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Original Report |
1 Both authors: Department of Radiology, Menorah Medical Center, 5721 W. 119th St., Overland Park, KS 66209.
Received September 3, 1999;
accepted after revision October 25, 1999.
Presented at the annual meeting of the American Roentgen Ray Society, San
Francisco, May 1998.
Abstract
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CONCLUSION. Paralabral cysts may be associated with labral disorders. The appearance of a paralabral cyst on MR imaging is a useful indirect sign of acetabular labral abnormality. Use of this sign may enable earlier and more accurate examination of labral disorders.
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Acetabular labral tears have been reported in patients with a history of trauma to the hip, dysplasia, or degenerative arthritis. Posttraumatic labral tears can occur after minor trauma or result from a severe injury such as a hip dislocation [1,3]. A previous study examining the MR imaging of the hip, without intraarticular contrast material, indicated a low sensitivity for the detection of acetabular labral tears compared with surgical findings (30% sensitivity and 36% accuracy compared with surgical findings) [2]. When the researchers used an intraarticular injection of gadolinium, the sensitivity of MR imaging increased to 90% with a 91% accuracy [2]. However, MR arthrography adds an invasive and often uncomfortable component to MR imaging.
We assessed whether paralabral cysts were useful signs of adjacent acetabular labral tears. This simple and easily seen sign can aid surgeons in selecting patients for hip arthroscopy or arthrotomy.
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All MR images were prospectively interpreted by one of two musculoskeletal radiologists and retrospectively reviewed by both radiologists. Eighty-seven patients were studied (age range, 15-82 years; mean age, 42 years).
Clinical, radiographic, and MR imaging findings were retrospectively reviewed in 13 patients (10 men and three women; age range, 22-72 years; mean age, 39 years) who complained of hip pain and had paralabral cysts on MR images. Ten of these patients (age range, 22-47 years; mean age, 33 years) underwent hip surgery: seven underwent hip arthroscopy and three underwent hip arthrotomy after MR imaging. Reviewers were unaware of surgical findings at the time of image interpretation. After retrospectively reviewing the MR images, our reviewers correlated the operative and pathology reports with MR imaging findings.
Conventional radiographs and MR images from all 13 patients were reviewed by both musculoskeletal radiologists. MR images were assessed for location and characteristics of paralabral cysts. Also, the acetabular labra were assessed for abnormal morphology and signal intensity that might suggest a tear according to the staging system described by Czerny et al. [2].
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On conventional radiographs, three patients had evidence of hip degenerative arthrosis. The remaining radiographs revealed normal findings. MR imaging revealed paralabral cysts in all 13 patients. Cysts were located on the posterior aspect of the hip in eight patients and the anterior aspect in five patients.
A 39-year-old woman underwent sonographically guided drainage of a paralabral cyst. Pain relief lasted approximately 6 months. Follow-up MR imaging was performed and revealed a reaccumulation of the cyst in the same location as the original (Fig. 1A,1B,1C,1D).
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Ten patients without evidence of osteoarthritis on conventional radiographs underwent hip arthroscopy or arthrotomy. All patients undergoing hip surgery had acetabular labral tears. Of the 10 patients who underwent surgery, seven had posterior labral tears and three had anterior labral tears. In all patients the location of acetabular labral tears correlated with the location of paralabral cysts. Of 10 patients, three had MR imaging findings suggestive of acetabular labral tears (noted prospectively and retrospectively) (Figs. 2A,2B and 3A,3B,3C).
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Pathology reports revealed myxoid degeneration and mucoid debris consistent with ganglion cysts in six of 10 patients. Four of 10 patients had identifiable synovial tissue in the pathology specimen, consistent with synovial cysts.
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Cystic lesions around joints commonly appear on imaging. Histologically, the cysts are either ganglial or synovial in origin. Ganglial cysts are lined with connective tissue, contain mucinous fluid, and rarely communicate with the joint. Synovial cysts are lined with synovial cells, contain fluid, and may or may not communicate with the adjacent joint. Cysts result from a herniation of synovium or from the fluid distention of a paraarticular bursa. The distinction between ganglial and synovial cysts is often impossible to determine on imaging, so the terms "ganglion cyst" and "synovial cyst" are often used interchangeably [4].
Paraarticular cysts are often associated with abnormalities in adjacent joints. Their relationship to abnormalities in the knee, shoulder, and wrist are well documented. If a cyst is associated with joint disease (as in a meniscal cyst), repair of the underlying joint abnormality is required to prevent cyst recurrence [4,5,6].
The MR imaging appearance of paralabral cysts around the hip has been previously described. A limited retrospective study of one patient (with surgical correlation) suggested that labral cysts that appear on MR imaging may be associated with acetabular labral tears [3]. Another article described the appearance of two labral cysts on MR imaging [5]. To our knowledge, no large series describing the surgical-pathologic correlation of paralabral cysts exists.
Paralabral cysts have been described in patients with developmental dysplasia of the hip, osteoarthritis, and remote trauma [4]. Three of our patients with paralabral cysts had osteoarthritis and all had a history of remote trauma. None of our patients had developmental dysplasia of the hip.
Shear stress on the labrum can cause labral degeneration and tearing [3]. Labral tears can result in a loss of congruity between the femoral head and acetabulum, resulting in increased intraarticular pressure. The increased pressure can force synovial fluid through the area of labral degeneration or through the tear in the acetabulum and the soft tissue adjacent to the acetabulum, resulting in a paralabral cyst [3].
The acetabular labrum contains nerve endings that contribute to pain perception. Patients with acetabular labral tears often complain of an acute exacerbation of hip pain, a sharp mechanical pain, or clicking in the hip. Many patients have a gradual onset of pain, and clicking sometimes develops after a minor injury [3].
Three previous articles have described increased sensitivity for the detection of acetabular labral tears on MR arthrography [1,2,7]. One study reported an MR arthrography sensitivity of 90% and an accuracy of 91% [2]. We did not perform MR arthrography on any of our patients. We assessed the correlation of paralabral cysts with acetabular labral tears. Additionally, we assessed whether the presence of paralabral cysts could be used as an adjunctive sign of labral disorders.
In our study, 10 patients who underwent surgery for paralabral cysts had associated labral tears located in the area of the paralabral cyst. Seven of the tears occurred posteriorly and three occurred anteriorly. In previous studies, most labral tears occurred anterosuperiorly [1,2]. The difference in our results may be caused by our small sample size of 10 patients. In only three of 10 patients was a labral tear suggested on MR imaging prospectively or retrospectively. The use of paralabral cysts as an indirect sign of labral abnormality significantly increased our sensitivity for the detection of acetabular labral tears.
In conclusion, paralabral cysts are frequently associated with labral abnormality. The appearance of a paralabral cyst on MR images is a useful indirect sign of acetabular labral disorders. Use of this sign may allow earlier and more accurate examination of labral abnormalities.
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