All About the Ligamentum Teres: From Biomechanical Role to Surgical Reconstruction

Associations Between Hip Pathology, Hip and Groin Pain, and Injuries in Hockey Athletes: A Clinical Commentary

Femoroacetabular impingement (FAI), particularly cam morphology, is highly prevalent among elite hockey athletes. Moreover, hip and groin pain has become a common issue in hockey, with approximately 50% of European professional athletes reported to experience a hip or groin problem during a season. While most athletes will not miss training or competition due to this, restricted competitive performance and increased risk of reduced physical and psychological well-being are likely. Recent research suggests that the development of cam morphology is related to the repetitive shear stresses experienced at the hip joint during adolescence from skating. This condition likely increases the potential for intra-articular and extra-articular injuries in these athletes later in their careers. Research also indicates that the hip joint mechanics during forward skating substantially increase the possibility of sustaining a labral tear compared to other sports. Such an injury can increase femoral head movement within the joint, potentially causing secondary damage to the iliofemoral ligament, ligamentum teres and joint capsule. These injuries and the high density of nociceptors in the affected structures may explain the high prevalence of hip and groin pain in hockey athletes. Compensatory adaptations, such as reduced hip strength, stability, and range-of-motion (ROM) likely increase the opportunity for core muscle injuries and hip flexor and adductor injuries. Specifically, the limited hip ROM associated with cam morphology appears to exacerbate the risk of these injuries as there will be an increase in pubic symphysis stress and transverse strain during rotational movements. It is hoped that this article will assist practitioners currently working with hockey athletes to develop evidence-informed monitoring strategies and training interventions, aimed at reducing the incidence and severity of hip and groin problems, ultimately enhancing athlete performance and well-being. Therefore, the purpose of this clinical commentary was to examine current evidence on common hip pathologies in hockey athletes, exploring potential associations between hip and groin pain and the biomechanics of hockey activities.

Level of Evidence

5.

The contribution of the ligamentum teres to the hip fluid seal: A biomechanics study

BACKGROUND

The suction seal of the hip plays an important role in maintaining hip stability; however, the function of the ligamentum teres in maintaining this seal remains poorly understood. This study aimed to evaluate the effectiveness of the hip suction seal in ligamentum teres deficient hips for joint positions occurring during gait.

METHODS

Six fresh-frozen human cadaveric hips were dissected and mounted to an Instron materials test system. Each specimen was analyzed for average peak distraction force, stiffness, and total energy during hip displacement. Testing was performed in the native intact ligamentum teres state and the deficient ligamentum teres state. Specimens were examined in 20° of flexion, neutral, and 10° of extension.

FINDINGS

In the neutral position, the ligamentum teres deficient state displayed a significant decrease in peak distraction force (mean difference: 33.2 N, p < 0.001), average stiffness (mean difference: 63.7 N/mm, p = 0.016), and total energy (mean difference: 82.3 mJ, p = 0.022) compared to the intact controls. In extension, the deficient state exhibited a significant decrease in peak distraction force (mean difference: 42.8 N, p < 0.001) and total energy (mean difference: 72.9 mJ, p = 0.007). In flexion, the deficient state displayed a significant decrease in peak distraction force relative to contols (mean difference: 7.1 N, p = 0.003).

INTERPRETATION

The ligamentum teres plays a significant role in maintaining the suction seal of the hip, with its effect being most prominent when the hip is in neural alignment or in extension. The findings suggest that ligamentum teres deficiency may be a relevant treatment target in the clinical setting.

Hip Capsulolabral Complex: Anatomy, Disease, MRI Features, and Postoperative Appearance

The hip is a uniquely constrained joint with critical static stability provided by the labrum, capsule and capsular ligaments, and ligamentum teres. The labrum is a fibrocartilaginous structure along the acetabular rim that encircles most of the femoral head. Labral tears are localized based on the clock-face method, which determines the extent of the tear while providing consistent terminology for reporting. Normal labral variants can mimic labral disease and can be differentiated by assessment of thickness or width, shape, borders, location, and associated abnormalities. The Lage and Czerny classification systems are currently the most well-known arthroscopic and imaging systems, respectively. Femoroacetabular impingement is a risk factor for development of labral tears and is classified according to bone dysmorphisms of the femur ("cam") or acetabulum ("pincer") or combinations of both (mixed). The capsule consists of longitudinal fibers reinforced by ligaments (iliofemoral, pubofemoral, ischiofemoral) and circular fibers. Capsular injuries occur secondary to hip dislocation or iatrogenically after capsulotomy. Capsular repair improves hip stability at the expense of capsular overtightening and inadvertent chondral injury. The ligamentum teres is situated between the acetabular notch and the fovea of the femoral head. Initially considered to be inconsequential, recent studies have recognized its role in hip rotational stability. Existing classification systems of ligamentum teres tears account for injury mechanism, arthroscopic findings, and treatment options. Injuries to the labrum, capsule, and ligamentum teres are implicated in symptoms of hip instability. The authors discuss the labrum, capsule, and ligamentum teres, highlighting their anatomy, pathologic conditions, MRI features, and postoperative appearance. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Quantitative cotyloid fossa thickness and proximity to obturator neurovascular bundle: implications for arthroscopic ligamentum teres reconstruction

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.

Graft Options for Hip Labral Reconstruction

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Arthroscopic hip labral reconstruction is a complex procedure which is growing in use as indications, techniques, and surgical expertise advance.

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Graft selection is an important component of labral reconstruction based on relative advantages and disadvantages of available types of autografts and allografts.

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The ideal graft should mimic the native acetabular labrum form and function while also being affordable, readily available, and associated with low morbidity.

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High rates of patient satisfaction and positive patient-reported outcomes have been reported after labral reconstruction using several graft types.

Editorial Commentary: Hip Joint Laxity, Microinstability, or Instability Require Precise Definition: No Matter What You Call It, It's Here to Stay!

Hip instability has gained recognition as an important cause of hip pathology. Causes include incongruency of the articular surfaces due to dysplasia and/or impingement, joint capsule pathology, labral pathology, ligamentum teres tears, ligamentous laxity, muscular imbalance, and tendon tears. Lacking clearly defined symptoms and tests has hindered identification and treatment of this condition. Furthermore, the relevant literature uses different terms such as hyperlaxity and microinstability to describe this patient population, conveying different messages. However, the different terms convey different messages. Joint hyperlaxity or hypermobility has sometimes been used in reference to the hip; however, these usually refer to a genetic ligamentous and capsular condition affecting collagen structure, such as in Ehlers Danlos Syndrome. More common, and often interchangeable, terms are instability and microinstability. As the authors state in the present study, 'instability' has the advantage of conveying the significant impact the condition has on a patient's life. On the other hand, 'microinstability' may more accurately reflect the vague clinical presentation that we often encounter in the average hip patient with instability. Most patients do not complain of symptoms commonly seen in other joints with "instability," such as giving way, subluxation, and recurrent dislocations. In the hip, the symptoms are generally less tangible, and hence, the term "microinstability" may be more appropriate.

Female gender, decreased lateral center edge angle and a positive hyperextension-external rotation test are associated with ease of hip distractability at time of hip arthroscopy

PURPOSE

To identify factors associated with ease of hip distraction at the time of hip arthroscopy.

METHODS

A retrospective review of patients 17-50 years old undergoing hip arthroscopy with a single high-volume hip arthroscopist was performed from 2014 to 2020. Demographics, clinical history, examination, and imaging findings were collected. Distractibility was quantified using turns of fine traction (1 turn = 4 mm axial distraction) with the patient paralyzed on a fracture table with a well-padded perineal post Fine axial traction was applied after the patient's perineum contacted the post. Demographic and clinical predictors of ease of distractibility were analyzed with simple linear regression models. Significant predictors were subsequently added to a multivariable linear regression model, estimating the effect of each variable.

RESULTS

In total, 453 patients were included, with an average age of 31.6 years (± 9.2) and 45.9% females. In univariate analysis, gender, race, BMI, range of motion, hyperextension-external rotation (HEER) test, the abduction-extension-external rotation test, and lateral center edge angle (LCEA) were associated with the number of fine traction turns required to distract the hip. On multivariable analysis, lower LCEA (p = 0.002), female gender (p < 0.001), and a positive HEER test (p = 0.045) were associated with decreased turns required for adequate hip distraction.

CONCLUSION

Female gender, decreased LCEA, and a positive HEER test are associated with decreased axial traction required for adequate hip distraction at the time of hip arthroscopy. As ease of distractibility has been associated with hip microinstability, these findings may allow pre-operative identification of hip instability patients and aid in pre-operative counseling, risk stratification and capsular management planning.

LEVEL OF EVIDENCE

IV.

CLINICAL RELEVANCE

Preoperative identification of risk factors for ease of hip distraction may raise pre-surgical suspicion and, when coupled with other intraoperative findings, may aid in the diagnosis and management of hip microinstability.

Edema of the Ligamentum Teres as a Novel MRI Marker for Non-Traumatic Painful Hip Pathology: A Retrospective Observational Study

Background

The ligamentum teres has been recognized as an important stabilizer of the hip joint and can be affected by various hip pathologies. This study aims to introduce ligamentum teres edema as an MRI marker to diagnose the underlying cause of hip pathology, mainly femoral acetabular impingement (FAI) and adult developmental dysplasia of the hip (ADDH), in non-traumatic patients.

Methodology

Adult patients presenting with non-traumatic hip pain of variable duration and ligamentum teres edema on MRI between 2014 and 2020 were included. A high-resolution standard MRI hip protocol was used for all patients in this series. MRI and plain radiographs were assessed. Ligamentum teres edema, alpha angle, center edge angle of Wiberg, and retroversion were assessed.

Results

In total, 55 patients with 110 hip joints (males: 29 (52.7%), females: 26 (47.3%)) of different ethnicities were included in this study. Out of the 55 patients with ligamentum teres edema, one had only unilateral right-sided FAI, seven had only unilateral left-sided FAI, and 46 (94 hip joints) had either bilateral FAI or ADDH. Therefore, eight (14.5%) patients with unilateral FAI had the absence of the contralateral FAI or ADDH (6.5% false-positive) despite the presence of ligamentum teres edema bilaterally, and the rest of the patients with bilateral ligamentum teres edema (102 joints: 92.7% positive predictive value) had findings of either FAI or ADDH.

Conclusions

Ligamentum teres edema can be considered as an early MRI marker to diagnose the underlying pathology of symptomatic painful hip disorders, especially FAI.

In-line Pullout Strength of 2 Acetabular Fixation Methods for Ligamentum Teres Reconstruction of the Hip: A Cadaveric Study

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.

The role and clinical relevance of the ligamentum teres: long-term outcomes after hip arthroscopic surgery of cam-type femoroacetabular impingement

We aimed to compare clinical and radiologic outcomes in patients with cam-type femoroacetabular impingement (FAI), with and without a partial ligamentum teres (LT) tear, who underwent hip arthroscopy (HA) with ≥10 years of follow-up. Among the patients who underwent HA for a cam-type FAI diagnosis with a labral tear, 28 patients (28 hips) with a partial LT tear and 87 patients (99 hips) with an intact LT were assigned to Groups A and B, respectively. All patients underwent partial labral debridement and femoroplasty. Debridement and thermal shrinkage were performed for LT tears. The grade of chondral damage was measured intraoperatively. Clinical items were assessed preoperatively and at the last follow-up. Patients’ satisfaction with the surgery and changes in postoperative sports ability in those who had previously been active in sports were assessed at the last follow-up. The Tönnis grade was assessed preoperatively and at the last follow-up for radiologic evaluation. Chondral damage to the acetabular and femoral head detected intraoperatively was significantly different between the groups (P = 0.005 and P &lt; 0.001). At the last follow-up, Group A patients experienced more difficulty performing sports activities than Group B patients (P = 0.056), and significantly, more Group A patients had stopped exercising despite their active participation in sports preoperatively (P = 0.002). Regarding the Tönnis grade, significant differences were found only at the final follow-up (P = 0.020). Patients with partial LT tear showed a higher grade of chondral damage, experienced decreased exercise capacity and had significantly worsened Tönnis grades, suggesting hip osteoarthritis progression compared to those with an intact LT.

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.

Ligamentum Teres Reconstruction May Lead to Improvement in Outcomes Following a Secondary Hip Arthroscopy for Symptomatic Microinstability: A Systematic Review

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.

Indications and Outcomes After Ligamentum Teres Reconstruction: A Systematic Review

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.

Graft Options in Hip Labral Reconstruction

PURPOSE OF REVIEW

The last decade has seen a boom in hip arthroscopy with refined indications. Improved understanding of pathoanatomy and disease progression has allowed for the development of advanced techniques. Labral reconstruction has been developed to substitute a non-functional or absent labrum. It has become an important technique in the armamentarium of high-volume arthroscopic hip surgeons.

RECENT FINDINGS

Basic science studies have improved understanding of hip biomechanics in the presence and absence of a labrum with a labral reconstruction allowing for reconstitution of normalcy. Current techniques have shown success with autograft and allograft tissue options. While autograft tissue allows for easy access intra-operatively and maintains patient biology, donor site morbidity is possible. Allografts negate donor site morbidity and allow for an abundance of tissue but can be resource-intensive and face availability concerns. Recent studies support outcomes of labral reconstructions using both autograft and allograft. Promising results have also allowed for performing labral reconstruction in a primary setting. Labral reconstruction can be successfully performed using both autograft and allograft. Patient biology should be respected, and native hip biomechanics restored. The literature is plentiful for appropriate surgical decision-making allowing the surgeon with multiple graft choices depending on training, experience, and resources.

Development of a Predictive Algorithm for Symptomatic Hip Abductor Tears in Patients Undergoing Primary Hip Arthroscopy

BACKGROUND

Patients presenting with lateral hip pain may pose a difficult diagnostic challenge, as pain can be due to various causes.

PURPOSE/HYPOTHESIS

The purpose was to identify risk factors and predictors for symptomatic hip abductor tears in a cohort of patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome. We hypothesized that body mass index (BMI), female sex, age, and presence of chondral damage would be significant predictors of hip abductor pathologies.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary hip arthroscopy between March 2009 and December 2019. Patients with Tönnis grade >1, previous hip conditions, incomplete radiographic data, or open procedures were excluded. All demographic variables, intraoperative measurements, and radiographic measurements were assessed using a bivariate analysis. A stepwise logistic regression was used to determine predictive variables.

RESULTS

In total, 255 hips with a hip abductor tear that underwent hip arthroscopy and 2106 hips without a tear that underwent hip arthroscopy were included. The stepwise logistic regression successfully created a predictive model using age, sex, BMI, lateral joint space, and alpha angle as variables. The efficiency of the predictive model was 90.7%, with an area under the curve of 0.894. The odds of having a hip abductor tear were 7.41 times higher in females (odds ratio [OR], 7.41; 95% CI, 4.61-11.9). Each additional year of age was associated with a 13.7% (OR, 1.137; 95% CI, 1.12-1.16) increase in the odds of having a tear. Similarly, with each 1-unit increase in BMI, the odds of having a tear increased by 3.4% (OR, 1.034; 95% CI, 1.01-1.06).

CONCLUSION

This study successfully created a predictive model that identified female sex (OR, 7.41), increasing age (OR, 1.137 for each year), and increased BMI (OR, 1.034 for each unit of BMI) as significant independent predictors of the presence of hip abductor tears in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome. This model can be used in support of physical examination and imaging suggestive of hip abductor pathology to preoperatively identify the probability of a symptomatic hip abductor tear in these patients.

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.

Editorial Commentary: "Loose Lips Sink Ships"-But What About "Loose Hips"?

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.