Acetabular Labral Tears:

Current Treatments

Mohammad Ameen, PGY1

Adult Reconstruction Rounds
Nov 9, 2017

Acknowledgement: Manisha Mistry

 Outline

Background and Significance

Anatomy & Function

Classification

Clinical Presentation

Imaging

Treatment options
 Background

Labral tear was first reported in literature by Paterson1 in 1957

First arthroscopic description of acetabular labrum tear by Suzuki1 in 1986

Recognized as an important cause of hip pain only in the last decade

 Significance

Prevalence of labral tear in hip on groin pain been has been reported to be
22-55%1
Patients visited 3.3 healthcare providers before having a correct diagnosis
of labral tear2
73% of patients with fraying or tearing of the acetabular labrum had
chondral damage
94% of those patients, the articular damage occurred in the same zone of
the acetabulum as the labral lesions
 Anatomy

Fibrocartileginous structure with

abundant type I collagen1
Attached to acetabular rim and TAL1
Wide and thin anteriorly, thick
posteriorly1
Vascular supply
Sensory and proprioceptive nerve
endings
 Anatomy

Vascular supply rich in the

outer zone
Difference in anterior and
posterior chondrolabral
junctions

Beaule et al
 Function

Shock absorber1
Pressure distributor1 (controversial in
Reduction of impact loading
normal hip)2 and repetitive trauma2
Seal around the head2
Fluid film maintenance/lubrication
Cartilage consolidation slowing1, 2
Stability (negative pressure)1
Load sharing by fluid pressure1
 Classification

Classification of tears:
According to location
According to morphology
According to etiology
 Classification

Classification of tears: Anterior (86%)3

According to location Posterior
According to morphology Superior/lateral
According to etiology
 Classification

Classification of tears: Radial flap

According to location Radial fibrillated
According to morphology1 Longitudinal peripheral
According to etiology Unstable
 Classification

Classification of tears: Traumatic (Rare)

According to location Congenital (DDH etc.)
According to morphology CE angle, Tnnis angle

According to etiology1, 2 Degenerative (OA)

Idiopathic
FAI2

Capsular Laxity1
 Clinical Presentation

Pain

Mechanical symptoms
 Clinical Presentation

Pain Pain made worse by long

period of standing, sitting or
Anterior hip/groin pain
(>90%)1 walking

Pain may be appreciated in the Insidious onset

gluteal area or the trochanteric
region (Rarely) No traumatic event (mostly)

Mechanical symptoms
 Clinical Presentation

Pain Clicking appears to be the

Mechanical symptoms1
Clicking, locking, catching or
giving way
most consistent of the
mechanical symptoms1
Mechanical symptoms might
not be indicative of intra-
articular hip pathology2

Instability Snapping hip syndrome?

Pyriformis syndrome?
 Clinical Presentation

Pain History:
Childhood hip diseases2
Dysplasia
Mechanical symptoms
LCP

SCFE
 Clinical Presentation

Physical Exam
Anterior Impingement test1, 2
(FADIR Flexion ADduction
Internal Rotation)

FABER (Flexion ABduction

Internal Rotation)/Patrick Test

Resisted SLR (labral loading

Martin et el)

Forced ER with hip extension2

 Clinical Presentation

Physical Exam Most reliable test

Anterior Impingement test
(FADIR Flexion ADduction
Internal Rotation)
FABER (Flexion ABduction
Internal Rotation)/Patrick Test
Resisted SLR
Forced ER with hip extension
Supine, hip and knee 90, hip
internal rotation and
adduction
Sensitivity 75% and
Specificity 43% for labral
tears (Austin)
 Clinical Presentation

Physical Exam Pain on the ipsilateral hip

Anterior Impingement test
(FADIR Flexion ADduction
Internal Rotation)
FABER (Flexion ABduction
Internal Rotation)/Patrick Test
88% sensitive for intra-
articular hip pathology (not
specific for labral tears)
(Martin et el)

Resisted SLR

Forced ER with hip extension

 Clinical Presentation
Physical Exam
Anterior Impingement test1, 2
(FADIR Flexion ADduction
Internal Rotation)
FABER (Flexion ABduction
Internal Rotation)/Patrick Test
Resisted SLR (labral loading
Martin et el)
Forced ER with hip extension2
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.
 Imaging

AP pelvis
Hip Lateral (Dunn/Cross
table)
MRI
MRA
Direct MRA

Indirect MRA
 Imaging

AP pelvis Assess x-ray quality before

further assessment
Hip Lateral (Dunn/Cross
table) Acetabular retroversion
MRI Crossover/figure of eight sign

MRA Posterior wall/Ischial sign

Coxa profunda/protrusio
Direct MRA

Indirect MRA FAI (Cam/Pincer lesions)

Beaule et el
 Imaging

AP pelvis Good visualization of labrum,

cartilage, and joint space as
Hip Lateral (Dunn/Cross well as depicting the regional
table) soft tissues.
MRI Not the best for labral
MRA visualization

Direct MRA

Indirect MRA
 Imaging

Test of choice2

AP pelvis Intra-articular/Intravenous injection

of Gadolinium
Hip Lateral (Dunn/Cross
table) Joint distension essential for good
diagnostic yield
MRI
Labral tears are demonstrated by
MRA contrast solution extending into the
Direct MRA substance of the labrum

Indirect MRA
 Imaging

As compared with hip arthroscopy (gold

standard for diagnosing labral
AP pelvis pathology) MRA has a sensitivity
92% to 100% and accuracy 93% to
Hip Lateral (Dunn/Cross
96%2
table)
False positive (from normal anatomic
MRI
variants of recess/sulci)
MRA
Direct MRA

Indirect MRA
 Treatment Options

Conservative
Rest and analgesic

Physiotherapy

Operative Treatment
Open surgery

Hip Arthroscopy (HA)

 Treatment Options

Focused physio (controversial)1

Conservative Limited WB
Rest and analgesic Intra-articular injections (for
degenerative joints only)
Physiotherapy
Might compromise labral nutrition1
Operative Treatment
Open surgery Less cost-effective than arthroscopic
surgery7
Hip Arthroscopy (HA)
 Treatment Options
Less used with the advent of advance
of arthroscopic techniques
Conservative
Mostly used for hip preservation and
Rest and analgesic FAI situations
Physiotherapy Can be used with resection of
acetabular margin in cases of pincer
Operative Treatment
lesion with refixation of labrum
Open surgery

Hip Arthroscopy (HA)

 Arthroscopy

Diagnostic (gold standard)

Therapeutic
Used for
Labral debridement

Labral Repair/refixation

Labral Reconstruction
 Arthroscopy

Early treatment option

Diagnostic (gold standard) Systematic review by Robertson et al

describes good results with labral
Therapeutic debridement
Used for Minimal benefit for older people4 and
Labral debridement degenerative labrum6

Labral Repair/refixation Later studies shows superiority of

repair/refixation5
Labral Reconstruction
 Arthroscopy

Diagnostic (gold standard) Multiple techniques described

for repair/refixation8
Therapeutic
Suture anchor
Used for
Transosseous suture
Labral debridement
Better outcome compared to
Labral Repair/refixation debridement alone9
Labral Reconstruction
 Arthroscopy

Most recently developing technique

Diagnostic (gold standard) Initially described by Philippon10

Therapeutic Multiple types of tissues used11

Used for Autograft

Labral debridement Allograft

Labral Repair/refixation

Labral Reconstruction
 Arthroscopy

Best results compared to all other

techniques11, 12
Diagnostic (gold standard)
Revascularization in the implanted
Therapeutic allograft tissue is reported13
Used for Still not widely usable
Labral debridement Complexity and novelty of the technique
Labral Repair/refixation Require extensive PT protocol which might not
be generally feasible
Labral Reconstruction
 References:
1. Groh & Harrera. 2009 A comprehensive review of hip labral tears. Current Review of Musculoskeletal
Medicine.
2. Beaule et al. 2009s Acetabular labral tears. Journal of Bone and Joint Surgery.
3. McCarthy et el. 2001 The role of labral lesions to development of early degenerative hip disease. Clin Orthop.
4. Wilkin et al. 2014 Arthroscopic acetabular labral debridement in patients forty-five years of age or older has
minimal benefit for pain and function JBJS
5. Larson et al. 2012 Arthroscopic debridement versus refixation of the acetabular labrum associated with
femoroacetabular impingement: mean 3.5 year followup. American Journal of Sports Medicine
6. Haddd et al. 2014 Debridement vs. re-attachment of acetabular labral tears: A review of the literature and
quantitative analysis BJJ
7. Lodhia et al. 2016 The economic impact of acetabular labral tears: A cost-effectiveness analysis comparing hip
arthroscopic surgery and structured rehabilitation alone in patients without osteoarthrisis Am J Sports Med
8. Prez-Carro et al. 2015 Transosseous Acetabular Labral Repair as an Alternative to Anchors
 References:
1. Krych et al. 2013. Arthroscopic labral repair versus selective labral debridement in female patients with
femoroacetabular impingement-A prospective randomized study. Arthroscopy
2. Philippon et. 2010 Arthroscopic Labral Reconstruction in the Hip Using Iliotibial Band Autograft. Arthroscopy
3. White et al. 2016 Allograft Use in Arthroscopic Labral Reconstruction of hip with front-to-back fixation
technique: Minimum 2-year follow up. Arthroscopy
4. Rathi et al. 2017 Arthroscopic acetabular labral reconstruction with fascia lata allograft: clinical outcome at
minimum one-year follow-up. Open Orthopedic Journal
5. Moya et al. 2016. Reconstruction of nonrepairable acetabular labral tears with allografts: mid-term results. Hip
International
 Learnt From The Audience (same day)

The CE angle described in this presentation is the Lateral CE angle.

There is an Anterior CE angle seen on false profile view
Ref: Anderson et al 2011 Orthopedics. 2011; 34 (2): 86
New MRI machines (3 tesla) can diagnose labral tear with regular MRI,
with same sensitivity and accuracy as MRA