Thursday, October 9, 2008

Hip labral (labrum) tears

Patients with hip pain may end up getting an MRI which shows a labral (labrum) tear. Inevitably I get asked "What is that? I've never heard of it before."

Most labral tears are not associated with a traumatic onset. Running, sprinting, and frequent rotation of the hip while playing sports is thought to result in tears of the labrum. Bony structural risk factors include hip dysplasia and femoroacetabular impingement (FAI). Clinical assessment including history, physical, and radiographic analysis is 98% accurate in determining the presence of an abnormality within the hip joint. MRI with contrast injected into the hip joint(arthrography) is 65-90% sensitive for detecting labral tears. Relief of pain (lidocaine pain test) from an intraarticular anesthetic injection at the time of arthrography is very suggestive of intraarticular abnormalities and is useful in predicting improvement with arthroscopic intervention, particularly in patients with normal imaging exams.

Signs and Symptoms
In greater than 90% of patients with labral tears, pain is reported in the anterior hip or groin region. Less often pain occurs in the lateral or posterior hip region. Patients may also report clicking, catching, locking, or giving away. Range of motion restrictions in flexion, internal rotation, and/or figure four position may be noted. Provocative tests include the anterior impingement test of flexion, internal rotation, and adduction. A positive test causes pain in the groin and restricted motion. Pain in the joint with a resisted straight leg raise may be indicative of a labral tear.

Unfortunately the labrum does not heal on its own if it is torn. The goak of non-operative treatment is to reduce the symptoms. If non-operative methods fail, surgical intervention of labral tears may be performed open or arthroscopically. The labrum can be debrided (cleaned-up) and/or repaired with suture anchors. Histologic studies have shown potential for labral healing. Conservative treatment may include limited weight bearing, NSAIDS, and avoidance of pivoting motions on the hip. Physical therapy can improve muscle recruitment to control hip motion.


Anonymous said...

Good tip Doc, thanks.

Anonymous said...

Are there studies out there comparing the outcomes of non-operative and operative treatments?

dom said...

There are no outcome studies regarding nonoperative versus operative treatment with hip arthroscopy. For this reason, I exhaust nonoperative treatments first and I have strict criteria based on physical exam, injections, and imaging. I give my patients a chance to get better without surgery. Oftentimes patients have been treated nonoperatively for months to years and have not improved before coming to see me.

It's important to note that there are many other orthopedic procedures which have not been studied this extensively and are routinely performed with improved patient outcomes. There are outcome studies for hip arthroscopy showing improvement as compared to before surgery.

Such a randomized study looking at nonoperative versus operative treatment would significantly add validity to hip arthroscopy, but would be difficult to complete given that the vast majority of these patients have had chronic symptoms which have been previously treated nonoperatively for several months to years.

Mike L. said...

What's the difference between repairing the labrum tear and cleaning it up?

Dr Carreira said...

I would like to first clarify some important terms.
Repair of an acetabular labrum tear (labral tear) also has been termed refixation or reattachment. Debridement refers to the “cleaning up” or removal of torn tissue, with the goal of leaving a stable rim of healthy tissue. The labrum can be damaged in many different ways, including by degeneration, instability, radial tears, longitudinal tears, detachment from the rim, and a combination of these. The indications for repair versus debridement of these different types of tears are not entirely clear. However, there is increasing evidence to support improved success with repair versus debridement. There are a number of studies demonstrated high success rates looking at groups of patients with repairs only, but there are few studies comparing these two methods of treatment directly. “Arthroscopic debridement versus refixation of the acetabular labrum associated with femoroacetabular impingement (FAI)” by Larson and Giveans in 2009, and “Treatment of femoroacetabular impingement: Preliminary results of labral refixation” by Espinosa et al in 2006 both demonstrated improved outcomes with the repair group compared to the debridement group.