Clinical Aspects of Pathologic Labral Conditions

Patients with labral tears will present with anterior inguinal pain, clicking sensation ,sensation of instability,locking of the joint etc Pain classically occurs on flexion combijned with internal rotation.. An audible click may also be present. [14]The patient history may reveal repetive use, history of fall ,dislocation, abnormal hip condition in small age group.  Radiographs in patients with labral tears are typically unremarkable. If early osteoarthritic disease is present, the pain is out of proportion to the radiographic changes.

The most accepted treatment of  labral tears is arthroscopic resection rather than doing open arthrotomy, but the unfortunate part is that it is not widely availaible.The result are good in early degenerative changes and doubtful in severe degenerative changes.

Patients with abnormality of femoral head like in developmental dysplasia or abnormality of acetabulum are at increased risk for labral tears and detachment because of abnormal stresses on labrum. This situation results in rim fragmentation and intraosseous cyst formation. In developmental dysplasia of the hip where the femoral head and acetabulum are incongruent, the acetabulum is vertical and the acetabular radius is greater than the femoral head radius; thus, abnormal shearing forces placed on the labrum lead to labral hypertrophy and detachment. [15]Perilabral cysts accompany this form of developmental dysplasia of the hip. The possibility of a pathologic labral condition should be considered in individuals with developmental dysplasia of the hip in whom the pain is disproportionate to the radiographic changes, as well as in patients who have not experienced significant improvement after osteotomy. The fact that a detached labrum increases the risk of failure of treatment has been recognized.

 

 

Figure 9 a) Labrum in developmental dysplasia of hip

 

Figure 9 b) contrast in the acetabular roof cyst

 

Marked developmental dysplasia of the hip in a 35-year-old woman. (a) T1-weighted MR image depicts a short acetabular roof. The labrum is markedly abnormal, having lost its triangular shape, and it has diffuse intermediate signal intensity (arrowheads). Its normal attachment to the acetabular rim has been disrupted (arrow). (b) Fat-suppressed T1-weighted axial MR image through the acetabular roof depicts a contrast-enhanced cyst within the soft tissues (long arrows), as well as its intraosseous extension into the anteroinferior iliac spine (short arrow).

 

Use of intraarticular contrast material is necessary to differentiate torn and detached labra from other forms of pathologic labral conditions). This includes separating internal signal intensity abnormalities secondary to tears from those due to other causes, as well as separating the normal signal intensity at the labral-acetabular junction from that secondary to detachment. The sensitivity and accuracy of MR arthrography for detection of labral tears and detachments is 90% and 91%, respectively, versus 30% and 36% for nonarthrographic MR images.

Detachments are the most common form of pathologic labral conditions. Detachments are identified on the basis of the presence of contrast material interposed at the acetabular-labral junction with or without accompanying displacement of the labrum. This signal intensity has been ascribed to cartilage degeneration, fissures, partial detachment, and irregular insertion of fibrocartilage onto subchondral bone. Most labral tears occur in the anterior through superior regions of the labrum. Tears of the posterior and posterosuperior labra have been identified in younger patients. Tears are recognized on the basis of the presence of intrasubstance contrast material. Chondral defects accompany approximately 30% of labral tears and detachments.

Figure 10.a) Bucket handle tear of labrum in DDH coronal image

Figure 10.b) Bucket handle tear of labrum in DDH  saggital image

Bucket handle labral detachment in a 17-year-old girl with developmental dysplasia whose pain was out of proportion to radiographic changes. (a) T1-weighted coronal MR image obtained with intraarticular contrast material demonstrates contrast material interposed along the entire superior acetabular-labral interface (arrowheads). (b) Fat-suppressed T1-weighted  sagittal MR image obtained with intraarticular contrast material shows that the detachment involves the anterior and anterosuperior labrum (arrowheads).

 

Figure 11 .a) Labral tear

 

Figure 11.b) labral tear

 

Figure 11. c) loss of articular cartilage

 

MR images of acetabular cartilage defect adjacent to complete labral tear in a 32-year-old man. a).b) and c) images clearly show the complete labral tear (large arrow in a and b) in the anterosuperior part of the labrum and the adjacent loss of articular cartilage (arrowheads) in the anterior part of the left superior acetabulum. Intact femoral cartilage (small arrows in a and b) in the corresponding area also is seen. The contrast material within the joint space is visible only in the area of cartilage loss.

 

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