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Acetabular Labrum Tear

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Other Names

  • Hip labral tear
  • Acetabular Labral Tear

Background

History

  • First reported by Peterson in 1957 in association with irreducible posterior hip dislocation[1]
  • Altenberg reported the first atraumatic labral tear in 1977[2]
  • Arthroscopic description first published by Suzuki in 1986[3]

Epidemiology

  • Prevalence
    • In patients with hip or groin pain, reported between 22-55%[4]
    • In cadaveric studies, labral tears found in 93-96% of hips[5]
  • Time to diagnosis
    • there is on average greater than 2 years before diagnosis is achieved (need citation)

Pathophysiology

  • Description
    • The term labral tear implies a labrum split into at least two parts
    • However most tears involve detachment of the labrum from the hyaline cartilage or bony acetabulum
  • McCarthy et al: [6]
    • 73% of labral tears have associated chondral damage, and chondral damage is more severe in patients with labral lesions
    • 94% of patients articular damage occurs in the same zone as labral lesions
    • Isolated labral tear found more often in younger patients
    • Older patients: labral tear in conjunction with chondral lesions
  • Location
    • Most commonly occurs along the anterosuperior labrum

Etiology

  • Trauma
    • Uncommon as an isolated injury, often associated with Hip Dislocation or subluxation
    • Associated with injuries to the articular cartilage
    • Occasionally, acetabular tear can cause irreducible dislocation or recurrent dislocation[7]
    • Approximately 25% of labral tears are not associated with any specific injury or traumatic event with the underlying etiology thought to be repetitive microtrauma.
  • Femoroacetabular Impingement (FAI)
    • Abnormal abutment of femoral head or acetabulum due to morphological changes
    • Cam-type: damage to anterosuperior acetabular cartilage, separation between labrum and cartilage
    • Pincer-type: either localized or circumferential and peripheral
  • Hypermobility (capsular laxity)
    • Underlying collage dysfunction, hormonal influences predispose patients to labral injury
    • Associated with repetitive rotational sporting activities, leading to rotational instability of hip
    • Weakenig of the iliofemoral ligament can occur in sports such as golf, soccer and hockey
  • Acetabular Dysplasia
    • Abnormal relationship between acetabulum and femoral head, leading to joint incongruity and increased stress on the labrum
    • Most commonly, anterior labrum infringing upon anterior acetabulum leads to hypertrophy, tearing of labrum
    • McCarthy et al: 72% (of 170) hips had labral tears, 93% were anterior[8]
  • Degenerative
    • Often considered part of the natural history of aging joints

Pathoanatomy

  • Hip Joint
  • Acetabular Labrum
    • Fibrocartilagenous structure which outlines the acetebular rim
    • Covers 170° of femoral head
    • Functions: shock absorption, joint lubrication, pressure distribution, stability

Associated Conditions


Risk Factors

  • Sports
    • Golf
    • Soccer
    • Ballet
    • Running
  • Other
    • Female gender

Differential Diagnosis


Clinical Features

  • History
    • Patient may endorse having seen multiple providers
    • Onset is typically insidious
    • Patients usually report anterior hip or groin pain, less commonly buttock pain
    • Burnett et al using arthroscopy as the diagnostic standard, looked at pre-surgical pain patterns and found the following: groin pain (92%), anterior thigh pain (52%), lateral hip pain (59%), buttock pain (38%)[9]
    • They may report clicking, locking, giving way, snapping sensation
    • Pain is often described as constant dull pain with intermittent episodes of sharp pain that worsens with activity
    • Activities that make it worse walking, pivoting, prolonged sitting, and impact activities, such as running
    • 71% of patients endorse night pain[10]
  • Physical Exam: Physical Exam Hip
    • Range of motion limitations are reported in the literature, especially with internal/external rotation
  • Special Tests

Evaluation

AP view of right hip demonstrates subtle calcification of superolateral acetabulum suspicious for labral pathology

Radiographs

  • Standard Radiographs Hip
    • Useful initial imaging as many of the causes of labral tears have radiographic findings
  • Potential Findings
    • Degenerative changes
    • Evidence of dysplasia
    • Evidence previous surgery
    • Coxa Valga (angle between the femoral shaft and neck of >135°)
    • Aacetabular retroversion (the acetabulum faces posterolaterally)
  • Peele et al: 49% of patients with symptomatic labral tears have radiographic abnormality [11]
    • Confirmed arthroscopically
    • 17% acetablum, 14% femur, 18% both anatomic sites
  • Note, many of these findings can be found in asymptomatic individuals
    • The significance of this is unknown

CT

  • Helpful to evaluate osseous abnormalities
  • Does not visualize the labrum well
  • Arthrography
    • May help better visualize the labrum in patients who can not get an MRI
    • However, sensitivity is lower than MR Arthrography[12]

Ultrasound

  • May have a role in evaluating anterosuperior labral tears
  • Overall role is likely limited but not well described in the literature
Axial cut of MRI arthrogram demonstrates full thickness tear of anterior labrum

MRI

  • Gold standard imaging modality for evaluating hip labrum
    • Arthroscopy is the diagnostic gold standard
  • Angiography
    • When performed on a 1.5T or larger machine, sensitivity increases for labral abnormalities[13]
    • Beaulé et al: MRA sensitivity 92-100%, accuracy 93-96% (compared to arthroscopy)[14]
  • 3T MRI
    • Increased availability of higher resolution MRI allows for opportunity to evaluate labrum without arthrography
    • Benefits: increase patient throughput, reduce costs for departments, improve patient experience[15]
    • Early literature suggests 3T MRI is superior to 1.5T MR Arthrography for evaluating labrum (need citation)
  • Pitfalls
    • Some individuals have a congenitally absent labrum, thought to be rare
    • Readers can misinterpret the high/ intermediate signal in the labrum
    • Cotten et al: 58% of asymptomatic labra examined on conventional MRI showed intermediate or high intra-labral signal intensity[16]
    • Normal paralabral rescess
    • Presence of a sublabral rescess
    • Bifid posterior labrum

Classification

  • Can be classified by
    • Location
    • Morphology
    • Etiology

Seldes classification

  • General[17]
    • Surgical classification system
    • Based on anatomical and histological features
    • Histologically, show hyalinization of the fibrocartilage along the edges of the tear with increased microvascularity at the base of the labrum adjacent to the bony attachment.
    • Myxoid change with cyst formation is sometimes seen within the adjacent fibrocartilage.
  • Type 1
    • Detachment of the labrum from the articular surface
    • Occurs at the transition zone between the fibrocartilaginous labrum and the articular hyaline cartilage
    • These are perpendicular to the articular surfaces
    • Can extend down to the subchondral bone
  • Type 2
    • Defined by one or more cleavage planes of variable depth within the labral substance

Lage Classification

  • Surgical classification system
  • Radial flap[18]
    • Disruption of the free margin of the labrum
    • Subsequent formation of discrete flap
    • Most common tear pattern
  • Radial fibrillated
    • Appearance of a shaving brush
    • Hairy appearance at the free margin
    • Common in degenerative disease
  • Longitudinal peripheral
    • Variable length along the acetabular insertion of the labrum
  • Unstable
    • Subluxing labrum
    • No discrete morphological pattern

Czerny classification

  • MR arthrography classification of labral tears[19]
  • Stage 0:
    • Homogeneous low signal intensity, triangular shape, continuous attachment to the lateral margins of the acetabulum without a notch or a sulcus.
    • A recess between the joint capsule and the labrum, which consists of a linear collection of the contrast material extending between the cranial margin of the acetabular labrum and the joint capsule
  • Stage 1A
    • Labra have an area of increased signal intensity in the center that does not extend to the margins, a triangular shape, and a continuous attachment to the lateral margin of the acetabulum without the sulcus.
    • A normal labral recess is also present
  • Stage 1B
    • Similar to stage 1A but are thickened and no labral recess is present
  • Stage 2A
    • An extension of contrast into the labrum without detachment from the acetabulum, triangular, and have a labral recess
  • Stage 2B
    • Like stage 2A but thickened, and the labral recess is not present
  • Stage 3A
    • Labrum is detached from the acetabulum but triangular in shape
  • Stage 3B
    • Like stage 3A but thickened

Blankenbaker Classification

  • MR arthrography classification of labral tears[20]
  • Type 1
    • Frayed: Irregular margins of the labrum without a discrete tear
  • Type 2
    • Flap tear: Contrast extending into or through the labral substance
  • Type 3
    • Peripheral longitudinal: Contrast partially or completely between the labral base and acetabulum labral detachment
  • Type 4
    • Thickened and distorted and thus likely unstable

Management

Prognosis

  • Arthroscopic debridement
    • Burnett et al: 89% of patients with continued ‘‘improved’’ status at an average of 16.5 months after arthroscopic debridement of a labral tear[9]
    • Farjo et al: 13/28 (46%) of patients reported being ‘‘better’’ or ‘‘much better’’ when monitored for at least 1 year following arthroscopic debridement[21]
    • Santori et al: at a mean of 3.5 years follow up, 39 (67.3%) reported being ‘‘pleased’’ with the results of the surgery, whereas 32.7% were not pleased[22]

Nonoperative

  • Indications
    • Generally initial treatment of choice
  • Relative rest
  • Physical Therapy
    • Trial for 10-12 weeks
    • Somewhat controversial
    • Some have argued that there is no benefit in acetabular labral tears[23]
  • Medications including NSAIDS
  • Corticosteroid Injection
    • May have both a therapeutic and diagnostic role
  • Platelet Rich Plasma
    • 8 patients improved symptoms at up to 8 weeks in this small study[24]

Operative

  • Indications
    • Symptoms that have failed to improve with nonoperative modalities
  • Technique
    • Arthroscopic labral debridement
    • Arthroscopic labral repair

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Needs to be updated

Complications


See Also


References

  1. Dameron TB. Bucket handle tear of acetabular labrum accompanying posterior dislocation of the hip. J Bone Joint Surg. 1959;41A:131–134
  2. Altenberg AR. Acetabulur labrum tears: A cause of hip pain and degenerative arthritis. South Med J. 1977;70:174–175.
  3. Suzuki S, Away G, Okada Y, et al. Arthroscopic diagnosis of ruptured acetabular labrum. Acta Orthop Scand. 1986;57:513–515
  4. Narvani AA, Tsiridis E, Kendall S, Chaudhuri R, Thomas P. A preliminary report on prevalence of acetabular labrum tears in sports patients with groin pain. Knee Surg Sports Traumatol Arthrosc. 2003;11:403–408.
  5. Lewis CL, Sahrmann SA. Acetabular labral tears. Phys Ther. 2006;86:110–121.
  6. McCarthy JC, Noble PC, Schuck MR, et al. The Otto E Aufranc Award the role of labral lesions to development of early degenerative hip disease. Clin Orthop. 2001;393:25–37.
  7. Paterson I. The torn acetabular labrum; a block to reduction of a dislocated hip. J Bone Joint Surg [Br] 1957;39-B(2):306–309.
  8. McCarthy JC, Lee JA. Acetabular dysplasia: a paradigm of arthroscopic examination of chondral injuries. Clin Orthop. 2002;405:122–128.
  9. 9.0 9.1 Burnett S, Della Rocca G, Prather H, et al. Clinical presentation of patients with tears of the acetabular labrum. J Bone Joint Surg Am. 2006;88(7):1448–57.
  10. Hunt D, Clohisy J, Prather H. Acetabular tears of the hip in women. Phys Med Rehabil Clin N Am. 2007;18(3):497–520.
  11. Keeney JA, Peelle MW, et al. Magnetic resonance arthrography versus arthroscopy in the evaluation of articular hip pathology. Clin Orthop Relat Res. 2004;429:163–169.
  12. Sutter R, Zanetti M, Pfirrmann CW. New developments in hip imaging. Radiology 2012;264(3):651–667
  13. Lazarus ML. Imaging of femoroacetabular impingement and acetabular labral tears of the hip. Dis Mon 2012;58(9):495–542
  14. Beaulé PE, O’Neill M, Rakhra K. Acetabular labral tears. J Bone Joint Surg Am 2009;91(3):701–710
  15. Robinson P. Conventional 3-T MRI and 1.5-T MR arthrography of femoroacetabular impingement. AJR Am J Roentgenol 2012; 199(3):509–515
  16. Cotten A, Boutry N, Demondion X, et al. Acetabular labrum: MRI in asymptomatic volunteers. J Comput Assist Tomogr 1998;22(1):1–7
  17. Seldes RM, Tan V, Hunt J, Katz M, Winiarsky R, Fitzgerald RH Jr. Anatomy, histologic features, and vascularity of the adult acetabular labrum. Clin Orthop Relat Res 2001;(382):232–240
  18. Lage LA, Patel JV, Villar RN. The acetabular labral tear: an arthroscopic classification. Arthroscopy 1996;12(3):269–272
  19. Czerny C, Hofmann S, Neuhold A, et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200(1):225–230
  20. Blankenbaker DG, De Smet AA, Keene JS, Fine JP. Classification and localization of acetabular labral tears. Skeletal Radiol 2007;36(5): 391–397
  21. Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy. 1999;15:132–7.
  22. Santori N, Villar RN. Acetabular labral tears: results of arthroscopic partial limbectomy. Arthroscopy. 2000;16(1):11–5.
  23. Hickman JM, Peters CL. Hip pain in the young adult: diagnosis and treatment of disorders of the acetabular labrum and acetabular dysplasia. Am J Orthop. 2001;30:459–67.
  24. De Luigi AJ, Blatz D, Karam C, Gustin Z, Gordon AH. Use of Platelet-Rich Plasma for the Treatment of Acetabular Labral Tear of the Hip: A Pilot Study. Am J Phys Med Rehabil. 2019 Nov;98(11):1010-1017. doi: 10.1097/PHM.0000000000001237. PMID: 31162277.
Created by:
John Kiel on 5 July 2019 08:48:17
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Last edited:
5 October 2022 13:08:57
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