A novel and simple classification for ligamentum teres pathology based on joint hypermobility

Ligamentum teres (LT) pathology (including synovitis, partial and complete tears) is common at the time of hip arthroscopy with a reported prevalence of 51-90%. Currently, there are four published classifications of LT injuries and tears. The majority focuses on differentiating partial from full thickness tears, whereas a more recently published classification also incorporates the presumed underlying mechanism of pathology. A recent review of the current classification systems found that all are deficient for lack of inclusion of what constitutes a normal ligament, lack of inclusion of synovitis as a source of pathology and lack of inclusion of hypermobility as part of the treatment algorithm. Also, the two most commonly used classification systems have only fair inter-observer reliability. Recent work has found that underlying joint hypermobility plays an important role in LT pathology and that the addition of capsular plication/suture at the time of surgery for LT pathology improves outcomes and reduces re-tear rates. In order to address these problems which have been identified with the currently available classification systems, we propose a novel and simple classification for LT pathology based on underlying joint hypermobility [as assessed by the Beighton test score (BTS)]. LT pathology is used to divide all patients into four types: 0 normal (which includes minor fraying), 1 synovitis (which would also include minor fraying), 2 partial tear and 3 complete tear. Further, all types are subdivided into two groups: Group A patients have no clinical evidence of joint hypermobility (BTS < 3), whereas Group B patients do have clinical evidence of joint hypermobility (BTS ≥ 4). On the basis of this classification system and the available literature, we have also developed a treatment algorithm for LT pathology.