The Journal of Arthroplasty Vol. 17 No.

1 2002

The Mechanical Properties of the Human Hip Capsule Ligaments

John D. Hewitt, MD, Richard R. Glisson, BS, Farshid Guilak, PhD, and T. Parker Vail, MD

Abstract: The human hip capsule is adapted to facilitate upright posture, joint stability, and ambulation, yet it routinely is excised in hip surgery without a full understanding of its mechanical contributions. The objective of this study was to provide information about the mechanical properties of the ligaments that form the hip capsule. Cadaver boneligament bone specimens of the iliofemoral, ischiofemoral, and femoral arcuate ligaments were tested to failure in tension. The hip capsule was found to be an inhomogeneous structure and should be recognized as being composed of discrete constituent ligaments. The anterior ligaments, consisting of the 2 arms of the iliofemoral ligament, were much stronger than the posterior ischiofemoral ligament, withstanding greater force at failure and exhibiting greater stiffness. Knowledge of the anatomy and mechanical properties of the capsule may help the hip surgeon choose an appropriate surgical approach or repair strategy. Key words: hip arthroplasty, ligament, stress, strain.

The hip capsule functions in conjunction with the bony components of the hip to constrain translation between the head of the femur and the acetabulum, while allowing complex combinations of rotation and planar movements [1]. Despite this important biomechanical function, the hip capsule often is excised partially or completely during total hip arthroplasty (THA) for treatment of arthritis and in hemiarthroplasty for displaced intracapsular hip fractures [2,3]. Additional knowledge of the contriFrom the Orthopaedic Research Laboratories, Department of Surgery, Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina. Submitted January 25, 2001; accepted July 5, 2001. Funds were received in partial or full support of the research material described in this article from the Virginia Flowers Baker Endowment and Johnson and Johnson Professionals, Incorporated. Reprint requests: T. Parker Vail, MD, Division of Orthopaedic Surgery, Box 3332, Duke University Medical Center, Durham, NC 27710. E-mail: vail0001@mc.duke.edu Copyright 2002 by Churchill Livingstone 0883-5403/02/1701-0014$35.00/0 doi:10.1054/arth.2002.27674

butions of this complex structure could inuence hip surgery signicantly because currently there is no consensus regarding the need to repair, preserve, or excise the ligaments of the capsule during hip surgery. The hip capsule consists of a supercial layer of longitudinal ligaments and a deep layer of circularly oriented bers lined with synovium [4]. The most important and anatomically consistent of these ligaments are the iliofemoral and ischiofemoral ligaments of the supercial layer and the femoral arcuate ligament of the deep layer of the capsule as described by Fuss and Bacher [5]. The iliofemoral ligament, also known as the Y-ligament of Bigelow, originates between the anterior inferior iliac spine and the acetabular rim and divides into superior and inferior branches as it crosses the joint. The superior branch inserts proximally along the intertrochanteric line anterior to the hip joint, whereas the inferior branch inserts distally along the intertrochanteric line (Figs. 13) [1,5]. The iliofemoral ligaments restrict extension of the hip, providing a

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Fig. 1. Anterior view of the hip. The iliofemoral ligament is shaded gray.

static restraint to full hip extension, which allows erect posture to be maintained without constant muscular action [1]. The ischiofemoral ligament originates from the ischial rim of the acetabulum, follows the spiral of the iliofemoral ligament as it crosses the joint, and inserts around the posterior aspect of the femoral neck (Figs. 2 4) [1]. Because of its posterior location, it primarily restricts internal rotation, but also restricts adduction when the hip is exed [5]. The femoral arcuate ligament is located in the deep capsular layer posterior to the hip. It originates at the greater trochanter, runs deep to the ischiofemoral ligament around the posterior circumference of the femoral neck, and inserts at the lesser trochanter (Figs. 3 and 4). It

Fig. 3. Medial view of the proximal femur. The head of the femur has been removed to visualize better the ligament origins and insertions. The insertion of the iliofemoral ligament is shaded light gray. The insertion of the ischiofemoral ligament is shaded black. The origin and insertion of the femoral arcuate ligament are shaded dark gray.

functions to tension the capsule at extremes of exion and extension. The femoral arcuate ligament corresponds to bers that were identied previously as the zona orbicularis because of the circular course of its bers. The femoral arcuate ligament has 2 bony attachments to the femur (Figs. 3 and 4), however, and does not run continuously around the circumference of the capsule as the zona orbicularis has been depicted previously [5]. The hip capsule also provides a protected route for the vascular supply to the femoral head in adults [6].

Fig. 2. Lateral view of the acetabulum. The origin of the iliofemoral ligament is shaded gray. The origin of the ischiofemoral ligament is shaded black.

Fig. 4. Posterior view of the hip. The ischiofemoral ligament is shaded dark gray. The femoral arcuate ligament is shaded light gray.

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In contrast to the anatomic descriptions of the hip capsule, the mechanical properties of the ligaments comprising the capsule have not been determined. The specic aim of this study was to identify and quantify the mechanical properties of the 3 major ligaments of the hip. Constant strain rate tests of boneligament bone complexes were performed to determine the maximal tensile force at ligament failure, maximal stress at failure, and structural and material strain at failure. Knowledge of these properties of the iliofemoral, ischiofemoral, and femoral arcuate ligaments provides information relevant to clinicians considering injury patterns, surgical approaches, and repair strategies during hip surgery.

Materials and Methods

Ten hip capsule specimens were obtained from fresh frozen cadavers. The cadavers consisted of 9 females and 4 males with an age range of 50 to 99 years at the time of death (mean, 78.8 years; SD, 14.0 years). The hip joints were removed en bloc after excising all soft tissues overlying the capsule ligaments [79]. The ilium was transected immediately proximal to the anterior inferior iliac spine and the posterior inferior iliac spine. The ischium was sectioned through the ischial tuberosity and the pubis through the pubic ramus. The femur was transected immediately distal to the lesser trochanter. Each hip was examined grossly during subsequent dissection to verify the absence of pathologic features, such as marked bone loss, brillation, or erosions on the articular surfaces. The samples were discarded if gross pathologic features were seen. One pair of hips was discarded because of severe osteopenia; 2 hips were discarded because of the presence of hardware, and 2 hips were discarded because of ligament damage during dissection. The individual ligaments of the hip capsule were identied by their origin, insertion, ber orientation, and thickness according to previously described anatomic characteristics (Figs. 1 4) [1,5]. Identication of the ligaments was performed by direct visualization, careful digital palpation, and transillumination of the capsular tissues. This technique allowed consistent and reproducible dissection of the major ligaments at their borders, along the pathway of major ber orientation as described previously [1,5]. Individual ligaments were separated from the interposing capsular tissue by sharply dividing the capsule parallel to the ber orientation along the periphery of the ligament [7]. The acetabulum and femur were sectioned with an

oscillating saw around the origin and insertion of each ligament to create boneligament bone specimens with bone blocks that were 2 to 5 cm in length [7,10]. The iliofemoral ligament was divided longitudinally into its 2 consistently occurring superior and inferior branches. The mechanical testing of the boneligament bone structures was performed using techniques similar to those described by other investigators for shoulder capsule ligaments [7,10 13]. The initial length of each ligament was measured in an unloaded state from the distal bers of the origin to the proximal bers of the insertion, along the longitudinal midline of the ligament, using a precision caliper [10,11,14,15]. The cross-sectional area was measured at 2 locations in the midportion of the ligament using a custom-designed area micrometer [12,14 16]. These measurements were averaged to obtain the initial cross-sectional area for each ligament. Steel screws were inserted transversely into the ligament bone blocks to ensure rigid xation of the bone in the potting material [13]. Then each bone block was inserted into an aluminum cylinder lled with polyester resin, while carefully aligning the predominant ber orientation with the axis of the cylinder [7,13]. The prepared specimens were mounted in a uniaxial servohydraulic testing machine (Model 1321, Instron Corporation, Canton, MA) with the longitudinal axis of the ligament bers in line with the axis of displacement [7,8,10,11,13]. The lower pot was clamped to the machine base, and the upper pot was attached to a load cell (Model 41/0571-01, Sensotec, Columbus, OH). The load cell was attached to a universal joint, and the universal joint in turn was mounted to the actuator piston. The universal joint allowed freedom of movement of the upper pot so that the ligament bers could orient with 3 of freedom [7]. During all manipulations, the ligaments were maintained in an unloaded state and kept moist in normal saline-soaked gauze [7,8,11,13,16]. Each ligament initially was placed under a tensile tare load of 0.98N and allowed to equilibrate [4,7,10,12,13,16,17]. For optical measurements of material strain, 2 equally spaced lines were marked transversely on the specimen using Verhoeff stain [9,11,13,15,16,18]. A preconditioning routine of 10 cycles of loading to 5% strain, based on the initial length of the ligament, was conducted at a rate of 0.5 mm/s [16]. Material testing of each ligament was performed by loading the ligament to failure at a displacement rate of 0.04 mm/s [7,10,13]. This rate was selected for consistency with the published literature and to minimize

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Fig. 5. Examples of experimental force-displacement curves for all 4 ligaments.

5) [7,13,15]. The energy absorbed by each ligament was calculated from the area under the force-displacement curve. The stiffness (tangent modulus) in the toe region of the curve was determined from the slope at 0% strain. The stiffness in the linear portion of the curve was calculated from the slope at 74% of failure displacement because this value represented a point at or near the middle of the linear portion of all 40 curves. A multivariate analysis of variance with a Newman-Keuls posthoc test was used to determine statistical differences in the mechanical properties among the 4 ligaments (Statistica for Windows Release 5.1, Statsoft Inc, Tulsa, OK). Statistical significance was reported at the 95% condence level (P .05).

Results
the viscoelastic effects of the material [7]. The tensile force on the ligament was measured from the load cell, and structural displacement was measured from the movement of the actuator piston [16]. Material displacement was measured by a video analysis system similar to previously described methods [7,10,1215,18]. A video camera (Model 4915-2000/0000, Cohu Inc, San Diego, CA) was used to record images of the ligament to a videotape recorder (Model HR-S7300U, United States JVC Corporation, Elmwood Park, NJ) at a rate of 30 frames/s throughout the entire experiment. A set of images from each experiment was digitized using a digital frame grabber system (ComputerEyes/PCI version 2.00, Digital Vision Inc, Dedham, MA). The distance between the stained lines bounding the central third of the ligament was measured on each frame using image analysis software (Scion Image Release Beta 2, Scion Corporation, Frederick, MD). Maximal force at failure was measured as the highest load cell output during distraction of the ligament ends [16]. The failure stress was dened as the maximal force divided by the average initial cross-sectional area of the central region of the ligament [15,16]. Structural engineering strain was computed by dividing the displacement of the actuator piston at failure by the initial length of the ligament [7,15,16]. Material engineering strain was calculated by dividing the average displacement of the 2 lines bounding the central portion of the ligament at failure by their original distance apart [7,15,16]. A least-squares nonlinear regression curve in the form F A(eBx 1) was t to the force (F) and displacement (x) data for each ligament (Fig. Multivariate analysis of variance revealed that the mechanical properties of the 4 ligament specimens tested were signicantly different (P .00005). The mean maximal force differed signicantly between the femoral arcuate ligament (78.2 37.9N [SD]) and the superior and inferior halves of the iliofemoral ligament (320.3 267.7N and 351.3 159.4N) (P .01) (Fig. 6). The maximal force sustained by the ischiofemoral ligament (136.0 74.6N) differed signicantly from both halves of the iliofemoral ligament (P .05). The mean failure stress of the femoral arcuate ligament (6.61 3.52 MPa) differed signicantly from that of the ischiofemoral ligament

Fig. 6. Mean maximal force at ligament failure. *Differed signicantly from the femoral arcuate ligament (P .01). #Differed signicantly from the ischiofemoral ligament (P .05). Error bars represent 1 SD.

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(2.29 1.69 MPa) and the superior half of the iliofemoral ligament (2.90 1.52 MPa) (P .01) (Fig. 7). The material strain at failure differed signicantly between the femoral arcuate ligament (15.0 7.5%) and all 3 of the other ligaments (7.7 2.2% for the superior half of the iliofemoral, 10.3 5.0% for the inferior half, and 9.3 3.4% for the ischiofemoral) (P .05) (Fig. 8). The structural strain at failure of the femoral arcuate ligament (39.4 13.0%) was signicantly different from the other 3 ligaments (17.0 5.6% for the superior half of the iliofemoral ligament, 18.9 5.4% for the inferior half, and 25.6 9.5% for the ischiofemoral) (P .005) (Fig. 8). With regard to stiffness, the femoral arcuate ligament (10.4 4.4 N/mm) differed signicantly from the superior and inferior halves of the iliofemoral ligament (97.8 67.5 N/mm and 100.7 54.0 N/mm) (P .001). The ischiofemoral ligament (36.9 24.4 N/mm) differed signicantly from both halves of the iliofemoral ligament (P .01) (Fig. 9). The slope of the toe region of the forcedisplacement curve was 2.1 2.8 N/mm for the superior half of the iliofemoral, 1.7 1.2 N/mm for the inferior half, 1.1 0.5 N/mm for the ischiofemoral, and 0.7 0.4 N/mm for the femoral arcuate ligament. No signicant differences were detected in this parameter among any of the ligaments. The energy to failure of each of the ligaments, or the area under the force-displacement curve, was 0.95 1.07 N m for the superior half of the iliofemoral, 1.17 0.76 N m for the inferior half of the iliofemoral, 0.44 0.36 N m for the ischiofem-

Fig. 8. Material (midsubstance) strain and structural strain. *Differed signicantly from the femoral arcuate ligament (P .05). #Differed signicantly from the femoral arcuate ligament (P .005). Error bars represent 1 SD.

oral, and 0.43 0.33 N m for the femoral arcuate ligament. No signicant difference was detected in energy to failure among any of the ligaments. The mean cross-sectional area was 13.1 5.77 mm2 for the femoral arcuate ligament, 72.7 37.1 mm2 for the ischiofemoral ligament, 107 40.4 mm2 for the superior iliofemoral ligament, and 88.5 41.2 mm2 for the inferior iliofemoral ligament. The mean cross-sectional area differed significantly between the femoral arcuate ligament and the other 3 ligaments (P .001).

Fig. 7. Mean maximal stress at ligament failure. *Differed signicantly from the femoral arcuate ligament (P .01). Error bars represent 1 SD.

Fig. 9. Stiffness in the linear region of the average forcedisplacement curves. *Differed signicantly from the femoral arcuate ligament (P .001). #Differed signicantly from the ischiofemoral ligament (P .01). Error bars represent 1 SD.

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Nine femoral arcuate ligaments failed in the midsubstance, and 1 failed as an avulsion from the greater trochanter. Of the ischiofemoral ligaments tested, 5 failed in the midsubstance, and 5 avulsed at the femoral bone block. Failure locations for the superior half of the iliofemoral ligament included 2 in the midsubstance, 3 avulsions at the femur, and 5 avulsions at the ilium. Of the inferior half of the iliofemoral ligament, 1 failed in the midsubstance, 2 avulsed at the femur, and 7 avulsed at the ilium.

Discussion
This study presents a structural biomechanical analysis of the 3 major hip capsule ligaments: the iliofemoral ligament, the ischiofemoral ligament, and the femoral arcuate ligament. The iliofemoral ligament, located in the anterior portion of the supercial joint capsule, was tested in 2 discrete anatomic portions. Each portion of the iliofemoral ligament withstood greater force at failure and was considerably stiffer than either the ischiofemoral ligament or the femoral arcuate ligament. The femoral arcuate ligament, which does not actually cross the joint and is located in the deep layer of the posterior capsule, possessed the highest failure strength among the 3 ligaments tested. This study has shown that the anterior ligaments of the hip capsule withstand signicantly more tensile force than the posterior ligaments. The anterior iliofemoral ligaments span the hip joint from ilium to femur, as does the ischiofemoral ligament. Consequently the ischiofemoral ligament, a discrete structure within the posterior capsule of the hip joint, may be the most important contributor to the mechanical integrity of the posterior capsule. In contrast, the anterior iliofemoral ligaments are paired structures, each stronger individually than the ischiofemoral ligament. The superior mechanical properties of the anterior hip capsule may contribute to the signicantly lower incidence of anterior dislocation of the hip [19]. This observation suggests that repair of the posterior ischiofemoral ligament may be crucial to the mechanical role of the posterior hip capsule. The cross-sectional anatomy and variations in the stiffness of the individual ligaments tested explain why no signicant differences were seen in the energy to failure among any of the ligaments. The stiffer iliofemoral ligament failed at the highest force but with the least displacement of the ligaments. The ischiofemoral ligament failed with less force but with greater displacement than the il-

iofemoral ligaments. The femoral arcuate ligament failed at the lowest force but with the highest displacement. The area under the average force-displacement curve for each ligament did not differ signicantly. Although there are no comparative data in the published literature on the mechanics of the hip capsule, there is a considerable body of information on the mechanics of the ligaments of the shoulder. Our experimental design was based on work previously done with ligaments in capsular structures of the shoulder. The values we present generally agree with values reported for the mechanical properties of the shoulder joint capsule [7,11,13]. Recurrent dislocation of the hip is a rare sequela of traumatic dislocation. Recurrence usually occurs as the result of a labral or posterior acetabular rim defect accompanied by a capsular tear. In the absence of any bony injury, recurrent dislocation can result from an isolated injury to the capsule [20 22]. Sequelae of traumatic hip dislocation include heterotopic ossication, avascular necrosis, and arthritis [19 21,23]. Understanding which structures in the capsule contribute most to hip stability helps in deciding which areas to avoid or to repair during a surgical approach to minimize complications related to joint instability. Knowledge of the mechanical properties of the hip ligaments assists in designing strategies to repair the capsule after traumatic injury. The incidence of hip dislocation after THA is approximately 3% in large series but varies according to approach, with the posterolateral approach associated with a higher incidence than the anterior approach [24,25]. Of dislocations, 70% occur within 4 to 5 weeks after surgery. Reasons for dislocation after THA are multifactorial but can be attributed to inadequate soft tissue constraint as a result of an unhealed hip capsule in the early postoperative period [26]. Repair and proper tensioning of the hip capsule after THA potentially could reduce soft tissue laxity and decrease the incidence of early dislocation after surgery. A study by Chiu et al [27] prospectively evaluated posterior capsulorrhaphy after THA via a posterior approach. After 38 months of follow-up, the group of patients randomized to repair of the capsule had a lower incidence of postoperative dislocation (0%) compared with patients who did not undergo repair (2.3%). Knowledge of the mechanical properties of the hip capsule may facilitate the development of new techniques and materials for capsular repair and help decrease the postoperative incidence of hip dislocation. If one is going to at-

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The Journal of Arthroplasty Vol. 17 No. 1 January 2002 8. Soslowsky LJ, An CH, DeBano CM, Carpenter JE: Coracoacromial ligament: in situ load and viscoelastic properties in rotator cuff disease. Clin Orthop 330:40, 1996 9. Woo SL-Y: Mechanical properties of tendons and ligaments: quasi-static and nonlinear viscoelastic properties. Biorheology 19:385, 1982 10. Bigliani LU, Keldar R, Flatow EL, et al: Glenohumeral stability: biomechanical properties of passive and active stabilizers. Clin Orthop 330:13, 1996 11. Itoi E, Grabowski JJ, Morrey BF, An K-N: Capsular properties of the shoulder. Tohoku J Exp Med 171: 203, 1993 12. Woo SL-Y, Gomez MA, Seguchi Y, et al: Measurement of mechanical properties of ligament substance from a bone-ligament-bone preparation. J Orthop Res 1:22, 1983 13. Ticker JB, Bigliani LU, Soslowsky LJ, et al: Inferior glenohumeral ligament: geometric and strain-rate dependent properties. J Shoulder Elbow Surg 5:269, 1996 14. Butler DL, Grood ES, Noyes FR, et al: Effects of structure and strain measurement technique on the material properties of young human tendons and fascia. J Biomech 17:579, 1984 15. Woo SL-Y, Peterson RH, Ohland KJ, et al: The effects of strain rate on the properties of the medial collateral ligament in skeletally immature and mature rabbits: a biomechanical and histological study. J Orthop Res 8:712, 1990 16. Woo SL-Y, An K-N, Arnoczky SP, et al: Anatomy, biology, and biomechanics of tendon, ligament and meniscus. p. 45. In Simon SR (ed): Orthopaedic basic science. American Academy of Orthopaedic Surgeons, Chicago, 1994 17. Woo SL-Y, Hollis JM, Adams DJ, et al: Tensile properties of the human femur-anterior cruciate ligament-tibia complex: the effects of specimen age and orientation. Am J Sports Med 19:217, 1991 18. Derwin KA, Soslowsky LJ, Green WDK, Elder SH: A new optical system for the determination of deformations and strains: calibration characteristics and experimental results. J Biomech 27:1277, 1994 19. DeLee JC: Fractures and dislocations of the hip. p. 1659. In Rockwood CA, Green DP, Gucholz RW, Heckman JD (eds): Fractures in adults. Lippincott-Raven, Philadelphia, 1996 20. Graham B, Lapp RA: Recurrent posttraumatic dislocation of the hip: a report of two cases and review of the literature. Clin Orthop 256:115, 1990 21. Weber M, Ganz R: Recurrent traumatic dislocation of the hip: report of a case and review of the literature. J Orthop Trauma 11:382, 1997 22. Vailas JC, Hurwitz S, Wiesel SW: Posterior acetabular fracture-dislocations: fragment size, joint capsule, and stability. J Trauma 29:1494, 1989 23. Olson SA, Matta JM: Fractures of the acetabulum, hip dislocations, and femoral head fractures. p. 587.

tempt to repair the hip capsule after surgery, the data in this article indicate the importance of repairing the ischiofemoral ligament after a posterior approach and the iliofemoral ligaments after an anterior approach to the hip. The goal of surgical repair is the restoration of normal joint function, and restoration of the normal mechanical properties of injured tissues may play an important role in this process. The mechanical properties of the specic hip capsule ligaments as dened in this study can be used as baseline data with which to develop repair guidelines and standards. From a basic experimental standpoint, future study might include determination of the strain rate dependent properties of the ligaments and site-specic material properties. These data can be used in nite element modeling of the factors contributing to hip joint stability [28]. This study on the mechanical properties of the hip ligaments enhances the understanding of the role played by the joint capsule in hip stability and movement, while highlighting the contribution of individual ligaments within the capsule itself. Similar studies on the shoulder have led to increased understanding of the mechanical function of constituent ligaments within the shoulder capsule. The hip capsule is not a homogeneous structure and should be regarded as a composite of discrete constituent ligaments.

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26. Mohler CG, Collis DK: Early complications and their management. p. 1125. In Callaghan JJ, Rosenberg AG, Rubash HE (eds): The adult hip. LippincottRaven, Philadelphia, 1998 27. Chiu FY, Chen CM, Chung TY, et al: The effect of posterior capsulorrhaphy in primary total hip arthroplasty. J Arthroplasty 15:194, 2000 28. Scifert CF, Brown TD, Pedersen DR, Callaghan JJ: A nite element analysis of factors inuencing total hip dislocation. Clin Orthop 355:152, 1998