Another interesting article

I came across this article this week, and if I remember how, I will add it to my "article" file.

Acetabular Labral Tears

Paul E. Beaulé, Michelle O'Neill and Kawan Rakhra

J Bone Joint Surg Am. 2009;91:701-710. doi:10.2106/JBJS.H.00802

A few key points:


Current Concepts Review
Acetabular Labral Tears
By Paul E. Beaul´e, MD, FRCSC, Michelle O’Neill, MD, FRCSC, and Kawan Rakhra, MD, FRCPC
-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.

"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 sixtysix
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"

"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>1041-43.
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-one17,44,45)
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 impingement
15: 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 labrum36,46 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"


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."


"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 sign"