Note: To access the video accompanying this report, visit the March issue of Arthroscopy at www.arthroscopyjournal.org.
Arthroscopy: The Journal of Arthroscopic & Related Surgery
Case Report With Video IllustrationArthroscopic Reconstruction of the Ligamentum Teres
Section snippets
Positioning and Setup
A lateral decubitus hip arthroscopic position was used; our detailed technique for hip arthroscopy has already been described.7 The patient was under general anesthesia, and a specialist hip distracter was used (Smith & Nephew, Andover, MA). Intravenous cefuroxime (1.5 g) was used as prophylactic antibiotic cover, followed by a 5-day course of oral erythromycin (500 mg four times daily). Lateral, anterolateral, and posterolateral portals were used throughout the procedure, together with a 70°
Graft Preparation
To eliminate the risk of donor-site morbidity, an artificial graft made of polyethylene terephthalate (Ligament Augmentation & Reconstruction System [LARS], Arc-sur-Tille, France) was used. Good results have been reported for this material in ACL reconstruction.8, 9 A synthetic knee medial collateral ligament graft (MCL 32, LARS) was used because this best suited the proposed procedure. The graft was looped over a 6-mm EndoButton (Smith & Nephew). The final construct comprising LARS ligament
Femoral and Acetabular Tunnels
The fovea of the femoral head was clearly visualized by use of a combination of hip flexion and internal rotation. A femoral tunnel aimer arm was developed by modifying an existing hip arthroscopy guide (Crosstrac hip guidance system; Smith & Nephew), the tip of the curved aimer being placed in the center of the fovea (Fig 3, Video 1) and then being attached to the hip guidance system. A 3.2-mm guidewire was passed through the greater trochanter and along the femoral neck, under image
Graft Positioning
The femoral and acetabular tunnels were then complete and suitably aligned. The EndoButton/ligament/reversed ACL passing pin complex was passed down the femoral tunnel under image intensifier control. Direct vision was used to guide the EndoButton into the acetabular tunnel (Fig 4, Video 1). Image intensifier views (Fig 5) were used to confirm exit from the acetabular tunnel on the inner lamina of the pelvis before the EndoButton was flipped (Fig 6). The introducer and all sutures were then
Rehabilitation and Recovery
The patient was discharged home the day after surgery and was restricted to touch weight bearing for 4 weeks. She was also asked to avoid any active external rotation of the hip but was permitted active hip flexion to a maximum of 60° for the same period. An intensive physiotherapy rehabilitation program was commenced a week postoperatively.
Ten weeks after her operation, the patient reported that she was no longer aware of the “knocking” feeling that had been present before surgery. She had
Discussion
The breadth of procedures available to the arthroscopic hip surgeon continues to grow,7 although clearly, arthroscopic reconstruction of the ligamentum teres is in its infancy. However, it has been established that a rupture of the ligamentum teres can be a source of pain4 and that the ligamentum does impart some stability to the hip joint.1 We believe that to arthroscopically reconstruct this structure is a reasoned and justifiable response in carefully selected individuals. The technique we
Acknowledgment
The authors wish to record the significant contribution made to the development of this technique during the cadaveric phase by Aslam Mohammed, F.R.C.S., F.R.C.S.(Orth), Wrightington Hospital, Wigan, England.
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