Severe Damage to the Ligamentous-Fossa-Foveolar Complex Is Common in Patients Undergoing Surgical Hip Dislocation for Femoroacetabular Impingement.
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BACKGROUND: Ligamentum teres lesions are increasingly linked to hip pain and poor surgical outcomes. However, the extent of damage to the full ligamentous-fossa-foveolar complex (LFFC) and the factors associated with this finding remain unclear in young patients undergoing joint-preserving surgery. QUESTIONS/PURPOSES: In this study, we sought (1) to determine the percentage of patients undergoing surgical hip dislocation for femoroacetabular impingement who have diagnosable LFFC lesions using a previously validated grading system and (2) to identify clinical and radiographic factors associated with more severe LFFC damage. METHODS: Between July 2016 and December 2023 the senior author treated 402 hips with surgical hip dislocation for symptoms and radiological signs of femoroacetabular impingement (cam morphology, decreased acetabular coverage, or femoral version abnormalities) without advanced osteoarthritis (Tönnis > II). Based on that, 34% (136 of 402) were excluded because of previous surgery, posttraumatic FAI etiologies, incomplete documentation, tumor associated, pediatric hip disorders (Perthes disease and slipped capitis femoris epiphysis), or avascular necrosis. This left 66% (266 of 402) for final analysis in this retrospective, institutional review board-approved study. Mean age was 29 ± 8 years, and 46% (122 of 266) were male. Standardized AP and axial radiographs assessed acetabular and femoral pathomorphology; CT scans were used to determine femoral version. Using a previously validated and established grading system, we determined (1) the percentage of patients undergoing surgical hip dislocation who have LFFC lesions and (2) the demographic, radiographic, and intraoperative factors associated with those lesions. RESULTS: Substantial LFFC damage was present in 65% (173 of 266) of hips. The ligamentum teres, fossa, and fovea were substantially affected in 44% (118 of 266), 52% (138 of 266), and 51% (135 of 266) of hips, respectively; 21% (57 of 266) of hips had severe lesions to all three structures. Patients with ligamentum teres injuries also had concomitant fossa and fovea damage. After controlling for potential confounding variables such as age, sex, and radiographic parameters, we found that male sex and abnormal femoral version (< 10° or > 25°) were associated with severe LFFC damage (hazard ratio [HR] 0.4 (95% confidence interval [CI] 0 to 1); p = 0.004 and HR 2 (95% CI 1 to 4); p = 0.03, respectively). Acetabular undercoverage was not associated with a greater likelihood of LFFC damage being present. CONCLUSION: In joint-preserving hip surgery, the primary focus is usually on the labrum and the peripheral compartment, but our findings show that lesions to the LFFC are also very common. As older age, male sex, and femoral version abnormalities were associated with more severe damage, these factors should be incorporated into preoperative considerations, and the accuracy of MRI for detecting LFFC damage should be evaluated. Future studies should also determine how these LFFC lesions influence symptoms and long-term outcomes and identify which management strategies best address them. LEVEL OF EVIDENCE: Level III, prognostic study.