Supermarket Hip: An Unusual Cause of Injury to the Hip Joint

Sporting activity can be a significant cause of injury to the hip joint, in particular tears of the acetabular labrum and, less commonly, tears of the ligamentum teres. Femoroacetabular impingement and acetabular dysplasia are also commonly associated with labral tears. However, shopping in a supermarket would not normally be regarded as an at-risk activity for the hip joint. Despite this, we report 3 separate cases of hip injury (2 labral tears, 1 partial avulsion of the ligamentum teres), each of which was sustained while shopping in a supermarket. None of the 3 patients involved had radiographic evidence of acetabular dysplasia or arthroscopic evidence of femoroacetabular impingement. All patients were successfully treated by arthroscopic surgery of the hip. We therefore suggest that shopping in a supermarket may need to be reclassified as an at-risk activity for the hip joint.     

Arthroscopic Labral Repair in the Hip: Surgical Technique and Review of the Literature

Hip pain can be caused by multiple pathologies. Injuries to the acetabular labrum are the most common pathologic findings identified at the time of hip arthroscopy. Five causes of labral tears have been identified; these include trauma, femoroacetabular impingement, capsular laxity, dysplasia, and degeneration. Studies have shown the function and the importance of the labrum. To restore function of the labrum, new surgical techniques, such as suture anchor repair, have been described. The goal of arthroscopic treatment of a torn labrum is to relieve pain by eliminating the unstable flap tear that causes hip discomfort. The goals of these treatments are to maintain the function of the hip joint and decrease the development of premature arthrosis.     

Peri-acetabular rotational osteotomy with concomitant hip arthroscopy for treatment of hip dysplasia

Reconstructive acetabular osteotomy is a well established and effective procedure in the treatment of acetabular dysplasia. However, the dysplasia is frequently accompanied by intra-articular pathology such as labral tears. We intended to determine whether a concomitant hip arthroscopy with peri-acetabular rotational osteotomy could identify and treat intra-articular pathology associated with dysplasia and thereby produce a favourable outcome. We prospectively evaluated 43 consecutive hips treated by combined arthroscopy and acetabular osteotomy. Intra-operative arthroscopic examination revealed labral lesions in 38 hips. At a mean follow-up of 74 months (60 to 97) the mean Harris hip score improved from 72.4 to 94.0 (p < 0.001), as did all the radiological parameters (p < 0.001). Complications included penetration of the joint by the osteotome in one patient, a fracture of the posterior column in another and deep-vein thrombosis in one further patient. This combined surgical treatment gave good results in the medium term. We suggest that arthroscopy of the hip can be performed in conjunction with peri-acetabular osteotomy to provide good results in patients with symptomatic dysplasia of the hip, and the arthroscopic treatment of intra-articular pathology may alter the progression of osteoarthritis.     

Hip arthroscopy: intra-articular saucerization of the acetabular cotyloid fossa

Hip arthroscopy is increasingly recognized as a treatment option for patients with hip pain and labral tears. When emphasis is placed on labral tears as a primary clinical finding in the peripheral compartment, a broader view of the pathophysiology of these tears may be missed. Therefore, it is imperative to gain arthroscopic surgical access to the central compartment and determine if its contents affect the congruency of the hip joint. Abnormal bone and fibro-fatty tissue in the cotyloid fossa decrease the space available for the ligamentum teres, leading to lateral subluxation of the femoral head and rim loading of the acetabulum at the chondrolabral junction. Rim loading of the acetabulum may induce articular-sided labral tears due to hip incongruency. Although these labral tears may require refixation, the congruency of the hip joint should be restored to the best extent possible. Arthroscopic intra-articular saucerization and debridement of space-occupying lesions in the cotyloid fossa increase the space available for the ligamentum teres, improve the congruency of the hip joint, and mitigate against acetabular rim loading. This article describes a case of arthroscopic intra-articular saucerization of the cotyloid fossa in a 25-year-old man with chronic hip pain.     

The acetabular labrum. Arthroscopic diagnosis and therapy of degenerate and traumatic lesions

The acetabular labrum makes a vital contribution to the stability of the hip joint. Hip arthroscopy has revolutionized the diagnosis and treatment of labral pathology. Lesions that would otherwise have gone unrecognised are now amenable to resection and in some cases repair. Symptomatic relief is generally good after treatment of traumatic tears but patients with co-existing articular cartilage degeneration do less well. The long-term results of arthroscopic surgery for the acetabular labrum are awaited.     

Labral Refixation: Current Techniques and Indications

Background

Labral tears have been associated with femoroacetabular impingement, instability, sports-related activity or trauma, capsular laxity or hypermobility, dysplasia, and degeneration. Disruption of the labrum increases the rate of acetabular cartilage compression and the contact stress between the femoral and acetabular cartilage. If left untreated, these lesions will alter normal hip joint function and may eventually lead to osteoarthritis.

Methods

For the labrum with adequate tissue (>7 mm), the labrum is repaired if it is detached or torn. If the labrum is bruised, a rim reduction and repair is performed, especially in the presence of cartilage damage and the labral–chondral junction. Labri are debrided only if there is enough substance to maintain the function of the labrum. Care must be taken to fix the labrum so that it provides adequate seal with the femoral head.

Results

Two-year outcome on 122 patients who underwent arthroscopic treatment for femoroacetabular impingement and chondrolabral dysfunction showed that, overall, most patients showed an improvement in symptoms and function and were satisfied with the results. Independent predictors of improved outcomes were joint space >2 mm and repair of labral pathology instead of debridement. Several other studies have shown excellent results following labral refixation and repair.

Conclusions

Labral tears have been associated with femoroacetabular impingement, instability, sports-related activity or trauma, capsular laxity or hypermobility, dysplasia, and degeneration. Untreated labral tears can result in premature osteoarthritis of the hip. Debridement only used to be the standard of care, but excellent results reveal arthroscopic labral repair and refixation are an option with good outcomes.     

Labrum acetabulare

The acetabular labrum makes a vital contribution to the stability of the hip joint. Hip arthroscopy has revolutionized the diagnosis and treatment of labral pathology. Lesions that would otherwise have gone unrecognised are now amenable to resection and in some cases repair. Symptomatic relief is generally good after treatment of traumatic tears but patients with co-existing articular cartilage degeneration do less well. The long-term results of arthroscopic surgery for the acetabular labrum are awaited.     

Editorial Commentary: Rehabilitation After Hip Arthroscopy—Bear in Mind the Bearing of Weight

Hip arthroscopy is the surgical treatment of choice for the treatment of femoroacetabular impingement syndrome and hip labral tears. Current guidelines on postoperative rehabilitation protocols are based on expert opinion, and evidence-based protocols are scarce. Previously, a non–weight-bearing protocol for several weeks after surgery was thought to prevent axial-load damage to the newly repaired labrum. However, there is a trend toward using immediate weight bearing as tolerated for early joint mobilization and pressurization. Strict weight-bearing restrictions may not be as necessary as once thought. We recommend that the first phase of rehabilitation prioritize joint protection to prevent joint inflammation and tissue irritation with a gradual increase in mobility exercises to restore range of motion. However, rehabilitation protocols should be tailored to address specific surgical findings, procedures, patient characteristics, and athletic goals. It is wise to be more conservative in older patients with poor bone quality. Bearing in mind this caveat, weight-bearing restrictions after hip arthroscopy may not improve outcomes and instead may have the negative effect of preventing patients from re-establishing a normal gait pattern.     

Current concepts in the diagnosis and management of femoroacetabular impingement

Femoroacetabular impingement is becoming increasingly recognised as a cause of hip pain in the young adult. It is thought that the condition may lead to acetabular labral tears, chondro-labral separation, chondral delamination and eventually predispose to osteoarthritis of the hip. Efforts have thus been directed to diagnosing and treating the underlying pathology and subsequent sequelae. This article presents the relevant literature with regards to the aetiology of femoroacetabular impingement, its clinical features, investigations and options of management. Finally outcomes relating to both open and arthroscopic approaches to treatment are discussed.     

Hip Arthroscopy Update

The management of hip injuries in the athlete has evolved significantly in the past few years with theadvancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in recreational and elite athletes alike. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular pathology that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and thus, left untreated. Current indications for hip arthroscopy include management of labral tears, osteoplasty for femoroacetabular impingement, thermal capsulorrhaphy and capsular plication for subtle rotational instability and capsular laxity, lateral impact injury and chondral lesions, osteochondritis dissecans, ligamentum teres injuries, internal and external snapping hip, removal of loose bodies, synovial biopsy, subtotal synovectomy, synovial chondromatosis, infection, and certain cases of mild to moderate osteoarthritis with associated mechanical symptoms. In addition, patients with long-standing, unresolved hip joint pain and positive physical findings may benefit from arthroscopic evaluation. Patients with reproducible symptoms and physical findings that reveal limited functioning, and who have failed an adequate trial of conservative treatment will have the greatest likelihood of success after surgical intervention. Strict attention to thorough diagnostic examination, detailed imaging, and adherence to safe and reproducible surgical techniques, as described in this review, are essential for the success of this procedure.     

Magnetic resonance imaging of acetabular labral tears

The acetabular labrum plays an important role in hip biomechanical function and stability. Labral tears can result in appreciable clinical symptoms and joint dysfunction and may predispose the hip to chondral damage and osteoarthritis. Magnetic resonance imaging is an effective tool for detecting and characterizing labral tears. Direct magnetic resonance arthrography is the most commonly used and validated technique for evaluating the labrum. However, indirect magnetic resonance arthrography and non-arthrographic magnetic resonance imaging are two less invasive and less resource-intensive techniques that should also be considered. Orthopaedic surgeons and radiologists should strive to develop and implement minimally and noninvasive diagnostic magnetic resonance imaging protocols for the investigation of labral pathology.     

Patient Satisfaction after Arthroscopic Repair of Acetabular Labral Tears

Background

Acetabular labral tear is a main cause of hip pain and disability, often requiring surgical treatment. Improvements of hip arthroscopic technique have produced positive outcomes after labral repair with arthroscopy. The purpose of this study was to determine clinical outcomes and patient satisfaction after arthroscopic repair of acetabular labral tear.

Methods

We interviewed 21 patients (10 men and 11 women; mean age, 36 years [range, 22 to 57 years]) with acetabular labral tears that had been repaired arthroscopically in terms of satisfaction of the procedure. In addition, clinical outcome was assessed using visual analog scale (VAS) score, University of California, Los Angeles (UCLA) activity, Western Ontario and McMaster Universities (WOMAC) osteoarthritis index, and Harris hip score, and radiologic outcome was assessed using serial radiography. The patients were followed for 24-50 months.

Results

The mean Harris hip score was 73 points (range, 64 to 84 points) preoperatively and 83 points (range, 66 to 95 points) postoperatively. Fifteen hips (71%) were rated excellent and good. The mean WOMAC osteoarthritis index and VAS scores were improved at final follow-up. UCLA activity at the latest follow-up improved in 16 patients. The Tonnis grade of osteoarthritis at the latest follow-up did not change in all patients. Eighteen of the patients (86%) were satisfied with the procedure.

Conclusions

High rate of satisfaction after arthroscopic repair of acetabular labral tears is an encouraging outcome. Arthroscopic treatment of labral tears might be a useful technique in patients with hip pathologies, such as femoroacetabular impingement with labral tears.     

Four-Quadrant Approach to Capsulolabral Repair: An Arthroscopic Road Map to the Glenoid

Advancing technology, improved instrumentation, and a desire to address intra-articular pathology with a minimally invasive approach have driven the expansion of arthroscopic shoulder surgery in the past 2 decades. Proponents cite greatly improved visualization, lack of the need to perform a capsulotomy, fewer subscapularis issues postoperatively, and improved access to the entire glenohumeral joint. Our understanding and recognition of glenohumeral joint pathology have improved, and our ability to appropriately treat it has also improved. Aside from the anteroinferior and superior capsulolabral injury, orthopaedic surgeons have encountered and are able to address combined lesions, posterior labral tears, 270° to 360° labral tears, capsular laxity, humeral avulsion of the glenohumeral ligaments, associated glenoid or humeral bone loss, and partial-thickness rotator cuff tears. To adequately address the extent of pathology encountered in a shoulder instability case, access to the inferior, posteroinferior, and posterior aspects is necessary. In this technical article we present a simplified approach using safe access points by dividing the glenohumeral joint into 4 quadrants that allows for ease of instrumentation and implant placement. This will provide a blueprint for the treatment of capsulolabral injuries. In addition to portal selection and location, we will discuss several instruments we believe are advantageous in tissue manipulation and suture management.     

Acetabular labral tears of the hip: examination and diagnostic challenges

The purpose of this clinical commentary is to provide an evidence-based review of the examination process and diagnostic challenges associated with acetabular labral tears of the hip. Once considered an uncommon entity, labral tears have recently received wider recognition as a source of symptoms and functional limitation. Information regarding acetabular labral tears and their association to capsular laxity, femoral acetabular impingement (FAI), dysplasia of the acetabulum, and chondral lesions is emerging. Physical therapists should understand the anatomical structures of the hip and recognize how the clinical presentation of labral tears is difficult to view isolated from other hip articular pathologies. Clinical examination should consider lumbopelvic and extra-articular pathologies in addition to intra-articular pathologies when assessing for the source of symptoms and functional limitation. If a labral tear is suspected, further diagnostic testing may be indicated. Although up-and-coming evidence suggests that information obtained from patient history and clinical examination can be useful, continued research is warranted to determine the diagnostic accuracy of our examination techniques.     

Conservative management of an elite ice hockey goaltender with femoroacetabular impingement (FAI): a case report

Objective:

To detail the presentation of an elite male ice hockey goaltender with cam-type femoroacetabular impingement (FAI) and acetabular labral tears. This case will outline the prevalence, clinical presentation, imaging criteria, pathomechanics, and management of FAI, with specific emphasis on the ice hockey goaltender.

Clinical Features:

A 22-year old retired ice hockey goaltender presented to a chiropractor after being diagnosed by an orthopaedic surgeon with MRI confirmed left longitudinal and chondral flap acetabular labral tears and cam-type femoroacetabular impingement (FAI). As the patient was not a candidate for surgical intervention, a multimodal conservative treatment approach including manual therapy, electroacupuncture and rehabilitation exercises were implemented.

Summary:

FAI is prevalent in ice hockey players, particularly with goaltenders. Both skating and position-dependent hip joint mechanics involved in ice hockey may exacerbate or contribute to acquired and congenital forms of symptomatic FAI. As such, practitioners managing this population must address sport-specific demands in manual therapy, rehabilitation and physical training, to improve functional outcomes and prevent future injury.     

Influence of labral tears on the outcome of acetabular augmentation procedures in adult dysplastic hips. Prospective assessment with a minimum follow-up of 12 years

Lesions of the acetabular labrum have been suspected to be one factor responsible for failures of Chiari osteotomy. We undertook a prospective investigation to adress this question. Twenty-six adult patients (mean age 34.5 years) with 26 dysplastic hips were enrolled consecutively. All the hips studied showed arthritic changes. The labrum was inspected by arthroscopy during surgery (19 shelf acetabuloplasties and 7 Chiari procedures). All hips were followed for a minimum of 12 years (12-14 years). Sixteen dysplastic hips (62%) were found to have labrum tears. Computed tomography (CT)-arthrography findings were similar to arthroscopic observations in 13 hips. Coxomety results showed that the acetabular roof angle (HTE), cervico-diaphyseal angle (CDA) and lateralisation were higher in cases with acetabular labral tears. On the other hand, the ventral center-edge angle (VCEA) was lower in hips with labral tears. During the follow-up period, eight hips which had undergone a Chiari osteotomy were converted to total hip replacement. Adult dysplastic hips are at risk for presenting labral tears. Clinical signs appear to have limited diagnostic value. Coxa valga, a small lateral center edge angle and a high acetabular roof angle were found in this study to be associated with a higher incidence of labral tears. Contrary to previous data reported in retrospective studies, the results of the present prospective investigation suggest that labral tears do not compromise the outcome of acetabulum enlargement procedures.     

The Otto E. Aufranc Award: The role of labral lesions to development of early degenerative hip disease.

The current authors examined the hypothesis that labral lesions contribute to early degenerative hip disease. Between 1993 and 1999, 436 consecutive hip arthroscopies were done by the senior author. In addition, 54 acetabula were harvested from human adult cadavers. Two hundred forty-one of the 436 (55.3%) patients who had arthroscopies had a 261 labral tears, all located at the articular, not capsular margin of the labrum. Stereomicroscopic examination of the 54 acetabula from cadavers revealed 52 labral lesions. Overall, there was no significant difference between the arthroscopic and cadaveric populations in terms of the incidence of labral tears. (Overall, 73% of patients with fraying or a tear of the labrum had chondral change. Arthroscopic and anatomic observations support the concept that labral disruption and degenerative joint disease are frequently part of a continuum of joint disease.     

Editorial Commentary: Hip Primary Labral Repair Versus Reconstruction: Equally Successful Outcomes Can Be Achieved Based on Proper Indications

One of the core principles of hip arthroscopy is preservation of the acetabular labrum. Compromise of the biomechanical function of the labrum underlies a significant symptom source in patients undergoing hip preservation surgery. As surgical techniques continue to improve and evolve beyond labral repair, increased use of advanced arthroscopic procedures like segmental and circumferential reconstruction shed further light on the optimal labral intervention. In the revision setting, labral deficiency warrants labral reconstruction or augmentation. Both segmental and circumferential techniques may significantly improve patient-reported outcomes. However, in the primary setting, controversy exists not necessarily in the surgical technique, but more in the indications to perform which specific labral intervention. Reasonable indications for primary labral reconstruction include a calcified or ossified labrum, irreparable labral tissue, and hypotrophy of the labrum (less than 2-3 mm) with a proven deficient suction seal without resistance to axial distraction. Short-term multicenter studies demonstrate similar success rates between primary labral reconstruction and repair using validated patient-report outcome scores. Mid- and long-term clinical and economic investigations comparing labral reconstruction and repair are needed to determine the role of primary reconstruction in modern arthroscopic hip preservation surgery.     

Clinical diagnosis and arthroscopic treatment of acetabular labral tears

Objective: To investigate the clinical diagnosis and arthroscopic treatment of acetabular labral tears. Methods: Twenty‐one patients with unilateral acetabular labral tears hospitalized from November 2008 to December 2009 were included in this retrospective study. A definitive diagnosis was made preoperatively on the basis of physical examination, plain radiography and magnetic resonance arthrography (MRA). All cases were treated with arthroscopic surgeries: labral debridement (14 cases), labral debridement plus femoral osteoplasty (5 cases), and labral repair plus osteoplasty (2 cases). All patients were followed‐up and the results evaluated using the visual analogue scale (VAS) and Harris hip score. Results: A positive flexion, abduction and internal rotation (FADIR) impingement sign was found in all 21 affected hips, a positive flexion, abduction and external rotation (FABER) impingement sign in 15, and a positive McCarthy test in 9. Plain radiography showed 11 cases had cam type impingement, in 6 of whom it was combined with pincer type impingement; and 2 cases had acetabular retroversion alone. Labral tears were observed on MRA in all cases and were all confirmed by arthroscopy. All patients were followed up for an average of 11.6 months (range, 6 to 19 months). The VAS decreased from (5.3 ± 1.3) preoperatively to (1.4 ± 0.9) 6 months postoperatively. The mean Harris hip score improved from (63 ± 9) preoperatively to (84 ± 10) 6 months postoperatively. All these differences were statistically significant. Conclusions: Acetabular labral injury is closely correlated with femoro‐acetabular impingement. Impingement tests and MRA have high sensitivity and accuracy in clinical diagnosis of labral tears. Arthroscopic debridement, repair and osteoplasty for labral tears results in a good early outcome.