Conclusion

In this study, we demonstrated that UISIH was a safe and effective treatment in patients with a partial tear or degeneration of the round ligament of the femur over the course of short-term follow-up. Age, sex, injection side, and follow-up time were not identified as prognostic factors for this treatment.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies

Load-deformation properties of the ligament of the head of femur in situ

The ligament of the head of femur (LHF) or ligamentum teres has been reported to tense during hip adduction and also to provide mechanical stability to the joint. LHF injury is more common in females and also in right hip joints compared with left ones. Although this could be due to leg dominance, pelvic size or muscle strength, there is no study that has looked into these differences. This cadaveric biomechanical study aimed to compare potential differences in the mechanical behavior of the LHF between neutral and 20° adducted hip joints, sex, and sides. Tensile tests of the LHF were performed on 25 hip joints (mean age at death of 85.7 ± 7.5 years; 9 females, 4 males; 13 left, 12 right), positioned either neutrally or in adduction. The maximum force required to rupture the ligament, its strain at failure, tensile strength, linear stiffness, and elastic modulus were obtained and statistically compared between analysis groups. The maximum force the LHF could withstand before rupture averaged 57 ± 37 N, strain at failure of 59 ± 33%, tensile strength of 2.9 ± 1.8 MPa, linear stiffness of 5.4 ± 3.5 N/mm, and elastic modulus of 7.2 ± 3.8 MPa. The LHF length at failure was significantly greater in males compared with females (P = 0.02). Irrespective of joint position, there were no statistical differences in the stress-strain properties of the LHF between females and males, or sides. There may be other anatomical, functional, and demographic factors that could render the ligament tissue vulnerable to injury in these groups. Clin. Anat., 33:705-713, 2020. © 2019 Wiley Periodicals, Inc.

Neurovascular structures of the ligament of the head of femur

The ligament of the head of femur (LHF), or ligamentum teres, is believed to provide blood supply to the head of femur and mechanical stability to the hip joint. But these functions in the adult are often debated. The existence and distribution of neurovascular structures within the ligament are not widely documented. This study examined the blood vessels and nervous tissue within the LHF to determine whether the ligament may have a vascular and proprioceptive function at the hip joint. Histological sections from the LHF from 10 embalmed hips (six female, four male; mean age 80.4 ± 8.7 years) were cut at three levels: the foveal attachment, mid-length and its base where it attaches to the transverse acetabular ligament. Sections were stained with haematoxylin and eosin to study general tissue architecture or with von Willebrand factor and neurofilament to identify blood vessels and nervous tissue, respectively. The proportion of the ligament's cross-sectional area occupied by blood vessels was expressed as a vascularity index (VI). Nerve endings within the ligament were identified and morphologically classified. Comparisons between the VI at the three levels, or between the tissue layers of the ligament, were made using 95% confidence intervals; statistical significance was set P < 0.05. The ligament tissue comprised three distinct layers: a synovial lining with cuboidal cells, a sub-synovial zone formed of loose connective tissue and the ligament proper composed of dense collagen bundles. Patent blood vessels and nerve fibres were present both in the sub-synovial zone and the ligament proper; Pacinian corpuscles and free nerve endings were found scattered only in the sub-synovial zone. The VI of the ligament proper at the fovea was significantly higher than its middle (P = 0.01) and basal levels (P = 0.04); it was also higher than that of the sub-synovial layer (P = 0.04). The LHF has three histologically distinct zones, and blood vessels and nerves are distributed both in the sub-synovial layer and ligament proper. Higher vascularity within the ligament proper at its foveal insertion suggests a possible nutritive role of the LHF to the adult head of femur. The presence of nerves and nerve receptors indicates the ligament is involved in the perception of pain and proprioception, thereby contributing to mechanical stability of the joint.