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CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 405, pp. 122128


2002 Lippincott Williams & Wilkins, Inc.

Acetabular Dysplasia: A Paradigm of


Arthroscopic Examination of
Chondral Injuries
Joseph C. McCarthy, MD; and Jo-ann Lee, RN

The current authors show the value of arthro- etabulum. The mechanism of injury is most
scopy in diagnosing labral and acetabular carti- likely hyperextension or torque of the hip or
lage injury and examining the relationship be- both. The ndings in the current study support
tween those injuries and acetabular dysplasia. the concept that labral disruption frequently is
Between 1989 and 2000, 170 hips in 163 patients a predecessor in the continuum of degenerative
with mild acetabular dysplasia or moderate dys- joint disease.
plasia with joint preservation had arthroscopic
evaluation. Surgical ndings were classied by
location and by severity of the chondral lesions Hip dysplasia is a well-recognized cause of ac-
of the femoral head, acetabulum, and labrum. celerated joint wear. When severe and associ-
Of the 170 hips with dysplasia, 122 had labral
ated with instability, the young patient with
tears (72%) at the free-margin articular sur-
face and 113 had anterior tears (66%). One hun-
dysplasia may require redirectional osteotomy.
dred hips (59%) had anterior acetabular chon- Several authors have reported improvement in
dral lesions. Among the 113 patients who had joint biomechanics and reduced cartilage pres-
anterior labral tears, 78 hips (69%) had anterior sure after acetabular osteotomy.7,11,12 Enlarge-
acetabular chondral defects, and 44 hips (39%) ment and tearing of the labrum have been re-
had anterior femoral head chondral lesions. ported in association with dysplasia. Harris et
Mild uncovering of the anterior femoral head al10 observed eight degenerated, intraarticular
subjects the labrum to increased load and po- labrums in patients with dysplasia who were
tential susceptibility to tearing most frequently having total hip replacement. Some authors also
anteriorly. Labral tears may contribute to or have suggested that alterations of the labrum
can occur in association with articular cartilage
may predispose the patient to osteoarthritis sec-
lesions of the contiguous femoral head or ac-
ondary to destabilization of the acetabular labral
complex.1,2,9,16
From the New England Baptist Hospital, Boston, MA. Milder forms of dysplasia often are unrecog-
Joseph C. McCarthy, MD, is consultant to Innomed, Sa- nized unless the contralateral hip has been treated
vannah, GA, Arthrex Corporation, Naples, FL. for more severe involvement. Conventional ra-
Reprint requests to Joseph C. McCarthy, MD, New En- diographs, including high-contrast gadolinium-
gland Baptist Hospital, 125 Parker Hill Avenue, Boston,
MA 02120. Phone: 617-738-6710; Fax: 617-566-2257; enhanced magnetic resonance imaging (MRI)
E-mail:jlee1@caregroup.harvard.edu. scans of patients with hip dysplasia are not al-
DOI: 10.1097/01.blo.0000038058.29678.54 ways sensitive enough to diagnose a labral tear

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Number 405
December, 2002 Acetabular Dysplasia 123

Fig 1AB. (A) An anteroposterior radiograph shows a patient with mild dysplasia. (B) A false prole
radiographic view of a patient with mild dysplasia is shown.

or chondral lesions. Standard anteroposterior toms referable to the involved hip. These symp-
(AP) radiographs of the pelvis do not reveal toms most frequently consisted of anterior inguinal
the extent of anterior femoral head uncoverage pain associated with catching episodes or locking
(Fig 1A). Although a false prole view of in 114 hips (67%) and buckling in 48 hips (28%).
The pain did not respond to activity modication,
Lequesne and a computed tomography (CT)
nonsteroidal antiinammatory drugs, physical ther-
scan will assess the extent of acetabular bony apy, or time (minimum 4 months). Thirteen patients
deciency more accurately, these studies do not (8%) had pain develop secondary to an acute trau-
show the articular cartilage13,16 (Fig 1B). matic event. Seven patients (4%) had a sport-induced
The purpose of the current study was to injury and 150 patients (88%) could not recall a
arthroscopically diagnose and treat labral and specic inciting event.
acetabular cartilage injuries, and examine the On evaluation, 117 (69%) patients had a posi-
relationship between acetabular dysplasia and tive McCarthy sign (with both hips fully exed, the
those injuries. patients pain is reproduced by extending the af-
fected hip, rst in external rotation, then in internal
rotation). In addition, 91 patients (54%) had in-
MATERIALS AND METHODS guinal pain develop with exion, adduction, and in-
ternal rotation of the hip. Thirty-six patients (21%)
Between 1989 and 2000, 170 hips in 163 patients also had anterior inguinal pain with ipsilateral re-
identied with mild acetabular dysplasia were eval- sisted straight leg-raising. All patients with these
uated arthroscopically because of symptoms that inclusion criteria had arthroscopic evaluation of
did not respond to conservative treatment. There their hip.
were 119 females and 44 males. Their average age On radiographic examination, mild dysplasia
was 35 years (range, 1258 years). There were 69 was dened as a center-edge angle of Wiberg as re-
left hips involved and 101 right hips involved. Each ported by Massie and Howorth14 of between 22
of these patients was evaluated because of symp- and 28 and moderate dysplasia was dened as an
Clinical Orthopaedics
124 McCarthy and Lee and Related Research

angle between 16 and 22. In addition, a patient


was considered to have dysplasia if the lateral roof
angle was 0 or upsloping. One hundred forty-four
hips (85%) in this series had mild dysplasia and 26
hips (15%) had moderate dysplasia. Excluded from
the study were patients with less than 2 mm joint
space shown on plain radiographs.
The arthroscopic examination allowed compre-
hensive investigation of the articular surfaces of the
femoral head, the acetabulum, the entire labrum, ac-
etabular fossa, and the synovium. This outpatient
procedure was done with the patient under general
or spinal anesthesia in the lateral decubitus position
using a specialized distraction device (Innomed, Sa-
vannah, GA). Two or three peritrochanteric portals
were sufcient to evaluate the joint thoroughly.17
Surgical time averaged 41 minutes (range, 2664
minutes).
Data for each procedure were recorded in the se- Fig 2. An arthroscopic photograph of an anterior
labral tear in a patient with mild dysplasia is shown.
nior authors prospective database. Clinical and fol-
lowup details were culled from patient records, an
outcome questionnaire, and direct patient commu-
nication. Surgical ndings and abnormalities were these lesions (13%) were Outerbridge Grade I,
recorded for the chondral surfaces of the femoral 23 (23%) were Grade II, 21 (21%) were Grade
head, acetabulum, labrum, acetabular fossa, and syn- III, and 43 (43%) were Grade IV (Fig 4). Fifty-
ovium. In addition, loose bodies were recorded, if
four hips (32%) had anterior femoral head
present. Acetabular and femoral head chondral le-
sions were classied by location (anterior, superior,
chondral lesions. Thirteen (24%) of the defects
posterior) and by severity using the criteria of Out- were Outerbridge Grade I, 16 (30%) were
erbridge (Grades IIV).19 Labral abnormalities also Grade II, 15 (29%) were Grade III, and 10
were described by location (posterior, lateral, ante- (19%) were Grade IV. In the 24 patients with
rior) and substance (articular free-margin or capsu- moderate dysplasia, 13 (54%) had Outerbridge
lar tear). Grade III or IV changes compared with 12
Synovial changes were described as being pre- (8%) with mild dysplasia.
sent or absent, focal (adjacent to a cartilage lesion)
or diffuse, or impinging (between femoral head and
socket) or not impinging. The ligamentum teres was
described as being avulsed or not being avulsed.

RESULTS

Of the 170 hips with dysplasia, 122 had labral


tears (72%). Eight of these tears were poste-
rior (5%), one tear was lateral (0.6%), and 113
hips had an anterior labral tear (66%) (Fig 2).
Every labral tear occurred at the margin of the
articular surface, not at the margin adjacent to
the capsule. All of the tears could be displaced
when probed with an arthroscopic hook.
One hundred hips (59%) had anterior ac- Fig 3. An arthroscopic photograph of a chondral
etabular chondral lesions (Fig 3). Thirteen of ap in a patient with mild dysplasia is shown.
Number 405
December, 2002 Acetabular Dysplasia 125

lesion was Grade III, and in six hips (13%)


there was a Grade IV Outerbridge defect.
Of the patients with dysplasia who had an
anterior labral tear and associated acetabular
chondral lesions, 42 hips (54%) had a lesion of
the subadjacent femoral head. Ten of these
hips (24%) were Grade I, 13 hips (31%) were
Grade II, 14 hips (33%) were Grade III, and
ve hips (12%) were Grade IV.
Seventeen patients in the current series had
total hip arthroplasty (10%). This was more
frequent in patients with moderate dysplasia
(13 of 24, 54%). The average length of time
from arthroscopy to arthroplasty was 2.5 years
Fig 4. An arthroscopic photograph of Outer- (range, 16 years). In contrast, only four of
bridge Grade IV chondral damage in a patient 146 hips (3%) with mild dysplasia eventually
with moderate dysplasia is shown. had total hip replacement. Despite their mini-
mal degenerative changes on plain radio-
graphs, all four had arthroscopic ndings of
Ligamentum teres hypertrophy or avulsion Outerbridge Grade III or IV anterior acetabu-
has been described in patients with dyspla- lar chondral lesions in addition to a labral tear.
sia.21,24 In the current series, there were no pa-
tients with mild dysplasia and a hypertrophic, DISCUSSION
impinging ligamentum. In addition, there were
no patients with rupture of the ligament. Syn- The effects of acetabular dysplasia on hip bio-
ovitis was present in 118 hips (69%). In gen- mechanics are being increasingly understood.
eral, the synovitis was focal and located in In its severest form, dysplasia often results in
the same quadrant as the cartilage lesion. It total joint arthroplasty at a young age. More
became diffuse only in patients with large moderate degrees of femoral head uncovering
Outerbridge Grade IV lesions. Synovial im- may produce joint pain, instability, and re-
pingement between the femoral head and ac- markable increases in articular cartilage con-
etabulum was uncommon, occurring in 22 tact pressure.11 In these patients, a redirec-
hips (13%). The hypertrophic synovial tissue tional pelvic osteotomy, properly timed and
was present only in patients with labral or executed, can signicantly reduce these ex-
chondral lesions and was more prevalent in cessive load pressures and improve anterolat-
patients with symptoms greater than 1 year. eral head coverage.18 Mild forms of dysplasia,
Among the 113 patients who had anterior however, often are unrecognized unless there
labral tears and mild dysplasia, 78 hips (69%) are compelling joint symptoms or the opposite
had anterior acetabular chondral defects. In hip previously has been treated for this condi-
seven of these hips (8%) the lesion was Grade tion. A partial explanation for the underre-
I, in 16 hips (21%) the lesion was Grade II, in porting is the standard screening radiographs
20 hips (26%) the lesion was Grade III, and in of the hip. Anteroposterior and shoot through
35 hips (45%) the lesion was Grade IV. views taken with the patient supine do not
Of the 113 patients with dysplastic hips and show the anterior column uncovering or sub-
labral tears, 44 hips (39%) had anterior femo- tle lateral femoral head translation as do radio-
ral head chondral lesions. In 10 of these hips graphs taken standing. The false prole view
(23%) the lesion was Grade I, in 14 hips (32%) of Lequesne is much more likely to recognize
the lesion was Grade II, in 14 hips (32%) the the anterior deciency.13 More sophisticated
Clinical Orthopaedics
126 McCarthy and Lee and Related Research

radiologic testing such as CT scanning and The current study of 170 hips with acetab-
MRI with three-dimensional reconstruction ular dysplasia reports the largest series of
also can readily identify and quantitate the skeletally mature adults with this condition
magnitude of the dysplasia. whose hips have been observed and treated
Although each of these radiographic tech- arthroscopically. The extent of joint problems
niques shows the bony architecture of the hip, present in this previously active group is re-
they do not reliably assess the articular cartilage markable. Seventy-two percent of hips had
changes present. Attempts at single or double labral tears. This is a substantially greater per-
contrast arthrography to show labral or acetab- centage than in other large arthroscopic se-
ular cartilage proved to be neither sensitive ries.6,16,24 As in the senior authors previous
nor specic. As MRI scanning techniques im- experience, the majority of labral lesions oc-
proved, better resolution of labral structures curred anteriorly (93% in the current series).
were reported.20 In contrast however, when Of concern however, is the 59% of hips that
MRI scans were compared directly with arthro- had anterior acetabular chondral lesions 64%
scopic ndings, conventional MRI studies of which were Outerbridge Grade III or IV in
missed several joint disorders including labral severity. In the current series and in a prior se-
tears, acetabular chondral ap lesions, and ries, all of the acetabular lesions initiated pe-
chondral loose bodies. McCarthy and Bus- ripherally in the watershed zone adjacent to
coni16 found the likelihood of MRI scanning the labrum.16 None of them occurred centrally
to detect a labral tear at 5%. A more recent near the fossa.
study found that dilute gadolinium combined In addition, among the 113 patients with
with off axis tangent reconstruction views in- dysplasia who had an anterior labral tear 78
creased the sensitivity for detecting labral (69%) had an anterior acetabular chondral le-
tears to 49%. Chondral and synovial disorders, sion. In this subgroup, 71% had an Outer-
however, were not well seen. (McCarthy J, bridge Grade III or Grade IV lesion. These
Marchetti M, Newberg A, Palmer W, Bono J: ndings suggest that the relatively uncovered
Improving diagnostic accuracy of chondral in- anterior portion of the hip allows the labrum to
juries: Correlation of gadolinium MR imaging be subjected to torsional and shear forces which
with arthroscopic surgery. Presented at the it cannot dissipate. A tear in the anterior labrum,
Annual Meeting of the American Academy of almost universally occurring on the articular
Orthopaedic Surgeons, New Orleans 1997.) margin portion, then separates the previously
Dienst et al3 and Edwards et al5 also found that seamless attachment to the acetabular cartilage.
arthroscopic ndings exceeded those of pre- This separation in the watershed zone, once ini-
operative imaging. In particular, chondral tiated, can extend farther because of repetitive
softening, brillation, and partial thickness femoral head torsional motions. The labroartic-
defects less than 1 cm were detected inconsis- ular cartilage ssure, once developed, subjects
tently by MRI. the subchondral bone to joint uid and under
Because all conventional radiographic stud- oscillating pressure dynamics similar to that
ies have limitations with respect to articular discussed by Schmalzried et al22 and presented
and labral cartilage pathomechanics it is not by Lanzer in patients after total hip arthroplasty
surprising that joint abnormalities in patients (Lanzer W: Intra-articular pressure differences
with mild dysplasia have not been well re- in loose and non-loose total hip arthroplasty.
ported to date. The advent of successful tech- Presented at the Sixty-Eight Annual Meeting of
niques to observe the hip arthroscopically has the American Academy of Orthopaedic Sur-
remarkably improved the ability to accurately geons San Francisco 2001). This pressure be-
detect and catalogue the counterface articular gins an inexorable delamination process of the
changes on the femoral head, acetabulum, anterior acetabular cartilage. The time- and
labrum, and synovium.4,8,19 activity-dependent pathophysiology helps to
Number 405
December, 2002 Acetabular Dysplasia 127

explain the high proportion of severe Outer- sensitivity to MRI scanning and the certitude
bridge ndings. In the current series, these ex- that patients without symptoms would not al-
tensive articular lesions were produced not by low a diagnostic surgical procedure on their
exion and impingement as has been proposed hip. The authors also could not control the
by others,12 but rather by hyperextension and length of patient symptoms before referral.
torsional forces, such as those seen in jogging, This may help to explain some of the Outer-
soccer, and sports that require pivoting.23 These bridge Grade III and Grade IV lesions. In ad-
articular lesions are corroborated by the higher dition, currently there is no approved proce-
percentage of patients whose symptoms were dure to replace lost articular cartilage in the
reproduced by a positive McCarthy extension hip, as there is in the knee. Therefore, although
sign rather than by hyperexion and internal some patients had microdrilling of subchon-
rotation. dral bone to facilitate brocartilage repair,
Seventeen patients in the current series had large Outerbridge Grade IV lesions were be-
total hip arthroplasty (10%). However, pa- yond the efcacy of that technique. These le-
tients with moderate dysplasia (13 of 24, 54%) sions were uniformly present in the subgroup
had a disproportionately higher likelihood of of patients who required total hip arthroplasty.
requiring total hip arthroplasty. This suggests This large cohort of patients with milder
that in addition to labral and chondral lesions, forms of dysplasia is a paradigm group. The
other factors such as instability and abnor- advent of hip arthroscopy allows observation
mally high joint contact pressures may have of the joint to an extent and accuracy never
contributed to the outcome. In contrast, of all achieved before. The dysplastic hip represents
the patients with mild dysplasia, only four hips a subpopulation particularly susceptible to joint
(3%) required total joint arthroplasty. All pa- injury. This study shows that even in mild dys-
tients who required arthroplasty had Outer- plasia labral and chondral injuries occur, and
bridge Grade III or Grade IV joint changes. they occur most frequently in the anterior re-
This suggests that with higher degrees of joint gion of the acetabulum. These injuries are pro-
uncovering that the labral changes are the re- duced more commonly by hyperextension and
sult of dysplasia pathomechanics. Conversely, torsion rather than by exion and impingement.
with mild degrees of dysplasia the labrum, al- Without the ability to heal, lesions of the
though somewhat more susceptible to injury, labrochondral junction (the watershed zone)
when treated early can be restored to allow a are likely to progress and subject the subchon-
high level of function. dral bone to joint uid, resulting in additional
The strengths of the current study are the articular delamination and eventually a sub-
size of the cohort and the safety and efcacy chondral bony cyst. These composite events
of the arthroscopic procedure in the senior au- are the precursor of accelerated joint wear and
thors hands. This minimally invasive outpa- help explain premature osteoarthritis of the
tient procedure allows not only thorough joint hip. Earlier detection and treatment of these
observation but also gentle tissue probing to cartilage lesions hopefully will obviate this in-
uncover the acetabular chondral aps not seen exorably negative pathologic arcade.
by MRI scanning. In addition to its sensitivity
and specicity this procedure can treat the in- References
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