Labral Pathology

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CHAPTER 3 Labral Pathology

Our understanding of labral pathology as a cause of hip pain is evolving. The exact prevalence of acetabular labral tears in the general population is unknown. Injuries to the acetabular labrum are the most consistent pathologic findings identified at the time of hip arthroscopy. In the review of their last 300 cases by Kelly and colleagues,¹ labral tears were present in 90%. Labral tears are most frequently anterior and often are associated with sudden twisting or pivoting motions.

Current surgical options, as well as the indication for surgery, are being developed. The ideal indication for labral repair would be a labral tear from a recent traumatic injury. The common presentation, however, has no inciting event, and is caused by chronic repetitive injuries that led to an attritional tear. Therefore, it is important to understand that treatment of the underlying pathology is as important as treating the labral tear, or the long-term results will be poor.

ANATOMY AND PATHOANATOMY

The hip labrum is a fibrocartilaginous structure that surrounds the rim of the acetabulum in an almost circumferential manner. It is contiguous with the transverse acetabular ligament across the acetabular notch. The labrum is widest in the anterior half, thickest in the superior half, and merges with the articular hyaline cartilage of the acetabulum through a transition zone of 1 to 2 mm.² The labrum is firmly attached to the rim of the acetabulum. Its junction with the osseous margin is irregular, and there may be extension of bone into the substance of the labrum. A group of three or four vessels is located in the substance of the labrum on the capsular side of this bony extension from the acetabulum and penetrates into the peripheral third of the labrum. The labrum is separated from the hip capsule by a narrow synovium-lined recess.³ Extrapolating from our understanding of the healing capacity of the meniscus, repair strategies should be considered for tears involving only the peripheral labrum.

Function

We are only beginning to understand the function of the labrum. The bony congruity of the hip joint allows for primary stability. The labrum functions as a secondary stabilizer by extending the acetabular congruity and helping maintain the negative intra-articular pressure within the joint. This has been confirmed through a poroelastic finite model that showed the labrum helps provide structural resistance to lateral motion of the femoral head within the acetabulum.⁴ Furthermore, it has been demonstrated that the labrum decreases the contact pressures within the hip, probably as a result of its effect on maintaining the articular fluid in contact with the weight-bearing cartilage.⁵

Causes of Labral Tearing

There are many theories on the mechanism of labral tearing, suggesting that the cause is multifactorial. Kelly and associates ¹ have identified at least five causes of labral tears: (1) trauma, (2) femoroacetabular impingement (FAI), (3) capsular laxity and hip hypermobility, (4) dysplasia, and (5) degeneration.

Injury to the labrum could occur with traction, which would cause a tear resulting from excessive or repetitive external rotation of the femoral head on the anterior labrum.⁶ Compression forces may also tear the labrum through excessive and repetitive flexion and/or internal rotation of the hip. This process could be accelerated with FAI (see Chapter 4). Atraumatic instability has also been attributed to a deficient labrum associated with redundant capsular or ligamentous tissue that allows for more strain, and may transiently cause an incongruent joint. Deformities of the femoral head or acetabulum (e.g., slipped capital femoral epiphysis lesions, Legg-Calvé-Perthes disease, developmental dysplasia of the hip) have been discussed as a cause of labral tearing from incongruities between the femur and acetabulum.⁷

In the setting of a normal labrum, supraphysiologic loads would be required to produce a labral tear. Conversely, in the setting of an abnormal labrum, tearing could occur at physiologic loads. Sports that require repeated hip rotation, such as football, golf, gymnastics, soccer, ballet, and baseball, are susceptible to overuse injuries to the labrum and capsuloligamentous complex.⁸

Regardless of the mechanism, most labral tears encountered at the time of arthroscopy occur in the anterior quadrant. In a series by Fitzgerald,⁹ 45 of 49 labral injuries were documented in the anterior marginal attachment of the acetabulum. These findings were supported by another study, which reported that 96% of labral tears encountered in a series of 436 consecutive hip arthroscopies occur in the anterior quadrant.¹⁰

The data from cadavers show that labral lesions are extremely common, present in 93% of specimens. Because the labrum is thought to be a stabilizing structure in the hip, labral lesions might contribute to the development of osteoarthritis in numerous ways. Injury or degeneration of the labrum may result in instability of the femoral head in the acetabulum, resulting in cartilage damage adjacent to the damaged labrum. This instability also might be more widespread, resulting in cartilage damage in the weight-bearing region of the acetabulum.⁶ Finally, the lack of a seal may affect cartilage density as a result of fluid loss from the central articular compartment.⁴

HISTORY AND PHYSICAL EXAMINATION

The clinical presentation of patients with a tear of the labrum is variable and, as a result, the diagnosis is often missed initially. Burnett and coworkers ¹¹ have reported on a series of 66 patients in whom the diagnosis of a labral tear had been made by arthroscopy. In this series, the mean time from onset of symptoms to diagnosis was 21 months. An average of 3.3 health care providers had seen each patient prior to their being diagnosed. Groin pain was the most common complaint (92%), with the onset of symptoms most often insidious. The most common examination finding was a positive impingement sign, which occurred in 95% of patients in this series.

Most patients who present with labral injury report activity-related groin pain in the affected hip. A few patients also report gluteal or trochanteric pain, secondary to aberrant gait mechanics. In some patients, the gluteal pain may be a sign of posterior labral injury. Although most patients do not specifically report loss of hip range of motion (ROM), this finding is almost universally seen. Hips with structural abnormalities, such as acetabular retroversion, coxa profunda, or pistol grip deformities, may have decreased ROM from anatomic limitations, but may also be limited by pain. Patients with pathologic hip conditions also commonly develop late capsulitis, synovitis, and/or trochanteric bursitis. Differential diagnosis of the classic mechanical symptoms (painful catching or clicking) of labral tears includes a snapping iliotibial tendon or hypermobile psoas tendon.¹ Many other conditions can produce symptoms around the hip. The differential diagnosis should include an array of disorders such as sacroiliitis, degenerative disk disease, abductor muscle problems, osteonecrosis, psoas tendinitis, pubic rami fractures, and stress fractures of the proximal femur. More chronic problems are usually associated with trochanteric bursitis.¹²

The physical examination for labral injuries is similar to examining for FAI. Clinical examination of the affected hip should begin with evaluation of the patient’s gait and foot progression angle and measurement of leg length. The antalgic gait pattern should be differentiated from the Trendelenburg gait, seen in patients with hip dysplasia who have weak abductors. Patients with deformities secondary to a slipped capital femoral epiphysis (SCFE) may ambulate with an externally rotated extremity and open foot progression angle, more than 10 degrees. Leg lengths should be measured by using blocks in the standing position or by taking true leg length measurements from the anterior-superior iliac spine to the distal aspect of the medial malleolus. Hip pathology may be detected on inspection of the lower extremity rotation with the legs at rest. Typically, both feet rest symmetrically at approximately 10 to 30 degrees of external rotation. Asymmetrical external rotation of the legs may indicate acetabular retroversion, femoral retrotorsion, or femoral head-neck abnormalities. The hip is then carried through a ROM. One hand should be kept over the spinous process during flexion to allow immediate detection of pelvic flexion once the proximal femur contacts the acetabulum. Rotation is then measured with the hip flexed at 90 degrees. The patient with retroversion and FAI has limited flexion and/or internal rotation.

In addition to functionally limiting symptoms, reproducible physical findings, and mechanical symptoms, restricted ROM from pain or a perceived mechanical block is a further indication of an intra-articular cause. Findings on physical examination can include a positive McCarthy sign—with both hips fully flexed, the patient’s pain is reproduced by extending the affected leg, first in external rotation and then in internal rotation. Also common is inguinal pain with flexion, adduction, and internal rotation of the hip, as well as anterior inguinal pain with ipsilateral resisted straight leg raising.¹³ The pain, which may be of sudden onset or associated with a traumatic event such as a fall or twisting injury, is generally exacerbated with activity and does not respond to conservative treatment including ice, rest, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. Conservative treatment may be successful for muscle strains but not for acetabular labral tears.

The impingement test was first described for patients with femoroacetabular impingement, but is equally useful for labral injuries. With the hip at 90 degrees of flexion, maximum internal rotation and adduction is performed. Contact between the anterosuperior acetabular rim and femoral neck elicits pain (Fig. 3-1). The hip can also be tested at varying degrees of flexion. Posterior labral tears can be tested with the leg externally rotated and in hyperextension.

FIGURE 3-1 Impingement maneuver. With flexion, adduction, and internal rotation, the patient’s symptoms can be reproduced.

DIAGNOSTIC IMAGING

Weight-bearing anteroposterior (AP) pelvic and frog-leg lateral radiographs are critical in the initial assessment to evaluate the patient for arthritis and FAI, as well as subtler dysplasia.

Multiple studies have demonstrated the superior accuracy of magnetic resonance arthrography (MRA) over standard magnetic resonance imaging (MRI) for diagnosing labral tears. Intra-articular gadolinium has been shown to improve the sensitivity of diagnosing labral pathology from 25% to 92% using a small field of view.¹⁴ Therefore, when clinical suspicion of a hip labral tear exists, MRA using a small field of view is the study of choice.

An intra-articular bupivacaine injection may be useful in situations in which the diagnosis of labral pathology is equivocal or if a tear has been diagnosed by MRA,¹⁵ but it is uncertain whether symptoms are related to this finding. Similar to its use in diagnosing external impingement of the shoulder, if patients experience relief from their symptoms following the injection, the diagnosis of pain secondary to hip intra-articular pathology is more certain. However, intra-articular pathology could still be present without pain relief from an injection.¹⁶

Finally, the most sensitive test for the documentation of labral pathology is arthroscopy of the hip. With symptoms and examination findings consistent with labral pathology, and MRA fails to show a tear, it is not unreasonable to consider performing an arthroscopy for diagnostic and therapeutic reasons after a period of conservative management has failed. Surgical intervention, however, should not be entertained until all other forms of treatment, including activity modification, physical therapy, and NSAIDs, have failed.

CLASSIFICATION

A outcome correlated classification system of labral injuries and chondral damage has been created by McCarthy and colleagues ¹⁷ Stage 0, as compared with a normal acetabular labrum, is a contusion of the labrum with adjacent synovitis. Stage 1 is a discrete labral free margin tear with intact articular cartilage of the acetabulum and femoral head. Stage 2 is a labral tear with focal articular damage to the subjacent femoral head but with intact acetabular articular cartilage. Stage 3 is a labral tear with an adjacent focal acetabular articular cartilage lesion, with or without femoral head articular cartilage chondromalacia. Stage 4 constitutes an extensive acetabular labral tear with associated diffuse arthritic articular cartilage changes in the joint (Fig. 3-2). The labral injury involved the anterior half of the joint 95% of the time. All patients who had combined anterior and lateral labral injuries had associated degenerative arthritis in the joint.

FIGURE 3-2 Classification of labral tears. A, Stage 0—labral contusion (arrow) with synovitis. B, Stage 1—labral tear (arrow) with intact articular cartilage of the acetabulum and femoral head. C, Stage 2—labral tear with focal articular damage (arrow) to the subjacent femoral head but with intact acetabular cartilage. D, Stage 3—labral tear (arrow) with an adjacent focal acetabular cartilage lesion, with or without femoral head (FH) articular cartilage damage. E, Stage 4—extensive acetabular labral tear, with associated diffuse arthritic articular cartilage changes in the joint. The arrow delineates transition to normal cartilage.

TREATMENT

Nonoperative Management

Once the diagnosis of a labral tear has been made, a discussion is held with the patient regarding treatment alternatives. Conservative treatment options include avoiding activities that cause symptoms and a supervised therapy program that emphasizes hip ROM and core strengthening. Although it is unlikely that the tear will heal over time, it is possible that symptoms may stabilize to the point where the patient no longer experiences problems. If conservative management is elected, the patient should understand the need to avoid activities that produce symptoms and the possibility that the tear may progress and potentially predispose to arthritic changes in the affected hip. To our knowledge, there are no published series detailing the results of physical therapy for the treatment of symptomatic hip labral tears.

Surgical Management

Arthroscopic Technique

The decision to proceed with operative intervention should be heavily weighted on refractory pain and mechanical symptoms. Most labral tears are treated with débridement. However, some tears are amenable to arthroscopic repair. As noted, the blood supply to the labrum enters from the adjacent joint capsule. Vascularity was detected in the peripheral third of the labrum whereas the inner two thirds of the labrum were avascular. Thus, peripheral tears have healing potential and repairs should be considered if this is observed at the time of surgery. However, McCarthy and colleagues ⁶ have reported on 436 consecutive hip arthroscopies, including 261 labral tears, and all the tears were located at the relatively avascular articular junction.

Arthroscopic Labral Débridement.

It is our preference to use a general anesthetic supplemented with a lumbar plexus block for post-perative analgesia and relaxation.¹⁸ The procedure can be performed in the supine or lateral position and should use both a 30- and 70-degree arthroscope for a thorough assessment of the labrum and any associated pathology. Modified arthroscopic flexible instruments, extended shavers, and hip-specific instrumentation should be available to improve access to all areas of the joint.

A diagnostic arthroscopic examination of the central compartment can be done systematically to evaluate not only the labrum from anterior to posterior, but also to locate possible cartilage lesions on the acetabular and femoral sides. As with the classification, the typical cartilage lesions are adjacent to injured labrum. In addition, the integrity of the ligamentum teres should be assessed. This area can be a source of pain as a result of impingement of the soft tissues between the femoral head and acetabulum. Any loose bodies should be noted and their source identified. Finally, an assessment should be made of any obvious capsular redundancy or laxity.

Many patients will have a significant synovitis associated with the labral tearing and an effort should be made to resect some of the inflamed tissue, not only for visualization of the joint but also to decrease the associated pain. It is our preference to use a radiofrequency (RF) probe to decrease the potential for bleeding and subsequent compromise of the surgical field.

The goal of the surgical procedure should be to preserve as much tissue as is technically feasible while resecting the degenerative or damaged material. This is important to maintain the labrum’s role as a secondary joint stabilizer and minimize the potential for arthrosis. Fraying from the labral tears should be débrided with the use of motorized shavers or RF probes. Placing absorbable suture through the defect and tying the suture through the capsule can stabilize intrasubstance labral tears. It is important to delineate the areas of abnormal tissue identified on radiographs (in the form of perilabral calcifications) and on MRA and MRI scans (abnormal signal intensity) to address the labral pathology thoroughly. Occasionally, perilabral calcifications can be in the formative stage; these should be sought out and decompressed (Fig. 3-3).

FIGURE 3-3 Perilabral calcification. A, AP radiograph depicting perilabral calcification (arrow). B, Arthroscopic view of left hip from the anterolateral portal showing decompression of calcified material (arrow). FH, femoral head.

Adjacent cartilage damage should be sought and thoroughly assessed. Superficial lesions can be gently débrided with mechanical shavers and perhaps stabilized with the use of RF probes. Grade IV Outerbridge lesions may be managed with a thorough débridement down to a bleeding bed and preparation with microfracture awls (Fig. 3-4).

FIGURE 3-4 Microfracture steps in a right hip viewed from the anterolateral portal. A, Initial lesion with curette in place working from the anterior portal. B, Creation of bleeding bed with awl in place.

Arthroscopic Labral Repair.

The decision to perform a labral repair is still a process in its infancy. The current indications are symptomatic tears that have obvious vascularity within their substance or are reparable to the acetabular bony wall or adjacent capsule. In general, a tear less than 1cm in length does not require repair because there are minimal associated instability and mechanical symptomatology. Expert arthroscopic skills and appropriate instrumentation are also required to perform this repair. It can be performed in the supine or lateral position under general anesthesia, often supplemented with a lumbar plexus block (see earlier).

Best results can be expected with operations with the correct indications, as follows:

Mechanical symptoms with rotational activities

Unremitting groin pain with weight-bearing activities

Concomitant FAI with healthy reparable tissue

Traumatic dislocation or subluxation with ongoing mechanical symptoms

Subluxation episodes in high-performance athletes

Tissue with obvious vascularity in proper (capsular) anatomic zone

Tears larger than 1 cm

The arthroscopic technique uses routine anterior and anterolateral portals and an accessory midanterior portal that is halfway between the two portals and 5 cm distal (Fig. 3-5). This accessory portal allows for a more appropriate angle for suture anchor placement. However, caution should be taken in creating this portal because excessively distal placement places the ascending lateral circumflex artery at risk, with the possibility of bleeding and compromise of the surgical field.¹⁹

FIGURE 3-5 Midanterolateral portal (MAL). The portal is created approximately halfway between the standard anterior portal (A) and the anterolateral portal (AL), creating an equilateral triangle between the points. AAL, accesory anterolateral portal; ASIS, anterior superior iliac spine; PL, posterolateral portal.

As with labral débridement, the procedure includes a diagnostic arthroscopy, with treatment of any associated pathology. Any degenerative tissue is débrided, and the labrum is elevated from the bone. The bony bed is prepared by decorticating with a curette or shaver to stimulate healing (Fig. 3-6).

FIGURE 3-6 Bony bed preparation for labral repair. This right hip is viewed from the anterolateral portal, and the burr is being used from the anterior portal. The arrow indicates the retracted labral tissue.

One important consideration is to develop adequate access to the joint. Unlike the shoulder, the hip capsule is significantly thicker and less forgiving with respect to maneuverability within the joint. Therefore, a generous capsulotomy should be considered in many cases so that instruments can be moved within the joint and to limit the amount of iatrogenic damage to the articular cartilage. The capsulotomy can be performed with an arthroscopic knife or RF probe (Fig. 3-7). In addition, the use of slotted cannulas can make delivery of curved instruments significantly easier (Fig. 3-8). These devices are available in a variety of lengths and circumferences to allow their use in the hip.

FIGURE 3-7 Capsulotomy to expand the mobility within the portal A, Use of a knife (arrow) for capsulotomy. B, Use of a radiofrequency probe (arrow). AW, acetabular wall; fh, femoral head l, labrum.

FIGURE 3-8 Use of a slotted cannula for instrument insertion. A, Endoscopic view of tool in place. The device is in the anterior portal of a right hip while viewed from the anterolateral portal. B, External view of cannula in place. C, Slotted cannula device.

FIGURE 3-9 Fluoroscopic and endoscopic visualization of anchor insertion point. A, Endoscopic view of anchor cannula (arrow) in place from the anterior portal while viewed from the anterolateral portal in a right hip. B, Fluoroscopic view of insertion point. L, labral tissue with circumferential suture in place.

FIGURE 3-10 Repair of labrum using a knotless technique. This is a right hip in a patient with an associated chondral area of delamination. A, Initial view of tear from the anterolateral portal. B, Prepared site viewed from the anterior portal. The burr is inserted from the anterolateral portal. C, Capture of the labral tissue with a penetrator device. D, Final suture mattress in place in robust tissue. The arrow is pointing to the prepared anchor insertion site. E, Anchor in position for insertion into acetabular wall with loose sutures viewed is from the anterolateral portal. F, Anchor in place with suture prepared for advancement. G, Final repair viewed from the peripheral compartment (anterolateral portal) showing re-creation of the labral contour. H, Final repair viewed from the central compartment (anterolateral portal). FH, femoral head.

Once the anchor is placed, a suture-passing device is used to penetrate the labrum and standard knot-tying techniques may be used. Most available instruments have been adapted from those used in shoulder arthroscopy.

With a tear in the labrocapsular junction, the repair can be performed, attaching the labrum to the adjacent capsular tissue. Intrasubstance tears may be addressed in a similar manner. The cleavage plane in the labrum should be defined and débrided of nonviable tissue. A suture shuttle device can be used to deliver a looped monofilament suture between the junction of the articular cartilage and the fibrocartilage labrum. A suture penetrator is used through the capsule to grasp the loop of monofilament. The looped shuttle is used to shuttle a monofilament suture around the labral tear and through the capsule. The suture is then tied in an extra-articular position.

PEARLS& PITFALLS

• Capsulotomy (enlarge your portals for better mobility).

A beaver blade can be inserted under direct visualization in the joint. The blade can be used to enlarge the portals by opening the capsule. Any portal can be extended in this fashion to gain more mobility. This is especially important for the novice hip arthroscopist because establishment of the portals in the ideal location takes some experience. With this technique, a slightly suboptimal portal can be made ideal. Alternatively, the portal can also be enlarged with the use of an RF probe. If labral repair is undertaken, mobility within the joint is critical for appropriate position of the suture anchor and also for knot tying. The expansion of the capsulotomy is often the critical step in allowing the procedure to be completed successfully, without damaging the articular surfaces.

• Use slotted cannulas.

The use of slotted cannulas, instead of disposable plastic devices (see Fig. 3-8), makes the insertion of longer tools and curved tools significantly easier in the hip joint. For the reasons noted, the hip capsule is very restricting. The insertion of plastic cannulas is fraught with difficulties, including articular cartilage damagepon insertion. With a slotted cannula, the capsular entry point is preserved and maneuverability within the joint is enhanced compared with using a closed cannula.

• Treat the underlying pathology—look for subtle indicators of impingement.

In the broadest sense, there are two types of impingement, cam and pincer. When conducting the diagnostic arthroscopy of the central compartment, the type of labral pathology and presence or absence of chondral delamination can serve as a subtle clue of the presence of any impingement lesion.

A hypertrophic and degenerative labrum in a relatively focal area with chondral delamination directly adjacent to the labral tear is indicative of a cam lesion. If the chondral surface is intact and the labrum appears generally frayed in a more peripheral location, the situation is likely a result of pincer impingement.

• Use fluoroscopic and endoscopic visualization for anchor placement.

The liberal use of fluoroscopy while anchor insertion points are chosen allows for anchors to be placed in a safe location, with a minimal likelihood of penetrating the articular cartilage and causing iatrogenic damage. Unlike the glenoid cavity, the acetabulum is concave, making the angle of approach completely different to avoid penetration. The distortion that accompanies the use of the 70-degree arthroscope further confuses the situation and makes the use of fluoroscopy even more important.

POSTOPERATIVE PROTOCOL

Rehabilitation Following Débridement

Formal therapy for ROM and strengthening of the operative hip is begun 7 to 10 days following surgery. Weight bearing following an isolated arthroscopic labral débridement should be unrestricted, with the use of crutches limited to the early postoperative period only (3 to 5 days). The standard protocol includes a gradual progression from increasing the ROM to unrestricted strengthening. Strengthening is only begun once the patient attains approximately 75% of normal motion. Aggressive hip flexor strengthening should be limited until full ROM is obtained and hip mechanics are relatively normal. If patients develop abnormal mechanics to assist the recovering psoas and/or hip flexors, a significant tendinitis can develop, which is difficult to treat and slows the patient’s recovery. Explosive and rotational activities should also be limited for at least 6 weeks. The return to unrestricted activity is predicated on a full painless ROM and normal strength of the pelvic, abdominal, and lower extremity musculature.

Rehabilitation Following Labral Repair

Formal therapy for ROM and strengthening of the operative hip is also begun 7 to 10 days following surgery. Early ROM is initiated to limit the scarring in the joint associated with surgical trauma. Weight bearing following repair should be restricted to foot-flat (20% of body weight) ambulation for the first 4 weeks. The most important principle is to limit the rotational stresses that the repaired labrum experiences in the first few weeks. The range that puts the repair at risk includes flexion past 90 degrees, abduction past 25 degrees, and internal or external rotation past 25 degrees.²⁰ Limitations are placed on flexion past 90 degrees for 10 days, whereas abduction and abduction are limited to 25 degrees for 4 weeks. Beginning at 4 weeks, a gradual progression from increasing the ROM to unrestricted strengthening is begun. The use of stationary bicycling is encouraged and instituted in the first 10 days. Aggressive hip flexor strengthening should also be limited until full ROM is obtained and hip mechanics are relatively normal. As noted, a significant tendinitis can develop, thus slowing recovery. Explosive and rotational activities should also be limited for at least 12 weeks. The return to unrestricted activity is also predicated on a full pain-free ROM, and normal strength of the pelvic, abdominal, and lower extremity musculature. This typically occurs at approximately 4 to 6 months postoperatively.

OUTCOMES

At a minimum of 2 years after hip arthroscopy, patient results were directly correlated with the stage of labral injury.²¹ There were 11 stage 0 lesions and 1 labral lesion, with all but one of these patients having good to excellent results (91%). There were 11 patients with stage 2 labral tears, with 82% good to excellent outcomes when the tear was resected. Two patients (18%) required additional surgical intervention, including open synovectomy, capsulectomy, and release of the reflected rectus femoris tendon secondary to poor results. Patients with stage 3 labral tears did not fare nearly as well and the extent of the acetabular cartilage erosion directly affected the result, with only 17% having good to excellent results. The results of patients with stage 4 labral tears (nine hips) directly correlated with the extent of hip degenerative arthritis. If the articular cartilage involvement was diffuse on the femoral head and acetabulum, regardless of the plain radiographic appearance, the symptomatic improvement after arthroscopy was transient. At follow-up, 78% had poor results and 43% eventually had total joint arthroplasty within 2 years of arthroscopy. These results have been confirmed with the only long-term outcome study of labral débridement by Byrd and Jones.²²

There have been numerous studies detailing the use of arthroscopy in treating lesions of the hip labrum. However, collective interpretation is confounded by the nonuniform use of outcome measures and a lack of validated outcomes for nonarthritic hip pain. Further complicating the matter is that many published series contained heterogeneous study populations in which subjects had associated hip pathology, such as arthritis, dysplasia, and FAI, in addition to labral tearing.

To date, there are no published series on the long-term outcome of arthroscopic repair of hip labral tears. Indications for which lesions constitute a reparable lesion are currently evolving. Recently, Hines and associates ²⁵ presented outcome results on a series of 52 patients who underwent arthroscopic hip labral repair, with a mean follow-up of 9 months. Another study of 19 patients by Murphy and coworkers²³ has also recently been published. The results of these studies, as well as those documenting the outcome of labral débridement, are summarized in Table 3-1.

TABLE 3-1 Results of Arthroscopic Débridement and Repair of Hip Labrum Tears

COMPLICATIONS

Hip arthroscopy has been shown to be relatively safe in several studies documenting its effectiveness and the number of complications. In one large series, there was a 1.6% complication rate, with problems including transient palsy of the sciatic or femoral nerves, paresthesias secondary to lateral femoral cutaneous nerve palsy, perineal injury, and instrument breakage.²⁴ Although this study was not specific to the repair of the hip labrum, specific problems may be associated with this procedure. As a result of the tight confines and the multiple instruments that are inserted into the joint, the possibility of serious articular cartilage damage exists. Care should be taken while working within the joint to ensure that cartilage damage is minimal. In addition, with the insertion of suture anchors, there is a possibility of joint penetration. The liberal use of fluoroscopy to document the position of anchor insertion angles prior to committing to a specific position is critical to a successful procedure.