Cumulative Findings

Of the 436 patients who underwent hip arthroscopy 250 (54.8%) were noted to have labral tears. There were 130 females and 110 males. The average age of this patient group was 37.3 years (range, 14-72). There was minimal difference (1.7 years) between the average age of the male and female patients. All labral tears were located at the articular, and not at the capsular margin of the labrum. Almost all of these lesions (234, or 93.6%) were located in the anterior quadrant of the acetabulum. Posterior labral pathology was more commonly associated with a discrete episode of hip trauma, typically involving impact loading of the extremity, causing the femoral head to be driven posteriorly within the acetabulum.

Tears at more than 1 site around the labrum were relatively uncommon, with an overall prevalence of 8.4%. However, in the majority of cases with a lateral tear (6 of 8), and half the cases (15 of 30) with a posterior tear, an anterior labral lesion was also present. This strongly suggests that in some patients the labrum tears anteriorly, then posteriorly or laterally, either in response to the same acute incident, or with increasing instability with repetitive loading of the joint at the extremes of motion, in many patients who had anterior tears. None of the labral tears involved the capsular margin of the labrum. In fact, 100% of the tears occurred along the articular margin of the labrum.

Of the 436 subjects, 223 (49%) were noted to have labral fraying in regions where there was no frank disruption (tearing) of the labrum. (Note: Some of these regions of labral fraying were associated with frank labral tears in other locations.) This fraying universally involved the articular margin of the labrum directly adjacent to the labral-cartilage junction. Seventy-four (33%) of patients had anterior labral fraying; 88 (40%) of patients had lateral labral fraying; and 61 (27%) of patients had anterior-posterior labral fraying.

Among the total 436 subjects, 269 (59%) had anterior acetabular articular cartilage injuries; 110 (24.1%) had lateral acetabular articular cartilage injuries; and 114 (25%) had posterior acetabular articular cartilage injuries.

Anterior Labral Tears

Among the 234 hips with anterior labral tears, 6 (2.6%) had associated lateral labral tears, and 15 (6.4%) had associated posterior labral tears.

Figure 12.15. A grade III anterior acetabular articular cartilage lesion.

Figure 12.15. A grade III anterior acetabular articular cartilage lesion.

Acetabular Cartilage Lesion

One hundred sixty-one (68.8%) of these patients had associated anterior acetabular articular cartilage lesions (14.3% of which were grade III and 59.6% of which were grade IV). (Figure 12.15) Seventy-seven (32.9%) of these patients had associated lateral acetabular articular cartilage lesions (27.3% of which were grade III and 5.2% of which were grade IV). Eighty-two (35%) of these patients had associated posterior acetabulum articular cartilage lesions (22% of which were grade III and 15.9% of which were grade IV).

Among the 234 hips with anterior labral tears, the prevalence of associated anterior, lateral, and posterior femoral head articular cartilage injuries was 45.7%, 21.8%, and 23.9% respectively.

Anterior Labral Fraying

Among the 74 hips with anterior labral fraying in the absence of a frank anterior labral tear, none had associated lateral labral tears, and only 3 (4%) had associated posterior labral tears. (Figure 12.16.)

Thirty-nine (53%) of these patients had associated anterior acetabular articular cartilage lesions (23% of which were

Figure 12.16. A posterior labral tear.

Figure 12.16. A posterior labral tear.

Femoral Head ArthritisChrondal Flap
Figure 12.17. A focal full-thickness chondral flap lesion.

grade III and 10% of which were grade IV). Thirteen (18%) of these patients had associated lateral acetabular articular cartilage lesions (46% of which were grade III and 23% of which were grade IV). Eleven (15%) of these patients had associated posterior acetabulum articular cartilage lesions (27% of which were grade III and 9% of which were grade IV).

Among the 74 hips with anterior labral fraying in the absence of a frank anterior labral tear, the prevalence of asso ciated anterior, lateral, and posterior femoral head articular cartilage injuries was 72%, 26%, and 23%, respectively.

Anterior Acetabular Articular Cartilage Lesions

Among the 269 hips with anterior acetabular articular cartilage lesions, 29 (10.8%) were grade I; 51 (19.0%) were grade II; 42 (15.6%) were grade III; and 147 (54.6%) were grade

Figure 12.18. Localized full-thickness chondral wear (with no associated chondral flap).
Femoral Head Arthritis

IV. There were three distinct patterns of grade IV lesions: Focal full-thickness chondral flaps (Figure 12.17); localized full-thickness chondral wear with no associated chondral flap (Figure 12.18); and full-thickness wear associated with global degenerative joint disease (Fig 12.19). Thirteen (8.8%) of the 147 patients with grade IV anterior acetabular articular carti lage lesions demonstrated degeneration throughout the involved hip.

The anterior acetabular grade IV lesions that consisted of chondral flaps frequently manifested the following constellation of features: They were associated with an adjacent tear of the articular margin of the anterior labrum (Figure 12.20);

Figure 12.20. A chondral lesion associated with an adjacent tear of the articular margin of the anterior labrum.
Anterior Labrum

the free margin of the articular chondral flap emanated from the adjacent anterior labral tear (Figure 12.21); the intact hinge of the articular flap was located medially. Chondral flaps in other regions of the acetabulum were present far less frequently, and they rarely presented with a similar constellation of features when they did occur.

Among patients with anterior acetabular articular cartilage lesions, the prevalence of associated anterior, lateral, and posterior labral tears was 59.9%, 2.6%, and 7.8%, respectively.

The prevalence of associated anterior, lateral, and posterior femoral head articular cartilage lesions in this subset of patients was 60.2%, 23%, and 23%, respectively.

Of these patients, 106 (39.4%) had associated posterior acetabular articular cartilage lesions (17.9% of which were grade III and 13.2% of which were grade IV). One hundred one (37.5%) of these patients had associated lateral acetabu-lar articular cartilage lesions (23.8% of which were grade III and 4.9% of which were grade IV).

Lateral Labral Tears

Among the 8 hips with lateral labral tears, 6 (75%) had associated anterior labral tears. Seven (88%) of the patients with lateral labral tears had associated anterior acetabulum articular cartilage lesions (25% of which were grade III and 38% of which were grade IV). Four (50%) of these patients had associated lateral acetabular articular cartilage lesions (13% of which were grade III and none of which were grade IV). Four (50%) of these patients had associated posterior acetab-ular articular cartilage lesions (25% of which were grade III and none of which were grade IV).

Among the 6 hips with lateral labral tears, the prevalence of associated anterior, lateral, and posterior femoral head articular cartilage injuries was 100%, 50%, and 50%, respectively.

Lateral Labral Fraying

Among the 88 hips with lateral labral fraying in the absence of a frank lateral labral tear, 9 (10.2%) had associated posterior labral tears, and 66 (75%) had associated anterior labral tears.

Seventy-six (86%) of these patients had associated anterior acetabular articular cartilage lesions (7% of which were grade III and 70% of which were grade IV). Forty-seven (53%) of these patients had associated lateral acetabular articular cartilage lesions (28% of which were grade III and 2% of which were grade IV). Forty-eight (55%) of these patients had associated posterior acetabular articular cartilage lesions (19% of which were grade III and 17% of which were grade IV).

Among the 88 hips with lateral labral fraying, in the absence of a frank lateral labral tear, the prevalence of associated anterior, lateral, and posterior femoral head articular cartilage injuries was 73%, 48%, and 39%, respectively.

Lateral Acetabular Articular Cartilage Lesions

Among the 110 hips with lateral acetabular articular cartilage lesions, 21 (19.1%) were grade I; 59 (53.6%) were grade II; 23 (20.9%) were grade III; and 7 (6.4%) were grade IV. Two (28.6%) of the 7 patients with grade IV lateral acetabular articular cartilage lesions had diffuse hip degeneration.

The prevalence of associated anterior, lateral, and posterior labral tears in this subset of patients was 70%, 3.6%, and 13.6%, respectively. The prevalence of associated anterior, lateral, and posterior femoral head articular cartilage lesions in this subset of patients was 69.1%, 59.1%, and 47.3%, respectively.

Eighty-three (75.5%) of these patients had associated posterior acetabular articular cartilage lesions (14.5% of which were grade III and 10.8% of which were grade IV). Of these patients, 102 (92.7%) had associated anterior acetabular articular cartilage lesions (11.8% of which were grade III and 65.7% of which were grade IV).

Posterior Labral Tears

Among the 30 hips with posterior labral tears, 15 (50%) had associated anterior labral tears. Posterior labral pathology was more commonly associated with a discrete episode of hip trauma, which typically involved a mechanism whereby the femoral head was driven posteriorly within the acetabulum. Fraying of the labrum, in the absence of frank separation of the labrum from the articular surface, was observed in 162 cases (36% 0f 456). Seventy-five (46%) of these patients were female and 87 were male (54%). The average age of this patient group was 40.0 years (range 14 to 72), 3 years older than patients with labral tears. There was no significant difference between the average ages of the male and female patients.

There were no instances of fraying and frank labral separation. (Note: Some of these regions of labral fraying were associated with frank labral tears in other locations.) In every instance, the frayed tissue involved the articular margin of the labrum directly adjacent to the labral-cartilage junction. There was a relatively uniform distribution of the frayed regions around the circumference of the acetabulum: 74 (33%) cases were located in the anterior acetabulum, 88 (40%) were lateral, and 61 (27%) were posterior.

There were two distinct patterns of association between frayed areas of the labrum and discrete labral lesions. Almost all cases of anterior fraying occurred in acetabula without a labral tear. Conversely, 75% of cases with posterior fraying (46 of 61) or lateral fraying (66 of 88) also had a tear of the anterior labrum. This suggests that anterior labral tears lead to a disruption of stability of the joint, causing abnormal motion between the labrum and the femoral head laterally or posteriorly, leading to localized fraying of the labrum. Another possibility is that, in the face of an anterior tear, the labrum gives way slightly in extremes of external rotation, leading to sliding of the femur in contact with the labrum. With repetitive loading, this in turn could lead to fraying of the labrum.

Twenty-one (70%) of these patients had associated anterior acetabular articular cartilage lesions (24% of which were grade III and 48% of which were grade IV). Fifteen (50%) of these patients had associated lateral acetabular articular cartilage lesions (20% of which were grade III and none of which were grade IV). Thirteen (43%) of these patients had associated posterior acetabular articular cartilage lesions (15% of which were grade III and 15% of which were grade IV).

Among the 30 hips with posterior labral tears, the prevalence of associated anterior, lateral, and posterior femoral head articular cartilage injuries was 47%, 27%, and 23%, respectively.

Posterior Labral Fraying

Among the 61 hips with posterior labral fraying in the absence of a frank posterior labral tear, none had associated lateral labral tears, and 46 (75%) had associated anterior labral tears.

Fifty (82%) of these patients had associated anterior ac-etabular articular cartilage lesions (8% of which were grade III and 60% of which were grade IV). Thirty-seven (61%) of these patients had associated lateral acetabular articular cartilage lesions (27% of which were grade III and 54% of which were grade IV). Thirty-five (57%) of these patients had associated posterior acetabular articular cartilage lesions (20% of which were grade III and 17% of which were grade IV).

Among the 61 hips with posterior labral fraying in the absence of a frank posterior labral tear, the prevalence of associated anterior, lateral, and posterior femoral head articular cartilage injuries was 74%, 46%, and 43%, respectively.

Posterior Acetabular Articular Cartilage Lesions

Among the 114 hips with posterior acetabular articular cartilage lesions, 21 (18.4%) were grade I; 52 (45.6%) were grade II; 24 (21.1%) were grade III; and 17 (14.9%) were grade IV. Five (29.4%) of the 17 patients with grade IV posterior ac-etabular articular cartilage lesions had diffuse hip degeneration. Posterior acetabular articular cartilage pathology was more commonly associated with a discrete episode of hip trauma, which typically involved a mechanism whereby the femoral head was driven posteriorly within the acetabulum.

The prevalence of associated anterior, lateral, and posterior labral tears in this subset of patients was 71.9%, 3.5%, and 11.4%, respectively.

The prevalence of associated anterior, lateral, and posterior femoral head articular cartilage lesions was 75.4%, 61.4%, and 50.8%, respectively.

Eighty-three (72.8%) of these patients had associated lateral acetabular articular cartilage lesions (27.7% of which were grade III and 3.6% of which were grade IV). One hundred six (93%) of these patients had associated anterior ac-etabulum articular cartilage lesions (9.4% of which were grade III and 64.2% of which were grade IV).

Cartilage Lesions

On arthroscopic examination, 329 patients (72%) had some form of injury to the acetabular cartilage. Of these patients, 171 (52%) were female and 158 (48%) were male. The average age of this patient population was 37.8 years (range 14 to 82). There was minimal difference in ages between males and females (1.1 years). Discrete chondral lesions were present anteriorly in 269 cases (59%), posteriorly in 110 cases (24.1%), and laterally in 114 cases (25%). The severity of cartilage pathology also varied with anatomic location within the socket. This is reflected in the average Outerbridge score, which was 3.17 (of a possible 4) anteriorly, 2.33 posteriorly, and 2.14 laterally. Similarly, 55% of anterior lesions involved exposure of subchondral bone (Outerbridge IV), compared with 15% of posterior lesions, and only 6% of lateral lesions.

There were 3 distinct patterns of grade IV lesions: Focal full-thickness chondral flaps; localized full-thickness chon-dral wear with no associated chondral flap; and full-thickness wear associated with global degenerative joint disease. The anterior acetabular grade IV lesions that consisted of chon-dral flaps frequently manifested the following constellation of features. They were associated with an adjacent tear of the articular margin of the anterior labrum; the free margin of the articular chondral flap emanated from the adjacent anterior labral tear; the intact hinge of the articular flap was located medially. Chondral flaps in other regions of the acetabulum were present far less frequently, and they rarely presented with a similar constellation of features when they did occur. Cases of diffuse degeneration of the articular surface were relatively rare, ranging from 4.8% anteriorly, 4.5% posteriorly, and only 1.8% laterally.

The Relationship of Labral and Chondral Pathology

There were highly significant associations between the presence of labral lesions and degeneration of the articular surface. Overall, 74% of patients with fraying or a tear of the labrum had chondral damage. Moreover, in 80% of these patients, labral and articular lesions were located in the same zone of the acetabulum. The strongest association between articular damage and labral pathology was present posteriorly and laterally; in both zones, only 12% of patients with cartilage lesions did not have a labral defect. Anteriorly, this was true in 29% of cases.

The severity of cartilage pathology was also greater in patients with labral tears or fraying. Of the 202 cases with a labral tear, 136 (67%) had a serious articular lesion (Outerbridge II, III, or IV), and 40% had full-thickness erosion. In comparison, the prevalence of these lesions in acetabula without labral tears was 43% and 21%, respectively (p < 0.0001). Stronger correlations were observed with fraying of the labrum, the presence of a frayed area being associated with more than twice the incidence of serious chondral defects (56% vs 21%) and full-thickness lesions (48% vs 22%). The strongest associations were observed when fraying and tears were combined as indicators of labral pathology. Of 193 patients with serious articular degeneration, only 14 (7%) had an intact labrum without fraying or a tear, compared to 43% of patients with little or no articular pathology (p < 0.0001).

The incidence of labral lesions (tears and fraying) and serious cartilage lesions (Outerbridge II, III, IV) was calculated for patients grouped by decade of age. With the exception of the youngest patient group (14-19 years), the incidence of labral pathology rose steadily with age to 34% in the 50-59 age group (p < 0.0001). Labral tears and fraying were almost universal in patients older than 60 years. Similarly, the frequency and severity of cartilage degeneration also increased with age, with an incidence of 24% in patients under 30, and 81% in those over 60 (p < 0.0001).

Dysplasia

Seventy (15.4%) of the 436 arthroscopy cases manifested mild to moderate occult (Crowe I) developmental hip dysplasia. Among the patients with dysplasia, there was a 48.6% prevalence of anterior labral tears, a 4.3% prevalence of posterior labral tears (all of which also had anterior labral tears), a 0% prevalence of isolated posterior labral tears, and also a 0% prevalence of lateral labral tears. The anterior labrum frequently demonstrated a bulbous, hypertrophied morphology in the context of dysplasia. (Figure 12.22.)

It should be noted that the prevalence of anterior labral tears in this subset of patients (48.6%) is quite similar to the prevalence of anterior labral tears in the study cohort as a whole (51.3%). However, the prevalence of lateral and posterior labral tears was lower in the dysplastic subset in comparison to its respective prevalence in the entire study cohort.

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