Ultrasound-guided biopsy of the equine forelimb proximal suspensory ligament by longitudinal access / [Biópsia guiada por ultrassom da origem do ligamento suspensor do boleto de equinos por acesso longitudinal]

A literatura atual discute múltiplas modalidades de imagem para acompanhar o processo de cicatrização da origem do ligamento suspensor do boleto (LSB) em equinos, mas nenhuma pode garantir que eles possuam fibras colágenas com calibre suficiente para suportar o retorno ao exercício. Já as técnicas morfológicas e bioquímicas, bem como a análise de birrefringência, podem ser mais apropriadas para caracterizar o processo de cicatrização e avaliar a eficiência do tratamento. O objetivo deste artigo é descrever procedimento simples que possibilita a coleta de amostras teciduais de boa qualidade e em sentido longitudinal, por biópsia em equinos em estação. Após antissepsia local, sedação e bloqueio do nervo palmar lateral no aspecto medial do osso acessório do carpo (OAC), o membro foi colocado em suspensão com o carpo flexionado em 90º; a agulha de biópsia guiada por ultrassom foi introduzida em sentido distoproximal, 11 a 13cm distal ao OAC, ângulo de 20º em relação ao LSB, até a região de sua origem. O equipamento foi disparado e coletou-se a amostra tecidual. Essa técnica possibilitou a coleta de fragmentos de boa qualidade para análise histológica e de birrefringência, sem reações adversas, podendo ser usada em modelos experimentais ou na prática clínica.(AU)

Spontaneous inflammation and necrosis of the falciform and round ligaments: a case report and review of the literature.

BACKGROUND: Necrosis of the falciform and round ligaments is extremely rare, thus making the diagnosis challenging. It is often misdiagnosed as gallbladder pathology due to the presenting symptoms. Due to the rarity of this pathology, there is limited literature available. CASE PRESENTATION: A 53-year-old white man presented to our hospital with signs and symptoms of gallbladder pain but turned out to have the rare entity of necrosis of the falciform and round ligaments. An extensive review of the world literature was performed using PubMed. Manual cross-referencing of reference lists was performed to obtain all available articles. The personal operative log of the senior author was also searched to reveal one additional case. Statistical analysis was descriptive only, given the small number of reported cases. Thirty-nine articles were found, among which forty-three case were identified, and one additional case was extracted from the operative log of the senior author. Unlike previous reports, we found that isolated inflammation and necrosis of the ligaments occurs at nearly the same frequency in both men and women, not predominantly in women as previously reported in smaller series. The mean age at presentation was 59.5 years old, and cases were typically initially diagnosed as gallbladder pathology, most commonly acute cholecystitis. Computed tomography more frequently than ultrasound revealed the falciform and round-ligament pathology. CONCLUSIONS: Isolated falciform and round-ligament inflammation and necrosis is a rare condition that is difficult to diagnose because it can present mimicking a wide variety of intra-abdominal pathologies, particularly gallbladder pathologies. It is often best treated by laparoscopic resection. Unlike prior reports, our review of the literature, which is the largest that we know of to date, shows that males and females are equally affected. Greater awareness of this entity will aid in future diagnosis.

All About the Ligamentum Teres: From Biomechanical Role to Surgical Reconstruction.

Intriguing anatomists and surgeons for centuries, the exact function and biomechanical significance of the ligamentum teres (LT) remains incompletely understood. The LT, also described as the ligamentum femoris capitis, is an intra-articular extrasynovial ligament extending from the cotyloid fossa of the acetabulum to the fovea on the femoral head. Some studies have described it as a vestigial structure in the adult hip. More recent biomechanical studies, however, along with histological and anatomical studies, have suggested the LT to have an important function in proprioception, nociception, and as a secondary stabilizer of the hip joint. The advent and increased utilization of hip arthroscopy to treat hip pathology over the past two decades has ignited a renewed interest in the role of the LT, as well as techniques and indications for management of pathology. In the constellation of intra-articular pain generators of the hip, LT injuries have historically been difficult to diagnose through physical examination or advanced imaging. Numerous classification systems have been proposed based on arthroscopic appearance, and for most cases, conservative management is adequate. In patients undergoing hip arthroscopy, LT débridement usually suffices, although in cases of persistent pain and severe instability, reconstruction of the ligament may be indicated. Multiple methods for reconstruction have been described, with the greatest variation in the method of acetabular fixation of the graft. Future research should focus on clarifying the role of the LT, appropriate surgical indications for reconstruction, and optimization of graft fixation within the acetabulum.

The Effect of Complete Tearing of the Ligamentum Teres in Patients Undergoing Primary Hip Arthroscopy for Femoroacetabular Impingement and Labral Tears: A Match-Controlled Study.

PURPOSE: To compare the patient-reported outcomes scores (PROs) of patients with femoroacetabular impingement (FAI), labral tears, and complete ligamentum teres (LT) tears to a matched-pair control group with intact LTs, as well as to report the relative risk of total hip arthroplasty (THA) conversion. METHODS: Data between February 2008 and April 2015 were retrospectively reviewed. Patients undergoing hip arthroscopy included those who had complete LT tear, labral tears, FAI, and minimum 2-year follow-up with modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS). Patients were excluded for Tönnis osteoarthritis grade >1, previous hip conditions or surgeries, and Worker's Compensation claims. Patients with full LT tears were matched in a 1:3 ratio with patients without LT tears based on age at surgery ± 5 years, sex, body mass index ± 5, capsular treatment, and acetabular Outerbridge grade. Revision surgeries and conversions to THA were documented. Relative risk for conversion to THA was determined (P = .05). RESULTS: Eighteen patients (18 hips) had minimum 2-year follow-up and were eligible for matching; as described, each study group patient was matched to 3 control patients, resulting in a size of 18 to 54 patients. PROs showed significant improvement in the complete LT tear group with the exception of the HOS-SSS measure. In the intact LT control group, all PROs significantly improved, with no exception. Based on relative risk, patients with complete LT tears were 3 times more likely to require THA than a matched control group. CONCLUSIONS: After hip arthroscopy, patients with FAI and complete LT tears reported significant improvement in PROs. Among hips that did not require THA, functional scores were comparable to a matched control group. However, patients with complete LT tears were 3 times more likely to require an eventual THA than the matched control group. We conclude that patients with complete LT tears should be considered an at-risk population, and that indications and treatment may be refined to incorporate the clinical significance of complete LT tears. LEVEL OF EVIDENCE: Level III, comparative trial, case-control.

Non-traumatic ligamentum teres tears: association with MRI morphometry of the hip.

BACKGROUND: The ligamentum teres has been recognized as an important stabilizer of the hip. PURPOSE: We aimed to examine the relationship between non-traumatic ligamentum teres (LT) tear and hip morphometry on magnetic resonance imaging (MRI). MATERIAL AND METHODS: Fifty patients who had undergone hip MRI were included (27 men, 23 women; average age = 54.0 years). The status of the LT and the morphometric hip parameters were assessed, including acetabular anteversion angle (AAA), acetabular depth (AD), acetabular index (AI), lateral center edge angle (LCEA), and extrusion index (EI). The morphometric hip parameters were compared between groups with one-way ANOVA, Student's t-test, and Mann-Whitney U test. RESULTS: A decreased acetabular coverage was noted in the severe tear group compared to the normal group, indicated by a significantly larger AD ( P = 0.001) and smaller LCEA ( P = 0.016). There was a statistically significant difference in the AAA, AD, and LCEA between the normal group and the complete tear group; the AAA was significantly larger ( P = 0.031), the AD was significantly larger ( P = 0.01), and the LCEA was significantly smaller ( P = 0.043) in the complete tear group compared to the normal group. CONCLUSION: There is an association between LT tears and acetabular bony morphology; an insufficient acetabular coverage is associated with complete tear of the LT. As the insufficient acetabular coverage may predispose to ligamentum teres tear, the ligamentum teres should be thoroughly evaluated in those with insufficient acetabular coverage, as a potential cause of hip pain.

Identification of a Patient Acceptable Symptomatic State Score for the International Hip Outcome Tool in People Undergoing Hip Arthroscopy.

PURPOSE: To determine a Patient Acceptable Symptomatic State (PASS) score for the 33-item International Hip Outcome Tool (iHOT-33) in people undergoing hip arthroscopy for primary diagnoses of femoroacetabular impingement syndrome, acetabular labral tears, and/or ligamentum teres pathology. METHODS: Consecutive participants underwent hip arthroscopy by a single surgeon between August 2011 and May 2016. Participants were included if they were between ages 18 and 60 years and underwent hip arthroscopy for femoroacetabular impingement syndrome, acetabular labral tears, or ligamentum teres pathology. Participants were excluded if they did not speak sufficient English to complete the iHOT-33, had evidence of hip dysplasia, had less than 2 mm of joint space on anteroposterior radiograph, or underwent subsequent total hip replacement surgery. Participants completed the iHOT-33 preoperatively and at a minimum of 1 to a maximum of 5 years postoperatively. Participants were also asked to answer yes or no to the external anchor question of "Taking into account all the activities you do during your daily life, your level of pain and also your functional impairment, are you satisfied with your current state following your surgery?" A receiver operating characteristic (ROC) curve was used to identify the PASS score. Multiple logistic regression was performed to determine if patient factors, primary preoperative diagnosis, or intraoperative findings predicted achievement of the PASS score. RESULTS: A total of 117 participants undergoing hip arthroscopy were included: 72 women (61.1%) and 45 men (38.5%) with mean age of 36.81 years (18-59). Forty-two (35.9%) had cam morphology, 18 (15.4%) had pincer morphology, 78 (67.2%) had labral tears, and 97 (82.9%) had ligamentum teres tears. Mean time to final follow-up was 2.25 years (range, 1-5). The PASS score at a mean of 2.25 years postoperatively was 58 as determined by the cutoff threshold on the ROC curve with the lowest difference between sensitivity and specificity (area under the ROC curve 0.88; P < .01; 95% confidence interval [CI], 0.81-0.95). No factors were predictors of achievement of the PASS score in this study (P > .05), including age (odds ratio [OR], 0.71; 95% CI, 0.32-1.56), sex (OR, 1.02; 95%, CI 0.98-1.06), preoperative iHOT-33 score (OR, 1.002; 95% CI, 0.98-1.03), primary preoperative diagnosis (OR, 0.86; 95% CI, 0.53-1.40), cam morphology (OR, 1.19; 95% CI, 0.54-2.64), Pincer morphology (OR, 0.50; 95%, CI 0.18-1.38), acetabular labral tears (OR, 1.93; 95% CI, 0.88-4.26), Outerbridge grade 3-4 chondral damage (OR, 0.97; 95% CI, 0.42-2.25), and ligamentum teres pathology (OR, 0.95; 95% CI, 0.35-2.61). CONCLUSIONS: This study reports a PASS score of 58 for the iHOT-33 at 2 years following hip arthroscopy. The PASS score will assist in assessing response to hip arthroscopy in research and clinical settings. LEVEL OF EVIDENCE: Level II, retrospective prognostic study.

Lesions of Ligamentum Teres: Diagnostic Performance of MRI and MR Arthrography-A Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study is to determine the diagnostic performance of MRI and MR arthrography for depicting ligamentum teres lesions. MATERIALS AND METHODS: A literature search was performed. Original studies reporting the diagnostic accuracy of MRI examinations for the depiction of ligamentum teres lesions were included. RESULTS: Eight studies entailing 1456 MRI examinations were included (frequency of median ligamentum teres injury, 25.9%; interquartile range, 14.1-45.3%). Two studies reported the results of unenhanced MRI examinations, and their diagnostic performance could not be estimated. Sensitivity, specificity, and diagnostic odds ratio (DOR) of all MRI examinations were 64.7%, 86.9%, and 12.2, respectively, whereas the sensitivity, specificity, and DOR of MR arthrography examinations were 82.2%, 88.6%, and 35.9, respectively. The heterogeneity (I2) for all MRI and MR arthrography examinations was 92.3% and 88.2%, respectively. Five blinded MR arthrography studies with 643 MR arthrography examinations found an appropriate threshold effect for summary ROC construction (AUC, 0.95). The summary estimate of these studies yielded a sensitivity of 87.8%, a specificity of 91%, and DOR of 73.1. The heterogeneity (I2) for this group was 64.3%. In patients with low pretest probability (25%), MR arthrography enabled the exclusion of ligamentum teres lesion (postprobability for a negative result, 4%; negative likelihood ratio, 0.13). CONCLUSION: MR arthrography can depict ligamentum teres lesions with high accuracy. However, its diagnostic performance for differentiating various types of ligamentum teres lesions (partial, complete ligamentum teres tears, and hypertrophic ligamentum teres), as well as the diagnostic performance of unenhanced MRI for the depiction of ligamentum teres lesions, is yet to be determined because of the paucity of reported data in the literature.

Medial approach open reduction with ligamentum teres partial excision and plication for the management of congenital hip dislocation.

Because of the known tendency for early redislocation following open reduction, we developed surgical methods for shortening the ligamentum teres to improve immediate postoperative stability when performing medial approach open reduction (MAOR) for the management of developmental dysplasia of the hip. Between 2004 and 2014, 32 patients with dysplasia of the hip were managed by MAOR with partial excision and plication of ligamentum teres. The patients were followed up for an average of 6.9 years. At the final follow-up, clinical outcomes achieved were categorized as excellent and good in 39 (39/40; 97.5%) hips. At the latest follow-up, 97.5% (39 hips) were classified as good or excellent on the basis of the Severin classification (Severin grade 1 or 2). In conclusion, this series of MAOR, in which ligamentum teres partial excision and plication was utilized, we found stable reduction in all hips. On the basis of these positive results, we recommend this method for children treated with MAOR. LEVEL OF EVIDENCE: Level IV: case series.

Effect of ligamentum teres tear on the development of joint instability and articular cartilage damage: an in vivo rabbit study.

The contribution of the ligamentum teres to the stabilization of the hip joint and the clinical influence of a compromised ligamentum teres are not well known. This study aimed to investigate joint stability and cartilage damage in a rabbit model by surgically inducing a complete ligamentum teres tear. Twenty adult New Zealand rabbits were used in this study. Rabbits were divided into complete ligamentum teres tear with capsulotomy (n = 9, group I) and capsulotomy only (n = 10, group II) groups. Unilateral surgery was performed on the left hip. Joint instability was assessed by measuring the preoperative and postoperative acetabulofemoral (A-F) distances. Rabbits were euthanized to assess cartilage damage at 24 weeks postoperatively. The median postoperative A-F distance of the operated side in group I [0.68 cm (0.37-1.04 cm)] was larger than that in group II [0.50 cm (0.30-0.65 cm)] (p = 0.041). The median postoperative A-F distance was larger in the operated side [0.68 cm (0.37-1.04 cm)] compared to the nonoperated side [0.45 cm (0.30-0.75 cm)] in group I; it also was larger in the operated side [0.50 cm (0.30-0.65 cm)] compared to the nonoperated side [0.44 cm (0.32-0.67 cm)] in group II, but only group I showed a significant difference (p = 0.016 and 0.395, respectively). Articular cartilage damage was detected at the apex of the femoral head in two rabbits (22.2%) in group I only. Rabbits with a complete ligamentum teres tear showed significant instability at the hip joint and articular cartilage damage in our rabbit model, supporting the potential clinical importance of ligamentum teres as a hip joint stabilizer.

Arthroscopy After Traumatic Hip Dislocation: A Systematic Review of Intra-articular Findings, Correlation With Magnetic Resonance Imaging and Computed Tomography, Treatments, and Outcomes.

PURPOSE: To describe the literature concerning patient demographic characteristics and intra-articular injury seen at arthroscopy after traumatic hip dislocation, describe the reported computed tomography (CT) and magnetic resonance findings with arthroscopic correlation, and describe the reported arthroscopic treatments performed with complications and outcomes. METHODS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines for assessment of arthroscopy after hip dislocation. Three databases were searched, and study screening and data abstraction were performed in duplicate. RESULTS: Thirty-one heterogeneous case series and case reports were included in the analysis from the initial search yielding 780 results, including reports of 151 patients who underwent arthroscopy after traumatic hip dislocation. A wide spectrum of intra-articular injury was reported, with a high prevalence of labral tears, intra-articular bodies, ligamentum teres injuries, and chondral damage. CT had a sensitivity of 87.3% for detecting intra-articular fragments; however, 43.3% of patients who had a preoperative CT scan with negative findings for intra-articular fragments did show fragments at arthroscopy. Magnetic resonance had a sensitivity of 95.0% for detecting labral tears. There were no major complications directly attributed to arthroscopic surgery. A total of 75 of 151 patients were followed up for a median of 2 years after surgery, with osteoarthritis reported in 4.0% and avascular necrosis in 2.7%. CONCLUSIONS: In patients with traumatic hip dislocation, heterogeneously reported previously published cases show that arthroscopy reveals a broad spectrum of intra-articular damage amenable to arthroscopic intervention. CT is not sensitive in the detection of intra-articular bodies in all cases. Although no serious periprocedural adverse events were reported, only 49.7% of patients had reported follow-up data, and further prospective studies would be necessary to show the safety and efficacy of arthroscopy in comparison with conventional treatment algorithms of hip dislocation. LEVEL OF EVIDENCE: Level IV, systematic review of Level IV studies.

Biliary architecture of livers exhibiting right-sided ligamentum teres: an indication for preoperative cholangiography prior to major hepatectomy.

OBJECTIVE: To obtain information about the basic biliary anatomy of livers with right-sided ligamentum teres (RSLT). SUMMARY OF BACKGROUND DATA: RSLT is a relatively rare anomaly with a reported incidence of 0.2-1.2%. Although the portal/hepatic venous and arterial anatomy of livers with RSLT has already been established, the biliary architecture of such livers remains unclear. METHODS: RSLT was detected in 48 patients during 12,071 consecutive image readings (0.4%). Of these patients, the cholangiograms of 46 patients were analyzed, and their intrahepatic biliary tree confluence patterns were classified. RESULTS: The following four unique biliary confluence patterns were identified in livers with RSLT: the symmetrical type (23/46), independent right lateral type (13/46), total left type (6/46), and total right type (1/46). Analyses of the portal and arterial branching patterns of these livers showed that there were no correlations between their biliary confluence patterns and their portal or arterial ramification patterns. CONCLUSION: The basic biliary architecture of livers with RSLT was clarified. As the RSLT patients' anomalous biliary confluences differed from those seen in normal livers and were difficult to predict, preoperative cholangiography should be performed prior to complex hepatobiliary surgery involving livers with RSLT to ensure patient safety.

Atraumatic tears of the ligamentum teres are more frequent in professional ballet dancers than a sporting population.

OBJECTIVES: To compare the frequency of atraumatic ligamentum teres (LT) tear in professional ballet dancers with that of athletes, and to determine the relationship with clinical and imaging findings. METHODS: Forty-nine male and female professional ballet dancers (98 hips) and 49 age and sex-matched non-dancing athletes (98 hips) completed questionnaires on hip symptoms and physical activity levels, underwent hip rotation range of movement (ROM) and hypermobility testing, and 3.0-Tesla magnetic resonance imaging (3 T MRI) on both hips to detect LT tears, acetabular labral tears, and articular cartilage defects, and to measure the lateral centre edge angles (LCE). RESULTS: A higher frequency of LT tear was found in dancers (55 %) compared with athletes (22 %, P = 0.001). The frequency and severity of LT tears in dancers increased with older age (P = 0.004, P = 0.006, respectively). The Hip and Groin Outcome Score (HAGOS) pain scores or hip rotation ROM did not differ significantly among participants with normal, partial, or complete tears of LT (P > 0.01 for all). Neither the frequency of generalised joint hypermobility (P = 0.09) nor the LCE angles (P = 0.32, P = 0.16, left and right hips respectively) differed between those with and those without LT tear. In most hips, LT tear co-existed with either a labral tear or a cartilage defect, or both. CONCLUSION: The higher frequency of atraumatic LT tears in professional ballet dancers suggests that the LT might be abnormally loaded in ballet, and caution is required when evaluating MRI, as LT tears may be asymptomatic. A longitudinal study of this cohort is required to determine if LT tear predisposes the hip joint to osteoarthritis.

Leiomyoma of the round ligament of the liver: report of one case.

Tumoral conditions in the round ligament of the liver are very uncommon and exhibit nonspecific manifestations, hence a high level of suspicion is necessary for their diagnosis. We report the case of a 47-year-old female patient who presented with abdominal pain for several months; imaging studies showed a lesion of indeterminate nature likely connected with the falciform ligament, and only intraoperative findings acknowledged the presence of an apparently benign tumor in the round ligament of the liver, which biopsy confirmed. Following the excision of the round ligament the patient had a favorable course. As this is a pathologically benign lesion we deem its surgical management both advisable and sufficient. However, because of its small prevalence and the scarcity of literature involving this condition, further studies would be needed to provide information on natural history, treatment, and long-term prognosis.

Mesothelial Cyst of the Round Ligament Mimicking a Metastasis: a Case Report

A mesothelial cyst of the round ligament is a rare cause of an inguinal mass. Clinically, it is frequently misdiagnosed as one of commoner diseases such as an inguinal hernia, femoral hernia, lipoma, and lymphadenopathy upon physical examination. Some previous reports elaborated the sonographic features of a mesothelial cyst of the round ligament. However, to our knowledge, few reports have described the CT features of a mesothelial cyst. We illustrated here the sonographic and multidetector CT features of a case of a mesothelial cyst of the round ligament that presented as an inguinal palpable mass and mimicked a metastasis in a patient with a Sertoli-Leydig cell tumor of the ovary.