Arthroscopic treatment of an avulsion fracture of the ligamentum teres of the hip in an 18-year-old horse rider

doi:10.1016/j.arthro.2004.04.041

Arthroscopy: The Journal of Arthroscopic & Related Surgery

Volume 20, Supplement 2, July–August 2004, Pages 64-66

https://doi.org/10.1016/j.arthro.2004.04.041 Get rights and content

Abstract

We present the case of an 18-year-old horse rider with an avulsion fracture of the ligamentum teres causing persistent hip pain and locking for 2 years. The patient had no history of major trauma; however, repeated minor hyperabduction injuries occurred. We were able to successfully treat this patient by arthroscopic removal of the bony fragments and two loose bodies and partial resection of the ligamentum teres.

Section snippets

Case report

An 18-year-old female patient was referred to our hospital for persistent pain and locking in the left hip for 2 years. No history of major trauma was reported; however, she experienced several minor traumatic events with hyperabduction of the hip during horseback riding. On physical examination, the patient had pain on abduction and internal rotation. Flexion was limited to 100°. Radiographs showed several intra-articular loose bodies in the left hip joint Figure 1, Figure 2. This was

Discussion

Hip arthroscopy has led to a better understanding of the pathology and pathomechanism of the ligamentum teres. Gray and Villar1 suggested a classification of its pathology based on 472 consecutive hip arthroscopies. Group 1 patients displayed complete ruptures of the ligamentum, group 2 only partial ruptures, and patients in group 3 showed degeneration of the ligamentum teres associated with osteoarthritis. All patients with complete rupture had a history of major joint disruption, either from

References (6)

A.J.R Gray et al.
The ligamentum teres of the hipAn arthroscopic classification of its pathology
Arthroscopy
(1997)
I.R Barrett et al.
Avulsion fracture of the ligamentum teres in a child
J Bone Joint Surg Am
(1989)
D.D Delcamp et al.
Traumatic avulsion of the ligamentum teres without dislocation of the hip
J Bone Joint Surg Am
(1988)

There are more references available in the full text version of this article.

Cited by (44)

Ligamentum Teres Lesions Are Associated With Poorer Patient Outcomes in a Large Primary Hip Arthroscopy Cohort of 1,935 Patients
2022, Arthroscopy, Sports Medicine, and Rehabilitation
To retrospectively evaluate the prevalence and characteristics of ligamentum teres (LT) lesions identified in a single-surgeon hip arthroscopy cohort and to compare surgical outcomes of those with, and without, identified LT lesions.
Patients who underwent primary hip arthroscopy between 2005 and 2018 in one surgeon’s clinic were identified. Those with a history involving extra-articular scoping or any previous surgery on the ipsilateral hip were excluded. Patient-reported outcome measures completed before and after surgery included the Hip Disability and Osteoarthritis Outcome Score, Nonarthritic Hip Score, and 12-item International Hip Outcome Tool. Conversion to hip joint replacement was ascertained through a national register.
A total of 1,935 primary hip arthroscopies (from 1,607 different patients) were included in this study. In total, 323 LT lesions were identified. Those with LT lesions were older than those without (40.3 ± 11.3 years compared with 33.9 ± 12.1 years; P < .001), and more frequently female (58.2% vs 41.8%; P = .001). Hips with lesions had a smaller lateral center-edge angle than other hips (33.0 ± 6.8° vs 34.1 ± 6.0°; P = .004). All patient-reported outcome measures improved significantly (P < .001) from pre- to post-surgery for patients with and without LT lesions. However, patients with LT lesions reported less improvement in the 12-item International Hip Outcome Tool (difference –5.60; P = .004) and in Hip Disability and Osteoarthritis Outcome Score symptoms (–4.41; P = .004), sports (–7.81; P < .001), and quality of life subscales (–8.85; P < .001) than those without lesions. Hips with LT lesions also had a 6.2% 2-year rate of subsequent hip replacement (20/323 hips) compared with those without lesions (0.9%; 14/1612 hips; P < .001).
In this single-surgeon hip arthroscopy cohort, identification of LT lesions was associated with poorer patient-reported outcomes and increased likelihood of conversion to arthroplasty within 2 years. These findings suggest a poorer prognosis for patients with LT injury compared with those without.
Level III, retrospective cohort study.
A Comparison of Supine and Lateral Decubitus Positions for Hip Arthroscopy: A Systematic Review of Outcomes and Complications
2016, Arthroscopy - Journal of Arthroscopic and Related Surgery
This systematic review examines outcomes and risk profiles of the hip arthroscopy in the supine versus lateral decubitus positions to elucidate any superiority of one approach over the other.
Three databases (Embase, PubMed, and Medline) were searched for studies that addressed hip arthroscopy performed in either position, and were subsequently screened by two reviewers with data abstracted in duplicate.
Similar outcomes were observed. Supine studies showed a greater mean postoperative improvement for modified Harris hip score (33.74), visual analog scale (−3.99), nonarthritic hip score (29.61), Harris hip score (35.73), and hip outcome score (31.4). Lateral decubitus studies showed greater improvement using the Western Ontario and McMaster University Osteoarthritis (14.76) score. Supine studies reported more neuropraxic injuries (2.06% v 0.47%), labral penetration (0.65% v 0%), and heterotopic ossification (0.21% v 0%). Lateral decubitus studies reported more fluid extravasation (0.21% v 0.05%) and missed loose bodies (0.08% v 0.01%). Similar rates of revision (1.8% lateral, 1.4% supine) and conversion to open procedures (2.6% in lateral, 2.0% in supine) were also identified.
Because of quality of evidence, direct comparisons are currently limited; however, the supine position is associated with more neuropraxic injuries, labral penetration, and heterotopic ossification, whereas lateral decubitus has increased risk of fluid extravasation and missed loose bodies. At this time, no evidence exists to establish superiority of one position.
Level IV, systematic review of Level II, III, and IV studies.
Current possibilities for hip arthroplasty
2014, Revista Brasileira de Ortopedia
A artroscopia de quadril tem sido popularizada na última década e com o avanço técnico, seja no diagnóstico por imagem, no entendimento da fisiopatologia ou na técnica cirúrgica, diversas aplicações foram descritas. Tanto a artroscopia, para afecções intra‐articulares, como a endoscopia, para procedimentos extra‐articulares, podem ser usadas no diagnóstico ou no tratamento de diferentes afecções. Este artigo de atualização tem como objetivo apresentar diversas possibilidades atuais da artroscopia de quadril.
Hip arthroscopy has been popularized over the last decade and, with technical advances regarding imaging diagnostics, understanding of the physiopathology or surgical techniques, several applications have been described. Both arthroscopy for intra‐articular conditions and endoscopy for extra‐articular procedures can be used in diagnosing or treating different conditions. This updating article had the objective of presenting the various current possibilities for hip arthroscopy.
Ligamentum teres injury is associated with the articular damage pattern in patients with femoroacetabular impingement
2014, Arthroscopy - Journal of Arthroscopic and Related Surgery
The objective of this study was to investigate the association between ligamentum teres injury and the hip joint cartilage damage pattern in patients with femoroacetabular impingement.
We compared articular cartilage damage between ligamentum teres–intact and–ruptured hips. Data were collected for 77 consecutive patients with femoroacetabular impingement who underwent hip arthroscopy. The locations of the chondral lesions were recorded on anatomic articular maps using the geographic zone method. The patients were divided into 2 groups (ligamentum teres–intact and–injured groups), and the incidence and degree of cartilage injury were compared between the 2 groups by use of the Mann-Whitney U test.
In patients with ligamentum teres injury, chondral damage extended to the middle-inferior area of the acetabulum (7.6% [grade 1] in ligamentum teres–intact group and 66.6% [grade 1, 12.1%; grade 2, 42.4%; grade 3, 12.1%] in ligamentum teres–injured group, P < .01) and the apex of the femoral head (anterior apex: 7.1% [grade 1, 3.8%; grade 2, 3.3%] in intact group and 42.4% [grade 1, 30.3%; grade 2, 12.1%] in injured group, P < .01; middle apex: 7.6% [grade 1, 3.8%; grade 2, 3.8%] in intact group and 63.5% [grade 1, 42.4%; grade 2, 18.1%; grade 3, 3.0%] in injured group, P = .04; posterior apex: 7.6% [grade 1, 3.8%; grade 2, 3.8%] in intact group and 42.4% [grade 1, 30.3%; grade 2, 12.1%] in injured group, P < .01).
This study showed the association between ligamentum teres injury and articular cartilage damage in the inferior middle part of the acetabulum and the apex of the femoral head in patients treated for femoroacetabular impingement.
Level IV, case-control study.
Ligamentum teres injuries of the hip: A systematic review examining surgical indications, treatment options, and outcomes
2014, Arthroscopy - Journal of Arthroscopic and Related Surgery
Citation Excerpt :
All patients were diagnosed with partial (type 2) or full-thickness (type 1) tears. Two thirds of the studies commented on the presence of associated pathologic conditions, including labral tear, degeneration of the labrum, loose bodies, chondral damage, degeneration of articular cartilage, femoroacetabular impingement, anteroinferior acetabular osteochondral defect, hypertrophic synovitic ligamentum teres, and avulsion fracture, in their patients.2,10,13-16 Specific reconstructive indications included the surgeon's subjective assessment of a given tear as “reparable,” reported instability, type 1 tears, and previous failed arthroscopic debridement of the ligamentum teres or anterior capsular plication, or both.
Hip arthroscopy is becoming a common technique for the diagnosis and treatment of ligamentum teres pathologic conditions. This systematic review aims to determine the indications/contraindications, treatments, and surgical outcomes for management of ligamentum teres injuries.
We searched EMBASE, MEDLINE, and PubMed databases from 1946 to November 28, 2013 for all relevant English articles pertaining to surgical treatment of the ligamentum teres. A hand search of the reference sections of included articles was performed, and all relevant articles were systematically screened in duplicate, with agreement and descriptive statistics presented.
We identified 1,016 studies, 9 of which (4 case series and 5 case reports) met our eligibility criteria. These studies had a total of 87 patients (89 hips) who had undergone either arthroscopic debridement (81 patients, 83 hips) or reconstruction with autografting, allografting, or synthetic grafting (6 patients) of a torn ligamentum teres. Major qualifications for surgery included persistent hip pain despite conservative treatment and mechanical symptoms or instability symptoms (e.g., clicking or locking). Advanced arthritis (i.e., radiographic joint space < 2 mm) was the only reported contraindication. Patients were followed postoperatively for 1.5 to 60 months and were assessed using subjective methods (i.e., modified Harris Hip Score [mHHS] and Non-Arthritic Hip Score [NAHS]). Overall, both debridement and reconstruction improved the condition of patients, with a 40% increase in reported postoperative functional scores as well as a reported 89% of patients who were able to return to regular activity/sport.
Ligamentum teres debridement is indicated for short-term relief of hip pain caused by partial-thickness tears (type 2) failing conservative management, whereas reconstruction with autografts, allografts, or synthetic grafts may be indicated for type 1 (full-thickness) ligamentum teres tears that are deemed “reparable,” cause instability, have failed previous debridement, or a combination of these conditions.
Level IV, systematic review of Level IV and Level V studies.
Risk factors for ligamentum teres tears
2013, Arthroscopy - Journal of Arthroscopic and Related Surgery
The purpose of this study was to examine the relationship between nontraumatic ligamentum teres (LT) tears and acetabular radiographic architecture.
The inclusion criteria for this study were all patients who had anteroposterior pelvis radiographic views and had undergone arthroscopic examination of the LT. The exclusion criteria were Tonnis arthritic grade 3 and traumatic high-energy mechanisms of injury. Radiographic data were measured preoperatively on an anteroposterior pelvis view, including acetabular inclination (AI), lateral center edge (CE) angle, magnitude of cross-over sign, and ischial spine prominence. A Lateral Coverage Index (LCI) was defined as the center edge angle minus acetabular inclination. Hips were divided into 3 groups according to the LCI: (1) high: 34° and above; (2) medium: 19° to 33°; and (3) low: below 19°.
Of the 463 hips (430 patients) included in the study, 226 (49%) had a partial- or full-thickness LT tear. Patients with tears were significantly older than patients without tears (P < .0001), with average ages of 38 and 33 years, respectively. Radiographically, patients with tears had less acetabular retroversion, as reflected by lower ischial spine prominence values and lesser cross-over signs (P = .01 and .0005, respectively). Using the LCI, 115 hips (25%) were classified as high, 236 (50%) as medium, and 114 (25%) as low. Hips with low LCI were 1.74 times more likely to have LT tears than high LCI hips.
This study found that the presence of LT tears was associated with acetabular bony morphology and age. LT tears were less frequent with high LCI and acetabular retroversion and less frequent in patients younger than 30 years. Further study is needed to establish whether there is a causal relationship between acetabular undercoverage and LT tears and whether LT tears may be a sign of microinstability of the hip.
Level IV, therapeutic case series

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Case ReportArthroscopic treatment of an avulsion fracture of the ligamentum teres of the hip in an 18-year-old horse rider

Abstract

Section snippets

Case report

Discussion

Arthroscopy

Avulsion fracture of the ligamentum teres in a child

J Bone Joint Surg Am

Traumatic avulsion of the ligamentum teres without dislocation of the hip

J Bone Joint Surg Am

Case Report
Arthroscopic treatment of an avulsion fracture of the ligamentum teres of the hip in an 18-year-old horse rider