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Acetabular Labral Pathologies and Interventions in Relation to Hip Joint Abnormalities

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Acetabular Labral Pathologies and Interventions in Relation to Hip Joint Abnormalities Iowa State University Capstones, Theses and Creative Components Dissertations Spring 2021 Acetabular Labral Pathologies and Interventions in Relation to Hip Joint Abnormalities Natalie Perez Follow this and additional works at: https://lib.dr.iastate.edu/creativecomponents Part of the Medical Anatomy Commons, and the Musculoskeletal System Commons Recommended Citation Perez, Natalie, "Acetabular Labral Pathologies and Interventions in Relation to Hip Joint Abnormalities" (2021). Creative Components. 781. https://lib.dr.iastate.edu/creativecomponents/781 This Creative Component is brought to you for free and open access by the Iowa State University Capstones, Theses and Dissertations at Iowa State University Digital Repository. It has been accepted for inclusion in Creative Components by an authorized administrator of Iowa State University Digital Repository. For more information, please contact [email protected]. Acetabular Labral Pathologies and Interventions in Relation to Hip Joint Abnormalities Natalie Perez Creative Component Iowa State University – One-year BMS program Abstract: The hip joint is pivotal for the basis of movement of the lower extremities. However, with increased movement often comes increased risk for injury. One of the most common injuries seen within the hip joint is damage to the acetabular labrum. There are various hip abnormalities that can attribute to these pathologies, but as knowledge of the labrum advances, these pathologies are becoming more commonly seen in athletes who have and isolated traumatic event or repetitive microtraumas to the hip joint seen in movements such as excessive pivoting and hyperextension of the hip. While the pain alone from a labral tear is enough for an individual to seek treatment, labral pathologies that are left untreated are also believed to contribute to the progression of early onset osteoarthritis of the hip joint. As labral pathologies are becoming more abundant in the world of sports medicine, the interventions also continue to evolve to better treat the pathologies. Introduction Whether it’s stepping out for a big race, running down the field to defend the ball, stepping up to the mound to pitch, or adjusting the body for the perfect pirouette, the hip is the foundation for movement of the lower body. The hip joint is often referred to as a 2 ball and socket joint surrounded by powerful, well-balanced muscles that allow for a wide range of motion while also keeping the lower half of the body stable (1). This wide range of motion, while great for movement, is also the basis for much of the injury that occurs in the lower extremities. The purpose of this review is to look specifically at the acetabular labral ligament and the pathologies that occur due to hip joint abnormalities that hinder one’s ability to compete at the level they once had and effects the ability to perform everyday tasks. The head of the femur makes up the ball portion of the joint, while the cup- shaped acetabulum of the pelvis constitutes the socket. While it is most often referred to as a ball and socket joint, it is better anatomically categorized as a diarthrodial joint meaning it contains a joint cavity, articular cartilage covering joint surfaces, synovial membranes, and is surrounded by a ligamentous capsule (1). Due to the joints unique anatomical structure, diagnostic challenges arise with diagnosing pathological conditions, yet one of the increasingly common pathologies that is being seen more regularly, particularly in athletes, is tears within the acetabular labrum (1-5), and these pathologies are the basis of this review. Within the hip joint, there are various ligaments that aid in the stability of the hip joint while allowing for a wide range of motion. These ligaments can be seen in Figure 1. While tears in the acetabular labrum were previously thought to be uncommon, they are now becoming diagnosed with increasing frequency due to improvements in MRI and arthroscopic surgical techniques (4, 5). While some studies suggest that labral abnormalities are a natural part of the aging process, other studies connect labral tears with joint pathology and pain (3). In a study conducted, it was reported that 93% of cadavers studied (average age of 78 years old) has at least one labral lesion (2). In comparison, a similar study looking at acetabular labral pathologies in a young (average age of 26) asymptomatic population, 38.6% were found to have labral tears (4). In 2009, the prevalence of labral tears in patients with hip or groin pain was reported to be 22- 55% (3), and in 2015, 90% of 300 hip arthroscopic cases were associated with labral tears (15). 3 Figure 1. Anatomical features of hip joint. Adapted from orthoinfo.aaos.org/en/diseases-- conditions/femoroacetabular-impingement/ (10) While interventions of acetabular labral tears have been seen as a controversial topic as the lack of vascularization within the labrum makes one question the ligaments healing abilities, today, treatment is more commonly being sought after as the labrum serves as shock absorber, joint lubricator, pressure distributor, and aids in the overall stability of the hip joint (4, 15). As seen in Figure 2, the acetabular labrum is a ligament that encompasses the outer ridge of the acetabulum with thinner portions in the anterior region and thicker in the posterior region (3). The ligaments circular shape is completed at the inferior portion by the transverse acetabular ligament (2, 3). Due to its all- encompassing shape, the labrum resists lateral and vertical motion of the femoral head and deepens the hip joint by 21%, while increasing the surface area of the acetabulum by 28%. The anterior and superior aspects of the labrum are thought to be the most innervated portions, consisting of free nerve endings and sensory nerve end organs which produce pain, pressure, and deep sensation (3). The vascular supply is provided by the obturator, superior gluteal and inferior gluteal arteries, however, blood supply is believed to be mostly peripheral with the outer one-third of the acetabular labrum being vascular, while the remaining majority is avascular (1,2, 3). Consisting of both fibrocartilage and dense connective tissue that attaches to the bony rim of the 4 acetabulum, the labrum is most often seen as a triangular shape, yet other variants such as round, irregular, and flattened have been noted in individuals with hip pain (3). Figure 2. Animation of acetabular labrum within the acetabulum of pelvis. Adapted from Lewis and Sahrmann (2006). Etiology Historically, acetabular labral pathologies were associated with structural abnormalities of the hip or high impact trauma, however, it is now proposed that there are at least five etiologies of labral tears: trauma, capsular laxity, dysplasia, degeneration, and femoroacetabular impingement. (1, 3, 14, 15). While labral injury can often occur due to an isolated traumatic event, it is more commonly associated with a gradual onset due to repetitive microtrauma due to repetitive forces into the connective tissue of the hip joint (5, 6). Isolated types of trauma are often seen in athletes with hip dislocations and acetabular fractures as this increases the susceptibility for hip labral tears (7). These individuals tend to have labral lesions in the posterior region of the labra, yet the magnitude of force will be the true determinant of whether the tear is initiated on the articular or acetabular side of the hip joint (7). Studies have shown that the hip hyperextension inherent in the stance of running leads to subtle instability and 5 increasing stress at the cartilage-labral junction (6). As this motion is repetitively performed during certain athletic activities the pattern of repeated hip hyperextension has been implicated as a mechanism of a torn labrum (6). Additionally, athletic activities that involve repetitive pivoting motions on a loaded femur, and excessive external rotation such as in soccer, hockey, golf, and ballet, have been associated with labral abnormalities as the repetitive motion causes microtrauma (3, 7). Capsular laxity or hypermobility of the hip has also been identified as a source of labral pathologies as excessive repetitive rotation places increased stress on the capsular tissue resulting in hip instability and increased pressure on the anterior superior labrum (4). Similarly, as seen in Figure 3, hip dysplasia results in inadequate containment of the femoral head within the acetabulum and often results in decreased joint surface area which causes increased stress on the acetabulum and labrum (2, 7). Pathologies of the acetabular labra due to dysplasia most often occur anteriorly but there have been studies linking posterior tears to hip dysplasia as well (7). Figure 3. Adapted from Lewis and Sahrmann (2006). Frontal views of a normal hip (left) and a dysplastic hip (right). 1. Center-edge angle or angle of Wiberg. Normally 30° to 40°, this angle represents the degree of femoral head coverage in the frontal plane. An angle of less than 30° is a characteristic sign of hip dysplasia. 2. Angle of inclination. This angle, between the femoral neck and the shaft of the femur, is normally 125°. In hips with dysplasia, it is most commonly increased but can also be decreased. 3. Head offset. This offset represents the perpendicular distance between the femoral head and the shaft. This distance often is decreased with dysplasia. Acetabular labral pathologies may also be associated with other intraarticular disorders such as degenerative diseases. Degenerative tears are seen with erosive 6 changes in the acetabulum, femoral head or both due to diseases such as Legg-Clave Perthes diseases, chronic slipped capital femoral epiphysis, femoral head anteversion, coxa vara, and extreme cases of coxa valga (2, 5, 7). Nevertheless, one of the most investigated sources of hip pain and labral tears is associated with femoroacetabular impingement (FAI) as FAI leads to limited hip range of motion. (3-9).
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