CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 405, pp. 122128
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-
scopy in diagnosing labral and acetabular carti-
lage injury and examining the relationship be-
tween those injuries and acetabular dysplasia.
Between 1989 and 2000, 170 hips in 163 patients
with mild acetabular dysplasia or moderate dys-
plasia with joint preservation had arthroscopic
evaluation. Surgical ndings were classied by
location and by severity of the chondral lesions
of the femoral head, acetabulum, and labrum.
Of the 170 hips with dysplasia, 122 had labral
tears (72%) at the free-margin articular sur-
face and 113 had anterior tears (66%). One hun-
dred hips (59%) had anterior acetabular chon-
dral lesions. Among the 113 patients who had
anterior labral tears, 78 hips (69%) had anterior
acetabular chondral defects, and 44 hips (39%)
had anterior femoral head chondral lesions.
Mild uncovering of the anterior femoral head
subjects the labrum to increased load and po-
tential susceptibility to tearing most frequently
anteriorly. Labral tears may contribute to or
can occur in association with articular cartilage
lesions of the contiguous femoral head or ac-
From the New England Baptist Hospital, Boston, MA.
Joseph C. McCarthy, MD, is consultant to Innomed, Sa-
vannah, GA, Arthrex Corporation, Naples, FL.
Reprint requests to Joseph C. McCarthy, MD, New En-
gland Baptist Hospital, 125 Parker Hill Avenue, Boston,
MA 02120. Phone: 617-738-6710; Fax: 617-566-2257;
E-mail:jlee1@caregroup.harvard.edu.
DOI: 10.1097/01.blo.0000038058.29678.54
122
2002 Lippincott Williams & Wilkins, Inc.
etabulum. The mechanism of injury is most
likely hyperextension or torque of the hip or
both. The ndings in the current study support
the concept that labral disruption frequently is
a predecessor in the continuum of degenerative
joint disease.
Hip dysplasia is a well-recognized cause of ac-
celerated joint wear. When severe and associ-
ated with instability, the young patient with
dysplasia may require redirectional osteotomy.
Several authors have reported improvement in
joint biomechanics and reduced cartilage pres-
sure after acetabular osteotomy.7,11,12 Enlarge-
ment and tearing of the labrum have been re-
ported in association with dysplasia. Harris et
al10 observed eight degenerated, intraarticular
labrums in patients with dysplasia who were
having total hip replacement. Some authors also
have suggested that alterations of the labrum
may predispose the patient to osteoarthritis sec-
ondary to destabilization of the acetabular labral
complex.1,2,9,16
Milder forms of dysplasia often are unrecog-
nized unless the contralateral hip has been treated
for more severe involvement. Conventional ra-
diographs, including high-contrast gadolinium-
enhanced magnetic resonance imaging (MRI)
scans of patients with hip dysplasia are not al-
ways sensitive enough to diagnose a labral tear
Number 405
December, 2002
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
(AP) radiographs of the pelvis do not reveal
the extent of anterior femoral head uncoverage
(Fig 1A). Although a false prole view of
Lequesne and a computed tomography (CT)
scan will assess the extent of acetabular bony
deciency more accurately, these studies do not
show the articular cartilage13,16 (Fig 1B).
The purpose of the current study was to
arthroscopically diagnose and treat labral and
acetabular cartilage injuries, and examine the
relationship between acetabular dysplasia and
those injuries.
MATERIALS AND METHODS
Between 1989 and 2000, 170 hips in 163 patients
identied with mild acetabular dysplasia were eval-
uated arthroscopically because of symptoms that
did not respond to conservative treatment. There
were 119 females and 44 males. Their average age
was 35 years (range, 1258 years). There were 69
left hips involved and 101 right hips involved. Each
of these patients was evaluated because of symp-
Acetabular Dysplasia 123
toms referable to the involved hip. These symp-
toms most frequently consisted of anterior inguinal
pain associated with catching episodes or locking
in 114 hips (67%) and buckling in 48 hips (28%).
The pain did not respond to activity modication,
nonsteroidal antiinammatory drugs, physical ther-
apy, or time (minimum 4 months). Thirteen patients
(8%) had pain develop secondary to an acute trau-
matic event. Seven patients (4%) had a sport-induced
injury and 150 patients (88%) could not recall a
specic inciting event.
On evaluation, 117 (69%) patients had a posi-
tive McCarthy sign (with both hips fully exed, the
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-
guinal pain develop with exion, adduction, and in-
ternal rotation of the hip. Thirty-six patients (21%)
also had anterior inguinal pain with ipsilateral re-
sisted straight leg-raising. All patients with these
inclusion criteria had arthroscopic evaluation of
their hip.
On radiographic examination, mild dysplasia
was dened as a center-edge angle of Wiberg as re-
ported by Massie and Howorth14 of between 22

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
Fig 4. An arthroscopic photograph of Outer-
bridge Grade IV chondral damage in a patient
with moderate dysplasia is shown.
Ligamentum teres hypertrophy or avulsion
has been described in patients with dyspla-
sia.21,24 In the current series, there were no pa-
tients with mild dysplasia and a hypertrophic,
impinging ligamentum. In addition, there were
no patients with rupture of the ligament. Syn-
ovitis was present in 118 hips (69%). In gen-
eral, the synovitis was focal and located in
the same quadrant as the cartilage lesion. It
became diffuse only in patients with large
Outerbridge Grade IV lesions. Synovial im-
pingement between the femoral head and ac-
etabulum was uncommon, occurring in 22
hips (13%). The hypertrophic synovial tissue
was present only in patients with labral or
chondral lesions and was more prevalent in
patients with symptoms greater than 1 year.
Among the 113 patients who had anterior
labral tears and mild dysplasia, 78 hips (69%)
had anterior acetabular chondral defects. In
seven of these hips (8%) the lesion was Grade
I, in 16 hips (21%) the lesion was Grade II, in
20 hips (26%) the lesion was Grade III, and in
35 hips (45%) the lesion was Grade IV.
Of the 113 patients with dysplastic hips and
labral tears, 44 hips (39%) had anterior femo-
ral head chondral lesions. In 10 of these hips
(23%) the lesion was Grade I, in 14 hips (32%)
the lesion was Grade II, in 14 hips (32%) the
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
(range, 16 years). In contrast, only four of
146 hips (3%) with mild dysplasia eventually
had total hip replacement. Despite their mini-
mal degenerative changes on plain radio-
graphs, all four had arthroscopic ndings of
Outerbridge Grade III or IV anterior acetabu-
lar chondral lesions in addition to a labral tear.
DISCUSSION
The effects of acetabular dysplasia on hip bio-
mechanics are being increasingly understood.
In its severest form, dysplasia often results in
total joint arthroplasty at a young age. More
moderate degrees of femoral head uncovering
may produce joint pain, instability, and re-
markable increases in articular cartilage con-
tact pressure.11 In these patients, a redirec-
tional pelvic osteotomy, properly timed and
executed, can signicantly reduce these ex-
cessive load pressures and improve anterolat-
eral head coverage.18 Mild forms of dysplasia,
however, often are unrecognized unless there
are compelling joint symptoms or the opposite
hip previously has been treated for this condi-
tion. A partial explanation for the underre-
porting is the standard screening radiographs
of the hip. Anteroposterior and shoot through
views taken with the patient supine do not
show the anterior column uncovering or sub-
tle lateral femoral head translation as do radio-
graphs taken standing. The false prole view
of Lequesne is much more likely to recognize
the anterior deciency.13 More sophisticated

126 McCarthy and Lee
radiologic testing such as CT scanning and
MRI with three-dimensional reconstruction
also can readily identify and quantitate the
magnitude of the dysplasia.
Although each of these radiographic tech-
niques shows the bony architecture of the hip,
they do not reliably assess the articular cartilage
changes present. Attempts at single or double
contrast arthrography to show labral or acetab-
ular cartilage proved to be neither sensitive
nor specic. As MRI scanning techniques im-
proved, better resolution of labral structures
were reported.20 In contrast however, when
MRI scans were compared directly with arthro-
scopic ndings, conventional MRI studies
missed several joint disorders including labral
tears, acetabular chondral ap lesions, and
chondral loose bodies. McCarthy and Bus-
coni16 found the likelihood of MRI scanning
to detect a labral tear at 5%. A more recent
study found that dilute gadolinium combined
with off axis tangent reconstruction views in-
creased the sensitivity for detecting labral
tears to 49%. Chondral and synovial disorders,
however, were not well seen. (McCarthy J,
Marchetti M, Newberg A, Palmer W, Bono J:
Improving diagnostic accuracy of chondral in-
juries: Correlation of gadolinium MR imaging
with arthroscopic surgery. Presented at the
Annual Meeting of the American Academy of
Orthopaedic Surgeons, New Orleans 1997.)
Dienst et al3 and Edwards et al5 also found that
arthroscopic ndings exceeded those of pre-
operative imaging. In particular, chondral
softening, brillation, and partial thickness
defects less than 1 cm were detected inconsis-
tently by MRI.
Because all conventional radiographic stud-
ies have limitations with respect to articular
and labral cartilage pathomechanics it is not
surprising that joint abnormalities in patients
with mild dysplasia have not been well re-
ported to date. The advent of successful tech-
niques to observe the hip arthroscopically has
remarkably improved the ability to accurately
detect and catalogue the counterface articular
changes on the femoral head, acetabulum,
labrum, and synovium.4,8,19
Clinical Orthopaedics
and Related Research
The current study of 170 hips with acetab-
ular dysplasia reports the largest series of
skeletally mature adults with this condition
whose hips have been observed and treated
arthroscopically. The extent of joint problems
present in this previously active group is re-
markable. Seventy-two percent of hips had
labral tears. This is a substantially greater per-
centage than in other large arthroscopic se-
ries.6,16,24 As in the senior authors previous
experience, the majority of labral lesions oc-
curred anteriorly (93% in the current series).
Of concern however, is the 59% of hips that
had anterior acetabular chondral lesions 64%
of which were Outerbridge Grade III or IV in
severity. In the current series and in a prior se-
ries, all of the acetabular lesions initiated pe-
ripherally in the watershed zone adjacent to
the labrum.16 None of them occurred centrally
near the fossa.
In addition, among the 113 patients with
dysplasia who had an anterior labral tear 78
(69%) had an anterior acetabular chondral le-
sion. In this subgroup, 71% had an Outer-
bridge Grade III or Grade IV lesion. These
ndings suggest that the relatively uncovered
anterior portion of the hip allows the labrum to
be subjected to torsional and shear forces which
it cannot dissipate. A tear in the anterior labrum,
almost universally occurring on the articular
margin portion, then separates the previously
seamless attachment to the acetabular cartilage.
This separation in the watershed zone, once ini-
tiated, can extend farther because of repetitive
femoral head torsional motions. The labroartic-
ular cartilage ssure, once developed, subjects
the subchondral bone to joint uid and under
oscillating pressure dynamics similar to that
discussed by Schmalzried et al22 and presented
by Lanzer in patients after total hip arthroplasty
(Lanzer W: Intra-articular pressure differences
in loose and non-loose total hip arthroplasty.
Presented at the Sixty-Eight Annual Meeting of
the American Academy of Orthopaedic Sur-
geons San Francisco 2001). This pressure be-
gins an inexorable delamination process of the
anterior acetabular cartilage. The time- and
activity-dependent pathophysiology helps to
Number 405
December, 2002
explain the high proportion of severe Outer-
bridge ndings. In the current series, these ex-
tensive articular lesions were produced not by
exion and impingement as has been proposed
by others,12 but rather by hyperextension and
torsional forces, such as those seen in jogging,
soccer, and sports that require pivoting.23 These
articular lesions are corroborated by the higher
percentage of patients whose symptoms were
reproduced by a positive McCarthy extension
sign rather than by hyperexion and internal
rotation.
Seventeen patients in the current series had
total hip arthroplasty (10%). However, pa-
tients with moderate dysplasia (13 of 24, 54%)
had a disproportionately higher likelihood of
requiring total hip arthroplasty. This suggests
that in addition to labral and chondral lesions,
other factors such as instability and abnor-
mally high joint contact pressures may have
contributed to the outcome. In contrast, of all
the patients with mild dysplasia, only four hips
(3%) required total joint arthroplasty. All pa-
tients who required arthroplasty had Outer-
bridge Grade III or Grade IV joint changes.
This suggests that with higher degrees of joint
uncovering that the labral changes are the re-
sult of dysplasia pathomechanics. Conversely,
with mild degrees of dysplasia the labrum, al-
though somewhat more susceptible to injury,
when treated early can be restored to allow a
high level of function.
The strengths of the current study are the
size of the cohort and the safety and efcacy
of the arthroscopic procedure in the senior au-
thors hands. This minimally invasive outpa-
tient procedure allows not only thorough joint
observation but also gentle tissue probing to
uncover the acetabular chondral aps not seen
by MRI scanning. In addition to its sensitivity
and specicity this procedure can treat the in-
volved tissue, restoring function to tissues that
otherwise have no healing potential.15
There are several limitations to the current
study. The cohort is not controlled by patients
with dysplasia who do not have symptoms. A
matched series would be almost impossible to
complete given the aforementioned lack of
Acetabular Dysplasia 127
sensitivity to MRI scanning and the certitude
that patients without symptoms would not al-
low a diagnostic surgical procedure on their
hip. The authors also could not control the
length of patient symptoms before referral.
This may help to explain some of the Outer-
bridge Grade III and Grade IV lesions. In ad-
dition, currently there is no approved proce-
dure to replace lost articular cartilage in the
hip, as there is in the knee. Therefore, although
some patients had microdrilling of subchon-
dral bone to facilitate brocartilage repair,
large Outerbridge Grade IV lesions were be-
yond the efcacy of that technique. These le-
sions were uniformly present in the subgroup
of patients who required total hip arthroplasty.
This large cohort of patients with milder
forms of dysplasia is a paradigm group. The
advent of hip arthroscopy allows observation
of the joint to an extent and accuracy never
achieved before. The dysplastic hip represents
a subpopulation particularly susceptible to joint
injury. This study shows that even in mild dys-
plasia labral and chondral injuries occur, and
they occur most frequently in the anterior re-
gion of the acetabulum. These injuries are pro-
duced more commonly by hyperextension and
torsion rather than by exion and impingement.
Without the ability to heal, lesions of the
labrochondral junction (the watershed zone)
are likely to progress and subject the subchon-
dral bone to joint uid, resulting in additional
articular delamination and eventually a sub-
chondral bony cyst. These composite events
are the precursor of accelerated joint wear and
help explain premature osteoarthritis of the
hip. Earlier detection and treatment of these
cartilage lesions hopefully will obviate this in-
exorably negative pathologic arcade.
References
1. Altenberg AR: Acetabular labrum tears: A cause of
hip pain and degenerative arthritis. South Med J
70:174175, 1977.
2. Cartlidge IJ, Scott JH: The inturned acetabular
labrum in osteoarthrosis of the hip. J R Coll Surg Ed-
inb 27:339344, 1982.
3. Dienst M, Seil R, Godde S, Georg T, Kohn D:
[Arthroscopy for diagnosis and therapy of early os-
teoarthritis of the hip]. Orthopade 28:812818, 1999.

128 McCarthy and Lee
4. Dvorak M, Duncan CP, Day B: Arthroscopic
anatomy of the hip. Arthroscopy 6:264273, 1990.
5. Edwards DJ, Lomas D, Villar RN: Diagnosis of the
painful hip by magnetic resonance imaging and
arthroscopy. J Bone Joint Surg 77B:374376, 1995.
6. Farjo LA, Glick JM, Sampson TG: Hip arthroscopy
for acetabular labral tears. Arthroscopy 15:132137,
1999.
7. Genda E, Konishi N, Hasegawa Y, Miura T: A com-
puter simulation study of normal and abnormal hip
joint contact pressure. Arch Orthop Trauma Surg
114:202206, 1995.
8. Glick J: Hip Arthroscopy. In McGinty J (ed). Opera-
tive Arthroscopy. New York, Raven Press 634676,
1991.
9. Harris WH: Etiology of osteoarthritis of the hip. Clin
Orthop 213:2033, 1986.
10. Harris WH, Bourne RB, Oh I: Intra-articular acetab-
ular labrum: A possible etiological factor in certain
cases of osteoarthritis of the hip. J Bone Joint Surg
61A:510514, 1979.
11. Hipp JA, Sugano N, Millis MB, Murphy SB: Planning
acetabular redirection osteotomies based on joint con-
tact pressures. Clin Orthop 364:134143, 1999.
12. Klaue K, Durnin CW, Ganz R: The acetabular rim
syndrome: A clinical presentation of dysplasia of the
hip. J Bone Joint Surg 73B:423429, 1991.
13. Lequesne MG: Femorocoxometry: Angles and seg-
ments characteristic of dysplastic and dysmorphic hip
conditions in adult: Measurement using a femorocox-
ometer for standard or reduced (digitized) lms. Rev
Rhum Engl Ed 66:136142, 1999.
14. Massie WK, Howorth MB: Congenital dislocation of
Clinical Orthopaedics
and Related Research
the hip: Method of grading results. J Bone Joint Surg
32A:519531, 1950.
15. McCarthy J, Noble P, Schuck M, Wright J, Lee J:
The role of labral lesions to the development of early
degenerative hip disease. Clin Orthop 393:2527,
2001.
16. McCarthy JC, Busconi B: The role of hip arthroscopy
in the diagnosis and treatment of hip disease. Ortho-
pedics 18:753756, 1995.
17. McCarthy JC, Day B, Busconi B: Hip arthroscopy:
Applications and technique. J Am Acad Orthop Surg
3:115122, 1995.
18. Murphy SB, Millis MB, Hall JE: Surgical correction
of acetabular dysplasia in the adult: A Boston expe-
rience. Clin Orthop 363:3844, 1999.
19. Outerbridge R: The etiology of chondromalacia
patellae. J Bone Joint Surg 43B:752754, 1961.
20. Potter HG, Schweitzer ME, Altchek DW: Advanced
imaging in orthopaedics: Current pitfalls and new
applications. Instr Course Lect 46:521529, 1997.
21. Salter RB: Etiology, pathogenesis and possible pre-
vention of congenital dislocation of the hip. Can Med
Assoc J 98:933945, 1968.
22. Schmalzried TP, Jasty M, Harris WH: Periprosthetic
bone loss in total hip arthroplasty: Polyethylene wear
debris and the concept of the effective joint space. J
Bone Joint Surg 74A:849863, 1992.
23. Trousdale RT, Ekkernkamp A, Ganz R, Wallrichs
SL: Periacetabular and intertrochanteric osteotomy
for the treatment of osteoarthrosis in dysplastic hips.
J Bone Joint Surg 77A:7385, 1995.
24. Villar RN: Hip arthroscopy. Br J Hosp Med
47:763766, 1992.