Acetabular labral tears represent a common finding on magnetic resonance imaging of the hip. Labral tears can arise from a multitude of underlying pathological processes or they may be an asymptomatic incidental finding. The prevalence of labral tears and their lack of specificity make this an area vulnerable to potential overdiagnosis. The overdiagnosis of labral tears leads to overtreatment by exposing patients to unnecessary surgeries as well as complications ranging from unsatisfying outcomes to deep venous thrombosis. This risk is compounded by the tabloid popularization of labral surgeries by celebrities such as Lady Gaga, which could potentiate patient perception of a two-tiered level of health care. Following a similar situation with spine nomenclature, one solution to this issue is to reclassify “labral tears” as “labral fissures” in some or all cases to mitigate the acute traumatic connotation of the term “tear.”
Introduction
“FFirst do no harm” represents the cardinal rule indoctrinated into medical trainees on their first day of training. Classically, this means working toward the prevention and treatment of disease, as well as mitigating suffering from disease. However, the combination of available modern imaging and myriad treatment options leads to an epistemological problem of the old adage—preventing the unnecessary diagnosis and treatment of entities which would otherwise be harmless to the patient, namely, “overdiagnosis.”
Disease is defined as a pathologic condition of a body or organ part. Since the age of Hippocrates, physicians have been utilizing tools ranging from enemas to stethoscopes to ascertain who has disease and how to treat it. Although the dictionary definition of disease is straightforward, the practical definition is far more nebulous. Between normal and abject abnormal lies a spectrum of gradation. Patients labeled as having a disease when the process would not result in a malady become Victims Of Modern Imaging Technology (VOMIT) and overdiagnosis. On the surface, this may seem like a trivial issue; however, the ripple effect can be far reaching. On an individual level, this can mean morbidity and mortality from unnecessary surgeries, whereas on a public health scale, this can balloon health care costs and propagate antibiotic resistance. In an attempt to diminish overdiagnosis and better characterize pathologic entities, scientists use a variety of statistical tests such as sensitivity and specificity, as well as positive and negative predictive value, to determine where on the normality curve a patient falls. When a patient meets the diagnostic threshold for disease, they have a “disease.” Once a patient is given a diagnosis, they often fall into some form of classification system. Examples within radiology include grading hip dysplasia or staging cancer. These classification systems are designed to meaningfully stratify patients to optimize an approach to management.
Acetabular labral tears (ALTs) were first recognized as a pathologic entity in 1957, when a bucket handle labral tear was discovered after an attempted reduction of a posterior hip dislocation . Twenty years later, the first degenerative ALT was reported . ALT can be associated with a variety of hip pathologies. In a young athlete, ALTs are associated with anterior hip and groin pain due to repeated flexion . Also affecting young individuals are a gamut of morphologic abnormalities affecting the articulation between the femur and the acetabulum, which comprise the spectrum of femoroacetabular impingement . Femoroacetabular impingement has been highly associated with ALTs . ALTs have also been associated with developmental dysplasia, osteonecrosis, and osteoarthritis .
With the ever-increasing availability of magnetic resonance imaging (MRI), the diagnosis of labral tears has markedly increased. Among patients with hip pain, the prevalence of an ALT ranges from 22% to 55% . However, given the multifactorial etiology, this may or may not be the cause of the patient’s pain, a supposition supported by a study by Lee et al. demonstrating that in asymptomatic volunteers with a mean age of 26.7, 38.6% had labral tears. An additional study by Register et al. showed that asymptomatic volunteers with a mean age of 37.8 had a 69% prevalence of labral tears . Although the advantages of surgical treatment include pain relief and the prevention of premature arthritis, complication rates range from 1.4% to 25% and include significant and life-threatening risks such as deep venous thrombosis . More tellingly, literature reports of surgical success rates and patient satisfaction vary considerably with values ranging from approximately 46% to 90% . The high prevalence of tears, as well as their multifactorial etiology, may at least contribute to the wide range of surgical outcomes.
The Dilemma of Acetabular Labral Tears
Given the wide array of pathologies associated with ALTs, the lack of specificity creates a diagnostic and clinical dilemma. If a clinician suspects an ALT, orders an MRI confirming an ALT, the question then becomes what is the significance of this finding? In a young athlete, the tear could be a cause of pain. Similarly, in a young adult with features of femoroacetabular acetabular impingement in addition to the tear, the finding could be both a source of pain and a harbinger of accelerated joint degeneration warranting fixation. However, what is the significance of an ALT in a patient with an extra-articular cause of hip pain? What about the significance of an ALT in an individual with mild osteoarthritis? According to guidelines established by the American Academy of Orthopedic Surgery, both femoroacetabular impingement and isolated labral tears are indications for arthroscopy . Although this grants the orthopedic surgeon greater latitude to operate, this leaves open the likelihood that patients in these populations could suffer harm from overdiagnosis of ALT.
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The Significance of Word Choice
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Nomenclature Change as a Solution to the Labral Dilemma
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Conclusion
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Acknowledgments
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