Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 113–118 doi: 10.1093/jhps/hnx039 Advance Access Publication 16 October 2017 Review article A novel and simple classification for ligamentum teres pathology based on joint hypermobility John M. O’Donnell* and Manit Arora Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC, Australia. *Correspondence to: J. M. O’Donnell. E-mail: email@example.com Submitted 18 April 2017; Revised 14 August 2017; revised version accepted 1 September 2017 ABSTRACT Ligamentum teres (LT) pathology (including synovitis, partial and complete tears) is common at the time of hip arthroscopy with a reported prevalence of 51–90%. Currently, there are four published classiﬁcations of LT injuries and tears. The majority focuses on differentiating partial from full thickness tears, whereas a more recently published classiﬁcation also incorporates the presumed underlying mechanism of pathology. A recent review of the current classiﬁcation systems found that all are deﬁcient for lack of inclusion of what constitutes a normal liga- ment, lack of inclusion of synovitis as a source of pathology and lack of inclusion of hypermobility as part of the treatment algorithm. Also, the two most commonly used classiﬁcation systems have only fair inter-observer reli- ability. Recent work has found that underlying joint hypermobility plays an important role in LT pathology and that the addition of capsular plication/suture at the time of surgery for LT pathology improves outcomes and re- duces re-tear rates. In order to address these problems which have been identiﬁed with the currently available classiﬁcation systems, we propose a novel and simple classiﬁcation for LT pathology based on underlying joint hypermobility [as assessed by the Beighton test score (BTS)]. LT pathology is used to divide all patients into four types: 0 normal (which includes minor fraying), 1 synovitis (which would also include minor fraying), 2 par- tial tear and 3 complete tear. Further, all types are subdivided into two groups: Group A patients have no clinical evidence of joint hypermobility (BTS < 3), whereas Group B patients do have clinical evidence of joint hypermo- bility (BTS 4). On the basis of this classiﬁcation system and the available literature, we have also developed a treatment algorithm for LT pathology. the capsular ligaments and works in a sling like manner to INTRODUCTION prevent subluxation of the femoral head at the extremes of Role of the ligamentum teres motion [6–9]. Further, it probably has a role in nocicep- The ligamentum teres (LT) and its role in hip function has tion [10, 11], and less defined role in proprioception  been controversial since Professor W.S. Savory’s presenta- and synovial fluid lubrication . tion to the Cambridge Philosophical Society in April 1874 on its function . The LT assumes an important role in Prevalence of LT pathology the neonatal hip as a stabilizing structure and a conduit for the blood supply of the femoral head [2, 3]. However, LT pathology (including synovitis, partial and complete traditional orthopaedic teaching has been to regard the LT tears) is commonly observed at the time of hip arthroscopy as a redundant or vestigial structure in the adult hip. With with a quoted prevalence of up to 51–90% [12–14]. the advent of hip arthroscopy in the last few decades there Further, it has been suggested that lesions involving the has been renewed interest in the role of LT in hip path- LT are the third most common cause of hip pain in ath- ology and hip motion . Our understanding of the role letes undergoing diagnostic arthroscopic procedures . of the LT in the adult hip [4, 5] has evolved. The LT is Less than 2% of LT tears are diagnosed on preoperative now believed to act as a secondary stabilizer to supplement magnetic resonance imaging and magnetic resonance V C The Author 2017. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by- nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact firstname.lastname@example.org Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/113/4554497 by Ed 'DeepDyve' Gillespie user on 20 June 2018 114 J. M. O’Donnell and M. Arora arthrography (MRA) scan . There have been recent <50% (low grade); Group II a partial tear of >50% (high reports of improved accuracy using MRA, and traction grade); and Group III full thickness tear . Cerezal et al. MRA [16, 17, 18 Act], but hip arthroscopy remains the (2010)  built on the earlier classifications of Gary and gold standard for the diagnosis of LT pathology . Villar by adding an avulsion fracture and absence of the Most current classification systems focus only on tears [12, LT. Salas and O’Donnell (2015)  proposed a more de- 13], which make up roughly half of the pathology to the tailed classification by describing possible pathological LT , the other half being synovitis alone. Fraying of causes, and potential treatments. The Gray and Villar clas- the LT is not typically reported in any classification or de- sification continues to be the most widely used. scriptive study. Need for a new classification system LT and joint hypermobility An effective classification system must be valid, reliable As our understanding of the LT has evolved so has its asso- and reproducible, but it should also standardize a language ciation with benign joint hypermobility and the impact on for consistent communication, provide guidelines for ap- treatment. Benign joint hypermobility, has been shown to propriate treatment, and aim to provide a reliable prognos- be associated with an increased incidence of LT tears . tic indication for the pathology . It should also aim to It has been hypothesized that the capsular laxity in such pa- provide a mechanism for evaluating and comparing treat- tients may allow over-stretching and tearing of the LT, typ- ment results across centers and institutions. ically from its femoral attachment. It has also been To date, there has only been one study  of the suggested that the LT may assume a more important role inter-observer and intra-observer reliability of the classifica- as a stabilizer of the hip when the capsular ligaments are tion of LT tears using the two most commonly applied lax . classification systems (Gray and Villar, and Botser and The Beighton test score (BTS) is the accepted clinical Domb), and it found only fair reliability of both. The major standard for determining joint hypermobility in children flaws identified in these two frequently used systems were: and adults [21–23]. The BTS, consisting of five clinical manoeuvres, is scored dichotomously (0/1) from which a i. Differentiation between normal LT and low total score ranging from 0 to 9 is calculated ; with a grade or partial tears was a common source of re- BTS score of 4 or more being widely accepted as the clinical viewer disagreement. definition of joint hypermobility [21, 24]. A BTS of 4 or ii. Synovitis was commonly identiﬁed as a potential more has been shown to be associated with a reduced cap- source of pain in the absence of any discrete LT sular thickness and with a high prevalence of partial tears of tear, but could not be included in either classiﬁ- the LT . Further, capsular laxity (thinning) alone is cation system. associated with a higher incidence of LT pathology . iii. There is no deﬁnition of a normal LT, meaning In patients with complete LT tears who have general- that even very minor tears, of uncertain clinical ized hypermobility, reconstruction of the LT, combined signiﬁcance, would be included as partial thick- with capsule plication, has improved patient related out- ness tears. This may, in part, explain the claimed come measures [26, 27]. Improved hip stability obtained rate of LT tears identiﬁed at hip arthroscopy of by routine anterior capsular tightening, using either radio- up to 90% . frequency energy (RF) or suture plication, also leads to sig- nificant improvement in results for patients having partial The importance of synovitis of the LT as a source of pain LT tear debridements . This method has resulted in a within the hip, with or without an associated partial thick- lesser re-tear rate than LT debridement alone . ness tear, is also evidenced by the report of the LT test (Fig. 1). The test was shown to be positive with syno- Current classification systems vitis of the LT. Furthermore, synovectomy of the LT to Currently there exist four arthroscopic classifications for treat synovitis without tear has been shown to be beneficial LT injuries and tears, and they can be summarized as fol- . lows. Gray and Villar (1997)  proposed the first classi- To address these identified flaws in the currently avail- fication: Type I complete tear; Type II partial thickness able systems, we propose a new classification system. tear; and, Type III tear associated with degenerative Specifically, this classification includes a Normal Group to changes. Botser and Domb (2011) proposed a more de- allow for very minor abnormalities, and a Synovitis Group scriptive classification by dividing partial tears into two so that patients with LT synovitis alone can be included. groups: Group I included a partial tear visualized to be Further, partial thickness tears have not been sub-classified Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/113/4554497 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Novel and simple classification for LT pathology 115 Fig. 1. Clinical image of the LT test. The LT test is performed with the patient in the supine position and the examiner standing next to the patient on the side of the examined hip. The patient’s knee is ﬂexed to 90 and the hip ﬂexed to 70 (a) without tilting the pelvis. From this position, the hip is then abducted as far as the patient will tolerate. The hip is then adducted until it is 30 short of full ab- duction (b). The hip is then fully internally and externally rotated until a ﬁrm end point is observed by the examiner. Internal and ex- ternal rotation are performed in a smooth, steady manner (c). We attempt to avoid causing undue pain in the patient by not pushing them past their pain tolerance. Pain provocation in either internal or external rotation is considered a positive test result. If pain is pro- duced early in internal or external rotation before reaching a ﬁrm end point, then the test result is considered to be positive in that dir- ection. The production of pain should be relieved with rotation in the opposite direction and reproducible with rotation in the direction of pain again. into low and high grade, as these gradings have not been Type 2 have partial tears of the LT with or without evi- shown to lead to differences in symptoms, differences in dence of synovitis (Fig. 4); and Type 3 have complete treatment or difference in treatment outcome. tears of the LT with or without evidence of synovitis In addition, this classification takes into account the im- (Fig. 5). All types are further subdivided into two groups portant added feature of any associated joint hypermobil- based on absence or presence of generalized joint hyper- ity. As noted earlier, treatment of hypermobility in mobility as determined by the BTS—Group A consists of addition to the treatment of the LT tears has been shown patients defined as not having clinical evidence of general- to result in improved outcomes. ized laxity with a BTS of 3 or less; and Group B consists of patients with clinical evidence of joint hypermobility with a Our proposed classification BTS greater than or equal to 4. Type 0 patients have not been subdivided into A or B as this does not change their All patients can be divided into four types (Table I) based on LT pathology found at the time of arthroscopy: Type 0 management. In addition to clinical evidence, the surgeon can use excessive joint distraction on the intra-operative have a normal LT which includes any minor fraying (Fig. 2); Type 1 have synovitis, with or without minor fray- fluoroscan to confirm evidence of laxity (Fig. 6). There is a general lack of consensus as to what consti- ing (Fig. 3), but without any evidence of tear including on dynamic testing intra-operatively (internal and external ro- tutes a normal LT however we have included in Type 0 all patients that had a normal appearing LT or those with tation of the hip; and dynamic intra-operative flexion); Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/113/4554497 by Ed 'DeepDyve' Gillespie user on 20 June 2018 116 J. M. O’Donnell and M. Arora Table I. Our proposed classiﬁcation system for LT pathology according to group and type Group A (no B generalized (generalized laxity; laxity; BTS < 3) BTS 4) Type 0 Normal (including 00 minor frayed) Fig. 4. Partial tear of the LT with mild fraying—Type 2. 1 Synovitis (6 fraying) 1A 1B 2 Partial tear (6 synovitis) 2A 2B 3 Complete tear 3A 3B (6 synovitis) BTS, Beighton test score. Fig. 5. Complete tear of the LT with fraying—Type 3. Fig. 2. Normal LT demonstrating the double bundle pattern— Type 0. Fig. 6. Intra-operative ﬂuoroscan of excessive joint distension in a hypermobility patient. only minor fraying but without any evidence of synovitis or tears. Additionally, there is a subset of patients with less common pathology of the LT (such as impingement against the articular cartilage and focal hyperemia of the acetabular surface ) which have not been included in the current classification system due to the need to balance Fig. 3. Synovitis and mild fraying of the LT—Type 1. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/113/4554497 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Novel and simple classification for LT pathology 117 LT pathology Type 0 Type 1 Type 2 Type 3 3B - debridement/RFA 1B - debridement/RFA 2B - debridement/RFA 3A - debridement/RFA No treatment 1A - debridement/RFA 2A - debridement/RFA or reconstrucon + + capsular + capsular or reconstrucon required alone alone capsular plicaon/suture plicaon/suture alone plicaon/suture Fig. 7. Treatment algorithm based on our proposed classiﬁcation system and available literature (LT, Ligamentum teres; RFA, radio- frequency ablation). a simple classification system against the need for inclusion [38–41] several authors have reported that arthroscopic re- of all probabilities of low frequency, but these can be construction offers a viable option for the treatment of broadly grouped under Type 1 as their treatment is similar complete tears of the LT with good results. to that of LT synovitis. In the group of patients with hypermobility and LT LT tears have been shown to occur in association with tears, the addition of capsular plication for such patients several bony abnormalities [4, 35, 36], most particularly (although they represented a subset of the total group) re- acetabular dysplasia, and femoroacetabular impingement, duces the re-tear rate . For patients with capsular lax- but also hypoplastic antero-inferior horn of the acetabulum, ity, reconstruction with the addition of capsular plication increased femoral anteversion, and femoral retroversion. has had good results [26, 27]. These bony anomalies have deliberately not been included CONCLUSION in this classification for a number of reasons., but most par- Current classification systems for LT pathology are defi- ticularly because each of these would be treated on its mer- cient across three broad domains: lack of inclusion of nor- its irrespective of any associated LT tear. For example, a mal; lack of inclusion of synovitis as a source of pathology; dysplastic acetabulum might be treated by peri-acetabular and lack of inclusion of hypermobility in the treatment al- Osteotomy, and it is unlikely that the status of the LT gorithm. Based on these inherent deficiencies in the cur- would be considered in this decision making process. rent classification systems, we present a novel and simple The classification is intended to take into account soft classification for patients with LT pathology (normal/ tissue factors relating to the severity, and treatment of LT frayed, synovitis, partial tears and complete tears) based on tears. It is not intended to be a classification of all causes of underlying joint hypermobility. We also present a treat- hip instability. In addition, any attempt to include all bony ment algorithm for all LT pathology based on the current anomalies or soft tissue factors in this classification system available evidence from the literature. would inevitably greatly complicate the new classification, and our principal aims for the system include simplicity CONFLICT OF INTEREST STATEMENT and ease of use. None declared. Treatment algorithm Our treatment protocol (Fig. 7) is based on the available REFERENCES literature. A recent systematic review of LT tears found that for partial tears arthroscopic debridement or radiofre- 1. Savory WS. The use of the ligamentum teres of the hip-joint. J Anat Physiol 1874; 8: 291–6. quency ablation (RFA) remains the currently accepted 2. McKibbin B. Anatomical factors in the stability of the hip joint in standard in providing short term relief whereas for full the newborn. Bone Joint J 1970; 52–B: 148–59. thickness tears reconstruction, preferably, or debridement/ 3. Chandler SB, Kreuscher PH. A study of the blood supply of the RFA are the main options . This is in concordance ligamentum teres and its relation to the circulation of the head of with the work of our group where we have found that the femur. J Bone Joint Surg Am 1932; 14: 834–46. arthroscopic debridement alone for LT tears results in 4. O’Donnell JM, Pritchard M, Salas AP, Singh PJ. The ligamentum short term relief in 80% of patients . More recently teres—its increasing importance. J Hip Preserv Surg 2014; 1: 3–11. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/113/4554497 by Ed 'DeepDyve' Gillespie user on 20 June 2018 118 J. M. O’Donnell and M. Arora 5. Philippon MJ, Rasmussen MT, Turnbull TL et al. Structural 23. Beighton P, Solomon L, Soskolne CL. Articular mobility in an properties of the native ligamentum teres. Orthop J Sports Med African population. Ann Rheum Dis 1973; 32: 413–8. 2014; 2: 1–5. 24. Scheper MC, Engelbert RHH, Rameckers EAA. et al. Children 6. Kivlan BR, Richard Clemente F, Martin RL, Martin HD. Function with generalised joint hypermobility and musculoskeletal com- of the ligamentum teres during multi-planar movement of the hip plaints: state of the art on diagnostics, clinical characteristics, and joint. Knee Surg Sports Traumatol Arthrosc 2013; 21: 1664–8. treatment. BioMed Res Int 2013; 2013: e121054. 7. Martin RL, Kivlan BR, Clemente FR. A cadaveric model for liga- 25. Devitt BM, Smith B, Stapf R et al. Generalized Joint mentum teres function: a pilot study. Knee Surg Sports Traumatol Hypermobility is Predictive of Hip Capsular Thickness. Orthop J Arthrosc 2013; 21: 1689–93. Sports Med 2017; 5(4): ecollection. 8. Demange MK, Kakuda CMS, Pereira CAM et al. Inﬂuence of the 26. Chandrasekaran S, Martin TJ, Close MR et al. Arthroscopic re- femoral head ligament on hip mechanical function. Acta construction of the Ligamentum Teres: a case series in four pa- Ortope´dica Bras 2007; 15: 187–90. tients with connective tissue disorders and generalized 9. Martin HD, Hatem MA, Kivlan BR, Martin RL. Function of the ligamentous laxity. J Hip Preserv Surg 2016; 3: 358–67. ligamentum teres in limiting hip rotation: a cadaveric study. 27. Hammarstedt JE, Redmond JM, Gupta A, Domb BG. Arthrosc J Arthrosc Relat Surg 2014; 30: 1085–91. Arthroscopic ligamentum teres reconstruction of the hip in 10. Dehao BW, Bing TK, Young JLS. Understanding the ligamentum Ehlers-Danlos syndrome: a case study. Hip Int 2015; 25: 286–91. teres of the hip: a histological study. Acta Ortop Bras 2015; 23: 28. Amenabar T, O’Donnell J. Successful treatment of isolated, par- 29–33. tial thickness ligamentum teres (LT) tears with debridement and 11. Haversath M, Hanke J, Landgraeber S et al. The distribution of capsulorrhaphy. Hip Int J Clin Exp Res Hip Pathol Ther 2013; 23: nociceptive innervation in the painful hip: a histological investiga- 576–82. tion. Bone Joint J 2013; 95–B: 770–6. 29. Haviv B, O’Donnell J. Arthroscopic debridement of the isolated 12. Gray AJ, Villar RN. The ligamentum teres of the hip: an arthro- Ligamentum Teres rupture. Knee Surg Sports Traumatol Arthrosc scopic classiﬁcation of its pathology. Arthrosc J Arthrosc Relat Surg 2011; 19: 1510–3. 1997; 13: 575–8. 30. Cerezal L, Kassarjian A, Canga A et al. Anatomy, Biomechanics, 13. Botser IB, Martin DE, Stout CE, Domb BG. Tears of the ligamen- Imaging, and Management of Ligamentum Teres Injuries. tum teres: prevalence in hip arthroscopy using 2 classiﬁcation sys- RadioGraphics 2010; 30: 1637–51. tems. Am J Sports Med 2011; 39(Suppl.): 117S–25S. 31. Porthos Salas A, O’Donnell JM. Ligamentum teres injuries - an 14. Devitt BM, Smith B, Stapf R et al. The reliability of commonly observational study of a proposed new arthroscopic classiﬁcation. used arthroscopic classiﬁcations of ligamentum teres pathology. J Hip Preserv Surg 2015; 2: 258–64. J Hip Preserv Surg 2017; 4: 187–93. 32. Belloti JC, Tamaoki MJS, Franciozi CE. d S et al. Are distal radius 15. Byrd JWT, Jones KS. Traumatic rupture of the ligamentum teres as a fracture classiﬁcations reproducible? Intra and interobserver source of hip pain. Arthrosc J Arthrosc Relat Surg 2004; 20: 385–91. agreement. Sao Paulo Med J 2008; 126: 180–5. 16. Blankenbaker DG, De Smet AA, Keene JS, Del Rio AM. Imaging 33. Chahla J, Soares EAM, Devitt BM et al. Ligamentum teres tears appearance of the normal and partially torn ligamentum teres on and femoroacetabular impingement: prevalence and preoperative hip MR arthrography. Am J Roentgenol 2012; 199: 1093–8. ﬁndings. Arthrosc J Arthrosc Relat Surg 2016; 32: 1293–7. 17. Chang CY, Gill CM, Huang AJ et al. Use of MR arthrography in 34. O’Donnell J, Economopoulos K, Singh P et al. The ligamentum detecting tears of the ligamentum teres with arthroscopic correl- teres test: a novel and effective test in diagnosing tears of the liga- ation. Skeletal Radiol 2015; 44: 361–7. mentum teres. Am J Sports Med 2014; 42: 138–43. 18. Llopis E, Cerezal L, Kassarjian A et al. Direct MR arthrography of 35. Domb BG, Martin DE, Botser IB. Risk factors for ligamentum the hip with leg traction: feasibility for assessing articular cartilage. teres tears. Arthrosc J Arthrosc Relat Surg 2013; 29: 64–73. Am J Roentgenol 2008; 190: 1124–8. 36. Domb BG, Philippon MJ, Giordano BD. Arthroscopic capsulot- 19. Baber YF, Robinson AH, Villar RN. Is diagnostic arthroscopy of omy, capsular repair, and capsular plication of the hip: relation to the hip worthwhile? A prospective review of 328 adults investi- atraumatic instability. Arthroscopy 2013; 29: 162–73. gated for hip pain. J Bone Joint Surg Br 1999; 81: 600–3. 37. de SA D, Phillips M, Philippon MJ et al. Ligamentum teres inju- 20. Devitt B. A prospective study exploring the relationship between ries of the hip: a systematic review examining surgical indications, hip capsular thickness and joint hypermobility: forewarned is treatment options, and outcomes. Arthrosc J Arthrosc Relat Surg forearmed. J Hip Preserv Surg 2016; 3(Suppl. 1) [Internet]. [cited 2014; 30: 1634–41. 3 February 2017]. Available at: https://academic.oup.com/jhps/ 38. Amenabar T, O’Donnell J. Arthroscopic ligamentum teres recon- article/3/suppl_1/hnw030.070/2353007/A-Prospective-Study- struction using semitendinosus tendon: surgical technique and an Exploring-the-Relationship unusual outcome. Arthrosc Tech 2012; 1: e169–74. 21. Juul-Kristensen B, Røgind H, Jensen DV, Remvig L. Inter-exam- 39. Lindner D, Sharp KG, Trenga AP et al. Arthroscopic ligamentum iner reproducibility of tests and criteria for generalized joint teres reconstruction. Arthrosc Tech 2013; 2: e21–5. hypermobility and benign joint hypermobility syndrome. 40. Simpson JM, Field RE, Villar RN. Arthroscopic reconstruction of the Rheumatology 2007; 46: 1835–41. ligamentum teres. Arthrosc J Arthrosc Relat Surg 2011; 27: 436–41. 22. Bulbena A, Duro´ JC, Porta M et al. Clinical assessment of hyper- 41. Philippon MJ, Pennock A, Gaskill TR. Arthroscopic reconstruc- mobility of joints: assembling criteria. J Rheumatol 1992; 19: tion of the ligamentum teres. J Bone Jt Surg Br 2012; 94–B: 115–22. 1494–8. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/113/4554497 by Ed 'DeepDyve' Gillespie user on 20 June 2018
Journal of Hip Preservation Surgery – Oxford University Press
Published: Oct 16, 2017
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