Labral tears

Epidemiology

Labral tear is extremely common in elderly people, less common in young adults. It is usually associated with developmental hip dysplasia (DDH) and trauma.

Classification

Cam type: The problem is on the femoral neck. Deformity of the femoral neck – Ganz bump. May be anterior or lateral. This results in enlarged head-neck junction, which leads to decrease head-neck offset, and impingement on the acetabular rim in flexion and internal rotation of the hip joint.

Pincer type: The problem is on the acetabular side. Results from over coverage by the anterior aspect of the acetabulum this is mostly due to acetabular retroversion.

Look at the AP X-Ray – the lines of the posterior and anterior acetabular walls should not cross. If they do, the cup is retroverted (“cross-over” sign).

Combined type: This is the commonest type of all.

Pathology 

Tear is located at the the cartilage-labrum junction (not the labrum-capsule junction)

Look for secondary changes: Femoral neck osteophytes, cysts, and adjacent acetabular rim oedema on MRI scan.

Clinical features

Groin pain, related to movement, worse on flexion, initially only with movement, but may progress to become continuous. Associated click. Provocation test is usually positive, best tested by flexion adduction and internal rotation (FADIR) of the hip joint.

Differential diagnosis

Snapping hip, internal or external, osteonecrosis of the femoral head, pigmented villonodular synovitis (PVNS), synovial chondromatosis and acute haemorrhage of ligamentum teres.

Treatment

Non-surgical includes activity modification, nonsteroidal anti inflamatories (NSAIDs), Corticosteroid injections. Poor efficacy (< 20% success).

Surgical treatment includes arthroscopic debridement this technique has good results with success rate between 85-90%. Open debridement. Ganz’s safe dislocation of the hip ( not commonly used due to the high risk of damaging the blood supply to the femoral head).

In general terms the aim is to remove of any Ganz bump, ring osteophytes of the acetabulum and labral debridement.

Hip Arthroscopy

Hip arthroscopy is an excellent minimally invasive operation that allows thorough visualization of the hip joint, diagnosing and addressing various pathology, inside and outside the hip joint. So far there is no radiographic study that is entirely sensitive or specific for the diagnosis of cartilage lesions such as labial tears or chondral damage. Hip arthroscopy is a technically demanding procedure, requiring in depth knowledge; therefore, this operation should not be performed without specific training and education in its methods.

Indications of hip arthroscopy:

• Diagnosis and treatment of labral pathology.
• Removal of loose bodies and foreign bodies.
• Osteochondral fragments and cartilage flap lesion.
• Synovial biopsy or limited synovectomy.
• Synovial chondromatosis.
• Wash out of infected joint as in septic arthritis.
• Evaluation of cartilage quality in avasculara vascular necrosis (AVN) mainly in early stages.
• Debridement of ruptured or impinging ligamentum tears.
• Assessment of the joint following fixation of a fracture acetabulum or femoral head.
• Assessment of a painful hip resurfacing or arthroplasty.
• Excision of osteophytes such as Ganz bump and acetabular spurs.
• Excision of impinging synovitis such as in case of collagen disease.
• Assessment of cartilage condition in dysplastic hip and perthes disease in adolescents.
• Debridement, joint wash-out and chondral microfractures may have a role in management of early arthritis especially in younger patients when it is advisable to delay joint replacement surgery as long as possible.

Contraindications:

This treatment is not advised if you have any of the following conditions: 

• Advanced hip arthritis,
• Acetabular protrusion,
• Hip ankylosis,
• Skin lesions at portal sites.

Technique:

The patient will be admitted into hospital for a day or overnight.

The procedure is performed under general anesthesia or spinal anesthesia.

Patient is positioned supine on a traction table, with traction through well padded peroneal post. The traction post is lateralised slightly against the operative leg to minimise risk to the pudendal nerve and to add a slight transverse component to the traction. The leg is positioned in neutral rotation, extension, and 25 degrees of abduction.

X-ray control using an image intensifier is used to gain access to the joint.

Two or three small incisions (portals) are made just above the bony prominence of the hip and instruments are inserted first to visualise and treat any spurs on the femoral neck or acetabulum then traction is applied and the instruments gain access to the hip joint to treat any pathology intra-articulary on the hip. These instruments can also smooth off rough surfaces, remove loose pieces of cartilage and excise bony osteophytes that may be causing a problem.

Sufficient traction is applied to open the joint by 7-8mm. The joint will open up with capsular creep and the spinal needle is inserted as the negative pressure in the joint is released.

Local anesthetic is injected into the hip and wound following the procedure.

Insert on occasions synvisc (lubrication that maybe can be injected).

Complications:

As with any operation, complications are possible but unlikely, these can include:

• Nerve injury – the pudendal nerve may be damaged by the traction post. This is usually temporary or rarely permanent.
• Permanent damage to the lateral femoral cutaneous nerve may occur in around 2%.
• Inadvertent chondral damage.
• Infection in the skin or deep in the hip in less than 1%.
• Vascular injury; resulting in excess bleeding.
• Ongoing pain; especially if there is significant arthritis.

Hip Arthroscopy: On the Mend

Dressings

The incisions are closed with absorbable cosmetic sutures and covered by a waterproof dressing.
The dressing remains intact for 7-10 days and will be removed by Dr Al Muderis during the first post operative review.
Keep the wounds dry.
Showering is advisable, applying warm water and soap gently to the wound, and then dry very well.

Pain and swelling

The hip and groin area will be painful and each patient will experience different levels of pain, but there should be no severe pain.
The patient will be prescribed analgesia and anti-inflammatories on discharge from hospital. It should be taken as prescribed and don’t wait for pain to set in.
Due to the traction during surgery there may be some numbness in the groin or thigh, but this should resolve.
Ice therapy around the incisions and groin will help (a maximum of 15 minutes per hour) for the first week until the inflammation subsides, then after one week keep the wound warm.

Mobilising

Once you recover from anesthetic you will be mobile and able to bear weight.
Crutches may be needed initially for support and safety.
Limping is expected for the first few weeks but you will notice a significant improvement in your gait (walking).

Exercise

Commence gentle exercise such as walking within a few days of surgery.
Hydrotherapy can commence after the wounds have been checked.
Non-impact exercises in the gym can commence within 7-10 days. Do strengthening exercises without deep flexion of the hip and use an exercise bike with the seat raised high.
Physiotherapy will improve range of motion, proprioception (strength), control and stability of the hip.

Exercise precautions

Avoid deep flexion.
No impact activity such as running for at least six weeks.

Concerns

Please contact the office if you are worried about your level of pain, have significant bleeding, or have fever or redness around the surgical site.
- Parramatta Office: (02) 9806 3333

If you require assistance after hours, please contact the hospital where the surgery was performed and they will contact Dr Al Muderis on your behalf.
- Norwest Private Hospital: (02) 8882 8882
- Sydney Adventist Hospital: (02) 9487 9111

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