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    Hip Arthroscopy for a Labral Tear with FAI

    A 21-year-old collegiate hockey player presents with a 2-year history of right hip and groin pain that has increased in frequency and intensity. When an MRI arthrogram reveals a labral tear with mixed CAM and pincer FAI, the author recommends hip arthroscopy to address the issue.

    Author

    John P. Salvo, Jr. MD

    Disclosures

    The author has no disclosures relevant to this article.

    Background

    Hip arthroscopy and hip preservation procedures have advanced tremendously in the last few decades, and hip arthroscopic procedures are performed with increasing frequency annually.

    Most hip arthroscopies are performed to address acetabular labral tears with concomitant femoroacetabular impingement (FAI). FAI is generally caused by a congenital malformation off the femoral head-neck junction (CAM), which creates a bony conflict between the femur and the acetabular rim.

    This bony conflict results in increased mechanical loads causing damage to the acetabular labrum and articular cartilage. [1] The underlying anatomic abnormalities may be due to abnormal head-neck offset (CAM type), abnormal acetabular over-coverage (pincer type), or, commonly, a combination of the two. [1,2] FAI is often undetected until there is damage to the acetabular labrum, the acetabular cartilage, or both. [2]

    Hip arthroscopy has emerged as a powerful treatment modality for the painful hip with labral tears and FAI. [1,3-5] Arthroscopic hip labral repair plus femoral (femoroplasty) and/or acetabular (acetabuloplasty) osteoplasty has been shown to be a viable treatment option for patients with FAI seeking an improvement in pain and function. [1,3-5]

    Case Report

    Patient Presentation and History

    A 21-year-old collegiate hockey player presented with a 2-year history of right hip and groin pain. The pain was described as generally achy and intermittent sharp with certain movements, especially hip flexion. He has pain arising from a seated position, even getting off the bench and on the ice. The achy pain lingers after games and practice.

    The patient has not lost any game time secondary to his symptoms, but the frequency and intensity of the symptoms has been increasing. He has undergone therapy with the athletic trainer at his school, with little relief. He has taken NSAIDs as needed but has not had any injections.

    He denies pain with abdominal work or core strengthening, and denies any radicular symptoms down his leg.

    Physical Examination

    • Normal gait 
    • Range of motion: Flexion 100 degrees; internal rotation 20 degrees (at 90 degrees of flexion); external rotation 45 degrees (at 90 degrees of flexion)
    • Positive straight leg raise
    • Positive “C sign”
    • Positive tests: anterior impingement test, subspine impingement test, psoas impingement test

    Differential Diagnosis

    • FAI
    • Labral tear
    • Hip osteoarthritis
    • Psoas tendonitis
    • Core muscle injury/athletic pubalgia
    • Lumbar spine radiculopathy
    • Trochanteric bursitis
    • Iliotibial band syndrome
    • Hip adductor strain

    Imaging

    Hip series: Weight-bearing anteroposterior (AP), lateral, false profile, 45-degree Dunn view (Figure 1)

    • Tonnis 0
    • Positive CAM (alpha angle 64 degrees)
    • Positive crossover
    • Lateral CE angle

    Direct MRI arthrogram  (Figure 2)

    • Labral tear with a paralabral cyst
    • CAM impingement
    • Synovial herniation pit on the femoral head-neck junction



    Figure 1. Preoperative x-rays: AP pelvis (top), frog lateral (middle), 45-degree Dunn view (bottom), and false profile show Tonnis grade 0, alpha angle of 64 degrees, positive cross-over sign, lateral CE angle.

    Figure 2. Direct MR arthrogram (sagittal, left; coronal, right) demonstrating labral tear and CAM FAI.

    Diagnosis

    • Symptomatic labral tear with mixed FAI, CAM and pincer

    Treatment

    The patient underwent right hip arthroscopy for labral repair, femoroplasty, and acetabuloplasty. For the procedure, he was positioned supine on a hip distractor, with distraction confirmed on fluoroscopy. Anterolateral and modified anterior portals were placed and an interportal capsulotomy was performed.

    Central Compartment

    • Arthroscopic examination confirmed an acetabular labral tear from the 10 o’clock (medial) to the 1 o’clock (lateral) position. This was a full-thickness tear through the base (Figure 3). The femoral head cartilage was intact.
    • Acetabular cartilage showed Grade 2 changes in the area of the tear but no full-thickness defect in the cartilage. Chondroplasty was performed with a shaver.
    • The acetabular rim was exposed and the labrum mobilized (Figure 4).
    • A round burr was used to perform an acetabuloplasty/rim-trimming, and a bony bed was prepared for the labral repair. 
    • Percutaneously through a mid-anterior portal, 3 2.3mm composite suture anchors were placed on the acetabular rim (Figure 5).
    • A single arm of the suture was passed in a vertical mattress or loop-around fashion and secured with arthroscopic knots.

    Figure 3. Arthroscopic images of the central compartment showing a labral tear at the base with grade 2 acetabluar cartilage damage.

    Figure 4. Arthroscopic images of thed central compartment showing pincer impingement after mobilization of the labrum.

    Figure 5. Anchors placed percutaneously through the mid-anterior portal. All anchors were placed prior to tying secure arthroscopic knots to repair the labrum to the acetabulum.

    Peripheral Compartment

    • Examination with traction removed through the capsulotomies.
    • Suction-seal effect of the repaired labrum was confirmed (Figure 6).
    • An area of CAM impingement was identified arthroscopically, revealing a bony prominence on the anterolateral femoral neck that corresponded with the labral tear and acetabular cartilage damage.
    • A 5.5-mm round burr was used to perform a femoroplasty
    • Resection of the bony conflict was confirmed arthroscopically and fluoroscopically (Figure 7).
    • Dynamic arthroscopic exam revealed resolution of the bony conflict.

    Figure 6. Labral repair viewed from the peripheral compartment. The suction-seal effect of the repaired labrum was confirmed as the hip was released from traction.

    Figure 7. View from the peripheral compartment showing the repaired labrum and resolution of the bony conflict from the CAM lesion post-femoroplasty.

    Postoperative Care

    • Postoperative images are shown in Figure 8.
    • The patient was placed in a brace that limited hip flexion to 90 degrees. He was allowed toe touch weight-bearing for 2 weeks. 
    • Continuous passive motion was used on POD1. Formal physical therapy was initiated within the first postoperative week.
    • Sutures were removed at 10 days postoperatively.
    • Foot flat weight-bearing was allowed at 2 weeks, advancing to full weight-bearing by 4 weeks
    • At the 2-month follow-up visit, the patient had good pain-free passive motion, with flexion to 110 degrees, internal rotation between 20 and 30 degrees, and external rotation 30 degrees. He was noted to have full strength and negative impingement testing. 
    • Three months postoperatively, he was allowed to resume skating and non-contact drills. 
    • At the 4-month mark, he had full motion compared with his opposite side and full strength, with no pain. He was cleared for full contact and resumed full collegiate ice hockey activities.



    Figure 8. Postoperative x-rays: AP pelvis (top), frog lateral (middle), 45-degree Dunn view (bottom).

    Author Information

    John P. Salvo, Jr., MD, is an orthopaedic surgeon specializing in sports medicine at The Rothman Institute, Philadelphia, Pennsylvania. He is also a clinical associate professor of orthopaedic surgery at Thomas Jefferson University Hospital.

    Sports Medicine Section Editor, Rothman Institute Grand Rounds

    Fotios P. Tjoumakaris, MD

    References

    1. Bedi Asheesh, Kelly Bryan T.. Femoroacetabular Impingement The Journal of Bone and Joint Surgery (American). 2013;95:82+
    2. Register Brad, Pennock Andrew T., Ho Charles P., Strickland Colin D., Lawand Ashur, Philippon Marc J.. Prevalence of abnormal hip findings in asymptomatic participants: a prospective, blinded study. The American Journal of Sports Medicine. 2012;40:2720-2724
    3. Byrd J. W. Thomas, Jones Kay S.. Hip Arthroscopy for Labral Pathology: Prospective Analysis With 10-Year Follow-up Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2009;25:365-368.
    4. Kamath Atul F., Componovo Roger, Baldwin Keith, Israelite Craig L., Nelson Charles L.. Hip Arthroscopy for Labral Tears The American Journal of Sports Medicine. 2009;37:1721-1727.
    5. Philippon M. J., Briggs K. K., Yen Y. M., Kuppersmith D. A.. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction Journal of Bone & Joint Surgery, British Volume. 2009;91-B:16-23.