Hip Labral Tears

Background

  • Narvani et al (2003) reported that 22% of athletes with groin pain were diagnosed with a labral tear.
  • McCarthy et al (2001) found that 55% of their patients with mechanical hip pain had a labral tear.
  • Santori and Villar (2000) reported on 412 arthroscopic surgeries for disabling hip pain of >6 months duration: 76 patients (18%) had acetabular labral tears.
  • North American studies have revealed the majority of tears are often associated with sudden twisting or pivoting and are located anteriosuperiorly (Baber, 1999; Dorfmann 1999; Fitzgeral 1995).
  • Tears can lead to abnormal motion causing labral fraying, bony abnormalities, and cartilage degeneration (Lage et al 1996; McCarthy 2001).
  • Wenger et al (2004) found that 87% of individuals with acetabular labral pathology had at least one bony abnormality present on radiographs.
  • Santori and Villar (2000) collected data on etiology from 58 of their 76 patients with acetabular labral tears: 29.3% were of unknown etiology, traumatic injury occurred in 25.9%, and in 44.8% the labral lesions were likely degenerative in nature.
  • Mason (2001) reported traumatic lesions accounted for approximately 46% of all lesions, and degenerative lesions account for 49%
  • Ages reported in the literature ranged from 8 to 72, although most patients were in the fourth decade of life (Leibold et al 2008)
  • Labral lesions may affect women more the men, at about 60% (Leibold et al 2008)

Risk Factors

  • Acetabular labral pathology frequently presents in highly active individuals in the second, third, and fourth decades of life (Phillipon 2006).
  • A higher activity level as found in runners, professional athletes, and those attending the gym 3 times a week has been suggested as a risk factor (Narvani 2003; Guanche 2005)
  • Wenger et al (2004) noted structural abnormalities in 31 patients with labral tears including acetabular retroversion, coxa valga, abnormal Tonnis (1999) angle, small femoral head-neck offset, and incongruent hips.
  • Peelle et al (2005) compared radiographs of 78 patients with labral tears confirmed on arthroscopy to those of 22 subjects without hip dysfunction. Of the patients with labral tears, 49% had an osseous abnormality including a lateral center-edge angle <25o, head-neck offset <9 mm, offset ratio <0.17, acetabular retroversion, femoral anteversion, an aspherical femoral head, and a Tonnis osteoarthritis grade (Table 326) of 1 and 2. Patients with labral tears demonstrated significantly smaller lateral center-edge angles (P=0.008), larger Tonnis angles (P=0.02), and a greater probability of acetabular dysplasia (P=0.001) than controls27.
  • Ito et al (2001) compared 24 patients to 24 control subjects and found that patients had significantly less femoral anteversion (P<0.001); they also noted a significant between-group difference for head-neck offset (P<0.002).
  • Siebenrock et al (2004) also found patients to have a significantly different head-neck offset when compared to a control group (P=0.01–0.04).
  • Kassarjian et al (2005) studied 42 hips with an antero-superior labral tear: 93% had an abnormal head-neck offset with a mean angle of 69.7o; abnormal was defined as >55o.
  • Acetabular retroversion, femoral anteversion, and abnormal head-neck offset all increase the chance of labral impingement against the acetabular rim, especially with active hip flexion with or without internal rotation.

Types of Tears

Labral tears have been classified into 4 types: radial flap, radial fibrillated, longitudinal peripheral, and abnormally mobile (Lage et al 1996). Lage et al (1996) found that radial flap tears were the most common.

They can also be classified as either traumatic vertical versus degenerative horizontal tears. Traumatic vertical tears are further classified as full substance or partial substance with avulsion (Hase 1999). Horizontal degenerative are further classified as either involving a detachment of the fibrocartilaginous labrum from the transition zone at the acetabular cartilage or separation of cartilaginous planes within the substance of the labrum (McCarthy 2002).

They are located most frequently in the anterior superior of posterior superior margins secondary to the inferior mechanical properties in those areas, increased demand, poor blood supply, and impact loading of the femoral head and neck junction against the labral rim.

History

  • Groin pain mostly , but sometimes buttock, trochanteric region, thigh, or a combination
    • Burnett et al (2006) found that 92% of their patients with labral tears complained of anterior groin pain.
    • In Keeney et al (2004), 97 of 102 patients with confirmed labral tears reported groin pain.
  • Night Pain
    • Ito et al (2001) found that night pain was present in 14 of 15 of their patients
    • Burnett et al (2006) reported 71% of their patients reported night pain.
  • Limp
    • Burnett et al (2006) reported 89% of patients with labral tears also mentioned a history of a limp.
    • Fitzgerald (1995) reported 5 of 55 patients had a limp
    • Keeney et al (2004) noted that 39 of 102 subjects mentioned a limp.
  • Some but not all patients with labral pathology have reported clicking, catching, or locking of the hip with motion.
    • McCarthy et al (2002) found that 67% of subjects complained of clicking or locking with hip motion. Of their subjects, 72% had labral tears. However, the authors did not state whether those with clicking indeed had a labral tear.
    • Narvani et al (2003) reported that 4 of 4 patients with labral tears noted clicking, but that 2 patients without labral tears also mentioned clicking.
    • Leunig et al (1997) reported that 6 of 23 patients with labral tears had locking symptoms.
    • Keeney et al (2004) found locking or catching in >50% of their patients
    • Farjo (1999) reported that 18 of 28 patients who were found to have labral tears upon arthroscopy had mechanical symptoms.
    • Fitzgerald (1995) reported that 34 of 64 patients had a click associated with hip pain and were also positive for labral tears.
  • Increase pain with sitting, climbing stairs

Examination

  • Pain and possible limitation during passive IR with the hip flexed, but not with the hip extended
  • Positive hip labrum special tests: See hip examination
  • MR Arthrography

Conservative Management

  • No evidence to support
  • Patient education on condition, decrease sitting hip flexion angle, reduce extensive sitting and use of stair
  • Therapeutic exercise to increase ROM and strength

Surgical Intervention

  • Arthroscopic excision with partial labrectomy (Byrd 2001; Suzuki 2005; Santori 2000)
  • Acetabular derotation osteotomy (Siebenrock 2003; Lavigne 2004)
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