The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 3

Current Concepts Review | March 01, 2009

Acetabular Labral Tears

Paul E. Beaulé, MD, FRCSC¹; Michelle O'Neill, MD, FRCSC¹; Kawan Rakhra, MD, FRCPC¹

¹ The Ottawa Hospital, University of Ottawa. 501 Smyth Road CCW 1646, Ottawa, ON K1H 8L6, Canada. E-mail address for P.E. Beaulé: pbeaule@ottawahospital.on.ca

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Also, commercial entities (Zimmer, Stryker, and Wright Medical Technology) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Mar 01;91(3):701-710. doi: 10.2106/JBJS.H.00802

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Abstract

Acetabular labral tears rarely occur in the absence of a structural osseous abnormality.

Labral tears are frequently associated with lesions of acetabular cartilage such as delamination.

Hip arthroscopy is the preferred operative approach in the treatment of labral injuries in the absence of substantial structural osseous abnormalities.

Figures in this Article

Introduction

The knowledge base and understanding of acetabular labral tears has greatly evolved in the last decade. Initial reports on labral pathology were limited to descriptions of alterations associated with well-established hip deformities such as hip dysplasia, Legg-Calvé-Perthes disease^1-4, and traumatic events⁵. Until recently, the diagnosis and imaging of these lesions were difficult, and operative intervention (i.e., hip arthroscopy) was often required to confirm the diagnosis^6-10. Because surgeons initially had to rely on hip arthroscopy for the diagnosis of labral tears in a large proportion of patients, this operative technique was commonly applied for the treatment of these conditions^7,10,11 without a complete comprehension of the exact etiology. With the advent of more advanced imaging techniques such as magnetic resonance arthrography^12,13 combined with a better understanding of the importance of a labral tear as it relates to degenerative hip arthritis^14,15, the treatment of labral injuries has generated a substantial amount of interest in recent years^9,16,17.

Despite the recent advancements in imaging as well as operative techniques, patients are often misdiagnosed. In one report, it was documented that patients visited, on the average, 3.3 health-care providers before being correctly diagnosed with a labral tear and waited an average of twenty-one months for the diagnosis¹⁸. More importantly, 33% (twenty-two) of sixty-six patients received an alternate diagnosis prior to being diagnosed with a labral tear. In addition, the lack of a complete understanding of the function of the acetabular labrum as well as its anatomy has made treatment recommendations difficult to establish. The goals of this review are to provide an overview of the anatomy and function of the acetabular labrum and review the current understanding of the diagnosis and treatment of lesions involving the labrum.

Anatomy and Function of the Acetabular Labrum

The acetabular labrum is triangular in cross section, with the base attached to the acetabular rim and the apex being the free margin¹⁹. The joint capsule attaches to its external edge, creating a potential recess between the capsule and the labrum. The labrum can be divided into two distinct zones, with the extra-articular side, consisting of dense connective tissue, being well-vascularized at its junction with the joint capsule and the intra-articular portion being largely avascular (Fig. 1). In addition, recent embryological studies of the hip joint have shown that the anterior and posterior chondrolabral junctions have different morphological appearances^20,21. In a study of eleven human embryos, it was found that the anterior aspect of the labrum has a rather marginal attachment to the acetabular cartilage, with an intra-articular projection, whereas the posterior aspect of the labrum is attached to and continuous with the acetabular cartilage²⁰. In addition, anteriorly the chondrolabral transition zone is sharp and abrupt while posteriorly it is gradual and interdigitated. These most recent findings are in contrast to initial descriptions of the acetabular labrum as being continuous with the articular cartilage throughout the acetabulum^19,22. This abrupt anterior transition zone would make the labrum more susceptible to tearing in this zone and corresponds to some extent to the so-called watershed lesion²³. On the basis of observations during a large number of hip arthroscopies for labral tears as well as cadaver dissections, McCarthy et al.²³ described the anterior aspect of the labrum as an at-risk zone due to potential inferior mechanical properties, higher mechanical demands, and relative hypovascularity and proposed that a labral tear alters the biomechanical environment of the hip, leading to degeneration of the articular cartilage and eventually to osteoarthritis¹⁴.

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Fig. 1: Left image: High-power photograph of a coronal section, prepared with the Spalteholz technique, from the anterosuperior aspect of the labrum of a left hip. Right image: Illustration depicting the zones of the acetabular labrum. The articular side of the labrum is adjacent to the femoral head and the capsular side is adjacent to the periacetabular sulcus. (Reprinted from: Kelly BT, Shapiro GS, Digiovanni CW, Buly RL, Potter HG, Hannafin JA. Vascularity of the hip labrum: a cadaveric investigation. Arthroscopy. 2005;21:6; with permission from Elsevier.)

Another important consideration in the treatment of labral tears is the vascularity of the labrum and how this may relate to its capacity to heal after injury and/or operative repair. Only the external one-third of the labrum at the junction with the capsule is well vascularized^19,22. In a recent cadaver study, it was found that the labrum had a relatively poor vascular supply but that there were regional differences, with the capsular side having more vascularity than the articular side²⁴. In terms of its predilection for failure, Dorrell and Catterall² correlated the occurrence of a labral tear with abnormal shear stresses transmitted by the uncovered femoral head as may occur in acetabular dysplasia. From this clinical situation, they postulated that the hypertrophied labrum contributes to the stability of the femoral head within the acetabulum in adulthood. This aspect of load-sharing was later supported by a study that demonstrated that the labrum contributes to the growth and development of the acetabular roof³. Although the labrum may have a load-sharing role, similar to that of the meniscus in the knee, in cases of dysplasia, more recent work has demonstrated that it does not have an important load-sharing role in the normal hip²⁵. Instead, a finite-element analysis and cadaver investigation showed that the labrum acts as a seal, ensuring more constant fluid-film lubrication within the hip joint and limiting the rate of fluid expression from the articular cartilage layers of the joint, as indicated by a greater hydrostatic fluid pressurization within the intra-articular space when the labrum is intact²⁶. In addition, because the labrum adds resistance to the flow path for interstitial fluid expression, cartilage consolidation was significantly quicker without the labrum^26,27. Consequently, disruption of the labral seal could be detrimental to the overall nutrition of the cartilage, leading to its premature degeneration²⁸. Takechi et al.²⁹ also showed the labrum contributing to the stability of the hip joint by its valve effect and structure. Both of these mechanisms are dependent on the fit of the labrum against the femoral head²⁷. In a similar study, the loss of the labral seal was found to be the critical event leading to destabilization of the hip, shifting the hip center of rotation and making the hip susceptible to increased impact loading and repetitive trauma through loss of the protective function provided by the intact labrum and its seal³⁰. This finding is supported by the fact that the labrum is known to contain nerve endings³¹, making it a source of pain as well.

Etiology of Labral Tears

Historically, the reported leading cause of acetabular labral tears has been traumatic events of varying intensity^5,32,33, with the proportion caused by traumatic events ranging from 19% to 55%^4,7,34,35, with most tears being minor injuries from running, twisting, or slipping. More importantly, 48% to 95%^23,34-37 of labral tears are associated with substantial damage to the acetabular cartilage (Table I). These findings have important implications, not only in terms of the long-term survival of the native joint and the pathogenesis of arthritis, but also for our understanding of the mechanism by which acetabular cartilage damage and labral tears occur^38,39 and how they should be managed.

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TABLE I Etiology of Labral Tears

Author(s)	No. of Patients	No. (%) with Traumatic Event	No. (%) with Acetabular Cartilage Damage
Fitzgerald⁴	55	30 (55)
Lage et al.⁷	37	7 (19)
Santori and Villar³⁴	58	15 (26)
Farjo et al.³⁵	28	10 (36)
McCarthy et al.²³	436		273 (62.6)
Santori and Villar³⁴	58		28 (48)
Farjo et al.³⁵	28		14 (50)
Beaulé et al.³⁷	37		28 (76)
Beck et al.³⁶	19		18 (95)

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TABLE I Etiology of Labral Tears

Author(s)	No. of Patients	No. (%) with Traumatic Event	No. (%) with Acetabular Cartilage Damage
Fitzgerald⁴	55	30 (55)
Lage et al.⁷	37	7 (19)
Santori and Villar³⁴	58	15 (26)
Farjo et al.³⁵	28	10 (36)
McCarthy et al.²³	436		273 (62.6)
Santori and Villar³⁴	58		28 (48)
Farjo et al.³⁵	28		14 (50)
Beaulé et al.³⁷	37		28 (76)
Beck et al.³⁶	19		18 (95)

Lage et al.⁷ described four categories of labral tears based on etiology.

1. Traumatic, based on a clear history of hip injury and the subsequent onset of symptoms. More recently, a traction injury of the labrum by the iliopsoas tendon has been reported in some cases⁴⁰, with the intra-articular portion of the iliopsoas tendon noted to be attached to the labrum in those cases.

2. Congenital, based on the presence of acetabular dysplasia, defined as a center-edge angle of <25° and/or a Tönnis angle of >10°^41-43.

3. Degenerative, based on radiographic evidence of arthritic changes, such as joint space narrowing or osteophytes, or the identification of severe chondral damage at the time of operative intervention.

4. Idiopathic, based on the absence of any other findings.

However, three recent studies in which the presence of osseous abnormalities was retrospectively examined in patients with a labral tear demonstrated that the majority (49% of seventy-eight, 79% of ninety-nine, and 87% of thirty-one^17,44,45) had an osseous dysmorphism consistent with femoroacetabular impingement. It would thus be more appropriate to rename the so-called idiopathic group femoroacetabular impingement. Ganz et al. described two mechanisms of femoroacetabular impingement¹⁵: pincer type secondary to acetabular overcoverage and cam type secondary to a lack of femoral head-neck offset (Fig. 2). In pincer-type impingement, repeated contact between the femoral neck and the prominent anterior aspect of the acetabular rim leads to initial damage of the labrum^36,46 and often a contre-coup lesion leading to premature wear of the posterior articular surface. In cam-type impingement, abnormal jamming of the head-neck junction causes an outside-in intrasubstance avulsion of the labrum from the adjoining acetabular cartilage^15,36. Labral tears secondary to impingement can also be differentiated histologically¹⁹. Tears caused by the pincer-type mechanism extend perpendicular to the surface of the labrum and, in more severe cases, to the subchondral bone, in which case the labrum will become calcified and can be seen as a duplication of the tidemark. Endochondral ossification within the labrum is also typically seen. Tears caused by the cam-type mechanism occur at the transition zone between the fibrocartilaginous labrum and the articular hyaline cartilage and are perpendicular to the articular surface.

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Fig. 2: Biomechanics of hip impingement as seen on an axial view of the hip joint. The reduced clearance leads to repetitive abutment between the femur and the acetabular rim. A: A normal hip. B: Reduced femoral head-neck offset (cam-type impingement). C: Excessive overcoverage of the femoral head (pincer-type impingement). D: Combination of cam and pincer types of impingement. (Reproduced, with modification, from: Lavigne M, Parvizi J, Beck M, Siebenrock KA, Ganz R, Leunig M. Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery. Clin Orthop Relat Res. 2004;418:62. Reprinted with permission and copyright © of Lippincott Williams and Wilkins.)

Interestingly, the morphological appearance of the labrum can also differ between hips with dysplasia and those with femoroacetabular impingement^47,48. Both Klaue et al.⁴⁹ and Leunig et al.⁴⁷ demonstrated that, in patients with hip dysplasia, the labrum is distinctly hypertrophic with myxoid degeneration and/or detachment from the osseous rim whereas, in those with femoroacetabular impingement, the labrum is characterized by an undersurface tear with no hypertrophy⁴⁷. These findings can be helpful in establishing the dominating underlying osseous abnormality.

Diagnosis of Labral Tears

Clinical Evaluation

In the majority of patients, the chief symptom is anterior groin pain made worse by long periods of standing, sitting, or walking. The pain can also be referred to the gluteal area or the trochanteric region. The onset of pain is usually insidious⁴, with the patient often unable to recall a specific traumatic event⁹. In one study, only 9% (six) of sixty-six patients with a labral tear had a major traumatic episode as a causative factor¹⁸. The pain is often sharp in nature and aggravated by activity such as walking and pivoting on the affected side. The presence of mechanical symptoms such as clicking and catching is highly variable and not necessarily indicative of intra-articular hip pathology⁹. When obtaining a history, it is critical to inquire about childhood hip diseases such as dysplasia³, Legg-Calvé-Perthes disease¹, and slipped capital femoral epiphysis⁵⁰, which are known causes of labral tears as well as hip arthritis^51,52.

On physical examination, the most reliable sign of labral pathology is pain reproduced with flexion beyond 90° combined with internal rotation and adduction⁴. This is referred to as the impingement sign⁴⁹. Forced external rotation with hip extension can also irritate the torn labrum⁵³. It is not possible to consistently differentiate between anterior and posterior labral tears on the basis of a physical examination³⁴. Other less common findings are a mild limp and a positive Trendelenburg sign. Rarely, the patient requires assistive devices to walk. Although labral pathology is now recognized as a common cause of hip pain, it is important to include in the differential diagnosis other causes of hip pain such as osteonecrosis, stress fractures, and snapping psoas tendon. In cases of abnormal physical findings and normal or equivocal radiographic findings, an anesthetic block of the symptomatic hip may provide important diagnostic information in terms of delineating intra-articular from extra-articular hip pathology. Temporary pain relief represents a positive finding for intra-articular hip pathology⁵⁴.

Radiographic Evaluation

Because a large proportion of labral tears are associated with an osseous abnormality, the initial investigation must include plain radiographs with a minimum of two views: an anteroposterior pelvic radiograph and a lateral (cross-table or Dunn view) radiograph^42,55 (Table II). For both of these views, proper patient positioning is critical to correctly assess the osseous anatomy. For the anteroposterior radiograph, the x-ray beam should be centered over the midline of the body with collinear alignment of the symphysis and coccyx, and the distance between the symphysis and sacrococcygeal junction should be 32 mm for men and 47 mm for women to assess acetabular version correctly⁵⁶. The normal acetabulum should cover the femoral head, with the anterior and posterior walls meeting at its most lateral edge. In cases of acetabular retroversion, the anterior and posterior walls of the acetabulum are seen to cross over the femoral head (the so-called crossover or figure-of-eight sign^57,58) (Fig. 3). Other signs of acetabular retroversion are the posterior wall sign (the posterior wall medial to the center of the femoral head⁴⁶) and the ischial sign (the ischial tuberosity seen on the anteroposterior pelvic radiograph⁵⁹). Coxa profunda is diagnosed when the anteroposterior pelvic radiograph shows the medial wall of the acetabulum lying on, or medial to, the ilioischial line³⁶ (Fig. 4), with protrusio (the femoral head crossing the ilioischial line) representing the more severe form³⁶. In the assessment of cam-type impingement, an insufficient head-neck offset and/or femoral head asphericity are best evaluated on a lateral radiograph such as the cross-table radiograph with the lower limb in 10° to 15° of internal rotation^60,61 or a Dunn view (an anteroposterior radiograph of the hip in 90° of flexion, 25° of abduction, and no rotation) (Fig. 5).

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Fig. 3: Radiograph of a sixteen-year-old girl with symptomatic impingement in the right hip. Pincer-type deformity is indicated by the crossover sign.

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Fig. 4: Anteroposterior pelvic radiograph of a thirty-eight-year-old woman with persistent left hip pain, clearly showing coxa profunda with the acetabular floor medial to the ilioischial line.

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Fig. 5: Anteroposterior radiograph of a symptomatic left hip of a forty-two-year-old man, demonstrating a normal joint space and a relatively spherical femoral head. The inset shows an insufficient femoral head-neck offset consistent with cam-type femoroacetabular impingement.

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TABLE II Key Radiographic Features of Dysplasia and Femoroacetabular Impingement

		Femoroacetabular Impingement
	Dysplasia	Pincer Type	Cam Type
Anteroposterior pelvic radiograph	Center-edge angle <25°, Tönnis angle >10°	Crossover and/or posterior wall sign, ischial sign, coxa profunda	Pistol-grip deformity
Lateral radiograph	—	—	Alpha angle >50.5°, offset ratio <0.15
False-profile radiograph	Anterior center-edge angle <25°	Narrowing of posterior articular surface	—

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TABLE II Key Radiographic Features of Dysplasia and Femoroacetabular Impingement

		Femoroacetabular Impingement
	Dysplasia	Pincer Type	Cam Type
Anteroposterior pelvic radiograph	Center-edge angle <25°, Tönnis angle >10°	Crossover and/or posterior wall sign, ischial sign, coxa profunda	Pistol-grip deformity
Lateral radiograph	—	—	Alpha angle >50.5°, offset ratio <0.15
False-profile radiograph	Anterior center-edge angle <25°	Narrowing of posterior articular surface	—

Magnetic resonance imaging is the preferred modality for the investigation of intra-articular hip pathology, as it provides exquisite resolution of the labrum, cartilage, and joint space as well as depicting the regional soft tissues. In addition, magnetic resonance imaging permits multiplanar image acquisition such as radial imaging. Magnetic resonance arthrography is the combination of magnetic resonance imaging with intra-articular injection of gadolinium-based contrast agents and is the test of choice for evaluation of the acetabular labrum^12,13,62-64. The arthrogram component distends the joint, causing separation of the labrum from the capsule and osteochondral structures and thus increased spatial resolution. The injected contrast solution outlines both normal anatomical structures and abnormalities, further improving contrast resolution and increasing the conspicuity of the labral pathology^65,66. Labral tears are demonstrated by contrast solution extending into the substance of the labrum and are most commonly seen in the anterosuperior quadrant^62,63,67-69 (Fig. 6). With labral detachments, the contrast medium undermines the base of the labrum at the chondrolabral and acetabular-labral junctions. As compared with hip arthroscopy, which is the gold standard for diagnosing labral pathology, magnetic resonance arthrography has a sensitivity and accuracy ranging from 92% to 100% and 93% to 96%, respectively^63,64,68. Pitfalls that may lead to a false diagnosis of a labral tear include a sublabral sulcus, an anteroinferior cleft at the junction between the labrum and the transverse ligament, cartilage undercutting of the labrum, and increased signal intensity at the chondrolabral junction^64,67,70-72. Given its high sensitivity and accuracy, magnetic resonance arthrography is an effective preoperative tool for defining the location and extent of a labral tear¹². Perhaps more importantly, magnetic resonance imaging with radial reformatting can permit the proper identification of associated osseous abnormalities of the femoral head-neck junction, which can be critical to the ability to offer a patient proper counseling^17,42.

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Fig. 6: T1-weighted magnetic resonance imaging with gadolinium arthrography demonstrating contrast medium at the chondrolabral junction extending into the labrum and representing a labral tear (arrow).

In patients for whom magnetic resonance imaging is contraindicated (because of claustrophobia, metallic prostheses, electronic implanted devices, cardiac pacing wires, or orbital metal bodies), computed tomographic arthrography is an acceptable alternative with equally high sensitivity, specificity, and accuracy, although it results in gonadal radiation exposure^73,74.

Treatment of Labral Tears

Most published data on the treatment of labral tears have been derived from larger clinical series of patients treated with hip arthroscopy for a wide spectrum of intra-articular pathology^53,75,76. This may be partially due to the use of hip arthroscopy as an investigative tool for idiopathic hip pain⁷⁷. Recent publications^37,39,78,79 on labral pathology have focused on the treatment of osseous dysmorphisms such as femoroacetabular impingement, and they have also provided critical insight into the importance of preserving labral integrity⁷⁹. When Espinosa et al.⁷⁹ compared the clinical outcomes of open treatment of femoroacetabular impingement, they found that patients who had been managed with refixation of the labrum after trimming of the acetabular rim did significantly better than those who had undergone labral resection. In that study, labral refixation was performed through the same operative exposure as was used for resection of the acetabular rim, which was required in order to correct the acetabular overcoverage. Other methods for treatment of labral tears are partial débridement^37,80 and/or repair⁸¹. The most common technique used for labral repair is the simple stitch technique, in which the suture is passed between the labrum and the acetabular rim and the looped monofilament is sutured as a lasso on the extra-articular aspect of the labrum⁴⁰. This technique was derived from shoulder surgery to repair the avulsed glenoid labrum⁸². However, techniques of labral repair are still evolving in order to minimize interference with fluid lubrication as well as the blood supply to the labrum.

In a systematic review of outcomes following labral débridement with hip arthroscopy, Robertson et al.⁸³ reported that 67% of fifty-eight patients and 91% of twenty-two patients were satisfied with their outcome at 3.5 years, with 45% of the twenty-two patients having complete resolution of mechanical symptoms and up to 90% of the twenty-two patients reporting some reduction in the frequency of symptoms. Table III summarizes the outcomes of isolated treatment of labral tears with débridement and/or excision, which for the most part were performed with hip arthroscopy.

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TABLE III Outcomes of Isolated Treatment of Labral Tears

Author(s)	No. of Patients	No. (%) with Decrease in Symptoms	No. (%) with Total Hip Replacement
Fitzgerald⁴	56	49 (88)	0
McCarthy et al.⁵³	20	17 (85)	2 (10)
Farjo et al.³⁵	28	13 (46)	8 (29)
Byrd and Jones⁷⁵	38	24 (63)	0
O'Leary et al.⁷⁶	17	15 (88)	1 (6)
Santori and Villar³⁴	76	39 (51)	0
Siebenrock et al.⁴⁶*	29	26 (90)	0
Beck et al.³⁹*	19	13 (68)	5 (26)
Murphy et al.⁹⁸*	23	14 (61)	0
Espinosa et al.⁷⁹*	35	33 (94)
Peters and Erickson⁷⁸*	30	26 (87)	3 (10)
Beaulé et al.³⁷*	34	28 (82)	0
Ilizaliturri et al.⁹⁹*	19	16 (84)	1 (5)

The osseous dysmorphism and labral tear were corrected.

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TABLE III Outcomes of Isolated Treatment of Labral Tears

Author(s)	No. of Patients	No. (%) with Decrease in Symptoms	No. (%) with Total Hip Replacement
Fitzgerald⁴	56	49 (88)	0
McCarthy et al.⁵³	20	17 (85)	2 (10)
Farjo et al.³⁵	28	13 (46)	8 (29)
Byrd and Jones⁷⁵	38	24 (63)	0
O'Leary et al.⁷⁶	17	15 (88)	1 (6)
Santori and Villar³⁴	76	39 (51)	0
Siebenrock et al.⁴⁶*	29	26 (90)	0
Beck et al.³⁹*	19	13 (68)	5 (26)
Murphy et al.⁹⁸*	23	14 (61)	0
Espinosa et al.⁷⁹*	35	33 (94)
Peters and Erickson⁷⁸*	30	26 (87)	3 (10)
Beaulé et al.³⁷*	34	28 (82)	0
Ilizaliturri et al.⁹⁹*	19	16 (84)	1 (5)

The osseous dysmorphism and labral tear were corrected.

Currently, hip arthroscopy requires an orthopaedic traction table and can be performed with the patient in either the lateral or the supine position^40,84,85. Portal placement can vary depending on patient position, but in general two portals are required: one anterolateral and one anterior, with a posterolateral portal being optional. Special instrumentation sets for performing hip arthroscopy are now widely available with 70° and 30° angled cameras. The labral débridement can be performed with a variety of tools, similar to those used in shoulder arthroscopy, such as radiofrequency ablators, motorized shavers, and basic graspers. As stated above, it is not uncommon for a labral tear to be associated with damage to the acetabular cartilage in the form of either a cartilage flap or subchondral erosion^14,36. How one should manage the cartilage lesions is still being debated, and methods can range from débridement and microfracture to labral refixation with resection of the cartilage flap to a stable edge after trimming of the acetabular rim^37,78,79.

Another consideration with regard to the technique of labral refixation is that it permits correction of overcoverage by the acetabular anterior wall (i.e., acetabular retroversion)⁷⁹. When correction of acetabular retroversion is being considered, the absence of a posterior wall sign (i.e., full coverage of the femoral head posteriorly) would currently favor trimming of the acetabular rim as the treatment of choice since a reverse periacetabular osteotomy could predispose to impingement posteriorly⁴⁶. If a posterior wall sign is present, it is unclear whether trimming of the acetabular rim or a reverse periacetabular osteotomy is preferable to correct the retroversion. It is important to differentiate the indications for, and rationale of labral refixation for, the treatment of acetabular retroversion⁷⁹, as discussed above, as opposed to isolated labral tears⁴⁰. If the labrum is detached from its extra-articular osseous insertion, refixation with use of suture anchors can be done with a high potential for healing since the labrum is very well vascularized in its outer third²⁴. However, the majority of labral tears occur on the articular side adjacent to the chondrolabral junction with the presence of fibrillation and/or radial tearing. As stated above, this area is avascular and, more importantly, a cleft is normally present at the chondrolabral junction in the anterosuperior area. Thus, in the presence of labral damage on the articular side, the indications for labral repair and/or refixation are not clear since the labrum is still attached to the acetabular rim. Alternatively, localized débridement of the torn intra-articular portion of the labrum addresses the main pathology and has also been shown to provide good-to-excellent outcomes in several clinical series, both when used as isolated labral treatment^53,75 and when performed in conjunction with the treatment of femoroacetabular impingement^37,78. For example, in one study of thirty-eight patients treated with isolated labral débridement with hip arthroscopy, sixteen had an excellent Harris hip score (range, 90 to 100 points)⁷⁵. Similarly, using validated functional outcome measures including general health-related quality-of-life questionnaires, in a series of patients with femoroacetabular impingement, one of us (P.E.B.) and colleagues reported significant improvements on the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), UCLA (University of California at Los Angeles) activity scale, and both the physical and the mental health component of the Short Form-12 (SF-12)³⁷ (Table III). At this point in time, there is no clear evidence as to whether labral repair/refixation or limited labral débridement is the preferred approach in the treatment of isolated labral tears since long-term follow-up data still are not available.

In addition to the heterogeneity in the treatment methods, the authors of most clinical studies have also used nonvalidated outcome measurement tools and/or ones commonly used to study the outcome of total hip replacements, making it difficult to draw broad conclusions regarding the treatment methods^86,87. Nonetheless, there is a sufficient body of evidence to recommend the treatment of isolated labral tears with hip arthroscopy (Figs. 7-A and 7-B). However, because the majority of labral tears are associated with osseous abnormalities such as dysplasia and femoroacetabular impingement, it is critical to carefully rule out these osseous dysmorphisms to ensure an optimal outcome⁸⁸. There have been reports of reoperations after failed arthroscopic labral débridement that, by correcting the underlying osseous abnormality, led to significant improvements in hip function^89,90. In their case series, May et al.⁸⁹ reported on five patients presenting with persistent hip pain after having undergone treatment with hip arthroscopy. All five patients had an osseous abnormality consistent with femoroacetabular impingement, and the correction of that abnormality led to significant improvement in function as well as pain relief. Similarly, Peters and Erickson⁹⁰ reported an improved outcome after correction of the underlying structural abnormality in eleven hips that had been referred because of persistent symptoms after isolated arthroscopic treatment of the labrum. Finally, because these osseous dysmorphisms are known causes of degenerative hip arthritis^48,91, it is not uncommon for patients to present with some degree of arthritic changes on radiographs. Currently, there are no clear guidelines regarding what degree of arthritis is a contraindication to hip arthroscopy, although patients presenting with >2 mm of joint space narrowing are certainly not appropriate candidates⁹².

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Fig. 7-A Fig. 7-B: Fig. 7-A Isolated labral tear at the chondral junction anteromedially. Fig. 7-B Appearance of the labrum after limited arthroscopic labral débridement.

Currently there is no definitive evidence that the clinical outcome achieved with combined treatment of the osseous abnormality^93,94 and the labral tear will be more favorable than that provided by isolated treatment of the labral tear⁹⁵. Other factors such as patient age, the severity of the osseous deformity, and damage to the articular cartilage may be more important than the simple presence of an osseous abnormality; however, it is still unclear how all of these factors interact or affect the natural history of the native hip joint^93,96. Better methods for cartilage imaging⁹⁷ and a better understanding of human hip kinematics are needed to determine how the treatment of labral pathology may affect the longevity of the native hip joint^23,26,27. Image Not Available

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Topics

neck ; congenital abnormality ; arthrogram ; acetabulum ; cartilage ; articular cartilage ; femur ; head of femur ; hip region ; hip joint

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Paul E. Beaulé, Michelle O'Neill, Kawan Rakhra; Acetabular Labral Tears. The Journal of Bone & Joint Surgery. 2009 Mar;91(3):701-710.

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