Entheseal Inser on of the Iliofemoral Ligament and Its Rela onship

EnthesealInser,onofthe
IliofemoralLigamentandIts
Rela,onshipwithFemoraland
AcetabularAnatomy.
RicardoG.Schröder,PT ;RobRoyLMar8n,PTPhD ;Juan
Gomez-Hoyos,MD ;AnthonyKhouryM.Sc. ;IanJ.
1
1,3
Palmer,PhD1;HalDMar8n,DO1.
2
1,4
1.  HipPreserva8onCenteratBaylorScoO&WhiteHealthSystem,
Dallas,Texas,EUA.
2.  DepartmentofPhysicalTherapy,DuquesneUniversity,PiOsburg,
Pennsylvania,EUA.
3.  UniversityofAn8oquia,Medellin,Colombia.
4.  DepartmentofBioengineering,UTArlington,Arlington,Texas,
EUA.
HalDMar8n–Educa8onalConsultantforSmith&Nephew
Background
•  TheILFLisanatomicallyandfunc8onallydividedintothemedial
andlateralarmsasitcrossestheanterioraspectofthejoint.
•  Accordingtothehipposi8on,botharmshavedifferentfunc8ons
stabilizingthefemoralheadduringrepe88verota8onaland
transla8onalforces.
•  Tendons,ligaments,andjointcapsulesaOachtoboneat
enthesesac8ngasananchor,concentra8ngstressastheforceis
transferredfromso_8ssuetobone.Thesizeofanenthesisisa
func8onofcumula8vestress.
Background
•  Themedialarmofthe
iliofemoralligamentis
aOachedtothefemuratthe
intertrochantericknobonthe
distalsegmentofthe
intertrochantericline
•  ThelateralarmaOachesinto
thecrestontheanterior
surfaceofthegreater
trochanter
Background
•  Anincreasedstrainattheinser8onsiteoftheILFLcharacterizedby
anenthesalforma8onmayreinforcetheILFLcontribu8ontowards
hipstability.
•  Duetothedirectanatomicinterac8onbetweenbonyandcapsular
ligaments,anabnormalbonygeometrymayincreaseloadand
mechanicalcompensa8onsbythecapsularligaments.
Purpose
•  Thepurposeofthisstudywastoexaminetheregionofthe
intertrochantericlineonhumancadavericfemurstoiden8fy
andquan8fyadis8nctenthesisforthemedialandlateral
armsoftheILFL.
•  Asecondarypurposewastoinves8gate,throughavalidated
andreliableMRItechnique,iffemoralandacetabularversion
couldinfluencetheenthesisoftheLateralArmofthe
IliofemoralLigament(LAILFL).
Methods
CadavericInves8ga8on:
•  Asampleofhumancadavericfemurs(n=107)archived
intheClevelandMuseumofNaturalHistory
(Cleveland,Ohio)wereu8lized.
•  Twoinves8gatorsindependentlyobservedthe
proximalsegmentofthefemurandindicatedifthe
crestandknobwereorwerenotdis8nctpalpable
structures.
•  Clayimpressionmoldsofthecrestandknobwere
madeoneachofthefemurspecimens.
•  Measuresofwidthandlengthofeachclaymoldwere
takenwithcaliperstoquan8fythesizeoftheenthesis.
Methods
MRIInves8ga8on:
LateralArmofIliofemoralLigamentCrestHeight(LAILFLch)x
FemoralandAcetabularGeometry:
•  50HipsMRIofsubjectswhounderwenttoexamina8ondue
tohippainwereseparatedintofourgroups:
Ø  Decreasedfemoralversion<20°(n=74hips)
Ø  Increasedfemoralversion≥20°(n=26)
Ø  Decreasedacetabularversion<20°(n=65)
Ø  Increasedacetabularversion≥20°(n=35)
Methods
Thelastandmostop8malMRIaxialsliceofthefemoralneckbelowthe
femoralheadwasu8lizedtomeasuretheheight(mm)oftheLAILFLinser8on.
Theimageshowingthehighestelongatedoval-shapedattheanterioraspectof
thegreatertrochanterrepresentedtheinser8onoftheLAILFL.Alineparallel
totheanteriorpor8onofthefemoralneckwasu8lizedasabaseofthecrest.A
rulerposi8onedinthemiddle(base)ofthebodyoftheoval-shapedstructure
anddrawun8lthe8poftheosseousbumpmeasuredtheheightoftheLAILFL
Results
CadavericResults:
•  Twoinves8gatorsagreedthat
uniqueanddis8nctentheses
werepresentforthemedial
andlateralarmsofthe
iliofemoralligamentin93%
(100/107)and100%(107/107)
ofspecimens,respec8vely.
•  Themedialandlateralarmsof
theiliofemoralligamentwere
iden8fiedasanuniqueand
separateaOachmentsatthe
intertrochantericknoband
greatertrochantericcrest.
Measuring:width6.6mm±3.4
and10.4mm±2.4;andlength
13.3mm±6.2and17.7mm±
4.3.
Results
MRIResults:
A_eranalysisofonehundredhipMRIs,thesecondpartofthestudy
revealedmeanvalueofLAILFLchaveraged4.17mm±1.73(0-8.2mm).
Femoralversionaveraged12.4°±11.77(-21°–41.28°)andacetabular
versionaveragedin17.1°±5.39(2.67°-32°).
Results
a)Normalfemoralanatomy b)DecreasedFemoralVersion c)IncreasedFemoralVersion
Conclusion
•  Themedialandlateralarmsoftheiliofemoralligamentwere
iden8fiedasuniqueandseparateenthesealaOachmentsat
theintertrochantericknobandgreatertrochantericcrest.
•  TheMRItechniquewasaconsistentandreliablemethodto
measuretheLAILFLch.
•  DecreasedFVincreasedLAILFLch,sugges8ngapoten8al
secondaryosseousresponsetoincreasedloadonthelateral
armoftheiliofemoralligament.
•  Thepresentstudydefinestheimportanceofproximalfemoral
anatomyforradiographicevalua8on,treatment,andsurgical
planningofiliofemoralligamentrepairorreconstruc8on.
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