Review Article

The Acetabular Labrum: Anatomic

and Functional Characteristics
and Rationale for Surgical
Intervention

Abstract
Marc R. Safran, MD The past decade has seen unprecedented growth in the number of
hip arthroscopies. Acetabular labral tears are the leading indication
for arthroscopy of this joint. However, labral anatomy and function,
as well as the effects of labral tears and surgical outcomes, have
only recently been studied. Labral tears may cause pain and
microinstability of the hip joint. They also may increase friction
within the joint, cartilage consolidation, and strain within the
articular cartilage, thereby possibly resulting in accelerated
degeneration of the joint. Partial labrectomy and labral repair are
the current surgical options, and basic science data suggest that
labral repairs can heal and subsequently restore function. However,
a good, validated outcomes measure to adequately assess active
patients with a painful nonarthritic hip is needed to determine the
efficacy of such repair and aid in managing patient expectations.

From the Department Orthopaedic
Surgery, Stanford University,
Redwood City, CA.
Dr. Safran or an immediate family
member serves as an unpaid
consultant to Cool Systems and
Ross Creek Medical, has received
research or institutional support from
Smith & Nephew and DJ
Orthopaedics, and has stock or
stock options held in Cool Systems
and Ross Creek Medical.
J Am Acad Orthop Surg 2010;18:
338-345
Copyright 2010 by the American
Academy of Orthopaedic Surgeons.
H ip arthroscopy is undergoing
unprecedented growth in popu-
larity, a trend that is reflected in the
increased number of publications on
the nonarthritic hip: two thirds of
papers on the topic of the labrum in-
dexed in PubMed were published in
the past decade. Labral tears are the
most common pathology in patients
undergoing hip arthroscopy and the
most common cause of mechanical
symptoms. Labral tears have been
found in >90% of cadaver specimens
with an average age of approxi-
mately 80 years.1 Although labral
tears may occur as an isolated prob-
lem, they are usually associated with
traumatic injury (eg, hip dislocation,
subluxation) or bony abnormality
(eg, hip dysplasia, femoroacetabular
impingement [FAI]).2 In one study,
nearly 90% of patients undergoing
hip arthroscopy for atraumatic la-
bral tears had radiographic evidence
of a bony abnormality such as dys-
plasia or FAI,2 whereas fewer than
half of patients with labral tears have
a history of associated trauma.3 Less
commonly, labral tears may be the
result of some other etiology, includ-
ing atraumatic microinstability or
capsular laxity, psoas impingement,
or symptomatic internal coxa sal-
tans.
Anatomy
Structure
The labrum is a horseshoe-shaped
structure whose inferior insertions
are in continuity with the transverse
acetabular ligament, a fibrous band
at the inferior acetabulum that con-
nects the anterior and posterior
horns of the labrum. Histologically,

338 Journal of the American Academy of Orthopaedic Surgeons


the acetabular labrum is divided into
two parts: capsular and articular.
The capsular side of the labrum is
composed of dense connective tissue
(types I and III), and the articular
side is composed of fibrocartilage.4
However, three layers can be identi-
fied on scanning electron micros-
copy. Starting at the articular margin
of the labrum and working toward
the capsular side, the first layer is a
10-µm wide network of delicate
fibrils without preferred orientation.
The second layer is 40 µm wide and
is oriented in a lamellar fashion, with
collagen fibrils tied together corre-
sponding to the superficial fibrocar-
tilage. The fiber bundles of this layer
intersect at various angles. The third
capsular and main layer of the la-
brum consists of circular collagen
fibrils measuring 200 to 300 µm.4
These circumferential fibers confirm
Pauwels’ theory that tissue structure
is related to the stress applied on it5 and
that it aligns itself to maximally offset
the forces of greatest tension. Macro-
scopically, the cross-section of the la-
brum has generally been thought to
have a triangular shape.
The wedge-shaped osseous rim of the
acetabulum penetrates into the labral
substance, attaching to the labrum at
the articular surface through a zone of
calcified cartilage, with a tidemark at
the articular side. No tidemark or zone
of calcified cartilage exists on the
capsular side.6 The labrum is widest
anteriorly and thickest superiorly
(ie, laterally).6 Anteriorly, the labral-
chondral transition zone is sharp and
abrupt, with minimal interdigitation
of fibers, because the collagen fibers
of the anterior labrum are arranged
parallel to the labral-chondral junc-
tion.7 Posteriorly, this transition is
more gradual; fibers perpendicular
to the labral chondral junction per-
mit convergence of fibers from the
articular cartilage and labrum.7 On
the articular side, anteriorly, the la-
brum blends into the articular hya-
June 2010, Vol 18, No 6
line cartilage of the acetabulum; a
transition zone of 1 to 2 mm is often
present.6 Also anteriorly, there is a
physiologic cleft between the artic-
ular cartilage and the labrum that
is visible via light microscopy.4
Whereas macroscopically visible sul-
cus may be seen at the posterior la-
brum–chondral junction, this occurs
less commonly anteriorly. The hip
capsular insertion is proximal to the
labrum onto the acetabulum directly,
creating a capsulolabral recess that
measures from 6.6 mm anteroinferi-
orly to 7.9 mm posteroinferiorly.
This recess contains well-vascu-
larized, loose connective tissue and
fat4,6 (Figure 1).
Vascularity
The acetabular labrum has no intrin-
sic vasculature.8 Most of the blood
supply comes from the capsule and
the synovium.4,6,9,10 In fact, there is a
significant diminution of vascular
density/penetration moving from the
capsular to the articular surface of
the labrum.4
The blood supply to the acetabular la-
brum comes from a vascular anasto-
motic ring surrounding the capsular at-
tachment of the labrum. This ring
originates from the superior gluteal ves-
sels, the obturator artery, and one as-
cending branch of the medial femoral
circumflex artery.10 Seldes et al6 dem-
onstrated that three to four vessels
travel circumferentially around the
labrum at its attachment site on the
capsular surface.
In an immunohistochemical study,
McCarthy et al8 showed abundant
vessels within the bony acetabulum
that reach the attachment site of the
labrum. However, no regions of rela-
tive microvascular supply have been
identified within the labral sub-
stance.1,9 In 2005, Kelly et al9 re-
ported that the overall mean vascu-
larity grade of the labrum was higher
at its capsular portion attached to
Marc R. Safran, MD
Figure 1
Schematic representation of a
cross-section of the acetabulum
and the labrum. The labral-chondral
junction is continuous (arrow).
Within the capsulolabral recess
(arrowhead) lies loose connective
tissue that also provides blood
supply to the labrum. The blood
supply is more prevalent at the
acetabular-capsular portion of the
labrum. Note the bony projection of
the acetabulum into the labrum.
the bony acetabulum (Figure 1). No
evidence of increased vascularity has
been found in cadaver specimens
with a torn labrum versus specimens
with an intact labrum.6,9
Innervation
Multiple types of nerve ending have
been identified within the labrum, re-
inforcing the fact that a torn labrum
can be a primary cause of hip pain.
This innervation is a distinguishing
factor between the acetabular la-
brum and the knee meniscus. Rami-
fied free nerve endings have been
found within the acetabular la-
brum.11,12 Labral innervation origi-
nates from a branch of the nerve to
the quadratus femoris as well as
from the obturator nerve.10 Kim and
Azuma12 identified multiple sensory
nerves and organs within the acetab-
ular labrum, such as the Vater-
Pacini, Golgi-Mazzoni, Ruffini, and
Krause corpuscles, in addition to free
nerve endings. Most (86%) of these
339
The Acetabular Labrum

Figure 2 sist distraction of the femoral head

from the socket by acting like a suc-
tion cup and maintaining the nega-
tive pressure within the joint. This
negative pressure improves joint sta-
bility by resisting distraction when
the labrum is intact.18,19
The second role of the labrum,
which may be more important, is its
sealing function to resist fluid flow.
This seal allows for a more uniform
distribution of the compressive
forces applied to the articular carti-
lage by maintaining the joint fluid in
the central compartment.14-16 By seal-
ing the central compartment, the
small amount of joint fluid within
the hip can also efficiently provide
nutrition to the hip articular carti-
Graphic representation of the resistance to rotation (RTR) in the hip joint at lage and allow for a smooth gliding
various amounts of applied load. The difference in RTR is statistically surface.20 The loss of mechanical
significantly higher at the greater applied loads for the partially resected
labrum compared with the intact labrum. This RTR is analogous to friction. support from this sealing function, in
The circled diamond indicates RTR at 0.5 BW in the intact hip. BW = body the form of maintaining the joint
weight. (Courtesy of Yong Nam Song, PhD, Stanford University.) fluid for nutrition, equal distribution
of forces, and smooth gliding sur-
face, may result in higher forces
sensory nerve end organs were ports on the function of the labrum within the cartilage, resulting in
within the articular side of the la- have helped to clarify its role in hip damage to the chondral surface.16
brum. The corpuscles present within biomechanics. Using pressure-sensi- Cadaver studies bear out these
the labrum are receptors of pressure, tive film, Konrath et al13 noted no ideas regarding the function of the
deep sensation, and temperature sen- significant increase in articular pres- labrum. Ferguson et al16 studied ca-
sation, whereas free nerve endings sure during the single-limb stance daver cartilage consolidation with
are pain receptors. There are mecha- phase after removal of the labrum and without the labrum. Cartilage
noreceptors in the labrum; thus, the and the transverse ligament. Despite consolidation was found to be
labrum may also play a role in joint these data, the labrum is believed to quicker and greater following labral
proprioception. The number and have several functions. resection as a result of decreased hy-
type of nerves and organs in the la- The acetabular labrum increases drostatic fluid pressurization within
brum do not differ based on age. the articular surface area by 22% the central compartment. Song et al20
However, more unmyelinated nerve and acetabular volume by 33%.6 The demonstrated the lubrication func-
endings, those that sense pain, were labrum is believed to create a seal for tion of the labrum in a cadaver
found in the superior and anterior the central compartment that op- model by evaluating resistance to ro-
quarters of the labrum. poses the flow of synovial fluid in tation with the acetabular labrum in
and out of this compartment.14-16 The the intact state and after a tear. Re-
central compartment is the part of sistance to rotation in a loaded hip
Biomechanics the intra-articular hip joint that is joint is progressively increased after
limited by the confines of the acetab- partial resection of the labrum (Fig-
Intact Labrum ulum and labrum, and the peripheral ure 2). This work indicates that the
Although Konrath et al13 concluded compartment is the intra-articular labrum maintains a low-friction en-
in 1998 that the labrum did not portion of the hip that lies outside vironment in the hip joint, possibly
serve any observable kinematic or the acetabulum and labrum, namely, by sealing the joint from fluid exuda-
load-sharing function in their ca- the region of the femoral neck.17 One tion.20 Partial removal of the labrum
daver model, several subsequent re- role of the sealing function is to re- may result in impaired sealing of the

340 Journal of the American Academy of Orthopaedic Surgeons


joint and progressively increased hip
joint friction, a condition that may
damage articular cartilage and lead
to osteoarthritis.20
The contribution of the labrum in
hip joint stability is greatest at the
extremes of motion.14-16,21 Crawford
et al21 showed that less force is re-
quired to distract the femur 3 mm af-
ter creating tears in the labrum than
when the labrum is intact. Dy et al22
demonstrated that abduction with
external rotation produces anterior
translation of the femoral head, re-
sulting in additional forces on the
anterior capsule and labrum. Thus,
sudden, traumatic overload or repet-
itive loading could cause the labrum
to separate from the articular margin
or cause tensile tearing of the la-
brum.
Many clinicians have noted that
the force required to distract the hip
decreases when the seal to the central
compartment of the hip has been
broken by placing a needle into the
central compartment of the joint.18,19
When traction is applied to the hip
and a needle is brought into the cen-
tral compartment, the joint space in-
creases significantly as the negative
pressure within the joint is released
and equilibrium with the ambient
pressure is reached. We have also
seen that when the needle is placed
on the femoral neck with traction
applied, the joint space does not in-
crease and the forces applied do not
decrease. This example demonstrates
how the labrum functions as a seal
separating the central compartment
from the peripheral compartment.
Ishiko et al23 demonstrated in a ca-
daver study that the labrum is sub-
ject to tensile loads. The authors an-
alyzed the superior quadrant of the
labrum, isolated from the hip joint.
The male labrum was stronger than
the female labrum under tensile load.
Overall, the mean tensile modulus
was found to be less than that of hu-
man menisci. The authors proposed
June 2010, Vol 18, No 6
that the degeneration of the fibers of
the labrum resulting from osteoar-
thritis may influence labral function.
Recently, Dy et al22 studied the ten-
sile strain of the anterior region of
the anterior acetabular labrum in ca-
davers using roentgen stereophoto-
grammetric analysis. The mean and
maximum strains of the labrum were
highest nearer the anterolateral por-
tion of the labrum than at the direct
anterior or anteroinferior portion.
External rotation and abduction of
the hip generated substantial tensile
strain in the anterior labrum.
Giordano et al24 studied tensile
strain by placing digital variable re-
sistance transducers in four locations
(ie, anterior labrum, anterolateral la-
brum, lateral labrum, posterior la-
brum) in intact human cadaver labra
and then taking each hip through 36
positions of motion. Strains were
identified throughout the labrum in
the neutral position (ie, neutral
flexion-extension, neutral abduction-
adduction, neutral rotation), and it
was noted that strains may increase
or decrease in the regions of the la-
brum based on hip motion. The an-
terior labrum experiences increased
strain when the hip is flexed, particu-
larly when abduction is added.
Strains decrease relative to the start-
ing strain with hip adduction and
with extension. The anterolateral la-
brum has significant increases in
strain with flexion, particularly with
internal rotation, whereas extension
and external rotation decrease strain
in this region. In the lateral labrum,
strain increases when the hip is
flexed, particularly with external (or
neutral) rotation and abduction (or
no abduction-adduction), and strain
decreases laterally when the hip is
extended. In the posterior labrum,
strain increases when the hip is
extended or is in neutral flexion-
extension, especially in abduction
and external rotation, and strain de-
creases when the hip is flexed and
Marc R. Safran, MD
adducted, regardless of rotation.
These same researchers also used
digital variable resistance transduc-
ers to study labral strain.25 An antero-
lateral radial tear was simulated in
six cadaver specimens, and data on
strain were noted, after which 1 cm
of the anterolateral labrum was re-
sected. In six different specimens,
strain was studied following the cre-
ation of a 1.5-cm labral-chondral
separation. The greatest change in
loss of strain occurred at the antero-
lateral labrum near the tear, as
would be expected, with diminishing
effects farther from the tear. Further
loss of labral strain occurred with
1-cm resection of the labrum, with
the greatest effects at the antero-
lateral labrum and diminishing ef-
fects farther from the tear. Loss of
labral strain was least with the ante-
rolateral labral-chondral separation.
These data suggest that the circum-
ferential fibers of the labrum serve
an important function because radial
sectioning disrupts the hoop stresses
of the circumferential fibers. The ef-
fect on labral function diminishes as
one measures away from the tear or
resection. This corroborates the idea
that the bony insertion of the labrum
plays a supporting role in labral
function at sites distant from tear.
This is in contradistinction with the
meniscus, which has no bony attach-
ments except the insertional horns
and which loses function following
complete radial tear.26
Early studies of the hip labrum
were static, and no labral function
was identified. However, recent stud-
ies clearly show that dynamic testing
is more important than static evalua-
tion in the assessment of hip labral
biomechanics and function.
Labral Tear
Controversy exists regarding the
consequence of labral tears. Thirty
years ago, Harris et al27 noted that
341
The Acetabular Labrum
labral tears often occurred in the
same location as chondral wear, al-
though no cause-and-effect relation-
ship could be established. In 2001,
Seldes et al6 concluded that “labral
tears occur early in the arthritic pro-
cess of the hip and may be one of the
causes of degenerative hip disease.”
However, no definitive study, either
clinical or basic science, currently ex-
ists that demonstrates whether labral
tears result in arthritis. Some recent
basic science studies help elucidate
the function of the labrum and the
consequences of labral tears and also
propose potential mechanisms of de-
generative change in the hip with la-
bral tears. These mechanisms include
microinstability, decreased articular
cartilage nutrition, increased carti-
lage consolidation, and reduced con-
tact area.
A recent international collabora-
tive study reported that the hip does
not exhibit a constant center of rota-
tion, as in a ball-in-socket joint mod-
el.28 Passive motion of the hip
through 36 positions results in signif-
icant femoral head centroid motion
when all of the soft tissues are intact,
with translations distally, laterally,
and inferiorly, compared with the
neutral starting position. These cen-
troid translations are increased when
the muscles and skin are removed;
they are increased even further fol-
lowing partial capsulectomy. Craw-
ford et al21 demonstrated increased
femoral head motion within the ace-
tabulum following the creation of a
labral tear in cadaver specimens. Dis-
traction force on the hip decreased
43% after venting of the capsule; it
decreased 60% after creation of a la-
bral tear. The structure of articular
cartilage suggests that the superficial
layers are constructed to optimally
resist compressive forces. As such,
increased translation of the femoral
head within the acetabulum may be
expected to result in greater shear
forces that may accelerate articular
342
cartilage wear and/or may result in
greater edge loading of the articular
cartilage on the acetabular rim, re-
sulting in breakdown of the chondral
surface at these locations.
It has been suggested that the la-
brum functions as a seal, allowing
the small amount of synovial fluid
present to remain in the central com-
partment. This allows nutrients to
reach the articular cartilage and al-
lows for uniform distribution of fluid
and resultant forces on the cartilage.
It may be that an impaired pathway
for nutrition to the articular cartilage
would lead to death of the cartilage,
resulting in arthritis. The uniform
distribution of fluid, allowing for
joint lubrication and a smoother
gliding surface, has been proposed as
an important function of the labrum.
Song et al20 demonstrated objectively
in a cadaver hip model that labral
tears increase the resistance to rota-
tion, confirming the importance of
the labrum in keeping the joint fluid
in the central compartment to allow
for smooth joint motion. Ferguson
et al14-16 also demonstrated, in both
finite-element modeling and cadaver
studies, that labral tears reduce resis-
tance to the flow path of interstitial
fluid expression and that this would
increase the rate of cartilage consoli-
dation and local stress and strain lev-
els within the layers of articular car-
tilage. Greaves et al29 used 7T MRI
to study the effects of labral tears on
hip cartilage strain. They reported
that a 3-cm longitudinal labral tear
at the labral-chondral junction re-
sults in a minimal increase in articu-
lar cartilage strain, whereas resection
of 3 cm of labrum results in signifi-
cantly increased strain on the articu-
lar cartilage of the femoral head.
These findings confirm the work of
Ferguson et al.14,16 These increased
strains within the articular cartilage
may result in breakdown and apop-
tosis of the chondrocytes and carti-
lage.
Journal of the American Academy of Orthopaedic Surgeons
Miozzari et al30 found no effect on
the hip joints of sheep at 6, 12, and
24 weeks following partial labral re-
section. In particular, there was no
evidence of arthritis at any time post-
operatively. Fibrous regrowth at the
site of labral resection was noted in
16 of the 18 specimens. This has not
been reported in humans.
Cadaver models indicate that the
labrum serves several important
functions that are lost when the la-
brum is torn or partially resected.
Basic science data suggest that loss of
labral function through tear or resec-
tion may have negative implications
on the joint, particularly the articular
cartilage, which may result in de-
layed joint degeneration.
Surgical Outcomes
Partial Labrectomy
Because it lacks blood supply, the la-
bral substance has limited capacity
to heal; thus, resection of the torn la-
brum has been the earliest treatment
of hip labral tears (Figure 3, A). The
goal of débridement of a torn labrum
is to relieve pain by eliminating the
unstable flap. This was traditionally
performed with open surgery. How-
ever, open labral surgery is associ-
ated with significant morbidity. The
advent of hip arthroscopy has al-
lowed easier access to the labrum
with significantly less morbidity. Ar-
throscopy allows greater access to all
areas of the hip compared with an
open approach.
Short-term good to excellent results
have been achieved in 67% to 93% of
cases of partial labrectomy.31-34 Shin-
dle et al35 recently published a meta-
analysis evaluating the outcomes of
partial labrectomy of the hip. In
those studies that used the modified
Harris hip score,31 scores improved
an average of 31% to 40% at 2- to
3.5-year follow-up.35 Shindle et al35
also noted resolution of mechanical

symptoms and a reduction in hip
pain in 91% of patients at an aver-
age follow-up of 2.5 years.
However, there are many limita-
tions to the early studies of partial
labrectomy. First, several studies did
not report the results of partial la-
brectomy as an isolated pathology.
In fact, labral tears occur frequently
with chondral lesions,36 and when ar-
ticular cartilage damage is seen with
labral tears, the success rate of sur-
gery drops to as low as 21%.32,34 Ad-
ditionally, many of these studies oc-
curred before FAI was described.
Kim et al37 and Tanzer and Noiseux38
demonstrated that patients who un-
derwent partial labrectomy in the
presence of untreated FAI had a
much poorer outcome than did those
with labral tears that underwent
resection and had no evidence
of FAI.37,38 Thus, many less-than-
optimal outcomes in earlier studies
may have been the result of unrecog-
nized and untreated FAI. Finally, cur-
rent outcomes scores are inadequate
to assess patients with isolated labral
tears. The outcomes ratings used cur-
rently were designed primarily to
study outcomes in patients undergo-
ing hip arthroplasty, and they are not
validated for younger, more active,
nonarthritic patients.
Labral Repair
Labral repair is a more recent tech-
nique than partial labrectomy. As a
result, data are lacking on the out-
comes of labral repair. Conceptually,
it seems as though the optimal
course of action would be to repair
and restore and/or maintain labral
function when practicable.39,40 Basic
science evidence suggests that labral
function is important to the health
and function of the joint. Because the
vascular supply to the labrum comes
from the acetabular margin, it seems
as though tears at the labral-
chondral junction would be the most
June 2010, Vol 18, No 6
Marc R. Safran, MD
Figure 3
A, Arthroscopic view from the anterolateral portal of an anterior
intrasubstance labral tear. Note the lack of vascularity. This type of tear is
typically débrided. B, Arthroscopic view of an anterior labral-chondral
separation. Such tears are often repaired arthroscopically.
likely to heal with repair (Figure 3, Currently, there are no studies in
B). the English-language literature re-
Philippon et al41 studied labral repair porting the results of isolated labral
in an ovine model. All labra were repair of the hip. In 2006, Espinosa
grossly stable and intact 12 weeks af- et al42 reported the outcomes of 60
ter arthroscopic repair of a 1.5-cm sequential cases of FAI treated with
labral-chondral separation with a sin- open surgical dislocation and either
gle suture anchor and simple loop labral débridement or labral repair.
stitch. However, the labral tears healed At 1 year, those treated with labral
incompletely, demonstrating fibrovas- repair had less progression of their
cular scar from the capsule and new Tönnis scores, which was indicative
bone from the acetabulum in all hips. of less radiographic progression of
A persistent small cleft of unknown sig- degenerative change in the hip. Out-
nificance was also identified at the ar- comes as measured using the Merle
ticular surface. d’Aubigne score were better at both
In a cadaver study, Greaves et al29 re- 1 and 2 years after surgery in pa-
ported that articular cartilage strains in tients treated with labral repair than
the femoral head were restored to the in those treated with labral resection.
level of strain of intact specimens fol- Philippon et al43 recently published
lowing repair of 3-cm labral-chondral their results of 112 patients treated
separation with three anchors, with the arthroscopically for FAI. Multivari-
sutures passed through the labrum in ate analysis demonstrated that labral
a vertical mattress fashion. In fact, the repair was predictive of an improved
mean and maximal chondral strains of modified Harris hip score. However,
labral repair evaluated with 7T MRI this was not a prospective trial, and
were lower than those in the specimens it is likely that those treated with la-
that underwent either labral-chondral bral resection had irreparable labral
separation or resection and were not tears. Thus, the pathology in this
different from the specimens with an in- group may have been more ad-
tact labrum. These data suggest that the vanced.
labrum can be repaired and function re- Evaluation of labral repairs is lim-
stored. ited by the lack of a validated out-
343
The Acetabular Labrum
comes questionnaire designed for the
nonarthritic hip in active patients.
Currently used rating systems were
generally designed for older patients
undergoing joint arthroplasty for ar-
thritis. These two patient groups
have different treatment goals and
activity requirements, and the cur-
rently used hip rating scales, such as
the modified Harris hip score and
the Merle d’Aubigne scores, are not
appropriate for patients undergoing
labral repair. Although basic science
research suggests that labral repair is
clinically better than partial labrec-
tomy, more outcomes studies are
needed to confirm this finding.
Summary
Basic science studies confirm that the
labrum has many functions. It serves
as a joint seal that allows for joint
lubrication and cartilage nutrition,
and it helps in providing joint stabil-
ity, assists in load sharing, and likely
has a role in joint proprioception.
Labral tears may cause pain and mi-
croinstability of the joint; they may
increase friction within the joint and
cartilage consolidation, as well as in-
crease strain within the articular
cartilage, thereby possibly resulting
in accelerated degeneration of the
joint.
Partial labrectomy may relieve pain
and eliminate mechanical symptoms;
however, the outcomes are markedly
better when (1) there is no chondral
damage to the articular surfaces and
(2) associated bony pathology is ad-
dressed concomitantly. Based on ba-
sic science data, one can infer that it
is beneficial to remove as little of the
labrum as possible because the re-
maining labral tissue still can func-
tion. With regard to strain in the la-
brum, the more that is removed, the
more labral function may be lost. Al-
though débridement of labral tears
will lead to pain relief, some believe
344
that these tears should be repaired
to maintain the chondroprotective
function of the labrum.
Although clinical data pertaining to
labral repair are lacking, basic science
data suggest that labral repairs can heal
and subsequently restore function. In
particular, labral-chondral separation
tears would likely have the best out-
comes because the blood supply from
the acetabulum would offer the poten-
tial for healing. However, intrasub-
stance tears likely have poor ability to
heal with repair. Currently, two stud-
ies confirm that clinical outcomes of
FAI surgery are better with labral repair
than with labral resection.
There is no good validated out-
comes score for the active patient
with a painful nonarthritic hip. Such
a tool is needed before clinicians can
really evaluate the efficacy of hip ar-
throscopic procedures such as partial
labrectomy and labral repair. With
an appropriate outcomes score in
place, prospective studies can be per-
formed to determine the true value
and efficacy of these surgeries. Such
studies could also aid in developing a
better understanding of the indica-
tions for labral repair and in manag-
ing patient expectations.
Evidence provided in the past few
years confirms that the acetabular la-
brum has clear clinical function and
is important in hip function and
health, and that labral tears should
be managed surgically. More data
are needed to better understand the
relative roles of labral function, indi-
cations for arthroscopic labral sur-
gery, optimal surgical technique for
labral resection and repair, and the
potential for labral reconstruction.
Acknowledgment
The author would like to acknowl-
edge Giovanni Giordano, MD, Hal
Martin, DO, Nicholas Giori, MD,
PhD, and James Rosneck, MD, for
Journal of the American Academy of Orthopaedic Surgeons
their contributions and help in
manuscript review.
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