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Hip Labral Cyst Caused by Psoas Impingement
Case Report With Video Illustration
Hip Labral Cyst Caused by Psoas Impingement Marc Tey, M.D., Sonia Álvarez, M.D., and Jose L. Ríos, M.D.
Abstract: Hip labral impingement can cause labral tears and secondary paralabral cyst formation. Femoroacetabular impingement is the main cause of labral impingement, but other conditions such as iliopsoas tendon impingement are described. There is no description of labral cyst resulting from psoas impingement treated arthroscopically in the literature. We present the case of a young sportsman with groin pain caused by psoas impingement with a labral tear and secondary paralabral cyst who was treated arthroscopically by cyst debridement, psoas tenotomy, and labral repair.
A
cetabular labral tears have recently received increased attention as a cause of hip pain in young, athletic patients. Labral tears have been reported to result from acute hip trauma or overload injury due to acetabular dysplasia, but recently, femoroacetabular impingement has been identified as the predominant cause of labral tears in the nondysplastic hip. A tight psoas tendon has been recognized as a less frequent cause of hip pain and labral impingement.1,2 Labral tears are sometimes accompanied by the formation of paralabral cysts by a mechanism similar to that of glenoid cysts. These cysts are found more frequently in the area adjacent to the peripheral aspect of the labrum and constitute an indirect sign of probable rupture of the labrum, although a tear itself is not clearly visible. Magnetic resonance arthrography is more accurate than magnetic resonance imaging to identify abnormal head-neck morphology, anterosuperior cartilage abnormality, labral tears, and paralabral cysts.3 We arthroscopically treated a case with a paralabral cyst of the hip caused by psoas impingement by excision of the cyst, psoas tenotomy, and labral suture.
From the Orthopaedic Department, ACTUA Serveis Medics (Medical Services), Clínica Bofill, Girona, Spain. Received February 19, 2012; accepted March 27, 2012. Address correspondence to Marc Tey, M.D., Clínica Bofill, Ronda Sant Antoni Maria Claret 19, Girona, Spain. E-mail: [email protected] © 2012 by the Arthroscopy Association of North America 0749-8063/12118/$36.00 http://dx.doi.org/10.1016/j.arthro.2012.03.028
1184
CASE REPORT A 37-year-old man had a history of right groin pain for months without recognized trauma. In the last month, his hip pain increased after strenuous exercise. He felt progressive limitation of motion of the hip joint, especially during athletic activities that had been affected by his symptoms, mainly climbing and cycling. Physical examination showed a positive impingement test and the C sign. The range of motion with the patient supine, compared with the contralateral hip, was normal. The radiographic findings showed no bony abnormalities on the pelvic anteroposterior view and Dunn axial view projections. Magnetic resonance arthrography of the right hip showed an anterosuperior labral tear with a clear paralabral cyst, defined as a paralabral fluid collection, which was hyperintense on either T1or T2-weighted images. We recommended the arthroscopic method because, in the literature, its outcomes had been equal to or better than those of open dislocation or mini-open surgery, with a lower rate of major complications when performed by experienced arthroscopic surgeons.4
ARTHROSCOPIC FINDINGS The patient was placed in the supine position on a traction table under general anesthesia. After a traction trial was performed, traction was released and the affected lower limb was positioned with 45° of flexion of the affected hip. A 70° arthroscope was
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 8 (August), 2012: pp 1184-1186
HIP LABRAL CYST
1185
FIGURE 1. Labral cyst in anterior labrum of right hip seen from proximal midanterior portal. The patient is in the supine position, and the hip is flexed to 40°, in neutral rotation, to increase space at the peripheral compartment. The relation between the iliopsoas tendon and paralabral cyst is shown. (A) The tendon is partially reflected with the radiofrequency probe to show the cyst. (B) Complete dissection of the cyst is achieved after psoas tenotomy.
inserted through a portal midway from the anterosuperior iliac spine and greater trochanter, as described by Dienst and colleagues,5 to access to the peripheral compartment. The arthroscopic findings in the peripheral compartment showed a paralabral cyst in the anterior acetabular rim, under the psoas tendon (Fig 1). Flexion-extension movement of the hip clearly showed labral impingement by the psoas tendon on the damaged labrum. Below this, a distal anterolateral portal was made for instrumentation. The psoas tendon was released with a flexible radiofrequency tissue ablator (SideWinder; ArthroCare, Sunnyvale, CA), and the paralabral cyst was resected (Video 1, www.arthroscopyjournal.org). Later, we extended the hip and applied traction to access to the central compartment. The labral tear was identified, and reattachment was performed with a 3.1-mmdiameter Bio-Mini Revo anchor (ConMed Linvatec, Largo, FL), as shown in Fig 2. Rehabilitation was addressed with the same postoperative program as for conventional femoroacetabular impingement, with progressive weight bearing, pre-
serving joint mobility to prevent capsulolabral adhesions, and with gluteus muscle strengthening. After 2 months, physical examination showed a negative impingement test and the hip flexion was preserved. After 3 months, the patient was running and was asymptomatic. DISCUSSION Acetabular labral tears may cause considerable pain and predispose patients to premature osteoarthritis. These tears have been reported in patients with a history of trauma to the hip, degenerative arthritis, or dysplasia. Post-traumatic labral tears can occur after minor trauma or result from a severe injury such as a hip dislocation. Stress on the labrum can cause labral degeneration and tearing. Labral tears can result in a loss of congruity between the femoral head and acetabulum, resulting in increased intra-articular pressure. The increased pressure can force synovial fluid through the area of labral degeneration or through the tear in the
FIGURE 2. A 70° arthroscope at the proximal midanterior portal shows a normal anterior labrum after cyst resection. (A) Access from the peripheral compartment without traction and hip flexion is used because labral tears are usually at the articular side. (B) Traction is applied to access the articular side, and labral reattachment is performed with translabral suture using 1 bone anchor. The black arrowhead indicates the knot of the bone anchor, and the white arrowhead shows the articular space.
1186 TABLE 1.
M. TEY ET AL. Diagnostic Pearls Concerning Iliopsoas Impingement
History and physical examination Anterior groin pain Sport activities Prolonged sitting position Positive impingement test Positive decompression test (impingement test with traction applied to hip, being positive when pain disappears) Positive infiltration test (pain relief after intra-articular anesthetic hip injection) Imaging studies Plain radiographs Impingement cysts at femoral head-neck transition Magnetic resonance studies Labral rupture at anterior rim; sometimes not seen even at arthroscopy magnetic resonance (MR) Paralabral cyst Ultrasonography Paralabral cyst at anterior rim Psoas impingement/snapping; during abduction, flexion, and external rotation, the iliopsoas tendon moves laterally, suddenly flipping over the paralabral cyst Intraoperative findings Paralabral cyst with direct access to peripheral compartment Psoas impingement over paralabral cyst when flexion and extension of hip are performed Labral rupture after traction is applied
acetabulum and the soft tissue adjacent to the acetabulum, resulting in a paralabral cyst. Paralabral cysts are more frequently seen at the anterolateral and anterior labrum and are related to a psoas tendon in 22% of cases.3 Disorders of the acetabular labrum have been well documented as a source of chronic hip pain, and patients may present with acute or chronic hip pain characterized by a clicking or snapping sensation with movement. Our patient did not report pain after the trauma, but pain occurred gradually after engaging in sports. When we performed arthroscopy, we could see the iliopsoas tendon impinging over an anterior paralabral cyst. This has been previously described in association with snapping iliopsoas tendon.6 Thus we
suspected that repetitive microtrauma was the main cause of the anterosuperior labral tear and cyst. Table 1 lists some diagnostic pearls regarding labral tears caused by psoas impingement. The indications for hip arthroscopy have changed since 1931 when Burman documented his initial experiences. The main indication for hip arthroscopy is femoroacetabular impingement, but current indications include the presence of hip capsular laxity and instability, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies (e.g., synovial chondromatosis) or symptomatic acetabular labral tears with cysts, as in our case.7 In summary, paralabral cysts can be associated with labral tears. The appearance of a paralabral cyst on magnetic resonance images is a useful indirect sign of acetabular labral disorders, and arthroscopy is a good surgical technique by which to remove it, repair the damaged labrum, and release the psoas tendon when it is causing labral impingement. REFERENCES 1. Di Lorenzo L, Jennifer Y, Pappagallo M. Psoas impingement syndrome in hip osteoarthritis. Joint Bone Spine 2009;76:98100. 2. Shindle MK, Kelly BT, Voos JE, Asnis PD, Pruett A. Labral pathology associated with psoas impingement. Arthroscopy 2008;24:e34 (Suppl, abstr). 3. Magerkurth O, Jacobson JA, Girish G, Brigido MK, Bedi A, Fessell D. Paralabral cysts in the hip joint: Findings at MR arthrography. Skeletal Radiol. 2012 March 21. [Epub ahead of print.] 4. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy 2011;27:252-269. 5. Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthroscopy 2006;22;907.e1-907.e4. Available online at www .arthroscopyjournal.org. 6. Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: New mechanisms using dynamic sonography. AJR Am J Roentgenol 2008;190:576-581. 7. Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy 2008;24:1135-1145.
Hip Labral Cyst Caused by Psoas Impingement Marc Tey, M.D., Sonia Álvarez, M.D., and Jose L. Ríos, M.D.
Abstract: Hip labral impingement can cause labral tears and secondary paralabral cyst formation. Femoroacetabular impingement is the main cause of labral impingement, but other conditions such as iliopsoas tendon impingement are described. There is no description of labral cyst resulting from psoas impingement treated arthroscopically in the literature. We present the case of a young sportsman with groin pain caused by psoas impingement with a labral tear and secondary paralabral cyst who was treated arthroscopically by cyst debridement, psoas tenotomy, and labral repair.
A
cetabular labral tears have recently received increased attention as a cause of hip pain in young, athletic patients. Labral tears have been reported to result from acute hip trauma or overload injury due to acetabular dysplasia, but recently, femoroacetabular impingement has been identified as the predominant cause of labral tears in the nondysplastic hip. A tight psoas tendon has been recognized as a less frequent cause of hip pain and labral impingement.1,2 Labral tears are sometimes accompanied by the formation of paralabral cysts by a mechanism similar to that of glenoid cysts. These cysts are found more frequently in the area adjacent to the peripheral aspect of the labrum and constitute an indirect sign of probable rupture of the labrum, although a tear itself is not clearly visible. Magnetic resonance arthrography is more accurate than magnetic resonance imaging to identify abnormal head-neck morphology, anterosuperior cartilage abnormality, labral tears, and paralabral cysts.3 We arthroscopically treated a case with a paralabral cyst of the hip caused by psoas impingement by excision of the cyst, psoas tenotomy, and labral suture.
From the Orthopaedic Department, ACTUA Serveis Medics (Medical Services), Clínica Bofill, Girona, Spain. Received February 19, 2012; accepted March 27, 2012. Address correspondence to Marc Tey, M.D., Clínica Bofill, Ronda Sant Antoni Maria Claret 19, Girona, Spain. E-mail: [email protected] © 2012 by the Arthroscopy Association of North America 0749-8063/12118/$36.00 http://dx.doi.org/10.1016/j.arthro.2012.03.028
1184
CASE REPORT A 37-year-old man had a history of right groin pain for months without recognized trauma. In the last month, his hip pain increased after strenuous exercise. He felt progressive limitation of motion of the hip joint, especially during athletic activities that had been affected by his symptoms, mainly climbing and cycling. Physical examination showed a positive impingement test and the C sign. The range of motion with the patient supine, compared with the contralateral hip, was normal. The radiographic findings showed no bony abnormalities on the pelvic anteroposterior view and Dunn axial view projections. Magnetic resonance arthrography of the right hip showed an anterosuperior labral tear with a clear paralabral cyst, defined as a paralabral fluid collection, which was hyperintense on either T1or T2-weighted images. We recommended the arthroscopic method because, in the literature, its outcomes had been equal to or better than those of open dislocation or mini-open surgery, with a lower rate of major complications when performed by experienced arthroscopic surgeons.4
ARTHROSCOPIC FINDINGS The patient was placed in the supine position on a traction table under general anesthesia. After a traction trial was performed, traction was released and the affected lower limb was positioned with 45° of flexion of the affected hip. A 70° arthroscope was
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 28, No 8 (August), 2012: pp 1184-1186
HIP LABRAL CYST
1185
FIGURE 1. Labral cyst in anterior labrum of right hip seen from proximal midanterior portal. The patient is in the supine position, and the hip is flexed to 40°, in neutral rotation, to increase space at the peripheral compartment. The relation between the iliopsoas tendon and paralabral cyst is shown. (A) The tendon is partially reflected with the radiofrequency probe to show the cyst. (B) Complete dissection of the cyst is achieved after psoas tenotomy.
inserted through a portal midway from the anterosuperior iliac spine and greater trochanter, as described by Dienst and colleagues,5 to access to the peripheral compartment. The arthroscopic findings in the peripheral compartment showed a paralabral cyst in the anterior acetabular rim, under the psoas tendon (Fig 1). Flexion-extension movement of the hip clearly showed labral impingement by the psoas tendon on the damaged labrum. Below this, a distal anterolateral portal was made for instrumentation. The psoas tendon was released with a flexible radiofrequency tissue ablator (SideWinder; ArthroCare, Sunnyvale, CA), and the paralabral cyst was resected (Video 1, www.arthroscopyjournal.org). Later, we extended the hip and applied traction to access to the central compartment. The labral tear was identified, and reattachment was performed with a 3.1-mmdiameter Bio-Mini Revo anchor (ConMed Linvatec, Largo, FL), as shown in Fig 2. Rehabilitation was addressed with the same postoperative program as for conventional femoroacetabular impingement, with progressive weight bearing, pre-
serving joint mobility to prevent capsulolabral adhesions, and with gluteus muscle strengthening. After 2 months, physical examination showed a negative impingement test and the hip flexion was preserved. After 3 months, the patient was running and was asymptomatic. DISCUSSION Acetabular labral tears may cause considerable pain and predispose patients to premature osteoarthritis. These tears have been reported in patients with a history of trauma to the hip, degenerative arthritis, or dysplasia. Post-traumatic labral tears can occur after minor trauma or result from a severe injury such as a hip dislocation. Stress on the labrum can cause labral degeneration and tearing. Labral tears can result in a loss of congruity between the femoral head and acetabulum, resulting in increased intra-articular pressure. The increased pressure can force synovial fluid through the area of labral degeneration or through the tear in the
FIGURE 2. A 70° arthroscope at the proximal midanterior portal shows a normal anterior labrum after cyst resection. (A) Access from the peripheral compartment without traction and hip flexion is used because labral tears are usually at the articular side. (B) Traction is applied to access the articular side, and labral reattachment is performed with translabral suture using 1 bone anchor. The black arrowhead indicates the knot of the bone anchor, and the white arrowhead shows the articular space.
1186 TABLE 1.
M. TEY ET AL. Diagnostic Pearls Concerning Iliopsoas Impingement
History and physical examination Anterior groin pain Sport activities Prolonged sitting position Positive impingement test Positive decompression test (impingement test with traction applied to hip, being positive when pain disappears) Positive infiltration test (pain relief after intra-articular anesthetic hip injection) Imaging studies Plain radiographs Impingement cysts at femoral head-neck transition Magnetic resonance studies Labral rupture at anterior rim; sometimes not seen even at arthroscopy magnetic resonance (MR) Paralabral cyst Ultrasonography Paralabral cyst at anterior rim Psoas impingement/snapping; during abduction, flexion, and external rotation, the iliopsoas tendon moves laterally, suddenly flipping over the paralabral cyst Intraoperative findings Paralabral cyst with direct access to peripheral compartment Psoas impingement over paralabral cyst when flexion and extension of hip are performed Labral rupture after traction is applied
acetabulum and the soft tissue adjacent to the acetabulum, resulting in a paralabral cyst. Paralabral cysts are more frequently seen at the anterolateral and anterior labrum and are related to a psoas tendon in 22% of cases.3 Disorders of the acetabular labrum have been well documented as a source of chronic hip pain, and patients may present with acute or chronic hip pain characterized by a clicking or snapping sensation with movement. Our patient did not report pain after the trauma, but pain occurred gradually after engaging in sports. When we performed arthroscopy, we could see the iliopsoas tendon impinging over an anterior paralabral cyst. This has been previously described in association with snapping iliopsoas tendon.6 Thus we
suspected that repetitive microtrauma was the main cause of the anterosuperior labral tear and cyst. Table 1 lists some diagnostic pearls regarding labral tears caused by psoas impingement. The indications for hip arthroscopy have changed since 1931 when Burman documented his initial experiences. The main indication for hip arthroscopy is femoroacetabular impingement, but current indications include the presence of hip capsular laxity and instability, chondral lesions, osteochondritis dissecans, ligamentum teres injuries, snapping hip syndrome, iliopsoas bursitis, and loose bodies (e.g., synovial chondromatosis) or symptomatic acetabular labral tears with cysts, as in our case.7 In summary, paralabral cysts can be associated with labral tears. The appearance of a paralabral cyst on magnetic resonance images is a useful indirect sign of acetabular labral disorders, and arthroscopy is a good surgical technique by which to remove it, repair the damaged labrum, and release the psoas tendon when it is causing labral impingement. REFERENCES 1. Di Lorenzo L, Jennifer Y, Pappagallo M. Psoas impingement syndrome in hip osteoarthritis. Joint Bone Spine 2009;76:98100. 2. Shindle MK, Kelly BT, Voos JE, Asnis PD, Pruett A. Labral pathology associated with psoas impingement. Arthroscopy 2008;24:e34 (Suppl, abstr). 3. Magerkurth O, Jacobson JA, Girish G, Brigido MK, Bedi A, Fessell D. Paralabral cysts in the hip joint: Findings at MR arthrography. Skeletal Radiol. 2012 March 21. [Epub ahead of print.] 4. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ. Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy 2011;27:252-269. 5. Wettstein M, Jung J, Dienst M. Arthroscopic psoas tenotomy. Arthroscopy 2006;22;907.e1-907.e4. Available online at www .arthroscopyjournal.org. 6. Deslandes M, Guillin R, Cardinal E, Hobden R, Bureau NJ. The snapping iliopsoas tendon: New mechanisms using dynamic sonography. AJR Am J Roentgenol 2008;190:576-581. 7. Bedi A, Chen N, Robertson W, Kelly BT. The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy 2008;24:1135-1145.