Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report

Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 166–173 doi: 10.1093/jhps/hny001 Advance Access Publication 6 February 2018 Research article Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report 1 1 2 Brian J. White *, Alexandra M. Scoles and Mackenzie M. Herzog Western Orthopaedics, 1830 Franklin Street, Suite 450, Denver, CO 80218-1217, USA and Professional Research Institute for Sports Medicine, LLC, Chapel Hill, NC 97515, USA *Correspondence to: B. J. White. E-mail: prismresearchconsulting@gmail.com Submitted 10 August 2017; revised version accepted 11 January 2018 ABSTRACT This study aims to present the surgical technique for reconstructing both the acetabular labrum and the ligamentum teres and to describe the early outcomes of this procedure in a 15-year-old male with recurrent hip instability. A 15-year-old patient with recurrent left hip dislocation, hip joint instability and failed non-operative intervention presented following two left hip dislocations. A labral reconstruction was performed utilizing an ilio- tibial band allograft tissue with a concomitant ligamentum teres reconstruction using a tibialis anterior allograft. The patient was assessed pre- and postoperatively using modified Harris Hip Score, Lower Extremity Functional Scale and Visual Analogue Scale for pain and satisfaction. The patient reported improvement on all measures, including hip stability 14 months following surgery. The patient has not reported any episodes or subjective feel- ings of instability, has not required further surgical procedures in the hip and has returned to full sports participa- tion. This case report demonstrates a technique for and early outcomes of simultaneous arthroscopic ligamentum teres and acetabular labrum reconstruction in a patient with recurrent hip instability. Short-term outcomes sug- gest improved hip stability, reduced pain, high patient satisfaction and return to pre-injury activities at 14 months postoperative in this single case report. ligamentum teres arises from the acetabular ligament along INTRODUCTION the inferior margin of the acetabulum and inserts into the The acetabular labrum has been demonstrated to play a fovea capitis of the femur [10, 11]. The ligamentum teres key role in the hip [1–4]. The labrum’s main function is to tightens in positions of flexion and external rotation, as create a tight seal with the femoral head to prevent fluid well as extension and internal rotation [12]. This finding flow outside of the joint space, enhance acetabular volume suggests that the ligamentum teres may be particularly and stability of the joint [2–5]. Degeneration or sudden important for stabilization in the setting of osseous hip tearing of the labrum can cause microinstability and pain instability. While individuals with normal hip anatomy [2, 3], and treatment options that restore the fluid seal sur- have osseous constraints protecting against instability, the rounding the hip joint have shown promise for improving ligamentum teres tension in positions where the hip is joint stability and alleviating pain among patients with lab- most vulnerable to instability may be critical for those with ral pathology [6–8]. In particular, complete arthroscopic allograft labral reconstruction is an emerging technique acetabular insufficiency [12]. Historically, the ligamentum teres in the immature hip that allows the surgeon to directly influence the size, qual- has been shown to provide a source of vascularity, while in ity and length of a labral graft, which consistently restores functional labral tissue [8, 9]. the adult hip it has long been regarded as a vestigial rem- nant without any biomechanical or biological function While the biomechanical role and importance of the lab- rum have been recently established in the literature, other [10, 13]. However, recent studies have determined the intra-articular structures of the hip have been studied histological presence of both nociceptors and mechanore- less frequently, including the ligamentum teres. The ceptors in the ligamentum teres, indicating that the V C The Author(s) 2018. 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 journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Simultaneous acetabular labrum and ligamentum teres reconstruction  167 ligamentum teres is part of the reflex pathway of the hip that is responsible for proprioception, pain sensation and overall stability of the joint [10, 14–16]. The increased understanding of the role of the ligamen- tum teres has led to the belief that degeneration or tearing of this structure may contribute to significant pain and gen- eral hip dysfunction in the pre-arthritic hip. In certain instances, reconstruction of this ligament may be recom- mended to mitigate pain and enhance stability of the hip [16, 17]. The importance of this case report stems from Fig. 1. Preoperative AP pelvis radiograph showing a left hip that the novelty of performing a complete allograft ligamentum is concentrically reduced with a lateral center edge angle of 32 teres reconstruction in combination with a complete allog- degrees. raft labral reconstruction to treat severe hip instability. The purpose of this article is to present the surgical technique and early outcomes for a case in a 15-year-old male with recurrent hip instability who underwent reconstruction of both the acetabular labrum and ligamentum teres. MATERIALS AND METHODS Patient presentation This case involves a 15-year-old male patient with no perti- nent orthopaedic past medical or surgical history. He sus- Fig. 2. Preoperative MRI of the left hip indicating posterior hip tained an initial injury to his left hip six weeks prior to dislocation. presentation following a direct lateral impact during a lacrosse match. The patient felt pain but was able to return (MRI) scan was ordered due to the lack of clinical suspi- to play. Two weeks later, he was running in a lacrosse cion for hip dislocation. It showed the left hip to be dislo- match and sustained a non-contact left hip injury. He was cated posteriorly with the ligamentum teres absent unable to ambulate and was taken by ambulance to the (Fig. 2). The hip was reduced with closed reduction tech- emergency room, where he was diagnosed with a posterior niques, and he was instructed to follow-up with our clinic. hip dislocation. He underwent uncomplicated closed Radiographic evaluation in our clinic showed a non- reduction within two hours of the injury and was referred arthritic joint with reasonable lateral coverage and a lateral for follow-up to the senior author’s practice. Upon exami- centre edge angle of 32 degrees with no crossover sign. His nation, his left hip had good range of motion, demon- overall acetabular volume was low with small anterior and strated no joint laxity and had a negative dial test. There posterior walls and neutral acetabular version. A CT scan was no laxity in his elbows, wrist, hands or knees. His hip was ordered to assess the volume of the cup and, specifi- range of motion was symmetric to his contralateral side cally, integrity of the posterior acetabular wall (Fig. 3a). with internal rotation to 10 degrees and external rotation Distal cuts were not made through the knee so femoral to 65 degrees. His radiographs showed a concentric reduc- version was not analysed. Both the anterior and posterior tion with no fracture (Fig. 1). He was instructed to limit walls were small and there was a mild flattening to the pos- weight bearing to 30% for 4 weeks, and to start a physical terior wall, on a cephalad cut on the CT scan there was therapy program focusing primarily on hip stabilization small ossification (Fig. 3b). It was not felt to be a fragment and gluteus medius activation. He was also given standard of the acetabular wall, but rather possibly some early heter- instructions for posterior hip precautions to limit flexion to otopic ossification. He was sent to an Orthopaedic 90 degrees, adduction to neutral and to limit internal rota- Traumatologist for confirmation, and he was sent back to tion. He was not braced, and the risks of avascular necrosis were discussed. He was instructed to follow-up with our our clinic for definitive treatment. Both he and his family were very concerned about the clinic in 6–8 weeks. stability of his hip and requested a surgical procedure to Approximately 4 weeks after his clinical evaluation, he dislocated his hip in his sleep. He was evaluated in the correct the problem and prevent it from happening again. Emergency Room where a magnetic resonance imaging A periacetabular osteotomy to increase acetabular coverage Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 168  B. J. White et al. Fig. 3. Preoperative CT scan of the left hip evaluating integrity of the posterior acetabular wall (a) and indicating mild flattening and small ossification of the posterior wall (b), which were determined to be negative for posterior wall fracture by an Orthopaedic Traumatologist. and bony stability was ruled out as it was felt that his ace- tabulum was in an optimal position for a low volume cup. His lateral X-ray showed mild CAM-type femoroacetabular impingement with an alpha angle exceeding 60 degrees (Fig. 4). His MRI showed a labral tear and no evidence of avascular necrosis. He and his family were offered hip arthroscopy to address both the labral tear and the liga- mentum teres deficiency, understanding the possibility of reconstruction of both. Fig. 4. Preoperative cross table lateral radiograph showing mild Data collection CAM-type FAI. The patient completed a pre- and postoperative subjective questionnaire that included a Visual Analogue Scale (VAS) deemed not suitable for repair as it was grossly insufficient for average pain at rest, average pain with activities of daily in size, inflamed and chronically torn. In the posterior living (ADL) and average pain with athletic activities in compartment the labrum and capsule complex was torn off addition to the Lower Extremity Functional Scale (LEFS) of the posterior aspect of the acetabular wall (Fig. 7). The [18] and the modified Harris Hip Score (MHHS) [19]. At posterior wall of the acetabulum was shallow, but there follow-up the patient also completed a satisfaction scale, was no evidence of a fracture from the previous instability where 1 was very dissatisfied and 10 was very satisfied. episodes. In the peripheral compartment there was reactive Failure was defined as subsequent intra-articular hip sur- wear over the neck from the underlying cam type impinge- gery or recurrent hip instability. ment. There was also an indentation medial to the head/ neck junction on the anterior femoral head in a crescent Arthroscopic findings shape that likely resulted from the previous posterior dislo- Hip arthroscopy was performed with a standard supine cations (Fig. 8). A grade 2 area of chondromalacia measur- approach. His hip capsule was grossly intact and was ing 5  15 mm was noted on the posterior inferior aspect opened roughly 3 cm with a linear capsulotomy between of the acetabulum, and diffuse grade 1 chondromalacia and the 10:30 and 2:30 position on the acetabulum for expo- softening of the cartilage on the posterior femoral head sure and a 1 cm medial sleeve of capsular tissue was pre- was also noted. Otherwise the cartilage was normal. As served for later repair. His labrum was extensively torn, expected, the ligamentum teres was completely absent and shredded, degenerative and severely bruised from the a large amount of inflammatory tissue was present in the 7:0–4:30 position of the acetabulum. It also appeared very fovea (Fig. 9). Additionally, in the peripheral compartment small, measuring 2 mm in diameter throughout (Fig. 5). any adduction in a flexed position caused the femur to vio- Additionally, it did not form a seal with a femoral head, so lently dislocate posteriorly. This indicated substantial joint it was non-functional and did not contribute to the stability instability and reinforced the need for combined labral and or volume of the acetabulum (Fig. 6). The labrum was ligamentum teres reconstruction. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Simultaneous acetabular labrum and ligamentum teres reconstruction  169 Fig. 5. Arthroscopic view from the anterolateral portal showing Fig.7. Arthroscopic view from the anteromedial portal of the an extensively torn, shredded and bruised labrum measuring posterior aspect of the hip joint showing a severely torn and 2 mm in diameter. inflamed labrum and capsule. Fig. 6. Arthroscopic view from the anteromedial portal of the Fig. 8. Arthroscopic view from the anteromedial portal with the anterior aspect of the reduced hip showing a severely torn and hip flexed showing an indentation in the femoral head, suggestive bruised labrum with no seal between the femoral head and of previous hip dislocation. acetabulum. preparation of securing the labral graft. Frozen iliotibial Surgical technique band allograft was used for this technique. The graft was Arthroscopically, femoral osteoplasty was performed, rolled and sutured using an accordion-type suturing techni- removing 4–7 mm of excess bone over a 3.5 mm width to que to create a final tubularized graft measuring approxi- create a more anatomic concavity, reducing the alpha angle mately 5.5 mm in diameter and 12.5 cm in length. After the to approximately 45 degrees and removing the cam graft was secured to the acetabular rim utilizing the nine deformity. The labrum was resected and the acetabular rim previously placed suture anchors, the hip was reduced and was excoriated, which, in addition to the femoral osteo- a perfect seal was noted between the reconstructed labrum plasty, provided a nice bleeding environment for incorpo- and the femoral head (Figs 10 and 11). The hip was also ration of the labral graft. The goal was to prepare the more stable in the peripheral compartment. acetabular edge without reducing the acetabular volume, so Following the labral reconstruction, the ligamentum less than 1 mm was removed to achieve this. teres reconstruction began using a similar technique as The torn, damaged labrum was removed from the ori- described previously [21, 22]. The joint remained in a gin of the transverse acetabulum (7:30) to approximately reduced position while a guide wire was placed over the 2/3 down the back of the acetabulum (4:00). The labral lateral aspect of the femur to establish an acceptable guide reconstruction was performed using a front-to-back fixa- to the inferocentral aspect of the femoral head over the tion technique described previously [20]. The extent of fovea (2:00 position). Once the guide wire was in an the labral deficiency was first measured to estimate graft acceptable position, the hip was distracted to view entry of length and anchors were placed in the acetabular rim in the guide wire through the femoral head. Parallel guides Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 170  B. J. White et al. Fig. 9. Arthroscopic view from the anterolateral portal showing a Fig. 11. Arthroscopic view from the anteromedial portal showing severely inflamed fovea and deficient ligamentum teres. a perfect seal between the allograft labral reconstruction and a concentrically reduced femoral head. Fig. 10. Arthroscopic view from the anteromedial portal of the Fig. 12. Arthroscopic view from the anteromedial portal showing posterior aspect of the joint showing the 12.5 cm labral recon- the ligamentum teres reconstruction with allograft. struction with allograft from approximately the 1: 00–4: 00 position. doubled over to create a final graft diameter of 10 mm. were used to make small adjustments and a 10 mm drill The suture was then used to pull the graft down the femo- ral tunnel to the base of the fovea. This zip loop construct was used to create a tunnel from the lateral aspect of the locked the medial aspect of the graft to the fovea of the femur to the femoral head. Once this was completed, the acetabulum. With the graft fixed, the hip joint was reduced synovium and the remnant of the ligamentum teres over and a perfect seal was noted between the labral reconstruc- the posterior aspect of the fovea down to the bone were tion and the femoral head. The anterior portion of the cap- then debrided working either down the tunnel in the femo- sulotomy was then closed with #1 vicryl to preserve the ral neck or through the arthroscopic portals. A 4.5 mm drill stability gained with an intact hip capsule. With the hip was inserted down the femoral neck tunnel and angled posteriorly into the fovea. This was used to drill through extended and externally rotated slightly, the ligamentum the fovea and fluoroscopic assistance was used to avoid teres graft was tightened and a 9  30 mm PEEK interfer- plunging through the medial wall of the pelvis. ence screw (Arthrex, Naples, Florida) was inserted in the Once the tunnel was created, a Zimmer Biomet femoral tunnel to secure the graft (Fig. 12). ToggleLoc (Zimmer Biomet, Warsaw, Indiana) was passed to the medial aspect of the pelvis and flipped under fluoro- Postoperative management scopic guidance. The ligamentum teres graft was created The rehabilitation program following the labral and liga- from a tibialis anterior allograft measuring approximately mentum teres reconstruction was similar to that following 5 mm in diameter and 18 cm in length (Allosource, labral reconstruction [8]. The patient was cautioned Centennial, Colorado). The graft was then looped through regarding the aneural properties of the grafts and began a the suture construct on the end of the ToggleLoc and supervised physical therapy program within 1 week of Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Simultaneous acetabular labrum and ligamentum teres reconstruction  171 surgery. Limited weight bearing at 30% for 6 weeks and in a young patient with recurrent, severe hip instability posterior hip precautions were maintained, including no resulted in excellent patient-reported outcomes. While flexion more than 90 degrees, no adduction across midline arthroscopic labral reconstruction and ligamentum teres or internal rotation and an abduction pillow for 4 weeks. reconstruction techniques have been reported separately in The focus of physical therapy was to regain motion, the literature [(20–22], to our knowledge, simultaneous strengthen the gluteus medius muscle and establish a nor- reconstructions have been rarely reported. Consistent with mal gait pattern. The long-term goal was to return to the the results identified in a previous systematic review on lig- full pre-injury level of physical activity approximately after amentum teres injuries [16, 17] and published outcomes 6 months. following arthroscopic labral reconstruction of the hip [8, 23, 24], the postoperative results in this case suggest RESULTS benefits of surgical reconstruction in the presence of recur- Subjective follow-up questionnaires were obtained from rent hip instability. the patient at 14 months postoperative. At the time of While the acetabular labrum’s role in hip stability is follow-up his MHHS improved from 58 preoperatively to increasingly recognized [2, 3], the ligamentum teres has 100 postoperatively and his LEFS improved from 56 to 79. recently emerged as a key stabilizer of the hip that may Similarly, his VAS pain scores decreased; at rest he also contribute to hip symptomology [10, 16, 17, 25–27]. improved from 3 to 1, with activity he improved from 3 to Nociceptive and proprioceptive nerve endings have been 1, and with athletics he improved from 5 to 1. Patient satis- identified in the ligamentum teres, indicating that damage faction was 10 out of 10. The only subjective complaint to this structure may produce pain [10, 16, 27, 28]. was ‘a little bit of difficulty’ with ‘making sharp turns while Additionally, although the published data regarding running fast’ on the LEFS. The patient has not reported mechanical and biological properties of the ligamentum any episodes or subjective feelings of instability and has teres are still limited, increasing evidence suggests that it not required further surgical procedures in the hip. may be critical for hip stability [16, 17]. Data from animal Imaging, including anteroposterior and lateral radio- models demonstrated a significant increase in the number graphs, was obtained at 3 months posteroperatively. The of hip dislocations when the ligamentum teres was resected radiographs showed a non-arthritic joint that is well compared with the control group with intact ligamentum reduced and hardware for the ligmentum teres reconstruc- teres [16, 25]. The ligamentum teres is believed to contrib- tion in the appropriate position (Fig. 13). ute to the stability of the hip most substantially when exter- nally rotated and flexed or internally rotated and extended, DISCUSSION and when other stabilizers of the hip such as the acetabular At 14 months postoperative, simultaneous arthroscopic labrum are deficient [12, 16]. labral reconstruction and ligamentum teres reconstruction As our understanding of hip anatomy evolves and improves, arthroscopic treatment options for both labral and ligamentum teres pathology have also advanced. Historically, surgical options for both labral and ligamen- tum teres pathology included predominantly debridement and resection [17, 29, 30]. In recent years, arthroscopic techniques for labral pathology have progressed to primar- ily labral preserving procedures. Complete labral recon- struction, in particular, has recently emerged as a first-line treatment option in the setting of insufficient or poor- quality labral tissue [8]. Several advantages for labral reconstruction over labral repair include the recreation of a normal labral size and quality and recreate a tight seal between the femoral head and the labrum, which results in improved stabilization of the hip and reduced pain [8, 13, 21, 31]. Similarly, while short-term successes in reducing pain following ligamentum teres debridement have been Fig. 13. Final AP pelvis radiograph showing anatomic tunnel appreciated, complete reconstruction may provide further placement and medial fixation of the ligamentum teres recon- struction and a concentric, stable reduction of the left hip. benefits for pain reduction and improved hip stability, Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 172  B. J. White et al. CONFLICT OF INTEREST STATEMENT especially in positions of extension or external rotation Brian J. White is a consultant for Smith & Nephew, Biomet, while squatting [13, 16]. and Conmed Linvatec, where he holds a role in surgeon Due to the important stabilization role of both the ace- tabular labrum and the ligamentum teres, arthroscopic liga- education and product development for hip arthroscopy. mentum teres reconstruction coupled with labrum reconstruction represents a novel way of approaching REFERENCES severe hip instability. In this case, the patient had severe recurrent hip instability with appropriate acetabular cover- 1. Stubbs AJ, Howse EA, Mannava S. Tissue engineering and the age following a lacrosse injury. Subsequently, the preferred future of hip cartilage, labrum and ligamentum teres. J Hip Preserv treatment choice was soft tissue reconstruction as opposed Surg 2016; 3: 23–9. 2. Philippon MJ, Nepple JJ, Campbell KJ et al. The hip fluid seal– to osteotomy. 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Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report

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Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 166–173 doi: 10.1093/jhps/hny001 Advance Access Publication 6 February 2018 Research article Simultaneous acetabular labrum and ligamentum teres reconstruction: a case report 1 1 2 Brian J. White *, Alexandra M. Scoles and Mackenzie M. Herzog Western Orthopaedics, 1830 Franklin Street, Suite 450, Denver, CO 80218-1217, USA and Professional Research Institute for Sports Medicine, LLC, Chapel Hill, NC 97515, USA *Correspondence to: B. J. White. E-mail: prismresearchconsulting@gmail.com Submitted 10 August 2017; revised version accepted 11 January 2018 ABSTRACT This study aims to present the surgical technique for reconstructing both the acetabular labrum and the ligamentum teres and to describe the early outcomes of this procedure in a 15-year-old male with recurrent hip instability. A 15-year-old patient with recurrent left hip dislocation, hip joint instability and failed non-operative intervention presented following two left hip dislocations. A labral reconstruction was performed utilizing an ilio- tibial band allograft tissue with a concomitant ligamentum teres reconstruction using a tibialis anterior allograft. The patient was assessed pre- and postoperatively using modified Harris Hip Score, Lower Extremity Functional Scale and Visual Analogue Scale for pain and satisfaction. The patient reported improvement on all measures, including hip stability 14 months following surgery. The patient has not reported any episodes or subjective feel- ings of instability, has not required further surgical procedures in the hip and has returned to full sports participa- tion. This case report demonstrates a technique for and early outcomes of simultaneous arthroscopic ligamentum teres and acetabular labrum reconstruction in a patient with recurrent hip instability. Short-term outcomes sug- gest improved hip stability, reduced pain, high patient satisfaction and return to pre-injury activities at 14 months postoperative in this single case report. ligamentum teres arises from the acetabular ligament along INTRODUCTION the inferior margin of the acetabulum and inserts into the The acetabular labrum has been demonstrated to play a fovea capitis of the femur [10, 11]. The ligamentum teres key role in the hip [1–4]. The labrum’s main function is to tightens in positions of flexion and external rotation, as create a tight seal with the femoral head to prevent fluid well as extension and internal rotation [12]. This finding flow outside of the joint space, enhance acetabular volume suggests that the ligamentum teres may be particularly and stability of the joint [2–5]. Degeneration or sudden important for stabilization in the setting of osseous hip tearing of the labrum can cause microinstability and pain instability. While individuals with normal hip anatomy [2, 3], and treatment options that restore the fluid seal sur- have osseous constraints protecting against instability, the rounding the hip joint have shown promise for improving ligamentum teres tension in positions where the hip is joint stability and alleviating pain among patients with lab- most vulnerable to instability may be critical for those with ral pathology [6–8]. In particular, complete arthroscopic allograft labral reconstruction is an emerging technique acetabular insufficiency [12]. Historically, the ligamentum teres in the immature hip that allows the surgeon to directly influence the size, qual- has been shown to provide a source of vascularity, while in ity and length of a labral graft, which consistently restores functional labral tissue [8, 9]. the adult hip it has long been regarded as a vestigial rem- nant without any biomechanical or biological function While the biomechanical role and importance of the lab- rum have been recently established in the literature, other [10, 13]. However, recent studies have determined the intra-articular structures of the hip have been studied histological presence of both nociceptors and mechanore- less frequently, including the ligamentum teres. The ceptors in the ligamentum teres, indicating that the V C The Author(s) 2018. 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 journals.permissions@oup.com Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Simultaneous acetabular labrum and ligamentum teres reconstruction  167 ligamentum teres is part of the reflex pathway of the hip that is responsible for proprioception, pain sensation and overall stability of the joint [10, 14–16]. The increased understanding of the role of the ligamen- tum teres has led to the belief that degeneration or tearing of this structure may contribute to significant pain and gen- eral hip dysfunction in the pre-arthritic hip. In certain instances, reconstruction of this ligament may be recom- mended to mitigate pain and enhance stability of the hip [16, 17]. The importance of this case report stems from Fig. 1. Preoperative AP pelvis radiograph showing a left hip that the novelty of performing a complete allograft ligamentum is concentrically reduced with a lateral center edge angle of 32 teres reconstruction in combination with a complete allog- degrees. raft labral reconstruction to treat severe hip instability. The purpose of this article is to present the surgical technique and early outcomes for a case in a 15-year-old male with recurrent hip instability who underwent reconstruction of both the acetabular labrum and ligamentum teres. MATERIALS AND METHODS Patient presentation This case involves a 15-year-old male patient with no perti- nent orthopaedic past medical or surgical history. He sus- Fig. 2. Preoperative MRI of the left hip indicating posterior hip tained an initial injury to his left hip six weeks prior to dislocation. presentation following a direct lateral impact during a lacrosse match. The patient felt pain but was able to return (MRI) scan was ordered due to the lack of clinical suspi- to play. Two weeks later, he was running in a lacrosse cion for hip dislocation. It showed the left hip to be dislo- match and sustained a non-contact left hip injury. He was cated posteriorly with the ligamentum teres absent unable to ambulate and was taken by ambulance to the (Fig. 2). The hip was reduced with closed reduction tech- emergency room, where he was diagnosed with a posterior niques, and he was instructed to follow-up with our clinic. hip dislocation. He underwent uncomplicated closed Radiographic evaluation in our clinic showed a non- reduction within two hours of the injury and was referred arthritic joint with reasonable lateral coverage and a lateral for follow-up to the senior author’s practice. Upon exami- centre edge angle of 32 degrees with no crossover sign. His nation, his left hip had good range of motion, demon- overall acetabular volume was low with small anterior and strated no joint laxity and had a negative dial test. There posterior walls and neutral acetabular version. A CT scan was no laxity in his elbows, wrist, hands or knees. His hip was ordered to assess the volume of the cup and, specifi- range of motion was symmetric to his contralateral side cally, integrity of the posterior acetabular wall (Fig. 3a). with internal rotation to 10 degrees and external rotation Distal cuts were not made through the knee so femoral to 65 degrees. His radiographs showed a concentric reduc- version was not analysed. Both the anterior and posterior tion with no fracture (Fig. 1). He was instructed to limit walls were small and there was a mild flattening to the pos- weight bearing to 30% for 4 weeks, and to start a physical terior wall, on a cephalad cut on the CT scan there was therapy program focusing primarily on hip stabilization small ossification (Fig. 3b). It was not felt to be a fragment and gluteus medius activation. He was also given standard of the acetabular wall, but rather possibly some early heter- instructions for posterior hip precautions to limit flexion to otopic ossification. He was sent to an Orthopaedic 90 degrees, adduction to neutral and to limit internal rota- Traumatologist for confirmation, and he was sent back to tion. He was not braced, and the risks of avascular necrosis were discussed. He was instructed to follow-up with our our clinic for definitive treatment. Both he and his family were very concerned about the clinic in 6–8 weeks. stability of his hip and requested a surgical procedure to Approximately 4 weeks after his clinical evaluation, he dislocated his hip in his sleep. He was evaluated in the correct the problem and prevent it from happening again. Emergency Room where a magnetic resonance imaging A periacetabular osteotomy to increase acetabular coverage Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 168  B. J. White et al. Fig. 3. Preoperative CT scan of the left hip evaluating integrity of the posterior acetabular wall (a) and indicating mild flattening and small ossification of the posterior wall (b), which were determined to be negative for posterior wall fracture by an Orthopaedic Traumatologist. and bony stability was ruled out as it was felt that his ace- tabulum was in an optimal position for a low volume cup. His lateral X-ray showed mild CAM-type femoroacetabular impingement with an alpha angle exceeding 60 degrees (Fig. 4). His MRI showed a labral tear and no evidence of avascular necrosis. He and his family were offered hip arthroscopy to address both the labral tear and the liga- mentum teres deficiency, understanding the possibility of reconstruction of both. Fig. 4. Preoperative cross table lateral radiograph showing mild Data collection CAM-type FAI. The patient completed a pre- and postoperative subjective questionnaire that included a Visual Analogue Scale (VAS) deemed not suitable for repair as it was grossly insufficient for average pain at rest, average pain with activities of daily in size, inflamed and chronically torn. In the posterior living (ADL) and average pain with athletic activities in compartment the labrum and capsule complex was torn off addition to the Lower Extremity Functional Scale (LEFS) of the posterior aspect of the acetabular wall (Fig. 7). The [18] and the modified Harris Hip Score (MHHS) [19]. At posterior wall of the acetabulum was shallow, but there follow-up the patient also completed a satisfaction scale, was no evidence of a fracture from the previous instability where 1 was very dissatisfied and 10 was very satisfied. episodes. In the peripheral compartment there was reactive Failure was defined as subsequent intra-articular hip sur- wear over the neck from the underlying cam type impinge- gery or recurrent hip instability. ment. There was also an indentation medial to the head/ neck junction on the anterior femoral head in a crescent Arthroscopic findings shape that likely resulted from the previous posterior dislo- Hip arthroscopy was performed with a standard supine cations (Fig. 8). A grade 2 area of chondromalacia measur- approach. His hip capsule was grossly intact and was ing 5  15 mm was noted on the posterior inferior aspect opened roughly 3 cm with a linear capsulotomy between of the acetabulum, and diffuse grade 1 chondromalacia and the 10:30 and 2:30 position on the acetabulum for expo- softening of the cartilage on the posterior femoral head sure and a 1 cm medial sleeve of capsular tissue was pre- was also noted. Otherwise the cartilage was normal. As served for later repair. His labrum was extensively torn, expected, the ligamentum teres was completely absent and shredded, degenerative and severely bruised from the a large amount of inflammatory tissue was present in the 7:0–4:30 position of the acetabulum. It also appeared very fovea (Fig. 9). Additionally, in the peripheral compartment small, measuring 2 mm in diameter throughout (Fig. 5). any adduction in a flexed position caused the femur to vio- Additionally, it did not form a seal with a femoral head, so lently dislocate posteriorly. This indicated substantial joint it was non-functional and did not contribute to the stability instability and reinforced the need for combined labral and or volume of the acetabulum (Fig. 6). The labrum was ligamentum teres reconstruction. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Simultaneous acetabular labrum and ligamentum teres reconstruction  169 Fig. 5. Arthroscopic view from the anterolateral portal showing Fig.7. Arthroscopic view from the anteromedial portal of the an extensively torn, shredded and bruised labrum measuring posterior aspect of the hip joint showing a severely torn and 2 mm in diameter. inflamed labrum and capsule. Fig. 6. Arthroscopic view from the anteromedial portal of the Fig. 8. Arthroscopic view from the anteromedial portal with the anterior aspect of the reduced hip showing a severely torn and hip flexed showing an indentation in the femoral head, suggestive bruised labrum with no seal between the femoral head and of previous hip dislocation. acetabulum. preparation of securing the labral graft. Frozen iliotibial Surgical technique band allograft was used for this technique. The graft was Arthroscopically, femoral osteoplasty was performed, rolled and sutured using an accordion-type suturing techni- removing 4–7 mm of excess bone over a 3.5 mm width to que to create a final tubularized graft measuring approxi- create a more anatomic concavity, reducing the alpha angle mately 5.5 mm in diameter and 12.5 cm in length. After the to approximately 45 degrees and removing the cam graft was secured to the acetabular rim utilizing the nine deformity. The labrum was resected and the acetabular rim previously placed suture anchors, the hip was reduced and was excoriated, which, in addition to the femoral osteo- a perfect seal was noted between the reconstructed labrum plasty, provided a nice bleeding environment for incorpo- and the femoral head (Figs 10 and 11). The hip was also ration of the labral graft. The goal was to prepare the more stable in the peripheral compartment. acetabular edge without reducing the acetabular volume, so Following the labral reconstruction, the ligamentum less than 1 mm was removed to achieve this. teres reconstruction began using a similar technique as The torn, damaged labrum was removed from the ori- described previously [21, 22]. The joint remained in a gin of the transverse acetabulum (7:30) to approximately reduced position while a guide wire was placed over the 2/3 down the back of the acetabulum (4:00). The labral lateral aspect of the femur to establish an acceptable guide reconstruction was performed using a front-to-back fixa- to the inferocentral aspect of the femoral head over the tion technique described previously [20]. The extent of fovea (2:00 position). Once the guide wire was in an the labral deficiency was first measured to estimate graft acceptable position, the hip was distracted to view entry of length and anchors were placed in the acetabular rim in the guide wire through the femoral head. Parallel guides Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 170  B. J. White et al. Fig. 9. Arthroscopic view from the anterolateral portal showing a Fig. 11. Arthroscopic view from the anteromedial portal showing severely inflamed fovea and deficient ligamentum teres. a perfect seal between the allograft labral reconstruction and a concentrically reduced femoral head. Fig. 10. Arthroscopic view from the anteromedial portal of the Fig. 12. Arthroscopic view from the anteromedial portal showing posterior aspect of the joint showing the 12.5 cm labral recon- the ligamentum teres reconstruction with allograft. struction with allograft from approximately the 1: 00–4: 00 position. doubled over to create a final graft diameter of 10 mm. were used to make small adjustments and a 10 mm drill The suture was then used to pull the graft down the femo- ral tunnel to the base of the fovea. This zip loop construct was used to create a tunnel from the lateral aspect of the locked the medial aspect of the graft to the fovea of the femur to the femoral head. Once this was completed, the acetabulum. With the graft fixed, the hip joint was reduced synovium and the remnant of the ligamentum teres over and a perfect seal was noted between the labral reconstruc- the posterior aspect of the fovea down to the bone were tion and the femoral head. The anterior portion of the cap- then debrided working either down the tunnel in the femo- sulotomy was then closed with #1 vicryl to preserve the ral neck or through the arthroscopic portals. A 4.5 mm drill stability gained with an intact hip capsule. With the hip was inserted down the femoral neck tunnel and angled posteriorly into the fovea. This was used to drill through extended and externally rotated slightly, the ligamentum the fovea and fluoroscopic assistance was used to avoid teres graft was tightened and a 9  30 mm PEEK interfer- plunging through the medial wall of the pelvis. ence screw (Arthrex, Naples, Florida) was inserted in the Once the tunnel was created, a Zimmer Biomet femoral tunnel to secure the graft (Fig. 12). ToggleLoc (Zimmer Biomet, Warsaw, Indiana) was passed to the medial aspect of the pelvis and flipped under fluoro- Postoperative management scopic guidance. The ligamentum teres graft was created The rehabilitation program following the labral and liga- from a tibialis anterior allograft measuring approximately mentum teres reconstruction was similar to that following 5 mm in diameter and 18 cm in length (Allosource, labral reconstruction [8]. The patient was cautioned Centennial, Colorado). The graft was then looped through regarding the aneural properties of the grafts and began a the suture construct on the end of the ToggleLoc and supervised physical therapy program within 1 week of Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Simultaneous acetabular labrum and ligamentum teres reconstruction  171 surgery. Limited weight bearing at 30% for 6 weeks and in a young patient with recurrent, severe hip instability posterior hip precautions were maintained, including no resulted in excellent patient-reported outcomes. While flexion more than 90 degrees, no adduction across midline arthroscopic labral reconstruction and ligamentum teres or internal rotation and an abduction pillow for 4 weeks. reconstruction techniques have been reported separately in The focus of physical therapy was to regain motion, the literature [(20–22], to our knowledge, simultaneous strengthen the gluteus medius muscle and establish a nor- reconstructions have been rarely reported. Consistent with mal gait pattern. The long-term goal was to return to the the results identified in a previous systematic review on lig- full pre-injury level of physical activity approximately after amentum teres injuries [16, 17] and published outcomes 6 months. following arthroscopic labral reconstruction of the hip [8, 23, 24], the postoperative results in this case suggest RESULTS benefits of surgical reconstruction in the presence of recur- Subjective follow-up questionnaires were obtained from rent hip instability. the patient at 14 months postoperative. At the time of While the acetabular labrum’s role in hip stability is follow-up his MHHS improved from 58 preoperatively to increasingly recognized [2, 3], the ligamentum teres has 100 postoperatively and his LEFS improved from 56 to 79. recently emerged as a key stabilizer of the hip that may Similarly, his VAS pain scores decreased; at rest he also contribute to hip symptomology [10, 16, 17, 25–27]. improved from 3 to 1, with activity he improved from 3 to Nociceptive and proprioceptive nerve endings have been 1, and with athletics he improved from 5 to 1. Patient satis- identified in the ligamentum teres, indicating that damage faction was 10 out of 10. The only subjective complaint to this structure may produce pain [10, 16, 27, 28]. was ‘a little bit of difficulty’ with ‘making sharp turns while Additionally, although the published data regarding running fast’ on the LEFS. The patient has not reported mechanical and biological properties of the ligamentum any episodes or subjective feelings of instability and has teres are still limited, increasing evidence suggests that it not required further surgical procedures in the hip. may be critical for hip stability [16, 17]. Data from animal Imaging, including anteroposterior and lateral radio- models demonstrated a significant increase in the number graphs, was obtained at 3 months posteroperatively. The of hip dislocations when the ligamentum teres was resected radiographs showed a non-arthritic joint that is well compared with the control group with intact ligamentum reduced and hardware for the ligmentum teres reconstruc- teres [16, 25]. The ligamentum teres is believed to contrib- tion in the appropriate position (Fig. 13). ute to the stability of the hip most substantially when exter- nally rotated and flexed or internally rotated and extended, DISCUSSION and when other stabilizers of the hip such as the acetabular At 14 months postoperative, simultaneous arthroscopic labrum are deficient [12, 16]. labral reconstruction and ligamentum teres reconstruction As our understanding of hip anatomy evolves and improves, arthroscopic treatment options for both labral and ligamentum teres pathology have also advanced. Historically, surgical options for both labral and ligamen- tum teres pathology included predominantly debridement and resection [17, 29, 30]. In recent years, arthroscopic techniques for labral pathology have progressed to primar- ily labral preserving procedures. Complete labral recon- struction, in particular, has recently emerged as a first-line treatment option in the setting of insufficient or poor- quality labral tissue [8]. Several advantages for labral reconstruction over labral repair include the recreation of a normal labral size and quality and recreate a tight seal between the femoral head and the labrum, which results in improved stabilization of the hip and reduced pain [8, 13, 21, 31]. Similarly, while short-term successes in reducing pain following ligamentum teres debridement have been Fig. 13. Final AP pelvis radiograph showing anatomic tunnel appreciated, complete reconstruction may provide further placement and medial fixation of the ligamentum teres recon- struction and a concentric, stable reduction of the left hip. benefits for pain reduction and improved hip stability, Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/166/4840655 by Ed 'DeepDyve' Gillespie user on 20 June 2018 172  B. J. White et al. CONFLICT OF INTEREST STATEMENT especially in positions of extension or external rotation Brian J. White is a consultant for Smith & Nephew, Biomet, while squatting [13, 16]. and Conmed Linvatec, where he holds a role in surgeon Due to the important stabilization role of both the ace- tabular labrum and the ligamentum teres, arthroscopic liga- education and product development for hip arthroscopy. mentum teres reconstruction coupled with labrum reconstruction represents a novel way of approaching REFERENCES severe hip instability. In this case, the patient had severe recurrent hip instability with appropriate acetabular cover- 1. Stubbs AJ, Howse EA, Mannava S. Tissue engineering and the age following a lacrosse injury. Subsequently, the preferred future of hip cartilage, labrum and ligamentum teres. J Hip Preserv treatment choice was soft tissue reconstruction as opposed Surg 2016; 3: 23–9. 2. Philippon MJ, Nepple JJ, Campbell KJ et al. The hip fluid seal– to osteotomy. 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Journal of Hip Preservation SurgeryOxford University Press

Published: Feb 6, 2018

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