The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 93, Issue Supplement 2

Scientific Articles | May 04, 2011

The Labro-Acetabular Complex

Richard E. Field, PhD, FRCS, FRCS(Orth)¹; Karthig Rajakulendran, MSc, MRCS¹

¹ The South West London Elective Orthopaedic Centre, Dorking Road, Epsom, Surrey KT18 7EG, England. E-mail address for R.E. Field: richardefield@aol.com. E-mail address for K. Rajakulendran: karthig.rajakulendran@esth.nhs.uk

View Disclosures and Other Information

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Stryker).

Investigation performed at The South West London Elective Orthopaedic Centre, Epsom, and St. Anthony's Hospital, North Cheam, Surrey, England

J Bone Joint Surg Am, 2011 May 04;93(Supplement 2):22-27. doi: 10.2106/JBJS.J.01710

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Abstract

The human hip is subjected to several hundred million loading cycles during a lifetime. Hip instability and femoro-acetabular impingement cause damage to the rim of the acetabulum. The acetabular rim is a highly specialized structure known as the labro-acetabular complex. A unidirectional flow of synovial fluid has been identified in this region. The synovial fluid circulation is driven by the bellows-like movement of the zona orbicularis and depends on hip flexion and extension. Surgical repair of the damaged labro-acetabular complex should satisfy two goals. First, the labrum should be preserved or reconstructed when possible. Second, the precipitating cause of the labro-acetabular damage must be addressed.

Figures in this Article

Introduction

The structure of the human hip joint reflects an uneasy balance between the requirements for movement and stability. The forces on the hip depend on the size, shape, and orientation of the joint; the balance and strength of the surrounding soft-tissue envelope; the body morphology; and the activities that an individual undertakes. The interplay of these variables makes every hip a unique structural and stress environment.

The periphery of the acetabular socket is known as the labro-acetabular complex. Structural incongruity or instability between the femoral head and the acetabulum, whether gross or subtle, causes perturbation of the labro-acetabular tissues, eventually leading to pathologic changes. The labro-acetabular complex may be likened to an automobile tire, which, when unbalanced, always develops rim wear.

Embryology

Osseous Element

The hip joint is first discernable during the sixth week of embryonic development as a cleft that forms between the cartilage models of the femur and acetabulum¹. During subsequent fetal development, the acetabular socket becomes progressively shallower. After birth, the acetabulum deepens again, and it attains its definitive depth-to-width ratio at around the end of the first decade of life². The acetabulum is formed by the union of the pubis, ilium, and ischium, each of which has both primary and secondary ossification centers³.

The pubic secondary ossification center, or epiphysis, develops into the anterior acetabular wall, while the iliac epiphysis forms a substantial portion of the superolateral joint surface. The ischial epiphysis is the smallest of the three. All appear during the latter part of the first decade of life and fuse by the age of seventeen to eighteen years⁴. To date, there has been a paucity of studies on the development and fusion of the secondary ossification centers and their influence on the shape and function of the labro-acetabular complex.

Labro-Chondral Element

Studies on the embryonic and postnatal development of the acetabulum have tended to focus on the normal growth of the hip joint and disturbance of this process in the development of acetabular dysplasia^1-6. In one study⁶, it was observed that anterosuperior microscopic clefts at the labro-chondral junction were present in 14% of specimens. This finding was further investigated by Cashin et al.⁷, who demonstrated that the collagen fibers of the anterior aspect of the labrum are arranged parallel to the labro-chondral junction. In contrast, a more gradual transition was observed posteriorly, where the labral collagen fibers are aligned perpendicular to the junction, with convergence of the fibers from the articular cartilage into the labrum. Several authors have suggested that this difference makes the anterior labro-acetabular junction weaker and more vulnerable to degenerative and traumatic damage during adult life^7-9.

Anatomy

Macroscopic

The opening of the acetabulum is directed obliquely forward, laterally, and downward. The geometry of the natural acetabulum is influenced by the subject's sex¹⁰. The acetabular rim is not circular but has a complex shape with both elevated and recessed regions¹¹. This margin is most prominent posteriorly and superiorly, where it forms reinforcing osseous buttresses. Computed tomography (CT) analysis of the morphology of the osseous acetabular rim and acetabular socket has demonstrated that hips with cam impingement are shallower than normal hips, which are shallower than hips with pincer impingement¹². The rim plane of all variants have similar version, but females have 4° more anteversion than males.

The acetabulum provides an inverted concave horseshoe-shaped surface for articulation with the femoral head. The inferior aspect is the deficient acetabular notch, with posterior attachment of the ligamentum teres. Directly above the notch, the acetabular floor is depressed below the level of the surrounding articular surface; this area is known as the acetabular fossa, or cotyloid fossa. The acetabular fossa contains fibrofatty tissue, known as the Haversian fat pad, which is covered with a synovial membrane.

The acetabular articular cartilage is generally thickest superolaterally, averaging 1.83 mm compared with an average thickness of 1.26 mm in other acetabular areas¹³. The acetabular margin is deepened by the fibrocartilaginous labrum, consisting of collagen fiber bundles that are oriented predominantly in a circumferential direction¹⁴. The labrum continues across the acetabular notch, where it blends into the transverse ligament and forms a complete circle enclosing the femoral head around its equator¹⁴. Tan et al. showed that the labrum increases the surface area of the acetabulum by approximately 27% and the volume, by 30%¹⁵.

The strong, fibrous capsule of the hip joint is attached circumferentially to the osseous rim of the acetabulum, outside the attachment of the labrum. A circumferential recess of between 6.6 mm (anteroinferior) and 7.9 mm (posteroinferior) is formed between the outer surface of the labrum and the inner surface of the capsule⁸. The labrum is widest in its anterior half and thickest in its superior half⁸.

Microscopic

Histological Structure of the Labro-Acetabular Complex

The mature labro-acetabular complex is a junctional interface consisting of seven distinct tissue elements: articular cartilage, labrum, bone, blood vessels, nerve fibers, synovium, and capsule (Fig. 1). The histological configuration of the seven elements has been elucidated in cadaveric studies and described by Seldes et al.⁸. On the articular surface, the hyaline cartilage does not extend to the most peripheral rim of the underlying acetabular bone. Instead, the tip of the osseous rim is covered by labral tissue. The 1 to 2-mm transition zone between the hyaline articular cartilage and the labrum was studied by Cashin et al.⁷ and identified as having different fiber alignment anteriorly and posteriorly. Like the adjacent hyaline cartilage, the acetabular surface of the labrum is attached to the underlying bone by a layer of calcified cartilage. In contrast, the attachment of the labrum to the nonarticular surface of the acetabular rim is directly into bone and it is in this zone that nerves and blood vessels traverse the circumference of the acetabular rim¹⁶. The synovium-covered capsule attaches to the external surface of the osseous acetabulum and forms the circumferential recess adjacent to the external aspect of the labrum.

Fig. 1

Diagrammatic representation of the labro-acetabular complex.

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Diagrammatic representation of the labro-acetabular complex.

Physiology

Load Transfer

The pelvic bone supports the weight of the body and transfers load to the lower extremities through the femoral heads. Two distinct contact areas are present on the anterior and posterior aspects of the acetabulum at low loads; these gradually merge with increasing load until the zenith (dome) of the acetabulum makes contact. The load required for this transition occurs at 50% body weight in young adults and at 25% body weight in elderly adults¹⁷.

Intra-articular contact pressures are lower than 12 MPa during normal joint loading^18-21. Maximum intra-articular hip pressures of up to 10.4 MPa at 4.1 times body weight have been found in cadaver studies²². The main region of load transfer is located in the anterosuperior portion of the joint.

The acetabulum deforms under load, and the amount of load affects the extent to which the acetabulum opens or closes. At low loads, the anterior and posterior horns separate, until a transition occurs at 36% to 38% of body weight. The anterior horn is more rigid than the posterior horn. During this transition, the posterior horn deflects forty times more than the anterior horn. The acetabulum closes with increased load, with three times more deflection in the posterior horn. The phenomenon of acetabular opening and closing permits the unstressed or minimally stressed acetabulum to release its grip on the femoral head, while the more highly stressed acetabulum tightens around the femoral head. This process also causes contact pressures to increase in the periphery of the joint²³.

Biomechanical Function

Two biomechanical roles have been attributed to the acetabular labrum. The first is to provide a seal that resists distraction of the femoral head and enhances joint stability^24,25. The second is to block extrusion of synovial fluid from the central compartment as the joint is loaded. Compromised labral integrity has been shown to decrease the fluid content of the articular cartilage with secondary compromise of articular cartilage nutrition and lubrication^14,26, which may lead to articular cartilage degeneration²⁶.

Synovial Fluid Circulation

Synovial fluid synthesis and metabolic exchange are performed by the synovium. In the hip joint, this tissue is predominantly in the peripheral compartment, with only a small proportion covering the Haversian fat pad and ligamentum teres. The hyaline articular cartilage covering both the femoral head and the lunate surface of the acetabulum requires synovial fluid to maintain fluid film lubrication and cartilage nutrition. Movement of synovial fluid from the peripheral to the central compartment necessitates an ascent of the pressure gradient between these compartments¹⁴. Magnetic resonance (MR) arthrograms of the hip demonstrate that the peripheral compartment comprises proximal and distal zones that are separated by the zona orbicularis (Fig. 2). Arthroscopic examination of the proximal zone of the peripheral compartment reveals that, as the hip flexes, the volume of the inferomedial space, proximal to the zona orbicularis, decreases and the transverse ligament separates from the femoral head (Fig. 3). Dynamic radiographic imaging of radiopaque contrast medium introduced into this zone shows flow of the contrast medium from the peripheral compartment into the cotyloid fossa as the hip flexes. As the hip is then extended, the contrast medium passes across the articular surface and pools adjacent to the labrum and in the labro-chondral sulcus. These observations suggest a unidirectional flow of synovial fluid from the inferomedial portion of the peripheral compartment to the cotyloid recess and a peripherally directed flow across the lunate articular cartilage with the labrum serving to delay fluid return to the peripheral compartment. The mechanism is driven by a dynamic bellows-like movement of the zona orbicularis.

Fig. 2

MR arthrogram. Coronal view of the hip joint showing fluid compartments.

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MR arthrogram. Coronal view of the hip joint showing fluid compartments.

Fig. 3

Arthroscopic view showing separation of the transverse ligament from the femoral head-neck junction on hip flexion.

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Arthroscopic view showing separation of the transverse ligament from the femoral head-neck junction on hip flexion.

Aging

Labral damage is a common finding in the aging adult hip^8,27. In a postmortem study, Byers et al.²⁷ found that the prevalence of pathology at the labro-chondral junction increased with advancing age. Cadaveric studies have demonstrated a 93% to 96% prevalence of labral tears^8,16. Seldes et al.⁸ found that the majority of tears (74%) were located in the anterosuperior acetabular quadrant and followed two distinct patterns. The predominant lesion was a separation of the labrum from the articular cartilage at the transition zone. The second lesion consisted of one or more cleavage planes within the substance of the labrum. Progressive lesions were associated with detachment of the labrum and adjacent articular cartilage, with tidemark reduplication and cystic destruction of subchondral bone. Other histological changes observed included chondrocyte proliferation, hyalinization of the labral fibrocartilage, myxoid changes and cystic degeneration within the labrum, and evidence of neovascularization⁸.

McCarthy et al.¹⁶ found that the cadavers that they studied had, on average, 2.1 labral lesions, with most located in the anterior and anterosuperior regions of the acetabulum. The two most commonly observed pathologic changes were a labral tear with separation from the articular surface, termed the "watershed lesion," and fraying at the labro-cartilage junction. Other abnormalities included an indentation at the labro-articular cartilage junction, fraying of the free end of the labrum, and a degenerative labrum composed of scar-like tissue¹⁶.

Damage Patterns and Mechanisms

Premature damage to the labro-acetabular complex can arise from trauma²⁸, developmental dysplasia of the hip²⁹, femoro-acetabular impingement³⁰, and repetitive twisting and pivoting maneuvers³¹. Some authors have suggested that functional alterations arising from capsular laxity, psoas impingement, and coxa saltans interna may be responsible for labral damage in some cases^9,32. Damage to the labro-acetabular complex starts with simple fibrillation of the labro-chondral junction and progresses to full-thickness labral tears with separation from the osseous acetabular rim, delamination of the adjacent hyaline articular cartilage, and subchondral cyst formation.

Instability

In developmental dysplasia of the hip, the abnormal osseous architecture of the hip leads to aberrant contact forces. The high shear stresses acting on the labro-chondral complex can induce labral hypertrophy, myxoid degeneration, and tearing³³. Klaue et al. proposed that the labral and capsular hypertrophy seen in dysplastic hips is a physiological response to the chronic shear force, as the joint attempts to compensate for its incongruency³³. The tears are most commonly found in the anterior aspect of the labrum, but they can be posterior or diffuse³⁴.

The labrum is vulnerable to damage from stretching during repetitive movements and trauma. Individuals, such as athletes, dancers, and martial artists, who subject their hips to repetitive rotational movements and axial hip-loading may attenuate the iliofemoral ligament and develop secondary joint instability^35,36. Several authors have suggested that laxity of the anterior aspect of the hip capsule allows increased anterior translation of the femoral head within the acetabulum^36,37. It has been hypothesized that instability is likely to result in progressive trauma to the acetabular rim, leading to labral and chondro-labral damage^38,39. Connective-tissue disorders may cause similar instability secondary to generalized ligamentous laxity.

Impingement

Recently, femoro-acetabular impingement has been acknowledged as a major cause of labral damage. The pattern of labral and cartilage damage is influenced by the underlying anatomical deformity and mechanism of impingement^40,41. In cam-type deformity, impingement occurs when the femoral head abuts against the anterosuperior aspect of the acetabular rim during internal rotation with flexion. This impact creates a compressive and shearing force at the labro-chondral junction and the subchondral tidemark³⁰. An outside-in pattern of injury is seen, as the labrum becomes stretched and pushed outward. With pincer-type impingement, excessive acetabular coverage causes linear contact and circumferential compression of the superolateral aspect of the labrum. Repeated microtrauma can result in ossification of the labrum, which deepens the socket and compounds the impingement. The labrum develops intrasubstance fissuring and cyst formation.

Surgical Treatments

Labral Debridement

Labral resection was initially performed through an open arthrotomy to alleviate the mechanical symptoms caused by labral tears⁴². This procedure evolved from a complete to a partial resection as an understanding of the functional importance of the labrum grew. Currently, arthroscopic labral debridement is undertaken in cases of irreparable tears. The outcomes of both techniques are variable, with short-term results suggesting an improvement in 67% to 93% of patients^43-45. However, there is no evidence that the labro-acetabular complex can regenerate, and if the labrum stabilizes the femoral head within the acetabular socket¹⁵ and maintains a pressure differential between the central and peripheral compartments¹⁴ it would be logical to infer that joint degeneration may be accelerated by labral resection.

Labral Repair

Labral preservation is desirable, and repair is undertaken with increasing frequency. Practitioners have described a variety of repair techniques in which bone sutures or screws are used to anchor a torn segment of the labrum to the acetabular rim. In a retrospective analysis of femoro-acetabular impingement-associated labral tears, Espinosa et al.⁴⁶ found that patients who had undergone labral repair demonstrated a better early recovery than did those treated with labral resection. However, there is a paucity of data in the literature to verify these results and confirm the outcomes of labral repair. It is clear that any intervention must be combined with surgery aimed at correcting the underlying reason for the labral pathology.

Labral Reconstruction

Recent publications have described techniques to reconstruct deficient or degenerate labra with use of autologous grafts. Sierra and Trousdale⁴⁷ used the ligamentum teres, while Philippon et al.⁴⁸ used an iliotibial band autograft. Both reported encouraging early results. The biomechanical advantage of reconstructing the labrum is gaining credence. However, this technique is still under evaluation and medium to long-term clinical results are required to validate the strategies being developed.

Conclusion

The human hip is subjected to several hundred million loading and movement cycles during a normal lifetime. The labro-acetabular complex provides a complex and highly differentiated structure to interface with the rotating femoral head. It has been suggested that this complex has an intrinsic mechanical weakness at the junction of the labrum and adjacent articular cartilage in the anterior segment. This zone is vulnerable to damage by femoro-acetabular instability or impingement. Synovial fluid maintains lubrication of the deformable articular surfaces and nourishment of the hyaline cartilage. A unidirectional dynamic circulation of synovial fluid has been proposed. Surgical repair or reconstruction must restore the anatomical integrity of the labro-acetabular complex and eliminate the cause of its injury. Preservation of normal synovial fluid circulation may depend on preservation of the zona orbicularis.

References

Watanabe RS. Embryology of the human hip. Clin Orthop Relat Res. 1974;98:8-26.[CrossRef][PubMed]

Rális Z; McKibbin B. Changes in shape of the human hip joint during its development and their relation to its stability. J Bone Joint Surg Br. 1973;55:780-5.[PubMed]

Ponseti IV. Growth and development of the acetabulum in the normal child. Anatomical, histological, and roentgenographic studies. J Bone Joint Surg Am. 1978;60:575-85.[PubMed]

Lee MC; Eberson CP. Growth and development of the child's hip. Orthop Clin North Am. 2006;37:119-32, v.[CrossRef][PubMed]

Harrison TJ. The influence of the femoral head on pelvic growth and acetabular form in the rat. J Anat. 1961;95:12-24.[PubMed]

Walker JM. Histological study of the fetal development of the human acetabulum and labrum: significance in congenital hip disease. Yale J Biol Med. 1981;54:255-263.[PubMed]

Cashin M; Uhthoff H; O'Neill M; Beaulé PE. Embryology of the acetabular labral-chondral complex. J Bone Joint Surg Br. 2008;90:1019-24.[CrossRef][PubMed]

Seldes RM; Tan V; Hunt J; Katz M; Winiarsky R; Fitzgerald RH. Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop Relat Res. 2001;382:232-40.[CrossRef][PubMed]

Safran MR. The acetabular labrum: anatomic and functional characteristics and rationale for surgical intervention. J Am Acad Orthop Surg. 2010;18:338-45.[PubMed]

Murtha PE; Hafez MA; Jaramaz B; DiGioia AM 3rd. Variations in acetabular anatomy with reference to total hip replacement. J Bone Joint Surg Br. 2008;90:308-13.[CrossRef][PubMed]

Vandenbussche E; Saffarini M; Delogé N; Moctezuma JL; Nogler M. Hemispheric cups do not reproduce acetabular rim morphology. Acta Orthop. 2007;78:327-32.[CrossRef][PubMed]

Cobb J; Logishetty K; Davda K; Iranpour F. Cams and pincer impingement are distinct, not mixed: the acetabular pathomorphology of femoroacetabular impingement. Clin Orthop Relat Res. 2010;468:2143-51.[CrossRef][PubMed]

Athanasiou KA; Agarwal A; Dzida FJ. Comparative study of the intrinsic mechanical properties of the human acetabular and femoral head cartilage. J Orthop Res. 1994;12:340-9.[CrossRef][PubMed]

Ferguson SJ; Bryant JT; Ganz R; Ito K. The acetabular labrum seal: a poroelastic finite element model. Clin Biomech (Bristol, Avon). 2000;15:463-8.[CrossRef][PubMed]

Tan V; Seldes RM; Katz MA; Freedhand AM; Klimkiewicz JJ; Fitzgerald RH Jr. Contribution of acetabular labrum to articulating surface area and femoral head coverage in adult hip joints: an anatomic study in cadavera. Am J Orthop (Belle Mead NJ). 2001;30:809-12.[PubMed]

McCarthy J; Noble P; Aluisio FV; Schuck M; Wright J; Lee JA. Anatomy, pathologic features, and treatment of acetabular labral tears. Clin Orthop Relat Res. 2003;406:38-47.[CrossRef][PubMed]

Greenwald AS; O'Connor JJ. The transmission of load through the human hip joint. J Biomech. 1971;4:507-28.[CrossRef][PubMed]

Bullough P; Goodfellow J; O'Conner J. The relationship between degenerative changes and load-bearing in the human hip. J Bone Joint Surg Br. 1973;55:746-58.[PubMed]

von Eisenhart R; Adam C; Steinlechner M; Müller-Gerbl M; Eckstein F. Quantitative determination of joint incongruity and pressure distribution during simulated gait and cartilage thickness in the human hip joint. J Orthop Res. 1999;17:532-9.[CrossRef][PubMed]

von Eisenhart-Rothe R; Eckstein F; Müller-Gerbl M; Landgraf J; Rock C; Putz R. Direct comparison of contact areas, contact stress and subchondral mineralization in human hip joint specimens. Anat Embryol (Berl). 1997;195:279-88.[CrossRef][PubMed]

Brown TD; Shaw DT. In vitro contact stress distributions in the natural human hip. J Biomech. 1983;16:373-84.[CrossRef][PubMed]

Afoke NY; Byers PD; Hutton WC. Contact pressures in the human hip joint. J Bone Joint Surg Br. 1987;69:536-41.[PubMed]

Lazennec JY; Laudet CG; Guérin-Surville H; Roy-Camille R; Saillant G. Dynamic anatomy of the acetabulum: an experimental approach and surgical implications. Surg Radiol Anat. 1997;19:23-30.[CrossRef][PubMed]

Takechi H; Nagashima H; Ito S. Intra-articular pressure of the hip joint outside and inside the limbus. Nippon Seikeigeka Gakkai Zasshi. 1982;56:529-36.[PubMed]

Terayama K; Takei T; Nakada K. Joint space of the human knee and hip joint under a static load. Eng Med. 1980;9:67-74.[CrossRef]

Song Y; Safran M; Ito H; Carter D; Giori N. Articular cartilage friction increases in hip joints after partial and total removal of the acetabular labrum. Presented at the 55th Annual Meeting of the Orthopaedic Research Society; 2009 Feb 22-25; Las Vegas, NV. Poster no. 1153.

Byers PD; Contepomi CA; Farkas TA. A post mortem study of the hip joint. Including the prevalence of the features of the right side. Ann Rheum Dis. 1970;29:15-31.[CrossRef][PubMed]

Kelly BT; Weiland DE; Schenker ML; Philippon MJ. Arthroscopic labral repair in the hip: surgical technique and review of the literature. Arthroscopy. 2005;21:1496-504.[CrossRef][PubMed]

Parvizi J; Bican O; Bender B; Mortazavi SM; Purtill JJ; Erickson J; Peters C. Arthroscopy for labral tears in patients with developmental dysplasia of the hip: a cautionary note. J Arthroplasty. 2009;24( 6 Suppl):110-3.[CrossRef][PubMed]

Beck M; Kalhor M; Leunig M; Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87:1012-8.[CrossRef][PubMed]

Crawford MJ; Dy CJ; Alexander JW; Thompson M; Schroder SJ; Vega CE; Patel RV; Miller AR; McCarthy JC; Lowe WR; Noble PC. The biomechanics of the hip labrum and the stability of the hip. Clin Orthop Relat Res. 2007;465:16-22.[PubMed]

Philippon MJ; Schroder e Souza BG; Briggs KK. Labrum: resection, repair and reconstruction sports medicine and arthroscopy review. Sports Med Arthrosc. 2010;18:76-82.[CrossRef][PubMed]

Klaue K; Durnin CW; Ganz R. The acetabular rim syndrome. A clinical presentation of dysplasia of the hip. J Bone Joint Surg Br. 1991;73:423-9.[PubMed]

Groh MM; Herrera J. A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2:105-17.[CrossRef][PubMed]

Philippon MJ; Schenker ML. Athletic hip injuries and capsular laxity. Oper Tech Orthop. 2005;15:261-6.[CrossRef]

Philippon MJ. The role of arthroscopic thermal capsulorrhaphy in the hip. Clin Sports Med. 2001;20:817-29.[CrossRef][PubMed]

Blakey CM; Field MH; Singh PJ; Tayar R; Field RE. Secondary capsular laxity of the hip. Hip Int. 2010;20:497-504.[PubMed]

Dy CJ; Thompson MT; Crawford MJ; Alexander JW; McCarthy JC; Noble PC. Tensile strain in the anterior part of the acetabular labrum during provocative maneuvering of the normal hip. J Bone Joint Surg Am. 2008;90:1464-72.[CrossRef][PubMed]

Philippon MJ. New frontiers in hip arthroscopy: the role of arthroscopic hip labral repair and capsulorrhaphy in the treatment of hip disorders. Instr Course Lect. 2006;55:309-16.[PubMed]

Leunig M; Beaulé PE; Ganz R. The concept of femoroacetabular impingement: current status and future perspectives. Clin Orthop Relat Res. 2009;467:616-22.[CrossRef][PubMed]

Ganz R; Leunig M; Leunig-Ganz K; Harris WH. The etiology of osteoarthritis of the hip: an integrated mechanical concept. Clin Orthop Relat Res. 2008;466:264-72.[CrossRef][PubMed]

Fitzgerald RH Jr. Acetabular labrum tears. Diagnosis and treatment. Clin Orthop Relat Res. 1995;311:60-8.[PubMed]

Beck M; Leunig M; Parvizi J; Boutier V; Wyss D; Ganz R. Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;418:67-73.[CrossRef][PubMed]

Santori N; Villar RN. Acetabular labral tears: result of arthroscopic partial limbectomy. Arthroscopy. 2000;16:11-5.[CrossRef][PubMed]

Byrd JW; Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000;16:578-87.[CrossRef][PubMed]

Espinosa N; Rothenfluh DA; Beck M; Ganz R; Leunig M. Treatment of femoro-acetabular impingement: preliminary results of labral refixation. J Bone Joint Surg Am. 2006;88:925-35.[CrossRef][PubMed]

Sierra RJ; Trousdale RT. Labral reconstruction using the ligamentum teres capitis: report of a new technique. Clin Orthop Relat Res. 2009;467:753-9.[CrossRef][PubMed]

Philippon MJ; Briggs KK; Hay CJ; Kuppersmith DA; Dewing CB; Huang MJ. Arthroscopic labral reconstruction in the hip using iliotibial band autograft: technique and early outcomes. Arthroscopy. 2010;26:750-6.[CrossRef] [PubMed]

Topics

aging ; arthrogram ; debridement ; herpes zoster disease ; acetabulum ; cartilage ; articular cartilage ; femur ; head of femur ; hip region

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Richard E. Field, Karthig Rajakulendran; The Labro-Acetabular Complex. The Journal of Bone & Joint Surgery. 2011 May;93(Supplement_2):22-27.

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