Systematic Review

Ligamentum Teres Injuries of the Hip: A Systematic Review Examining Surgical Indications, Treatment Options, and Outcomes Darren de SA, M.D., Mark Phillips, B.Sc. (cand), Marc J. Philippon, M.D., Shelby Letkemann, B.Sc. PA (cand), Nicole Simunovic, M.Sc., and Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.C.

Purpose: 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. Methods: 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. Results: 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. Conclusions: 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 of Evidence: Level IV, systematic review of Level IV and Level V studies.

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athologic processes of the ligamentum teres have long evaded clinical and preoperative diagnostic detection.1,2 Only recently, in part because of the exponential increase and application of hip arthroscopy,3,4 has From Division of Orthopaedic Surgery, Department of Surgery (D.D.S., O.R.A.), the Department of Life Science (M.P.), the Physician Assistant Education Program (S.L.), and the Department of Clinical Epidemiology and Biostatistics (N.S.), McMaster University, Hamilton, Ontario, Canada; and the Steadman Philippon Research Institute (M.J.P.), Vail, Colorado, U.S.A. The authors report the following potential conflict of interest or source of funding in relation to this article: O.R.A. receives support from Smith & Nephew; M.J.P. receives support from Smith & Nephew, MIS, Ossur, Siemens, Vail Valley Medical Center, Arthrosurface, DonJoy, Slack, Elsevier, Linvatec, and HIPCO. Received April 24, 2014; accepted June 4, 2014. Address correspondence to Olufemi R. Ayeni, M.D., M.Sc., F.R.C.S.C., McMaster University Medical Centre, 1200 Main Street West, 4E15, Hamilton, ON L8N 3Z5, Canada. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/14348/$36.00 http://dx.doi.org/10.1016/j.arthro.2014.06.007

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renewed interest developed in the ligamentum teres as a source of intra-articular hip pain. The incidence of ligamentum teres rupture identified during hip arthroscopy is approximately 9%,1 with ligamentum teres rupture reported as the third most common cause of hip pain in the athlete.2 This pyramidal-shaped structure, originating from the posteroinferior acetabular fossa and inserting on the femoral fovea capitis,2,5 is surrounded by a thin synovial lining intimately tied to a posterior branch of the obturator artery6 and encompasses an undefined central sensory nerve supply.7,8 Although it is believed to serve as a secondary stabilizer of the hip, much remains unknown about this purpose or any additional contributions to propioception, nociception, and joint lubrication.2 Arthroscopically, ligamentum teres tears as pain generators have been classified as type 1 (complete), type 2 (partial), or type 3 (degenerative).9 However, whether or not these tears cause pain is contentious, because there

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SURGICAL TREATMENT OF LIGAMENTUM TERES INJURY

are reports of asymptomatic individuals without a ligamentum teres.7 The same skepticism for these tears as a cause of instability remains, because the lack of a taut ligamentum teres observed during joint distraction in hip arthroscopy brings into question its ability to block femoral subluxation. Thus, this structure has been referred to as vestigial and is often sacrificed in various hip procedures.10 Despite inconclusive evidence, surgeons continue to attempt to arthroscopically address the ligamentum teres for presumed persistent pain or mechanical instability, or both. As such, this systematic review aims to address 3 fundamental questions when considering operative treatment of ligamentum teres injuries: (1) What are the surgical indications and contraindications? (2) What treatment options exist? (3) What are the patient-important outcomes regarding its management? This review was conducted to examine the current literature and identify potential gaps for further study. Given that pathologic conditions of the ligamentum teres served as a pain generator and contributed to instability of the hip, our hypothesis was that surgical reconstruction of a torn structure would lessen pain and improve patient function.

Methods Search Strategy Three online databasesdEMBASE, MEDLINE, and PubMeddwere searched for all available articles from 1946 to November 28, 2013 addressing surgical indications and clinical outcomes of management for ligamentum teres injuries of the hip. The search terms “ligamentum teres” and “ligamentum teres.mp.” were used. Study Screening Titles, abstracts, and full texts were screened independently and in duplicate. If at any stage, one reviewer expressed doubt regarding the eligibility of a particular study, it was advanced to the next stage for further review to ensure that all possibly relevant articles were included. Disagreements were addressed at the full-text stage through discussion between the 2 reviewers (S.L., M.P.), with a third reviewer (D.D.S.) addressing unresolved discrepancies. The references of the included studies were also searched to capture any additional articles that may have been missed in the initial search strategy. Assessment of Study Eligibility The research questions and inclusion/exclusion criteria were determined a priori. Specific inclusion criteria were (1) studies published in English, (2) studies composed of all levels of evidence, (3) studies performed on human patients, (4) studies with

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surgically managed ligamentum teres pathologic injuries (e.g., inflammation, tear, rupture), and (5) studies using an open or arthroscopic technique, or both. Studies that (1) were review or technical articles, (2) solely addressed nonsurgical management of ligamentum teres injuries, (3) and addressed pediatric patients undergoing surgery for hip dysplasia were excluded. Data Abstraction Two reviewers (S.L., M.P.) collected data in duplicate and recorded it in a Microsoft Excel, version 2007 (Microsoft, Redmond, WA) spreadsheet. Descriptive study data, including year of publication, author, location of study, and study design were recorded. Data were recorded regarding patient history, presentation on examination, radiographic findings, and associated pathologic conditions. Descriptive statistics for these study data, including means, ranges, and proportions are presented. Surgical outcome data were analyzed quantitatively using the modified Harris Hip Score (mHHS) or the Non-Arthritic Hip Score (NAHS), or both, or qualitatively by assessing general patient satisfaction and outcome. Articles that did not provide quantitative data determined surgical success subjectively. Changes in range of motion, as well as the patient’s ability to return to sport, were also recorded. A methodological quality assessment was not performed because each included study was Level IV or Level V evidence (inherently low quality). Assessment of Agreement Weighted kappa (l) and 95% confidence intervals (CIs) were calculated for all 3 stages of screening. A priori, k values greater than 0.61 were specified to indicate substantial agreement; k values between 0.21 and 0.60, inclusive, were specified to indicate moderate agreement; and l less than 0.20 was specified to indicate slight agreement.11

Results Search Strategy Of the initial 1,016 studies retrieved, 35 proceeded to full-text screening after the removal of 830 duplicates. Nine studies ultimately satisfied the eligibility criteria for this review (Fig 1 and Appendix 1). There was substantial agreement between reviewers (S.L., M.P.) at all stages of screening (title, l ¼ 0.88, 95% CI, 0.82 to 0.94; abstract, l ¼ 0.73, 95% CI, 0.54 to 0.92; and full text, l ¼ 0.76, 95% CI, 0.46 to 1.00, respectively). Study Characteristics The systematic search retrieved 4 case series and 5 case reports, with the majority of the studies conducted in Australia and the United States. Participants were

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D. DE SA ET AL.

Fig 1. Flow chart of screening process.

predominantly female individuals (80.46%), and sample sizes ranged from 1 to 29 individuals, with one third of the studies examining at least 23 participants. All studies followed their patients for a minimum of 3 months postoperatively. No patients were lost to follow-up; however, 2 studies did not explicitly report follow-up rates1,2 (Table 1). Table 2 organizes each study’s individual reported indications/contraindications for arthroscopic surgery. Generally, the main indications for arthroscopic debridement involved symptoms not responding to conservative measures such as physiotherapy. Specific clinical history and physical examination indications included persistent localized groin pain, symptoms of hip instability, altered range of motion, and pain with provocative tests (e.g., passive internal rotation at 90 flexion and log rolling of hip). Additional imaging indications were reported in

67% (6 of 9) of studies; however, 5 studies noted that radiographic imaging was unsuccessful in identifying the presence of a ligamentum teres tear.1,2,12-14 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. Only one study explicitly reported a contraindication for

Table 1. Demographics of Included Studies Addressing Surgical Management of Ligamentum Teres Pathologic Conditions Study

Level of Evidence

Type

Country

Sample Size

% Male

Mean Age, y (range)

Debridement Amenabar and O’Donnell, 201312

IV

Case series

Australia

7.60

24.4 (12-45)

32 (23-49)

Haviv and O’Donnell, 20101 Byrd and Jones, 20044 Yamamoto and Usui, 200614 Romero and Hutchinson, 200913

IV IV V V

Case Case Case Case

series series report report

Australia USA Japan USA

20.70 39.10 0 0

25 (14-36) 28.3 (15-53) 78 14

30 (12-48) 29.2 (12-60) 24 10.5 (9-12)

Kusma et al., 200416 Reconstruction Amenabar and O’Donnell, 201217 Philippon et al., 201210 Simpson et al., 201115

V

Case report

Germany

27 hips (26 patients) 29 patients 23 patients 1 patient 2 hips (1 patient) 1 patient

0

18

3

V IV V

Case report Case series Case report

Australia USA England

1 patient 4 patients 1 patient

0 0 0

NR, not reported.

NR 36 (30-41) 20

Mean Follow-up, mo (range)

12 31 (6-60) 5.2 (1.5-8)

X

X

X

Kusma et al., 200416 Reconstruction Amenabar and O’Donnell, 201217 Philippon et al., 201210

Simpson et al., 201115

X X

X X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

Pain During Provocative Tests

X

X

X

X

MRI

X

CT

X

X

X

X

Plain Radiograph

MRA

Other

Radiographic Techniques Used

Mechanical symptoms include popping, locking, catching, and knocking. CT, computed tomography; MRA, magnetic resonance angiography; MRI, magnetic resonance imaging; NR, not reported; ROM, range of motion.

X

X

Romero and Hutchinson, 200913 X

X

X

X

X

X X

X

X

Instability

Arthroscopic Visualization of Tear

Findings on Examination Decreased ROM

X

Mechanical

Pain

Yamamoto and Usui, 200614

Study Debridement Amenabar and O’Donnell, 201312 Haviv and O’Donnell, 20101 Byrd and Jones, 20044

Previous Hip Surgery

Patient History

Table 2. Reported Indications and Associated Pathologic Conditions in Included Studies

Yes: femoroacetabular impingement, labral tear Yes: anteroinferior acetabular osteochondral defect

NR

Yes: 39.1% labral tear, 21.7% loose bodies, 21.7% chondral damage Yes: degeneration of articular cartilage, degeneration of articular labrum Yes: bilateral symptomatic hypertrophic synovitic ligamentum teres Yes: avulsion fracture

No

No

Associated Pathologic Conditions

SURGICAL TREATMENT OF LIGAMENTUM TERES INJURY

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surgerydradiographic evidence of joint space narrowing (i.e., < 2 mm). Eighty-seven patients across all included studies underwent arthroscopic surgery with debridement (81 patients) or reconstruction (6 patients). Four studies reported procedures in the lateral decubitus position versus 4 studies with procedures in the supine position.13 Of the 3 studies examining reconstruction, each used different graft sources. Graft types used included a synthetic knee medial collateral ligament (32 using a Ligament Augmentation & Reconstruction System [LARS] graft; LARS, Arcsur-Tille, France)15 a doublestranded semitendinosus tendon autograft,17 and an iliotibial band tendon autograft.10 Overall, both debridement and reconstructive procedures on the ligamentum teres tears and associated pathologic conditions resulted in both improved subjective and objective (range of motion tests) clinical outcomes, with no major or moderate complications reported (Table 3). Ligamentum Teres Reconstruction. All 3 studies reporting reconstruction of the ligamentum teres reported that 83% (5 of 6) of patients (one patient progressed to total hip replacement) were able to return to their preoperative daily activities or sports. Reconstruction was recorded to achieve an increase of mean mHHS from poor (52.76; 95% CI, 52.47 to 53.05) to good (74.36; 95% CI, 58.43 to 90.29)10,17 and an increase of mean NAHS from pain and function from 57.5 (95% CI, 27.12 to 87.88) to 85.5 (95% CI, 75.95 to 95.05).15,17 Ligamentum Teres Debridement. Of the 6 studies evaluating arthroscopic debridement, 3 case reports reported all 3 patients capable of return to sport (return to sport was not recorded in 3 studies using debridement1,2,12). Debridement was recorded to have an increase in mean mHHS from poor (60.73; 95% CI, 47 to 74.46) to good (88.4; 95% CI, 85.98 to 90.82)1,2,12 and an improvement in pain and function of mean NAHS from 65.1 (95% CI, 62.94 to 67.26) to 86.35 (95% CI, 85.66 to 87.04).1,12 Two case studies that used debridement as a surgical method did not report mHHS or NAHS; however, both studies reported pain-free full range of motion and patient satisfaction postoperatively.13,16 Complications There was recurrence of ligamentum teres tears postoperatively, with 17% (5 of 29) of patients in the study by Haviv and O’Donnell1 having a symptomatic ligamentum teres tear recur within 12 to 48 months after the index operation. No other study reported retearing of the reconstructed ligament throughout their follow-up period. However, it should be noted that 2 of 9 studies reported patients who required a second surgery not for repair failure but for secondary management such as fluid collection at the TiCron

(Covidien, Mansfield, MA) knot site (1 of 1 patient),17 and lysis of adhesions or iliopsoas tendon release (2 of 4 patients).10 Other complications presented include neuropraxia (1 of 1 patient)2 and resorption of graft (1 of 1 patient).2 One study did note a failed surgical repair caused by an irreparable ligament condition identified intraoperatively.10 This specific patient ultimately required a total hip replacement 15 months postoperatively. Table 3 presents additional study-specific outcome information.

Discussion The results of this review show that individuals who have exhausted conservative treatment for persistent hip pain or instability, or both, attributable to ligamentum teres tears may achieve short-term benefit (recorded up to 60 months postoperatively) from either debridement or reconstruction. There is limited evidence to suggest that debridement plus anterior capsular plication is superior to either ligamentum teres debridement alone or reconstruction, although direct comparison is limited by the variability of surgical techniques, indications, and outcomes reported. Martin et al.18 have proposed stability as the major role of this structure. Therefore, further research into the necessity of stabilization procedures such as anterior capsular plication would be beneficial. Domb et al.19 have systematically assessed the role of the hip capsule as well as outcomes from capsulotomy, capsulectomy, capsular closure, and plication, and have suggested that ligamentum teres deficiency is a factor for either capsular closure or plication.19 Although one study in our review suggested that the recurrence rate for tears was attributable in part to lack of a capsular procedure during the first surgical intervention,1 our outcomes data are equivocal when comparing the 4 studies that reported debriding the ligamentum teres alone versus the one study that reported debridement and addressed capsular plication. In addition, the literature notes patients without a ligamentum teres, either congenital or iatrogenic, being asymptomatic.7 For example, Phillips et al.20 found that in patients whose ligamentum teres was resected after open osteochondroplasty (in effect, simulating a type 1 tear), 77% and 61%, respectively, had no groin pain at rest or on exercise, and only 35% and 24%, respectively, experienced subjective popping, locking, or instability. Thus, before delineating the nuances of surgical management for such tears, clearly defining the structure and biomechanical function of the ligamentum teres is paramount. Future Directions Debridement has shown excellent results and is the current standard of care.5 Reconstruction has shown moderate improvements as well; however, it is clear

Arthroscopic debridement

Kusma et al., 200416

Arthroscopic debridement and reconstruction

42

NR

47-59 (52.7)

NR

73

NR

NR

NR

53

NR

NR

NR

NR

47

6 mo: 40-67 (53.5) 12 mo: 40-74 (61.3) 24 mo: 54-96 (75) 36 mo: 68-96 (82) NR

100

NR

NR

NR

90

86

84.2-94.5 (89.3  11.6)

mHHS

Yes

Yes

NR

1.5 mo: 72 6 mo: 86 8 mo: 89

Yes

Yes

Yes

Yes

NR

NR

NR

Return to Normal Activity/Sport

95

NR

NR

NR

NR

86

81.9-91.5 (86.7  11)

NAHS

Postoperative Hip Score (mean)

mHHS, modified Harris Hip Score; NAHS, Non-Arthritic Hip Score; NR, not reported; ROM, range of motion.

Simpson et al., 201115

Reconstruction Amenabar and O’Donnell, 201217 Philippon et al., 201210

Arthroscopic reconstruction Arthroscopic reconstruction

Arthroscopic debridement

Romero and Hutchinson, 200913

Yamamoto and Usui, 200614

64

60.4-72.1 (66.2  13.3)

NAHS

70

59.5-71 (65.2  13)

Arthroscopic debridement and capsular tightening

Arthroscopic debridement Arthroscopic debridement Arthroscopic debridement

mHHS

Surgical Approach

Haviv and O’Donnell, 20101 Byrd and Jones, 20044

Study Debridement Amenabar and O’Donnell, 201312

Preoperative Hip Score (mean)

Table 3. Surgical Technique and Outcome Measures of Ligamentum Teres Repair Procedures in Included Studies

ROM improved at follow-up Mean flexion 112 (106 120 ), mean abduction 24 (15 -30 ), mean external rotation 43 (20 -59 ), mean internal rotation 44 (30 -56 ) Regained normal hip flexion, external rotation restricted 50% at 10 wk postoperatively

NR

Restriction in external rotation relieved postoperatively Full and pain-free ROM 12 mo postoperatively right hip and 9 mo postoperatively left hip Full ROM regained at follow-up

NR

NR

Hip rotation range decreased 10 -15 postoperatively

Range of Motion

Mechanical symptoms relieved

Patient stated procedure was beneficial Patient claims to be symptom free

NR

NR

14.8% of patients had positive Dial test results preoperatively and negative scores postoperatively NR

Other Outcomes/ Additional Procedures

SURGICAL TREATMENT OF LIGAMENTUM TERES INJURY

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from the few reported series that there is a need to define surgical indications for debridement or reconstruction, or both. Regarding ligamentum teres reconstruction, an approach similar to that used for hip labrum reconstruction21 is needed to identify ideal graft options, donor sites, and their associated risks/benefits. Mention is made of using, e.g., the semitendinosus tendon in ligamentum teres reconstruction given its efficacy in anterior cruciate ligament reconstruction.17 However, caution must be exercised in applying these principles to the hip joint, whose inherent properties, stresses/loads, and forces are quite different from those of the knee. Furthermore, because hip arthroscopy is noted to present challenges caused by the anatomy of the hip joint and the associated learning curve, the impact of the learning curve on the success of a procedure such as ligamentum teres reconstruction needs evaluation.4 Ultimately, efforts need to be concentrated first on refining the physical examination and imaging criteria to better detect these patients preoperatively. Byrd and Jones2 highlight the low sensitivity (i.e., 2 diagnoses) made among 37 patients who underwent magnetic resonance imaging or magnetic resonance arthrography, computed tomography, or bone scanning for ligamentum teres pathologic conditions. This remains a major barrier to advancing our understanding of the natural history of the pathologic process of this tear. However, the recently reported “ligamentum teres test”di.e., hip pain at extremes of internal and external rotation with the hip in 70 of flexion and 30 from full abduction, with 90% and 85% sensitivity and specificity, respectivelydin detecting ligamentum teres tears may be invaluable going forward.22 The combination of clinical history, physical examination findings, and imaging findings that help delineate who may benefit from surgical management will be an important focus of research that advances current understanding of ligamentum teres injuries. Consulting multiple databases plus our duplicate database and our systematic approach to reviewing the literature are strengths ensuring that we have presented the current best-available evidence addressing indications/contraindications, surgical options, and validated outcomes data for ligamentum teres pathologic conditions. Limitations From a methodological standpoint, limitations of this study include the lack of evidence from high-quality randomized controlled trials or prospective cohort studies. In fact, the studies presented here lacked an adequate control group and comprised a heterogeneous small sample size with insufficient follow-up periods to facilitate meaningful statistical analysis.

Ultimately, we are limited by the developing nature of surgical ligamentum teres management. Clear indications for debridement versus reconstruction do not yet exist and technical aspects such as reconstructive options (i.e., autograft, allograft, synthetic grafts), fixation, and postoperative rehabilitation are in their infancy.

Conclusions Ligamentum teres debridement is indicated for shortterm 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 factors.

References 1. Haviv B, O’Donnell J. Arthroscopic debridement of the isolated ligamentum teres rupture. Knee Surg Sports Traumatol Arthrosc 2011;19:1510-1513. 2. Byrd JWT, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy 2004;20:385-391. 3. Colvin AC, Harrast J, Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am 2012;94:e23. 4. Hoppe DJ, de Sa D, Simunovic N, et al. The learning curve for hip arthroscopy: a systematic review. Arthroscopy 2014;30:389-397. 5. Lindner D, Sharp KG, Trenga AP, Stone J, Stake CE, Domb BG. Arthroscopic ligamentum teres reconstruction. Arthros Tech 2013;2:e21-255. 6. Howe W, Lacey T, Schwartz R. A study of the gross anatomy of the arteries supplying the proximal portion of the femur and the acetabulum. J Bone Joint Surg Am 1950;32:856-866. 7. Villar R, Santori N. Arthroscopic anatomy of the hip. In: Byrd JWT, ed. Operative hip arthroscopy. Ed 2. New York: Springer-Verlag, 2005;124-126. 8. Haversath M, Hanke J, Landgraeber S, et al. The distribution of nociceptive innervation in the painful hip: a histological investigation. Bone Joint J 2013;95-B:770-776. 9. Gray AJ, Villar RN. The ligamentum teres of the hip: An arthroscopic classification of its pathology. Arthroscopy 1997;13:575-578. 10. Philippon MJ, Pennock A, Gaskill TR. Arthroscopic reconstruction of the ligamentum teres: Technique and early outcomes. J Bone Joint Surg Br 2012;94:1494-1498. 11. McGinn T, Wyer PC, Newman TB, Keitz S, Leipzig R, For GG. Tips for learners of evidence-based medicine: 3. Measures of observer variability (kappa statistic). CMAJ 2004;171:1369-1373. 12. Amenabar T, O’Donnell J. Successful treatment of isolated, partial thickness ligamentum teres (LT) tears with debridement and capsulorrhaphy. Hip Int 2013;23:576-582. 13. Romero A, Hutchinson M. Bilateral symptomatic hypertrophic ligamentum teres of the hip in a young athlete. BMJ Case Rep 2009:2009.

SURGICAL TREATMENT OF LIGAMENTUM TERES INJURY 14. Yamamoto Y, Usui I. Arthroscopic surgery for degenerative rupture of the ligamentum teres femoris. Arthroscopy 2006;22:689.e1-e3. 15. Simpson JM, Field RE, Villar RN. Arthroscopic reconstruction of the ligamentum teres. Arthrosc J Arthrosc Relat Surg 2011;27:436-441. 16. Kusma M, Jung J, Dienst M, Goedde S, Kohn D, Seil R. Arthroscopic treatment of an avulsion fracture of the ligamentum teres of the hip in an 18-year-old horse rider. Arthroscopy 2004;20:64-66 (suppl 2). 17. Amenabar T, O’Donnell J. Arthroscopic ligamentum teres reconstruction using semitendinosus tendon: Surgical technique and an unusual outcome. Arthrosc Tech 2012;1: e169-e174. 18. Martin RL, Palmer I, Martin HD. Ligamentum teres: A functional description and potential clinical relevance. Knee Surg Sports Traumatol Arthrosc 2012;20:1209-1214. 19. Domb BG, Philippon MJ, Giordano BD. Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: Relation to atraumatic instability. Arthroscopy 2013; 29:162-173. 20. Phillips AR, Bartlett G, Norton M, Fern D. Hip stability after ligamentum teres resection during surgical dislocation for cam impingement. Hip Int 2012;22:329-334. 21. Ayeni OR, Alradwan H, de Sa D, Philippon MJ. The hip labrum reconstruction: Indications and outcomesda systematic review. Knee Surg Sports Traumatol Arthrosc 2014;22:737-743. 22. O’Donnell J, Economopoulos K, Singh P, Bates D, Pritchard M. The ligamentum teres test: A novel and effective test in diagnosing tears of the ligamentum teres. Am J Sports Med 2014;42:138-143.

Appendix 1. List of Articles Excluded During Full-Text Screening 1. Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery: Current concepts and perspective. Bone Joint J 2013;95-B:10-199. 2. Bohnsack M, Lekkos K, Borner CE, Wirth CJ, Ruhmann O. Results of hip arthroscopy in sports related groin pain. Sportverletz Sportschaden 2006;20:86-90 [in German]. 3. Byrd JWT. Hip arthroscopy in athletes. Oper Tech Sports Med 2005;13:24-36. 4. Byrd JWT. Hip arthroscopy in the athlete. N Am J Sports Phys Ther 2007;2:217-230. 5. Byrd, JWT, Jones K. Hip Arthroscopy in high level baseball players. Presented at the 2013 ISAKOS Biennial Congress, Toronto, Canada, May 12-16, 2013.

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6. Domb BG, McAsey CJ. Cartilage injuries in the degenerative hip. Oper Tech Sports Med 2011;19:129-133. 7. Fortun CM, Streit J, Patel SH, Salata MJ. Cartilage defects in the hip. Oper Tech Sports Med 2012;20:287-294. 8. Houben R, Londers J, Somville J, McKee A. Post-traumatic incongruent hip in a 12-year-old boy. Acta Orthop Belg 2007;73:255-257. 9. Kelly BT, Buly RL. Hip arthroscopy update. HSS J 2005;1: 40-48. 10. Klein GR, Purtill JJ. Hip arthroscopy: Indications and technique. Semin Arthroplasty 2005;16:63-69. 11. Larson CM, Swaringen J, Morrison G. Evaluation and management of hip pain: The emerging role of hip arthroscopy. Phys Sportsmed 2005;33:26-32. 12. Lim B-H, Jang S-W, Park Y-S, Lim S-J. Open repair and arthroscopic follow-up of severely delaminated femoral head cartilage associated with traumatic obturator fracture-dislocation of the hip. Orthopedics 2011;34:199. 13. Lindner D, Sharp KG, Trenga AP, Stone J, Stake CE, Domb BG. Arthroscopic ligamentum teres reconstruction. Arthrosc Tech 2013;2:e21-e25. 14. Lynch TS, Terry MA, Bedi A, Kelly BT. Hip arthroscopic surgery: Patient evaluation, current indications, and outcomes. Am J Sports Med 2013;41:1174-1189. 15. Pasa L, Hart R, Kocis J, Muzík V, Veselý R. Arthroscopy of the hip joint. Acta Chir Orthop Traumatol Cech 2005;72: 16-21 [in Czech]. 16. Ranawat AS, Kelly BT. Anatomy of the hip: Open and arthroscopic structure and function. Oper Tech Orthop 2005;15:160-174. 17. Rühmann O. Arthroscopy of the hip joint: Indication, technique, results. Dtsch Arztebl Int 2008;105: 559-566. 18. Safran MR, Hariri S. Hip Arthroscopy assessment tools and outcomes. Oper Tech Orthop 2010;20:264-277. 19. Schenker ML, Philippon MJ. The role of flexible radiofrequency energy probes in hip arthroscopy. Tech Orthop 2005;20:37-44. 20. Shindle MK, Domb BG, Kelly BT. Hip and pelvic problems in athletes. Oper Tech Sports Med 2007;15:195-203. 21. Weiss JM, Ramachandran M. Hip and pelvic injuries in the young athlete. Oper Tech Sports Med 2006;14: 212-217. 22. Yoshino H. The radiological study on the open reduction of congenital dislocation of the hip by Ludloff’s method. Cases more than 5 years after operation. Nihon Seikeigeka Gakkai Zasshi 1984;58:281-294 [in Japanese].

Ligamentum teres injuries of the hip: a systematic review examining surgical indications, treatment options, and outcomes.

Hip arthroscopy is becoming a common technique for the diagnosis and treatment of ligamentum teres pathologic conditions. This systematic review aims ...
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