Ligamentum teres maintenance and transfer as a stabilizer in open reduction for pediatric hip dislocation: surgical technique and early clinical results

Abstract

Purpose: The ligamentum teres has primarily been considered as an obstruction to reduction in children with developmental dislocation of the hip (DDH). In the early surgical descriptions of both the medial (Ludloff) approach and the anterior (Salter) approach to the hip, it was generally accepted that the ligamentum teres was an obstruction to reduction and was excised (similar to the discarding of menisci for knee surgery in our orthopedic history). Because of the known propensity for early re-dislocation following open reduction, we developed surgical methods for maintaining the ligamentum teres when performing open reduction for hip dislocation in young children. This study presents the surgical methods developed for ligament maintenance and transfer, and analyzes the early clinical and radiographic results in a study group.

Methods: The techniques for open reduction by both the medial Ludloff approach and the anterior open reduction were developed and refined. Twenty-one children (23 hips) had ligamentum teres shortening and transfer performed as part of either a medial Ludloff or anterior open reduction for hip dislocation. Complete pre-operative and post-operative clinical and radiographic analysis was performed.

Results: All patients had stable hips at follow-up. The transferred ligamentum teres appeared to provide additional stability to prevent repeat dislocation. We noted no apparent loss of hip motion or other adverse events. One patient had avascular necrosis (AVN).

Conclusions: In this series of 23 hips, in which ligamentum teres transfer/tenodesis was utilized, we found no residual subluxation or dislocation in either the medial Ludloff or the anterior open reduction groups. Based on these early positive results, we recommend the method for children treated with the Ludloff open reduction procedure. Although we have less experience with it, the technique presented for ligamentum maintenance and transfer in anterior open reduction may provide similar added stability. This is an early follow-up study, and long-term follow-up will be required to confirm the ultimate femoral head and acetabular development.

Fig. 1

Lateral view of a right hip porcine model used for biomechanical testing. The size, strength, and orientation of fibers in this model is similar to that noted in the infant human and suggests a functional role

Fig. 2

Sequence of drawings demonstrating the technique for ligamentum teres shortening and reattachment when performing the medial Ludloff open reduction. a Left femoral head in the dislocated position with elongated ligamentum teres. b Ligamentum teres detached from its origin from the inferior acetabulum, with a segment resected to normalize the ligamentum teres length (approximately 1 cm resected). c Non-absorbable suture placed in the ligamentum teres (Bunnell type suture pattern). The arrow indicates the planned ligament re-attachment site. d Shortened ligamentum teres sutured into the anterior-inferior acetabular rim

Fig. 3

Series of films demonstrating the successful use of ligamentum teres transfer/tenodesis for correcting hip dislocation in a 4-month-old child who failed Pavlik harness treatment and closed reduction. a Dislocated left hip. b Film taken 6 months after Ludloff anterior approach plus ligamentum teres transfer. c Anterior-posterior (AP) view of the pelvis taken at 3 years follow-up (age 3.6 years)

Fig. 4

Series of drawings and radiographs demonstrating the technique for ligamentum teres transfer/tenodesis via an anterior approach to the hip. a Hip in dislocated position with an elongated ligamentum teres. b Detaching the elongated ligamentum teres from inside the inferior acetabulum (via separate medial adductor incision—similar approach as in a Ludloff procedure). An appropriate segment of ligamentum teres (often of size 1.5 cm) is excised. The femur has been shortened and de-rotated. c Use of a rongeur to create an area of decorticated bone at the antero-inferior border of the acetabulum ( arrow designates the proposed re-attachment site). d A suture anchor has been placed in the antero-inferior acetabulum just anterior and medial to the transverse acetabular ligamentum insertion. e The shortened ligamentum teres is attached to the suture anchor with the femoral head reduced. f Photograph of an intraoperative radiograph in a typical case with a suture anchor placed ( arrow)