Female, 25 years old, softball coach. Patient had already undergone two prior right hip arthroscopies and two left hip arthroscopies.

The last left hip surgery (1 year before) included labral debridement, lysis of adhesions, chondroplasty, synovectomy, psoas lengthening, and a labral reconstruction using an IT band autograft.

The patient complains of left hip pain that continues to bother her daily. She has signs of hip instability. She complains of her left hip giving out multiple times a day, preventing her from performing daily activities. Sometimes she has the feeling that the hip “pops out.”

Past surgical history: positive for multiple surgeries on both hips, both shoulders, and left foot.

Normal strength of the muscles surrounding the hip joint, including hip flexors bilaterally. Normal sensation throughout lower extremities. Positive anterior impingement sign. Physical exam is consistent with generalized laxity. ROM: flexion 126°, abduction 45°, and adduction 30°. Grossly positive left hip manual distraction test.

Before putting the leg into table traction, a physical exam was performed under anesthesia. The joint could be distracted with manual traction alone, confirming severe hip laxity (Fig. 30.8).

Initial arthroscopic inspection: significant synovitis throughout the joint, significant adhesions especially at the capsulolabral recess, and a visible ligamentum teres tear (Fig. 30.9).

Synovectomy was done using a combination of the electrocautery wand, ablator, and shaver. Hemostasis was assured with the RF device.

We then removed the adhesions by using the RF ablator and shaver, clearing up the capsulolabral recess. The labral reconstruction was intact and the suction seal was restored once the adhesions were removed.

Ligamentum teres: the LT was torn and grossly insufficient. The scar tissue surrounding it was debrided.

To begin the LT reconstruction, the arthroscopic shaver and burr were used to debride the cotyloid fossa, partially removing the pulvinar fat, and to expose the footprint of the ligamentum teres.

Then, using the C-arm, a K-wire was inserted from the lateral cortex of the femur, in line with the femoral neck. The trajectory was 1 cm below the center of the neck, so the tip of the K-wire would exit at the femoral fovea. The correct position of the K-wire was confirmed at both lateral and AP views (Fig. 30.10).

We then drilled a hole using a cannulated 6 mm reamer over this K-wire. This was then enlarged to 7 mm and finally to 8 mm. The tunnel went all the way to the femoral fovea, and a curette was placed inside the joint to protect the acetabular joint surface from damage by the reamer and the K-wire (Fig. 30.11a–c).

The anchor guide was placed through this hole on the femoral neck; a hole was drilled on the cotyloid fossa for insertion of a 2.9 mm anchor loaded with a #2 suture.

This #2 suture was retrieved arthroscopically through the anterolateral portal. One of the suture limbs was passed through a tibialis anterior allograft using a free needle. Then an arthroscopic knot was used to push the graft into the joint through a cannula, until it was compressed against the fossa. A sequence of knots secured this end of the graft at this position (Fig. 30.12a, b).

Then an arthroscopic grasper was inserted through the femoral neck hole to pull the allograft into the femoral neck tunnel. About 2.5 cm of the graft remained between the fovea and the fossa, with the leg in extension and external rotation (Fig. 30.13a, b). This is critical to avoid loss of movement.

Tension level was verified by checking the hip’s range of motion and graft excursion. After reaching the desired tension, an 8 × 35 mm interference screw was placed to assure fixation of the graft inside the tunnel. After fixation, the hip range of motion was again verified to be satisfactory.

To end the case, we performed a capsular plication to make sure that the capsule would heal with an appropriate amount of tension, restoring its function as a secondary stabilizer.

There are conceptual and technical points to consider upon review of this case. Conceptually, we believe that hip microinstability is multifactorial. The ligamentum teres is a secondary stabilizer of the hip joint. LT insufficiency may become symptomatic in patients with dysplasia and/or following surgical LT debridement. Technically, the LT reconstruction with an allograft needs to be associated with other procedures to address microinstability, such as capsular plication. Meticulous attention should be given to correct allograft length and tension. Reduced length may impair full range of motion. This procedure requires mastery of all advanced hip arthroscopy techniques prior to performance and is presented here as an example of the frontier of treatment in the salvage setting.