Transverse acetabular ligament

T transverse acetabular ligament

(
transverse ligament
) is part of the acetabular labrum, although different from it, having no cartilaginous cells among the fibers.

It consists of strong, flattened fibers that cross the notch of the acetabulum and turn it into an opening through which nutrient vessels enter the joint. This is the intra-articular structure of the hip. [1]

Links[edit]

This article incorporates public domain text from page 336 of the 20th edition

"Grey's Anatomy"
(1918).

1. Lee, Sun Hyuk; Chan, Woo Young; Choi, Gi Won; Lee, Young Geun; Jeong, Hae Woong (April 2021). “Is the transverse acetabular ligament hypertrophied and does it interfere with its contraction in dysplasia of the development of the hip joint?” . Arthroscopy: Journal of Arthroscopic and Allied Surgery
   .
   34
   (4):1219–1226. DOI: 10.1016/j.arthro.2017.10.024. ISSN 0749-8063.

Acetabular labral tear

A tear of the acetabular labrum (labrum) can cause pain if the labrum is torn, frayed, or damaged. Labral tears cause pain in the groin or pain in the anterior thigh, and less commonly pain in the buttocks [1]. This mechanically induced pathology is believed to result from excessive forces in the hip joint. For example, a tear can reduce the contact area of ​​the acetabulum and increase stress, leading to joint damage and destabilization of the hip joint [2].

Labral tears can be further classified as:

• Anterior Labral Tears - Pain will typically be more constant and localized to the front of the thigh (anterosuperior quadrant) or groin [3][4][5][6][7][8]. They are common in individuals in European countries and the United States.
• Posterior labral tears - located in the lateral area or deep in the back of the buttocks. They are less common in people in European countries and the United States, but are more common in people from Japan [3][5][7].

Clinically Relevant Anatomy

The acetabular labrum is a fibrocartilaginous rim that surrounds the circumference of the acetabulum. This helps hold the head of the femur inside the acetabulum and varies greatly in shape and thickness.

The labrum has three surfaces:

1. Inner articular surface—adjacent to the joint (avascular)
2. External articular surface - in contact with the joint capsule (vascularized)
3. Basal surface - attaches to the acetabulum and ligaments.

The transverse ligaments surround the hip and help hold it in place during movement.

On the anterior aspect, the labrum is triangular in radial section. On the posterior aspect, the labrum is square, but with a rounded distal surface [9][10].

The functions of the acetabular labrum are as follows:

• Joint stability
• Sensitive shock absorber
• Joint lubricant
• Pressure distributor
• Reducing contact stress between the acetabulum and femoral cartilage [5][11][1]

Epidemiology/etiology

In studies of patients with labral tears, researchers have attributed the injury to various causes:

• Direct trauma - such as motor vehicle accidents, falls with or without hip dislocation
• Sports that require frequent external turning or overexertion - such as ballet, football and hockey, running and sprinting
• Specific movements including torsion or twisting movements, hyperabduction, hyperextension, and hyperextension with lateral rotation

This condition is not associated with age. The reported age of people with hip pain and labral tear ranges from 8 to 75 years.

Structural risk factors for this condition include:

• Acetabular dysplasia
• Degeneration
• Capsular weakness and hypermobility of the hip joint
• Femeroacetabular impingement (Byrd and Jones, 2003, Wenger et al., 2004) [2]

Characteristics/clinical picture

• Gender – Occurs in both sexes with equal frequency [12][8][13][14]
• Symptoms: Constant dull pain with periods of sharp pain that gets worse with activity. Walking, turning, prolonged sitting and impactful activities aggravate symptoms. Some patients describe night pain [1]. Symptoms can be long-lasting, averaging more than two years [15].
• Mechanical Symptoms - A variety of mechanical symptoms have been reported, including clicking (most common), locking, or pinching. The meaning of these signs is questionable [16].
• Range of Motion: These specific maneuvers may cause groin pain: [9] Flexion, adduction and internal rotation (FADDIR TEST) of the hip joint are associated with anterior superior tears
• Passive hyperextension, abduction, and external rotation are associated with posterior tears

Differential diagnosis

Differential diagnosis of labral tears may include the following diagnoses:

• Sports pubalgia
• Snapping hip
• Septic (Infectious) arthritis
• Piriformis syndrome
• Injury
• Tension
• Osteitis of the pubis
• Trochanteric bursitis
• Avascular necrosis of the femoral head
• Fracture
• Dislocation
• Inguinal or femoral hernia
• Legg-Calvé-Perthes disease
• Epiphysiolysis of the femoral head
• Radiating pain from the lumbosacral and sacroiliac regions
• Tumor [17]

Conservative treatment

Includes relative rest, anti-inflammatory medications, and pain medications if needed. Combined with a 10-12 week intensive physical therapy program. The patient's pain may decrease during this period, but it is possible that the pain will return once the patient returns to their normal activities. When conservative treatment fails to control the patient's symptoms, surgery may be considered [18].

Survey

Physical examination

The test is considered positive if one or more of these symptoms are reproduced during the test: clicking, squeaking or pain in the groin area [18][19].

• Impingement test - the hip joint is passively flexed to 90°, internally rotated and abducted.
• FABER Test - The lower limb is passively placed in a figure-of-four position and slight pressure is applied to the medial aspect of the knee. (Positive result in 7 out of 18 cases)
• Resisted Straight Leg Raise Test - The patient's hip is flexed 30°, the knee is extended, and downward pressure is applied. (Positive result in 1 out of 18 cases)
• McCarthy/Thomas Test (Hip Flexion and Extension Maneuver) - With the patient in the supine position, the subject fully flexes both hips. The examiner slowly/passively extends the subject's lower limbs and moves the hips into a position of external rotation. The test is repeated, but with the hip in internal rotation.
• Internal Rotation Load/Friction Test - With the patient in the supine position, the examiner passively flexes the patient's hip to 100° and then rotates the subject's hip from internal rotation to external rotation, pushing along the axis of the hip through the knee to induce "friction."
• Fitzgerald test - To evaluate the anterior labrum. The patient's hip is sharply flexed and then extended into internal rotation and full abduction.
• Patrick's Test - To evaluate the posterior labrum. The patient's hip is flexed and then extended into abduction and external rotation.

Diagnostic tests

• Magnetic resonance arthrography (MRA) - Provides the best results because it requires an intra-articular or systemic infusion of gadolinium to obtain the details necessary to study the labrum. The principle of the procedure is based on stretching the capsule. Highlighting the labrum with contrast and filling any gaps that may be present. MRA has limitations in sensitivity for the diagnosis of acetabular and articular cartilage abnormalities, and it has been shown that MRA may be less effective in detecting posterior and lateral tears [3].
• Diagnostic image-guided intra-articular injections of the hip joint may also be useful in diagnosing labrum tears.
• Hip Arthroscopy - Used as the diagnostic gold standard for anterior labral tears and used as a therapeutic modality.

Treatment

Arthroscopy

Repair of a labral acetabular injury can be performed in either the supine or lateral position. A fracture couch is used in the supine position with an increased perineal position for traction. The affected hip is placed in slight extension/adduction to allow access to the joint. During traction, it is important that the pressure in the perineal area is minimal to avoid neurological complications. The procedure is performed under the guidance of a fluoroscopist. During distraction, a 14- or 16-gauge spinal needle is inserted into the joint to break the vacuum seal and allow further distraction. Three portals are used (anterolateral, anterior, and an additional distal lateral).

To restore the detached labrum, the edges of the tear are outlined and suture anchors are placed over the acetabular edge in the area of ​​the detachment. If the labral tear has a secure outer rim and is still attached to the acetabulum, a mid-tear suture can be used for fixation [20].

Physiotherapy [20]

It is necessary to avoid movements that cause stress in this area. The rehabilitation protocol after correction or restoration of the acetabular labrum is divided into four stages.

Phase 1 - Initial (Week 1-4)

The main goals after acetabular reconstruction are to minimize pain and inflammation and begin early range of motion exercises. This phase initially consists of isometric contraction exercises of the hip adductors, abductors, transverse abdominis, and extensor muscles. Once the labrum has been corrected, closed-chain exercises such as the leg press can begin.

The protocol for weight transfer to the leg after correction is 50% over 7-10 days, and in the case of labral repair the process will take 3-6 weeks. Unnecessary hypomobility will limit progress in future phases, so it is important to ensure that sufficient mobility and range of activities are maintained during this phase.

Treatment methods:

• Aquatic therapy is a suitable treatment approach - movement in water can improve gait by allowing appropriate stress to be placed on the joint without causing unnecessary stress to the healing tissue. For example, the patient can do light jogging in the water using a flotation device. It is important to know the patient's range of motion as it may vary during correction or restoration.
• Manual therapy to reduce pain and improve joint mobility and proprioception. Considerations include gentle hip mobilization, stretching with release for internal and external rotation, long-axis distraction, and assessment of lumbosacral mobility.
• Cryotherapy
• Proper pain management with medications.
• Gentle stretching of thigh muscle groups including piriformis, psoas, quadriceps, hamstrings with passive range of motion.
• A non-resistance exercise bike with a seat height that limits the hips to less than 90°
• Exercises such as: water walking, piriformis stretches, ankle pumps.

To advance to Phase 2, range of motion must be greater than or equal to 75%.

Phase 2 - Intermediate (5-7 Weeks)

The goal of this phase is to continue to improve range of motion and soft tissue flexibility. Manual therapy should continue with more aggressive mobilization, and passive exercises should become more aggressive as needed for external and internal rotation.

• Flexibility exercises involving the piriformis, adductor, psoas/rectus femoris should be continued
• Exercise bike with resistance
• Side steps for abductors
• Core strengthening
• Swimming
• Exercises such as wall sitting, two leg bridges

To progress to the third phase, it is important that the patient has a normal gait without Trendelenburg sign. The patient should have a symmetrical and normal range of motion with minimal complaints of pain.

Phase 3 - Advanced (Week 8-12)

• Manual therapy should be performed as needed
• Interventions on flexibility and passive range of motion should become slightly more aggressive if restrictions persist (if the patient has reached their full range or flexibility, stretching should be started)
• Strengthening exercises: walking lunges, lunges with torso twists, cable resistance, forward/backward walking, plyometric jumping jacks.
• Exercises such as core stabilization, golf progressions, lunges

To move into phase four, it is important to have a symmetrical range of motion and flexibility in the psoas and piriformis muscles.

Phase 4 - Specific Sports Training (Week 12-*)

At this point, it is important to return to competition or previous activity levels safely and effectively. Manual therapy, flexibility and range of motion exercises may continue as needed.

It is important that the patient has good muscular endurance, good eccentric muscle control, and the ability to generate energy.

The patient may be given specific sport-specific exercises and should be able to demonstrate good neuromuscular control of the lower extremity during activities.

Exercises such as: sports specific exercises, functional testing.

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