0:00

In terms of the classification of labral uh, lesions,

0:04

the initial classification system came out of Austria Erni

0:09

and his colleagues talked about a classification system

0:13

utilizing three grades, depending upon the signal.

0:16

Was it abnormal, the contour, whether

0:19

or not the contra abnormality was associated

0:22

with signal abnormality, and then labral detachment with

0:27

or without signal abnormality.

0:29

I don't think this particular method

0:31

of classification is being used, uh, very much.

0:34

And there have been, or arthroscopy classification

0:38

systems for labral tears.

0:40

This taken from an old article.

0:42

Now, what was a description of four types of,

0:46

of labral tears?

0:47

I don't think now, uh, that this, uh,

0:51

classification system is being used by the arthroscopist.

0:55

So we come along again

0:56

and what kind of classification system do we use?

1:00

And often we turn to the clock face.

1:04

Let me briefly talk about this clock face.

1:09

In our practice, typically we use a clock face where

1:14

superior is 12 o'clock, anterior is three o'clock.

1:17

Posterior would be nine o'clock,

1:19

inferior would be six o'clock.

1:21

Now the clock face of the glenoid labrum is well

1:24

established, I think with anter being three o'clock.

1:28

But the clock face for the acetabular labrum is

1:31

not as well established.

1:32

So if you're using a clock face, you might want to indicate

1:36

what are the hours, where are they located?

1:39

Three o'clock being anterior.

1:41

And most of the labral tears that we see are

1:44

between 12 o'clock and three o'clock

1:47

and often involve all areas of the labrum

1:49

between 12 and three o'clock.

1:52

This is where we like to see the label pathology, the tears.

1:57

This is what it would look like on a coronal sagittal image

2:00

labeled tearing at 12 o'clock.

2:02

This is what it would look like on coronal

2:05

and sagittal images at three o'clock.

2:07

So this was a lab tear that extended from the 12 o'clock

2:11

to three o'clock position.

2:14

Now comes the diagnostic dilemma.

2:17

This was not the first article,

2:19

but it was one of the early articles that said,

2:21

wait a minute, you may have a normal sub-label recess

2:25

that can appear as an area typically of intermediate signal,

2:30

not generally of high signal,

2:32

but of intermediate signal separating the labrum from the

2:37

margin of cartilage and bone.

2:39

And in this particular article, that recess shown here,

2:43

taken from the article,

2:45

predominated in the antral inferior location.

2:48

Well, if that's the case,

2:49

if the recess occurs a**l inferiorly

2:53

and most of our tears are occurring, uh, superiorly

2:56

and anthro superiorly, that not, might

2:58

Not be a great diagnostic problem.

3:01

And also the recess as described here, typically was gray

3:06

and generally did not, uh, have fluid within it.

3:10

So they also showed in that same article

3:13

what a labral tear might look like.

3:16

And here you can see a larger gap

3:18

and a gap in fact,

3:19

where you have fluid collecting within it.

3:22

This would be a labral tear.

3:25

Now this is but one of several pitfalls in diagnosis.

3:30

Another one has been called the sub-label sulcus.

3:33

This is seen in the postal inferior aspect of the lab.

3:38

A small gap shown here that may collect fluid

3:41

or contrast agent as shown in this example related

3:46

to the nearby transverse

3:47

or inferior transverse acetabular ligament.

3:51

I don't worry too much about this particular location

3:54

because most

3:55

of the symptomatic labral tears we see is much higher up.

4:00

This is common and this is considered a normal sub labral

4:04

sulcus complicating all of this

4:08

or some articles such as the one that I'm quoting here that

4:13

indicate that wait a minute, you can see sub-label recesses,

4:17

clefts, and sulci throughout the hip,

4:20

present in 46% of arthroscopies

4:23

and the anterosuperior quadrant.

4:26

The quadrant where we'd like to see tears might be the same

4:30

location for one of these normal variants.

4:33

And so we do struggle with this.

4:35

There's no question about it.

4:37

If the area is large, if it collects fluid

4:41

or contrast agent, if it is located superiorly

4:45

or ant orly, I generally favor it is a sub, a

4:50

sub labral, uh, a tear

4:53

or detachment rather than a sub-label recess, cleft,

4:57

or sulcus.